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Electronic Method of Evaluating Effort and Compliance in Using Headgear Appliance (Compliance Science System)
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Carlos Rodrigues Junior - Graduated in Orthodontics by Dentistry Faculty of Federal University of Rio Grande do Sul and engaged in the private practice of orthodontics in Porto Alegre - RS - Brazil
Headgear appliances have been worn in Orthodontics since 1800. After that many technical changes have been performed , but cooperation problems that appear during the treatment remain untouchable.
Lack of cooperation can waste time to reach a good result and shorten treatment time. Cases that could be finished in 18 to 20 months sometimes reach 3 to 4 years.
There's no doubt about the technical efficiency of the headgear appliance, specially in cases that need growth change. However, most patients don't follow the number of hours indicated to be worn and orthodontists don't have the right psychological arguments to convince and encourage the patients to cooperate in wearing the headgear appliance.
The most common methods for evaluating the wearing of the headgear appliance are subjective: teeth mobility, double tube cleanness, strap appearance, ability in putting the headgear arch, oral or verbal evaluation, comparison with pre-treatment models, spaces between teeth, internal arch sliding facility, anchorage maintenance.
Nowadays, with the help of microelectronics we have objective methods to measure the level of cooperation of the patients in wearing headgear appliances. Northcutt(1) reports his experience using an electronic watch and a memory circuit to evaluate the numbers of hours the patients wore the headgear. Results showed that average patients shifted from 35-to-50 hours a week to over 100 hours a week in three appointments. Besides, Northcutt asked about how many mm/hours are needed to correct 8 mm overjet. This way it's possible to correlate time units with treatment results.
Cureton(2) concluded that monitored patients that were not told about the timing device gave the orthodontist an answer about his motivational technique. Cureton(3) reported that patients generally wear the headgear about half the time recommended by their orthodontists. Cureton(4), in another study utilizing headgear timers and calendars, reported there was more compliance of those patients who wore a calendar to control their average hours.
It can be concluded that electronic monitoring represents an advantage to orthodontists improving patient effort and cooperation in wearing headgear appliances. Hawthorne Effect is well known in business: people improve their effort when they are measured. Orthodontists who have experience in electronic monitoring report that the number of hours increases 100%.
Northcutt, in 1974, used a headgear timer made by Aledyne Corporation (Aledyne Timers); Cureton used a timer combining a Seiko Lorus Quartz watch and a Unitek strap for traction.
In the 1998 AAO meeting in Dallas, Ortho Kinetics Corporation(5) presented the Compliance Science System (CSS). CSS was designed to inform the orthodontist and the patient about the level of cooperation in using headgear appliances. The system measures hours of wearing and sessions of wear. With CSS there's the possibility of evaluating if 8 sessions of 1 hour result in the same teeth movement of 1 session of 8 hours. With CSS orthodontists have a good tool to change patient behavior to increase cooperation in using headgears.
The system is simple and its components are:
The function of the software is store the data that come from the module and that informed the hours the patient is wearing the headgear. This reading is done during the normal orthodontic visit. The software reads and updates the data automatically, creating graphs and showing the behavior the patient has between the different periods of reading. Each headgear appliance has a module, and inside it is the electronic part that measures and registers time of wearing. CSS is supported by the idea that the most important variables that influence tooth movement after wearing headgears is the time of each session and the frequency of the sessions per day.
During an office visit the module is put on the reader that sends the data to the software in the computer.
The software shows by graphs the hours and sessions the patient has worn the headgear.
The software automatically reads the modules, uptakes the data and generates reports of patient compliance histories.
Graph1. Results of a patient planned to wear 10 hours/day in a period of 30 days.
There are different ways to see the graphs which show how to improve compliance and the value of using headgear appliance registered by objective arguments.
Each patient has his own graphs that change and sum new data in each new orthodontic visit. This way it is possible to compare data in monthly periods and show the patient how long or near he is from the planned hours/day of wearing the headgear.
Graph2. Results of a patient during 6 months of wearing the headgear planned to wear 10 hours/day.
CSS is a system of easy application and that permits the orthodontist to evaluate with more precision the hours per day our patient is using the headgear appliance. Now we can think about how many hours are needed for growth change, anchorage maintenance or a Class II malocclusion treatment. Research studies can use CSS as a real possibility in response questions such as: what energy do we need to reduce 8 mm overjet? What are the intersections of time and pressure which are optimal for tooth movement? 24 hours of wearing of 1 pound of force or 12 hours of wearing of 2 pounds force?
CSS permits the orthodontist to program wished and established hours/day in the moment when the headgear is installed, determining patient compliance.
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