Dentofacial Aesthetics and Quality of Life

Dentofacial Aesthetics and Quality of Life Ulrich Klages and Andrej Zentner This article reviews, from the socio-psychological perspective on physical attractiveness, recent research on the psychosocial impacts of dental aesthetics. Research on personal impression forming suggests that visual perceptions of detrimental dental conditions might lead to conclusions about social impairments of the target person. Consumers conform considerably with professional assessment of dental aesthetics. Psychosocial impacts of dental appearance in childhood include teasing by peers. Existing research suggests that dental aesthetics contributes to psychosocial well-being of both children and adults. The concept of public self-consciousness is introduced for explaining differences in subjective psychosocial impacts of malocclusion. A promising research direction is the investigation of the relationship between dental aesthetics and oral health behavior, and further development and application of dental aesthetics-related quality-of-life measures is warranted. In addition a description of the behavioral signs of overconcern with dental aesthetics is given to facilitate its recognition and professional psychological attention. (Semin Orthod 2007;13:104-115.) © 2007 Elsevier Inc. All rights reserved.

ecently, dental aesthetics and its psychological implications have received growing interest in orthodontic research. Excellent extensive reviews have been published by Albino and coworkers1 15 years ago, by Giddon2 10 years ago, and most recently by Nevin and Keim.3 The present article focuses on the relevant research of the relationship between aesthetics and its psychosocial impacts, which is a variant of the socio-psychological attractiveness research. It is of considerable interest to explore the relationships between the theoretical concepts on one hand, and the research data on physical attractiveness in general and on dental aesthetics in particular on the other.

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Lecturer and Clinical Psychologist, School of Dentistry, University of Mainz, Mainz, Germany. Professor and Chairman, Department of Orthodontics, Academic Centre for Dentistry Amsterdam ACTA, Amsterdam, The Netherlands. Address correspondence to Andrej Zentner, BDS, PhD, Dr habil, FDSRCS, Department of Orthodontics, Academic Centre for Dentistry Amsterdam, Louwesweg 1, 1066 Amsterdam EA, The Netherlands. Phone: 31 (0)20 5188 524; E-mail: [email protected] © 2007 Elsevier Inc. All rights reserved. 1073-8746/07/1302-0$30.00/0 doi:10.1053/j.sodo.2007.03.006

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Six issues will be addressed in the present review. First, expectations of psychosocial traits in an individual with a particular level of dental aesthetics will be discussed under the heading of “impression forming.” They are important because they might reflect memories of actual observations or of cultural standards imposed on all members of a society. Moreover, they might have an influence on the self-concept of the individuals concerned. The views and perceptions of professionals and consumers will then be discussed. They are important in particular for understanding the views of our patients. The third issue will be the relationship between the dental aesthetics and individual psychosocial well-being. Following this the concept of public self-consciousness will be presented in an attempt to explain individual differences in the psychosocial impacts of dental aesthetics. A new perspective will be presented by discussing recent studies on the relationship between dental aesthetics and oral health behavior and attitudes, serving as the fifth topic of the present review. Finally, the diagnostic and treatment implications of problem patients with exaggerated impairment

Seminars in Orthodontics, Vol 13, No 2 (June), 2007: pp 104-115

Dentofacial Aesthetics and Quality of Life

in their quality of life caused by unfavorable dental appearance will be described.

Impression Forming and Psychosocial Impacts of Bodily Attractiveness General Physical Attractiveness Socio-psychological research on impression forming about physically attractive versus nonattractive persons suggests a halo effect, which was originally described as “what is beautiful is good.”4 It is assumed that attractive individuals are perceived as possessing desirable personality characteristics and social success. The social cognition theory hypothesizes that individuals develop knowledge structures, the so-called stereotypes, to make sense of other people’s behavior. Expectations about personality traits of members of a specific subgroup help to direct observer’s own behaviors.5 The beliefs about characteristics of group members are organized in implicit personality theories,6 which define personal attributes, covariations among them, and their links to a social subgroup, as attractive people may be perceived. Research on evaluative dimensions of personality has found seven principal components. These are social and intellectual competence, potency and adjustment, integrity and concern for others, and finally, physical attractiveness.7 Hypothetically, the perception of attractiveness is differentially related to attributions along the remaining characteristics. Presumably, perceived beauty has stronger impacts on attributed social competence than on the other evaluative dimensions. A meta-analysis8 of 76 studies on physical attractiveness stereotyping tested this hypothesis, and found a strong overall effect of perceived attractiveness on impressions of social competence. Furthermore, good looks seem to induce weaker inferences about potency, adjustment, and intelligence. Finally, they appear to have no effect on beliefs about integrity and concern for others. In contrast, a negative association was found in evaluations of modesty (as opposed to vanity) suggesting a “dark side” of the attractiveness stereotype.9 It may be concluded that the generality of the beauty as a good stereotype is confined to specific contents. It seems to be particularly strong in social competence impressions suggesting that attractive

