Psychosocial impact of dental aesthetics on dental patients

Abstract

Objective: This study aimed to evaluate the contribution of demographic and clinical characteristics on the psychosocial impact of dental aesthetics of dental patients. Methods: The psychosocial impact of dental aesthetics was assessed by the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ). Data validity was estimated using confirmatory factor analysis (CFA). Reliability was assessed using standardised Cronbach’s alpha coefficient (α). A structural model was developed to assess the contribution of demographic and clinical characteristics to the results. The fit of the model was evaluated and the z test (α = 5%) was used to estimate the significance of the contributions (β). Results: A total of 505 dental patients (80% female; age: 36.3, SD = 11.4) participated in the study. Data showed adequate validity (CFA: χ²/df = 3.3, Tucker–Lewis index [TLI] = 0.92, comparative fit index [CFI] = 0.92 and root mean square error of approximation [RMSEA] = 0.07) and reliability (α = 0.77–0.92). The fit of the structural model was adequate (χ²/df = 2.8, TLI = 0.89, CFI = 0.91, RMSEA = 0.06). People of a lower economic level, with incomplete dentition, who did not undergo previous aesthetic dental treatment, and who did not like their own smile showed greater psychosocial impact of dental aesthetics. Conclusions: Demographic and clinical characteristics should be considered in the evaluation of the impact of dental aesthetics on individuals’. Moreover, PIDAQ is an alternative tool for clinical evaluation of the psychosocial impact of dental aesthetics because it provides valid and reliable data.

INTRODUCTION

Physical appearance has an important impact on people’s lives and orofacial aesthetics can play a major role, especially concerning social interactions1., 2., 3.. Therefore, the perception of characteristics such as teeth color, shape, size, position, and exposal might become psychosocially important regardless of whether there is a relevant functional or aesthetic impairment1., 4., 5..

A direct consequence of this concern with appearance is the greater demand for aesthetic dental treatments, such as prosthetic dental bleaching and orthodontics2., 3., 6.. However, treatment plans should be based on clinical needs and a detailed investigation of the reasons leading to the perceived ‘negative’ appearance⁷. This is important, on the one hand, to achieve treatment success taking into account both clinical parameters and patient expectations and, on the other hand, to understand the real need for the desired procedures. Moreover, as the perceptions of dentists and patients are often different, a thorough evaluation of the treatment need and patient expectations is important for a satisfactory outcome7., 8..

Therefore, the assessment of the psychosocial impact of dental aesthetics might be relevant for patient management and treatment planning⁸. For this purpose, the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) was developed⁹. The PIDAQ has four domains of psychosocial impact (dental self-confidence, social impact, psychological impact, and aesthetic concern)⁹ and although originally developed for orthodontics, the instrument has been used in several clinical and epidemiological contexts7., 10., 11., 12., 13., 14..

In addition, the characteristics that influence the psychosocial impact of dental aesthetics should be identified before treatment. Thus, a more individualised treatment plan can be established, meeting the expectations of the patient. Some studies have shown that sex10., 11., 15., 16., 17., 18., 19. and age12., 19. may affect the impact of dental aesthetics, however, other authors did not find this relationship7., 8., 20., 21.. Regarding clinical characteristics, studies indicate that more compromised dental aesthetics have greater psychosocial impact7., 8., 16., 18., 20..

Thus, considering the use of the PIDAQ in dental clinics, this study evaluated the contribution of clinical and demographic characteristics on the psychosocial impact of dental aesthetics.

METHODS

Study design

This was an observational cross-sectional study. Adults aged between 18 and 59 years who sought care at the university clinics (periodontology, dentistry, emergency, prosthodontics, oral medicine and surgery) were invited to participate in 2016 and 2017. People with severe cognitive impairment were excluded.

The sample size was calculated based on the recommendation of Hair et al.²² that suggest at least five subjects per parameter of the model to be elaborated. Considering that the largest model to be tested (structural model) has 60 parameters, the minimum sample size required was 300.

Study variables

Demographic information such as sex, age, marital status, work activity (no/yes), and economic level were collected. The economic level was estimated using Brazilian Economic Classification Criteria (Brazilian Market Research Association [ABEP])²³. The clinical characteristics collected were presence of teeth (complete dentition/partial dentition), use of dental prostheses (no/yes), previous dental aesthetics treatment (no/yes), and if the individual likes his or her own smile (no/yes). Finally, the PIDAQ was completed.

