Orthodontic patients present with a variety of malocclusions, but also with an even greater variety of motivations, perceptions, and expectations. Motivations and expectations can also be different between patients and their parents. Managing these intangible factors is not typically taught in detail during orthodontic education, but orthodontists must learn to address them because they may significantly influence treatment success.

Motivation for orthodontic treatment

Learning about patients’ motivations for orthodontic treatment is the key to meeting their needs and expectations. Research into the motivation of patients and their parents for orthodontics has typically been carried out through questionnaires administered at the beginning of treatment. Wędrychowska‐Szulc and Syryńska (2010) gathered information from 674 children aged 7–18, a parent or guardian of each, and 86 adult patients in Poland to explore their reasons for seeking orthodontic treatment. Each questionnaire had nine options and the respondent could select multiple reasons for treatment. Examples of reasons included “I want to correct my appearance,” “I have been referred by my dentist,” and “my parents want me to be treated.” These reasons were reworded for the parental questionnaire. The main motivational factor reported was “I have irregular teeth,” checked by 50–70% of each age group. Another significant factor for patients younger than 16 years was “my parents wanted me to be treated.” Females more than males checked “I want to correct my appearance” and the percentage of both genders indicating this increased with age. Geoghegan et al. (2019) carried out a similar study of patients in private practices in the UK. They administered a different questionnaire to 238 patients aged 8–20 (with nearly half aged 11–13) at the screening appointment. Their results were similar in that esthetic concerns played a major role. Over 80% were concerned about the appearance of their teeth. The top three concerns were “crookedness,” “sticking out,” and “bite.”

Daniels et al. (2009) compared the motivation and cooperation of patients aged 7–16 and their parents before and during treatment. They surveyed 83 patients at the screening visit and 144 during treatment at a university clinic. Like previous studies, esthetic concerns were by far the most important motivating factor for treatment, with >90% of both parents and patients giving this response. Interestingly, however, the parents were always more motivated than the children for treatment, particularly during treatment, while the children’s responses did not change during treatment. It was found that children who were more highly motivated for treatment also had greater cooperation. Ernest et al. (2019) studied a group of 100 children aged 7–17 years in Nigerian public hospitals both before and during orthodontic treatment. The patients and their parents completed similar surveys regarding motivation and expected cooperation. In contrast to Daniels’ study, Ernest et al. (2019) found that before treatment, children were more motivated than their parents to have treatment. However, as Daniels et al. (2009) reported, the parents had more motivation than the children during treatment. Ernest did find that the children’s motivation decreased slightly during treatment, although the percentage of children who agreed that braces were important increased significantly. Clinicians should realize that although parents are responsible for bringing their children to the orthodontist, the child‘s motivation is important for the success of treatment.

Bauss and Vassis (2023) investigated the influence of bullying on the motivation for and expectations of orthodontic treatment. They surveyed 1020 children with a mean age of 11.8 years. Based on their responses to a questionnaire, the subjects were divided into three groups: those who reported being bullied due to dentofacial features, those who were bullied due to other physical features, and a control group who had not been bullied. Overall, 23.7% reported being bullied. Being bullied due to dentofacial features distinguished this group in several ways. They were significantly more likely to initiate treatment for themselves (as opposed to parents or their dentist), and had a greater desire for orthodontic treatment than those who were bullied for other physical features. In addition, although esthetics was the main motivation throughout the sample, this group said they had “ugly teeth,” in contrast to the other groups’ stated reason of wanting “to look pretty.”

Tristão et al. (2020) carried out a systematic review to evaluate the relationship between malocclusion and bullying in children and adolescents. They found numerous methodological shortcomings that prevented them from drawing firm conclusions. For example, of the nine articles ultimately reviewed, six studies used the term “bullying” while four used “teasing” and one other used “harassment” to describe the unwanted behavior; in addition, five different questionnaires were used to elicit the patient’s experiences. In the end, the quality of evidence given in the studies was judged to be “very low,” and only two studies were classified as methodologically sound. However, the authors still concluded that severe malocclusion may be related to bullying.

Clearly, being bullied specifically for the appearance of their teeth and mouth makes children with significant malocclusion particularly motivated for orthodontic treatment. Clinicians should be sensitive to the perception of all patients, including children.