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individuals might have advantages in social relationships. There are several sources for the development of the physical attractiveness stereotype.9 First, visual perception of beauty might be pleasing and thus elicit a positive affect, whereas ugly faces might provoke feelings of misery and sympathy. Some supporting evidence has been produced by experimental studies that used photographs of attractive faces for inducing positive affects. Second, perceivers might observe that attractive persons receive positive reactions, and assume that these reactions are caused by other favorable personality traits. Third, cultural messages suggest in general a beauty-is-good association. Children learn from book illustrations that dumb villains have ugly faces and crooked teeth whereas good looking heroes have beautiful teeth. Television commercials suggest that good looks are associated with sociability, popularity, and interpersonal ease whereas ugly teeth and bad breath cause problems in sexual relationships. Teenage magazines show models with perfect teeth, which in adolescent readers might provoke dissatisfaction with their own dental appearance.10

Dental Aesthetics Several studies have addressed the relevance of the physical attractiveness stereotype in the field of orthodontics. A novel experimental approach to studying effects of dental arrangement on impression forming was introduced by Sergl and coworkers.11,12 In the preliminary investigation 20 female en face portrait photographs with smiling faces were evaluated for their attractiveness by 40 judges.11 One photograph ranging in the median with the smallest standard deviation was chosen as a reference picture. In the investigation proper this picture was systematically varied by photomontage resulting in different arrangements of the anterior teeth. These were crowding, median diastema, buccally placed canines, proclined and retroclined incisors, and good occlusion. Each variant was evaluated by 30 lay persons by means of the method of paired comparisons and indication of aesthetic preferences of the test picture against the reference photograph. There were substantial differences such as the photomontage variants with buccal canines, proclined upper incisors, and median

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diastema being given the lowest attractiveness ratings and retroclined upper incisors given least unfavorable attractiveness scores. The results of those early studies11,12 demonstrated sensitivity of lay persons to differences in dental arrangements. Following this approach, Shaw13 published a frequently cited investigation of the influence of six major variations in dentofacial appearance on social impression forming by peers and lay adults. In the view of peer judges, children with normal occlusion were evaluated to be better looking (physical attractiveness) compared with each of the other conditions. They were believed to be more likable as friends (social attractiveness) compared with faces showing crowding and cleft lip. In addition they were assumed to be less likely to pick on other people and fight (aggressiveness) than children with missing teeth or cleft lip. From the perspective of adult judges the results were replicated with regard to physical attractiveness and desirability as a friend, but not for aggressiveness. The inferred intelligence did not differ between the dental conditions. The results suggest that dental arrangement might contribute substantially to impression forming in children and adult persons with regard to social characteristics of the target person. In a follow-up study14 Welsh teachers judged photographs to which a school record presenting an educational history of an average pupil was attached. The judges were instructed to evaluate their expectations along 16 items pertaining to academic ability, social and family relations, and personality. None of the ratings proved to be different among the five dental arrangement conditions, suggesting that in contrast to earlier reports from other countries, Welsh educational professionals were not prejudiced by physical appearance in forming impressions about schoolchildren. A third investigation by the same group15 used adults for arranging test photographs. College students judged the portraits for expected personality traits. The fictitious persons behind the test pictures with normal incisor relationships were rated most favorable in 4 of 10 personality traits. They were believed to be friendlier, more popular, of a higher social class, and, albeit to a lesser degree, more intelligent. Unilateral cleft target persons received the lowest ratings. No differences were found in extraversion, fun, honesty, kindness,

