INTRODUCTION
Prior to this study, information about or- thodontic treatment was usually de- scribed verbally to patients during screening and treatment in the UKM Dental Clinic. The purpose of the screening was to identify patients who were suitable to undergo orthodontic treatment. Initial consultation was also carried out to facilitate the patients in making informed decisions.
The patients who attended the screening were commonly teenagers and young adults of various ethnicity. Sometimes, adult patients attended the screening be- cause they require adjunctive treatment for periodontal disease or for restorative purposes.
Orthodontic screening was carried out by fifth year dental students, who were taught to convey important information regarding orthodontic treatment to the patients. Nevertheless, there was no clear guideline on what and how messages should be conveyed to the patient. Hence, the amount of information given was dependent on the individual clinician. This contributed to varying levels of retention among patients.
Therefore, concern was raised regard- ing the relationship of the mode of deli- very to the retention of information about orthodontic treatment. Since it was im- portant for patients to understand the various aspects of orthodontic treatment before they make their commitment to- wards it, it was crucial to evaluate the methods of communication which aid in the patients’ ability to recall essential in- formation about orthodontic treatment.
The aim of the study was to compare patients’ level of recall on verbal and written information. To achieve that, it was necessary to validate translation of the information leaflet, develop and test the questionnaire, as well as evaluate the patients’ ability to recall the information.
Locker (1989) stated effective commu- nication facilitates diagnosis making and treatment planning, and has a huge influence on the result of the treatment. Greater patient satisfaction with less patient litigation was reported. Sufficient understanding of the treatment process eased decision making and consent (Cannavina et al. 2000). Furthermore, effective communication and good understanding of the information given were important to achieve compliance and cooperation (Anderson & Freer 2005). Whether or not a patient was satisfied with the clinician was influenced by the information and consultation given and understood (Ley 1988).
In particular, patients and parents some- times faced difficulty in fully realizing the consequences and requirements of orthodontic treatment (Pratelli et al. 1996). Insufficient information about orthodontic treatment and lack of communication can cause lack of patient cooperation and premature termination of orthodontic treatment (Brattstrom et al. 1991).
Unfortunately, the amount of informa- tion received by the patients is generally perceived unsatisfactory (Newton 1995), even though information giving is noted as an important communication skill rele- vant to dentists. Successful communica- tion often involved the patient’s exposure to the messages, drawing attention to personal benefits, understanding the messages, accepting and retaining the messages (Ashford & Blinkhorn 1999).
The most common form of imparting dental knowledge is by verbal provision of information. Nevertheless, physical barriers and noise of handpieces in the clinic hinder effective verbal communication (Humphris & Ling 2000).
Additionally, in a multicultural society, communication difficulties frequently exist when the patients have limited understanding of the language use by the dentists (Williams et al. 1995). To over- come the language barrier, the use of interpreters is recommended. Non-verbal adjuncts such as dental health publica- tions may be used to enhance information communication, provided the pa- tients can read (Goldsmith et al. 2005).
A German study (Chatziandroni-Frey et al. 2000) found that briefing media such as demonstration models and leaflets were used primarily in the orthodontists’ waiting room and surgery. Space taking
media (video-films, computers) and books were rarely used. The advantages of information leaflets are non-intrusive, inexpensive and time neutral (Humphris & Field 2003). However, its effectiveness is dependent on its readability (Albert & Chadwick 1992; Roger 2000).
Also, a study found that patients who were motivated to read the leaflets showed significant improvement in know- ledge when compared to patients who were passively given the leaflets (O’Neill et al. 1996). Hence, it appeared that the provision of a leaflet alone gave limited benefits. Often it must be combined with verbal information.
Humphris & Ling (2000) suggested factors such as patient education level is not strongly related to the degree of re- call. However, studies focusing on reten- tion of orthodontic information had shown varying results. Parents’ educational level was marginally associated with their recall of risks, but their vocabulary level was significantly correlated with the number of reasons for treatment that they would recall (Baird & Kiyak 2003).
In one study, written, verbal and visual methods were tested but little difference was found (Thomson et al. 2001). Nevertheless, the study suggested verbal information should always be supple- mented by written and/ or visual information.
