Introduction
In recent years, the demand for adult orthodontic treatment has grown rapidly; yet there is a paucity of information on this subgroup of patients. It is well known that understanding the psychological characteristics and motives of any patient is fundamental and that these factors might affect patient satisfaction and adherence with treatment. There is therefore a need for clinicians to improve their understanding of this subgroup to enhance the patient’s experience of treatment delivery and to increase the potential for a successful treatment outcome. The aim of this study was to develop a measure for the assessment of motivating factors and psychological characteristics of adults seeking orthodontic treatment.
Methods
This study involved the qualitative development of a valid patient-centered questionnaire to assess motivating factors for adults seeking orthodontic treatment. This was achieved through semi-structured in-depth interviews; key themes were identified and used to construct a questionnaire assessing motivation for treatment. This was then combined with 3 previously validated questionnaires to measure self-esteem, anxiety or depression, and body image and facial body image. The questionnaire was distributed to 172 adult orthodontic patients at different stages of treatment in a large teaching hospital in the United Kingdom. In addition, the self-esteem, body image, and facial body image scores were compared with data on orthognathic patients from the same hospital and with data from members of the general public.
Results
Desire to straighten the teeth and improve the smile were the key motivating factors for the adult group studied. Other motives included to improve the bite, improve facial appearance, and close (dental) spacing. With respect to the psychological characteristics of self-esteem, body image, and facial body image, the adult orthodontic group was comparable with the general public. However, differences were noted when comparing data from the adult orthodontic group with previously collected data on orthognathic patients.
Conclusions
The motives for adults to seek orthodontic treatment are numerous and varied, whereas psychological traits appear to be closer to those of the general public than to orthognathic patients.
Several authors have commented on the increase in the number of adults coming for orthodontic treatment. This phenomenon has been attributed to various factors including the improved appearance of fixed appliances, increased awareness of the possibilities of orthodontic treatment, and the social acceptability of fixed appliances. Regardless of this, there is little information on this subgroup of patients; in particular, there is a lack of research on adults’ motives for seeking orthodontic treatment. As early as 1971, Edgerton and Knorr proposed the source of motivation to be the most crucial factor in determining and predicting patient satisfaction with treatment. This statement was made in relation to patients seeking esthetic surgery; however, it is likely that this hypothesis can be extrapolated to many types of treatment, including adult orthodontic treatment.
Motivation stems from several sources and can be defined as a concept that describes the conscious or unconscious stimulus for action toward a desired goal: ie, goal-directed behavior. Motivation for seeking treatment can also be classified as external or internal. External motivation results from pressure from significant others, such as family members, friends, or partners, whereas internal motivation is provided by a person’s own desire for treatment to correct a problem he or she perceives. This is important because it is suggested that internally motivated patients are more likely to be satisfied with their treatment outcome than those who are externally motivated. Patients’ motives for seeking orthodontic treatment are numerous, and not every reason or person desiring treatment is suitable. Proffit and White have long recognized the importance of exploring a patient’s motivation for treatment at the initial consultation with the patient’s list of treatment objectives.
A number of studies support esthetic concerns as the key motivational factor. Furthermore, recognition of a malocclusion by dental health professionals might motivate a person to seek orthodontic care. Stenvik et al stated that the decision can be influenced by a number of consumer and provider aspirations that have been summarized into patient factors (age, sex, environmental influence, desire to improve appearance, and social class), and orthodontist factors (appreciation of treatment need, access to services, cost of treatment, and treatment priority).
Whereas children often come for orthodontic treatment as a result of a parental decision, adult patients tend to be self-motivated to seek treatment. The most extensive research on motivation of adults, to date, is now over 10 years old, and previous studies have used questionnaires developed solely by clinicians. In their questionnaire-based study, McKiernan et al found a desire to improve dental appearance to be the primary motivating factor, followed by a wish to improve facial appearance. Similarly, Sergl and Zentner studied the psychosocial aspects of adults undergoing orthodontic treatment and found that over two thirds of them were concerned about poor esthetics, with more than a third acknowledging that their facial appearance had caused significant distress and personal insecurity. However, for many of their subjects, a functional benefit was also an important motive in seeking treatment.
It is therefore apparent that orthodontists should understand the motives and personality traits of their prospective patients, thus facilitating a mutually beneficial alliance. It has been suggested that this should reduce patient dissatisfaction with their treatment outcome, when the clinician understands what patients want, why they want it, and how they arrived at the decision to embark on treatment.
In this study, we aimed to determine why adults seek orthodontic treatment and to establish whether they have personality traits that are similar to members of the general public or whether their traits vary from the norm, as reported in some studies on orthognathic patients. It was intended that the results will offer a valuable insight in addressing patients’ motives and expectations, thereby reducing the risk of patient dissatisfaction with treatment outcomes.
