Despite the increases in adults undergoing orthodontic treatment in both the public and private sectors, satisfaction with the treatment process has not been widely explored. In this study, we investigated factors influencing satisfaction with the process of orthodontic treatment in adult patients.
This was a prospective cross-sectional qualitative study. Participants were adults who had completed orthodontic treatment with fixed appliances and were recruited from 2 sites (a National Health Service public sector teaching hospital and a private specialist practice). Data were collected using in-depth interviews, and a content thematic analysis with a framework approach was used to analyze the data.
A total of 26 adults were recruited (13 at each site). Five main themes were identified relating to patient satisfaction with the process of treatment: communication, staff, physical environment, appointments, and impact of appliance treatment. Effective communication was a dominant theme, particularly relating to explanations during treatment and making patients feel involved in their own care.
In general, adult orthodontic patients were satisfied with the process of treatment, and good communication played a major part in this. Despite the differences in working models in the public and private sectors, many similarities arose when comparing the factors between the 2 sites.
A prospective cross-sectional qualitative study of patient satisfaction is described.
Five themes relating to satisfaction with the process of treatment were identified.
Effective communication was a dominant theme.
Others were staff, physical environment, appointments, and impact of appliance treatment.
Many similarities arose when comparing factors between public and private sectors.
Patient satisfaction has been defined as “positive evaluations of distinct dimensions of healthcare.” Patient satisfaction is a fundamental measure of the quality of health care provision; however, satisfaction is the result of a complex process with many antecedent factors that we are far from fully understanding. The treatment process is arguably as important as treatment outcome, and it is therefore essential to understand and quantify satisfaction at all stages of treatment from the patient’s perspective to provide the best possible treatment outcomes. Patient-reported measures are increasingly used to assess and compare treatment outcomes, and inclusion of patient values is at the core of evidence-based practice.
In orthodontics, clinician-derived objective measures have been used to assess outcomes of treatment for many years, but recently there has also been an increase in research involving patient-based subjective measures. Measuring satisfaction with the process of orthodontic treatment is a complex task because multiple dimensions of treatment must be considered. Although some attempts have been made to quantitatively assess satisfaction with treatment, previous studies have mainly focused on children and adolescents. It is important to appreciate that adult orthodontic patients may differ from children and adolescents with regard to psychological experience.
The lack of condition-specific, standardized measures to investigate satisfaction with the process of treatment in orthodontics complicates research in this area further, and previous studies have adapted questionnaires developed for use in the general dental setting (eg, the Dental Visit Satisfaction Questionnaire) or the orthognathic setting, neither of which is ideal. This is further complicated by the fact that instruments are not always developed based on qualitative methodology, considering patient views.
Bennett et al developed a reliable self-reported measure of parental satisfaction with orthodontic treatment in children and adolescents using mixed methods of qualitative and quantitative research and found the questionnaire to be useful in assessing satisfaction with both the process and the outcome of treatment. However, this method has yet to be applied to investigating satisfaction in adult orthodontic patients. There is still a relative paucity of information relating to adult orthodontics, despite the increase in adults seeking treatment. Research in this patient group is key to enabling provision of treatment that matches patient expectations, providing an understanding of patient satisfaction in health care, and thereby enhancing our provision of holistic care. There is also a need for investigations of this type in both the public and private sectors, since most adult treatment is carried out in the private sector.
Therefore, in this study, we investigated the factors that influence satisfaction with the orthodontic treatment process in adult patients in both the public and private sectors.
Material and methods
Ethical approval was granted by the National Research Ethics Service, North West-Lancaster (reference number 15/NW/0595), in the United Kingdom, and written consent was obtained from all participants. This was a prospective, cross-sectional qualitative study undertaken at 2 sites. The orthodontic department at the Eastman Dental Hospital is a public-sector postgraduate teaching hospital in London where patients do not contribute toward the cost of treatment and are funded by the government’s National Health Service. Treatment is primarily undertaken by postgraduates in specialty training programs. The private practice site was located in Oxford, United Kingdom. Treatment planning was conducted by a specialist orthodontist, and treatment appointments were shared between the orthodontist and a dentist with a special interest in orthodontics.
