Compliance with removable orthodontic appliances and adjuncts: A systematic review and meta-analysis

INTRODUCTION:
The primary aims of this systematic review were to assess objective levels of wear of removable orthodontic appliances and components vs both stipulated and self-reported levels. We also aimed to consider patient experiences and the effectiveness of interventions geared at enhancing compliance.
METHODS:
Electronic databases and reference lists of relevant studies were searched with no language restriction (PROSPERO: CRD42016036059). Randomized and nonrandomized controlled trials, prospective cohort studies, case series, qualitative and mixed-methods studies objectively assessing compliance levels were identified. The quality of the studies was assessed using the Cochrane Collaboration's risk of bias tool, risk of bias in non-randomized studies of interventions (ROBINS-I), or mixed-methods appraisal tool based on their design.
RESULTS:
Of 4269 records, 80 full texts were obtained, with 24 studies meeting the selection criteria. Of these, 11 were included in the quantitative synthesis. A weighted estimate of objectively assessed compliance levels in relation to stipulated wear time was calculated with the discrepancy highest in the headgear group (5.81 hours per day, 95% confidence interval, 4.98, 6.64) based on 6 studies. The mean discrepancy between self-reported and objectively assessed headgear wear was 5.02 hours per day (95% confidence interval, 3.64, 6.40). Compliance level was not directly related to appliance type (P = 0.211). Thematic synthesis was not undertaken because of the limited number of qualitative studies.
CONCLUSIONS:
Compliance with removable orthodontic appliances and adjuncts is suboptimal, and patients routinely overestimate duration of wear. Techniques for improving compliance have promise but require further evaluation in high-level research.