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Original Article
Impact of orthodontic treatment on self-esteem and quality of life
of adult patients requiring oral rehabilitation
Vanessa de Couto Nascimento
a
; Ana Cla´udia de Castro Ferreira Conti
b
; Maurı
´cio de Almeida
Cardoso
b
; Danilo Pinelli Valarelli
b
; Renata Rodrigues de Almeida-Pedrin
b
ABSTRACT
Objective: To evaluate whether orthodontic treatment in adults requiring oral rehabilitation is
effective for increasing patients’ self-esteem and quality of life (QoL).
Materials and Methods: The sample consisted of 102 adult patients (77 women and 25 men)
aged between 18 and 66 years (mean, 35.1 years) requiring oral rehabilitation and orthodontic
treatment simultaneously. Rosenberg’s Self-Esteem (RSE) Scale and a questionnaire about QoL
based on the Oral Health Impact Profile (OHIP-14) were used to determine self-esteem and QoL
scores retrospectively. Questionnaires were carried out in two stages, T1 (start of treatment) and
T2 (6 months after). To compare score changes between T1 and T2, the data obtained from the
RSE Scale were evaluated with paired ttests, and data from the quality-of-life questionnaire were
assessed by applying descriptive statistics.
Results: The results showed a statistically significant increase in self-esteem (P,.001) and
a great improvement on patients’ QoL.
Conclusions: Orthodontic treatment causes a significant increase in self-esteem and QoL,
providing psychological benefits for adult patients in need of oral rehabilitation. (Angle Orthod.
2016;88:1–7.)
KEY WORDS: Adult; Self-esteem; Orthodontics; Quality of life; Oral rehabilitation
INTRODUCTION
There is an increasingly tendency nowadays for adult
patients to seek orthodontic treatment,
1–12
especially
those needing oral rehabilitation. Esthetics are important
in people’s lives, and facial appearance has a profound
influence on personal attractiveness and self-esteem
because it affects health and reverberates in social,
affective, and professional relationships.
2–4,6,10,12–18
Adult treatment demands an interdisciplinary ap-
proach,
1,2,4,7
since periodontal disease increases with
age,
5
and tooth and bone loss cause migration of
teeth and malocclusion. Periodontology prevents tissue
damage, and orthodontics improves tooth position,
promotes hygiene conditions and improves bone in-
sertion.
1,5
Thus, it is evident that an interdisciplinary
interaction plays an important role in patients’ quality of
life and self-esteem, especially in oral rehabilita-
tion.
1,2,4,7,11,19
Severe malocclusion involving the anterior teeth
exerts both emotionally and psychosocially negative
effects on patients’ lives.
3,9,13,15
In addition, their
perception of the malocclusion is often different from
that of the orthodontist. It is common that patients
present with high levels of concern for visible problems,
but tolerate a less noticeable but more severe
problem.
6,15,17,20
Considering treatment time as one of
the main concerns of adult patients, solving patients’
complains with an individualized approach, limiting the
treatment to a functional correction and therefore
reducing treatment time, should be the focus of
orthodontic treatment.
1,2,4,6,9,10,20
Some studies
3,4,6,8,11–23
performed to collect evidence
about the psychosocial profile of people seeking
orthodontic treatment suggest that dentofacial prob-
lems can affect peoples’ well-being. The gap in the
literature concerning this subject, as this treatment
may affect patients in need of rehabilitation because it
a
MSc Student, Department of Orthodontics, Institute of
Dentistry, Sagrado Corac¸a˜ o University, Bauru, SP, Brazil.
b
Professor, Department of Orthodontics, Institute of Dentistry,
Sagrado Corac¸a˜ o University, Bauru, SP, Brazil.
Corresponding author: Dr Vanessa de Couto Nascimento,
Department of Orthodontics, Institute of Dentistry, 10-50 Irma˜
Arminda Street, Cep: 17.011-160, Bauru-SP, Brazil
(e-mail: vanessacouto3009@gmail.com)
Accepted: December 2015. Submitted: July 2015.