Inclusion criteria were patients who had commenced active treatment over the age of 18 years, had completed fixed appliance treatment, and were willing to be interviewed. Patients with syndromic conditions (including clefts of the lip or palate) or patients who underwent orthodontics in preparation for orthognathic treatment were excluded from the study.
The ability to draw wider inferences from qualitative research depends largely on the nature and quality of the sampling. Convenience sampling was used in this study, and equal numbers of patients were recruited to allow some comparisons between sites. The intention was to recruit men and women of varying ages and with a variety of malocclusions, including patients who underwent orthodontics only and some who had multidisciplinary care (including restorative and periodontal treatment but excluding orthognathic treatment). In contrast with quantitative research, sample size was not a consideration since it was dictated by the saturation of the emerging themes.
All interviews were undertaken in a private room away from clinical areas to ensure privacy. The interviews were undertaken by 1 researcher (L.W.) who had undergone in-depth interview training provided by attendance at a course given by an independent social research agency. The interviews followed a semistructured format using a topic guide; any relevant new topics that arose during the process were subsequently added to the topic guide for further exploration in subsequent interviews. The interview duration depended on the amount of information provided, and recruitment was terminated once no new themes arose.
A content thematic analysis using a framework approach was used to analyze the data. This involved transcription of the interviews verbatim and identification of recurrent themes by 2 researchers (L.W. and S.J.C.) independently. Both researchers read and reread the data and agreed on the themes and subthemes. Each theme was then color coded, and the transcripts were labeled accordingly for ease of sorting. Quotes were input into an Excel workbook (Microsoft, Redmond, Wash); each theme was allocated a separate worksheet, and the columns represented the subthemes. Each patient was allocated a row, and any relevant quotes from the transcriptions were entered accordingly.
A total of 26 participants were recruited for this study, 13 at each site. All patients from the private practice were women, with an age range of 40 to 57 years. At the National Health Service site, 4 participants were men, and 9 were women; they were between the ages of 23 and 58 years. Overall, the average time since debond was 10 months: 7 months (range, 1.5-13 months) at the dental hospital and 14 months (range, 1.5-33 months) in the private practice. Interviews lasted between 12 and 57 minutes.
From the analysis, 5 main themes were elicited. In each main theme, there were several subthemes ( Fig ). Overall, similarities were noted between patients treated in the public and private settings in relation to the factors that influenced their satisfaction with the treatment process. The main difference between the 2 sites was the greater impact of the physical environment on satisfaction in patients in the private setting compared with those treated at the public hospital.
The results are presented, using direct verbatim quotes to support the generation of the themes and subthemes. Quotes include the site and participant number (eg, PP 1 is private patient 1, and NHS 1 is National Health Service patient 1) and the associated line numbers from the transcript. When necessary, explanatory commentary has been provided. Large volumes of data were analyzed to generate the themes and subthemes, but in the interest of brevity, limited examples have been provided.
Theme 1, communication
Four subthemes were identified as detailed below.
Subtheme 1a, planning and decision making. Patients in both settings described how comprehensive discussions of treatment options and information, including risks and benefits, helped their understanding and decision making and made them feel empowered.
“I was assessed and I had a very, very comprehensive explanation of what my problems were, what my options were. I felt like I was in control all the time.” (NHS 1; 215-8)
Subtheme 1b, communication between colleagues. Interviewees described the positive experiences of seeing their orthodontist communicate with their own dentist or with other dentists involved in multidisciplinary treatment.
