Exploring Young People's Perspectives of Fixed Orthodontic Treatment Sarah Joanna Longstaff

346 Pages·2017·1.89 MB·English

Exploring Young People’s Perspectives of Fixed Orthodontic
Treatment

By:

Sarah Joanna Longstaff

A thesis submitted in partial fulfilment of the requirements for the degree of
Doctor of Philosophy

The University of Sheffield
Faculty of Medicine Dentistry and Health.
School of Clinical Dentistry

April 2017
Contents

Acknowledgements ......................................................................................... 5
Abstract............................................................................................................. 6
Chapter 1: Introduction ................................................................................... 8
1.1 Background .............................................................................................. 8
1.1.1 Orthodontic Treatment ...................................................................... 8
1.1.2 Why is it Important to Understand Young People’s Perspectives?. 9
1.1.3 My Approach ................................................................................... 11
1.2 Aim and Objectives of the Study ........................................................... 11
1.3 Structure of the Thesis .......................................................................... 13
1.3.1 Analysis Chapters ........................................................................... 15
Chapter 2: Literature Review ....................................................................... 18
2.1 Introduction ............................................................................................ 18
2.2 The History of Orthodontics ................................................................... 18
2.3 Research Methods ................................................................................. 23
2.4 The Position of Children in Society ....................................................... 26
2.5 Approaches used in Research with Children ........................................ 29
2.7 Orthodontic Literature ............................................................................ 33
2.7.1 Sociology of Orthodontics ............................................................... 42
2.8 Further Literature ................................................................................... 43
2.9 Conclusion ............................................................................................. 45
Chapter 3: Methods ....................................................................................... 48
3.1 Introduction ............................................................................................ 48
3.2 My Training as a Researcher ................................................................ 49
3.3 Data Collection....................................................................................... 51
3.3.1 Methods of Data Collection ............................................................ 51
3.3.2 Addressing the Power Imbalance................................................... 52
3.3.3 Longitudinal Data Collection ........................................................... 56
3.3.4 Interviews ........................................................................................ 58
3.3.5 Video ............................................................................................... 63
3.3.6 Alternative Approaches................................................................... 70
3.3.7 Chronology of Collecting Data ........................................................ 71
3.3.8 Research Setting ............................................................................ 75
3.3.9 Safety .............................................................................................. 76
3.3.10 Data Recording and Management ............................................... 76
3.4 Ethics and Approval ............................................................................... 77
3.5 Access and Recruiting the Sample ....................................................... 78
3.5.1 Inclusion criteria .............................................................................. 79
3.5.2 Exclusion criteria ............................................................................. 80
3.5.3 Chronology of Events in Recruitment............................................. 81
3.5.4 Incentives ........................................................................................ 83
3.5.5 My Role ........................................................................................... 84
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3.5.6 Challenges to Recruitment ............................................................. 87
3.5.7 Access to Participants in Practice .................................................. 91
3.5.8 Consent ........................................................................................... 91
3.5.9 Sample ............................................................................................ 93
3.6 Data Analysis ......................................................................................... 94
3.6.1 Thematic Analysis ........................................................................... 95
3.6.2 Case Study Analysis ....................................................................... 98
3.6.3 Narrative Analysis ......................................................................... 100
3.7 Dropouts ............................................................................................... 101
3.8 Details about Participants .................................................................... 104
Chapter 4: Being a Little Kid, to a Teenager and an Adult .................... 105
4.1 Introduction .......................................................................................... 105
4.2 Literature .............................................................................................. 105
4.3 Jasmin .................................................................................................. 110
4.3.1 Case Study Conclusion ................................................................ 130
4.4 Other Young People ............................................................................ 132
4.4.1 The Brace as a Rite of Passage................................................... 132
4.4.2 Ambivalence About the Future ..................................................... 139
4.4.3 Fateful Moments ........................................................................... 143
4.5 Conclusion ........................................................................................... 147
Chapter 5: I Just Want to See What I Look Like with Straight Teeth.... 149
5.1 Introduction .......................................................................................... 149
5.2 Literature .............................................................................................. 149
5.2.1 The Importance of Appearance .................................................... 149
5.2.2 The Significance of the Appearance to a Child............................ 150
5.2.3 The Body as a Flexible Entity ....................................................... 151
5.2.4 Appearance of the Mouth ............................................................. 153
5.2.5 Influences on our Opinions About our Appearance ..................... 156
5.2.6 Summary of Literature .................................................................. 163
5.3 Case Studies ........................................................................................ 164
