Download Issues in Decision Making: Should I Have Orthognathic Surgery?

Issues in Decision Making: Should I Have
Orthognathic Surgery?
HiUary L. Broder, Ceib Phillips, and Sharon Kaminetzky
This article reviews theoretical issues related to self-perception and decision making in patients with dentofacial disharmony. The decision-making process among
patients seeking treatment for severe malocclusion is not well understood. Using
phone interviews and chart audits, attitudes, behaviors, and demographics of 118
patients for whom orthognathic surgery was recommended within the past 2
years at 2 university-based dentofacial centers were examined. The mean age was
similar (24.6 and 24.2 years) at both sites. Gender and ethnic distributions differed
slightly. The northeast site (UMDNJ) had 50% females and 36% white, while the
southeast site (UNC) had 77% females and 79% white. Treatment decisions were
comparable across sites: approximately 60% of the patients chose orthognathic
surgery, 30% chose orthodontics only, and 10% were undecided, waiting, or under
observation. No perceptual differences across sites were observed. More than 50%
of patients reported awareness of their condition since early adolescence: 11%
indicated that someone else (eg, dentist) made them aware of their problem.
Twenty percent said the timing for seeking care was related to financial security or
schedule flexibility. Fifty percent reported aesthetics and function were their primary motives. Focus groups/interviews were held (orthognathic v orthodontics
only; 2 groups per site). Emerging themes included the importance of patientdoctor communication and interpersonal skills (patient education, patience, and
willingness to use "my words," take time to explain), the importance of the
patients' readiness to change, and availability of resources such as social support
and finances/insurance. Knowing someone who had completed treatment at their
facility was a significant facilitator expressed across sites. No insurance and fear
were relevant barriers in the orthodontic group only. The decision-making process
is muitifaceted. Interpersonal communication skills (rapport, understanding), enabling resources (financial, social support), and psychosocial factors (stress, motivation) were primary factors in patients" decision making. Implications for clinicians are presented as well. (Semin Orthod 2000;6:249-258.) Copyright © 2000 by
W.B. Saunders Company
or patients whose facial skeleton or dentoalis too severe to be completely camouflaged or masked by orthodontics
alone, orthognathic surgery in conjunction with
F veolar p r o b l e m
From the Department of Gen~'al Dentistry and Community
Itealth, University of Medicine and Dentistry of NewJersey, Newark,
NJ," the Department q["Orthodontics, University of North Carolina,
Chapd Hill, NC," and the University of Medicine and Dentistry of
New Je~:~ey, Newark, NJ~
Supported in part by NIH NIDCR De 10028.
Address correspondence to Hillary Brode~; PhD, MEd, 110
Bergen St, UMIJNJ-Nfl)S, Department of General Dentistry and
Community Health, Newark, NJ 07103-2400.
Copyright © 2000 by W.B. Saundera Company
1073-8746/00/0604-0008510. 00/0
doi: 10.1053/sodo. 2000.19073
orthodontics is r e c o m m e n d e d . Orthodontics
alone can provide dental correction but can not
alter underlying disharmony. T h e decision-making process used by a patient ("Should I have any
treatment? .... Which t r e a t m e n t should I have?"
"When should I have treatment?") is multifaceted. This process is difficult to explore because
the factors that influence the process range from
the concrete factors to m o r e subtle and often
abstract factors such as psychosocial issues. (Table 1). Attempts to u n d e r s t a n d patients' decision making is further complicated by the complex process that precedes seeking a t r e a t m e n t
consultation: recognition that a p r o b l e m exists,
wanting to m a k e a change, and finally, actively
Semina,~ in Orthodontics, Vol 6, No 4 (December), 2000: pp 249-258
249
250
Broder, Phillips, and Kaminetzhy
Table 1, Factors That May Influence the
Decision-Making Process
Subtle~Abstract Factors
Concrete Factors
Social issues
Psychologic well-being
Social support
Self-worth
Expectations for self and future
Patient/clinician interaction
Financial resources
Health care provider
Time availability"
Morphologic findings
Physical problems
seeking possible solutions. ~ Accepting change
involves several specific stages f r o m p r e c o n t e m plation to action.
Biological, functional, and health processes
can be clearly linked to a patient's motivation to
seek t r e a t m e n t for a dentofacial disharmony.
