Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 References 1. ProchaskaJO, DiClemente C, NorcrossJC. In search of how people change. Aaner Psych 1992;47:1102-1114. 2. Kenny DA, Depaulo BM. Do people know how others view them? An empirical and theoretical account. Psychol Bull 1993;114:145-161. 3. Nurminen L, Pietila T, Vinkka-Puhakka H. Motivation for and satisfaction with orthodontic-surgical treatment: A retrospective study of 28 patients. EurJ Orthod 1999; 21:79-87. 4. Phillips C, Broder HL, Bennett ME. Dentofacial disharmony: Motivations for seeking treatment. Internat J Adult Orthod Orthognath Surg 1997;12:7-15. 5. Forssell H, Finne K, Forssell K. Expectations and perceptions regarding treatment: A prospective study of patients undergoing orthognathic surge~T. Int J Adult Orthod Orthognath Surg 1998;13:107-113. 6. Nurminen L, Pietila T, Vinkka-Puhakka H. Motivation tbr and satisfaction with orthodontic-surgical treatment: A retrospective study of 28 patients. EurJ Orthod 1999; 21:79-87. 7. Zebrowitz IA. Reading Faces. Window to the soul? Boulder, CO: Westview Press, 1997. 8. Eagly AH, Ashmore RD, Makhijani MG, et al. What is beautiful is good, b u t . . . : A recta-analytic review of research on the physical attractiveness stereotype. Psychol Bull 1991;110:109-128. 9. Bull R, Rumsey N. The social psychology of facial appearance. New York, NY: Springer-Vertag, 1988. 10. Feingold A. Good-looking people are not what we think. Phychol Bull 1992;111:304-341. 11. Jackson LA. Physical appearance and gender: Sociobiological and sociocultural perspectives. Albany, NY: SUNY Press, 1992;83-124. 12. Dion K, Berscheid E. Physical attraction-peer perception among children. Sociometry 1974;37:1-2. 13. Mendelson BK, ~rhite DR, Mendelson MJ. Children's global self:-esteem predicted by body-esteem but not by weight. Perceptual and motor skills. 1995;80:97-98. 14. Barnett PC. Self-concept and selt:esteem in elementaiy school children. Psych in the Schools 1994;31:164-171. 15. Barnett NP, Smoll FI., Smith RE. EftiecLs of enhancing coach-athlete relationships on youth sport attrition. Sport Psych 1992;6:111-127. 16. Ommundsen Y, Vaglum P. Soccer competition anxiety and enjoyment in young boy players: The influence of perceived competence and significant others' emotional involvement. IntJ Sport Psych 1991;22:35-39. 17. Broder HL. Body image and facial malformation. Oral and Maxillofacial surgery in children and adolescents, in Kaban L (ed): Oral and Maxillofacial Surg Clin of NAm, Philadelphia, PA, Saunders, 1994, pp 89-100. 18. Fisher S, Cleveland SE. Body image and personality (2nd ed). New York, NY, Dover Publications, 1968. 19. Sheats RD, McGorray SP, Keeling SD, et al. OcclusaI traits and perception of orthodontic need in eighth grade students. Angle Orthod 1998;68:107-114. 20. Tung AW, Kiyak HA. Psychological influences on the timing of orthodontic treatment. AmJ Orthod Dentofhcial Orthop 1998;113:29-39. 21. Kilpelanien P, Phillips C, Tulloch JFC. Anterior tooth 258 Brode~, Phillips, and Kaminetzky position and motivation for early treatment. Angle Orthod 1993;63:171-174. 22. Berscheid E, Walster E, Bohrnstedt G. The happy American body: A survey report. Psych Today 1973;7:119-131. 23. Arndt EM, Lefebvre TA, Niec A, et al. Beauty and the eye of the beholder: Social consequences and personal adjustments for facial patients. BrJ Plastic Surg 1986;39:81-84. 24. Shaw WC. The influence of children's dentofacial appearance on their social attractiveness as judged by peers and lay adults. ,Mn J Orthod 1981;79:39-41. 25. Shaw WC, Rees G, Dawe M, et al. The influence on dentofacial appearance on the social attractiveness of young adults. Am J Orthod 1985;87:21-26. 26. Rubin KH, Stewart SL. Social withdrawal, in Mash EJ, Barkley RA (eds): Child psychopathology. NewYork, NY, Guilford Press, 1996, pp 277-307. 27. Parker JG, Aher SR. Peer relations and later personal adjustment. Psychol Bull 1987;102:357-389. 28. Cash T. Physical appearance and mental health, in Graham A, Lligman A (eds): The Psychology of Cosmetic Treatments. New York, NY, Praeger, 1985. 29. Epkins CC. Cognitive specificity and aflective confounding in social anxiety and dysphoria in children. J Psychopathol Behav Assess 1996;18:83-101. 30. SanzJ, Avia MD. Cognitive specificity in social anxiety and depression: Self-statements, self-tocused attention, and dysfimctional attitudes. J Soc Clin Psych 1994;13:105-137. 31. LaGreca AM, Stone WL. Social anxiety scale for children-revised: Factor structure and concurrent validity. J Clin Child Psych 1993;22:17-27. 