INTRODUCTION

Orthodontic risk may be defined as any deleterious influence, iatrogenic effect, or adverse consequence during orthodontic treatment, such as pain or discomfort, external root resorption, and black triangles.^1–3 The overriding principle in managing orthodontic risk is to anticipate and minimize risk, thereby eliminating any potential side effects for patients as much as possible. However, it is unfortunate that some well-defined risks are inevitable even when treatment is delivered appropriately, and this is not acceptable to some patients.⁴ Meanwhile, failing to properly identify and warn about underlying risks beforehand could be construed as negligence from a medicolegal perspective, potentially leading to patient dissatisfaction and dentolegal issues for orthodontists.^2,4,5 Consequently, effectively communicating orthodontic risks with sufficient and balanced information is essential.^1,6

Despite its great importance, communicating risks in orthodontics may be particularly challenging for several reasons. Patients often rely heavily on suggestions of professionals to make quick and effortless decisions, despite a shared decision-making process being advocated and pursued.^7,8 With such expectations, orthodontists are required to provide patients with a reasonable amount of information regarding risk that is both professional and straightforward. However, apart from explaining those apparent risks recognized from clinical or radiological evidence, the extent to which orthodontists should discuss risks with patients remains inconclusive. Additionally, it is important to identify the specific needs of individual patients and provide further information according to their circumstances.⁴ Therefore, a thorough exploration of potential risks is considered fundamental and essential in orthodontic practice. The pathogenesis, prophylaxis, remedy, and prognosis of specific orthodontic risks have been well-summarized.^1–3 However, little is known about how these risks are accepted by patients seeking for orthodontic treatment.

As an intrinsic characteristic of individuals, personality includes multiple traits that influence the way people make decisions.^9,10 Personality has been organized into five dimensions: neuroticism, conscientiousness, agreeableness, openness, and extraversion.¹¹ Personality evaluation has drawn great attention in the field of behavioral dentistry, as it can help to predict patient perceptions, expectations, treatment selections, and adherence as well as outcome satisfaction.^12–19 For example, Hansen et al.⁹ analyzed the association between personality traits and willingness to undergo various orthodontic modalities, and recognized agreeableness to be the most useful predictor. Additionally, Al-Omiri et al.¹⁷ found that personality traits could impact the perception of smile attractiveness for black triangles. To date, however, authors of few studies have focused on whether and how personality traits could influence the acceptance of orthodontic risks.

In the current study, we aimed to provide insights into patient-focused risk communication in orthodontic practice by examining how patients accepted multiple potential risks of orthodontic treatment and whether that acceptance was influenced by their personality traits.

MATERIALS AND METHODS

This study was approved by the ethics committee of West China Hospital of Stomatology, Sichuan University. Fully informed consent was acquired from all participants before the study.

Participant Inclusion

The sample size was estimated through G*power (version 3.1.9, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). Based on similar reports published previously, it was determined that 153 participants were required to achieve a power of 95%, with an α error of .05 and an effect size of 0.15.^18,20

Adult patients seeking orthodontic consultation at West China Hospital of Stomatology, Sichuan University, from January to June 2024 were recruited and screened according to the inclusion and exclusion criteria (Table 1).

Table 1.Inclusion and Exclusion Criteria for Participants

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Data Collection

A structured questionnaire, including demographic information (age, sex), an investigation of orthodontic risk acceptance, and a personality evaluation, was delivered to each patient during his or her initial appointment before starting any orthodontic treatment.

To evaluate the acceptance of orthodontic risks, a list of risks was compiled based on previous publications.^1–3 In total, 21 orthodontic risks were investigated, as presented in Table 2. Details about these risks were also included in the questionnaire for patient reference. Participants were then asked to rate their acceptance of the corresponding risks on a scale from 0 (completely unacceptable) to 4 (completely acceptable). Scores of 3 and 4 were categorized as accept. Any confusion about an orthodontic risk was further explained by an experienced orthodontist (J.W.) throughout the whole process. To validate the test-retest reliability of the self-defined instrument and evaluate general understanding of participants regarding the investigated orthodontic risks, a pilot study was conducted by asking individuals to complete the same questionnaire online after a 1-week interval. The κ coefficient was used to assess the test-retest reliability according to the Landis and Koch scale, and only orthodontic risks with at least moderate reliability were included in the subsequent study.²¹

Table 2.Orthodontic Risks and Reliability Assessment

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Personality traits of participants were assessed with a validated Chinese version of the Big Five Inventory (BFI), one of the most widely used tools for measuring personality.^22,23 The assessment evaluated five dimensions: neuroticism, conscientiousness, agreeableness, openness, and extraversion.