Measuring instrument

The PIDAQ is composed of 23 items distributed in four domains (Table 1), and a general domain called ‘Psychosocial Impact’ can also be added. For the present study, an item was added in the self-confidence domain based on the importance that teeth color might have on dental esthetics¹³. The new item was based on the original item 23 but with the word ‘position’ replaced by ‘color’, as follows: ‘24. I like my tooth color’. A 5-point Likert type scale was used for responses (0: I do not agree, 1: I agree a little, 2: I somewhat agree, 3: I agree a lot, 4: I totally agree). The Portuguese version of the PIDAQ proposed by Sardenberg et al.⁵ was used. For the cultural adaptation, three people (one Brazilian researcher, one Portuguese researcher, and one Portuguese language teacher) analysed its adequacy to the orthographic agreement established among the Portuguese-speaking countries in 2009. Then, a pilot study (25 individuals, 88% women, mean age of 44.7, SD = 15.4) was carried out to verify the individuals’ understanding of the items.

Table 1.

Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ)

Factor	Item	Portuguese version†	English version‡
Dental self-confidence	it4	Eu tenho orgulho dos meus dentes	I am proud of my teeth
	it7	Eu gosto de mostrar meus dentes quando eu sorrio	I like showing my teeth when I smile
	it12	Eu fico contente quando eu vejo meus dentes no espelho	I am happy about seeing my teeth in the mirror
	it17	As pessoas acham meus dentes bonitos	Other people like my teeth
	it21	Eu estou satisfeito com a aparência dos meus dentes	I am content with the look of my teeth
	it23	Eu acho a posição dos meus dentes muito boa	I like my tooth position
	it24	Eu acho a cor dos meus dentes muito boa§	I like my tooth color§
Social impact	it2	Eu me contenho/controlo quando sorrio; assim, meus dentes não aparecem muito	When I smile, I sometimes try not to reveal my teeth completely
	it5	Se eu não conheço bem as pessoas, algumas vezes eu me preocupo com o que elas podem achar dos meus dentes	If I don’t know someone well, I imagine what they might think about my teeth
	it9	Eu tenho receio de que outras pessoas possam fazer observações desagradáveis sobre os meus dentes	I sometimes fear others might tease me because of my teeth
	it14	De alguma forma eu fico inibido nos encontros sociais por causa dos meus dentes	I occasionally feel a little self-conscious toward others because of my teeth
	it15	Eu às vezes me pego colocando minha mão na frente da minha boca para esconder meus dentes	I would sometimes like to put my hand in front of my mouth in order to hide my teeth.
	it13	Às vezes eu acho que as pessoas estão olhando fixamente para meus dentes	I sometimes have the feeling that people are giving me funny looks when they see my teeth
	it19	Comentários sobre os meus dentes me irritam mesmo que seja de brincadeira	Stupid jokes about my teeth upset me, even if they are only said in fun
	it22	Eu às vezes me preocupo com o que pessoas do outro sexo pensam sobre meus dentes	I sometimes fear that other boys (or girls) might think my teeth are ugly
Psychological impact	it3	Eu sinto inveja dos dentes bonitos de outras pessoas	I sometimes envy friends whose teeth are more beautiful
	it6	Eu fico um pouco incomodado quando vejo os dentes de outras pessoas	If I compare my own teeth with others‘, I may get upset
	it10	Às vezes eu fico um pouco triste com a aparência dos meus dentes	The look of my teeth sometimes makes me a bit unhappy
	it11	Eu acho que a maioria das pessoas que eu conheço tem dentes melhores do que os meus	I think that most of my friends have more beautiful teeth
	it16	Eu me sinto mal quando eu penso na aparência dos meus dentes	I sometimes feel ashamed because of my tooth position
	it20	Eu gostaria que meus dentes tivessem uma aparência melhor	I sometimes wish my teeth would look better
Aesthetic concern	it1	Eu não gosto de ver meus dentes no espelho	I don’t like my teeth when I look at myself in the mirror
	it8	Eu não gosto de ver meus dentes em fotos	I dislike seeing my teeth on pictures of me
	it18	Eu não gosto de ver meus dentes quando eu assisto a um vídeo em que eu apareço	I don’t like my teeth when I see myself in a video

^†Portuguese version of Psychosocial Impact of Dental Aesthetic Questionnaire proposed by Sardenberg et al. [5].

^‡English version of Psychosocial Impact of Dental Aesthetic Questionnaire proposed by Klages et al. [9].

^§Item added in this study.

The content validity ratio (CVR) was estimated to verify the essentiality of each item for evaluation of domains, as proposed by Lawshe²⁴. Participants at this stage included eight specialists in dental aesthetics who classified each item of the instrument into ‘essential’, ‘useful but not essential’, and ‘unnecessary’. To evaluate the significance of the CVR, a proposal presented by Wilson et al.²⁵ was used, considering α = 5%.