“With the dentistry I had over the decade I never ever experienced this sort of process where the two professionals worked together to help… that gave me a lot of confidence in the process but also what was going to be the outcome.” (PP 10; 51-4)
Subtheme 1c, communication with the patient during treatment. Communication between the orthodontist and the patient during treatment was discussed by the majority of those interviewed. Patients valued being asked their opinions and being involved in the treatment process; when this happened, satisfaction was enhanced. Understanding more about the treatment process gave patients confidence in the likelihood of getting a good outcome.
“It made the whole process feel a bit more collaborative…it was kind of a shared process.” (NHS 9; 116-20)
“In the past doctors and dentists were God, nobody dared to speak to them, but I think that has changed, particularly in dentistry. They ask you for your opinion, they show you things and I felt that I’d come to the right place.” (PP 10; 167-79)
Subtheme 1d, customer care and approachability. The majority of patients in both settings described the approachability and availability of staff to ask questions or gain more information. A few patients thought that they would have liked more information from their orthodontist.
“If you have questions afterwards or you need to pop in, that is their open door policy, which I think is great.” (PP 7; 227-9)
“They gave me some leaflets and each time I had a question they were always open to answer my question which was really good because if I was anxious something they were approachable. (NHS 4; 258-60)
“I sometimes felt like I had to ask questions to get the information I wanted but I didn’t want to be irritating” (NHS 13; 255)
Theme 2, staff
Four subthemes were identified.
Subtheme 2a, professionalism. Professionalism was discussed by many patients, and this positively affected their satisfaction; patients associated professionalism with good teamwork and good technical abilities. Patients also discussed the importance of making the patient feel at the center of the process, and failure to do so was seen as unprofessional.
“The client must feel like they’re the main centre of attention and everybody is concentrating on them. It’s just not professional otherwise.” (NHS 6; 157-65)
“It’s a very professional practice” (PP 3; 159)
“They were professional…they all worked well together, there was a real calmness during each appointment and they were all very pleasant.” (PP 11; 237-8)
Subtheme 2b, being treated by different clinicians. As described earlier, the 2 sites had different treatment models, but both were perceived positively, since the patients were confident in the clinicians’ abilities. Several patients expressed satisfaction with the hierarchy of care at the teaching hospital, whereby a supervisor was available to oversee all treatment, and this made them feel reassured. Patients in the National Health Service setting also discussed being transferred from 1 trainee to another when the treating clinician finished his or her training. Interestingly, this did not appear to affect satisfaction as long as the patients were appropriately prepared for it, although it sometimes took time to adapt. Similarly, in the private sector, patients were satisfied with the model of being seen by both clinicians in the practice.
“What’s making the icing on the cake is that not only do you have one carer, you have two carers. So I have you guys that have looked after me, but on top of that it’s Mr XXX who comes and makes sure that everything is absolutely correct.” (NHS 5; 155-60)
“It didn’t affect my overall satisfaction…I already knew the way they work, I was in safe hands.” (NHS 4; 268-70) [Talking about transfer of care from one trainee to another.]
“I felt that XXX [dentist with a special interest] was very experienced and I felt very, very confident with what they were doing. It was like an extra bit of reassurance because it would be every couple of months I might see XXX (owner) and they would both be in agreement on what they were doing and they were both relaying the same information back to you.” (PP 11; 192-6)
Subtheme 2c, personality. When discussing satisfaction with staff, interviewees commented on the effects of personality and manner on their experience. Patients in both settings were satisfied with the personality and manner of their orthodontist, discussing this extensively. Many patients were satisfied with the reassurance they received from their orthodontist; additionally, calmness, being spoken to on the same level, and remembering personal details about the patient’s life were all perceived as important.
“It comes down to the whole relationship, remembering names of my kids, how things are going, just made me feel warm and welcomed.” (NHS 13; 271-2)
“I mean they’re very, very calm and I think that very calm, relaxed environment is important with teeth because people get quite nervous with teeth.” (PP 2; 78-80)
In contrast, the introduction of a self-check-in kiosk at the hospital had replaced the need for interaction with the reception staff when patients arrived for their appointments, and some patients found this lack of personal contact unsatisfactory.
