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original article factors associated with long-term patient satisfaction nair galvao maiaa david normandob francisco ajalmar maiac maria angela fernandes ferreirad e maria do socorro costa feitosa alves abstract objective to identify factors associated with patient satisfaction at least 5 years after orthodontic treatment materials and methods a total of 209 orthodontic patients were included in the study all subjects were treated with upper and lower fixed orthodontic appliances dental casts n 5 627 were examined using the peer assessment rating par index pretreatment t1 at the end of treatment t2 and at a long-term follow-up mean 8.5 years t3 at t3 a dental impact on daily living questionnaire was used to assess the long-term effects of orthodontic treatment on daily living and satisfaction with the dentition multiple regression analyses were used to quantify associations between patient satisfaction and changes produced by the orthodontic treatment par t2-t1 posttreatment stability par t3 age at the start of treatment t1 treatment duration t2-t1 gender and extraction results orthodontic treatment produced a significant improvement of 94.2 in the par index t2-t1 but this change was not associated with the level of satisfaction when the patient was questioned at least 5 years after treatment regression analysis showed that satisfaction was significantly associated only with the long-term posttreatment par index r 2 5 0.125 p .0001 no significant association was observed with the severity of malocclusion at the beginning part1 or end of the orthodontic treatment par-t2 age at t1 the amount of time taken during orthodontic treatment gender or extraction conclusions over the long term patient satisfaction is slightly associated with the stability of the orthodontic treatment regardless of the initial occlusal condition or the final result of the orthodontic treatment angle orthod 2010;80:1155­1158 key words long-term stability patient satisfaction orthodontic treatment introduction a assistant professor department of pedodontics federal university of rio grande do norte faculty of dentistry natal brazil b assistant professor department of orthodontics faculty of dentistry federal university of para belem brazil ´ ´ c associate professor and department chair department of ´ orthodontics faculty of dentistry paraiba state university campina grande brazil d associate professor department of public health federal university of rio grande do norte faculty of dentistry natal brazil e associate professor department of public health federal university of rio grande do norte faculty of dentistry natal brazil corresponding author dr francisco ajalmar maia uepb federal university of rio grande do norte dentistry­orthodontics rua manoel machado 683 petropolis natal rn 59012320 brazil e-mail coi@digi.com.br g accepted march 2010 submitted december 2009 2010 by the eh angle education and research foundation inc 1155 the final goal of orthodontic treatment is to obtain normal or ideal occlusion follow-up studies of treated cases have shown that although ideal occlusion and dental alignment have been achieved there is a tendency for posttreatment relapse toward the original malocclusion.1­5 the quality and stability of orthodontic treatment outcomes have traditionally been assessed by established metrics or categorical scales as health services exist primarily to benefit the patient an important variable for measuring outcome should be overall patient satisfaction with the care provided patient satisfaction with orthodontic treatment is poorly covered in the literature satisfaction with dental appearance has been correlated with age and sex in individuals who have not received orthodontic treatment it has been reported that satisfaction with dentofacial appearance decreases with age.6,7 therefore adults are expected to be less satisfied with their dentofacial appearance than are angle orthodontist vol 80 no 6 2010 doi 10.2319/120909-708.1

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1156 adolescents females are more dissatisfied with the appearance of their dentition than are males.8­10 investigations of patient satisfaction after orthodontic treatment have shown a wide range of satisfaction levels ranging from 34%11 to 74­75 12,13 birkeland et al.14 recorded a high degree of satisfaction 95.4 with orthodontic treatment results among children in addition to the countless variables that could interfere with patient satisfaction the use of different questionnaires to assess satisfaction after orthodontic treatment makes comparison difficult.11 the level of satisfaction of orthodontic patients has been examined just after the end of treatment some factors have been reported as predictors of patient satisfaction at this