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Open Journal of Stomatology, 2017, 7, 225-233
http://www.scirp.org/journal/ojst
ISSN Online: 2160-8717
ISSN Print: 2160-8709
DOI: 10.4236/ojst.2017.74016 April 17, 2017
Dental Aesthetics: A Study Comparing Patients’
Own Opinions with Those of Dentists
Richard John Moon1, Brian James Millar2*
1General Dental Practice, Wetherby, UK
2Restorative Dentistry, King’s College London Dental Institute, London, UK
Abstract
Objective: A beautiful smile
is perceived as important but the components
that contribute to the patient’s concept of a beautiful smile have not been fully
investigated. Hence
this study aimed to compare the views of patients on their
own dental aesthetics with those of a group of dentists. It also assessed the p
a-
tients’ willingness to undergo aesthetic treatment. Methods: Fifty patients, who
ranged in age from 24 to 76 years, completed self-
assessment questionnaires.
Photographs were taken of these patients, which were subsequently
assessed
by six dentists using a questionnaire with visual analogue scale to assess each
parameter. Results: Significant differences (p
< 0.05) were found between the
opinions of the dentists and the patients. Older patients were generally more
satisfied with their smile than the dentists. Eighty-
six percent of the patients
were willing to undergo aesthetic treatment, although factors such
as the
complexity of treatment, time involved, discomfort and financial costs, d
e-
terred many. The cost of treatment was the main deterrent. The younger p
a-
tients were least likely to be put off treatment. Conclusion: Patients’ views of
their own smile differed from the dentists’ opinion. Those who were the least
satisfied and were most likely to undergo aesthetic treatment
were in the
younger age groups. Satisfaction increased with age and older patients were
less likely to seek the aesthetic treatment.
Keywords
Dental Aesthetics, Self-Assessment, Patient, Dentist
1. Introduction
Patients are increasingly seeking cosmetic dental treatment and an attractive
smile is often considered important to them. Studies have shown that attractive
people are perceived as being more intelligent [1] and more popular [2]. The
How to cite this paper:
Moon,
R.J. and
Millar
, B.J. (2017) Dental Aesthetics: A Stu-
dy Comparing Patients’ Own Opinions with
Those of Dentists
.
Open Journal of Stom
a-
tology
,
7
, 225-233.
https://doi.org/10.4236/ojst.2017.74016
Received:
January 24, 2017
Accepted:
April 14, 2017
Published:
April 17, 2017
Copyright © 201
7 by authors and
Scientific
Research Publishing Inc.
This work is
licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
R. J. Moon, B. J Millar
226
importance of the smile in social attractiveness and even skill assessment is
known [3] [4]. Patients who seek the cosmetic dental treatment are often those
who consider themselves to be essentially normal in appearance but wish to
make some improvements [5].
It is important that the prescribing clinician is aware about patient percep-
tions of aesthetics in order to satisfy their aesthetic needs even when the restora-
tions are technically correct [6]. However, aesthetic opinions vary according to
the person making the assessment [6] [7] [8] [9] [10].
Brisman’s study [11] sought the opinions of patients, dental students and den-
tists, reporting that all groups preferred teeth of a similar shape, although the
dentists preferred relatively longer and thinner teeth than the patients. Mehl
et
al.
(2015) showed a difference between students and dentists and emphasised the
need to teach aesthetics at dental school [7]. Prahl-Andersen’s study [12] com-
pared the opinions of laypeople, general dentists and orthodontists, finding that
the general dentists and orthodontists essentially agreed in their responses but as
a combined group, they were much more critical than the laypeople that were
more likely to accept increased or reverse overjets and mild crowding [12].
Shiyan
et al.
(2016) stressed the need to be aware of the difference in percep-
tion between orthodontists and patient [9]. Others agreed and found orthodon-
tists were found to be more critical than general dentists [10] [13]. Geographic
variation in opinions also exists [8].
