Non-compliant patients are patients who are not following their recommended wear schedule (at least 22-hours a day). Compliance is the most common reason things go off track during treatment.
If you break down the subject of non-compliant patients a bit further, you can see there are two main types:
- The deliberately non-compliant patient
- The inadvertent non-compliant patient
With clear aligners the deliberately non-complaint patient may be less common. But differentiating the two may help you to understand them better. Here are some tips on this which don't promise to resolve the issue, but may help us to better motivate the non-compliant patients.
Patients come up with any number of reasons for not wearing their aligners for 22-hours a day, however here are some of the main reasons:
- Lack of education on the basics, importance of and reasons behind the specific instructions
- The aligners are uncomfortable, embarrassing, interfering with work or life conditions
- Patient is forgetful
Understanding the specific issue for that patient can help you both to come up with workable solutions.
Below are our recommended solutions to patient non-compliance:
- Educating patients in their initial visit on the importance of wearing their aligners at least 22-hours a day. We suggest going over osteoclastic & osteoblastic activity with your patients and/or showing them the instructional video "How Clear Aligners Work" in their very first visit so they know what is expected of them to get optimal results in their treatment. And a couple more references for them are:
If you find that your patient has been non-compliant in the middle of treatment, you can remind them of the necessity of wearing their aligners 22-hours a day and re-educate them on this.
Having the patient repeat your instructions back to you can help to ensure that they have been accurately understood.
2. Involve the patient in every step
- Involving the patient from the initial consult, to records, to appointments and retention with details of the procedures and a timeline can help to enlist cooperation.
- Set goals that patients understand (the setup is a good visualization of the final goals) and establish mini-goals along the way (for example, we have finished closing spaces, we are now half done, we are in the finishing steps, etc)
3. Communicate and support
- Be honest when non-compliance is suspected and remind patients without scolding them. For example "I'd like to see you finished by ___ date, can we work together to make this happen?"
- Encourage patients and share your enthusiasm with their treatment—e.g., "Your teeth are moving like that of a teenager. Keep up the good work!”
- Let them know you care. Listen to patients. Sometimes they have life events or situations where aligner wear may not be the highest priority. Let them know you are there for them no matter what and you will bend over backwards to help them achieve their goal of a beautiful smile.
- Show the patient what their teeth will look like if they wear their aligners properly. Use the final image in the treatment setup to re-inspire them towards accomplishing their original goal in starting treatment.
- All documentation is important as is true in most industries. For non-compliant patients it is especially good practice to document throughout treatment, as you may need this later.
Key notes for documentation:
- Missed appointments
- Patient comes to appointment without their aligners on or with them
- Mysteriously "clean" aligners (2 or 3 weeks of wear on an aligner will show)
- Aligners are still tight after 2-3 weeks of wear (should be loose, easy to insert and remove).
5. Adjust treatment as needed
- Extend the time the patient has to wear their current aligners by a couple weeks. They'll learn that the more diligently they wear their aligners, the less time they have to be in treatment.
- Try backtracking.
- Remind the patient that there are no refunds. Why pay all that money and not get the results they want?
Here are a few suggestions on how to determine if your patient has been wearing their aligner properly.
- Your patient comes to the appointment not wearing their current aligner. This is a big red flag. If they aren't wearing their current trays when they arrive at their appointment, your patient may not be wearing their aligner properly.
- Aligner is tight after 2 weeks of wear, or is still hard to remove or insert. After two weeks of wear, the aligners should sit loose on their respective arches and should be easily removable.
- A clean aligner is a neglected aligner. Anything that gets put in a human mouth for two weeks is not going to come back out looking clean. If your patient has suspiciously clean trays when they come to their appointment, it's a good bet they haven't been wearing them.
- Frequently missed or rescheduled appointments. They're probably not wearing their aligners as recommended.
- Spaces between teeth made by IPR don't close when expected. When you look at your treatment plan and gaps between teeth don't decrease as they should, your patient probably isn't wearing their aligners properly. There are compliance checkpoints in your treatment plans telling you exactly when to check for closed gaps.
- Aligners gradually fit worse as treatment progresses. If the fit of the aligners progressively worsens over time, your patient might not be wearing their trays as prescribed.
We’ve included a helpful article from our Chief Technology Officer, Dr. James Mah, on his three keys for ensuring compliance:
Motivation for aligner patients is most often verbal praise for a job well done. In my office, we provide 'wooden nickel tokens' as rewards for cooperation. Patients can trade the tokens for gift certificates and other rewards. Additionally, we remind them that orthodontics is serious business and continually remind them that the result will be well worth the effort.
In situations where compliance is lacking, we often need to have a frank discussion with the patient. Even before treatment begins, I let patients know that treatment success is a team effort between them and my office. I simply state that 50% of their success is up to me and the other 50% is up to them. If they don't live up to their end, we have to accept more compromises. In addition, decreased wear often results in no net tooth movement. When the aligner is worn, teeth begin to move toward the correction but when it is removed the tooth moves back to its original position. I ask patients "Why pay me to rock your teeth back and forth?"
On the topic of verification, first I warn them from the first aligner on that we'll be checking wear "under the microscope" and if I find it lacking, I'll be brutally honest with them. This makes it easier when I come down hard on a patient for non-compliance. I can then say 'I told you from the beginning that I'll be checking.'"
Finally, if you're looking for a few more tips on how to discreetly verify whether a patient is wearing their aligner, keep the following things in mind:
- Well worn aligners fit loosely and will almost fall out on their own. If there are any tight spots or binding, you can be clear the aligner has not been worn enough.
- Ask patients to bring in their current aligners. A lot of non-compliant patients will "forget" their aligners at home and encourage their clinician to dispense the next set.
- Well worn aligners will feature discoloration and the occlusal surfaces will show signs of wear.
- The next aligner will fit tightly, but won't be too difficult to get in.