INTRODUCTION

Orthodontic anomalies may impact function and well-being, thus affecting overall quality of life.¹ There is consensus that malocclusion may affect dental and periodontal health,^2,3 as well as oral functions such as mastication.⁴ Additionally, orthodontic abnormalities may greatly affect smile esthetics, therefore having a significant psychosocial impact.^1,5

Evaluation of severity of malocclusion and orthodontic treatment need includes the use of a variety of tools and indices based on objective clinical findings. However, treatment uptake is reportedly influenced by various functional and esthetic factors and the motivations for its initiation may be psychosocial.^6–8 Consequently, perceived need for orthodontic treatment is affected by orthodontic characteristics, defining the objective need, and multiple other factors related to the perception of dental appearance and sociocultural state, defining the subjective desire.^6–9

Despite the intention to initiate orthodontic treatment, individuals often decide to postpone its uptake due to several reasons. Although a few studies investigated relevant factors influencing the pursue of treatment, they were conducted either in an orthodontic clinic setting or included adolescents.^10–13 Thus, there are no available data on such predictors or qualitative data that explore the barriers in up taking therapy “through young adults’ eyes,” addressing a community population. This study aimed to investigate the predictors of willingness to uptake orthodontic treatment and the reasons for postponing its initiation in young adults.

MATERIALS AND METHODS

RESULTS

A total of 338 students were approached, with 39 (11.5%) declining participation for personal reasons and an additional 29 (8.6%) refusing to sign the informed consent form, leading to a sample size of 270 participants (79.9% response rate). Participant demographic characteristics and distribution according to IOTN-AC score are presented in Table 1.

Table 1.Demographic Characteristics and Distribution in the IOTN-AC Groups of the Participants (n = 270)

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Among them, 57% (n = 154) believed that their dental appearance needed improvement, and 38.8% (n = 105) were willing to pursue orthodontic treatment. However, 58 (55.2%) of those who intended to initiate treatment stated that they would not pursue it within the next year.

Predictors of Willingness to Pursue Orthodontic Treatment

Univariable logistic regression revealed that demographic variables such as age and gender had no significant impact on participant willingness to uptake orthodontic treatment. On the contrary, the IOTN-AC and the PIDAQ subscales (DC, SI, PI, and AC) significantly influenced participants’ self-perceived need for dental appearance improvement and willingness to pursue treatment. The multivariable logistic regression revealed that the only statistically significant predictor of willingness to undergo treatment was PIDAQ-Psychological Impact subscale score (aOR: 1.24; 95% CI: 1.11–1.37; P < .001). No significant problems regarding multicollinearity were reported (VIF range: 1.05–1.44) (Table 2).

Table 2.Factors Influencing Patient Willingness to Pursue Orthodontic Treatment^a

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DISCUSSION

This cross-sectional, questionnaire-based study investigated the predictors of willingness to uptake orthodontic treatment and provided qualitative insights into the reasons for postponing it in young adults who expressed such a self-perceived need. It is worth noting that this was the first international, mixed-methods study conducted in an adult community population, rather than in patients attending an orthodontic clinic. Its findings suggested that, although the presence of orthodontic abnormalities as described by the IOTN-AC index influenced willingness to uptake orthodontic treatment, they did not constitute the main driver to initiate therapy. The single statistically significant factor predicting the willingness to initiate treatment was the psychological impact of dental esthetics and malocclusion. Additionally, the seven main themes on the reasons for postponing treatment, though willing, could be summarized to: (a) Fear of the procedure; (b) Embarrassment about appearance during treatment; (c) High cost of treatment; (d) Prolonged duration of treatment; (e) Low prioritization of esthetics; (f) Insufficient information; and (g) Residential mobility.