32. Nelson C. Satisfaction with Orthodontic Care. Thesis, University of North Carolina, Chapel Hill, NC, 1998. 33. Proffit WR, Field HW, Moray LJ. Prevalence of malocclusion and orthodontic treatment need in the United States: Estimates from the N-HANES III survey, lnt J Adult Orthod Orthogn Surg 1998;13:97-106. 34. Johnson PD, Cohen DA, Aiosa L, et al. Attitudes and compliance of pre-adolescent children during early treatment of Class II malocclusion. Med Image Analysis 1998;1:20-28. 35. Richmond S, Daniels CP. Internet comparisons of professional assessments in orthodontics: Part l-Treatment need. Am J Orthod Dentofacial Orthop 1998;113:180185 (published erratum appears in Am J Orthod Dentofacial Orthop 1998;113:591). 36. Barbosa ALB, Marcantonio EM, Barbosa CEM, et al. Psychological evaluation of patients scheduled for orthognathic surgery.J Nihon Univ Sch Dent 1993;35:1-9. 37. Mayo KH, Vig KD, Vig PS, et al. Attitude variables of dentofacial defolTnity patients: Demographic characteristics and associations. J Oial Maxillofac Surg 1991;49:594602. 38. Garvill J, Garvill H, Kahnberg ICE, et al. Psychological factors in orthognathic surgery. J Craniomaxillofac Surg 1992;20:28-33. 39. Pruzinsky T, Cash TF. Medical interventions for the enhancement of adolescents' physical appearance: Implications for social competence, in Gulotta TP, Adams GR, Montemajor R (eds) : Advances in adolescent development, vol III. The promotion of social competence in adolescence. Newbury Park, N], Sage, 1990. 40. Fox K. Physical education and development of self-es- 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. teem in children, in Armstrong N (ed): New Directions in Physical Education II. Towards a National Curriculum. Champaign, IL, Human Kinetics, 1992. Marsh HW, Barnes J, Cairns L, Tidman M. The Self Description Questionnaire (SDQ): Age effects in the structure and level of self-concept ratings of preadolescent children. J Educational Psychology 1984;76: 940-956. Anshel MH, Muller D, Owens VL. Effect of a sports camp experience on the multidimensional concepts of boys. Percept Mot Skills 1986;63:363-369. Phillips C, Bennett ME, Broder HE. Dentofacial disharmony: Psychological status of patients seeking treatment consultation. Angle Orthod 1998;68:547-556. Bandura A. Human agency in social cognitive theory. Amer Psych 1989;44:1175-1184. Betelho RJ, Skinner H. Motivating change in health behavior. Print Care 1995;22:565-589. American Psychiatric Association. Diagnostic and Statistical Manuel of Mental Disorders, DSM-IV, (4th ed). Washington, DC: American Psychiatric Press Inc, 1994; 466-669. Di Matteo MR. A social-psychological analysis of physician-patient rapport: Toward a science of the art of medicine. J Soc Issues 1979;35:12-33. Geist P. Negotiating cultural understanding in health care communication, in Samovar LA, Porter RE (eds): Intercultural communication, 8th ed. Belmont, C,A, Wadsworth Publishing Co, 1997, pp 340-348. Auerbach SM, Martelli MF, Mercuri LG. Anxiety, information, interpersonal impacts, and adjustment to a stressful healthcare situation.J Pers Soc Psychol 1993;44: 1284-1296. Chambers DW, Abrams RG. Persuasion and motivation. Dental Communication. Norwalk, CT, AppletonCentury-Crofts, 1986, pp 89-102. Morgan DL. Successful focus groups: Advancing the state of art. NewbmT Park, NJ, Sage Pubs, 1993. Krueger RA. Focus groups: A practical guide for applied research. Thousand Oaks, CA, Sage, 1994. Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that predict patient satisfaction orthodontist-patient relationship, and patient adherence in orthodontic treatment. Am J Orthod Dentofacial Orthop 1996;110:370-377. Becker MH. Sociobehavioral determinants of compliance with health and medical care recommendations. Medical Care 1975;13:10-24. Leventhal H. Theories of compliance, and tm~aing necessities into preferences: Application to adolescent health action, in Krasnegor NA, Epstein L, Johnson SB, Yaffe SJ (eds): Developmental aspects of health compliance beha~ ior. Hillsdale, NJ, L. Erlbaum Associates, 1993;91-124. Revenson TA, Majerovitz SD. The effects of chronic illness on the spouse: Social resources as stress buffers. Arthritis Care and Research 1991;4:63-72. Hugo B, Becket S, Witt E. Assessment of the combined orthodontic-surgical treatment front the patient's point of view. J Orofacial Orthop 1996;57:88-101. van Steenbergen E, Litt MD, Nanda R. Presurgical satisfaction with facial appearance in orthognathic surgery patients. AmJ Orthod Dento~tcial Orthop 1996;109:653-659.