and sexual attractiveness. These findings are in agreement with the above meta-analysis8 on the general attractiveness stereotype to the extent that impression forming is selective and includes mainly characteristics that are related to social easiness. In a more recent investigation of social stereotyping16 test faces with less salient dental disharmonies such as median diastema, crowding, and prominent incisors were presented to Finnish university students. The judgments according to 11 characteristics were factorially analyzed and resulted in three dimensions such as beauty and success, personal virtue, and social capability. Test faces with diastemas and crowding were judged as less favorable on the first factor than those with normally appearing teeth while no differences were found in scoring on personal virtue and social capability. These findings, too, parallel the results of the above meta-analysis on impression forming.8 Taken together, it seems that individuals form specific beliefs about other individuals with aberrant dental appearance. It further appears that, in agreement with the research on the general physical attractiveness stereotype, the beholders attribute compromised psychosocial well-being or lower quality of life to targets with visibly aberrant tooth position. It appears likely that these impressions originate from observation or societal cultural standards.

Professional and Consumer Evaluation of Dental Esthetics Little agreement has been found in socio-psychological research between judge- and self-evaluations of physical attractiveness.17 This lack of consistency might have various reasons. For instance, judges have been shown to be more or less lenient depending on their own self-perceived attractiveness and age.13,18 Furthermore, targets’ self-esteem and narcissistic tendencies are likely to influence over- or underrating of own attractiveness.19 However, in the case of dental appearance the situation might differ. Valid objective evaluation can be made by professionals, and from consumers’ perspective the corresponding criterion of evaluation, such as the regularity of tooth position, is also a more definite one.

Dentofacial Aesthetics and Quality of Life

Six studies addressed the issue of agreement between professional and consumer’s evaluation, three of which were conducted on children and three on adults. Espeland and coworkers20 investigated the awareness of occlusion in 93 randomly selected Norwegian schoolchildren who answered six questions on self-perception of their dental arrangement such as spacing, crowding, irregularity of upper and lower incisors, and maxillary overjet. An agreement of 72% was found for traits that would normally meet the criteria of a marked malocclusion. When criteria of a mild or moderate malocclusion were applied, the agreement was somewhat lower at 56%. Incisor spacing was most readily recognized (80%), while children showed least awareness (30%) of upper incisor crowding. As expected, there was high agreement of 78% for traits of regular tooth position. However, the implication of the latter finding is that 22% of regular traits were incorrectly perceived as aberrant. Interestingly, evaluation by parents in that study resulted in nearly the same figures. An indirect assessment of dental awareness in 75 randomly selected Finnish 15- to 16-year-olds was conducted by asking the study subjects about their satisfaction with own tooth alignment.21 High agreement of 89% was found between the professional assessment of treatment need using the Aesthetic Component of Index of Orthodontic Need (IOTN-AC)22 and the subjects’ satisfaction. However, notwithstanding the treatment need identified in a smaller subgroup, 47% of the subjects were still satisfied with their tooth position. A recent study23 on 84 Polish 12-yearold schoolchildren showed a 41% agreement between professional assessment and self-perception of aesthetics using the IOTN-AC, which supports the notion of a relatively high consistency between professionals and consumers in judging dental aesthetics. However, approximately 32% of the study subjects rated their aesthetics one grade above and 16% one grade below the corresponding professional ratings. A number of investigations addressed the perception of dental appearance in adults. In Oslo Espeland and Stenvik24 investigated a sample of young adults aged 17 to 20 years. At 79% spacing was a most easily recognizable trait. An agreement of 68% was found for dental traits that corresponded to moderate and severe malocclusions, and that of 55% regarding minor occlusal

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deviations. On the other hand, an agreement of 91% was found for ideal occlusion. In a large Swedish study, 669 subjects aged from 20 to 60 years were interviewed whether they were aware of a presence of malocclusion or tooth malposition.25 Overall a rather low rate of awareness was found. Of those respondents who were diagnosed as having a malocclusion, only 25% were aware of having tooth malposition. The awareness was higher in females and in subjects aged 20 to 39 years. The highest agreement of 37% was found in females below 40. In another study the consistency between self-perceived and professionally assessed IOTN-AC grades was investigated in 60 Finnish persons aged 18 to 19 years.26 A high agreement was found in 45% of the sample. Furthermore, 38% of the subjects gave their dental appearance higher ratings than the examiners did, while in 17% these ratings were less favorable. The results are in accordance with the finding of the above study on Polish schoolchildren.23 In may be concluded from the findings of these investigations that the agreement between the professional and consumer ratings of dental aesthetics is higher than in perception of general physical attractiveness. There appears to be no difference between children and young adults in their awareness of dental appearance. Correct self-perception of minor deviations may be found in about one-half of lay persons. Dental traits in the range of a major deviation are recognized by two-thirds of consumers. Despite this high agreement, 1 in 3 subjects might tend to overrate own dental appearance. Approximately 1 in 7 might be overconcerned and rate own dental aesthetics less favorably than it would appear to a professional.

