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Expectations of treatment and satisfaction with dentofacial appearance in patients applying for orthodontic treatment
ORIGINAL ARTICLE
Expectations of treatment and satisfaction with dentofacial appearance in patients applying for orthodontic treatment Naomi A. van Wezel,a Annemieke Bos,b and Charlotte Prahlb Amsterdam, The Netherlands
Introduction: Satisfaction with dentofacial appearance and expectations of orthodontic treatment have been analyzed in many studies. In 2002, in a study in The Netherlands, significant correlations were found between dental satisfaction and orthodontic treatment expectations. Satisfaction significantly decreased with increasing age. The aim of this study was to compare the satisfaction and expectations of current patients with the results of a study 10 years ago. Methods: A questionnaire about dentofacial satisfaction and a questionnaire about the expectations of orthodontic treatment were completed by 146 subjects. The mean scores in the present study were compared with the mean scores 10 years ago. Results: The subjects in the present study were more satisfied with their dental appearance. Differences in expectations were found on the subscales of general well-being and self-image. As in the study in 2002, no significant correlations were found between sex, satisfaction, and expectations of orthodontic treatment. Dentofacial satisfaction predicts expectations about orthodontic treatment, especially in the group of subjects aged 17 years and above. Conclusions: The subjects in this study had greater expectations of orthodontic treatment about general well-being and were more satisfied with their dental appearance than were the subjects studied 10 years ago. (Am J Orthod Dentofacial Orthop 2015;147:698-703)
Y
ou never get a second chance to make a first impression. In verbal and nonverbal communication, the face matters. The advantages of beauty seem to be true, at least at first meeting. Facial attractiveness is positively associated with high school marks, good work performance, positive peer relations, social acceptance, high social status, positive body image, and good self-concept. It has also been proven that a malocclusion can have a negative effect on the quality of life.1-9 Tooth color, missing teeth, and poor tooth alignment are the most common reasons for dissatisfaction with dentofacial appearance.10-12 It is therefore not
From the Department of Orthodontics, Academic Centre for Dentistry, University of Amsterdam and Free University, Amsterdam, The Netherlands. a Orthodontist. b Assistant professor. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Naomi A. van Wezel, Department of Orthodontics, Academic Centre of Dentistry, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, The Netherlands; e-mail, [email protected]. Submitted, February 2014; revised and accepted, January 2015. 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2015.01.024
698
surprising that people seek esthetic dental and orthodontic care.11-13 Inconsistent results have been found regarding the association between dentofacial satisfaction, age, and sex.2,10,14 In some studies, no sex differences were found regarding dentofacial satisfaction and treatment expectations,2 but other studies showed that female subjects were less satisfied than were male subjects.10,15 However, it seems that dentofacial satisfaction is significantly correlated with expectations of orthodontic patients about general well-being, improvement of selfimage, and future dental health.2 Also, orthodontic patients seem to expect improvements in esthetics and self-esteem, regardless of their sex.2,15-17 Attitudes about dental health change over time.18 In an epidemiologic dental study in The Netherlands, more patients were undergoing orthodontic treatment in 2005 than in 1999.19 Also, a change in orthodontic treatment need was found. The question is whether these findings are related to current dentofacial satisfaction and expectations of orthodontic patients at the start of treatment. In this study, we replicated the study by Bos et al2 and compared our results with those results. Because of controversy about the impact of malocclusion on
van Wezel, Bos, and Prahl
dentofacial satisfaction and treatment expectations in the orthodontic literature, we examined the effect of malocclusion on dentofacial satisfaction and treatment expectations as well.20-22 Based on the results of previous studies, female patients were expected to be less satisfied with their dentofacial appearance than male patients.10,14 Based on the results of Bos et al,2 younger subjects were assumed to be more satisfied with their dentofacial appearance than older subjects. Furthermore, significant correlations between dentofacial satisfaction and treatment expectations were expected. We explored whether dentofacial satisfaction and orthodontic treatment expectations have changed over time. Finally, based on the results of Zhang el,20 we expected that malocclusion would have no effect on dentofacial satisfaction and treatment expectations. MATERIAL AND METHODS