5.4 Ashley................................................................................................... 165
5.4.1 Dissatisfaction with the Appearance ............................................ 165
5.4.2 The Focus of the Dislike ............................................................... 170
5.4.3 Wanting Perfection........................................................................ 171
5.4.4 Appearance of the Brace .............................................................. 174
5.5 Matthew ................................................................................................ 177
5.5.1 Motivation for Treatment ............................................................... 177
5.5.2 Not Wanting Perfection ................................................................. 180
5.5.3 Appearance of the Brace .............................................................. 183
5.6 Madison ................................................................................................ 185
5.6.1 Dissatisfaction with the Appearance ............................................ 185
5.6.2 Motivation for Treatment ............................................................... 187
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5.6.3 Appearance of the Brace .............................................................. 191
5.7 Conclusion ........................................................................................... 193
Chapter 6: How Braces Feel....................................................................... 195
6.1 Introduction .......................................................................................... 195
6.2 Literature .............................................................................................. 195
6.2.1 Orthodontic Pain ........................................................................... 195
6.2.2 Different Approaches to Examining Pain Narratives ................... 196
6.2.3 Cultural Influences on Pain Accounts .......................................... 200
6.2.4 Relationship with a Medical Device .............................................. 201
6.2.3 Summary of Literature .................................................................. 203
6.3 Sensation of the Braces ...................................................................... 203
6.4 Reassigning the Feeling of Normal ..................................................... 210
6.5 Acceptance that Braces Cause Pain .................................................. 221
6.6 Pain is not Normal and does Affect Life .............................................. 227
6.7 How Young People Narrated their Pain Experiences ........................ 236
6.8 Conclusion ........................................................................................... 243
Chapter 7: Sharing the Treatment Experience ........................................ 245
7.1 Introduction .......................................................................................... 245
7.2 Literature .............................................................................................. 246
7.2.1 Summary of Literature .................................................................. 249
7.3 Eleanor ................................................................................................. 249
7.3.1 Mum’s Feelings about Dentistry ................................................... 251
7.3.2 Eleanor’s Resilience and Independence...................................... 253
7.3.3 Eleanor’s Views on the Process of Treatment ............................. 257
7.3.4 Changes Longitudinally ................................................................ 264
7.4 The Relational Aspect of Treatment ................................................... 269
7.4.1 Treatment Experience Shared with Friends ................................ 277
7.5 Conclusion ........................................................................................... 281
Chapter 8: Conclusion ................................................................................ 283
8.1 Introduction .......................................................................................... 283
8.2. Summary of my Contribution .............................................................. 284
8.2.1 The Importance of the Brace ........................................................ 284
8.2.2 How Young People Interpret Appearance ................................... 287
8.2.3 How Young People are Embedded in Relationships ................... 290
8.2.4 Physical Feeling of the Brace ....................................................... 293
8.2.5 The Significance of Gender .......................................................... 295
8.2.6 Moving the Orthodontic Literature Forward ................................. 297
8.3 Practical Considerations – What Clinicians can Learn ....................... 298
8.3.1 The Significance of Having a Brace ............................................. 299
8.3.2 Appearance ................................................................................... 301
8.3.3 The Sensation of the Brace and Pain .......................................... 301
8.3.4 Advice Provided ............................................................................ 303
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8.3.5 Power Imbalance .......................................................................... 305
8.4. Reflections on the Study..................................................................... 305
8.4.1 Reflections on the methodology ................................................... 306
8.4.2 Reflecting on my Role ................................................................... 310
8.5 Summary of Conclusion ...................................................................... 313
8.6 Further work ......................................................................................... 314
8.6.1 The Young People’s Level of Involvement................................... 314
8.6.2 Data Collection .............................................................................. 315
8.6.3 Areas of Interest ............................................................................ 316
References.................................................................................................... 318
Appendix 1 Parent/ Guardian Information Sheet .................................... 330
Appendix 2 Participant Assent Form ........................................................ 334
Appendix 3 Consent Form ......................................................................... 337
Appendix 4 Participant Information Sheet ............................................... 340
Appendix 5 Topic Guide for First Interviews ........................................... 343
Appendix 6 Topic Guide for Final Interviews .......................................... 344
Appendix 7 Topic Guide for Mid-Treatment Interviews.......................... 345

80,180 words

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Acknowledgements
I carried out this study on a part-time basis alongside doing specialist training
in orthodontics and my post as a Clinical Lecturer. For this reason, it has
been a long journey, but one which I have learnt a huge amount from, and I
have thoroughly enjoyed. First I would like to thank my supervisors. Philip
Benson for his long-standing patience, guidance and for always standing by
me. Thank you also to Katherine Davies for her enthusiasm and
encouragement which were regular sources of motivation for me. Thank you
to my interim supervisors who have helped me along the way, Allison James
and Kate Weiner, for their helpful and supportive words.