Treatment expectations

Several authors explored the expectations of patients and their parents about orthodontic treatment. Geoghegan et al. (2019) included several questions about what treatment required on his questionnaire discussed previously. Nearly 100% of the patients knew that they would need to alter their diet and that oral hygiene would be very important, but only 24% knew how often they should brush their teeth. Half of the parents thought treatment would take 1–2 years, and an additional 40% thought it would take less than 1 year. Michelogiannakis et al. (2021) used a validated questionnaire from a European study to explore the expectations of 70 prospective patients and their parents in a university setting. Comparing patients and parents, they learned that patients expected less discussion and diagnosis at the screening appointment and more dietary restrictions than parents. Parents more than patients expected a better smile and more social confidence after treatment. Examining sociodemographic factors, those parents with more than 12 years of education expected more problems with eating, less improvement in mastication, and more discussion about treatment than those parents with 12 years of education or less. The more educated group also expected more improvement in social confidence. Expectations should be probed, with both patients and parents being asked detailed questions to identify and clarify the specific features they dislike and how they would like to have them changed. The patient and parent may be guided toward realistic expectations using photos and questions that elicit detailed responses.

Perception of malocclusion

Patients’ perceptions of their malocclusion are influenced by personal factors, perhaps due to the deeply personal significance of the mouth and teeth. In addition to determining patients’ motivation and expectations, exploring how they perceive their condition is also useful when formulating a treatment plan so that their concerns can be addressed.

Several research approaches can give insight into how patients see their malocclusion. One key method is to show the patient profiles. By altering one aspect of the profile in successive photographs or silhouettes and asking the patient to indicate which profile is most like theirs, it is possible to determine how accurately patients perceive profiles (Tufekci et al., 2008). A version of this is the Perceptometrics technique developed by Giddon et al. (1996), in which computer alterations are made to photographic images, with the feature of interest moved back and forth in one dimension at gradual, predetermined intervals. By clicking on the image, the range of photographs can be traversed. Patients can then indicate the acceptable range of profiles, and they can also indicate which profile is most attractive. This tool enables clinicians to determine the range of what patients consider acceptable.

Many studies have been done using the Perceptometrics method. Kitay et al. (1999) found that orthodontic patients are less tolerant of variations in their profiles than are nonorthodontic patients. To determine their range of acceptability, 16 patients and 14 nonorthodontic adult patients were asked to respond to computer‐animated profiles that distorted the lower third of their own faces using the Perceptometrics program. Both groups of subjects were equally accurate in identifying their own profiles. However, the orthodontic patients had a smaller zone of acceptability (ZA) in features in a control face, with a significant disparity between one feature in their own profile and the most pleasing position for that feature. This suggests that orthodontic patients are motivated to seek treatment by specific features in their own face that they perceived as undesirable.

Using the Perceptometrics technique, Arpino et al. (1998) compared the acceptable profiles selected by orthognathic surgery patients with those of their “significant others,” orthodontists, and oral surgeons. Patients with both Class II and Class III jaw discrepancies evaluated their own photographs with the upper lip, lower lip, both lips together, and chin altered horizontally and one feature, lower facial height, altered vertically. Although there was some variation, the ZA was smallest for the patient, followed by the surgeon, the significant other, and finally the orthodontist. Whereas the patient and the significant other groups differed in only two instances, the orthodontists and oral surgeons had significantly different ZAs for all but the Class II bimaxillary relationship. These results show that orthodontists are most tolerant of different profiles, while the patients themselves are least tolerant.

Hier et al. (1999) used the same technique to compare the preferences for lip position between orthodontic patients and untreated subjects of the same age. They found for both males and females that the untreated subjects preferred fuller lips than did orthodontically treated subjects, which is greater than Ricketts’s ideal measurement of lip protrusion.

Miner et al. (2007) compared the self‐perception of pediatric patients with the perceptions of their mothers and their treating orthodontists. Using the Perceptometrics technique, the upper lip, lower lip, and chin were distorted as the images moved from retrusive to protrusive extremes. The patients, mothers, and clinicians were asked to indicate the ZA for each feature and the most accurate representation of the child’s profile, as well as to indicate the ZA for a neutral female face. Both patients and mothers were found to overestimate the protrusiveness of the child’s actual mandible, and both groups preferred a more protrusive profile for both the child and the neutral face. In addition, the mothers had the smallest tolerance for change in the soft tissue profile. These studies are valuable for pointing out the potential inaccuracies of patients’ perceptions as well as their differing preferences.

