The study of associated factors in relation to patient satisfaction during fixed orthodontic treatment from patients’ aspects

ABSTRACT

Objective

The principal objective of this study is to assess the associated factors of patient’s self-assessment problems to their satisfaction during fixed orthodontic treatment. The secondary objective is to evaluate the oral health-related quality of life index (GOHAI) of patients with a fixed orthodontic appliance.

Method

Adult patients older than 15 years of age with fixed orthodontic treatment were recruited to fill the questionnaires from validated Chinese version of GOHAI assessment and other parts of questions with patient’s satisfactions for the purpose of this study. Descriptive statistic test was performed between demographic variables of patient’s reported GOHAI assessment and patient’s satisfaction towards fixed orthodontic appliances. Chi-square test or fisher’s exact test was performed to determine associations between scores of GOHAI and patient’s self-reported satisfaction to tooth movement with patient satisfaction towards fixed orthodontic appliance.

Result

Among 125 volunteers, both males (77.4%) and females (76.6%) were satisfying during fixed orthodontic treatment. In our study, GOHAI total mean scores of 125 patients resulted (43.44) with a minimum of 28 and maximum of 58 points. There was a correlation of treatment duration, awareness of tooth movement improvement, increased frequency of visiting to orthodontic clinic to patient’s satisfaction during their treatment conditions (p < 0.05).

Conclusion

In this study, patient satisfaction during orthodontic treatment is in relation with ;(1) Duration period of orthodontic treatment, ;(2) Self-awareness of tooth position improvement, ;(3) Frequency of in-between visits, Yet, there is negligible associated between oral health related quality of life assessed by using GOHAI and patients satisfaction during fixed orthodontic treatment.

KEYWORDS:

• Satisfaction
• GOHAI
• discomforts
• tooth movement
• recall visit

1. Introduction

Dentofacial problems can affect patients’ daily lives. These are in turn affecting social functioning and behaviours such as working ability or school activity [1]. Nowadays, we have a lot of methods to improve our dentition like using the veneer method, placing prostheses, orthodontic or orthognathic treatment, and so on. Among them, orthodontic treatment is still a classic method and its techniques are improving day by day.

The impact on the quality of life of such treatment methods was checked in a 2017 study and wearing dental braces showed second most patient satisfaction (67%) [2]. However, the rate of failure of treatment completion is also high and common (4–23%) [3]. Failure came with the patient’s non-compliance or unsatisfied, incorrect diagnosis, and management. In all ways, successful treatment outcome mainly depends on the patient’s attitude towards the orthodontic treatment [4].

Since orthodontic appliances are considered foreign bodies, they will bring such discomforts as physical, psychological, and pain to patients. This might decrease the patients’ satisfaction. There are many studies that examined the pain responses between different orthodontic treatments and found that patients wearing fixed appliances faced many more problems than patients with other types of treatment [5–7].

To our current knowledge, there are very few research articles concerning patient’s experiences during treatment. Most lead to the pain perception or periodontal status study centred by dentists throughout treatments. Very few studies have combined the effects of patients’ centred research about satisfaction, oral health conditions, and quality of life (QOL) in their orthodontic treatment process.

Therefore, the principal objective of this study is to assess the determinant factors of patient’s oral health problems for their satisfaction during orthodontic treatment, and the secondary objective is to evaluate the oral health-related quality of life index (GOHAI) during receiving treatment with further valuable information to ensure patients who feel insecure in taking fixed orthodontic treatment.

2. Material and method

An observational cross-sectional study was carried out with a total of 125 adult patients older than 15 years of age. Participants were receiving fixed orthodontic treatment within an active period of one-year treatment duration with multi-bracket devices excluding retention periods. Volunteers were recruited by asking for informed consent to fill out the survey form and when they visited the orthodontic department. They had the right to deny participation in the research project. Data collection was done from October to December 2019 with 100% response.

Brackets were required to place labial at least 20 teeth from both arches. As this study was targeted to find out the relationship with patients’ satisfaction, there was no control of type and degree of malocclusion. However, patients with a history of periodontitis, bad oral hygiene, or previous orthodontic treatment combined with orthognathic surgery were excluded to avoid biased data when we measured oral hygiene conditions after placement of fixed orthodontic braces. Moreover, patients with another accessory device like a temporary palate appliance or temporary anchorage device were excluded. Patients with systemic diseases that had already affected their daily quality of life were also excluded. Part of the questionnaire used in this study was the General Oral Health Assessment Index (GOHAI), a validated Chinese version [8] while the other parts were constructed for the purpose of the study.