According to the multivariable logistic regression model, the only statistically significant factor predicting willingness to uptake orthodontic treatment was the psychological impact of the dental condition, as described by the PIDAQ-PI subscale scores, regardless of the individual’s gender, age, and IOTN-AC score. The findings were in line with a previous Chinese study in patients of the same age group visiting an Orthodontic Department, that concluded that the SI, PI, and AC PIDAQ subscale scores predicted orthodontic treatment uptake, whereas age did not have a significant impact on treatment initiation.¹⁶ Consistent with previous findings, gender also did not influence the desire to undergo orthodontic treatment.^6,16,17 Nevertheless, adult women are reportedly more concerned and dissatisfied with their dental image,¹⁸ seeking orthodontic treatment more often.¹⁹ Other studies reported that age¹¹ and gender^9,20 were key predictors; however, the first study did not take into consideration participant gender, whereas the other addressed only adolescents. In agreement with the findings of a previous multivariate analysis, IOTN-AC index was also not a statistically significant predictor of treatment uptake.¹¹

Participants willing, yet postponing, orthodontic treatment could further document the rationale for this decision through the open-ended question in the study tool. The main themes suggested that one of the most important factors in young adult decision-making was how uptake would affect their psychology and social life. Participants’ fear was consistent across studies, illustrating that orthodontic treatment may cause functional limitations, discomfort and pain, leading to its avoidance.^10,16,21 According to Oliveira et al., 12.5% of patients who had received orthodontic treatment reported fear of pain as the reason for initially rejecting it.²² Participants’ concerns over their appearance stated in the current study, also echoed those documented in the previous Brazilian study, which highlighted that 10.7% of patients rejected initial indications for orthodontic treatment due to perceived esthetic concerns of wearing orthodontic appliances.²² Additionally, the probability of speech impairment while wearing orthodontic appliances and their visibility were major stress factors.¹⁰

Decision-making was mainly influenced by the treatment cost. Participants’ financial status and dependence on family was found to have greatly affected treatment initiation. In line with previous studies, cost was a key factor to consider in this decision.^{10,12,22–24} Additionally, the prolonged duration of orthodontic treatment,²² and the time for transportation to and from the orthodontic office,¹⁰ were found to discourage individuals.

Certain participants stated that orthodontic abnormalities were of minor importance since they mostly affected their appearance and not function or overall health, hence, orthodontic treatment constituted no immediate priority. Similar views were reported in past studies in which, though aware of their malocclusion, individuals did not consider undergoing orthodontic treatment as a necessity.^22,24,25 Also, although ease of access²³ and proximity to the orthodontic practice have been reported as important issues,¹⁰ residential mobility, a typical situation for student population, has not been explicitly reported in previous studies as a barrier to initiating treatment. This could probably be attributed to the fact that previous studies were mainly conducted with patients already visiting orthodontic clinics.

Lack of adequate information about the cost, duration, overall process, and effectiveness of orthodontic treatment were additionally noted in the findings. Doubts about its effectiveness led to initial rejection in nearly a fifth of patients in Brazil.²² According to a UK study,²⁶ some patients were, surprisingly, not aware that adults can undergo orthodontic treatment, contradicting the notion that awareness has led to increased demand among adults.²⁷ According to Oliveira et al., good communication between the orthodontist, the general dentist and other healthcare professionals, combined with an initial appointment to design the treatment plan, characterized by honesty and clarity, may address the main reservations for initial rejection of orthodontic treatment by reassuring and motivating patients.²²

Certain limitations may affect the interpretation of the current findings. The qualitative data were obtained through completing an open-ended question, and not following traditional methods of qualitative research, such as individual interviews or focus groups; hence, the method did not allow for additional questions, which could have helped to clarify interesting aspects of some responses, leading to more elaborate findings.²⁸ Nevertheless, avoidance of personal contact, inevitable in the traditional processes, was expected to minimize participant hesitation to respond truthfully. Also, additional demographic questions could have been included, such as marital status^11,16,26 and socioeconomic background.^12,17 However, it was decided to omit them since the population consisted of students, and they were not expected to be married or financially independent generally.

CONCLUSIONS

• The psychological impact of dental esthetics constitutes the main driver to pursue orthodontic treatment in young adults.

• Possible reasons for postponement of orthodontic treatment that a patient-centered orthodontic approach should address include: fear of the procedure, embarrassment about appearance during treatment, high cost and prolonged duration of treatment, low prioritization of esthetics, insufficient information, and residential mobility that could constitute barriers for some patients.

• Increasing young adults’ health literacy regarding orthodontic treatment could enable them to make better informed decisions about their oral health-related quality of life.