Factors Affecting Patient Satisfaction after Orthodontic Treatment

Among the most important goals of dental care is helping patients in their attempts to reach an acceptable level of satisfaction with their oral cavity and dentition.1 Dentofacial problems have known definitive effects on patient satisfaction with their dentition because it affects esthetics, performance, and function.2,3 It has been shown that people who are dissatisfied with their facial appearance often express more dissatisfaction with their teeth.4 

Satisfaction with dental appearance has been correlated with age and sex. It has been reported that satisfaction with dentofacial appearance decreases with age.5–7 Therefore, adults are expected to be less satisfied with their dentofacial appearance than an adolescent.

Females are more dissatisfied with the appearance of their dentition than are males.5,8 It has been shown that malaligned teeth concern girls more than boys,9,10 and females perceive more need for orthodontic treatment than males.8–11 

Personality has certain effects on patient satisfaction with their dentofacial conditions and treatment. Extroversion, anxiety, calmness, and warmth have been proved to have well-defined effects on patient satisfaction and patient opinion regarding dentofacial esthetics.12 Satisfaction with dental treatment has been correlated and predicted by certain personality traits such as self-esteem, self-confidence, obedience, accommodating, calmness, extroversion, anxiety, warmth, neuroticism, and conscientiousness.12–14 It has been reported that female patients with high neuroticism scores and male patient with high introversion scores are less likely to be satisfied immediately after orthognathic surgery.15 

Satisfaction with orthodontic treatment is poorly covered in the literature. This study was undertaken to identify the possible effect of patient sex, age, extraction therapy, severity of orthodontic problem, and personality traits on their satisfaction with orthodontic treatment.

A total of 64 patients (mean age 20.7 ± 4.2 years, median, 22 years; range, 13 to 28 years) were randomly selected from records of the Orthodontic Department at Jordan University of Science and Technology Dental Teaching Center in Irbid. The patients were given two questionnaires, the Dental Impact on Daily Living (DIDL) questionnaire for assessment of his/her satisfaction after orthodontic treatment and the NEO Five Factor Inventory (NEO-FFI) questionnaire for assessment of patient's profile and traits. Ten of the patients did not return the questionnaire, and four of them did not fill it completely (response rate 0.84%). Thus, 50 subjects were included in this study.

The DIDL questionnaire has 36 items that are placed in five major categories and tackles five major dimensions of dental satisfaction, namely appearance, pain, oral comfort, general performance, and chewing and eating (Appendix 1). The DIDL scale measures the effect and the proportional importance of each dimension to the patient. The scale has a score from 0 to 10 to show the relative importance of each dimension to the patient.2,16 

The DIDL questionnaire is a reliable, valid, and comprehensive test to measure patient satisfaction and effect of dental disease on patient daily living.2,16,17 The test has shown the ability to assess satisfaction with different aspects of oral cavity and dental status, and for these reasons, it was selected for this study. Orthodontic problems can affect many aspects of dental esthetics and function, and these aspects are well covered by the DIDL test.

Assessment of patients' personality profiles and traits was carried out using the NEO-FFI.18 NEO refers to Neuroticism (N), Extroversion (E), and Openness (O) (Appendix 2). This test provides a comprehensive assessment of personality using five major domains namely Neuroticism, Extroversion, Openness, Agreeableness, and Conscientiousness. The test consists of 60 items, 12 for each domain, and the response to each item is chosen from five answers. NEO-FFI is short, highly valid and reliable, easy to answer and score, easy for the researchers to interpret, able to tackle the five dimensions of personality accurately, and well documented in the literature.19–21 

NEO-FFI is practical in dental studies because it saves time, is easy to score, and yet is valid, reliable, and comprehensive for the assessment of the five dimensions of the personality.17 

Subjects were subdivided into two groups according to sex (20 males, 30 females; 19 subjects ≤18 years, 31 subjects >18 years). Pretreatment Index of Orthodontic Treatment Need (IOTN) scores showed 26 subjects with borderline need and 24 subjects with high need. A total of 25 patients were treated with the extraction of teeth, and 25 subjects were treated nonextraction. All subjects were treated with upper and lower fixed appliances for an average duration of 19 ± 4 months and were in retention 6–12 months with upper Hawley and lower fixed bonded retainers. The inclusion criteria included no mental retardation and no severe medical illness that might affect their ability to understand and complete the questionnaires or to cooperate with the investigator. Patients' informed consent was obtained before going any further in the study.