Studies have shown that the demand exists for invasive and non-invasive aes-
thetic dental treatment [14]. If such treatment is to be carried out successfully, it
is important that the dentist fulfils or exceeds the patient’s aesthetic expecta-
tions. Some of the investigations have found similarities between patients’ and
dentists’ opinions of beauty, whilst others have found disagreement [11] [12]. If
the dentists are more critical of a patient’s appearance than the patient is, then
there is a risk that they may be over-treated. However, if they are less critical,
then the patient may not be satisfied with the treatment outcome. Both factors
could be relevant in the increasing complexity in managing patient’s aesthetic
concerns. The use of self-perception in assessing patients’ treatment needs has
been stressed [15].
The aims of the study were to compare the opinions of dentists on a patients’
dental aesthetics with those of the patients themselves and to assess which fac-
tors influence patients’ demand for treatment. Specific objectives were to look at
age and gender in relation to self perception of dental aesthetics regarding tooth
shape, shade, size, position and the impact of soft tissues and restorations.
2. Materials and Methods
This study was designed to compare dentists’ perceptions of the aesthetic zone
bounded by the lips during a smile matched to those of patients. Seven areas
were assessed: the overall appearance, tooth shape, tooth shade, tooth size, posi-
tion of the teeth, appearance of the gingiva and of any restorations or prosthetic
teeth. The assessment was carried by looking at clinical photographs (Figure 1).
R. J. Moon, B. J Millar
227
A questionnaire was designed by the authors and evaluated via a pilot study, de-
signed to examine patients’ overall satisfaction with the appearance of their an-
terior teeth (Table 1). Dentists assessed the aesthetics of the smile zone using
photographs and a questionnaire as in other studies [8] [10].
In order to allow the patients time to assess their own dentition they were
asked to complete the questionnaire at home. The subjects assessed the overall
aesthetics as well as tooth shape, the shade of the teeth, tooth size, tooth position
and the soft tissues and the aesthetic impact of any restorations present. Visual
Analogue Scales (VAS) were used and the patients marked the points on the line
Figure 1. Photographic views and information for one of the patient assessments.
Table 1. The questionnaire used in the study.
Patient No. __________
Please mark a point on the line, below the question, indicating how satisfied you are with the
issue covered by that question, ranging from completely unsatisfied , to fully satisfied .
For example:
_______________________________________________
How happy are you with the overall appearance of the anterior teeth?
_______________________________________________
How happy are you with the shape of the anterior teeth?
_______________________________________________
How happy are you with the shade of the anterior teeth?
_______________________________________________
How happy are you with the size of the anterior teeth?
_______________________________________________
How happy are you with the position of the front teeth?
_______________________________________________
How happy are you with the appearance of the gingiva, around the front teeth?
_______________________________________________
How happy are you with the appearance of any fillings, crowns or denture teeth present
on the anterior teeth? (If none are present, please tick the following box )
_______________________________________________
R. J. Moon, B. J Millar
228
that represented their view. Ethical permission for this analysis was not required
at the time of the study (2003).
The patients were randomly selected from the patient list in a private general
dental practice situated in Leeds city centre. The concept of the study was ex-
plained to the patients and those that were happy to participate were given ques-
tionnaires to take home, complete and return to the surgery in a stamp-addressed
envelope.
The assessing dentists were given a similar questionnaire together with three
photographs of each patient and information regarding the patient’s overjet,
overbite and the shade of the bodies of the central incisors (Figure 1). Scores
were generated from the marked visual analogue scales by measuring the point
at which they were marked. The marked point was measured to the nearest mil-
limetre, where the point lay between whole numbers the score was rounded up.
The lines were 10 cm long and therefore, the measured point gave a “score” out
of 100.
Six dentists assessed the patients: two general practitioners, two orthodontists
and two specialist (restorative or prosthodontic lists) dentists. The mean and
standard deviation of the dentists’ scores were then calculated for each question,
patient by patient. From these figures 95% confidence intervals were calculated.
Where the patient’s own scores fell outside these intervals they were considered
to be significantly different, from those of the dentists assessment of the images
of the patients (t-test, p < 0.05).