Data validity was estimated using confirmatory factor analysis (CFA) considering the following indices: χ²/df ≤5.0, Tucker–Lewis index (TLI) and comparative fit index (CFI) ≥0.9, and root mean square error of approximation (RMSEA) <0.1026., 27.. Reliability was assessed using standardised Cronbach's alpha coefficient (α ≥ 0.70)²⁶.

Structural model

To estimate the contribution of demographic and clinical characteristics to the psychosocial impact of dental aesthetics, a structural model was developed. Therefore, the general psychosocial impact factor (second order factor) was considered the dependent variable. The variables sex (0 = male, 1 = female), work activity (0 = no, 1 = yes), economic level (1 = D/E, 2 = C, 3 = B, 4 = A), oral status (0 = partial dentition, 1 = complete dentition), use of dental prostheses (0 = no, 1 = yes), current or previous aesthetics dental treatment (0 = no; 1 = yes), if the person liked his or her smile (0 = no, 1 = yes), and age were the independent variables.

The fitting of the structural model was evaluated using the previously cited indexes (χ²/df, CFI, TLI, and RMSEA).²⁶ The trajectories (β) were estimated and evaluated with the z-test. A significance level of 5% and a stepwise procedure were used; independent variables with significant (P < 0.05) β were maintained in the final model26., 27..

The analyses were performed in IBM SPSS Statistics 22 (IBM Corp., Armonk, NY, USA) and AMOS 22.0 (IBM Corp., Armonk, NY, USA) software.

Procedures and ethical aspects

Individuals undergoing treatment at the University dental clinic were invited to participate in the study by a researcher who approached patients in the waiting room. The instrument was self-completed in general, however, support was provided if anyone had difficulty filling out the questionnaire or preferred to be interviewed. Thus, 72.4% of the data were collected through self-completion and 27.6% by means of an interview. This study was approved by the Ethics Committee on Human Research.

RESULTS

A total of 623 people were invited to participate in this study. However, 118 were excluded because they did not either meet the inclusion criteria (n = 29) or respond to all items of the instrument and demographic questionnaire (n = 89). The mean age was 36.27 (SD = 11.37) years. The sample characteristics are shown in Table 2.

Table 2.

Distribution [n (%)] of participants according to their characteristics

Characteristic	n (%)
Sex
Female	404 (80.0)
Male	101 (20.0)
Marital status
Single	191 (37.8)
Widowed	7 (1.4)
Married	262 (51.9)
Divorced	45 (8.9)
Economic level†
A	29 (5.7)
B	185 (36.7)
C	256 (50.7)
D/E	35 (6.9)
Work activity
No	179 (35.4)
Yes	326 (64.6)
Oral status
Complete dentition	203 (40.2)
Partial dentition	302 (59.8)
Use of dental prostheses
No	369 (73.1)
Yes	136 (26.9)
Current or previous aesthetics dental treatment
No	144 (28.5)
Yes	361 (71.5)
Do you like your smile?
No	162 (32.1)
Yes	343 (67.9)

^†Brazilian Economic Classification Criteria²³, mean income per stratum: A = R$20,888.00 (U$5,722.74); B = R$4,852.00-R$9,254.00 (U$1,329.32-U$2,535.34); C = R$1,625.00-R$2,705.00 (U$445.20-U$741.10); D-E = R$768.00 (U$210.41). Estimated from the Central Bank of Brazil (U$1.00 = R$3.65) in 05/23/2018.

The majority of participants were women and had work activity. Most had partial dentition, were not using dental prostheses, were receiving or had had aesthetic dental treatment, and reported liking their own smile.

Descriptive statistics of the participant responses to the items of the PIDAQ and the CVR are shown in Table 3. No severe violation of normality was observed in the responses (skewness <3 and kurtosis <7 in absolute values). Items 6, 11, 16, 18, and 21 were not considered essential by the specialists. The data showed adequate validity (CFA: χ²/df = 3.3, TLI = 0.92, CFI = 0.92, and RMSEA = 0.07) and reliability (α = 0.77–0.92). The structural model fit, considering all the independent variables, was acceptable (χ²/df = 2.8, TLI = 0.89, CFI = 0.91, RMSEA = 0.06). However, not all independent variables had a significant contribution, and therefore, the model was refined (Table 4).

Table 3.