Published Online: February 22, 2016
G2016 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/072215-496.1 1 Angle Orthodontist, Vol 88, No 4, 2016
usually has its esthetic and compromised function,
stimulated the development of this study.
The objective of this study was to determine whether
orthodontic treatment in adults requiring oral rehabil-
itation is effective in enhancing patients’ self-esteem
and quality of life.
MATERIALS AND METHODS
This cross-sectional and prospective study was
based on patients’ answers to questions on assisted
self-report forms. The ethics-in-research committee of
Sagrado Corac¸a˜ o University approved all procedures
in this study.
Samples were selected from an orthodontic post-
graduate program, a specialization course, and a pri-
vate practice. Inclusion criteria were patients with
a minimum age of 18 presenting with malocclusion
requiring oral rehabilitation associated with orthodontic
treatment. Patients with craniofacial syndromes, neu-
rological or psychiatric disorders, or a history of
previous orthognathic surgery were excluded.
The sample size was calculated by adopting
a variation of dichotomous answers from T1 to T2,
with a minimum mean difference to be detected of 20
(percentage points), a significance level of 5%, and
power of 80%. Sample-size calculation required
a minimum of 97 patients.
Initially, 130 patients with fixed appliances presenting
with malocclusions caused by dental losses and
agenesis in T1 were selected for the study. Three patients
refused to participate in the study and 25 patients did
not answer the questionnaires in T2, thus were
excluded from the sample. The final sample consisted
of 102 adult patients: 77 women (75.5%) and 25 men
(24.5%) between 18 and 66 years of age (Table 1).
Patients agreed to participate in this research by
signing a written informed consent, and after a brief
explanation of the questionnaires, completed Rosen-
berg’s Self-Esteem (RSE) Scale and The Oral Health
Impact Profile-14 (OHIP-14) questionnaire. Both ques-
tionnaires were applied during two stages: T1—early
orthodontic treatment (1–3 months of treatment) and
T2—after leveling and alignment phase (minimum of
8 months of treatment); the minimum interval from T1
to T2 was 6 months.
To evaluate self-esteem, the RSE questionnaire
(Figure 1) had been previously validated and adapted
to patients’ conditions.
24
This scale comprises
10 questions; 5 are related to positive opinions and
5 to negative opinions, being interspersed to increase
reliability of the questionnaire. For each question, a
Likert Scale, consisting of four points (strongly agree,
agree, disagree, strongly disagree), was applied in
order to provide adequate weight to the responses.
Scores range from 0 to 3, where zero represents the
highest level of self-esteem and 3 the lowest (Table 2);
the lower the scores, the higher the patients’ self-
esteem. This method proved to be a reliable method to
measure self-esteem not only in the general population
but also in orthodontic patients.
15
The applied questionnaire for quality of life assess-
ment (Figures 2 and 3) was an adapted version of the
OHIP-14.
25
Modifications were made so that it would be
more effective in measuring the quality of life related
to orthodontic treatment. Thus, it was composed of
14 questions that were applied in T1 and T2 and 3 more
added to the T2 stage to answer any doubts of the
orthodontists regarding discomfort from the appliance
and satisfaction with the treatment outcomes, which
need no comparison. Another modification was di-
rected to the response scheme, whereas the gradation
system would not be sensitive to a two-stage modality.
Finally, for better adaptation of this questionnaire, the
researcher was advised by a psychologist with expe-
rience in this research protocol.
Statistical analysis was performed using Statistica
software version 12 (StatSoft Inc, Tulsa, Okla). Paired
ttests were used to compare the score changes from
T1 to T2 in the RSE questionnaire. Descriptive
statistics were used to assess the QoL-questionnaire
scores. The results are described in the tables, using
absolute frequency (n) and relative frequency (%), in
addition to the mean and standard deviation parame-
ters. The significance level was 5% (P,.05).
