Introduction
Our objective was to identify factors associated with orthodontic treatment satisfaction of patients and their caregivers, when applicable.
Methods
MEDLINE via Ovid, PubMed, EBM Reviews and EMBASE via OVIDSP, LILACS, Web of Science, and Google Scholar were searched electronically. Reference lists of included articles were also screened for potential relevant studies missed during the electronic searches. Studies evaluating the satisfaction levels of patients or caregivers after orthodontic treatment were considered. Methodologic quality of the included studies was assessed using a modified Newcastle-Ottawa scale.
Results
Eighteen studies satisfied the inclusion criteria, representing 2891 patients and 464 parents. The risk of bias was moderate in 13 and low in 4 of the included articles. The studies used different questionnaires and timings to assess postorthodontic treatment satisfaction. Based on the available limited evidence, satisfaction was associated with perceived esthetic outcomes, psychological benefits, and quality of care. The latter was specifically linked to dentist-staff-patient interactions. Dissatisfaction was associated with treatment duration, pain levels and discomfort, and the use of retention appliances. When both assessments were available, the patient’s and the parent’s satisfaction levels were strongly correlated.
Conclusions
Based on the limited available evidence with moderate risk of bias, we identified factors that appear to be more commonly associated with a high or low level of satisfaction. Consideration of these factors could be important for practitioners attempting to set realistic expectations of their patients and caregivers regarding orthodontic treatment outcomes.
Most dentists consider orthodontic treatment successful based not only on an esthetic result but also on a stable functional occlusion. For patients, the motivation to undergo orthodontic treatment varies from being completely uninterested (some children and adolescents) to a strong willingness to undergo treatment. Parents’ treatment expectations appear to be based on perceived socio-occupational advantages and improved dental health for their children. Esthetic improvement is usually the main reason that adults seek orthodontic treatment.
Because of the different reasons for seeking orthodontic treatment, patients, parents, and orthodontists may assess treatment outcomes differently. Therefore, a professional assessment is not necessarily closely related to patient satisfaction. Associations between patient satisfaction and factors such as doctor-patient relationships, occlusion stability perception, tooth alignment, patients’ commitment and interest, personality and neuroticism traits, and patient motivation have been reported. The considerable variations among these factors and how closely they are related to patients’ perceptions suggest that patients should become an integral part of the decision-making process and treatment outcome assessment in any orthodontic practice’s efforts to be successful.
Patient satisfaction has had relatively limited coverage in the orthodontic literature. Various tools have been used to measure patient satisfaction with orthodontic care. The tools used primarily relied on patients’ perceptions, rather than on professional assessments. In 2006, a systematic review attempted to address the concept of orthodontic patient treatment satisfaction, but only as it related to the stability of the results. No definite evidence-based conclusion could be drawn at that time. Because more than 8 years have passed since that literature synthesis was published and because of its limited scope, it seems justified to explore and analyze whether newly available literature could shed more light on this important area. In addition, since it is important to focus not only on treatment stability as a proxy of patient and parent satisfaction, we also chose to examine several other factors that might affect satisfaction.
The focus of this systematic review was therefore to identify factors associated with orthodontic treatment satisfaction among patients and their parents after treatment.
Material and methods
This systematic review followed the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist.
Protocol and registration
Neither a protocol nor a protocol registration was available.
Eligibility criteria
We included studies evaluating satisfaction levels of patients or parents and caregivers after orthodontic treatment, assessed by any tool, with no language or study design restrictions. The assessment of satisfaction had to occur after the active phase of the orthodontic treatment. Review articles, book chapters, letters, case reports, personal opinion publications, and studies that assessed orthodontic treatment combined with orthognathic surgery were excluded.
Information sources and search
Electronic databases searched included MEDLINE, PubMed, EBM Reviews and EMBASE via OVIDSP, LILACS, and Web of Science. A limited gray literature search was explored in Google Scholar by limiting the search by the first 100 most relevant hits. All electronic searches were inclusive until March 29, 2014. In addition, the reference lists of the included articles were hand screened for potential relevant studies that could have been missed during the electronic database search.