time personality traits were found to be correlated with patients satisfaction with their dentition after orthodontic treatment in orthodontically treated patients higher neuroticism scores were associated with lower levels of satisfaction with the dentition.11 patients treated with nonextraction showed more dissatisfaction with their dentition while age sex and pretreatment orthodontic treatment need had no relationship to patient satisfaction.11 a systematic review15 regarding the long-term stability of orthodontic treatment and patient satisfaction concluded that only a few studies have been conducted on long-term patient satisfaction furthermore most of these studies showed little scientific evidence and no conclusions could be drawn this review concluded that there is a great need for studies in this area materials and methods the sample n 5 209 was selected from a total of 4102 angle class i or ii patients treated in a private clinic with more than 5 years of postorthodontic treatment posttreatment time ranged from 5 years to 25 years with a mean of 8.5 years standard deviation [sd 5 3.4 years subjects with facial anomalies and mental disorders class iii patients and those submitted to orthognathic surgery were excluded the research protocol was submitted to the research ethics committee of the federal university of rio grande do norte and was approved under no 110/2005 sample size was calculated from a pilot study involving the first 20 consecutive cases the minimum regression coefficient r 2 was found to be 0.2 having a sd of 2 and an a level of 5 in a two-tailed model with a power of 80 the estimated sample size was 194 individuals initially 400 patients who still lived in town and who met the inclusion criteria were randomly called by phone the response rate and attendance at the clinic was 62 n 5 248 thirty-nine patients refused to make new orthodontic records angle orthodontist vol 80 no 6 2010 maia normando maia ferreira alves a total of 88 class i and 121 class ii malocclusions were examined n 5 209 these numbers included 70 males and 139 females all of these patients were treated with straight-wire full appliances thirty patients 14.4 had undergone tooth extractions for orthodontic reasons class ii molar relationships were corrected through headgear or functional appliances according to the mandibular deficiency the mean ages were 14.3 years range 8.6­42.9 years at pretreatment t1 16.2 years range 10.8­44.1 years at the end of treatment t2 and 24.9 years range 17.9­59.2 years at long-term follow-up t3 the dental impact on daily living didl index was used to assess the degree of satisfaction the didl questionnaire comprises five major categories and tackles five major dimensions of dental satisfaction namely appearance pain oral comfort general performance and chewing and eating the didl scale measures the effect and the proportional importance of each dimension to the patient the scale yields a score ranging from 0 to 10 to show the relative importance of each dimension to the patient the didl questionnaire is a reliable valid and comprehensive test for measuring patient satisfaction and the effects of dental disease on patient daily life.16 orthodontic problems can affect many aspects of dental esthetics and function and these aspects are well covered by the didl index.11 the didl was collected using a questionnaire at t3 at least 5 years posttreatment to determine occlusal changes during and after orthodontic treatment the peer assessment rating par index17 was used this index was developed to provide a single score for all of the occlusal changes morphologic occlusion examinations were performed on the dental casts n 5 627 of 209 subjects at three periods in time t1 t2 and t3 mean 8.5 years multiple regression analysis at p .05 was used to assess the association between the primary variable satisfaction and the following independent variables par index at t1 t2 and t3 age at the start of treatment t1 gender orthodontic extraction and duration of treatment t2 2 t1 the dental cast examination to collect par index data was performed by one previously calibrated orthodontist intraexaminer reliability was assessed using the intraclass correlation coefficient at p .05 results the intraclass coefficient for the intraexaminer was 0.91 this result indicates an excellent reproducibility of the method by considering the initial par index at t1 to be 100 median 5 17 the changes produced after orthodontic treatment led to a mean improvement of 94.2 in this index t2 detailed information about