From November 2011 to June 2012, we sent 2 questionnaires to every person applying for orthodontic treatment at the Academic Centre of Dentistry Amsterdam in The Netherlands. The first questionnaire included 16 items about satisfaction with facial appearance before orthodontic treatment to be scored on a 5-point response scale (from “I am very unsatisfied” to “I am very satisfied”). It was a modification of the body-cathexis scale introduced by Secord and Jourard23 in 1953 and was further developed in the 1980s. It gives an assessment of perceived dentofacial appearance; a high score shows greater satisfaction with the dentofacial body part being measured.24-28 The second questionnaire included 23 items about expectations of orthodontic treatment to be scored on a 7-point response scale (from “worse” to “much better”). It was initially developed for patients undergoing orthognathic surgery and was adjusted for orthodontic patients. It measures long-term expectations of orthodontic treatment.26,29,30 The same subscales were used as in the study by Bos et al.2 The questionnaire about satisfaction with facial appearance was divided into 2 subscales (facial satisfaction and dental satisfaction). The questionnaire about expectations of orthodontic treatment was divided into 4 subscales (general well-being, self-image, oral function, and future dental health). The questionnaires were sent to 220 persons applying for orthodontic treatment at the Academic Centre of Dentistry in Amsterdam; none had visited the orthodontic department before. To this type of social science research, the Dutch Medical Research on Humans Act was not applicable. The questionnaires
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were returned by 146 subjects (53 male, 93 female), resulting in a response rate of 67%. There were no significant differences in age and sex between responding and nonresponding persons. Subjects with more than 3 missing responses (n 5 10) were excluded from the analysis. There were no significant differences in age and sex between subjects who completed the questionnaire and those who did not. Subjects older than 60 years (n 5 1) and younger than 8 years (n 5 1) were excluded from the study. The mean age of the remaining 134 subjects was 19.6 years (SD, 13.49 years; median, 13 years; age range, 8-60 years). After the initial analysis, the subjects were divided into 2 age groups, as Bos et al2 did in 2003. The first group included subjects from 8 to 16 years old (n 5 84; 35 boys; mean age, 11.42 years; SD, 1.78 years); the second group included subjects from 17 to 60 years (n 5 50; 15 men; mean age, 33.36 years; SD, 13.43 years). All subjects were invited for a first consultation. During this consultation, the subjects (n 5 123) were scored with a Class I (n 5 59), Class II (n 5 57), or Class III (n 5 7) malocclusion. Statistical analysis
First, the internal consistencies of the scales and subscales were determined using the Cronbach alpha. To analyze the effects of sex and age on dental and facial satisfaction and expectations of orthodontic treatment, the Mann-Whitney U test was used. Also, the mean scores of the subscales for the subjects with a Class I malocclusion were compared with the mean scores for subjects with a Class II malocclusion using the MannWhitney U test. The Spearman correlation coefficient was calculated for satisfaction with dental and facial appearance and expectations of orthodontic treatment. Next, a multiple regression analysis was performed to estimate the effect of the initial facial and dental satisfactions on expectations of orthodontic treatment. To analyze changes in satisfactions and expectations over time, the mean scores in our study were compared with the mean scores from the study by Bos et al2 using 1-sample t tests. RESULTS
The internal consistency in 2012 of the questionnaire on satisfaction was satisfactory. The Cronbach alpha for the total scale was 0.93. Internal consistency values for the 2 subscales were 0.93 and 0.52, respectively, for satisfaction with facial appearance and dental appearance. The internal consistency of the questionnaire on expectations was satisfactory as well. The Cronbach
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Table I. Correlations between expectations and satis-
faction
Expectation Age #16 years Satisfaction with facial appearance Satisfaction with dental appearance Age $17 years Satisfaction with facial appearance Satisfaction with dental appearance
Future General Self-image/ dental Oral well-being appearance health function 0.97
0.36
0.33
0.78
0.64
0.11
0.69
0.13
0.31*
0.29
0.29
0.30*
0.15
0.24
0.14 0.07
*P \0.05.
alpha for the total scale was 0.94, and the internal consistency values for the 4 subscales were 0.94 for general well-being, 0.91 for self-image, 0.83 for future dental health, and 0.85 for oral function. No significant differences on the subscales and total scales were found between the male and female subjects for age and sex differences in 2012. However, age was significantly related to facial satisfaction (U 5 1403.500; P 5 0.004), dental satisfaction (U 5 1461.500; P 5 0.003), and expectations about self-image (U 5 1536; P 5 0.049). Patients younger than 17 years of age were more satisfied with their facial and dental appearances, and they had lower expectations of orthodontic treatment with regard to improvements in self-image in comparison with older subjects. The group of subjects with a Class III malocclusion (n 5 7) was relatively small and was therefore excluded from the analysis. The scores for subjects with a Class I malocclusion (n 5 59) were compared with the scores for subjects with a Class II malocclusion (n 5 57). The Mann-Whitney U test showed no significant differences in the subscales and the total scale between subjects with Class I and Class II malocclusions (facial satisfaction: U 5 1486.50, P 5 0.527; dental satisfaction: U 5 1433.00, P 5 0.163; general well-being: U 5 1287.50, P 5 0.295; self-image: U 5 1285.00, P 5 0.131; future dental health: U 5 1576.00, P 5 0.908; and oral function: U 5 1306.00, P 5 0.275). In Table I, the Spearman correlations between the different variables were analyzed for the 2 age groups. Satisfaction with facial appearance was significantly correlated with expectations about general well-being and oral function only for subjects 17 years and older. No correlation was found between sex and expectations of orthodontic treatment.