Tailored truncation and word combinations were applied and adapted for each database search ( Appendix 1 ). Duplicate references were removed with a reference manager software (RefWorks-COS; ProQuest, Bethesda, Md).
Study selection
The eligibility of the selected articles was determined in 2 phases. In the first phase, 2 reviewers (C.P.P., J.R.P.) independently screened the titles and abstracts identified by all electronic databases related to satisfaction with orthodontic treatment. In the second phase, the reviewers assessed the full-text articles to confirm their final eligibility. The reviewers were not blinded to the authors and the results of the studies. Disagreements between them were solved by consensus. A third person (C.F.M.) was involved when necessary.
Data collection process and data items
We developed a standardized data collection form based on the Cochrane Consumers and Communication Review. Key features, such as sample size, timing after treatment, methodology, assessment tool, response rate, statistical analysis, and findings from the included articles, were extracted by 2 reviewers ( Table ). One reviewer (C.P.P.) did data extraction, and the other (J.R.P.) crosschecked all collected information. Once again, disagreements were solved by consensus. When required, the authors of the studies were contacted for clarification.
| Authors | Sample size Age, mean or range |
Timing | Patients’ treatment place | Psychometric properties of the elected tool, satisfaction (S) questions | Method of application of survey response rate | Risk of bias score † |
|---|---|---|---|---|---|---|
| Feldmann, 2014 | n = 120 Mean age, 16.9 y SD, 1.78 y |
At first visit of retention | Consecutive patients/orthodontic clinic/public dental service | Validated questionnaire S = 3 |
Questionnaire, retainer recall 90%-100% per question |
4 |
| Oliveira et al, 2013 | n = 54 Ages, 20-61 y |
Completed treatment (recall) | 12 patients, university 42, private practice. |
Nonvalidated questionnaire S = 3 |
Questionnaire, recall consultation 100% |
3 |
| Keles and Bos, 2013 | n = 115 17.2 y SD, 3.76 y |
3 y of postorthodontics | Consecutive patients, department of orthodontics | Validated questionnaire S = 15 |
Questionnaire 6 weeks after debonding 55% |
4 |
| Maia et al, 2010 | n = 209 Ages; T1, 14.3 y SD, 8.6-42.9 y T2, 16.2 y SD, 10.8-44.1 y T3, 24.9 y SD, 17.9-59.2 |
Posttreatment (mean, 8.5 y) | Private clinic | Validated Dental Impact on Daily Living Index to assess long-term satisfaction | Patients randomly selected phone calls and questionnaire 100% |
4 |
| Mollov et al, 2010 | n = 214 21.9 y SD, 12.20 y |
Retention stage (average 5.3 y) | College students, first-year undergraduate and patients from private practice | Invalidated questionnaire S = 3 |
Students surveyed during class time and finished patients mailed 77.11% ‡ |
3 |
| Anderson et al, 2009 | n = 147 11.61 y SD, 1.92 y |
Maximum of 3.5 y postorthodontics | Patients who had completed their orthodontic treatment and parents | Post-Surgical Patient Satisfaction Questionnaire Maede and Inglehart’s scale |
Questionnaire mailed 96% ‡ |
5 |
| Uslu and Akcam, 2007 | n = 40 5-22.5 y |
Postretention | University | Invalidated questionnaire S = 13 |
Mailed questionnaire 15.8% |
3 |
| Al-Omiri andAbu Alhaija, 2006 |
n = 50 20.7 y SD, 4.20 |
Retention stage (6-12 mo) | Randomly selected from orthodontic department of university | Validated Dental Impact on Daily Living NEO-FFI ‡ 60 questions |
Questionnaire mailed 84% |
6 |
| Barker et al, 2005 | n = 294 26.0 y |
Not specified | Orthodontic patients born at the same selected hospital | Validated 177-item modified version of multidimensional personality questionnaire | Asked whether result was excellent, pretty good, fair, or poor. 95.6% ‡ |
5 |
| Bos et al, 2005 | n = 70 15.8 y SD, 1.81 y |
3 y posttreatment. | Academic Centre of Dentistry | Nonvalidated questionnaire adapted from a validated tool S = 20 |
Questionnaire mailed to patients 70% |
4 |