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factors associated with patient satisfaction 1157 table 1 multiple regression analysis dependent variable satisfaction dental impact on daily living didl index f 5 5.267 p 5 .0001a independent variable par t1 par t2 par t3 gender extraction age at t1 time of treatment b coefficient 20.001 20.092 20.209 0.162 20.205 0.005 0.007 t-value 20.107 21.342 24.556 0.579 20.560 0.229 0.749 p-value .915 ns .182 ns 001 .563 ns .576 ns .819 ns .455 ns a par indicates peer assessment rating t1 pretreatment t2 end of treatment t3 long-term follow-up and ns 5 no significance p .001 figure 1 t3 par index correlation with didl index the par findings can be obtained in a previous article.5 patient satisfaction regarding dental occlusion at least 5 years posttreatment t3 was examined by the didl index with regard to the five major dimensions of dental satisfaction namely appearance pain oral comfort general performance and chewing and eating this revealed that 162 subjects 77.5 reported being satisfied with their dentition while 46 individuals 22 were relatively satisfied only one individual 0.5 reported being unsatisfied with his occlusion the value of the level of satisfaction reported by this individual was 21.05 while the par index at t1 was 17 and at t2 the level of satisfaction was reduced to 12 nine years after treatment t3 the par index remained at 12 with regard to predictive variables only the par index at t3 showed a significant relationship with patient satisfaction p .001 figure 1 shows that the higher the par index at t3 the lower the patient s satisfaction however the par index at t3 only explained 12.5 of the variation in the didl index r 2 5 0.125 the other variables such as par at t1 p 5 .91 par at t2 p 5 .18 age at beginning of treatment p 5 .86 duration of treatment p 5 .41 extraction p 5 .58 and gender p 5 .56 showed no significant association with the dependent variable satisfaction table 1 discussion this study showed that patients reported a high degree of satisfaction with their dentition in a long-term follow-up after orthodontic treatment around 77 of the patients reported being satisfied with their dentition when they were questioned at least 5 years after the end of treatment orthodontically treated patients demonstrated high levels of satisfaction with their teeth in general this might be due to the fact that orthodontic treatment can affect dental performance positively which can lead to higher levels of satisfaction the changes produced after orthodontic treatment in this sample led to a mean improvement of 94.2 par t2 2 t1 compared to previous studies,18,19 this finding can be considered a high standard of excellence in orthodontic finishing there is a possibility that although some degree of dissatisfaction may be reported years after orthodontic treatment this level may be considerably more than it was at the beginning of treatment and less than at the end of the treatment this cannot be determined from the collected data and a longitudinal evaluation of patient satisfaction should be performed although the use of different questionnaires to assess satisfaction makes comparisons difficult investigations of patient satisfaction after orthodontic treatment have shown a wide range of satisfaction levels ranging from 34%11 to 95 14 we used the same satisfaction questionnaire employed by al-omiri and alhaija.11 these authors reported 34 satisfied and 62 relatively satisfied patients just after orthodontic treatment while the percentage of dissatisfied patients was 4 given the differences in the timing during which the questionnaires were applied immediately after treatment and long term comparisons with previous results are difficult because countless factors can be associated with these differences predictive factors related to patient satisfaction are controversial in the literature a small number of studies have examined this issue untreated patients have reported that satisfaction with dentofacial appearance decreases with age,6,7 and females are more dissatisfied with the appearance of their dentition than are males.8­10 our results showed that gender age and duration of treatment were not related to patient satisfaction the lack of a relationship between gender and patient satisfaction seems to be a common angle orthodontist vol 80 no 6 2010