Material and methods
Ethical approval was granted for this study (UCL/UCLH Committee on the Ethics of Human Research No. 07/Q0505/13), and it was emphasized that a refusal to participate would not affect current or future treatment. Assurances were also given regarding the confidentiality of the information provided.
The first stage of the study involved running a focus group to generate specific open-ended questions relating to patients’ motivations for seeking orthodontic treatment. A focus group was formed consisting of the main researcher (S.P.), 3 experienced orthodontists, and 2 general dental practitioners. A clear explanation of the purpose of the focus group was provided to all involved. A topic guide, developed from background reading of the literature, was used when prompts were necessary. The questions generated were then included in an interview schedule to be used as a guide in the next phase of the research.
Twenty-five participants were interviewed by a researcher (S.P.): 12 patients and 13 clinicians. The patients were all aged 18 years or over and at various stages of treatment: pretreatment, undergoing fixed appliance therapy, or within 1 year of completing fixed appliance therapy and wearing retainers. Exclusion criteria were patients with clefts of the lip or palate, and craniofacial syndromes; orthognathic patients were not included because they do not represent the general adult orthodontic population. The clinician sample was varied and included clinicians of different levels of experience working in hospitals and specialist practices around the United Kingdom. A wide variety of participants was chosen to ensure a diversity of viewpoints.
Face-to-face interviews were conducted for all patients and for clinicians based near the researcher (S.P.). For clinicians working elsewhere in the United Kingdom, telephone interviews were conducted. All interviews were tape recorded and immediately transcribed verbatim by using Microsoft Word (Microsoft, Redmond, Wash). The transcription and interview analysis were ongoing activities to ensure that the researcher was aware of emerging themes.
Interview analysis was undertaken both manually and with software (N6; QSR International [UK], Southport, UK). This software allows users to easily organize, code, retrieve, and create links between data, as well as run searches of the text and coding. The frequency of common themes was generated by the N6 software and also manually, and the most salient concepts were then included in the questionnaire.
The overall design of the questionnaire was based on the guidelines of Williams. The questions were developed from the qualitative analyses of the interview data by using the most relevant themes raised, with appropriate lay language in the formulation of comprehensive answers to the questions. A mixture of closed-ended multichotomous and dichotomous questions were formed with responses presented as either simple yes or no choices, or multiple tick boxes. The range of responses listed was as exhaustive as possible, to avoid biasing the responses. At the end of the closed-ended multichotomous questions, an “other” category was included to allow for unanticipated responses or comments, thus ensuring that all viewpoints were covered.
The questionnaire that had been developed was then combined with 3 health assessment scales that have been previously evaluated for reliability and validity: the hospital anxiety and depression scale, the Rosenberg self-esteem scale, and Secord and Jourard’s body cathexis scale to assess body image and facial body image. These questionnaires were selected primarily because they were of interest to the study and allowed comparisons of these data with published norms and previous data collected on orthognathic subjects treated at the same hospital and with members of the general public.
The questionnaire was piloted on 5 adult orthodontic patients at the teaching hospital where the study was undertaken. Participants were asked to comment on any aspect of the questionnaire, including areas that were not easy to follow or required further clarification. The questionnaire underwent further revision after this. All respondents completed the questionnaire in less than 15 minutes; this was thought to be acceptable.
There is substantial debate over whether qualitative and quantitative methods should be assessed according to the same quality criteria. Therefore, all viewpoints were included when assessing the properties of the questionnaire but modified to take into account the distinctive goals of this mixed-methods research. How these quality criteria were applied and assessed is outlined in Table I . Psychometric properties that can be examined to assess quality in questionnaires include validity, reliability, readability, and acceptability ( Table I ).
