Predictors of willingness to uptake orthodontic treatment and qualitative insights into the reasons for its postponement in young adults

Abstract

Objectives

To investigate the predictors of willingness to uptake orthodontic treatment and to explore the reasons for postponing its initiation in young adults.

Materials and Methods

Students, aged 18–30 years old, were randomly approached at the Central Library of the Aristotle University of Thessaloniki Campus and invited to complete the study tool anonymously and voluntarily. The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) and the esthetic component of the Index of Orthodontic Treatment Need (IOTN-AC) were used to evaluate students’ psychosocial impact of dental esthetics and severity of malocclusion, whereas the rationale for postponing the initiation of orthodontic treatment was recorded through an open-ended question, analyzed using thematic content analysis.

Results

In total, 270 students, 55.2% female, participated. The single statistically significant factor predicting willingness to uptake orthodontic treatment was the PIDAQ-Psychological Impact subscale (OR: 1.24; 95% CI: 1.11–1.37, P < .001). Gender and age were not associated with willingness to pursue treatment. Seven main themes emerged regarding reasons for postponement: fear of the procedure, embarrassment regarding appearance during treatment, low prioritization of esthetics, insufficient information, high cost of treatment, prolonged duration of treatment, and residential mobility.

Conclusions

The findings suggest that psychological impact of dental esthetics constitutes the main driver to pursue orthodontic treatment. A patient-centered orthodontic approach should address the possible barriers to its initiation. Increasing young adults’ oral health literacy could be key in empowering them to make better informed decisions regarding their oral health-related quality of life.

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

Participants

Young adults with an age range from 18 to 30 years old were randomly approached at the Central Library of the Aristotle University of Thessaloniki Campus from August to November 2023. The sample size was determined at 267 participants, allowing for a 95% confidence interval (CI) and a 0.06 margin of error. After being verbally informed about the study purposes, they were invited to participate voluntarily and anonymously upon reading and signing the study’s informed consent form. No incentives were provided to increase the participation rate. Individuals with moderately to severely discolored anterior teeth, missing or fractured teeth, cavities or extensive anterior restorations, craniofacial anomalies, and previous or ongoing orthodontic treatment were excluded by a qualified dentist who administered the paper-and-pencil study tool. Dentists and dental students were also excluded due to their expertise.

Study Tool

The study tool consisted of five demographic questions (including gender, age, school, year, and level of studies), the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ),⁵ the esthetic component of the Index of Orthodontic Treatment Need (IOTN-AC),¹⁴ three dichotomous questions on participants’ self-reported need to improve their dental image, willingness to uptake orthodontic treatment, and intention to initiate treatment within the next year (yes/no), along with an open-ended question exploring the reasons for postponing it.

PIDAQ is a 23-item self-assessment scale used to evaluate the psychosocial impact of dental esthetics,⁵ in which participants respond to the degree of agreement using a five-point Likert scale, and four subscales: Dental Self-Confidence (DC), Social Impact (SI), Psychological Impact (PI), and Aesthetic Concern (AC). Higher scores are indicative of lower satisfaction with current dental condition.

IOTN-AC is an index widely used to evaluate perception of dental esthetics and severity of malocclusion, consisting of 10 photographs of anterior teeth displaying various degrees of malocclusion (score from 1 to 10, with a proportional relationship between the score and the severity of malocclusion).¹⁴ Participants were asked to assess their dentition by indicating which photograph most closely resembled their own.

The study tool was pretested to assess the level of comprehension in a convenience sample of 15 participants who met the inclusion criteria.

Ethics Approval

Permission was obtained from the Bioethics Committee of the Department of Medicine of the Aristotle University of Thessaloniki (Protocol No. 208/2023/14-07-2023).

Statistical Analysis

Collected data were processed using the open Jamovi software (Version 2.3). The Shapiro-Wilk test examined the distribution of continuous variables. Categorical variables were summarized by absolute and relative frequencies. Logistic regression analyses were performed to examine potential predictors of orthodontic treatment demand, controlling for demographic variables such as gender and age. Independent variables with statistically significant correlations in the univariable analyses were included in the final, multivariable model. Multicollinearity was assessed with the variance inflation factors (VIFs) of all the independent variables. Adjusted odds ratios (aOR) are presented along with corresponding 95% confidence intervals (95% CI). Significance level was set at 0.05, two-tailed (P < .05).

An inductive thematic content analysis of participant responses to the open-ended question was conducted, until data saturation was reached.¹⁵ Data analysis was carried out independently by two researchers (CA, IP), trained and experienced in qualitative data analysis, who open-coded and identified several themes.