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A multiple regression analysis was used to determine which variables affected the expectations of orthodontic treatment for the 2 age groups. Table II shows that facial satisfaction and dental satisfaction are significant predictors for expectations about future dental health for subjects younger than 17 years. Dental and facial satisfaction together explained 12% of the variance of the subjects' expectations about future dental health. Dental satisfaction was also a significant predictor for expectations about oral function for subjects younger than 17 years. Table III shows that satisfaction with facial appearance was a significant predictor for all expectations of orthodontic treatment for subjects 17 years and older. Dental satisfaction was a significant predictor only for expectations about self-image. Dental and facial satisfaction explained 16% of the variance on subjects' expectations about self-image. In Table IV, the mean scores and standard deviations on all subscales of both questionnaires are presented for both groups in 2002 and 2012. The mean scores from the present study were compared with the mean scores from the study of Bos et al.2 Significant differences between the subjects in this study and those from the earlier study were found for dental satisfaction and expectations about general well-being. The subjects in 2012 were significantly more satisfied with their teeth than were those in 2002 and had higher expectations of orthodontic treatment for their general well-being. The mean scores for the different age groups from the present study were compared with the mean scores for the same age groups from the study in 2002 using 1-sample t tests. For subjects younger than 17 years, only 1 significant difference was found for facial satisfaction in both boys (2002, 55.75 [n 5 36]; 2012, 60.79 [n 5 35]; t 5 3.00; P \0.01) and girls (2002, 60.56 [n 5 36]; 2012, 57.32 [n 5 49]; t 5 2.19; P \0.05). In 2012, boys younger than 17 years were significantly more satisfied with their facial appearance than were the boys 10 years ago. Girls younger than 17 years in 2012 were significantly less satisfied with their facial appearance than were the girls 10 years ago. In Tables V and VI, the mean scores and standard deviations on all subscales of both questionnaires are presented for the age groups 17 years and older in 2002 and 2012. As illustrated in Tables V and VI, both sexes 17 years and older were significantly more satisfied with their teeth in 2012 compared with 2002. Women 17 years and older, however, were significantly more satisfied with their facial appearance as well and had significantly higher expectations about general well-being and self-image than did the women 10 years ago.
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Table II. Multiple regression for subjects #16 years of age
Expectation Satisfaction with facial appearance Satisfaction with dental appearance R Adjusted R2
General well-being
Self-image/appearance
Future dental health
b P 0.176 0.260 0.177 0.258 0.146 0.006
b 0.121 0.246
b 0.436 0.458
Oral function
0.189 0.009
0.351 0.123
b P 0.251 0.194 0.323 0.036* 0.245 0.034
General well-being
Self-image/appearance
Future dental health
Oral function
ß P 0.441 0.004y 0.149 0.314 0.413 0.133
ß 0.372 0.385
P 0.435 0.114
P 0.005y 0.003y
*P \0.05; yP \0.01.
Table III. Multiple regression for subjects $17 years of age
Expectation Satisfaction with facial appearance Satisfaction with dental appearance R Adjusted R2
P 0.011* 0.009y
P 0.025* 0.180
ß 0.345 0.203
0.437 0.156
ß P 0.343 0.028* 0.098 0.523 0.324 0.064
0.331 0.071
*P \0.05; yP \0.01.
Table IV. Means and standard deviations of all subscales for the total groups in 2002 and 2012 Total groups 20022 (n 5 100) Subscale Satisfaction questionnaire General facial satisfaction Dental satisfaction Expectation questionnaire General well-being Self-image/appearance Future dental health Oral function
2012 (n 5 134) t
P
Mean
SD
Mean
SD
56.04 5.99
10.59 1.86
56.76 6.49
10.24 1.87
0.804 3.116
0.420 0.002y
26.54 18.00 19.70 9.56
10.93 7.53 5.97 4.30
28.90 18.73 19.35 9.92
13.21 7.88 5.93 4.77
1.986 1.055 0.680 0.849
0.049* 0.294 0.497 0.397
*P \0.05; yP \0.01.
DISCUSSION
In this study, decreased dentofacial satisfaction with increasing age was found, as expected. This finding was consistent with previous studies.2,31 Because the older subjects were less satisfied with their dental and facial appearance than the younger subjects, it is not surprising that the older subjects expected more improvement in their self-image. Dental and facial satisfactions were significant predictors for all expectations of orthodontic treatment in the older age group. For the younger subjects, facial satisfaction was found to be a significant predictor only for expectations of orthodontic treatment about future dental health. This was in contrast to previous studies. Philips
et al17 found that older patients showed more concern about functional problems and future dental health than did younger subjects, and Bos et al2 found that dental and facial satisfactions were predictors for expectations about general well-being in the younger age group. Although female subjects were expected to be less satisfied with their dentofacial appearance, no significant correlations were found between sex, satisfaction with dental and facial appearances, and expectations of orthodontic treatment. Also, there was no effect of malocclusion on dentofacial satisfaction. This result was also found by Taylor et al.21 In comparison with the subjects in 2002, the subjects in the 2012 study had significantly higher expectations
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Table V. Means and standard deviations on all subscales for men $17 years in 2002 and 2012 Men 2002 (n 5 11)
2012 (n 5 15)
2
Subscales General facial satisfaction Dental satisfaction General well-being Self-image/appearance Future dental health Oral function
Mean 53.36 5.00 26.73 19.73 21.82 10.64
SD 10.98 1.73 6.23 8.15 4.26 3.96
Mean 52.53 6.13 27.57 17.20 20.20 11.29
SD 9.90 1.25 13.66 7.59 6.56 5.12
t 0.323 3.523 0.230 1.291 0.956 0.472
P 0.751 0.003* 0.821 0.218 0.355 0.645
*P \0.01.