Pretreatment and posttreatment study models were assessed for each patient to evaluate the success of the orthodontic treatment using the Peer Assessment Rating (PAR) index. All patients had a reduction in the weighted PAR of more than 80% indicating a good standard of treatment.22 

Data analysis was carried out by the Statistical Package for Social Science (SPSS) computer software version 11.0 (Chicago, Ill). Descriptive statistics were obtained, and means, standard deviation, and frequency distribution were calculated. Comparisons between groups were made using a chi-square test. Correlations between personality traits and satisfaction were performed using Pearson's correlation test.

Ten subjects answered the questionnaire twice with a one-week interval. Reliability was carried out on all questions using correlation coefficients. The correlation coefficients were high and ranged from 0.82 to 0.88. Intraexaminer reliability was performed on the IOTN and PAR scores using kappa statistics.23 Kappa was 0.79 for the IOTN and 0.88 for PAR scores indicating substantial agreement.

Total satisfaction scores of the DIDL questionnaire showed that 4% of the treated patients were dissatisfied with their teeth and scored below 0, 62% were relatively satisfied and scored between 0 and 0.69, and 34% were totally satisfied with their teeth. The highest total satisfaction score was 0.94, whereas the lowest total satisfaction score was −0.48, with a mean of 0.59 ± 0.28. Distribution of satisfaction outcome according to sex, age, IOTN, and extraction therapy is shown in Table 1.

Table 2 shows the distribution of subjects according to personality domains. Ten percent of subjects had low neuroticism scores, 36% had average scores, and 54% had high neuroticism scores. Twenty percent of subjects had low extroversion scores, 56% had average scores, and 24% had high extroversion scores. Forty-two percent of subjects had low openness scores, 50% had average scores, and 8% had high openness scores. Seventy percent of subjects had low agreeableness scores, 24% had average scores, and 6% had high agreeableness scores. Thirty percent of subjects had low conscientiousness scores, 48% had average scores, and 22% had high conscientiousness scores.

Satisfaction with each dimension of the DIDL questionnaire is shown in Table 3. Ninety-two percent of subjects were satisfied with the eating and chewing dimension, 90% were satisfied with appearance and pain dimensions, 88% were satisfied with the oral comfort dimension, and 70% were satisfied with general performance dimensions.

Tables 4 through 7 show the effects of sex, age, IOTN, and extraction decision on the patients' satisfaction after orthodontic treatment. No statistically significant differences were detected in satisfaction scores between males and females and between younger and older age groups. Two females (4%) and none of the males were totally dissatisfied with their appearance after treatment. Both sexes were comparable in their satisfaction with pain, comfort, and general performance dimensions. The older age group showed more dissatisfaction with respect to the pain (4%) and general performance (16%) dimensions, whereas the younger age group showed more dissatisfaction with respect to comfort. The differences between the two age groups were not significant.

Borderline and high treatment need and extraction/ nonextraction groups were comparable in their satisfaction with appearance, pain, general performance, and eating and chewing. However, none of the high treatment need subjects nor those treated with extraction showed dissatisfaction with the comfort dimension compared with 8% dissatisfaction in each of the borderline treatment need subjects and those treated nonextraction (P = .052 and .048, respectively).

Personality traits demonstrated no relationship with satisfaction after orthodontic treatment except for neuroticism (Table 8). Sixty-six percent of the dissatisfied and the relatively satisfied subjects had average or high neuroticism scores (P = .021), and none of them demonstrated a low neuroticism score. Pearson's correlation coefficient revealed a negative correlation between neuroticism and total satisfaction (R ² = −0.367, P < .01). Extroversion was found to be positively correlated with satisfaction with appearance (R ² = 0.356, P = .011). Consciousness was found to be positively correlated with oral comfort (R ² = 0.306, P = .031) (Table 9).

Total satisfaction was highly correlated with satisfaction with comfort (R ² = 0.46, P = .001), satisfaction with general performance (R ² = 0.441, P = .001), satisfaction with eating and chewing (R ² = 361, P = .01), and satisfaction with pain (R ² = 0.34, P = .016). Satisfaction with appearance (R ² = 0.257, P = .071) was not significantly correlated with total satisfaction (Table 10).

There was a 2:3 male to female ratio for the sample of treated patients chosen from those who were referred to the department. This finding reflects the fact that females are more concerned with their esthetics, so they demonstrated better attendance to have their dentition maintained and checked and thus were more represented in the sample.

Assessment of patient satisfaction with their dentition after orthodontic treatment was carried out using the DIDL questionnaire. The DIDL is a reliable, valid, and comprehensive test for measurement of patient satisfaction and the effect of dental disease on patient daily living.2,16,17 The test has shown the ability to assess satisfaction with different aspects of the oral cavity and dental status. Because the DIDL was the only measure of oral health effect, which was tested on Jordanian subjects,24 it was used in this study.