Dentofacial p r o b l e m s impact on the patient's
quality of life (QOL). In fact, a recent r e p o r t
f r o m a r a n d o m i z e d clinical trial of fixation techniques used in m a n d i b u l a r a d v a n c e m e n t indicated that the presurgical psychosocial healthrelated Q O L dimension a p p r o a c h e d the level
observed in patients with chronic obstructive
p u l m o n a r y disease or oropharyngeal cancer. 2
Specific oral problems r e p o r t e d by patients include difficulties in biting, chewing, swallowing,
drooling, speech, a n d oral hygiene problems. 3-5
The link of psychosocial factors to a patient's
t r e a t m e n t decisions are m o r e difficult to delineate, although self-image, social, and interpersonal issues are consistently r e p o r t e d as motivations. 4-6 This article includes a review of
theoretical issues related to patient self-perception and decision making in patients with dentofacial disharmony, interviews and focus group
data f r o m a recent cohort of subjects who have
sought a t r e a t m e n t consultation at 2 dentofacial
centers, as well as discusses research findings
and clinical implications.
Theoretical Considerations
Developmental and Psychosocial Issues
T h e association of physical attractiveness with
socially desirable qualities and unattractiveness
with undesirable attributes is well documented. v-11 Even children as young as 3 years of age
show a p r e f e r e n c e for attractive preschoolers as
friends and j u d g e unattractive children as m o r e
antisocial? 2 In the preadolescent, how m u c h a
child likes his or her a p p e a r a n c e and their per-
ception of their attractiveness is highly related to
their global feelings and beliefs a b o u t themselves. 1~,14 This is especially relevant because
children and adolescents are particularly influenced by the feedback of others, 15,16 and are
m o r e likely to experience some psychosocial
"hurt" when teased a b o u t their facial appearance than adults. The m o u t h and teeth are the
i m p o r t a n t attributes in facial attractiveness ~7,as
and are frequently the focus of negative comments. T h e majority of individuals seeking treatm e n t for severe malocclusion r e p o r t childhood
teasing at home. 17,m,2° In a study of children
u n d e r 16 years of age, those with increased overj e t ( > 7 m m ) were 5.5 times as likely to report
having b e e n teased when c o m p a r e d with those
children with lesser overjets, m Even as adults,
subjects who self-report early experiences of being teased for unattractiveness associate t h e m
with long-term negative effects on body image
and feelings of self. 29
T h e positive relationship between dentofacial
esthetics and social desirability is especially imp o r t a n t during adolescence, 2s-25 because the dev e l o p m e n t of social c o m p e t e n c e during adolescence is greatly influenced by p e e r relations.
Social isolation f r o m peers can cause loneliness,
anxiety and inhibition, 26 and p e e r problems in
childhood have b e e n considered by some as possible early markers of psychologic problems in
adolescence and adulthood. 27 A strong relationship appears to exist between self-perceived
body image, unattractiveness and depression,
but no relationship has b e e n f o u n d between
depression and objective attractiveness. 2s Negative thoughts, in general, including a negative
view of self, are f o u n d m o r e f r e q u e n t l y in anxious and depressed children 29 and may be imp o r t a n t in the genesis of social anxiety? °,3~ Although preadolescents and adolescents may not
recognize the potential long-term psychosocial
consequences of skeletal a n d / o r dental anomalies, parents of adolescents who have c o m p l e t e d
orthodontic t r e a t m e n t endorse the i m p o r t a n c e
of a p p e a r a n c e in a future social and economic
context. ~2 T r e a t m e n t is not sought for a child
simply for esthetic reasons, but for the improvem e n t in psychosocial functioning and economic
opportunity that is perceived as a potential corollary of treatment. Scant data are available across ethnic groups but evidence f r o m the
National Health and Nutrition Examination Sur-
Decision Making in Orthognathic Surgery
vey (NHANES III) suggests that increasing numbers of patients f r o m lower and middle socioeconomic groups are seeking c a r e ? -~
Research reports in adults confirm the complexity of the interactions between physical attractiveness, social status, sell:concept, and psychologic well-being. 2°,34,35 How a person views
him or herself tends to influence the way a
person thinks others view him or h e r 2 and how a
person thinks he or she looks has a strong influence on social and personal outcomes I° and on
motivation for orthognathic surgery. 4,:~6--~s People with unattractive faces often report that they
see themselves as less outgoing, less popular,
and less socially skilled. TM Negative self-perceptions can have an adverse effect on psychosocial
adjustment by generating self-consciousness
which can manifest in shyness, social anxiety,
and low self-esteem. 39
T h e m a g n i t u d e of the effect that positive or
negative feedback and social interaction has on
feelings of self-worth and self-esteem 4° depends
on several factors: (1) the frequency and consistency of the person's perception of the feedback, (2) who is providing the feedback, 41 and
(3) the i m p o r t a n c e of the feedback of the individual and the situation. 42 Dentofacial disharm o n y a n d / o r severe malocclusion is usually not
a sudden occurrence but rather represents a
progressive discrepancy during development.