Table VI. Means and standard deviations of all subscales for women $17 years in 2002 and 2012 Women 2002 (n 5 17)
2012 (n 5 35)
2
Subscales General facial satisfaction Dental satisfaction General well-being Self-image/appearance Future dental health Oral function
Mean 48.94 5.12 27.00 19.00 19.00 9.47
SD 9.01 1.50 8.31 5.85 5.72 3.86
Mean 54.03 5.77 32.36 22.26 19.62 10.33
SD 9.95 1.78 13.76 8.41 6.11 4.36
t 3.027 2.181 2.239 2.263 0.589 1.137
P 0.005y 0.036* 0.032* 0.030* 0.560 0.264
*P \0.05; yP \0.01.
about orthodontic treatment. This was especially true for women aged 17 years and older. A reason for the higher expectations of orthodontic treatment might be that orthodontic treatment has become more common in The Netherlands during the last decade.19 It can be assumed that patients see friends and acquaintances who have been treated successfully and therefore have high expectations for their own orthodontic treatment. Unexpectedly, the subjects in this study were more satisfied with their dental and facial appearances than were those studied 10 years earlier. A possible explanation for the increased satisfaction over time may be that decreased anterior crowding in the Dutch population was found between 1999 and 2005.19 Several studies have shown that anterior crowding is the main reason for dissatisfaction with dental appearance.10-13 Some limitations of this study must be noted. First, it describes the responses of subjects applying to the Academic Centre of Dentistry Amsterdam for orthodontic treatment. Therefore, our results cannot be used for orthodontic patients in general. Furthermore, the group in 2002 might not be comparable with the group in 2012. Both groups included different people who might not be similar for socioeconomic status and
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malocclusion. However, because both groups were large samples of subjects applying for orthodontic treatment at the Academic Centre of Dentistry in Amsterdam, a comparison between them seemed acceptable. Additionally, if the sample of subjects 17 years and older had been larger and the distribution of the sexes had been more equal, it is possible that significant correlations between sex and satisfaction with dental and facial appearances would have been found. Finally, although the reliability of the questionnaire on satisfaction with facial appearance was high, that of the questionnaire on dental satisfaction was only moderate. To compare the results of the 2012 study with the results from 2002, the same items were used. To increase the reliability, more items could be added to the subscale of dental satisfaction in a future study. In our study, changes in dental and facial satisfaction and expectations of orthodontic treatment over time were found. In the future, this study can be replicated to examine whether there are tendencies toward increasing dental and facial satisfactions and expectations of orthodontic treatment over time. Additionally, to analyze the correlations between objective orthodontic treatment need and dental and facial satisfactions
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and treatment expectations, the index of orthodontic treatment need could be used.
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13.
CONCLUSIONS
1.
2.
3.
4.
The subjects in 2012 had higher expectations of orthodontic treatment about general well-being than did those studied in 2002, especially the women 17 years and older. The subjects in this study were more satisfied with their dental and facial appearances than were those studied 10 years earlier. No significant correlations were found between sex, satisfaction with dental and facial appearances, and expectations of orthodontic treatment. Facial satisfaction was a significant predictor for all expectations of orthodontic treatment in subjects 17 years and older. For the younger subjects, facial satisfaction was found to be a significant predictor only for expectations about future dental health.
REFERENCES 1. Duggal R, Bansal S. Expectations from orthodontic treatment patient/parent perspective. J Clin Diagn Res 2010;4:3648-53. 2. Bos A, Hoogstraten J, Prahl-Andersen B. Expectations of treatment and satisfaction with dentofacial appearance in orthodontic patients. Am J Orthod Dentofacial Orthop 2003;123:127-32. 3. Wedrychowsa-Szulc B, Syrynska M. Patient and parent motivation for orthodontic treatment—a questionnaire study. Eur J Orthod 2010;32:447-52. 4. Philips C, Bennett ME, Broder HL. Dentofacial disharmony: psychosocial status of patients seeking treatment consultation. Angle Orthod 1998;68:547-56. 5. Tung AW, Kiyak HA. Psychological influences on the timing of orthodontic treatment. Am J Orthod Dentofacial Orthop 1998;113: 29-39. 6. Trulsson U, Strandmark M, Mohlin B, Berggren U. A qualitative study of teenagers' decisions to undergo orthodontic treatment with fixed appliance. J Orthod 2002;29:197-204. 7. Seehra J, Newton JT, DiBiase AT. Bullying in schoolchildren–its relationship to dental appearance and psychosocial implications: and update for GDPS. Br Dent J 2011;210:411-5. 8. Helm S, Kreiborg S, Solow B. Psychosocial implications of malocclusion: a 15-year follow-up study in 30-year-old Danes. Am J Orthod 1985;87:110-8. 9. Agou S, Locker D, Steiner DL, Tompson B. Impact of self-esteem on the oral-health-related quality of life of children with malocclusion. Am J Orthod Dentofacial Orthop 2008;134:484-9. 10. Samorodnitzky-Naveh GR, Geiger SB, Levin L. Patients' satisfaction with dental esthetics. J Am Dent Assoc 2007;138:805-8. 11. Tessarollo FR, Feldens CA, Closs LQ. The impact of malocclusion on adolescents' dissatisfaction with dental appearance and oral functions. Angle Orthod 2012;82:403-9. 12. Marques LS, Pordeus IA, Ramos-Jorge ML, Filagonio CA, Filagonio CB, Pereira LJ, et al. Factors associated with the desire