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)

Characteristic	n (%)
Gender
Male	121 (44.8%)
Female	149 (55.2%)
Age
18–24	239 (88.5%)
25–30	31 (11.5%)
Study cycle
Undergraduate	254 (94.1%)
MSc	11 (4.1%)
PhD	5 (1.8%)
Year of undergraduate studies
1st	9 (3.3%)
2nd	45 (16.7%)
3rd	46 (17%)
4th	59 (21.9%)
5th	38 (14.1%)
6th	25 (9.3%)
Final year (soon to graduate)	32 (11.9%)
IOTN-ACa group
1	126 (46.7%)
2	52 (19.3%)
3	64 (23.7%)
≥4	28 (10.4%)

^a IOTN-AC indicates index of orthodontic treatment need-aesthetic component.

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

Variables	Univariable Analysis			Multivariable Analysis
	OR	P value	95% CI	aOR	P value	95% CI	VIF
Gender	0.73	.205	0.44–1.19	*	*	*	*
Age	1.03	.618	0.93–1.13	*	*	*	*
PIDAQ-DC	1.21	< .001	1.13–1.29	1.04	.360	0.95–1.14	1.27
PIDAQ-SI	1.24	< .001	1.15–1.34	1.05	.301	0.95–1.16	1.30
PIDAQ-PI	1.31	< .001	1.22–1.41	1.24	< .001	1.11–1.37	1.42
PIDAQ-AC	1.39	< .001	1.24–1.57	0.97	.725	0.81–1.16	1.44
IOTN-AC:
2 – 1	1.10	.800	0.54–2.25	0.55	.165	0.24–1.27	1.05
3 – 1	3.07	< .001	1.64–5.75	1.18	.664	0.56–2.49
≥4 – 1	9.92	< .001	3.71–26.56	1.87	.299	0.57–6.11

^* Missing values represent variables with no statistically significant correlation in the univariable models.

^a OR indicates odds ratio; 95% CI, 95% confidence interval; aOR, adjusted odds ratio; VIF, variance inflation factor; PIDAQ-DC, dental self-confidence subscale; PIDAQ-SI, social impact subscale; PIDAQ-PI, psychological impact subscale; PIDAQ-AC, aesthetic concern subscale; IOTN-AC, index of orthodontic treatment need-aesthetic component.

Reasons for Postponing Orthodontic Treatment

Seven main themes emerged from the analysis of responses to the open-ended question on reasons why the participants willing to uptake orthodontic treatment did not intend to initiate it within the next year:

Fear of the Procedure

Concerns and fears were raised about potential pain or discomfort during treatment and how this would affect their life.

“I need braces … . but I am afraid they will hurt” [P79, female, IOTN-AC = 3]

Embarrassment about their Appearance During Treatment

Participants expressed concern about their appearance should they undergo orthodontic treatment, in relation to their peers, and the potential treatment impact on their social life.

“I wouldn't want to wear aligners when I am not at home” [P258, female, IOTN-AC = 4]

High Cost of Treatment

A frequently reported rationale was the treatment cost, considering that most students are not financially independent.

“My financial situation at the moment, as a student financially supported only by my parents, does not allow me to initiate treatment” [P110, female, IOTN-AC = 1]

Prolonged Duration of Treatment

The duration of orthodontic treatment acted as a deterrent for young adults that are not able to allocate the necessary time coping with treatment and their everyday obligations.

“Due to limited time, knowing that it is not a short treatment” [P111, male, IOTN-AC = 2]

Low Prioritization of Esthetics

It was often emphasized that orthodontic treatment constituted no immediate priority, as malocclusion is not directly related to pain.

“I have not identified any issue that causes a problem (pain etc.) and needs immediate treatment” [P12, female, IOTN-AC = 2]

Insufficient Information

Lack of adequate information about orthodontic treatment was expressed as a factor leading to its postponement.

“… ignorance of treatment duration and effectiveness” [P183, male, IOTN-AC = 3]

Residential Mobility

The fact that orthodontic treatment requires multiple appointments, usually on a monthly or bimonthly basis, deterred those intending to move in the near future from initiation of treatment.

“I will finish my studies next year and when I go back to my home city I would look into initiating therapy.” [P212, female, IOTN-AC = 3]

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.

Author Contributions

Chrysanthi Anagnostou (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing-original draft, Writing-review and editing (Lead)), Ioannis P Zogakis (Conceptualization, Data curation, Formal analysis, Investigation, Methodology (Equal), Writing-original draft, Writing-review and editing (Lead)), Ilias Pagkozidis (Data curation, Formal analysis, Investigation, Methodology (Equal), Writing-original draft, Writing-review and editing (Supporting)), Theodoros Dardavesis (Conceptualization, Methodology, Writing-review and editing (Equal)), Apostolos Matiakis (Conceptualization, Investigation, Methodology, Writing-review and editing (Equal)) and Zoi Tsimtsiou (Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing-review and editing (Lead)).