RESULTS
Results of the RSE questionnaire demonstrated a sta-
tistically significant improvement in self-esteem level from
T1 to T2 (Table 3). In total, 70.6% of patients showed self-
esteem improvement, 12.7% were unaltered, and self-
esteem worsened in only 16.7% (Table 4).
Table 1. Sample Distribution Regarding Age (Years)
Mean SD Minimum Maximum
T1 34.8 12.7 18 65
T2 35.1 12.8 18 66
Table 2. Calculation of Rosenberg’s Self-Esteem Scale Scores
Answers Scores
Questions 1, 3, 4, 7, & 10
Strongly agree 0
Agree 1
Disagree 2
Strongly disagree 3
Questions 2, 5, 6, 8, & 9
Strongly agree 3
Agree 2
Disagree 1
Strongly disagree 0
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Angle Orthodontist, Vol 88, No 4, 2016
Results of the QoL questionnaire were similar to
those of the RSE Scale and demonstrated an
increased QoL level. Only for those patients who had
answered yes in T1, questions 1 to 6 were separated
and applied again in T2 (Table 5). Among the patients
who had trouble speaking (question 1), 85% reported
an improvement. One hundred percent of the patients
who had alignment problems (question 2) and 76% of
those who had bruxism (question 3) also reported
improvement. Considering the patients who had
suffered from headaches (question 4), 71.8% reported
improvement as well. In addition, 86.5% of the patients
who felt uncomfortable when eating (question 5) and
80% of those presenting with impaired mastication
(question 6) reported improvement (Table 5).
Concerns related to oral hygiene (question 7)
increased from 78.4% to 98%. The percentage of
Figure 1. Rosenberg’s Self-Esteem Scale.
Table 4. Frequency of Sample Score Variation in RSE
Questionnaire: Improved (Scores Decreased From T1 to T2) or
Worsened (Scores Increased From T1 to T2)
Variation in RSE N %
Improved 72 70.6
Maintained 13 12.7
Worsened 17 16.7
Total 102 100.0
Table 3. Paired TTests Comparing the Average Score in T1 and
T2 for Rosenberg’s Self-Esteem (RSE) Scale Questionnaire
Score
T1 T2
Dif. PMean SD Mean SD
RSE 7.72 4.11 5.41 3.54 22.30 ,.001*
* Statistically significant difference (P,.05).
IMPACT OF ORTHODONTIC TREATMENT ON ADULT PATIENTS 3
Angle Orthodontist, Vol 88, No 4, 2016
patients satisfied with their faces (question 8) in-
creased from 38.2% to 77.5%. In addition, the number
satisfied with their smiles (question 9) increased from
14.7% to 97.1%. Specific issues related to self-esteem
increased from 56.9% to 97.1% and regarding self-
confidence from 60.8% to 96.1% (questions 10 and 11,
respectively).
Only for those patients who had responded no in T1
did we separate questions 12 to 14 and apply them
again in T2 (Table 6). Among those who had problems
with social acceptance (question 12), 81.8% reported
an improvement in this issue and, similarly, 80% of
those who reported difficulties in social relationships
and emotional well-being (question 13) demonstrated
a noticeable improvement. When asked whether
people liked their smile (question 14), 96.8% reported
improvement; only 3.2% did not know about other
people’s opinion, and there were no reports of disliking
their smiles (Table 6).
When patients were asked if they would undergo
treatment again, 96.1% said yes; no, 1%; and 2.9%
could not decide. It was interesting to note that 100%
of patients recommended the treatment to adult
patients. Finally, 35.3% of the patients reported
considerable discomfort while using the appliances
(Table 7).
DISCUSSION
The increase in demand for orthodontic treatment in
adults is justified, especially by the increasing pre-
ventive perspective of modern dentistry, esthetic
appeal of society, longevity, increased access to
information, technological advances of orthodontics,
and psychosocial variations.