Psychosocial Impacts of Bodily Attractiveness General Physical Attractiveness One of most interesting questions of sociopsychology is whether there is a “kernel of truth” in the beauty-is-good stereotype. It may be speculated that attractive people develop desirable characteristics in response to expectations by others. If an individual is expected to be sociable, he or she will be treated in accordance with

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these expectations. The individual will internalize sociability as a constituent of his or her selfconcept. He will expect social success and improve interaction skills eliciting positive reactions, which, in turn, will confirm his selfconcept. This process, termed self-fulfilling prophecy, was demonstrated in an experiment by Snyder and coworkers,27 in which male college students expecting a telephone conversation with an unknown female were manipulated by means of photographs to believe that their partner would be of high or low physical attractiveness. Conversation transcripts showed that those test subjects who believed that their conversation partner was attractive were more responsive and in turn elicited more responsiveness from their female conversation partners. It may be concluded on the basis of that experiment that males’ prophecy of a high sociability of their assumingly attractive partner was fulfilled by their own behavior. To test the hypothesis that beauty is associated with desirable personality characteristics, a meta-analysis of 75 studies of judge rating of physical attractiveness was conducted.17 In those studies the personality traits were assessed by psychometric tests. The assumption of an association between the beauty and intelligence was rejected on the basis of intelligence tests. However, attractive people proved to be more socially skilled in interaction tasks, and they attained higher popularity. Less attractive respondents were more prone to loneliness and social anxiety. A similar pattern emerged in a meta-analysis of 72 studies of self-rating of physical attractiveness.17 The relationships found were stronger than in the judge ratings above. Whereas self-perceived beauty was not associated with intelligence, there were substantial relationships with measures of social comfort. More attractive individuals tend to be more popular, less lonely, and less socially anxious. Furthermore, they tend to have a more positive self-concept.17 In summary, research has substantiated the assumption of a relationship between physical attractiveness and psychosocial well-being. Additionally, it may be concluded that less attractive people suffer from their condition especially with regard to social responsiveness and selfconcept.

Dental Aesthetics Several studies have investigated the impact of malocclusion on psychosocial well-being in childhood and adolescence. It has been shown that deviant dental appearance in the childhood is an object of teasing by peers. Shaw and coworkers,28 for instance, asked 531 school children which of their physical features most provoked teasing. Among 14 facial features teeth were mentioned in the fourth place. Of the children, 7% reported that they were repeatedly teased because of their teeth. Among the physical features that were objects of teasing remarks about teeth were indicated by 61% as most upsetting. Furthermore, half of the respondents who were teased about teeth reported harassment such as malicious verbal or physical intimidation. It may be concluded that teasing is relatively often directed at the dental appearance, and it may have a marked upsetting effect on child’s well-being. A study on about 600 Danish young adults investigated retrospectively and from the current perspective potential psychosocial impacts of malocclusions, which had been diagnosed in these subjects 15 years ago and had been left untreated.29 Compared with a control group with normal occlusion, the subjects remembered more dissatisfaction with their dental appearance. Teasing at school was reported seven times more by the study subjects than by the controls. In particular, 50% of the subjects with severe overjet reported teasing. At the time of the study the subjects with malocclusion tended to have a compromised body image with regard to their teeth especially if they had increased overjet, deep bite, or crowding. The overjet had a stronger impact leading to dissatisfaction with the face as a whole. Smiling was negatively affected in subjects with crowded incisors. These reports suggest that negative impacts of malocclusion in childhood were sufficiently strong to be vividly remembered in adulthood. It might be expected that during the period of 15 years the subjects should have been sufficiently successful in coping with the unfavorable effects. On the contrary, they still seemed to suffer from specific deficiencies in body image. In another investigation of nearly 500 orthodontic patients aged up to 16 years, 44% of their parents reported that their child had been teased because of their