Descriptive statistics of the participant responses to the items of the PIDAQ and the CVR

Item	Mean	Median	Standard deviation	Skewness	Kurtosis	CVR†
it1	1.19	1	1.45	0.88	−0.64	0.75
it2	1.19	0	1.52	0.89	−0.80	1.00
it3	1.01	0	1.48	1.16	−0.26	1.00
it4	1.49	1	1.53	0.54	−1.21	0.75
it5	1.06	0	1.48	1.04	−0.50	1.00
it6	0.66	0	1.22	1.74	1.66	0.50
it7	1.59	1	1.57	0.42	−1.39	1.00
it8	1.26	0	1.57	0.79	−1.01	1.00
it9	1.15	0	1.58	0.90	−0.89	1.00
it10	1.48	1	1.58	0.55	−1.30	0.75
it11	1.44	1	1.53	0.54	−1.25	0.50
it12	1.47	1	1.53	0.53	−1.24	0.75
it13	1.11	0	1.47	0.95	−0.65	1.00
it14	1.10	0	1.50	0.99	−0.60	1.00
it15	0.75	0	1.35	1.53	0.75	1.00
it16	1.23	0	1.54	0.78	−1.01	0.50
it17	0.81	0	1.22	1.35	0.67	1.00
it18	1.08	0	1.51	1.01	−0.59	0.50
it19	1.10	0	1.57	0.97	−0.78	0.75
it20	2.66	3	1.51	−0.65	−1.13	1.00
it21	1.21	1	1.44	0.82	−0.73	0.50
it22	1.08	0	1.50	1.00	−0.61	1.00
it23	1.53	1	1.53	0.44	−1.31	1.00
it24	1.11	0	1.39	0.94	−0.48	1.00

*PIDAQ, Psychosocial Impact of Dental Aesthetics; CVR, content validity ratio.

^†CVR_8;0,05 = 0.693.

Table 4.

Complete structural model considering demographic and clinical variables (independent variables) of the psychosocial impact of dental aesthetics (second-order hierarchical model) and refined models using stepwise procedure

	Characteristic
	Sex	Age	Economic level	Work activity	Oral status	Use of dental prostheses	Aesthetics dental treatment	Like own smile
Complete model
β	0.014	0.006	−0.248	−0.204	−0.492	0.174	−0.276	−1.140
βs	0.005	0.060	−0.157	−0.087	−0.216	0.069	−0.112	−0.476
SE	0.105	0.004	0.060	0.088	0.102	0.109	0.094	0.100
P	0.894	0.180	<0.001	0.020	<0.001	0.112	0.003	<0.001
E.V. = 0.42
First refinement
β	—	0.006	−0.249	−0.206	−0.492	0.173	−0.275	−1.141
βs	—	0.061	−0.157	−0.088	−0.216	0.069	−0.111	−0.477
SE	—	0.004	0.059	0.086	0.102	0.109	0.093	0.099
P	—	0.170	<0.001	0.016	0.001	0.112	0.003	<0.001
E.V. = 0.42
Second refinement
β	—	—	−0.243	−0.191	−0.547	0.220	−0.277	−1.132
βs	—	—	−0.153	−0.082	−0.240	0.087	−0.112	−0.473
SE	—	—	0.059	0.085	0.095	0.104	0.094	0.099
P	—	—	<0.001	0.025	<0.001	0.034	0.003	0.001
E.V. = 0.42
Third refinement
β	—	—	−0.236	−0.174	−0.626	—	−0.226	−1.144
βs	—	—	−0.149	−0.074	−0.275	—	−0.091	−0.478
SE	—	—	0.059	0.085	0.088	—	0.091	0.099
P	—	—	<0.001	0.041	<0.001	—	0.013	<0.001
E.V. = 0.42
Final model
β	—	—	−0.241	—	−0.629	—	−0.241	−1.149
βs	—	—	−0.152	—	−0.276	—	−0.098	−0.480
SE	—	—	0.06	—	0.088	—	0.091	0.100
P	—	—	<0.001	—	<0.001	—	0.008	<0.001
E.V. = 0.41

E.V., explained variance; SE, standard error; β_s, β standardised.

During model refinement, it was observed that the variables ‘use of dental prostheses’ and ‘work activity’ were at the limit of significance and, because of the large sample size used, these variables were removed in the subsequent analyses. In the final model the variables that remained were economic level, dentition status, dental aesthetics treatment, and appreciation of own smile.

DISCUSSION

The present study demonstrated that data obtained by PIDAQ has adequate validity and reliability for Brazilian adult dental patients. A significant contribution to the psychosocial impact of dental aesthetics was found for economic level, dentition status, dental aesthetic treatment, and appreciation of own smile.

Several studies have used the PIDAQ but few have evaluated the validity and reliability of data in a similar sample or context as was done in this study8., 9.. Although the PIDAQ was originally developed for orthodontic patients⁹, the present study showed that its use in different contexts is feasible.