The impact of the skeletal/dental p r o b l e m o n
the individual may be m o r e highly related to the
d e v e l o p m e n t of the p r o b l e m and the feedback
from peers and family than to the actual severity
of the problem. T h e r e are no substantive data
regarding the effect of dentofacial p r o b l e m s on
social and psychological d e v e l o p m e n t in preand early adolescence and future decision
making.
Psychologic Well-Being
Psychologic distress plays a complicated and
sometimes contradictory role in treatment-seeking behavior. For example, health-seeking behaviors are typically thwarted in patients immobilized or functionally impaired with severe
clinical depression or anxiety. However, the
emotional uneasiness and u n h a p p i n e s s experie n c e d either transiently or long-term by less severely affected anxious or depressed patients
may trigger t h e m to seek medical solutions as a
251
relief f r o m their emotional discomfort. Approximately 25% of individuals seeking care for
dentofacial disharmonies had sufficient elevated
distress to qualify as a positive diagnosis on a
well-documented and highly valid standardized
psychologic instrument, the SCL 90-R. 43
Some anxious patients may r e p o r t a longterm history of anxiety in both social a n d vocational settings: act nervous or worried that they
look different, are stared at, or are being treated
differently because of their morphological problem. 4~ Depressed patients will r e p o r t low selfesteem and gloominess. Such patients may have
patterns of behavior characteristics, ie, learned
helplessness a n d hopelessness, which make
treatment-seeking for self-improvement unlikely. However for a variety of reasons people
experiencing psychologic distress frequently
evolve to the "action" stage of Prochaska's
change m o d e P a n d are ready to b r e a k patterns
of behaviors and address long-term concerns.
Believing that one can impact o n e ' s health status, known as self-efficacy, is theoretically linked
to health p r o m o t i o n behaviors. 4<45
In some psychologic disorders, such as body
dysmorphic disorder and obsessive-compulsive
disorder (OCD), the n e e d to seek t r e a t m e n t is
not directly related to the presence of a problem. A patient with a body dysmorphic disorder
has a distorted body image characterized by obsessive thoughts a n d concerns a b o u t their
perceived physical "defect. "46 Such distorted
t h o u g h t patterns typically result in consecutive
t r e a t m e n t requests for nonexistent or very min o r facial differences. These patients will have a
significant history of "doctor-shopping" to correct their imperfections. OCD is a m o r e generic
and prevalent psychologic disturbance. Individuals with OCD are obsessed with their thoughts
and behaviors associated with their specific concern(s) and can b e c o m e so impaired that they
c a n n o t adhere to t r e a t m e n t regimens and are
rarely satisfied regardless of the objective outc o m e of treatment. A 38-year-old woman with
OCD was referred for counseling to the lead author after she discontinued contact with friends,
church, and took a leave of absence from work
subsequent to undergoing orthognathic surgery
for a severe Class II malocclusion. Contrary to the
patient's perspective, data from models and radiographs postsurgery confirm treatment success.
The patient reported "looking weird" and felt that
252
Broder, Phillips, and Kaminetzky
the dentist had not done what she wanted and
ruminated about her perceived multiple imperfections and needs. This scenario illustrates perceptual differences and expectations between the
treatment team and the patient, and that psychologic disorders may be associated with treatment
decisions. In essence, changing the morphology
will not "rescue" patients and satisfy their underlying mental health problems.
Patient-Doctor C o m m u n i c a t i o n
The last area in patient decision-making highlights interpersonal c o m m u n i c a t i o n between
the patient and doctor. Listening to patient concerns, addressing patient expectations, educating the patient and using language understandable to the patient are reportedly key elements
in successful interpersonal c o m m u n i c a t i o n s in
health care. 47 Such elements are u n d e r s c o r e d in
cross-cultural c o m m u n i c a t i o n as well as when
t r e a t m e n t decisions include dental surgical intervention. 4s,49 T h e impact of information-transfer may be correlated with the m a n n e r of the
presentation of information as well as the m o d e
of presentation. According to persuasion theory,
such variables influence decision-making in
health care. 5° Therefore, issues such as c o m m u nication style (eg, acceptance, avoiding scare
tactics, appealing to values) and m o d e of presentation are i m p o r t a n t elements in p e r s u a s i o n that is, " c o m m u n i c a t i o n to change attitudes or
move others to action. ''5° To date, scant information is available linking t r e a t m e n t decisions
with patient-doctor interaction a m o n g patients
with dentofacial deformity. However, clinical experience and anecdotal accounts indicate that
even when options are presented fully and
clearly, body language, voice inflection, and
choice of words can be persuasive c o m p o n e n t s
influencing medical t r e a t m e n t decisions. Patient
fears, especially when invasive options are discussed, may also i m p e d e interpersonal c o m m u nication. 4~ To better u n d e r s t a n d issues involved
in decision making a m o n g individuals seeking
consultation for dentofacial disharmony, a
2-center study was undertaken.