Dentofacial Aesthetics and Quality of Life

teeth.30 Presence of severe overjet increased the chance of teasing by 5.5 times; tooth malalignment increased it by 2.4 times. Together these studies demonstrate that the experience of teasing is a common one in children with severe malocclusion. Derogatory remarks on physical features in patient histories are known to precede later development of disturbed body image. Conceivably, early orthodontic treatment might, therefore, be an effective preventive measure of appearance anxietyrelated disorders. While the above studies measured dental appearance-related psychosocial impacts by single questions, two other investigations applied more standardized instruments. A quality-of-life measure assessing psychosocial impacts of dental aesthetics was proposed by Mandall and coworkers.31 The Oral Aesthetic Subjective Impact Scale (OASIS) is an instrument comprising six items pertaining to teasing, comments, concerns, avoidance of smiling, or covering teeth in children. In that study a relationship with objective treatment need as assessed by the IOTN-AC was investigated in 439 school children aged 11 to 12 years, and a small but significant correlation between examiner-rated AC grades and the OASIS sum score was found (␳ ⫽ 0.24). The results suggest that a less favorable dental appearance might have detrimental social impacts in children. A large scale study involving more than 1600 randomly selected Brazilian 15- to 16-year-old schoolchildren investigated the relationship between the normative treatment need as assessed by the IOTN-Dental Health Component (DHC) and oral health impacts.32 Two quality of life measures were used. The Oral Impacts of Daily Performance (OIDP) consists of nine items pertaining to oral health.33 The short form of the Oral Health Impact Profile (OHIP-14) comprises 14 items.34 Both had been developed for adult samples. Half of the children with definite treatment need reported at least one complaint on the OIPD compared with one-fourth of adolescents with no or mild treatment need. Comparable results were found for the OHIP-14. A limitation of the study is the low agreement rate in answering the items of the instruments, which might indicate that they were less applicable to this sample. Furthermore, it was not clear that the oral health impacts pertain to dental appear-

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ance impediments. Nonetheless the results suggest that occlusal disharmony may have effects on daily living. The Child Perception Questionnaire (CPQ) has been developed for assessment of oral health-related quality of life in children.35 The CPQ has been applied in a UK sample of 204 pupils, 10 to 12 years old, to study associations with dental aesthetics.36 The emotional and social impact subscales showed a significant but small relationship with IOTN-AC self-ratings attaining a common variance around 3%. When the slight associations between dental aesthetics and quality of life as reported in the above three studies are considered, one must take into account that adolescents live in a period of a changing and unstable self-concept and perception of physical attractiveness.37 They may have difficulties in explaining their reactions to their own dental appearance, which might have reduced the reliability of the answers. A new questionnaire designed to measure specifically orthodontic-related quality of life in adults38 was developed by Klages and coworkers on the basis of the studies by Cunningham and coworkers.39,40 This instrument, termed the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ), comprises four scales which are Dental Self-Confidence, Social Impact, Psychological Impact, and Aesthetic Concern. The factor structure was confirmed on two independent samples, and the subscales showed good internal consistencies. They were able to discriminate between subjects with varying degrees of examiner- and self-rated dental aesthetics as assessed by means of the IOTN-AC, the Perception of Occlusion Scale and the Dental Aesthetic Index.41,42 The PIDAQ might be a useful instrument for investigating orthodontic-specific quality of life and for clinical assessment of treatment need from the patient’s perspective.

Public Self-Consciousness Individuals react differently to their own physical appearance. While some feel no handicap from severe facial disharmonies, others are strongly concerned about minor aesthetic deviations. The personality disposition of the socalled public self-consciousness might help explain these differences. Public self-consciousness is basically a habitual personal awareness of the