| Psychometric property | Tested | Methods used in this study |
|---|---|---|
| External validity | No | Not appropriate to assess in qualitative research. |
| Internal validity | Yes | Questionnaire formulated from qualitative phase using in-depth interviews. |
| Content validity | Yes | Expert opinion obtained concerning whether items in questionnaire represented what they intended to measure. |
| Face validity | Yes | Assessed by a panel of experts and by participants in the pilot study. |
| Criterion validity | No | No measure to make a comparison with. |
| Construct validity | No | Not appropriate to test and is usually established after experience with tool over a significant time period. |
| Reliability | Yes | Methodology for data generation and analysis was accurate and transparent. |
| Readability | Yes | Assessed with Flesch reading ease score and Flesch-Kincaid grade level. |
| Acceptability | Yes | Time taken to complete the questionnaire and ambiguities in question wording identified by participants in pilot study. |
| Quality criteria | Criteria applied | Methods used in this study |
|---|---|---|
| Triangulation | Yes | Studying data from questionnaires and interviews and assessing for convergence. |
| Reflexivity | Yes | Personal biases avoided during interviews and an ‘other’ box included in the questionnaire. |
| Fair dealing | Yes | Bias reduced by interviewing patients at different stages of treatment and clinicians from different areas in the United Kingdom working in different settings. |
| Respondent validation | No | Not considered appropriate to assess. Feedback from participants cannot be taken as direct validation of our results, since the account of 1 or 2 participants is likely to vary to our findings developed from a range of participants. |
| Deviant case analysis | Yes | Unexpected viewpoints arising in interviews were not forced into categories. Instead, these viewpoints were included and coded to aid theory development and understanding. |
It was not possible to perform a sample size calculation for this part of the study, because there were no previous comparative studies on which to base this. Therefore, as many adult patients as possible were recruited within the time constraints of this study. The self-completion questionnaires were distributed personally by the researchers to patients attending routine orthodontic appointments. These patients were either pretreatment, in treatment, or within 1 year of debond. Each participant was left alone to complete the questionnaire, which was then either handed to one of the reception staff on the same day or posted backed to the researcher if the patient preferred.
Responses were analyzed by using SPSS software (version 14.0 for Windows; SPSS, Chicago, Ill), and data were subjected to descriptive and comparative statistics. The chi-square test was used to investigate whether there was any significant association between the stage of treatment and the responses in the questionnaire. To investigate differences in scores for the psychological characteristics across the 3 stages of treatment, analysis of variance (ANOVA) for the equality of means was used. When a significant P value was obtained, a Bonferroni correction was applied to protect against spurious conclusions. Independent sample t tests were used to compare scores for the psychological characteristics according to sex and ethnicity. Before these tests, the data were checked for normality by using a histogram with a normal distribution curve.
A linear correlation analysis (using Pearson’s product moment correlation coefficient [r]) was used to measure the association between 2 numeric variables: eg, age and the score for a particular variable. Multiple regression analyses were performed with self-esteem, body image, and facial body image as the dependent variables to determine the extent to which at least 1 of the explanatory variables (age, sex, ethnicity, and stage of treatment) predicted the dependent variables, while controlling for the effect of the other explanatory variables in the equation. Error bar plots were used to display mean scores and 95% CIs for the psychological characteristics of self-esteem, body image, and facial body image and to allow a visual comparison of these adults with data on orthognathic patients and members of the general public (control group). A statistical analysis of these data was not considered appropriate, since this study was cross-sectional, whereas the orthognathic study was longitudinal, and the general public group was analyzed only at 1 time point.
Results
The questionnaire was assessed for readability by using 2 scores produced by Microsoft Word. The Flesch reading ease score was 83.3, and the Flesch-Kincaid grade level was 2.8, both of which were considered acceptable. A response rate of 78% was achieved; a total of 172 adult patients agreed to participate in the study, and 135 patients (31 pretreatment, 70 in treatment, and 34 posttreatment) completed and returned the questionnaire. The demographic details of this group are outlined in Table II .
| Stage of treatment | |
| Pretreatment | 23.0% |
| In treatment | 51.8% |
| Posttreatment | 25.2% |
| Marital status | |
| Married/civil partnership | 34.6% |
| Single | 39.1% |
| Cohabiting | 17.3% |
| Widowed | 0.8% |
| Divorced | 4.5% |
| Separated | 3.8% |
| Sex | |
| Male | 26.7% |
| Female | 73.3% |
| Mean age, last birthday | 33.8 years |
| Ethnicity | |
| White | 71.9% |
| Other | 28.2% |
Question A1 asked patients their reasons for wanting to undergo orthodontic treatment, and the responses are shown in Table III ; a desire to straighten the teeth and improve the smile were the most commonly cited reasons. Question A2 asked whether it was the patient’s own decision to be referred for treatment, and, if not, who suggested this. The initial decision to be referred was from the patients in just over 50% of cases, and, if not the patient’s own decision, it was the general dental practitioner who most frequently suggested orthodontic treatment (78.9% of remaining respondents).
| Which of the following were reasons for you wanting braces? | % | n |
|---|---|---|
| To improve my smile | 68.1 | 92 |
| To improve the appearance of my face | 34.8 | 47 |
| To straighten my teeth | 78.5 | 106 |
| To close spaces | 39.3 | 53 |
| Previous treatment did not work | 12.6 | 17 |
| To improve cleaning/toothbrushing | 17.8 | 24 |
| To improve my speech | 5.2 | 7 |
| To improve my “bite” | 40.7 | 55 |
| To stop my teeth wearing away | 19.3 | 26 |
| Because I heard about braces that you cannot see | 2.2 | 3 |
| To make another type of dental treatment for my teeth easier | 13.3 | 18 |
Question A3 enquired about other external influences on the patient’s decision to have braces. For those who answered “yes,” the 2 most common influences were someone the patient knew had braces, and the need to look good in today’s society. The main perceived benefits of treatment (question A4) were thought to be improved appearance (77.8%), less likely to be self-conscious about their smile (77.8%), improved self-confidence and self-esteem (63.7%), and more confidence when talking to new people (60.0%).