In order to confirm repeatability, paired t-tests and an intra-class correlation
coefficient (ICC) were performed on the dental assessors. Five randomly chosen
patients were reassessed. ICCs were calculated for each dentist by comparing the
scores given for all of the questions in the initial assessment and in the reassess-
ment. An overall ICC was also calculated. An ICC above 0.70 is generally con-
sidered acceptable. All statistical analyses were performed by SPSS.
3. Results
Questionnaires were given to 60 patients, 52 of whom replied. Unfortunately 2
of these responses were returned too late to be analysed, therefore 50 patients
were assessed. Of the respondents, 26 were female and 24 male with an age range
from 24 to 76 years. The breakdown of the patients is shown in Table 2.
ICCs together with any associated bias were calculated for each of the assess-
ing dentists. An ICC of 0.700 or greater is considered to indicate a high level of
consistency, the measured ICCs ranged from 0.814 - 0.903 thus the consistency
of the dentists was high.
Table 3 shows those patients who were more satisfied than the assessing den-
tists, whilst Table 4 shows those who were less content. The results are expressed
as percentages of the age group for both male and female respondents.
The final question regarding the appearance of restorations or prostheses caused
the greatest difficulty. In 8 of the 50 assessments at least one the dentists could
not detect restorations. In two cases, the patients gave scores for restorations
R. J. Moon, B. J Millar
229
Table 2. Breakdown of patients enrolled in the study.
Pt Age Female Male Total in age group
20 - 29 yrs 5 3 8
30 - 39 yrs 4 6 10
40 - 49 yrs 6 1 7
50 - 59 yrs 7 7 14
60 - 69 yrs 2 6 8
70 - 79 yrs 2 1 3
Totals 26 24 50
Table 3. Percentage of age group more satisfied than the assessing dentists.
AGE 20 - 29 yrs 30 - 39 yrs 40 - 49 yrs 50 - 59 yrs 60 - 69 yrs 70 - 79 yrs
F M F M F M F M F M F M
Overall 20% 33% 25% 17% 50% 100% 57% 29% 0% 50% 100% 100%
Shape 0% 33% 25% 17% 33% 0% 71% 29% 0% 50% 50% 100%
Shade 0% 0% 0% 0% 67% 100% 14% 43% 0% 33% 50% 100%
Size 20% 33% 25% 17% 50% 100% 43% 29% 50% 33% 50% 100%
Position 20% 33% 0% 33% 50% 100% 29% 43% 0% 33% 50% 100%
Gingiva 20% 67% 25% 0% 33% 100% 29% 43% 0% 33% 50% 100%
Restorations 60% 0% 25% 0% 33% 0% 57% 43% 0% 50% 50% 100%
Table 4. Percentage of age group less satisfied than the assessing dentists.
AGE 20 - 29 yrs 30 - 39 yrs 40 - 49 yrs 50 - 59 yrs 60 - 69 yrs 70 - 79 yrs
F M F M F M F M F M F M
Overall 20% 33% 25% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Shape 40% 33% 0% 0% 17% 0% 29% 0% 0% 0% 0% 0%
Shade 40% 67% 50% 67% 0% 0% 14% 14% 0% 0% 0% 0%
Size 40% 33% 0% 0% 0% 0% 0% 14% 0% 0% 50% 0%
Position 20% 0% 0% 33% 0% 0% 0% 0% 0% 0% 0% 0%
Gingiva 60% 33% 0% 50% 17% 0% 14% 0% 50% 0% 0% 0%
Restorations 0% 33% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
that were not present, whilst in another the patient and one of the dentists
scored unrestored teeth. In four of the assessments the patients did not detect
the presence of their restorations. In situations where not all of the dentists
spotted the restorations, the values of those that did, have been used.
The questionnaire also asked how willing the patients would be to undergo
dental treatment in order to improve their appearance. They were given various
options ranging from refusal to have any treatment to acceptance of treatment
no matter how time consuming, costly or uncomfortable. The results are shown
in Table 5.
R. J. Moon, B. J Millar
230
Table 5. The willingness or otherwise of patients to undertake aesthetic treatment as a percentage of their age group.