In contrast, another study found that the participants who were given information leaflets about orthodontic treatment per- formed poorer in recalling the informa- tion, when compared to participants who were given mind maps or acronyms (Newton & Thickett 2006).
Similarly, when a group of patients receiving computer-based visual information was compared to another group receiving information leaflets, the computer-based visual information was superior to information leaflets (Patel et al 2008).
MATERIALS AND METHODS
A questionnaire based study was carried out at the Faculty of Dentistry, Universiti Kebangsaan Malaysia (UKM). Ethics ap- proval was obtained from the UKM Re- search and Ethics Committee.
The subjects were recruited from the Orthodontic Screening Clinic at UKM Dental Polyclinic, over a period of 13 weeks. All patients aged 12 years and above were invited to participate in the study, regardless of gender or ethnicity.
Patients younger than 12 years old were not included due to their limited capability to comprehend the information. Instead, one parent for each young patient would take part in the research.
When the patients (or parents of young patients) arrived, they were given infor- mation sheets about this research. The patients (or parents of young patients) were informed on the benefits, risks, con- fidentiality involved and participation re- quired. After that, those who agreed to participate would have to complete and return the consent form. Those who de- clined would be interviewed briefly to find out the reason for not doing so.
Those who had worn braces before would be excluded because their baseline knowledge was more than the average population. Hence, this group of subjects tended to recall not only information given during the study, but also based on their experience and prior knowledge.
Initially, the study was intended to be a randomised control trial. However, during the pre-test, difficulty of randomisation was encountered. Even though patients could be selected randomly using a series of random numbers, overspill of informa- tion occurred due to close proximity of dental chairs. Therefore, convenient sam- pling was chosen in the end, in order to prevent overspill of information which would affect the final result. Patients would be called into one of the two rooms by the Dental Surgical Assistant, without any knowledge of this study. Hence, con- venient sampling was done accordingly. The orthodontic information leaflet was originally produced by the British Ortho- dontic Society. It contained pictorial and textual information, presented under headings designed in a ‘Question and Answer’ format on a multicoloured, six sec- tion, double-sided A4 sheet. Information included introduction, type of braces, pro- cedure involved, effects, risks and precautions, emergency appointments, retainers, and success rates. In the Malay- sian context, changes were done to the pictures, to portray Asian faces in order to maintain patients’ acceptability. A questionnaire was developed according to the ‘Question and Answer’ in the leaflet.
The leaflet and the questionnaire were translated into Malay and Chinese lan- guages. The translations were done by the researchers and validated by two qualified translators who had experience translating medical or dental publication materials. Then, validation was repeated by two Orthodontists who were native speakers of Malay and Chinese, respec- tively.
The questionnaires were pre-tested on 20 screening patients in the beginning of this study. There were no major adjustments apart from the layout and omission of redundant words. Both researchers were able to converse fluently in English, Malay and Chinese.
The content of both verbal and written information was exactly the same. The difference was solely the mode of communication. Each participant would be exposed to only ONE type of information, either verbally or in written form, according to their language preference. There were 39 participants in the Verbal group and 40 participants in the Written group.
Participants were exposed to the infor- mation; either verbally or in writing for 10 minutes. Participants were not allowed to ask additional questions. Clinicians and accompanying family or friends of the subjects were instructed not to provide help. Those who were given written information were prohibited from keeping the informa- tion leaflet after the exposure time. This was followed by a 15 minutes interval.
Self-administered questionnaires were distributed after the 15 minutes interval to assess subject’s short-term recall of the information presented. The questionnaire (Appendix 1) was divided into three parts: Part A was on sociodemographic data of the subject. Part B and C were closed questions to assess the subject’s level of recall.
Part B (Question 1 to 12) covered topics such as indications of orthodontic treat- ment, types of braces, duration of treat- ment, pain experience, frequency of ap- pointments, risks and precautions, emer- gency appointment, retainer, and success rate. Each question was followed by three choices, with only one correct answer. The subject was instructed to circle only one answer.
For Part C (Question 13), the subject could choose more than one answer. Such an arrangement was done because it was about the consequences of not taking care of the braces. This informa- tion was of great importance, yet fre- quently ignored by the patients under- going orthodontic treatment.
Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) version 15.0. Chi- square test was used to compare the pro- portion of correct responses for both ver-bal and written for each question.
RESULTS
A total of 89 subjects were approached for this study. However, eight of them refused to participate in this study. The commonest reason given was they did not have the time. Two subjects were excluded because they had orthodontic treatment before. The final numbers of subject were 79 in total.
The sociodemographic characteristics of the study sample were analysed (Ta- ble 1). The mean age for the verbal group was 20.67, and 21.60 for the written group.
A high level of correct responses was received. There were no significant dif- ferences among both groups for all the questions (Table 2 & Table 3).
Table 4 showed the information given in Malay, English and Chinese in both ver- bal and written forms.
In order to ascertain there was no influ- ence of the language on the results, analysis was done and results showed no significant differences. Therefore, the confounding factor of language used was insignificant (Table 5 & Table 6). DISCUSSION There were more females recruited in this study, as there were more females seeking orthodontic treatment. This is in accordance with a study which stated that girls were more concerned about their smiles and requested orthodontic treatment more often than boys (Chris- topherson et al. 2009). The samples comprised mostly of Malays, followed by Chinese and Indians.
Most of the subjects had Sijil Pelajaran Malaysia (SPM) qualification, followed by university graduates. The subjects with Ujian Penilaian Sekolah Rendah (UPSR) qualification came in third, and finally those with Penilaian Menengah Rendah (PMR) qualification.
All questions received a high proportion of correct answers. Thomson et al. (2001) suggested such findings could be due to the extra attentiveness of the subjects who were aware that they were taking part in a study.
Exception was observed for question 4, which asked whether orthodontic treat- ment is painful. Four subjects of the Ver- bal group and one subject of the Written group gave wrong answers, while two subjects of Written group failed to give any answer. In other words, 7 subjects (8.86%) failed to give the correct answer. This was due to the complexity of the question, which required subjects to think critically.
Question 10 received all correct an- swers from both groups. It was a ques- tion about what action to be taken if the orthodontic brace broke during treatment. The question and the correct answer were almost similar to the information given to the subjects. Less thinking was required and all subjects performed well in this question.
There were no significant differences between the Verbal and Written groups in all the questions. This finding con- firmed the results of previous study (Thomson et al. 2001).
The subject could choose more than one answer in Question 13. The question was about the risks of orthodontic treat- ment. There were a total of three correct answers. Most of the Verbal group (48.7%) gave three correct answers, but most of the Written group (52.5%) only managed to get two correct answers. This could probably be explained by the arrangement of information. Although the sequence of information given was similar for both groups, the written informa- tion had shown more clear-cut partition of information in different paragraphs. The subjects could recall answers from the last paragraph in order to answer this question. However, the risk of ‘permanent scarring’ could only be found in the ear- lier paragraph. Such arrangement could confuse the subjects with Written infor- mation, but not for the subjects with Ver- bal information. The continuity of the in- formation, and therefore subsequent un- derstanding and recall were in one-piece rather than in partition form. Hence, the succession of one thought to another would not be interrupted.
One of the differences between this study and earlier studies was the use of three languages in this study, whereas previous studies only used English (An- derson & Freer 2005; Newton & Thickett 2006; Patel et al. 2008). Therefore, it was mandatory to ascertain that the language used had minimal influence on the re- sults obtained. No significant difference was found between groups given infor- mation in different languages. This, com- pounded with the fact that all translated leaflets were validated by qualified inter- preters and orthodontists, excluded the possibility of the language used resulting in bias in this study.
When age, gender, ethnicity, method of information provision and other factors were analysed, Patel et al. (2008) found that only the method of information provision was significant. However, this study showed no significant difference in all the factors listed, even the method of infor- mation provision. Few limitations were recognized during the course of the study, which included sampling method and interval for recall. In order to prevent overspill of information, convenient sampling was selected, but this compromised randomisation of the study. Most of the previous studies compare both short- and long-term recall in order to reflect the memory of the subjects as time went by. However, the time limit of this study did not allow the long-term recall rate to be studied.
CONCLUSION
Most of the subjects were able to recall correctly the information that was given. However, no significant difference was found when comparing the level of recall between verbal and written information about orthodontic treatment.