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impressions one makes on others.43 In the state of awareness of oneself individuals compare their behavior or appearance with their own standards. When physically attractive individuals face their own appearance they might judge that this appearance meets their standards, which might lead to a positive mood. Less attractive persons might fail in meeting their standards, which in turn might elicit negative feelings.44 A typical means for arousing self-awareness is the confrontation with one’s own mirror image. It is conceivable that physically attractive individuals might like to encounter their own appearance and to approach self-awareness, whereas less attractive ones prefer to avoid it. This assumption was tested in a field experiment45 when recordings were made of university students gazing at their images when they passed a walkway with a wall of reflective windows. It was found by independent observers that attractive students took substantially longer to look at their images than their less attractive counterparts. It appears from this observation that own physical appearance might be important in influencing people whether they like to approach self-awareness or try to avoid it. A measure to assess the habitual awareness of a person’s self was proposed by Fenigstein and coworkers,46 namely the Self-Consciousness Scale, which comprises two subcomponents. One of the latter, the Private Self-Consciousness Scale, refers to reflecting covert aspects of the self, such as personal thoughts, feelings, and motives, while the other, the Public Self-Consciousness Scale, measures a habitual focus on overt or social aspects of the self, including social appearance and impression one makes on others. The personality trait public self-consciousness has been of special interest in several investigations of psychosocial implications of physical attractiveness. It has been proposed that public self-consciousness is related to the physical attractiveness schema, which is thought to store information in the readily accessible memory.47 Individuals with raised public selfconsciousness are expected to quickly process information about their appearance. An experimental investigation47 tested this prediction by measuring reaction time in a task on evaluating one’s own physical features. The individuals with higher public self-consciousness gave quicker re-

sponses showing a higher preparedness for processing appearance-relevant information. Another interesting assumption that raised public self-consciousness might increase social sensitivity was confirmed by a questionnaire study that showed that individuals with this personality trait had an improved ability to understand emotions, beliefs, and attitudes of others.48 Furthermore, another experimental study49 found that subjects with high public selfconsciousness correlated more with independent observers in evaluating their impression on others. Individuals with raised public selfconscious were also more sensitive to comparison processes than their counterparts, to the extent that they rated their own appearance less favorably when exposed to highly attractive stimulus persons.50 A hypothesis was proposed that apart from reacting differently to social situations, individuals with high public self-consciousness prepare themselves differently by appearance enhancement. It was tested by interviewing and judge rating of females on use of cosmetics.51 The study showed that the disposition to public self-consciousness was related both to judge-rated and to self-reported use of cosmetics, and to test persons’ belief that makeup enhances their appearance. These investigations point out an association of public self-consciousness with the individual’s appearance- and social interaction-related sensitivities and abilities. It may hence be postulated that psychosocial impacts of appearance are stronger in individuals with high public self-consciousness. This hypothesis, which was originally stated by Buss,52 was applied to orthodontics and tested on a sample of German university students.53 The study subjects rated their dental aesthetics using the IOTN-AC and answered an aesthetic-specific form of the Orthognatic Quality of Life Questionnaire.39 In subjects with low public self-consciousness the degree of dental aesthetics had no impact on social concerns about appearance. However, in subjects with high public self-consciousness the impact of perceived dental aesthetics on social concerns was highly significant in the range of a strong effect.54 Those individuals with raised public selfconsciousness whose dental aesthetic appearance was less than highly favorable tended to be more compromised in dental self-confidence. Interestingly, this effect was smaller in subjects

Dentofacial Aesthetics and Quality of Life

with low public self-conscious. These findings confirm the validity of the hypothesis of a moderating role of public self-consciousness on the psychological effects of attractiveness for the field of orthodontics. This implies that individuals with high public self-consciousness are more susceptible to compromised quality of life if they perceive deviations from the ideal dental appearance.

Bodily Attractiveness and Health-Related Behavior and Attitudes General Physical Attractiveness Findings of several investigations suggest that physically attractive individuals make special efforts in health-related behaviors to enhance or preserve their condition. Physically attractive university students were found to be especially actively engaged in fitness training, healthy nutrition, and guarding for sufficient sleep.55,56 Self-perceived bodily attractiveness was associated with recent physical activity and leisure time activity levels.56 In a sample of more than 600 adolescent females, subjects with a less attractive body shape, as indicated by high body mass index values, recorded less activity in a 7-day recall than more attractive subjects.57 This finding was stable in a 1-year follow-up.57 It has been suggested that the relationship between physical attractiveness and health behaviors might be explained as mediating affective responses.58 A favorable self-rating of physical attractiveness elicits positive affective responses, which in turn stimulate a motivation to engage in appearancerelated health behaviors. In contrast, an unfavorable physical self-perception might lead to dysphoric or anxious moods and inhibit behavioral motivations and intentions for self-control. This hypothesis is supported by the results of two studies. One of these studies showed a relationship between negative physical self-ratings by obese women and anxiety about own appearance, which determined maladaptive nutritional habits.59 Another study60 found that physical self-worth predicted a positive activity-related affect, which was related to physical activity. It may be concluded from the above that in normal and psychologically adjusted individuals, physical attractiveness might be an incentive for health behavior.

