Noncompliant patients

From: Utley3 <>
Subject: noncompliant patients
Date: Monday, February 28, 2011, 8:02 AM


I just finished reading an article in The Bulletin about treating noncompliant patients.  The authors suggested that the orthodontist was too agreeable with the parents in allowing treatment to continue despite his poor oral hygiene.  They note that if the orthodontist would have terminated treatment after “a few months”, the parents would have been more accepting of his decision to terminate treatment.  It seems to me that we are required to be clairvoyant in situations like this.  I have fought the oral hygiene battle for many years.  Most of the time, I win, but not always.  If I were to have terminated treatment after just a few months on every poor brusher, many patients would not have their malocclusion corrected today.  Besides, in the vast majority of cases I have treated with poor oral hygiene, the worst “damage” can be repaired with conservative measures (enamel microabrasion, composite restorations…etc)  I think that is better than leaving someone with a 10 mm overjet with no decalcifications.  It is obvious in hindsight what the orthodontist in the article should have done, but we have to make judgements in the present.  Clearly, in a small percentage of patients, treatment should be terminated, but the guidelines in this article would apply to a significant percentage of my patients.
Kevin C. Utley


3 responses to “Noncompliant patients

  1. Jayaram Mailankody

    Non-compliance, is a issue requiring largely case specific, tailored methods of management. However, some general guidelines are worth considering:
    1. Hasty starts end up in dissatisfaction. It is better to have optimum oral health and home care established, before starting treatment, taking periodontist, pedodontist, or hygienist help in advance, if necessary. Many a times ‘heroism’ leads to problem. Thinking before jumping is better.
    2. Once started, four degrees of management(the Indian way: ‘Sama, Dana, Bhedha and Danda’) strategies may be deployed. a)General advicing and appraising continuously, b) Positive reinforcements by verbal compliments and appreciations, c) Reminding the negative side of the issue, hazards of bad oral hygiene, negating the orthodontic progress and results, d) the ultimate punitive action of termination/surgery etc.
    3. Effective ‘Mind Management Methods’ have to be devised and deployed. Adding a fourth ‘M'(Mind) to the three ‘Ms'(Graber) is highly desirable.
    Jayaram Mailankody

  2. I agree that each patients noncompliance needs to be individually managed, and the techniques you describe are perfectly valid. My point was that in a small number of cases, compliance will not happen no matter what management techniques we employ. In the case of poor oral hygiene, the consequences are decalcifications, gingival inflammation…etc. I don’t think any of us is perfectly able to predict which poor brushers are going to turn it around, so sometimes consequences happen. The article I referenced earlier implied that orthodontists are not using good judgement to allow poor oral hygiene to continue for more than a “few months”. In my practice that is about 2-3 visits. I don’t think I am practicing recklessly from a risk management standpoint by not terminating treatment after only 2 consecutive poor oral hygiene evaluations.

    Kevin C. Utley

  3. Just following up on my post. What are other offices policies/procedures for determining when to terminate treatment for poor oral hygiene? Does anyone routinely terminate treatment after just “a few months” as was recommended in the referenced article?

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