These techniques are also useful for exploring the perceptions of different racial and ethnic groups. In a study by Mejia‐Maidl et al. (2005), 30 Mexican Americans and 30 white people of varying age, sex, education, and acculturation indicated their perceptions of four profiles of individuals of Mexican descent. Using the Perceptometrics program, the authors found that in general Mexican Americans preferred less protrusive lips than did white people. In addition, there was a wider ZA for male lip positions and female lower‐lip positions among the white people than among the Mexican Americans of low acculturation. These observations were not true of highly acculturated Mexican Americans, who may have assimilated white American esthetic preferences. Park et al. (2006) compared the perceptions of Korean American orthodontic patients with those of white orthodontists and Asian American orthodontists. Statistically significant differences were found between the Korean American patients and the white orthodontists for the acceptable and preferred positions of the female nose and the male chin, finding that the Korean Americans preferred a more protrusive nose for females and a more retrusive chin for males. McKoy‐White et al. (2006) compared the ZA for Black females among Black female patients, Black orthodontists, and white orthodontists. The patients were also asked to identify their most accurate pretreatment and posttreatment profile. It was found that the white orthodontists preferred flatter profiles than did the Black women, who in turn preferred fuller profiles than the Black orthodontists. Although the patients could correctly identify their own posttreatment profile, they all recalled a fuller pretreatment profile than they actually had.

Another method of assessing patients’ perception of their own malocclusion or facial disharmony is by assessing their oral health‐related quality of life (QOL). QOL is defined as individuals’ perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards, and concerns (de Avila et al., 2013). The oral cavity is the center of much of life – eating, speaking, esthetics – that any problem may significantly influence a patient’s overall feeling of well‐being. In the past few years, the effect of malocclusion on patients’ QOL has been studied.

Several studies were carried out at Boston University to explore the oral health‐related QOL in teens and adults. A specific Teen Oral Health‐Related Quality of Life (TOQOL) instrument (Wright et al., 2017) was developed that probed the oral health‐related QOL in five domains: role (everyday functioning), oral health, social, emotional, and physical. Each item in each domain is explored by asking a question beginning “Due to problems with your teeth and mouth, how often in the past 3 months have you…?” Rich et al. (2015) surveyed 161 parent–teen pairs from diverse ethnic backgrounds and no previous orthodontic treatment. The severity of malocclusion was determined using the Index of Orthodontic Treatment Need (IOTN; Brook and Shaw, 1989) and those teens with mild to moderate malocclusions were compared with those with severe malocclusions. Parents were also surveyed as to their perception of the effect of their child’s malocclusion on the QOL. Children with severe malocclusion had poorer oral health‐related QOL in the esthetic domain, while their parents reported worse QOL in the emotional, physical, and role domains. Neely et al. (2017) compared these scores with those of 146 adults with a mean age of 32. In general, scores overall and by domains were higher for adults than for teens, signifying a greater effect on QOL. Mean TOQOL scores were worse (17.55) in adults than in teens (11.92, p <0.01); emotional domain scores were 16.54 in adults compared with 9.39 in teens (p <0.01); and the social domain score was 35.29 for adults compared with 21.59 for teens (p <0.01). It can be concluded that both teens and adults can be greatly affected by their malocclusions, and specific areas of influence can be identified.

Multiple authors (Dimberg et al., 2015; Kragt et al., 2016; Sun et al., 2017, 2018; Alrashed and Alqerban, 2021) have carried out systematic reviews or meta‐analyses exploring the relationship between malocclusion and the patient’s perceived oral health‐related QOL. All analyses revealed a negative impact of malocclusion on oral health‐related QOL, and some detected more nuanced associations. Sun et al. (2018) evaluated 11 qualifying studies and found that while malocclusion had an impact on all subscale scores of the Oral Health Impact Profile survey instrument, patients with severe malocclusion had worse QOL in the areas of physical disability, physical pain, psychological discomfort, psychological disability, and social disability. Kragt et al. (2016) discovered significant findings in two areas. First, the age of the patient had an influence in the impact of malocclusion on oral health‐related QOL. Although younger adolescents (age 11–14) were more likely to be affected by malocclusion, teens older than 14 years had a more severe impact on their oral health‐related QOL. Second, the outcomes from the different countries represented in the studies suggested that cultural differences may influence the impact of malocclusion on oral health‐related QOL. This is consistent with the definition of QOL as the individual’s perception of his/her position in life. In addition, the local healthcare system and the presence or absence of other significant oral disease may place malocclusion in a very different context for the individual.