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for orthodontic treatment among Brazilian adolescents and their parents. BMC Oral Health 2009;9:34. Xiao-ting L, Tang Y, Huang XL, Wang H, Cheng YX. Factors influencing subjective orthodontic treatment need and culture-related differences among Chinese natives and foreign inhabitants. Int J Oral Sci 2010;2:149-57. Tin-Oo MM, Saddki N, Hassan N. Factors influencing patient satisfaction with dental appearance and treatments they desire to improve aesthetics. BMC Oral Health 2011;11:6. Prabakaran R, Seymour S, Moles DR, Cunningham SJ. Motivation for orthodontic treatment invested with Q-methodology: patients' and parents' perspectives. Am J Orthod Dentofacial Orthop 2012; 142:213-20. Pabari S, Moles DR, Cunningham SJ. Assessment of motivation and psychological characteristics of adult orthodontic patients. Am J Orthod Dentofacial Orthop 2011;140:263-72. Philips C, Broder HL, Bennett ME. Dentofacial disharmony: motivations for seeking treatment. Int J Adult Orthodon Orthognath Surg 1997;12:7-15. Bos A, Hoogstraten J, Prahl-Andersen B. A comparison of dental health care attitudes in the Netherlands in 1985, 1995, and 2001. Community Dent Oral Epidemiol 2003;31:207-12. Poorterman JHG. Tandheelkundige verzorging Jeugdige Ziekenfonds verzekerden. Eindmeting 2005. Amsterdam: Academisch Centrum Tandheelkunde Amsterdam, 2005. Zhang M, McGrath C, H€agg U. The impact of malocclusion and its treatment on quality of life: a literature review. Int J Paediatr Dent 2006;16:381-7. Taylor KR, Kiyak A, Huang GJ, Greenlee GM, Jolley CJ, King GJ. Effect of malocclusion and its treatment on the quality of life of adolescents. Am J Orthod Dentofacial Orthop 2009;136:382-92. Masood Y, Masood M, Zainul NN, Araby NB, Hussain SF, Newton T. Impact of malocclusion on oral health related quality of life in young people. Health Qual Life Outcomes 2013;11:25. Secord PF, Jourard SM. The appraisal of body-cathexis: bodycathexis and the self. J Consult Psychol 1953;17:343-7. Kiyak HA, West RA, Hohl T, McNeill RW. The psychological impact of orthognathic surgery: a 9-month follow-up. Am J Orthod 1982; 81:404-12. Kiyak HA, McNeill RW, West RA, Hohl T, Heaton PJ. Personality characteristics as predictors and sequelae of surgical and conventional orthodontics. Am J Orthod 1986;89:383-92. Kiyak HA, Zeitler DL. Self-assessment of profile and body image among orthognathic surgery patients before and two years after surgery. J Oral Maxillofac Surg 1988;46:365-71. Maxwell R, Kiyak HA. Dentofacial appearance: a comparison of patient self-esteem techniques. Int J Adult Orthodon Orthognath Surg 1991;6:123-31. Philips C, Bennett ME. Psychosocial ramifications of orthognathic surgery. In: Oral and Maxillofacial Surgery. Philadelphia: W. B. Saunders; 2000, p. 506-34. Ostler S, Kiyak HA. Treatment expectations versus outcomes among orthognathic surgery patients. Int J Adult Orthodon Orthognath Surg 1991;6:123-31. Philips C, Hill B, Cannac C. The influence of video imaging on patients' perceptions and expectations. Angle Orthod 1995;65: 263-70. Gosney MB. An investigation into some of the factors influencing the desire for orthodontic treatment. Br J Orthod 1986;13:86-94.
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Expectations of treatment and satisfaction with dentofacial appearance in patients applying for orthodontic treatment Naomi A. van Wezel,a Annemieke Bos,b and Charlotte Prahlb Amsterdam, The Netherlands
Introduction: Satisfaction with dentofacial appearance and expectations of orthodontic treatment have been analyzed in many studies. In 2002, in a study in The Netherlands, significant correlations were found between dental satisfaction and orthodontic treatment expectations. Satisfaction significantly decreased with increasing age. The aim of this study was to compare the satisfaction and expectations of current patients with the results of a study 10 years ago. Methods: A questionnaire about dentofacial satisfaction and a questionnaire about the expectations of orthodontic treatment were completed by 146 subjects. The mean scores in the present study were compared with the mean scores 10 years ago. Results: The subjects in the present study were more satisfied with their dental appearance. Differences in expectations were found on the subscales of general well-being and self-image. As in the study in 2002, no significant correlations were found between sex, satisfaction, and expectations of orthodontic treatment. Dentofacial satisfaction predicts expectations about orthodontic treatment, especially in the group of subjects aged 17 years and above. Conclusions: The subjects in this study had greater expectations of orthodontic treatment about general well-being and were more satisfied with their dental appearance than were the subjects studied 10 years ago. (Am J Orthod Dentofacial Orthop 2015;147:698-703)
Y
ou never get a second chance to make a first impression. In verbal and nonverbal communication, the face matters. The advantages of beauty seem to be true, at least at first meeting. Facial attractiveness is positively associated with high school marks, good work performance, positive peer relations, social acceptance, high social status, positive body image, and good self-concept. It has also been proven that a malocclusion can have a negative effect on the quality of life.1-9 Tooth color, missing teeth, and poor tooth alignment are the most common reasons for dissatisfaction with dentofacial appearance.10-12 It is therefore not
From the Department of Orthodontics, Academic Centre for Dentistry, University of Amsterdam and Free University, Amsterdam, The Netherlands. a Orthodontist. b Assistant professor. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Naomi A. van Wezel, Department of Orthodontics, Academic Centre of Dentistry, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, The Netherlands; e-mail, [email protected]. Submitted, February 2014; revised and accepted, January 2015. 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2015.01.024
698
