Adult orthodontics, motivations for treatment, choice, and impact of appliances: A qualitative study

Introduction

Understanding the rationale for adult patients undertaking orthodontic treatment and the impact of appliances on their quality of life has become increasingly important to research efforts and clinical care. This study aimed to understand why adult patients undergo orthodontic treatment and their overall experience with the choice of appliance.

Methods

A cross-sectional qualitative study using semistructured interviews with adult patients from 4 private specialist orthodontic practices in the London region involving a purposive homogeneous sampling technique to obtain variation regarding gender, treatment modalities (fixed ceramic [FC], removable aligner [RA], and fixed lingual [FL] appliances), and stages of treatment (early, late, and posttreatment stage) was undertaken. A piloted topic guide was used to standardize data collection. Interviews were audio recorded, and field notes were taken. Data were transcribed verbatim and analyzed using framework methodology until data saturation was reached.

Results

A total of 22 participants (FC, 8; RA, 8; and FL, 6), with a mean age of 38.9 ± 11.7 years, with the majority being female (n = 13; 59.1%), were interviewed. Psychosocial and dental health-related factors were reported as the main reasons to seek orthodontic treatment. Social factors and appliance features influence an adult’s decision-making in selecting a specific orthodontic appliance. Wearing FC, RA, and FL was seen to have both positive and negative impacts on an adult’s quality of life. Functional and psychological factors were the strong influencers on patients’ treatment experience.

Conclusions

The study highlighted the influence of psychosocial factors and dental health concerns in the decision-making processes of adults seeking orthodontic treatment. FC, RA, and FL appear to affect an adult’s quality of life, with functional and psychosocial factors being commonly reported.

Highlights

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We performed a qualitative study exploring the reasons why adults undergo orthodontic treatment.
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We explored the factors that influence their choice of appliance therapy.
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A range of positive and negative functional and psychosocial impacts are reported.
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The findings are important in terms of managing expectations and obtaining consent.

Within the specialty of orthodontics, there has been a significant increase in the demand for adult orthodontic treatment. This has been thought to result, in part, from an increased public awareness of the potential perceived benefits of improved dental esthetics, the availability of a range of alternate esthetic appliances, the more traditional fixed labial metal appliances, and, in part, the growth of social media. ^,

Adult patients seeking orthodontic treatment are concerned by the esthetics of the appliance being offered. It is clear that orthodontic appliances have evolved as public demand, and technology has improved, with the underlying goal being to provide more esthetically acceptable appliances for use in adult orthodontics. Presently, in this respect, adults wishing to undergo orthodontic treatment are offered 1 or a combination of the 3 following appliance systems: fixed ceramic labial (FC) appliances, with or without esthetic wires; fixed lingual (FL), either customized or noncustomized appliances, and removable clear aligner therapy (RA).

An in-depth understanding of the adult patient’s rationale and preferences would allow orthodontists to provide more relevant information to patients and, in turn, facilitate the development of a patient-centered approach to providing more optimal care. Notwithstanding this, there is relatively very little understanding of the factors that adults consider in terms of the decision-making process of whether to undergo orthodontic treatment, the determinant factors in the type of appliance they choose, and the impact of the appliance choice on their daily lives. To date, there have been only 2 quantitative studies that have compared the 3 appliance systems in relation to pain and oral health-related quality of life in adults, with their findings being inconclusive. ^,

In contrast, several studies have compared clear aligner therapy with FC appliances and overall reported participants treated with the former with less pain, eating difficulties, and an overall lower in-treatment negative experience during the early stages of treatment. Compared with FC and FL appliances, there does not appear to be any significant difference in pain experience. However, FL appliances resulted in greater oral discomfort, dietary change, swallowing and speech disturbances, and social problems than those in the FC appliance group. ^,

Thus, considering the growing popularity of adult orthodontics and the availability of alternative esthetic appliances, there is a need for further research to gain a deeper understanding of the factors that adults consider when making their decision to seek not only orthodontic treatment but also the type of appliance and their experiences. In the last 2 decades, qualitative research has become a widely accepted and popular method for gaining a more in-depth understanding of the relevant topic of interest. ^, When a study seeks to understand the experiences and feelings of participants, qualitative methodology is highly appropriate. With respect to adult orthodontic treatment, there are no well-designed qualitative studies in the literature, and this context would be an invaluable addition. Therefore, this study aimed to adopt a qualitative approach to understand the adult patients’ reasoning for undergoing orthodontic treatment, the determinant factors for selecting a type of appliance, and overall experience with their choice of appliance.