Methods
Between 1998 and spring 1999, 33 patients at the
University of Medicine and Dentistry of New
Jersey (UMDNJ) and 85 patients at the University of North Carolina (UNC) were evaluated for
possible surgical t r e a t m e n t options. Chart audits
and telephone interviews were conducted to
confirm their t r e a t m e n t decisions and to obtain
d e m o g r a p h i c information, primary reason for
seeking treatment, and availability of insurance.
To explore issues related to c o n s u m e r decision making (eg, motivations for care, facilitators, barriers to care), focus groups and semistructured individual interviews were held with
individuals f r o m both institutions. Beginning in
the 1980s, these techniques have b e e n used increasingly as a research tool when there is a n e e d
to better u n d e r s t a n d c o n s u m e r perceptions, service utilization and adherence. 51,52 Qualitative
and descriptive analyses were used to identify
specific factors and themes within and across
groups and centers.
Individuals who were evaluated at the institutions within the past 18 m o n t h s and had not
u n d e r g o n e orthognathic surgery were contacted
by telephone and asked to participate in focus
groups in accordance with Institutional Review
Board (IRB) protocol. Subjects were paid $40
for their participation. Each g r o u p was composed of a h o m o g e n e o u s g r o u p of patients with
dentofacial disharmony: those who elected orthodontics only, and those who chose orthodontics in conjunction with surgical t r e a t m e n t (orthognathic group). Each group discussion lasted
approximately 1.5 hours. Two discussion groups
with both patient groups at each site were completed. G r o u p discussions were audiotaped,
transcribed, and analyzed independently for
themes across subject g r o u p and institutions.
Results
Chart Audit/Telephone Interviews
T h e average age of the patients was quite similar
(24.6 and 24.2 years) at the 2 centers. G e n d e r
and ethnic distributions were slightly different.
UMDNJ, the northeast center, had 50% females
and 50% males, 36% being white; whereas UNC,
the southeast center, had 77% females and 23%
males, 79% being white. T r e a t m e n t decisions
were quite similar: m o r e than half of the patients
elected to have orthognathic surgery, about onethird of the participants chose orthodontics
only, and approximately 10% were undecided,
253
Decision Making in Ozlhognathic Surgery
waiting, or u n d e r observation. The pattern of
t r e a t m e n t decisions was similar for males and
females, but not for whites and nonwhites (Table 2). A larger p r o p o r t i o n of whites chose orthognathic t r e a t m e n t c o m p a r e d with the nonwhites who were mostly African American. T h e
majority of patients who had medical insurance
elected orthognathic surgery. However 40% of
those with no medical insurance chose surgery.
Additional interview data revealed that across
sites, m o r e than 50% of patients had b e e n aware
of their p r o b l e m for a long period of time (eg,
"ever since I can r e m e m b e r " ) . Responses regarding initial awareness ranged f r o m 8 years of age
to 20 years old with most individuals reporting
initial awareness in the early adolescent period.
Approximately 11% of the total patient pool
indicated that a n o t h e r individual (professional
a n d / o r family/friend) had m a d e t h e m aware of
their problem, typically that person being a dentist or family m e m b e r / f r i e n d . Twenty p e r c e n t
r e s p o n d e d that the reason for seeking t r e a t m e n t
at that particular time was related to financial
security or schedule flexibility. Such responses
(eg, financial) were elicited by 42% of the orthodontic only respondents c o m p a r e d with 15% of
the orthognathic group. Additionally, older patients cited these decision making issues related
to finances and scheduling m o r e frequently
than the younger patients. More than 50% of
the patients indicated that the desire to improve
social s t a t u s / a p p e a r a n c e was the most i m p o r t a n t
reason for seeking care at this time. O t h e r stated
motives included physical complaints like sinus
or headaches, vocational aspirations, a n d / o r
pragmatic issues such as "finished growth."