surprising that people seek esthetic dental and orthodontic care.11-13 Inconsistent results have been found regarding the association between dentofacial satisfaction, age, and sex.2,10,14 In some studies, no sex differences were found regarding dentofacial satisfaction and treatment expectations,2 but other studies showed that female subjects were less satisfied than were male subjects.10,15 However, it seems that dentofacial satisfaction is significantly correlated with expectations of orthodontic patients about general well-being, improvement of selfimage, and future dental health.2 Also, orthodontic patients seem to expect improvements in esthetics and self-esteem, regardless of their sex.2,15-17 Attitudes about dental health change over time.18 In an epidemiologic dental study in The Netherlands, more patients were undergoing orthodontic treatment in 2005 than in 1999.19 Also, a change in orthodontic treatment need was found. The question is whether these findings are related to current dentofacial satisfaction and expectations of orthodontic patients at the start of treatment. In this study, we replicated the study by Bos et al2 and compared our results with those results. Because of controversy about the impact of malocclusion on
van Wezel, Bos, and Prahl
dentofacial satisfaction and treatment expectations in the orthodontic literature, we examined the effect of malocclusion on dentofacial satisfaction and treatment expectations as well.20-22 Based on the results of previous studies, female patients were expected to be less satisfied with their dentofacial appearance than male patients.10,14 Based on the results of Bos et al,2 younger subjects were assumed to be more satisfied with their dentofacial appearance than older subjects. Furthermore, significant correlations between dentofacial satisfaction and treatment expectations were expected. We explored whether dentofacial satisfaction and orthodontic treatment expectations have changed over time. Finally, based on the results of Zhang el,20 we expected that malocclusion would have no effect on dentofacial satisfaction and treatment expectations. MATERIAL AND METHODS
From November 2011 to June 2012, we sent 2 questionnaires to every person applying for orthodontic treatment at the Academic Centre of Dentistry Amsterdam in The Netherlands. The first questionnaire included 16 items about satisfaction with facial appearance before orthodontic treatment to be scored on a 5-point response scale (from “I am very unsatisfied” to “I am very satisfied”). It was a modification of the body-cathexis scale introduced by Secord and Jourard23 in 1953 and was further developed in the 1980s. It gives an assessment of perceived dentofacial appearance; a high score shows greater satisfaction with the dentofacial body part being measured.24-28 The second questionnaire included 23 items about expectations of orthodontic treatment to be scored on a 7-point response scale (from “worse” to “much better”). It was initially developed for patients undergoing orthognathic surgery and was adjusted for orthodontic patients. It measures long-term expectations of orthodontic treatment.26,29,30 The same subscales were used as in the study by Bos et al.2 The questionnaire about satisfaction with facial appearance was divided into 2 subscales (facial satisfaction and dental satisfaction). The questionnaire about expectations of orthodontic treatment was divided into 4 subscales (general well-being, self-image, oral function, and future dental health). The questionnaires were sent to 220 persons applying for orthodontic treatment at the Academic Centre of Dentistry in Amsterdam; none had visited the orthodontic department before. To this type of social science research, the Dutch Medical Research on Humans Act was not applicable. The questionnaires
699
were returned by 146 subjects (53 male, 93 female), resulting in a response rate of 67%. There were no significant differences in age and sex between responding and nonresponding persons. Subjects with more than 3 missing responses (n 5 10) were excluded from the analysis. There were no significant differences in age and sex between subjects who completed the questionnaire and those who did not. Subjects older than 60 years (n 5 1) and younger than 8 years (n 5 1) were excluded from the study. The mean age of the remaining 134 subjects was 19.6 years (SD, 13.49 years; median, 13 years; age range, 8-60 years). After the initial analysis, the subjects were divided into 2 age groups, as Bos et al2 did in 2003. The first group included subjects from 8 to 16 years old (n 5 84; 35 boys; mean age, 11.42 years; SD, 1.78 years); the second group included subjects from 17 to 60 years (n 5 50; 15 men; mean age, 33.36 years; SD, 13.43 years). All subjects were invited for a first consultation. During this consultation, the subjects (n 5 123) were scored with a Class I (n 5 59), Class II (n 5 57), or Class III (n 5 7) malocclusion. Statistical analysis
First, the internal consistencies of the scales and subscales were determined using the Cronbach alpha. To analyze the effects of sex and age on dental and facial satisfaction and expectations of orthodontic treatment, the Mann-Whitney U test was used. Also, the mean scores of the subscales for the subjects with a Class I malocclusion were compared with the mean scores for subjects with a Class II malocclusion using the MannWhitney U test. The Spearman correlation coefficient was calculated for satisfaction with dental and facial appearance and expectations of orthodontic treatment. Next, a multiple regression analysis was performed to estimate the effect of the initial facial and dental satisfactions on expectations of orthodontic treatment. To analyze changes in satisfactions and expectations over time, the mean scores in our study were compared with the mean scores from the study by Bos et al2 using 1-sample t tests. RESULTS
The internal consistency in 2012 of the questionnaire on satisfaction was satisfactory. The Cronbach alpha for the total scale was 0.93. Internal consistency values for the 2 subscales were 0.93 and 0.52, respectively, for satisfaction with facial appearance and dental appearance. The internal consistency of the questionnaire on expectations was satisfactory as well. The Cronbach
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Table I. Correlations between expectations and satis-
faction
Expectation Age #16 years Satisfaction with facial appearance Satisfaction with dental appearance Age $17 years Satisfaction with facial appearance Satisfaction with dental appearance
Future General Self-image/ dental Oral well-being appearance health function 0.97
0.36
0.33
0.78
0.64
0.11
0.69
0.13
0.31*
0.29
0.29
0.30*
0.15
0.24
0.14 0.07
*P \0.05.