“Halfway through my treatment they changed from going to the desk to the machine. That’s weird because you want to say hello and have that human contact…” (NHS 9; 165-6)
Subtheme 2d, perceived technical ability and confidence in care. Confidence in the clinicians contributed to satisfaction, due to their orthodontist’s academic achievements, perceived knowledge and abilities, and stage in his or her career. Patients discussed being satisfied that their orthodontist was gentle; the care taken by the clinicians was perceived as a passion for their job and that they had good technical abilities.
“I know that he has academic interests and those things make you know that you are in good hands. It gives you confidence…you are trusting him to rearrange your teeth and you want somebody who is experienced, qualified, well regarded.” (PP 3; 169-78)
Theme 3, the physical environment
Two subthemes were identified relating to satisfaction with the physical environment.
Subtheme 3a, location and external environment. Factors relating to the physical environment included the location, transport links, access, and parking facilities. Several patients treated in the private setting commented positively on the good location and the availability of parking. Most patients who came for treatment at the dental hospital were satisfied with the proximity of the hospital to good transport links, and patients found it easy to attend from within or outside central London. Some patients at both sites traveled a significant distance to attend appointments, but this did not affect their satisfaction.
“No, it [regular travel to appointments] never affected my satisfaction because if I’m getting something that’s worth a lot of money, having braces would be thousands of pounds, so I have to put my bit into it too…You can’t expect to get all this treatment for nothing and not do anything for it.” (NHS 11; 290-3)
“Very good. I come from a long way away, it’s not round the corner from me, but when it comes to orthodontics I would travel to the right person.” (PP 2; 133-4)
Subtheme 3b, appearance and the internal environment. There was a high level of satisfaction with the esthetics of the private practice. Furthermore, some patients related the upkeep of the physical environment as a reflection of professional abilities and standard of service.
“I suppose just keeping the surgery nice matters, so it matters to you that you keep abreast about what the latest developments are in your profession. If you’re a personality that’s not that bothered about things, that would make me question would you be applying the same thoughts to your professional career.” (PP 1; 330-4)
The National Health Service patients also commented on surroundings; 1 patient said that the older surroundings of the Eastman Dental Hospital made her feel that she was attending a “hospital,” but another patient found the older building “more comfortable” than a “modern hospital.”
“I suppose because the surroundings are quite old, it really hits you like it’s a ‘hospital’, whereas if you are going to other dentists where it’s more modern you don’t feel like you’re in that sort of environment.” (NHS 3; 225-7)
“The environment was good, it was just what I expected from a public teaching hospital…It’s all about teeth, whereas when you’re in a bigger hospital, like the XXX hospital, it’s probably a bit more modern but not as comfortable I think…” (NHS 11; 395-7)
Theme 4, appointments
Four subthemes were elicited from the data relating to satisfaction with appointments.
Subtheme 4a, punctuality and waiting lists. All patients in the private setting were satisfied with the smooth and seamless running and punctuality of the service. Several patients at the National Health Servicce site discussed waiting times at routine appointments and how they were not always told how long they were likely to have to wait. However, despite this, overall satisfaction with the treatment process did not appear to be much affected. One patient discussed satisfaction with the short time on the treatment waiting list.
“Coming from a different department, seeing how long patients wait compared to here…for me was fine, didn’t take long at all.” (NHS 2; 278-82)
“Sometimes you just didn’t know how long you would have to wait, they couldn’t always tell you…” (NHS 6; 297)
“Being seen on time, appointments taking about the time you think they’re going to take except in exceptional circumstances…it all runs smoothly…they get it right here.” (PP 6; 300-4)
Subtheme 4b, flexibility and emergency appointments. Patients in both settings commented on their satisfaction with the flexibility of appointments. Patients in the private setting all had reminders via text messages, which helped with organization. The good availability and accommodating nature of emergency appointments for appliance breakages were also discussed in both settings.