GOHAI index contains a total of 12 questions. The responses to these questions were summed up to give an overall impact score. 12 questions were grouped into 3 subscales: functional impacts(eating, speaking, and swallowing): (question 1,2,3), psychosocial impacts (concern or care for one’s own oral health, dissatisfaction with appearance, self-consciousness regarding oral health, and the avoidance of social contacts due to dental problems) : (questions 4,5,6,7,8) and pain-related impacts discomfort (use of drugs to relieve these feelings, provided they come from the mouth): (questions 9,10,11,12).

Each category contained 5 statements and each question has a value between 1 and 5 in alternatives with Likert format (5: every day, 4: most of the time, 3: sometimes, 2: very little, 1: Not at all). The total score ranges between 12–60 points, where a higher score shows a higher quality of life of patients. However, Questions 4 and 11 were modified since higher scores could result in more negative impact. Since there is no recommended cut-off value to indicate good or poor oral health [9]. Our starting point was 12 and the ending point was 60. 37 points will be the midpoint of between 12 and 60 on a scale of 0–60. Therefore, we marked a total score of 37 as the reference point for good or poor oral health in this study.

Another part explored the patient’s self-awareness of the orthodontic teeth movement, experience of oral hygiene impacts, and self-reported satisfaction with fixed appliances during orthodontic treatment. Moreover, a pilot survey was carried out with 10 patients for reliability and sensitivity. The pilot survey form was found that quite understandable, clarified, and simplified for patients and it could be finished within 15 minutes.

3. Statistical analysis

Survey data was analysed using SPSS 23 for Windows. Data entry, checking, and analysing were done in the evenings of the days of data collection. Descriptive statistics were obtained; means, standard deviation, and frequency distribution were calculated.

The chi-square test or Fisher’s exact test was performed to determine any relationship between simple scores of GOHAI and Patient satisfaction as well as patients’ self-reported satisfaction with tooth movement from fixed orthodontic appliances.

The confidence interval was set at 95% and the probability of alpha error was set at 5%. The level of significance was set at p < 0.05.

4. Results

4.1. Sample characteristic

Among 125 volunteers, there are 31 males (24.8%) and 94 females (75.2%) participated in this study with a 100% response rate (Figure 1). In this study, gender was not statistically significant to patient satisfaction (p < 0.05) with more than 70% of both male and female satisfied patients (Table 1).

Figure 1. Characteristics of the participants.

Table 1. Relationship of Treatment Satisfaction with Respect to Gender, Age, and treatment duration.

Demographic Variables		During Treatment Satisfaction		P Value
		No	Yes
Gender	Male	7 (22.6%)	24(77.4%)	0.569
	Female	22 (23.4%)	72 (76.6%)
Age	<24	18 (24.3%)	56 (75.7%)	0.446
	>24	11 (21.6%)	40 (78.4%)
Treatment Duration	<6 months	21 (33.9%)	41 (66.1%)	0.004*
	6–12 months	8 (12.7%)	55 (87.3%)

Data are presented as the number of participants (%). Chi-square with significance level <0.05.

*and bold represent the significant difference between variables.

In this study, recruited patients were in the age range of 15–33 years of age. Around 20% of volunteers of within the age range are not satisfied with their orthodontic treatment conditions although it is not statistically significant (Table 1).

We could clearly find out that the patients who come to orthodontists to receive orthodontic treatment were mostly with the reason of their physical appearance (67%) (Figure 2). In the current study, (15%) of patients were seeking treatment due to difficulty in chewing while (10%) were referred by general dentists despite patients’ self-awareness of their dental problems. The reason for receiving orthodontic treatment would be due to dental or facial pain being the lowest percentage (8%).

Figure 2. Reasons for receiving orthodontic treatment.

4.2. Relationship between treatment duration and patient satisfaction

Again, within 6 months of orthodontic treatment duration, satisfied patients (66.1%) were two times greater than unsatisfied ones (33.9%). With increased time, over six months duration, satisfied patients (87.3%) were drastically higher than the unsatisfied patients (12.7%) and there were statistically significant (p < 0.004) (Table 1)

4.3. Patient’s oral health-related quality of life (GOHAI) assessment

In our study, GOHAI total mean scores resulted (43.44) with a minimum of 28 and maximum of 58 points. Means score of trouble in biting/chewing and worried about appliances (Q-2 and Q-7) are the lowest means among the other 12 questionnaires (Figure 3).

Figure 3. Distribution of mean score of GOHAI impacts.

4.4. Relationship between GOHAI total scores and patient satisfaction

To find the association between oral health-related problems and patients’ satisfaction during orthodontic treatment, GOHAI total score is divided into two categories as high impact (GOHAI total score between 12–37) and low impact (GOHAI total score between 38–60).