1,2,4,6–19,22
Moreover, the
perception of malocclusion differs between profes-
sionals and patients.
23
Some people with severe
malocclusion do not report a negative impact, while
others with mild irregularities cited major impacts on
Figure 2. QoL questionnaire at T1 (orthodontic treatment beginning).
Table 5. Quality of Life Questionnaire Descriptive Statistics on T2 (Patients Who Answered Yes on Questions 1 to 6 in T1)
Improvement From T1 to T2:
T2
Yes, % No, % Do Not Know, %
1. Difficulties when speaking (n 527) 85.2 14.8 0.0
2. Teeth alignment problems (n 596) 100.0 0.0 0.0
3. Bruxism (n 525) 76.0 20.0 4.0
4. Headaches (n 539) 71.8 20.5 7.7
5. Discomfort when eating (n 537) 86.5 13.5 0.0
6. Impaired mastication (n 55) 80.0 20.0 0.0
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Angle Orthodontist, Vol 88, No 4, 2016
their QoL.
20
Esthetic reasons alone justify treatment,
not only because it almost always results in a better
patient self-image,
23
but also because patients value
esthetic and psychological benefits more than func-
tional and dental health improvements.
13,16
Women are more concerned with beauty and have
a better perception of treatment need as well as
esthetic results.
1,4,9,11,12,14,22
This fact explains why,
even in random samples such as in our study, there
is a prevalence of females.
4,6,9,11,14,18,21,22,26
Figure 3. QoL questionnaire at T2 (after leveling and alignment phase).
Table 6. Quality of Life Questionnaire Descriptive Statistics on T2 (Patients Who Answered No on Questions 12 to 14 in T1)
Improvement From T1 to T2
T2
Yes, % No, % Do Not Know, %
12. Good social acceptance (n 511) 81.8 18.2 0.0
13. Emotional well-being, good relationship with friends and others (n 55) 80.0 20.0 0.0
14. Do the people surrounding you (work partners, relatives, friends) like your smile? (n 531) 96.8 0.0 3.2
IMPACT OF ORTHODONTIC TREATMENT ON ADULT PATIENTS 5
Angle Orthodontist, Vol 88, No 4, 2016
In this study, it was found, by assessing the RSE
questionnaire, that 70.6% of patients showed improve-
ment in self-esteem, 12.7% were unaltered, and self-
esteem worsened only in 16.7%. Therefore, there was
a statistically significant difference in the self-esteem
level of individuals, which improved from 7.72 at T1 to
5.41 at T2 (P,.001). At the end of treatment, this
trend should increase even more, since patients
posttreatment usually have higher self-esteem than
during treatment or pretreatment.
22
Another cross-
sectional study assessed the effect of improvement
after therapy in the long-term (6 months to 10 years)
and stated that these benefits seem to be long-
lasting.
20
In order to assess more clearly the impact of
treatment on a patient’s QoL, only for those patients
who had answered yes in T1, we separated questions
1 to 6 and applied them again in T2. The patients
whose answers were positive are considered the focus
of this study. Among the 26.5% of patients who had
trouble speaking, 85.2% reported an improvement. All
patients who had alignment problems (94.1%) and
76% of those who had bruxism (24.5%) also reported
improvements. Considering the patients who had
suffered from headaches (38.2%), 71.8% reported
improvement as well. In addition, 86.5% of the patients
who felt uncomfortable when eating (36.3%) and 80%
of the patients who presented with impaired mastica-
tion (4.9%) reported improvement. At the end of
treatment, the percentage of patients who reported
improvement in masticating would probably increase,
as reported in another study.
14
Health and body care are also considered quality-
of-life issues. This could justify the increasing concern
in oral hygiene from 78.4% to 98% of sample patients.
The number of patients satisfied with their faces
increased considerably, from 38.2% to 77.5%. Even
though orthodontic treatment not always privileges the
face, this great improvement seems to be related to
the better QoL reported by patients. Furthermore, the
number of patients satisfied with their own smile
increased, from 14.7% to 97.1%.