alpha for the total scale was 0.94, and the internal consistency values for the 4 subscales were 0.94 for general well-being, 0.91 for self-image, 0.83 for future dental health, and 0.85 for oral function. No significant differences on the subscales and total scales were found between the male and female subjects for age and sex differences in 2012. However, age was significantly related to facial satisfaction (U 5 1403.500; P 5 0.004), dental satisfaction (U 5 1461.500; P 5 0.003), and expectations about self-image (U 5 1536; P 5 0.049). Patients younger than 17 years of age were more satisfied with their facial and dental appearances, and they had lower expectations of orthodontic treatment with regard to improvements in self-image in comparison with older subjects. The group of subjects with a Class III malocclusion (n 5 7) was relatively small and was therefore excluded from the analysis. The scores for subjects with a Class I malocclusion (n 5 59) were compared with the scores for subjects with a Class II malocclusion (n 5 57). The Mann-Whitney U test showed no significant differences in the subscales and the total scale between subjects with Class I and Class II malocclusions (facial satisfaction: U 5 1486.50, P 5 0.527; dental satisfaction: U 5 1433.00, P 5 0.163; general well-being: U 5 1287.50, P 5 0.295; self-image: U 5 1285.00, P 5 0.131; future dental health: U 5 1576.00, P 5 0.908; and oral function: U 5 1306.00, P 5 0.275). In Table I, the Spearman correlations between the different variables were analyzed for the 2 age groups. Satisfaction with facial appearance was significantly correlated with expectations about general well-being and oral function only for subjects 17 years and older. No correlation was found between sex and expectations of orthodontic treatment.
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A multiple regression analysis was used to determine which variables affected the expectations of orthodontic treatment for the 2 age groups. Table II shows that facial satisfaction and dental satisfaction are significant predictors for expectations about future dental health for subjects younger than 17 years. Dental and facial satisfaction together explained 12% of the variance of the subjects' expectations about future dental health. Dental satisfaction was also a significant predictor for expectations about oral function for subjects younger than 17 years. Table III shows that satisfaction with facial appearance was a significant predictor for all expectations of orthodontic treatment for subjects 17 years and older. Dental satisfaction was a significant predictor only for expectations about self-image. Dental and facial satisfaction explained 16% of the variance on subjects' expectations about self-image. In Table IV, the mean scores and standard deviations on all subscales of both questionnaires are presented for both groups in 2002 and 2012. The mean scores from the present study were compared with the mean scores from the study of Bos et al.2 Significant differences between the subjects in this study and those from the earlier study were found for dental satisfaction and expectations about general well-being. The subjects in 2012 were significantly more satisfied with their teeth than were those in 2002 and had higher expectations of orthodontic treatment for their general well-being. The mean scores for the different age groups from the present study were compared with the mean scores for the same age groups from the study in 2002 using 1-sample t tests. For subjects younger than 17 years, only 1 significant difference was found for facial satisfaction in both boys (2002, 55.75 [n 5 36]; 2012, 60.79 [n 5 35]; t 5 3.00; P \0.01) and girls (2002, 60.56 [n 5 36]; 2012, 57.32 [n 5 49]; t 5 2.19; P \0.05). In 2012, boys younger than 17 years were significantly more satisfied with their facial appearance than were the boys 10 years ago. Girls younger than 17 years in 2012 were significantly less satisfied with their facial appearance than were the girls 10 years ago. In Tables V and VI, the mean scores and standard deviations on all subscales of both questionnaires are presented for the age groups 17 years and older in 2002 and 2012. As illustrated in Tables V and VI, both sexes 17 years and older were significantly more satisfied with their teeth in 2012 compared with 2002. Women 17 years and older, however, were significantly more satisfied with their facial appearance as well and had significantly higher expectations about general well-being and self-image than did the women 10 years ago.
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Table II. Multiple regression for subjects #16 years of age
Expectation Satisfaction with facial appearance Satisfaction with dental appearance R Adjusted R2
General well-being
Self-image/appearance
Future dental health
b P 0.176 0.260 0.177 0.258 0.146 0.006
b 0.121 0.246
b 0.436 0.458
Oral function
0.189 0.009
0.351 0.123
b P 0.251 0.194 0.323 0.036* 0.245 0.034
General well-being
Self-image/appearance
Future dental health
Oral function
ß P 0.441 0.004y 0.149 0.314 0.413 0.133
ß 0.372 0.385
P 0.435 0.114
P 0.005y 0.003y
*P \0.05; yP \0.01.
Table III. Multiple regression for subjects $17 years of age
Expectation Satisfaction with facial appearance Satisfaction with dental appearance R Adjusted R2
P 0.011* 0.009y
P 0.025* 0.180
ß 0.345 0.203
0.437 0.156
ß P 0.343 0.028* 0.098 0.523 0.324 0.064
0.331 0.071
*P \0.05; yP \0.01.