Approximately 75% of patients had sought treatm e n t before with only 25% of them having actually h a d previous orthodontic treatment. Regarding the timing of treatment, the responses
varied f r o m social support, knowing s o m e o n e
who had treatment, to access to care issues, eg,
insurance or j o b security. Motives for t r e a t m e n t
related to aesthetic, social, and vocational advancement. O t h e r Q O L concerns, eg, s p e e c h /
c o m m u n i c a t i o n and eating as well as resolution
of health p r o b l e m s were also cited.
In analyzing the expressed facilitators and
barriers to care, several major themes regarding
decision making emerged. These included intrapersonal issues (stress, health attitudes, social
support) ; interpersonal c o m m u n i c a t i o n (patientdoctor relationship); and specific health care
delivery system factors physical environment, access to care) (Table 4).
For all subjects, intrapersonal issues impacting on Q O L were significant. As previously reported, p r o b l e m s ranged f r o m medical health
issues such as headaches and oral facial pain, to
aesthetic concerns. Vocational aspirations like
wanting to do "camera work" and commercials
were expressed reasons for seeking care now.
Speech, sinus/nasal problems, and social teasing
were also issues. Yet the p r e d o m i n a n t t h e m e was
that the facial/dental "problem" r e p r e s e n t e d a
long-standing unresolved concern (ie, unfinished adolescent business). Almost all of the
discussants described "baggage" or social anxiety
f r o m their early adolescence. O n e male in his
late 20s f r o m the NJ orthognathic g r o u p said:
"This (the treatment) is like an investment in
myself." A 25-year-old w o m a n talked a b o u t going
to school and the timing being right for selfi m p r o v e m e n t . O n e m a n said, "My fantasy would
be to go back to Costa Rica and see all those guys
that used to m a k e fun of me. I would just tell
t h e m who I a m . . . W h e n this is over I will do
whatever I want in public: talk, smile, whatever.
T h e r e are no limits." A n o t h e r male uttered: "Af-
Focus Group/Structured Interviews
The interview schedule/focus g r o u p guide and
sample responses are presented in Table 3.
T h e majority of the subjects r e p o r t that word
of m o u t h was the most pervasive m o d e of finding out a b o u t care and the dental school facility.
Table 2. Percentages of Subjects Who Chose Different Treatment Options
Male (%)
Female(%)
No lnsu,zmce
(%)
Has I'nsurance
Treatmerzt
(%)
White (%)
Nonwhite(%)
Ortho and surgmy
Ortho only
Other*
53
35
12
59
32
9
40
55
5
63
29
8
61
28
12
47
47
6
* Either refused treatment, undecided, or waiting pending insurance.
Btvder, Phillips, and Kaminetzky
254
Table 3. Focus Group Questions and Responses Among Health-Seeking Individuals With
Dentofacial Disharmony
Questions
1.
2.
3.
4.
5.
6.
7.
8.
9.
How did you find out about the school?
Have you sought treatment elsewhere?
Have you been treated elsewhere?
What is the payoff or motive for you to
get care?
What influenced you to get treatment
now?
When did yon first know you had a
problem?
What made getting care easier for you?
What were barriers or things that turned
you off about getting care?
What is the best way to advertise or let
people know about care?
Responses
Word of mouth-friends, relatives, dentists
Eighty percent yes
Seventy live percent no
Social~appearance, .job, unfinished business, health, speech
Reputation of the school, social support, access to care, knowing someone
who had treatment, patient-doctor interaction, timing
Twenty years ago, early adolescence, 14 years old, 20 years old
Insurance coverage, children are grown, transportation, payment plans
Cost, low knowledge, waiting, poor communication, logistics, unclean
facility
Word of mouth, internet, pamphlets in other offices, home mailings,
finders' discount for referring future patients
ter t r e a t m e n t is over I m i g h t m e e t s o m e o n e a n d
c o u l d have a lot o f fun. I was the o d d m a n o u t all
the time." Yet o t h e r m e m b e r s c o n c e n t r a t e d o n
m o r e c o n c r e t e issues like " e a t i n g a steak a n d
carrots, s p e a k i n g m o r e clear so e v e r y o n e u n d e r stands me."