Thirty-four percent of subjects in this study were completely satisfied with their teeth after orthodontic treatment, and only 4% reported complete dissatisfaction. Larsson and Bergsröm7 using QPP (Quality from Patient's Perspective) questionnaire reported that 74% of subjects expressed complete satisfaction with the quality of orthodontic treatment. In their study, 29% of subjects evaluated were dissatisfied or partially satisfied. The use of different questionnaires to assess satisfaction after orthodontic treatment in previous studies makes comparison with other studies more difficult.

The presence of certain levels of dissatisfaction with the dentition after orthodontic treatment might be because of patient compliance or unrealistic expectations.13 Phillips et al25 found that males have different expectations of orthodontic treatment than females. However, this difference in expectations was not translated to a significant difference in patient satisfaction in this study. Also, there is a possibility that although dissatisfaction at the end of treatment is apparent, these individuals may be considerably less dissatisfied than they were at the beginning of treatment. This cannot be known from the collected data, and an evaluation of patient satisfaction should have been performed before orthodontic treatment for these subjects. Orthodontically treated patients demonstrated high levels of satisfaction with their teeth in general. This might be justified by the fact that orthodontic treatment could affect dental performance positively, which could lead to higher levels of satisfaction. This finding coincides with the results of previous studies that revealed higher levels of satisfaction with the dentition after orthodontic treatment.26–30 

In this study sex showed no association with any dimension of dental satisfaction. This was in agreement with those reports that sex has no effect on patient satisfaction7,31 and is contrary to other studies, which suggested that females are more dissatisfied with appearance of their dentition than males.5,8 However, in this study, dissatisfaction with appearance was expressed by females only. This might be explained by the fact that females are more concerned about their appearance9 and they perceive more need for treatment than males.8,9,11 Satisfaction with the pain dimension was comparable between both sexes. This was in agreement with studies reporting no sex differences in pain threshold32,33 and is contrary to those reports that females have a lower pain threshold than males.10,34 

Satisfaction with the dentition after orthodontic treatment showed no relationship with age. This was contrary to other studies reporting that satisfaction decreases with age.5–7,9,31 Although not statistically significant, the older age group showed more dissatisfaction related to pain and general performance dimensions, whereas the younger age group showed less satisfaction because of the comfort dimension. This could be explained by findings of others who reported that the pain threshold lowers with age34,35 and that older subjects express more concern about general dental health25 than do the younger age groups. On the other hand, Ngan et al32 reported a similar pain threshold for those below 16 years and those above 16 years. Younger subjects showed less satisfaction with the comfort dimension and that is related to periodontal health status. This may be because of hormonal changes that occur during pubertal growth.36 

Pretreatment orthodontic treatment need for treatment and the extraction decision were not correlated with satisfaction. Borderline treatment need and high treatment need subjects and extraction and nonextraction subjects perceived the results of orthodontic treatment similarly. However, borderline treatment need and nonextraction treatment subjects expressed more dissatisfaction with the comfort dimension, which included the gingival status. This may be explained by the fact that borderline treatment need and nonextraction treatment cases had mild malocclusion and were mainly externally motivated by the parents. This might result in the milder malocclusion patients neglecting their oral hygiene with resulting gingival inflammation.

In this study, dissatisfied subjects scored average or high on neuroticism. The finding that neuroticism was associated with dental satisfaction was in agreement with reports by others.15,37 Kiyak et al15 reported that persons who scored higher on the neuroticism scale are less likely to be satisfied immediately after surgery but express increased satisfaction later.

In this study, although improving dental appearance was the patient's main concern, satisfaction with the appearance dimension was not correlated with total satisfaction. This was contrary to that reported by Berscheid et al4 who suggested that people who are dissatisfied with their facial appearance express more dissatisfaction with their teeth than any other facial feature. However, it was satisfaction with other aspects of the dentition such as comfort, general performance, eating and chewing, and pain dimension that contributed to the total satisfaction scores.

The results of this study emphasize the importance of considering psychological assessment for patients undergoing orthodontic treatment. Patients with a neurotic personality should be treated with greater care and provided with greater psychological support throughout orthodontic treatment.

• Personality and satisfaction were correlated, and each had its effect on the other.

• Orthodontically treated patients with high neuroticism scores were associated with lower levels of satisfaction with the dentition.

• Satisfaction with oral comfort, general performance, eating capacities, and pain dimensions during orthodontic treatment had definitive effects on total satisfaction.

• Orthodontic patients treated as nonextraction expressed dissatisfaction in the oral comfort dimension.

The authors would like to thank Mrs Abdel Aziz for her help during the preparation of this manuscript.

1. I am not a worrier.

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