“They will give you the time that suits you, which was really good.” (NHS 4; 303)
“The fact that you can come in at certain times any day, it was brilliant, so you were never left a long time with the broken brace.” (NHS 6; 214)
“I particularly like every time you do have an appointment they remind you by text two days before.” (PP 9; 312)
Subtheme 4c, number and duration of appointments. Patients from both sites commented on the frequency of appointments and durations. Although the 6 weekly intervals were seen as difficult at times due to work commitments, this did not affect overall satisfaction with the treatment process.
“I think what was good was the amount of visits.” (NHS 1; 51)
“It was always very good, they always tried to be as quick as possible.” (NHS 6; 259)
Subtheme 4d, duration of treatment as a whole. There were some discussions from both sites regarding how patients felt about the duration of treatment as a whole. Although some patients commented on the personal commitment required, satisfaction with the process did not appear to be affected.
“Although it was a huge commitment in time, and of course in cost, but in time more than anything else, the whole process was probably over 3 years…it was a big personal commitment, but I just knew I wanted to have good healthy teeth.” (PP 5; 34-7)
Theme 5, impact of appliance treatment
Four subthemes arose relating to the impact of appliance treatment on satisfaction with the treatment process.
Subtheme 5a, discomfort. Some patients discussed their experiences of pain or discomfort during treatment, particularly during the initial phases. However, their satisfaction with the treatment overall was not affected because they thought that it was an expected part of the treatment journey, and they were prepared for this in advance.
“I had no pain or anything that caused me discomfort. I was warned beforehand.” (NHS 1; 207-8)
“It didn’t bother me really, I just feel I was on this journey and that was OK.” (PP 9; 247)
Subtheme 5b, function and oral hygiene. The inability to eat certain foods and having food trapped in the appliance were discussed. However, these problems did not appear to affect overall satisfaction with the treatment process because the patients had generally found ways of managing the inconvenience.
“To begin with, not being able to bite into things and eat certain foods was a bit of a shock, but actually I found quite crafty ways round things.” (PP 1; 216-7)
Subtheme 5c, esthetics. Most of the patients accepted the esthetics of the appliances. The impact of esthetics was also “made slightly easier” due to other adults having braces or when the esthetic option of ceramic or lingual appliances was available. Patients at the National Health Service site were treated only with conventional stainless steel fixed appliances. They were generally not affected by the esthetics of these appliances, although initially some were concerned about the social or work implications.
“At the beginning you feel conscious, but after a while I don’t really care…everyone’s wearing it, it’s kind of one of those barriers that you just have to break it mentally, it’s fine.” (NHS 8; 320-7)
“I think I stopped smiling as much when I was wearing the braces because I didn’t like wearing them.” (PP 11; 124-5)
Satisfaction with having a choice of lingual, ceramic, or metal appliances was discussed by the patients in the private setting. Generally, they were satisfied with this choice since they associated metal braces with children and teenagers and felt it would have been a more difficult decision to proceed with the treatment if that was the only option. Some patients said they would not have had the treatment if the option of esthetic appliances was not available.
“It’s interesting that I don’t know if I would have had the treatment if I had the outside braces, so I’m very satisfied that I could have them inside. From that point of view I am very satisfied with the braces otherwise I wouldn’t have had it done, or it would have been a much bigger decision.” (PP 6; 337-40)
One patient found that he or she was smiling a lot more, and another overcame the “mental barrier,” particularly when he or she noted that more adults were undergoing treatment.
“I’d find that I’ll be smiling a lot more and not worried about people think or say ‘cause I know that we’re going to get an end result and we’re in the treatment now.” (NHS 2; 185-6)
Subtheme 5d, postdebond care. Postdebond care was discussed, and patients in both settings accepted wearing retainers. They also felt that the follow-up appointments were reassuring; these influenced their overall satisfaction.
“It was just reassuring and that they’re professional and caring and the aftercare is there, which is a good feeling, not just being forgotten and left.” (PP 11; 322-3)