T h e t i m i n g issue, that is, the r e s o l u t i o n of
specific stressors i n o n e ' s life, was r e m a r k a b l e
a m o n g the o l d e r patients, i n particular. Now
h a v i n g g r o w n c h i l d r e n , time for myself, m o n e y
saved, i n s u r a n c e , t r a n s p o r t a t i o n , a n d a r e g u l a r
j o b were a m o n g s o m e of the i n t r a p e r s o n a l fac-
Table 4. Summary of Barriers/Facilitators
Regarding Decision Making
Health attitudes:
Knowledge/attitude towards health providers/dentist1T
Concern about infection and/or complicationsjFamily stress:
Business; dystunction*
Divorce, child birth S
School/job*
Child care, social support*
Logistics/quality of care:
Scheduling]
Waiting; expeditiousness*
Continuity of care]
Prior orthodontic experience~
Facility/physical environment:
Comfortable-~
Clean*
Interpersonal communication:*
Dentist/staff behaviors*
Educating the patient/tamily
Access to care:*
Costs, transportation*
Regulations (insurance, third party payors):~
* Across groups.
t Predominantly orthodontic only groups.
~;Mostly orthognathic groups.
tors facilitating the h e a l t h - s e e k i n g behaviors.
O n e p a t i e n t in the o r t h o d o n t i c s only g r o u p
m e n t i o n e d h a v i n g i n h e r i t i n g some m o n e y .
Regardless o f site, g r o u p p a r t i c i p a n t s i t e r a t e d
the i m p o r t a n c e o f t h e i r social s u p p o r t system.
Most of t h e m said that it was t h e i r d e c i s i o n b u t
c o n f e r r e d with others to legitimize t h e i r concerns a n d e n d o r s e t h e i r t r e a t m e n t - s e e k i n g behaviors. Each o f the o r t h o g n a t h i c p a t i e n t s h a d
e i t h e r k n o w n s o m e o n e who h a d h a d such care
or was favorably i m p r e s s e d with the doctor-pat i e n t c o m m u n i c a t i o n a b o u t t r e a t m e n t . Several
o f the o r t h o d o n t i c i n d i v i d u a l s said that low
k n o w l e d g e a n d / o r cost were e x p r e s s e d r e a s o n s
for n o t h a v i n g h a d p r i o r care. "I have w a n t e d to
fix m y t e e t h forever, b u t m y m o t h e r c o u l d n o t
afford it w h e n I was y o u n g . " A n o t h e r e x p l a i n e d :
"I n e v e r k n e w t h a t adults c o u l d get braces." For
a c o u p l e of the patients, the severity of the p r o b l e m was n o t a p p a r e n t to t h e m u n t i l a t r e a t m e n t
s i m u l a t i o n was shown. O n e 48-year-old female
p a t i e n t r e m a r k e d , "I n e v e r k n e w I l o o k e d so bad.
I d i d n ' t k n o w that e v e r y o n e saw m e l o o k i n g that
way." Several o t h e r y o u n g e r p a t i e n t s were imp r e s s e d with the visual p r e s e n t a t i o n ( t r e a t m e n t
s i m u l a t i o n ; b e f o r e / a f t e r C D / o r slides). O n e
o l d e r a d o l e s c e n t r e m a r k e d : "I really like the 3-D
stuff-it showed m e how I w o u l d look a n d I liked
how I was g o n n a look."
T h e r e l e v a n c e o f the p a t i e n t - d o c t o r relationship a n d effective c o m m u n i c a t i o n were param o u n t across sites. H a v i n g c o n f i d e n c e a n d trust
i n the d o c t o r was i t e r a t e d repeatedly. My d o c t o r
is terrific, really knows what h e is d o i n g . " Ano t h e r s c e n a r i o r e l a t e d w e n t like this: "I w o u l d
Decision Making in Orthognathic Surgery
not go to that guy, it was like a salesman's pitch
and I d i d n ' t think he was c o n c e r n e d a b o u t me."
A couple of m e m b e r s in the orthodontics only
g r o u p m e n t i o n e d that they had h a d m o r e than
one postgraduate student taking care of t h e m
and resented having "lost" their doctors. "I kind
of f o r m e d a b o n d with her, she was really sweet
and i looked forward to m e e t i n g with her every
month." In short, continuity of care a n d the
doctor-patient relationship were frequently rec o u n t e d facilitators to care. Positive personal
attributes used to describe their doctor or the
ideal health p r o v i d e r / t e a m m e m b e r s included:
"kind," "caring," "funny," and "knowledgeable."
Patients also discussed the i m p o r t a n c e of using
words that they could understand. Individuals
f r o m working class backgrounds and ethnic minority populations explicitly expressed their
c o n c e r n a b o u t "being taken seriously" and not
"being talked down to."