The inclusion of an item to the model (Item 24, self-confidence domain, Table 1), was based on the relevance that teeth color can have on the psychosocial impact of dental esthetics¹³. With such an item, the possibilities for the use of the PIDAQ are extended to different clinical contexts. During the CFA, we verified that this item presented good factorial loading (λ_it24 = 0.61), indicating that teeth color is relevant for the ‘self-confidence’ domain. Therefore, the maintenance of this item is recommended when applying the PIDAQ in clinical contexts other than orthodontics.

The CFA showed adequate validity of data obtained by PIDAQ considering the four domains and the general domain ‘psychosocial impact’, reinforcing the theory underlying the instrument development, which states that the model evaluates a global aspect of the psychosocial impact of dental aesthetics. Thus, the decision whether to use the domains separately or the general domain should be based on the desired outcome. By using this tool, a better assessment of patients’ expectations and needs can be carried out allowing individualised clinical management and treatment.

The demographic and clinical characteristics that presented a significant contribution to the model were economic level, dentition status, dental aesthetics treatment, and being pleased with own smile. The influence of economic level on the psychosocial impact of dental aesthetics has been studied before. Contrary to our findings, Bellot-Arcís et al.²⁰ did not observe a significant difference among social classes. This disparity can be attributed to the different methods used for economic level classification, different samples or contexts of the studies, and methodologies used to evaluate the psychosocial impact. However, other authors found that people from a lower economic level are more influenced by dental appearance28., 29., indicating that income might directly affect access to health services. Furthermore, individual health-related psychological and psychosocial resources, such as ability to build coping strategies, adequate social support, and social control, seem to vary among different economic levels³⁰, justifying the results found in the present study.

Age and sex did not significantly contribute to the psychosocial impact of dental aesthetics in the present sample. Although our findings are in agreement with other studies7., 8., 21., the subject is controversial4., 10., 11., 12., 19.. It is known that the body is perceived differently by men and women and by different age groups³¹, which could be extrapolated to dental appearance. However, the concept evaluated by the PIDAQ is the psychosocial impact of appearance, and not the perception of appearance. That is, the different perception of dental aesthetics of different sexes and age groups does not mean greater impact of aesthetics on people’s lives, which might explain the lack of sex and age influence in our study.

On the other hand, seeking dental aesthetics treatment and appreciating one’s own smile indicated greater influence of dental appearance on people’s lives. When undergoing an aesthetic procedure and a troublesome feature is modified or eliminated, the patient perception of the feature also changes, and his or her expectation is fulfilled by the treatment³². Liking the one’s own smile, however reduces the psychosocial impact that dental aesthetics can exert on someone’s life¹⁶.

Participants missing one or more teeth had an increased psychosocial impact of dental aesthetics, while the use of a prosthesis did not contribute to this impact. Although no studies were found on the psychosocial impact of tooth loss, it is known that tooth loss greatly affects oral health-related quality of life and the impact is greater with increasing number and location of missing teeth³³.

As for limitations, this study did not perform a detailed clinical evaluation of the participants, which could provide relevant data to establish associations with the psychosocial impact of dental aesthetics and help confirm the validity of PIDAQ. Thus, future studies should include more detailed clinical exams to explore these associations. In addition, the cross-sectional design of the study does not allow the establishment of a cause-and-effect relationship. However, this design is commonly used in association and validation studies. Another limitation was the non-probability sampling, which was minimised by the large sample size.

The present study provides evidence that can improve clinical practice, identifying characteristics that contribute significantly to the psychosocial impact of dental aesthetics. A patient’s treatment can be based on clinical needs and the patient’s expectations regarding that treatment success.

CONCLUSION

The data obtained by PIDAQ was valid and reliable. People of lower economic level, with incomplete dentition, who did not undergo previous aesthetic dental treatment, and who did not like their own smile, showed greater psychosocial impact of dental aesthetics. These characteristics should be considered for the development of a more targeted and individualised treatment plan.

Acknowledgements

The authors would like to thank Prof. Dr. Osmir Batista de Oliveira Junior for the incentive to carry out this study and the financial support from the São Paulo Research Foundation (FAPESP; Process #2016/00043-0 and #2018/06739-1) and the Coordination for the Improvement of Higher Education Personnel (CAPES; Finance Code 001).

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. The Ethics Committee on Human Research of the School of Dentistry of São Paulo State University.

Informed consent

All individuals who participated in the study agreed and signed the written informed consent form previously approved by the Ethics Committee on Human Research of the School of Dentistry of São Paulo State University (CAAE Registry No. 53584016.0.0000.5416).