RESULTS

In the pilot study, 35 participants returned the second survey, and the κ coefficient for the reliability test ranged from 0.27 to 0.84. Therefore, 3 out of 21 orthodontic risks were disqualified due to unreliability and were excluded from the subsequent study, including missing school lessons/time off work, pain/discomfort, and black triangle (Table 2).

Finally, 261 participants were enrolled, including 107 males and 154 females aged 18 to 60 (mean age = 27.59 ± 7.52 years). Generally, acceptability of investigated orthodontic risks ranged from 47.1% to 87.0%. As presented in Table 3, six risks were identified as having high acceptability rates exceeding 80%. These included length of treatment (81.6%), tooth extraction and associated risks (80.8%), cuts and ulcers (83.5%), problems eating (83.9%), problems speaking (87.0%), and esthetic problems (85.4%). By contrast, the acceptability was found to be lower than 50% for two orthodontic risks: periodontitis (47.1%) and devitalization (49.8%).

Table 3.Acceptability of the Investigated Orthodontic Risks

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Personality traits of participating patients were assessed for each dimension with BFI. Results are presented in Table 4.

Table 4.Personality Traits of Included Participants

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Demographic characteristics were compared between patients accepting and not accepting the listed orthodontic risks. As shown in Table 5, patients accepting length of treatment as a risk factor were significantly younger (26.75 ± 6.16 vs 31.29 ± 11.15 years, P = .015) as were those accepting relapse (26.79 ± 6.85 vs 29.45 ± 8.66 years, P = .007). Female patients were found to be significantly less likely to be accepting of periodontitis as a risk factor than male patients (40.9% vs 56.1%, P = .016).

Table 5.Demographic Characteristics of Patients Accepting or Not Accepting Corresponding Risks^a

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Additionally, binary logistic regression was performed for each orthodontic risk to determine the correlation between risk acceptance and personality traits, while controlling for sex and age. Results presented in Table 6 indicated that, among the five dimensions of personality traits, conscientiousness showed a positive correlation with accepting tooth extraction and associated risks (odds ratio [OR] = 1.131, P = .002), problems eating (OR = 1.182, P < .001), problems speaking (OR = 1.111, P = .022), and appliance breakage (OR = 1.109, P = .008). Openness was identified as a significant predictor for acceptance of length of treatment (OR = 1.090, P = .044). No significant correlation was found between orthodontic risk acceptance and neuroticism, agreeableness, or extraversion. The pseudo-R²s of the logistic regression models with statistical significance are summarized in Table 7.

Table 6.Correlation between Personality Traits and Orthodontic Risk Acceptance^a

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Table 7.Binary Logistic Regression Model Analysis

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DISCUSSION

In this study, we aimed to assess the acceptance of various risks potentially existing for adult orthodontic treatment and to determine whether acceptance is influenced by personality traits of patients.

Overall, the acceptance rate of orthodontic risks ranged from 47.1% to 87.0% in this investigation. Two were identified as having a low rate of acceptance (<50%): periodontitis and devitalization. This may indicate the importance of emphasizing oral hygiene maintenance to patients before the commencement of orthodontic treatment, which directly influences the prevention of periodontitis.^24,25 Additionally, a thorough examination for dental health at the initial appointment is indispensable. Despite there being no direct relationship verified between pulp devitalization and orthodontic treatment, this indirect risk can still emerge during the lengthy treatment process.^26,27 Any pretreatment conditions should be discussed with patients and managed with specialists as necessary before initiating orthodontic treatment.