Regarding the specific issues of self-esteem and
self-confidence, there was also a significant improve-
ment with increased percentage of 56.9% to 97.1% for
self-esteem and from 60.8% to 96.1% for self-
confidence. These results show that self-esteem,
social well-being, and QoL are closely related.
11,15
Since the perception of facial appearance can affect
health, social behavior, and happiness of the in-
dividual, it is safe to say that people with well-balanced
smiles are considered more intelligent and have
a greater chance of being employed.
6,17
In order to
observe more clearly the impact of these character-
istics, we considered only patients who said no in T1 to
questions 12 to 14 in the QoL questionnaire to be the
focus of this research, because others have reported
positive aspects. Of the 10.8% who originally said they
did not have good social acceptance, 81.8% reported
improvement; of the 4.9% who said they did not have
a good relationship with people, 80% reported im-
provement in their relationships.
When patients were asked about others’ perception
of their smile, 96.8% reported improvement, only 3.2%
reported not knowing people’s opinions, and no patient
reported others’ not liking his or her smile.
Several patients reported that they usually sought
information about orthodontic treatment from other
patients, which emphasized the latter’s important role
in adult patient referrals.
22
In another survey, 100% of
patients would undergo treatment again if necessary
and, based on their personal experience, would
encourage other adults to undergo treatment as well.
11
In this study, the results were similar, wherein 96.1% of
the patients said they would undergo orthodontic
treatment again if necessary, 1% would not, and
2.9% could not provide this information. It is notewor-
thy that all patients would recommend the treatment to
other adults with similar problems. Thus, orthodontists
should target this group, which is able to refer new
patients for treatment.
The patients’ chief complaint during orthodontic
treatment was oral pain,
11,12,14
especially in the first 3
months, generating a negative impact on the overall
QoL, then improving subsequently, although a signifi-
cant improvement in self-esteem was reported.
6
This
information is useful in motivating patients during the
adjustment period and encouraging them to finish
treatment, considering that their expectations will
probably be fulfilled.
6
Corroborating those authors,
35.3% of patients in this study felt uncomfortable while
using the appliances. The responses suggest that
esthetic improvement generates a significant increase
in QoL of adult patients,
4,20
corroborating a systematic
review stating that there is a modest association
between malocclusion, orthodontic treatment need,
and QoL.
16
Table 7. Orthodontic Treatment Perception After Leveling and Alignment Phase
Question Yes, % No, % Do Not Know, %
Would you undergo treatment again if necessary? 96.1 1.0 2.9
Would you recommend orthodontic treatment for other adults with the same problems? 100.0 – –
Did you feel very uncomfortable when using the appliances? 35.3 64.7 –
6DE COUTO NASCIMENTO, DE CASTRO FERREIRA CONTI, DE ALMEIDA CARDOSO, VALARELLI, DE ALMEIDA-PEDRIN
Angle Orthodontist, Vol 88, No 4, 2016
Even considering the significant sample size, these
results should be analyzed with caution because the
sample was selected in a specific area of the country.
Therefore, it is important to conduct future studies
involving more patients from different areas in de-
veloping countries such as Brazil.
Among the important features of this study were the
significant sample size, the collection of data from
a postgraduate program and a private practice, the
assistance of a single researcher, a sample comprising
only patients needing rehabilitation, and a QoL ques-
tionnaire specifically adapted for orthodontic patients.
Moreover, the large variation in patients’ ages (43
young adults at 18–30 years, 55 adults at 31–59 years,
and 4 adults aged over 60), made this study reliable
because it covered all age groups.
CONCLUSIONS
NOrthodontic treatment causes a significant increase
in patients’ self-esteem and QoL.
NThe psychological benefits for adult patients in need
of oral rehabilitation may occur because of the
motivation obtained by the improved occlusion and
smile esthetics.
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