AGE 20 - 29 yrs 30 - 39 yrs 40 - 49 yrs 50 - 59 yrs 60 - 69 yrs 70 - 79 yrs
F M F M F M F M F M F M
Pts unwilling to undergo aesthetic treatment 0% 33% 0% 17% 33% 100% 0% 0% 0% 17% 50% 0%
Pts willing to undergo treatment with NO provisions 60% 67% 25% 33% 17% 0% 0% 57% 0% 0% 0% 0%
Pts willing to undergo simple treatment only 40% 0% 25% 0% 33% 0% 14% 29% 0% 17% 0% 100%
Pts unwilling to undergo treatment because of time. 0% 0% 0% 17% 0% 0% 29% 0% 0% 0% 0% 0%
Pts unwilling to undergo treatment because of discomfort 0% 0% 25% 17% 0% 0% 43% 0% 50% 17% 50% 0%
Pts unwilling to undergo treatment because of costs 0% 0% 0% 67% 50% 0% 43% 14% 100% 50% 50% 0%
4. Discussion
This study was undertaken to find out whether dentists’ perceptions of the aes-
thetic zone bounded by the lips during a smile matched those of patients. Seven
areas were assessed: the overall appearance, tooth shape, tooth shade, tooth size,
position of the teeth, appearance of the gingiva and of any restorations or pros-
thetic teeth. In all areas significant differences (p < 0.05) were found between the
views of patients and the dentists.
As the study was carried out in a city centre private general dental practice
there will be a sampling bias and, although the patients were randomly selected
from the patient list, they may not represent the general population. Fifty pa-
tients took part in the study 26 women and 24 men, ranging in age from 24 to 76
years old. The small size of the study meant that in some of the age range groups
there were only a very small number of participants.
Six dentists assessed the patients and all proved to be reliable with regard to
their consistency as shown by the calculated intra-class correlation coefficients
(ICC). In general the dentists were more critical than the patients as reported in
other studies and more patients were satisfied with their appearance than were
unsatisfied [13]. For satisfaction with their overall appearance, 40% of the re-
spondents were significantly more content, than the dentists, with their appear-
ance (p < 0.05). Whilst there was no gender bias, as in agreement with other
studies [16], there was a tendency for older patients to be more content. By
comparison only three of the patients (6%) were significantly less satisfied with
their appearance; two of these were in the 20 to 29 year group and the other in
the 30 to 39 year old group.
Tooth shape was considered to be significantly more pleasing by 34% of the
patients, whilst only 12% were significantly less pleased (p < 0.05). In a similar
distribution to “overall appearance”, no sexual bias was found and a greater per-
centage of older patients were happier with their tooth shape than younger ones.
Similar findings were found regarding tooth size, where 36% were signifi-
cantly more satisfied and 10% less satisfied than the assessing dentists (p < 0.05).
Again there was an even split between men and women in the more content
group and although a direct association with age was not found, there was a
tendency for older patients to be more pleased.
R. J. Moon, B. J Millar
231
The assessment of tooth position again found comparable results, 34% were
significantly more satisfied whereas only 6% were less pleased than the dentists
(p < 0.05). Patients’ opinions on the appearance of their gingiva were not so one
sided with 32% being significantly more content whilst 20% were less satisfied (p
< 0.05). Younger patients again predominated in the less satisfied group of re-
spondents, 70% of them lying in the 20 - 29 and 30 - 39 year old groups.
Nineteen patients significantly differed with the dentists in their views on the
appearance of restorations or prosthetic teeth (p < 0.05). The vast majority were
more content than the dentists and only one was less pleased. No direct associa-
tion was found with age. It would therefore appear that the majority of patients
are either as pleased as or are more pleased than the dentists on the appearance
of their restorations. However, it is possible that the assessing dentists are par-
ticularly critical in this area, as they are looking at the work of other dental prac-
titioners.
Tooth shade was the area where greatest dissatisfaction was found. Of the 25
patients who significantly disagreed with the assessing dentists (p < 0.05), 12
were unhappy with the shade of their teeth. Self-perception of tooth shade has
been shown to be biased by patients who are unhappy with their body image
overall [17].