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Dental Aesthetics Potential interrelationship between aesthetics and health behaviors and attitudes may be of special interest in dentistry. Intensive oral hygiene practice requires meticulous observation of one’s teeth in the mirror. Confronted with the mirror image of one’s own dentofacial appearance, a person with unfavorable aesthetics might experience negative feelings when comparing it to his or her standards.44 As a consequence he or she may reduce the exposure to the mirror image,45 and tend to avoid regular and meticulous oral care. On the other hand, a person with a highly aesthetic dental appearance might be pleased by seeing his oral condition and become highly motivated for dental care. In addition, a favorable dental appearance may be perceived as a result of personal efforts.61 As a consequence it may be expected that subjects with superior dental aesthetics would tend to report favorable oral health attitudes,62 more regular dental care,63 and better oral health.64 To test this assumption, dental aesthetics of 298 young adults was assessed according to the IOTN-AC, and the subjects were interviewed about their dental health attitudes and behaviors.65 In contrast to the subjects with less favorable dental aesthetics, those with highly aesthetic dental appearance reported more favorable attitudes toward oral health. They attached higher value to dental health, expected more success from oral hygiene practice, and, in line with internal locus of control, explained personal oral health as a result of their own preventive efforts. They reported stricter following of health care instructions including regularity and frequency of tooth brushing and dental check-ups, and had less gingival bleeding and caries treatment. In a subsample of subjects65 the Quigley-Hein-Index66 revealed less plaque accumulation. These findings65 support the hypothesis of an association between dental aesthetics and oral health motivation on the level of subjective report.

Exaggerated Sensitivity to Dental Appearance Both adolescent patients and their parents expect from orthodontics not only improved oral functioning, health, and aesthetics, but also an enhancement of self-esteem and social life.67-69

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Dissatisfaction with their own dental appearance raises expectations of self-image enhancement, including social self-confidence, self-image, and general appearance.70 However, sometimes these expectations are overdone and not met by the treatment results. In one study of patients’ satisfaction with orthodontic treatment results, 26% of improved and 19% of greatly improved patients, as identified using objective standards, were dissatisfied with the treatment outcome.71 It was found that dissatisfaction before treatment predicted dissatisfaction at treatment end. Thus, some patients tend to be dissatisfied both before and after orthodontic correction. As discussed above, professionals and patients do not always coincide in ratings of dental aesthetics. While some individuals appear satisfied despite a conspicuous malocclusion, others are discontented with nearly an ideal occlusion. For instance, in the investigation of Polish schoolchildren23 cited above, one-third of the subjects with IOTN-AC grade 1 and one-half of those with grade 2 expressed a desire for treatment. Dissatisfaction with a nearly ideal dental arrangement, from the professional point of view, might occasionally cause problems for the practicing orthodontist. Patients might persistently demand treatment despite the lack of objective need or they may be dissatisfied and complain despite great improvement during treatment. Litigation claims might be warranted when patients’ subjective treatment results do not meet their expectations.72 Presumably some of these patients have a psychological problem that cannot be solved by orthodontic interventions. In cases of overconcern about dental arrangements of minor clinical significance patients may be classified as displaying a syndrome of appearance anxiety. This term was introduced by Dion and coworkers73 to characterize a condition of apprehensive concern with various aspects of own appearance and of how the latter might be rated by others. Appearance anxiety seems to be moderately related to other forms of social anxiety, such as interaction anxiety, or social avoidance and distress.73 Based on the results of an investigation of young adult women, a suggestion has been made that appearance anxiety might be preceded by negative social experiences in childhood and adolescence, which are associated with childhood and early adolescent appearance dissatisfaction.74