Regarding barriers to accepting care, several
health system issues were presented. Concern
a b o u t cleanliness was expressed across groups at
both sites. "Personally I am really picky, I like
everything clean. Sometimes I c o m e f r o m work
and really n e e d to go to the b a t h r o o m , but the
b a t h r o o m has nothing to do with the chair the
doctor works in but if is a dirty b a t h r o o m , then
I am thinking they do not really keep this place
clean." Complaints a b o u t the waiting time, the
length between appointments, securing financial coverage and t r e a t m e n t plans were discussed. The feelings a b o u t the e q u i p m e n t a n d
structure varied: "I like it simple, the bells a n d
whistles d o n ' t spin me." "I like the cost-I accept
that a school may have older stuff, but the price
is real good." It was c o m m o n l y believed and
valued that patients felt that the cost reduction
was a major factor in choosing the dental school.
Cost of care was a n o t h e r frequently m e n t i o n e d
potential barrier. O n e e m e r g i n g t h e m e in the
orthodontic only t r e a t m e n t groups was c o n c e r n
a b o u t the consequences of surgery, ie, temporary a n d / o r p e r m a n e n t sensory disturbances,
swelling and pain, and extent of facial change
("too m u c h " or "why bother").
In short, multiple issues are relevant in patients seeking care for dentofacial disharmony.
Patient needs, priorities, education, health values, and backgrounds are diverse and a p p e a r to
impact on decision making.
255
Discussion
Focus g r o u p data across groups and sites corroborate that t r e a t m e n t decisions are influenced by
several factors related to the doctor-patient interaction: having confidence in the doctor's ability, attributing positive personal characteristics
like caring, feeling that the doctor was conc e r n e d a b o u t tile patient's well-being, and educating the patient. 6,45,47,53
T h e emphasis on visual presentations of treatm e n t or knowing others who have had such
treaunent is likely related to reducing fear of
the unknown in the patient. Further, the importance of social support was often cited in patients accepting treatment. Realistic expectations
and positive support are important components
with theories on enhancing patient education as
well as acceptance and adherence with treatment
regimen. 54-56Yet such issues may be overlooked in
providing treaunent consultation a m o n g patients
with dentofacial disharmony and remain largely
unexplored when examining treatment decisions.
Both interview and focus g r o u p data underscore that access to enabling resources such as
third-party payors (insurance coverage) is a maj o r facilitator to decision making but not necessarily predictive of t r e a t m e n t decisions. Although increasing n u m b e r s of patients are
b e c o m i n g m o r e aware of orthodontic a n d / o r
orthognathic surgexT, health care policy is becoming increasingly stringent regarding coverage for what is d e e m e d "elective care. ''~3 For
instance, Medicaid is required to cover orthodontics for severely affected children in all
states; however, there are reports nationwide of
increased difficulty of third-party payor endorsem e n t for orthognathic treatment. Therefore,
conflict accessing care within our current health
care system is created.
Focus g r o u p and interview data support that
treatment-seeking behaviors were related largely
to social and aesthetic concerns that interfered
with p e o p l e ' s daily lives. 4 Despite the democratic
inclination to decline that m o r p h o l o g y is related
to o n e ' s happiness and success, facial attractiveness appears correlated to psychologic distress
and a strong underlying motivator for t r e a t m e n t
a m o n g dentofacial patients. 4~ Across groups and
sites, patients r e c o u n t e d emotionally painful interpersonal experiences (eg, teasing) supporting prior r e p o r t s ) 7,19-21 T h e results reinforce 2
256
B~vde~; Phillips, and Kaminetzky
previous reports that m o r e than 50% of the
patients felt "disadvantaged" socially by their appearance, and indicated that these feelings influenced their decision for treatment. 44,57 These
expressed concerns were rooted to earlier child
and adolescent experiences, thereby lending
credence to the notion that body image and
self-concept are f o r m u l a t e d early and can impact on future health-seeking behaviors. 41 In
short, decision-making is multifaceted involving
long-term concerns which are often abstract and
not readily apparent.
Interestingly, the findings support the readiness to change m o d e l ] as the issue of thinking
a b o u t and knowledge were only prerequisites for
accepting change (treatment). Resolution of
personal stressors (eg, graduation f r o m school,
financial security) was also associated with
health-seeking despite patients' longstanding issues a b o u t their facial disharmony. Therefore,
a p p r o p r i a t e "timing" for t r e a t m e n t includes thctors other than physical growth. 4,58
Although the sample size is small and no
generalizations can be made, the results highlight potential differences in access to care and
decision making across cultures. Given technological advancements in terms of t r e a t m e n t options as well as delivery of information (eg,
videoimaging), the interrelationships a m o n g decision making, ethnicity and socioeconomic status are unclear and warrant further consideration. Therefore, in addition to access to care,
effective c o m m u n i c a t i o n a n d delivery of information and care may be d e p e n d e n t on personality and cultural factors in the patients. This
notion had previously b e e n addressed in the
context of m o d e of delivery and style of presentation in oral surgery 5° and recently has received
attention in the context of health care beliefs
and utilization across cultures. 49 After viewing
her projected video image of before and potential after treatment, the response of the 48-yearold w o m a n from rural NC regarding her unawareness of "looking so bad" may reflect denial,
different values and priorities, a n d / o r low
knowledge. Regardless of the reason, this scenario underscores potential cultural factors in
patients. Such unresolved issues challenge orthodontists to investigate some of these m o r e subtle, social variables as dental professionals seek
to u n d e r s t a n d the decision making process in
patients with dentofacial disharmony.