One can speculate as to why the younger patients are more self-deprecating.
They may be generally more image conscious and some may have celebrity role
models whom they wish to copy. They may be embarking on new careers and
feel that they need to improve their appearance in order to promote themselves.
Or they may be looking for a partner and thus wish to appear as attractive as
possible. By comparison, the older generations may not be so influenced by to-
day’s “image society”. Perhaps they are more likely to be settled in a job or have
a partner. They may simply have become used to their appearance and are now
quite content with it. Hirsch
et al.
[18] put forward the theory of cognitive dis-
sonance in his study where patients rapidly adapted to dentures whose appear-
ance they initially disliked. It may be that older patients subconsciously ignore
any displeasing features and concentrate on “better” areas. The reasons sug-
gested above as to why younger patients are more discerning may of course ap-
ply to older patients and this may explain the dissatisfaction felt by some of these
patients in this study.
Out of the 50 patients in the study 43 (86%) said that they would undergo
dental treatment in order to improve their appearance. Therefore the desire for
treatment is present amongst the patients. When the study looked at how willing
patients would be to have aesthetic treatment carried out, it was the younger pa-
tients who were happier to have treatment, no matter how much time, discom-
fort or money was involved.
Ten patients would only have treatment if it were relatively simple and they
were evenly spread between both sexes and age groups. Of those patients who
would embark on more complicated treatment, the time involved did not put
many off. However, the thought of pain dissuaded eight of these patients, six of
R. J. Moon, B. J Millar
232
whom were women. There was no obvious age association.
The potential high cost of treatment was the area that would put most people
off treatment. Thirty four percent of patients said that it would deter them; men
and women shared this concern equally. Again no age association was found,
however none of the patients in the 20 - 29 year old age group said that costs
would put them off.
5. Conclusion
This was a relatively small study carried out in a private, city dental practice in
the north of England and ideally a much larger and more widespread study
should be carried out. However, that said interesting although perhaps not sur-
prising results were recorded. This study found significant differences between
the patients and the dentists in all of the areas that were examined (p < 0.05). In
general, the patients were more satisfied that the dentists with their appearance.
However, a number of patients were less satisfied and these tended to be the
younger ones. Satisfaction with appearance was greater amongst the older pa-
tients. Least satisfaction was found in relation to the shade of the teeth. Eighty-
six percent of the patients were willing to undergo the treatment in order to im-
prove the appearance of their teeth. The issue that would deter most people from
complex treatment was the financial cost, although no members of youngest group
of patients were put off by this.
References
[1] Clifford, M. and Walster, E. (1973) The Effect of Physical Attractiveness on Teacher
Expectations.
Sociology of Education
, 46, 248-258. https://doi.org/10.2307/2112099
[2] Kleck, R.E. and Rubenstein, C. (1975) Physical Attractiveness, Perceived Attitude
Similarity, and Interpersonal Attraction in an Opposite-Sex Encounter.
Journal of
Personality and Social Psychology
, 31, 107-114. https://doi.org/10.1037/h0076243
[3] Somani, A., Newton, J.T., Dunne, S.M. and Gilbert, D.B. (2010) The Impact of Visi-
ble Dental Decay on Social Judgements: Comparison of the Effects of Location and
Extent of Lesion.
International Dental Journal
, 60, 169-174.
[4] Henson, S.T., Lindauer, S.J., Gardner, W.G., Shroff, B., Tufekci, E. and Best, A.M.
(2011) Influence of Dental Esthetics on Social Perceptions of Adolescents Judged by
Peers.
American Journal of Orthodontics and Dentofacial Orthopedics
, 140, 389-
389. https://doi.org/10.1016/j.ajodo.2010.07.026
[5] Sheets, C.G. (1987) Modern Dentistry and the Esthetically Aware Patient.
The Jour-
nal of the American Dental Association
, 115, 103E-105E.
https://doi.org/10.14219/jada.archive.1987.0323
[6] Al Moaleem, M.M., Alkhayrat, F.M., Madkhali, H.A., Geathy, I.H., Qahhar, M.A.,
Yaqoub, A. and Mattoo, K.A. (2017) Subjective Differences between Dentists and
Patients about Relative Quality of Metal Ceramic Restorations placed in the Esthetic
Zone.