From the surveying of 125 patients, either people with high impact or low impact, more than 75% of patients were satisfied with the current condition of fixed orthodontic treatment and this finding was not statistically significant (p > 0.05) (Table 2).

Table 2. Relationship between Oral health-related problems and Patients’ satisfaction.

		During Treatment Satisfaction
Oral Health Related problem (GOHAI total score)		No (%)	Yes (%)	P Value
	High impact (<37)	19 (25%)	43 (75%)	0.559
	Low Impact (>37)	10 (23%)	53 (77%)

Data are presented as the number of participants (%). Chi-square with significance level < 0.05.

4.5. Relationship between patient’s experience and satisfaction during treatment

4.5.1 Frequency of patients’ experiencing oral hygiene problems and discomfort

Figure 4 shows the mean value of patients’ experiencing discomforts during fixed orthodontic treatment.

Figure 4. Patients experiencing oral hygiene problems.

Among other problems, bleeding gum is the highest problem with a mean score of 4. Together with bleeding gum, gingival inflammation was the second most experienced problem. Some components of fixed orthodontics appliances such as brackets, wire bending, or wire hooks may irritate lips, cheeks, or gums. Continuing irritation to these areas will create painful small ulcers. This is the third most happening oral hygiene problem for patients with the fixed appliance (mean score- 3.5). However, our patients were still experiencing cheek biting in our study (mean score − 3.86). Foul-smelling (mean score-2.31) is the least patients experience during orthodontic treatment.

4.5.2 Relationship between awareness of tooth movement and satisfaction

Patients’ self-awareness of their tooth movement during orthodontic treatment is the major influence factor for treatment satisfaction (Table 3). Patients with awareness of their tooth movement showed 81.8% of satisfaction and those without awareness showed 64.9%. They are statically significant with patient satisfaction (p < 0.05) (Table 3).

Table 3. Relationship between Patients’ experience and satisfaction during treatment.

Patients experience during treatment		During Treatment Satisfaction		P Value
		No	Yes
Visiting to orthodontics with complaints	Yes	19 (30.6%)	43 (69.4%)	0.040*
	No	10 (15.9%)	53 (84.1%)
Tooth Movement Awareness	Yes	16 (18.2%)	72 (81.8%)	0.037*
	No	13 (35.1%)	24 (64.9%)

Data are presented as the number of participants (%). Chi-square with significance level <0.05.

*and bold represent the significant difference between variables.

4.5.3 Relationship between frequency of visits to orthodontist and satisfaction

Patients with fixed orthodontic appliances have to pay a visit to the orthodontic department once a month to modify or improve the steps of orthodontic treatment. In our study, 62 patients had the experience of coming back to the clinic multiple times instead of regular check-up visits. Among them, 69.70% of people were coming back with the complaint of bracket dislodge. 25.76% of people with wire sticking problems and 4.55% with discomfort (Figure 5)

Figure 5. Percentage of return visit reasons.

By comparing the satisfaction between patients who frequently visit the clinic with complaints (69.4%) and patients who only visit the clinic once a month (84.1%), these two visits were statically significant in patient satisfaction (p < 0.05) (Table 3).

5. Discussion

5.1. Relationship between gender and patients satisfaction

In recent studies, there is not much discussion about satisfaction from patients’ aspect during orthodontic treatment. From gender aspects, females are mostly concerned with the appearance of their dentition than males [9–11]. However, in this study, even though female participants were two times more than male ones, their satisfaction with the current treatment condition was almost the same as males. This result totally agrees with Keles et al. study in which there was no correlation between gender and patient satisfaction [12].

Alqufare et al. concluded that the satisfaction level with fixed orthodontic treatment was higher in females than males [13]. In another study by Younis et.al, female patients were more willing to take care of their oral hygiene and more satisfied with their current treatment condition rather than male patients [14]. However, these results were in contrast with our current study in which there is no statically significant between gender and satisfaction towards fixed orthodontic treatment. This result might be affected by the small sample size and needs to do further research.

5.2. Relationship between age and patient satisfaction

According to the previous study, satisfaction towards fixed orthodontic brackets and the age difference were not statistically significant[15]. This result totally agrees with this study in which most of the patients of any age group were satisfied with their current orthodontic treatment condition. However, a recent study showed that there was a relationship between age and patient satisfaction[16] which was in contrast with our study.