The relationship between orthodontic risk acceptance and demographic characteristics was explored. Results indicated that patients who accepted length of treatment and relapse tended to be younger, possibly due to a higher perception of esthetics among younger individuals, which increases their willingness to undergo orthodontic treatment.^15,22,28 With growing popularity of adult orthodontics over the past decades, treatment duration becomes a nonnegligible concern of patients.^29–31 In general, the average time for orthodontic treatment is currently 2–3 years, but it could be extended due to factors such as inadequate patient cooperation and severity of the malocclusion.³² Although additional treatments, such as low-level laser therapy and corticotomy have been shown to be beneficial in reducing orthodontic duration, the invasiveness and additional cost of these therapies may also introduce additional perceived risks for patients.^33,34 Therefore, the lengthy duration of treatment could hinder patients from pursuing orthodontic care and may result in posttreatment dissatisfaction. This issue should be thoroughly discussed with patients, particularly those of older ages.^30,31,35

Female patients were found to be less likely to accept periodontitis than males. This finding was consistent with the fact that females generally attribute more importance to their oral health than males. Authors of previous studies on periodontitis have demonstrated that female patients exhibited greater oral health literacy and, thus, demonstrated better oral hygiene habits such as toothbrushing and flossing.^11,36,37 Orthodontists should emphasize the importance of preventing periodontitis to all patients throughout orthodontic treatment, with particular attention to male patients.

Little is known about whether and how personality traits could influence the acceptance of orthodontic risks. In the current study, we showed that conscientiousness was positively correlated with the acceptance of tooth extraction and associated risks, problems eating, problems speaking, and appliance breakage. These results can be interpreted when considering the intrinsic characteristics of conscientiousness. Generally, conscientiousness assesses an individual’s organization, adherence, and motivation in relation to goal orientation, reflecting his or her ability to control impulses.²² Individuals with high conscientiousness are rational, systematic, persistent, and use more goal-directed and problem-focused coping.^10,17 Consequently, it might be implied that patients with higher conscientiousness are more willing to make changes and overcome potential difficulties when considering receiving orthodontic treatment. In contrast, openness was shown to be a positive predictor of accepting the length of treatment. As shown previously, the duration of orthodontic treatment may extend beyond expectations under various circumstances.³¹ Interestingly, openness describes one’s cognitive style, intellectual curiosity, and willingness to accept the unexpected. People scoring high in this trait are open-minded and exhibit tolerance and willingness to explore unanticipated situations, which may contribute to a greater likelihood for acceptance of lengthy orthodontic treatment.^10,18

Although personality has been extensively researched, inconsistency across studies has limited its application for prediction in behavioral dentistry. Also, the willingness to accept certain orthodontic risks may be affected by multiple factors beyond personality. The classification of the Big Five personalities may underestimate the impact of specific situations on the behavior of individuals.³⁸ Therefore, it is not possible to make predictions about the acceptance of orthodontic risks solely based on specific personality dimensions. However, orthodontists should be aware that the personality traits of patients do show some tendencies regarding the acceptance of orthodontic risks, and the risk communication process in orthodontic practice should be conducted in a patient-centered personalized way.

Some limitations of the current study need to be considered. First, the investigation was conducted in a single center among patients sharing a similar cultural background, which might influence their perception and decision-making regarding risks to some extent. Second, orthodontic risks associated with specific treatment modalities, such as lingual orthodontics and functional appliances, were not surveyed, as they exceeded the scope of the current study. Likewise, other sociodemographic characteristics that possibly play a role in risk acceptance, such as educational level, economic status, and other psychological dimensions like perfectionism and self-esteem, were not investigated. Therefore, authors of future studies should be multicentered, with a broader scope, and include larger sample sizes from diverse cultural settings.

CONCLUSIONS

• Despite the limitations, conclusions with significant clinical implications can still be drawn.

• Periodontitis was the least accepted risk by patients consulting for orthodontic treatment.

• Older patients displayed less tolerance to length of treatment and relapse. Periodontitis was more unacceptable to female patients than male participants.

• Conscientiousness demonstrated a positive correlation with acceptance of tooth extraction and associated risks, problems eating, problems speaking, and appliance breakage.

• Openness was positively associated with accepting the risk of length of treatment.