Regarding a history of teasing or receiving negative comments (question A5), 45.9% of the respondents reported currently experiencing, or having previously experienced, teasing regarding their teeth. Of this group, 56.9% stated that this had directly influenced their decision to have braces.
A total of 21.5% of respondents had undergone previous fixed appliance treatment (question A6). Of those who did not have previous treatment, the most common reasons were that treatment had not been recommended (48.1%) and that treatment could not be afforded earlier (23.5%). Question A7 asked which resources patients had used to find out more about braces, in addition to the information their own orthodontist had provided. The most common responses were speaking to other adult patients who have had braces (37.0%) and a discussion with their own general dental practitioner (54.1%).
Question A8 asked whether respondents would consider any other cosmetic dental or plastic surgery procedure for their teeth or any other part of their body. A total of 36.1% of patients would consider, or had undergone, other cosmetic dental work or cosmetic surgery procedures.
For questions A4, 6, 7, and 8, each response was divided into 3 groups according to the stage of treatment to examine the data for any potential recall bias. Interestingly, the only statistically significant difference was for question A4 (benefits of treatment), and there was an association between the perceived likelihood of finding a boyfriend or girlfriend and the stage of treatment ( P = 0.02). The perceived likelihood of finding a boyfriend or girlfriend increased from pretreatment to treatment and then to posttreatment. However, closer inspection of the data suggested that this was only a trend, since the chi-square test in this circumstance was not robust because of the small number of patients in each category.
The scoring systems for the self-esteem, anxiety and depression, and body image/facial body image questionnaires were as follows: For self-esteem, higher scores represent higher self-esteem (scoring range, 10-40). For both subscales of the hospital anxiety and depression scale, scores of 0 to 7 are considered normal, 8 to 10 are mild, 11 to 14 are moderate, and 15 to 21 are severe impacts. Lower body image scores suggest higher satisfaction (range, 27-135). Lower scores for facial body image suggest higher satisfaction (range, 10-50).
Multiple linear regression analyses with each psychological trait as the dependent variable were undertaken. The R 2 values for all regression equations ranged from 4% to 7%, indicating that, for each psychological trait, only a small percentage of the variability in the scores for each trait could be explained by the variables entered into the model (age, ethnicity, sex, and stage of treatment).
The mean self-esteem score for adult orthodontic patients was 32.2. The only variable that was significantly related to self-esteem was whether the patient had finished treatment ( P = 0.02). For patients who had finished treatment, their self-esteem scores were an average of 2.4 points higher than for those who had not finished treatment, after controlling for age, sex, and ethnicity.
The mean anxiety scores were in the normal range for the whole group (score, 6.9) and for the pretreatment and posttreatment groups separately, but scores were at the upper end of the normal range for the in-treatment group (score, 7.3). The only variable that was significantly related to the anxiety score was sex ( P = 0.04). On average, women had an anxiety score 1.4 points higher than men after controlling for age, ethnicity, and stage of treatment.
The mean depression score was 3.2 for the whole group, again within the normal range, and there were no significant differences between the 3 stages of treatment. After taking all other variables into consideration, only age was close to significance ( P = 0.06), with the depression scores increasing, on average, by 0.04 points per year of increase in age.
The mean body index score was 68.9, and there were no significant differences between the 3 stages of treatment, although there was a trend for satisfaction with body image to improve during and after treatment. The mean facial body image score was 25.6, with no significant differences between the 3 stages of treatment; however, there was a trend for increased satisfaction with facial body image as treatment progressed. The only variable that was significantly related to facial body image score was whether the patient had finished treatment ( P = 0.03). Therefore, on average for a patient who had finished treatment, the facial body image score was likely to be 4.3 points higher compared with a patient who had not yet finished treatment.
We compared the psychological profile of adult orthodontic patients with orthognathic patients and members of the general public. Figures 1 through 3 show the mean scores and 95% CIs for self-esteem, body image, and facial body image for the cohort of adult orthodontic patients in this study and also those from a previous study for orthognathic patients at different stages of treatment and for members of the general public. The solid line shows that the orthognathic patients were followed longitudinally through the different stages of treatment, whereas this study of adult orthodontic patients was cross-sectional; hence, no line is shown joining the time points.