5.3. Relationship between treatment duration and patient’s satisfaction

The most influencing factor on patient satisfaction in this study was treatment duration. This was contrasted with another study which showed that treatment duration did not correlate with patient satisfaction [17]. This might be because the study mainly focused on the participants who were already finished orthodontic treatment and there was no comparison and contrast between their first experiences of wearing fixed orthodontic brackets. Also, patients’ satisfaction and acceptance of fixed appliances should be directly proportional to the treatment duration. Therefore, we planned to study two groups according to treatment duration: 0–6 months and 6–12 months. In this study, patients with long-term wearing of fixed appliances were more satisfied than patients with short-term wearing. Based on the findings, we can assume that patient acceptance of orthodontic treatment during the first three months is crucial [18, 19] and that patient acceptance of their teeth position changes as a result of fixed orthodontic treatment increases with treatment duration. The longer duration and pre-existing malocclusion conditions should be evaluated to obtain more accurate data and to be able to draw the causal relation. However, due to COVID-19 conditions and time constraints, only patients recruited within a year and without taking into account any pre-existing conditions were included in this study.

5.4. Relationship between oral health-related problems and patients’ satisfaction

For measuring the Oral health-related quality of life, GOHAI is regarded as the most comprehensive and appropriate for focusing on minor clinical changes aspects [20]. Since orthodontic brackets are placed against the surface of the teeth, it might disturb the movement of the tongue and cheeks during speaking or eating. However, from this study, such usual discomforts are no longer influencing participants’ satisfaction during treatment. Nevertheless, orthodontists still need to guide patients to speak slowly and strengthen tolerance for some speech interference during that time [21].

Moreover, if discomfort from fixed appliances occurs, the patient needs to go to the clinic again and it might affect significant indirect costs, absence of work, and school to attend multiple appointments [22]. This result is associated with our thesis which showed that patients who frequently visited clinics were less satisfied. The increasing number of visits is one of the main drawbacks of patient satisfaction during treatment. In Ghulam Rasool et al’.s study, they found that there was an association between bracket failure and patients ‘treatment satisfaction levels [23]. In our study, the frequency of clinical visits was increased due to the treatment span complained.

Most of the studies supported that improvement of dental appearance is the most patients expected [24,25]. Our study was also in agreement with the fact that patients who were aware of their teeth position improvement during treatment were more satisfied. However, this remark does not correspond with the other study in which they stated that although patients’ main interest is dental appearance, satisfaction with the appearance changes was not associated with total satisfaction [26].

For better acceptance of orthodontic treatment plans, orthodontists should relay important information about treatment and should explain possible complications during treatment to increase the dentist-patient relationship. In addition, patients need to follow oral hygiene instructions to improve their oral hygiene condition and accelerate their tooth movement.

6. Conclusion

In this study, patient satisfaction during orthodontic treatment is in relation with

1. Duration period of orthodontic treatment

2. Self-awareness of tooth position improvement

3. Frequency of in-between visits

Limitation of food intake, difficulty in speech, discomfort at cheek and lips, and difficulty in swallowing are the distinct discomforts found among 125 volunteers. Yet, there is a negligible association between oral health-related quality of life assessed by using GOHAI and patient satisfaction during fixed orthodontic treatment.

The results from this study are all pointing out that there were no distinct discomforts and complications during orthodontic treatment. These are valuable messages that can be given to patients who are planning to wear orthodontic braces but are worrying about discomfort. This study can conclude that better control of orthodontic treatment handling by orthodontics is the most important one that can bring about patients’ satisfaction, happiness, and acceptance for continuing from the alignment stage to the finishing stage of the orthodontic treatment journey with their orthodontist.

7. Limitation

This study provides the patients’ satisfaction and oral health-related quality of life; however, it has several drawbacks as well. First off, we were unable to determine the direction of the effects due to the cross-sectional nature of the study. Furthermore, this study was limited in that it was unable to account for the participants’ plexus levels and other pre-existing malocclusion conditions. In order to get information about the opinions, attitudes, and behaviours of the participants at that specific moment in time, this study used a one-time survey type that was only conducted once.

Future research involving a more diverse population and longer-term variable considerations are needed to distinguish between orthodontic treatments in order to gather more accurate and thorough data regarding patient satisfaction with fixed orthodontic treatment.

Author Contributions

Author 1 contributed to the conception, design, data acquisition, and interpretation and performed all statistical analyses.

Author 2 contributed to critically revising the manuscript.

Author 3 contributed to supervising the concept, and design and critically revised the manuscript.

Ethical approval

Due to the survey type of research, the institution agreed that the approval of the Institutional Review Board was not needed where the data were properly anonymized and informed consent was obtained at the time of original data collection.

Disclosure statement

No potential conflict of interest was reported by the author(s).