I would also like to thank my friends and family who have supported me
throughout. In particular, I am eternally grateful to my mum, I could not have
completed this without her unwavering support and encouragement at every
stage. Thank you also to my fiancé Ben, for being so understanding without
question.

Finally I would like to thank all the participants who gave their time to talk to
me about their experiences, without their openness, this study would not
have been possible.

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Abstract
Introduction
This thesis describes a qualitative study which explored young people’s
perspectives of having a brace throughout their fixed orthodontic treatment.
Fifteen young people were recruited from the Orthodontic Department at
Charles Clifford Dental Hospital and a specialist orthodontic practice in
Sheffield.

Methods
Qualitative in-depth interviews were carried out with each of the young
people before they had their brace fitted, throughout their orthodontic
treatment, and after they had had their brace removed. In addition to
collecting data using in-depth interviews, participants had the option to use a
video camera to record video diaries. This was to enable the young people to
describe their experiences of having a brace at times that were relevant to
them. The interview data and video data were analysed together using
thematic analysis, case study analysis and narrative analysis.

Results
The findings of this study contribute to the existing knowledge base by
providing an understanding of the temporal experiences of having a brace.
Some of the young people regarded having a brace as a rite of passage
through adolescence. In addition, having the brace removed, together with
the educational transition was a symbolic event in their youth transition. The
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appearance of the teeth was the primary motivating factor for the young
people undergoing orthodontic treatment, and it carried more significance
than simply improving the appearance; it reflected their identity. Opinions
about appearance were influenced by gender, peers, and images seen in the
media. The sensation of the brace changed during treatment. All young
people became used to the brace, although some built a bond with the
appliance. Some young people shared their experience of having a brace
with people around them and the relationships they were embedded in,
influenced how they experienced treatment.

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Chapter 1: Introduction
1.1 Background
In this thesis I explore young people’s perspectives of fixed orthodontic
treatment. I have used qualitative methodology because I wanted to
understand young people’s views. In this Introduction I will start by explaining
what orthodontic treatment is. I will then outline why I think it is important to
understand young people’s perspectives of orthodontic treatment, and the
ontological position, from which I approached this study. Following this, I will
describe the aim of the thesis and research questions I felt needed to be
addressed. Finally, I will outline the structure of the thesis.

1.1.1 Orthodontic Treatment
Orthodontics is a branch of dentistry, which specialises in improving the
position of the teeth using a brace. Braces are fitted for several reasons, for
example to correct the bite, to accommodate unerupted or impacted teeth or
to improve the alignment by resolving crowding or closing spaces. Treatment
is carried out to improve the function of the dentition, the aesthetics, or the
long-term prognosis of the teeth. There are several different types of brace
although the majority of patients are treated with a fixed appliance because it
allows the greatest control of tooth movement. The fixed appliance is a brace
that is attached to the teeth, it needs adjusting by the orthodontist every six
to eight weeks and treatment usually takes around two years.

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In England and Wales, every year, over 200,000 children and teenagers
undergo orthodontic treatment on the National Health Service (NHS) (British
Orthodontic Society, 2016). These are patients who were assessed, and
based on the severity of their malocclusion, were judged to qualify for
treatment funded by the NHS. In addition to these patients, some young
people, and adults undergo orthodontic treatment on a private basis. Despite
so many young people undergoing fixed orthodontic treatment, research has
not been carried out exploring their lived experiences. It is thought that the
demand for orthodontic treatment is rising among both adults and children.
Data from the decennial national children’s dental health surveys reflect this;
from the first survey in 1983, there has been a gradual rise in the number of
children undergoing orthodontic treatment. For example, in 2003, fourteen
percent of fifteen year olds were wearing an orthodontic appliance, whereas,
in 2013, this figure rose to eighteen percent (Chestnutt et al., 2006, HSCIC,
2015 Table 4.35). The reason for this increase in the demand for, and uptake
of orthodontic treatment has not been examined.

1.1.2 Why is it Important to Understand Young People’s
Perspectives?
In orthodontics, the majority of research is quantitative in nature, i.e.
collecting data that is amenable to statistical analysis, for example,
comparing different types of orthodontic treatment. The focus of orthodontic
research being on the modes of treatment, has allowed clinicians to practice
an evidence-based approach, to ensure we are providing the most efficient
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