Table IV. Means and standard deviations of all subscales for the total groups in 2002 and 2012 Total groups 20022 (n 5 100) Subscale Satisfaction questionnaire General facial satisfaction Dental satisfaction Expectation questionnaire General well-being Self-image/appearance Future dental health Oral function
2012 (n 5 134) t
P
Mean
SD
Mean
SD
56.04 5.99
10.59 1.86
56.76 6.49
10.24 1.87
0.804 3.116
0.420 0.002y
26.54 18.00 19.70 9.56
10.93 7.53 5.97 4.30
28.90 18.73 19.35 9.92
13.21 7.88 5.93 4.77
1.986 1.055 0.680 0.849
0.049* 0.294 0.497 0.397
*P \0.05; yP \0.01.
DISCUSSION
In this study, decreased dentofacial satisfaction with increasing age was found, as expected. This finding was consistent with previous studies.2,31 Because the older subjects were less satisfied with their dental and facial appearance than the younger subjects, it is not surprising that the older subjects expected more improvement in their self-image. Dental and facial satisfactions were significant predictors for all expectations of orthodontic treatment in the older age group. For the younger subjects, facial satisfaction was found to be a significant predictor only for expectations of orthodontic treatment about future dental health. This was in contrast to previous studies. Philips
et al17 found that older patients showed more concern about functional problems and future dental health than did younger subjects, and Bos et al2 found that dental and facial satisfactions were predictors for expectations about general well-being in the younger age group. Although female subjects were expected to be less satisfied with their dentofacial appearance, no significant correlations were found between sex, satisfaction with dental and facial appearances, and expectations of orthodontic treatment. Also, there was no effect of malocclusion on dentofacial satisfaction. This result was also found by Taylor et al.21 In comparison with the subjects in 2002, the subjects in the 2012 study had significantly higher expectations
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Table V. Means and standard deviations on all subscales for men $17 years in 2002 and 2012 Men 2002 (n 5 11)
2012 (n 5 15)
2
Subscales General facial satisfaction Dental satisfaction General well-being Self-image/appearance Future dental health Oral function
Mean 53.36 5.00 26.73 19.73 21.82 10.64
SD 10.98 1.73 6.23 8.15 4.26 3.96
Mean 52.53 6.13 27.57 17.20 20.20 11.29
SD 9.90 1.25 13.66 7.59 6.56 5.12
t 0.323 3.523 0.230 1.291 0.956 0.472
P 0.751 0.003* 0.821 0.218 0.355 0.645
*P \0.01.
Table VI. Means and standard deviations of all subscales for women $17 years in 2002 and 2012 Women 2002 (n 5 17)
2012 (n 5 35)
2
Subscales General facial satisfaction Dental satisfaction General well-being Self-image/appearance Future dental health Oral function
Mean 48.94 5.12 27.00 19.00 19.00 9.47
SD 9.01 1.50 8.31 5.85 5.72 3.86
Mean 54.03 5.77 32.36 22.26 19.62 10.33
SD 9.95 1.78 13.76 8.41 6.11 4.36
t 3.027 2.181 2.239 2.263 0.589 1.137
P 0.005y 0.036* 0.032* 0.030* 0.560 0.264
*P \0.05; yP \0.01.
about orthodontic treatment. This was especially true for women aged 17 years and older. A reason for the higher expectations of orthodontic treatment might be that orthodontic treatment has become more common in The Netherlands during the last decade.19 It can be assumed that patients see friends and acquaintances who have been treated successfully and therefore have high expectations for their own orthodontic treatment. Unexpectedly, the subjects in this study were more satisfied with their dental and facial appearances than were those studied 10 years earlier. A possible explanation for the increased satisfaction over time may be that decreased anterior crowding in the Dutch population was found between 1999 and 2005.19 Several studies have shown that anterior crowding is the main reason for dissatisfaction with dental appearance.10-13 Some limitations of this study must be noted. First, it describes the responses of subjects applying to the Academic Centre of Dentistry Amsterdam for orthodontic treatment. Therefore, our results cannot be used for orthodontic patients in general. Furthermore, the group in 2002 might not be comparable with the group in 2012. Both groups included different people who might not be similar for socioeconomic status and
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malocclusion. However, because both groups were large samples of subjects applying for orthodontic treatment at the Academic Centre of Dentistry in Amsterdam, a comparison between them seemed acceptable. Additionally, if the sample of subjects 17 years and older had been larger and the distribution of the sexes had been more equal, it is possible that significant correlations between sex and satisfaction with dental and facial appearances would have been found. Finally, although the reliability of the questionnaire on satisfaction with facial appearance was high, that of the questionnaire on dental satisfaction was only moderate. To compare the results of the 2012 study with the results from 2002, the same items were used. To increase the reliability, more items could be added to the subscale of dental satisfaction in a future study. In our study, changes in dental and facial satisfaction and expectations of orthodontic treatment over time were found. In the future, this study can be replicated to examine whether there are tendencies toward increasing dental and facial satisfactions and expectations of orthodontic treatment over time. Additionally, to analyze the correlations between objective orthodontic treatment need and dental and facial satisfactions
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and treatment expectations, the index of orthodontic treatment need could be used.
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13.
CONCLUSIONS
1.
2.
3.
4.
The subjects in 2012 had higher expectations of orthodontic treatment about general well-being than did those studied in 2002, especially the women 17 years and older. The subjects in this study were more satisfied with their dental and facial appearances than were those studied 10 years earlier. No significant correlations were found between sex, satisfaction with dental and facial appearances, and expectations of orthodontic treatment. Facial satisfaction was a significant predictor for all expectations of orthodontic treatment in subjects 17 years and older. For the younger subjects, facial satisfaction was found to be a significant predictor only for expectations about future dental health.
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