Because of the wide variation in patient perception and the effect of the malocclusion on the patient’s life, it is critical for the orthodontist to explore the patient’s ideas and expectations when discussing treatment. Here, education of the patient and the parents, if applicable, is important, because most have a limited understanding of what are reasonable treatment goals and procedures.

Patients do not always understand or remember what they have been told about their malocclusion or the orthodontic treatment. Mortensen et al. (2003) interviewed 29 patients aged 6–12 years and their parents 30 minutes after obtaining informed consent. Both the children and their parents were asked about the reasons for treatment, risks, and responsibilities mentioned during the discussion. It was discovered that although an average of 4.7 risks were mentioned during each discussion, the parents remembered on average 1.5 risks and the children remembered less than 1. Similarly, 2.3 reasons for treatment were mentioned by the orthodontist, but the parents and children remembered on average 1.7 and 1.1, respectively. Clearly, patients and parents do not remember all the information told to them. Clinicians need to convey such information to patients in writing or graphic form.

Patients with psychological disorders

In addition to physical problems, many orthodontic patients may have preexisting psychological disorders when they present for orthodontic treatment. Although these patients are usually controlled, it is important to recognize how these disorders may be manifested. In addition, orthodontists should be aware of side effects of medications that may have implications for oral health.

Common psychological conditions are delineated by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, or DSM‐5‐TR (American Psychiatric Association, 2022). The most common conditions that orthodontists may encounter are attention‐deficit/hyperactivity disorder (ADHD), obsessive‐compulsive disorder (OCD), body dysmorphic disorder (BDD), bipolar disorder, panic disorder, and depression. In addition, there are some personality disorders and other psychological conditions, such as eating disorders, that may acutely affect adolescents.

ADHD is a chronic disorder characterized by inattention, impulsivity, and hyperactivity. A survey carried out in 2013 reported that 8.8% of children aged 3–17 were diagnosed with ADHD (Friedlander et al., 2007). Some diagnostic criteria, however, are nonspecific and the disorder may be overdiagnosed. Nevertheless, the main criterion is that the behavior must cause impairment in the individual’s life for a prolonged period of time (American Psychiatric Association, 2022). Hyperactivity and the inability to focus can be problems during orthodontic treatment. Patients with ADHD may have trouble sitting still during procedures and may not be compliant in maintaining good hygiene, wearing elastics, or performing other tasks because of inattentiveness. These patients can be best managed by giving short, clear instructions and written instructions or reminders to them or their parents, with follow‐up questions to determine their comprehension and rewards for successful compliance. Dental prophylaxis may be needed more frequently to avoid decalcification and caries. To increase the likelihood of treatment success, it may be wise to avoid treatment plans that require a high degree of patient compliance. During treatment, it is often helpful to give the patient breaks during prolonged procedures.

OCD (Zohar, 1999), depression (Kessler and Walters, 1998; Neely et al., 1998; Friedlander and Mahler, 2001), panic disorder (Becker, 2008), and bipolar disorder (Friedlander et al., 2002) may all present with a wide variety of symptoms, including intrusive thoughts, suicidal ideation, apathy, and anxiety, and more than one disease may coexist in the same patient. In addition, these conditions are frequently treated with serotonin reuptake inhibitors. These medications serve to increase the amount of neurotransmitters in the postsynaptic space, but may have side effects including glossitis, xerostomia, and gingivitis (Ferguson, 2001).

BDD is characterized by an intensely negative emotional response to a minimal or nonexistent defect in the patient’s appearance. Because the head and face are common foci for the disorder, orthodontists may see patients who have excessive concerns about their dentofacial appearance (Veale et al., 1996). Other characteristics of this disorder involve multiple consultations about their perceived defect, an obsessive concern with appearance, and emotional volatility (Anthony and Farella, 2014). This preoccupation may lead to stress and related disorders and behaviors. Patients with BDD will frequently see multiple providers in an effort to get treatment, but even if they receive treatment they are rarely satisfied. In some cases, these patients become violent or commit suicide (Philips, 1991).