In cases of extreme apprehension and dramatic quality-of-life impairments because of unfavorable dental aesthetic appearance the patients might fulfill the criteria for the diagnosis of the so-called body dysmorphic disorder (BDD), a mental disorder affecting 0.7% of the population.75 A comorbidity with depression, obsessive-compulsive disorder, or social phobia is often found in BDD cases. According to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV),76 BDD is defined as a preoccupation and excessive concern about an imagined defect or a slight physical anomaly. Symptoms are time-consuming rituals of mirror gazing checking the defect, constant comparison of particular features with those of others, poor quality of life, depressed mood, and a history of needless aesthetic treatments. A history of bullying or abuse in childhood is also often present. When symptoms of appearance anxiety or BDD are apparent, cooperation with a mental health professional is required. Patients with appearance anxiety may benefit from a cognitive behavioral treatment program, as suggested by Cash and Strachan77 for patients with body image dissatisfaction. It includes relaxation and desensitization for exposure to one’s looks. Cognitive distortions, such as comparing, dichotomous thinking about looks, or blaming appearance for life difficulties, are identified and corrected. Avoidant behavior relating to activities, situations, or people is monitored and aimed to be altered. Finally, exercises for body image affirmation, mastery, and pleasure are conducted. Those interventions have been found to be efficient in several studies. A selfhelp book is available. When a diagnosis of BDD is made, patients appear to benefit from cognitive behavior therapy or serotonin reuptake inhibitors.75

Conclusions and Directions for Further Research Compared with socio-psychological research related to general physical attractiveness, a relatively small number of studies have dealt with the implications of dental aesthetics for subjective well-being. Investigations of impression forming demonstrate that the perception of a person’s dental condition might guide the observers to making conclusions about that per-

Dentofacial Aesthetics and Quality of Life

son’s social competence. Individuals with dental aesthetic impairment might constitute a subgroup of community members that is associated with the stereotype of a social handicap. Further research is needed to answer the question of which types of malocclusions incite inferences about various personality traits. Studies of professional and consumer ratings of dental aesthetics show that the agreement is far higher than at first expected on the basis of general physical attractiveness research. The concordance rate is generally about 50% in both children and adults. There is some tendency for lay persons to overrate their aesthetic appearance, especially when their dentition is affected. A small proportion of people, especially those with a favorable occlusion, might underrate their aesthetics. However, there are critical questions about the validity of assessing dental aesthetics by means of the IOTN-AC. The proportion of subjects with treatment need according to the IOTN-AC is lower than when the criteria of the IOTN-Dental Health Component are applied. In a community study the ratios were 6% versus 48%,26 suggesting that the IOTN-AC might not reflect objective treatment need. Furthermore, the instrument does not represent typical forms of malocclusion seen by orthodontists. A refinement of methods of assessment of dental aesthetics is therefore needed. Investigations of the relationship between dental aesthetics and psychosocial well-being suggest that there might be a kernel of truth in the dental attractiveness stereotype. For instance, some studies have shown small but significant associations between oral health-related quality of life and dental aesthetics. Malocclusion is a developmental disorder without pain or physical discomfort, which refers to societal aesthetic norms.40 Therefore, there is a need to develop instruments specifically designed for measuring the psychosocial impacts of dental aesthetics. A multidimensional questionnaire developed for this purpose has been introduced.38 Young adults with different degrees of dental aesthetics differed in their quality of life as assessed by this instrument. More research efforts in test development are needed using study samples with varying sociodemographic characteristics and dental conditions.

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Public self-consciousness is a personality construct that has been successfully applied to research of general physical attractiveness as a means of explaining individual differences in psychosocial impacts of appearance. Exploratory studies have shown that this concept might be equally successfully applicable to the field of orthodontics. Individuals with high public selfconsciousness report more severe psychosocial impairments caused by malocclusion than those scoring low in this personality trait. Further research is needed to explain why people react differently to their own dental aesthetics with regard to quality of life. Physical attractiveness has been shown to be associated with health-preserving behaviors. Preliminary study applied this approach to dentistry and found that persons with highly aesthetic dentitions reported more favorable attitudes toward dental health, more compliance, and fewer oral health complications. Following this approach would be of great interest when benefits of orthodontic treatment are evaluated by further research. Patients with apprehensive concern about dental aesthetics can be a problem. Their complaints might be caused by psychological malfunction, which must be recognized at an early stage. More research is needed to explain excessive psychosocial impairments related to dental aesthetics in this patient group.

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