The Journal of Contemporary Dental Practice
, 18, 112-116.
https://doi.org/10.5005/jp-journals-10024-2000
[7] Mehl, C.J., Harder, S., Wolfart, S., Vollrath, O., Trinkler, A., Wenz, H.J. and Kern,
M. (2015) Influence of Dental Education on Esthetic Perception.
International Jour-
nal of Esthetic Dentistry
, 10, 486-499.
R. J. Moon, B. J Millar
233
[8] Mehl, C., Harder, S., Lin, J., Vollrath, O. and Kern, M. (2015) Perception of Dental
Esthetics: Influence of Restoration Type, Symmetry, and Color in Four Different
Countries.
The International Journal of Prosthodontics
, 28, 60-64.
https://doi.org/10.11607/ijp.4005
[9] Huang, S., Qu, X., Xu, S., Rao, N. and Li, X. (2016) Orthodontists’ and Laypeople’s
Perception of Smile Height Aesthetics in Relation to Varying Degrees of Transverse
Cant of Anterior Teeth.
Australian Orthodontic Journal
, 32, 55-63.
[10] Cotrim, E.R., Vasconcelos Júnior, Á.V., Haddad, A.C. and Reis, S.A. (2015) Percep-
tion of Adults’ Smile Esthetics among Orthodontists, Clinicians and Laypeople.
Dental Press Journal of Orthodontics
, 20, 40-44.
https://doi.org/10.1590/2176-9451.20.1.040-044.oar
[11] Brisman, A.S. (1980) Esthetics: A Comparison of Dentists’ and Patients’ Concepts.
The Journal of the American Dental Association
, 100, 345-352.
https://doi.org/10.14219/jada.archive.1980.0093
[12] Prahl-Andersen, B., Boersma, H., van der Linden, F.P.G.M. and Moore, A.W.
(1979) Perceptions of Dentofacial Morphology by Laypersons, General Dentists,
and Orthodontists.
The Journal of the American Dental Association
, 98, 209-212.
https://doi.org/10.14219/jada.archive.1979.0456
[13] Thomas, M., Reddy, R. and Reddy, B.J. (2011) Perception Differences of Altered
Dental Esthetics by Dental Professionals and Laypersons.
Indian Journal of Dental
Research
, 22, 242-247. https://doi.org/10.4103/0970-9290.84295
[14] Nalbandian, S. and Millar, B.J. (2009) The Effect of Veneers on Cosmetic Improve-
ment.
British Dental Journal
, 207, 72-73. https://doi.org/10.1038/sj.bdj.2009.635
[15] Moura, C., Cavalcanti, A.L., Gusmao, E.S., Soares Rde, S., Moura, F.T. and Santillo,
P.M. (2013) Negative Self-Perception of Smile Associated with Malocclusions
among Brazilian Adolescents.
The European Journal of Orthodontics
, 35, 483-490.
https://doi.org/10.1093/ejo/cjs022
[16] Mehl, C., Wolfart, S., Vollrath, O., Wenz, H.J. and Kern, M. (2014) Perception of
Dental Esthetics in Different Cultures.
The International Journal of Prosthodontics
,
27, 523-529. https://doi.org/10.11607/ijp.3908
[17] Bauer, J., Vasilache, I., Schlegel, A.K., Wichmann, M. and Eitner, S. (2012) Esthetics
and Psyche—Part 1: Assessment of the Influence of Patients’ Perceptions of Body
Image and Body Experience on Selection of Existing Natural Tooth Color.
The In-
ternational Journal of Prosthodontics
, 25, 36-43.
[18] Hirsch, B., Levin, B. and Tiber, N. (1972) Effects of Patient Involvement and Esthe-
tic Preference on Denture Acceptance.
Journal of Prosthetic Dentistry
, 28, 127-132.
https://doi.org/10.1016/0022-3913(72)90129-1
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