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1158 outcome for patients who have received orthodontic treatment.11,12 al-omiri and alhaija11 found that satisfaction with the dentition after orthodontic treatment showed no relationship to age no association was observed between patient satisfaction and extraction for orthodontic reason in the present study a previous study11 reported that patients treated with nonextraction showed more dissatisfaction with their dentition when the patient was examined immediately after orthodontic treatment it is possible that the diagnostic criteria for tooth extraction and its impact on dentofacial morphology are more relevant than the procedure itself among the predictive factors investigated in this study the only one able to produce any prediction of long-term patient satisfaction was the par index at t3 figure 1 however this variable explains only 12.5 of variations in the didl index thus patient satisfaction is not related to the improvement produced by the orthodontic treatment par t1 and t2 when the patient is asked some years after the orthodontic treatment a previous investigation14 showed that orthodontic treatment outcome par t2 is related to 20 of the variability of children s opinion of psychosocial benefits the results of this study show that a few years after orthodontic treatment this feeling of benefit appears to be lost thus for patients the current status of the dentition is more relevant than the benefits obtained just after orthodontic treatment a previous investigation5 examining this sample showed that the use of a lower fixed retainer was one important factor related to treatment stability par t3 as well as the time of use of the hawley upper retainer therefore the use of orthodontic retention can contribute to a higher level of satisfaction in patients who have undergone orthodontic treatment since patient satisfaction were slightly associated with orthodontic variables and higher neuroticism scores were associated with lower levels of satisfaction with the dentition,11 further investigations are necessary in order to meet a wider range of factors able to predict patient satisfaction conclusions n from a long-term perspective patient satisfaction is slightly associated with stability of the orthodontic treatment regardless of the initial occlusal condition or the final result of the orthodontic treatment n neither gender age extraction for orthodontic reasons nor the amount of treatment time has a significant relationship with long-term patient satisfaction maia normando maia ferreira alves references 1 mcnamara ja jr baccetti t franchi l herberger ta rapid maxillary expansion followed by fixed appliances a long-term evaluation of changes in arch dimensions angle orthod 2003;73:344­353 2 little rm riedel ra artun j an evaluation of changes in mandibular anterior alignment from 10 to 20 years postretention am j orthod dentofacial orthop 1988;93 423­428 3 mcreynolds dc little rm mandibular second premolar extraction postretention evaluation of stability and relapse angle orthod 1991;61:133­144 4 al yami ea kuijpers-jagtman am van t hof ma stability of orthodontic treatment outcome follow-up until 10 years postretention am j orthod dentofacial orthop 1999;115 300­304 5 maia ng normando adc feitosa ms ferreira ma maia fa factors associated to orthodontic stability a longitudinal retrospective study of 209 patients world j orthod 2010;11:61­66 6 shaw wc factors influencing the desire for orthodontic treatment eur j orthod 1981;3:151­162 7 cunningham sj gilthorpe ms hunt np are orthognathic patients different eur j orthod 2000;22:195­202 8 sheats rd mcgorray sp keeling sd wheeler tt king gj occlusal traits and perception of orthodontic need in eighth grade students angle orthod 1998;68:107­114 9 gosney mbe an investigation into some of the factors influencing the desire for orthodontic treatment br j orthod 1986;13:87­94 10 wheeler tt mcgorray sp yurkiewicz l keeling sd king gj orthodontic treatment demand and need in third and fourth grade school children am j orthod dentofacial orthop 1994;106:22­23 11 al-omiri mk abu alhaija es factors affecting patient satisfaction after orthodontic treatment angle orthod 2006 76:422­431 12 larsson bw bergsrom k adolescents perception of the ¨ quality of orthodontic treatment scand j caring sci 2005 19:95­101 13 anderson le arruda a inglehart mr adolescent patients treatment motivation and satisfaction with orthodontic treatment do possible selves matter angle orthod 2009 79:821­827 14 birkeland k bøe oe wisth pj relationship between occlusion and satisfaction with dental appearance in orthodontically treated and untreated groups a longitudinal study eur j orthod 2000;22:509­518 15 bondemark l holm a hansen k axelsson s mohlin b brattstrom v paulin g pietila t long-term stability of orthodontic treatment and patient satisfaction angle orthod 2007;77:181­191 16 leao a the development of measures of dental impacts on daily living [phd thesis london uk london university 1993 17 richmond s shaw wc o brien kd buchanan ib jones r stephens cd the development of the par index peer assessment rating reliability and validity eur j orthod 1992;14:125­139 18 birkeland k furevik j boe oe wisth pj evaluation of treatment and posttreatment changes by the par index eur j orthod 1997;19:279­288 19 wood m lee d crawford e finishing occlusion degree of stability and the par index aust orthod j 2000;16:9­15 angle orthodontist vol 80 no 6 2010

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