Implications for the Clinician
Based on prior reports, clinical experience and
research findings f r o m the principle authors,
and the findings f r o m the focus groups, the
following implications for clinical practice
emerge:
• Accepting the diversity of patient concerns
without making value j u d g m e n t s , which inhibit patients f r o m sharing openly. Fostering
inhibition smwes as a barrier to care in patients. Allow patients to ask questions and encourage t h e m to discuss this matter with their
support systems.
• Providing patients with b a c k g r o u n d on the
philosophy of your health team, your experience, the facility's compliance with OSHA regulations, etc. Such information will address
potential concerns a b o u t the c o m p e t e n c e , experience, and cleanliness of the facility.
• I n f o r m i n g the patient a b o u t what can and
c a n n o t be achieved. Use of visual aides helps
most patients. Whenever possible, allow patients
to speak with others who have had such care.
Word of mouth and knowing others who have
had care typically reduces patient fear of the
unknown. Avoid the word "fix," as this implies
something is broken and may conjure or support unrealistic expectations in the patient.
• Screening patients for psychosocial distress,
using either standardized questionnaires which
can be scored with a c o m p u t e r p r o g r a m or
p e r h a p s developing or using health checklists
a n d / o r m e n t a l / h e a l t h questionnaires for patients to complete. Discussing the patient's
history of present concern is critical in understanding the patient's expectations and assuring the patient/family that you care and are
interested in them. Why now? Is an excellent
question to follow-up with their histories. Typically the patient who accepts t r e a t m e n t is
aware and can readily answer this question. If
the patient is unable to answer, it is a "red
flag" that should be addressed or at least
noted. If the patient's motivations are exclusively "other" directed, a d h e r e n c e can be
problematic. In such patients, the timing may
not be right. Some patients who return for
t r e a t m e n t r e p o r t that they did not wear their
retainer, etc, because of immaturity (got treatm e n t early because my parents t h o u g h t I
n e e d e d it). R e m e m b e r who is the identified
Decision Making" in Orthognathic Surgery
•
•
•
•
•
patient. The motivation o f the support system
(significant other, parent) is important, but
the patient's motivation is a better predictor of
adherence.
Checking patient understanding is essential. If
patients repeat questions, it is often helpful to
provide a written summary. In addition, pay
attention to the repeated questions (eg, cleanliness, costs) as such information may indicate
unresolved issues o f c o n c e r n to the patient.
The medical history form should query the
patient about obsessive thoughts and rituals,
history o f depression, anxiety, reasons for visits
to mental health practitioner, health care utilization, (eg, has sought other health care for
similar facial concerns within the past year?).
Asking to m e e t another person w h o may be
providing social support during the pre- and
postoperative period. Patients and their support systems may n e e d to be clear about their
expectations as well as facilitating the coordination o f efforts to ensure adherence with
treatment regimen and satisfaction with care.
In the case o f the individual w h o can not
identify a support system, this may be a "red
flag" regarding his or her psychologic development.
Developing a cadre of specialists who you can
consult with and to refer to w h e n addressing
the multiple associated features in patients
with dentofacial disharmony. In addition to
the m o r e obvious physical concerns (eg, otolaryngeal, etc), addressing psychosocial needs
and consulting with mental health professionals may be warranted.
Knowing your biases and preferences. Accepting and respecting patients' questions, concerns, histories, and motives are crucial in developing and tailoring the potential treatment
plans for every patient.
Providing written summary material is essential as clarity of explanations at the consultation visit may not be completely u n d e r s t o o d or
remembered. Such information also facilitates
patients dealing with insurance, employees,
other health providers, and the patients' significant others.
Acknowledgment
The authors thank Dr Diane Rekow for her support as well as
Amit Desai and Erin Kazmierski for their help in organizing
the focus groups.
257
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