| Mascarenhas et al, 2005 | n = 157 orthodontists n = 121 pediatric Age, not declared |
At least 6 mo posttreatment | Consecutive patients from orthodontists and pediatric private practices | Validated patient satisfaction questionnaire S = 25-item instrument |
Self-administered parental satisfaction questionnaire, not declared | 3 |
| Bennett et al, 2001 | n = 299 Children under 18 y and parents |
Within 2 y after debonding | Random sample: 2 orthodontic clinics at universities | Phase 1: phone interview Phase 2: questionnaire Phase 3: clinical assessment and questionnaire. S = 41 |
Validated questionnaire: telephone interview, focus group and mailed questionnaire 65% and 49% |
7 |
| Eberting et al, 2001 | n = 100 patients Age: 21 y was the based age for analysis |
Not specified | Completed orthodontic treatment in 3 private practices | Validated American Board of Orthodontics scores S = 9 |
Mailed questionnaire with 9 questions 46.5 % |
2 |
| Birkeland et al, 2000 | n = 224 67 treated patients Control: 157 untreated T1, 11 y, T2, 15 y |
Children and parents at T1 and T2 | Random sample from schools T1: 359 children divided by demographic area. T2: 224 subjects |
Peer Assessment Rating Index Global Self-Evaluation Scale for self-esteem evaluation |
Questionnaires filled by children Parents: mailed questionnaire Parents: 83.3% Children: 81.6% |
5 |
| Fernandes et al, 1999 | n = 99 children n = 52 orthodontic treated + 93 parents T1, 11 y; T2, 16 y |
Children and parents at T1 and T2 | Four classes of 3 schools | Nonvalidated questionnaire S = 2 |
Questionnaire filled out during follow-up after treatment Child: 94.9% Parents: 93.9% |
5 |
| Riedmann et al, 1999 | n = 9 Average age, 30 y T1, before treatment T2, 5.3 y posttreatment |
Adult patients, 42% in long-term retention | 88 of 147 consecutive patients from a university | Peer Assessment Rating Index S = 3 |
Mailed questionnaire 80% |
6 |
| Bergstrom et al, 1998 | n = 67 Control, 57untreated Age not declared |
Not declared 8 y after first consultation | Patients from private practices | QQP-orthodontics modified from quality from patients’ perspective (QPP) | Mailed questionnaire 81% |
6 |
| Espeland and Stenvik, 1991 | n = 100 40 treated 21-22 y |
Completed orthodontic treatment | Orthodontic treatment by general practitioners | Validated questionnaire S = 2 |
During annual visit Not declared |
5 |
Risk of bias in individual studies and summary measures
Faced with the lack of a properly validated tool that is clearly indicated for risk of bias assessment among observational cross-sectional studies based on surveys and questionnaires, a decision was made to identify a validated method that was as objective and systematic as possible. The Newcastle-Ottawa scale, modified for cross-sectional studies, was applied to all the selected articles. This scale addresses 3 domains (selection, comparability, and outcome), and the studies could be awarded 1 star for each factor in the first 2 categories (sum of 5 stars) and 2 stars for each factor in the comparability section. The sum of the stars, up to a maximum of 7, reflected the overall quality rating of each study. The higher the number of stars, the higher the quality rating. In addition, the quality of each survey or questionnaire was assessed by applying a validated questionnaire quality-assessment tool.
Two reviewers (C.P.P., J.R.P.) separately completed the quality assessments of the selected studies. Disagreements were solved by consensus, which included a third person (C.F.M.) when necessary.
The primary outcomes for this systematic review were the impacts of any factors considered in the studies about the patients’ and their parents’ satisfaction levels with their orthodontic treatment results.
Synthesis of results and risk of bias across studies
It was decided a priori that if the data from different studies were sufficiently homogeneous and the combination of the collected data was justifiable, a meta-analysis would be carried out.
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