Material and methods

A qualitative research design was adopted, using semistructured interviews with adult patients from private specialist orthodontic practices in London through the online platform Microsoft Teams (Redmond, Wash). The design was reported in line with the consolidated criteria for reporting qualitative research. Ethics committee approval was obtained from the Queen Mary University of London Research Ethics Committee (reference no. QMERC2019/60_).

Eight private specialist orthodontic practices in the London region that provide adult orthodontic treatment were invited via e-mail to participate; 4 of those practices expressed willingness to take part in the study. Potential participants who met the selection criteria ( Table I ) were identified and selected by the treating clinician at a routine appointment and given a verbal and written explanation of the nature of the study. All participants were subsequently contacted by the researcher, provided with an information sheet and consent form, and given 1 week to make their decision. Written informed consent to participate in the study was obtained before the interview and for anonymous data to be published.

Table I

Selection criteria

Criteria	Description
Inclusion	• Adults aged at least 18 years at the time of the interview • Orthodontic treatment with RA, FC, or FL appliances (single or double arch) • Undergoing treatment for at least 2 months to assess the effect of the appliance on their quality of life • Willingness to participate in the study • Fluent in English
Exclusion	• Malocclusions with craniofacial syndromes or dental anomalies • Subjects who exhibit temporomandibular dysfunction • Patients who were prescribed analgesics or antidepressant • Medication for psychiatric disease • Patients with chronic medical conditions

A piloted topic guide including open-ended questions, informed by the literature and previous research, explored participants’ rationale for wanting to undergo orthodontic treatment and their appliance choice, along with their views on the effect of these appliances on their quality of life.

Mutually convenient times within office hours were agreed on, with interviews conducted by a formally trained researcher (S.H.D.) and recorded using an audio device (WS-831; Olympus Corporation, Tokyo, Japan). An online platform was used for the interviews as the study was initiated during the coronavirus disease 2019 (COVID-19 [severe acute respiratory syndrome coronavirus 2 {SARS-CoV2}]) pandemic, when access to face-to-face meetings was restricted and thus to comply with the government guidelines. The 40-70 minute interviews were transcribed verbatim by a confidential service (Essential Secretary Ltd, Farnborough, United Kingdom) without the inclusion of any personally identifiable information.

A purposive homogeneous sampling technique was employed to allow comparison between participants having different treatment modalities (FC, RA, and FL appliances) and being at 3 different stages of treatment: early (2-6 months into treatment), late (>6 months into treatment), and posttreatment (appliance removed). Participants underwent dual arch treatment and did not require treatment to facilitate any planned restorative, prosthodontic treatment, such as implant/bridge therapy.

All data were anonymized and entered into Microsoft Office Excel (Washington, DC) for analysis using the framework methodology. This rigorous approach for ordering, synthesizing, and presenting qualitative data was informed by relevant literature, topic guides, and emerging text of the interviews. Key steps of analysis involved familiarization, identification of a provisional thematic framework, indexing, charting, mapping, and interpretation. The data saturation point was reached when no new themes were produced from the last 2 interviews. To ensure validation and reliability of the data, triangulation through multiple analyses was undertaken. The research team (S.H.D., F.C.-S., and A.J.) regularly met during data collection and analysis to discuss and agree on the emerging themes; any disagreement was discussed and resolved jointly.

Results

Semistructured interviews were conducted involving 22 participants. Most of them (n = 13; 59.1%) were females, and the overall mean age for the whole sample was 38.9 ± 11.7 years at the time of the interview. For both the FC and RA groups, there was an equal male-to-female distribution; however, for the FL appliance group, of the 6 participants recruited, 5 were females.

Table II summarizes participant distribution of appliance group and stage of treatment. Eight participants underwent FC appliances, 8 underwent RA, and 6 underwent FL appliances. Seven were in the early stages of treatment, 9 in the late stage, and 6 were posttreatment. Data saturation was reached after interviewing the 19th participant, with no new themes or subthemes generated for the subsequent 3 interviews.

Table II

Distribution of participants by appliance group and stage of treatment

Appliance group	Treatment stage			Total participants
Appliance group	Early	Late	Post	Total participants
FC		3, 6, 7, 8	1, 2, 4, 5	8
RA	9, 10, 11, 12	13, 14, 16	15	8
FL	17, 18, 22	19, 20	21	6

Note. Participants identification numbers (1-22) were distributed according to the treatment stage.

Two principal themes, psychosocial influence and dental health-related issues, were reported as the motivating factors for undergoing orthodontic treatment. Each theme comprised 2 subthemes, which are detailed below ( Fig 1 ).

Psychosocial influence, in turn, comprised 2 subthemes, namely self-image and perception and social acceptance, although most reports centered around the former.

There was universal agreement that the “poor looking” appearance of their teeth affected the way these participants felt about themselves and resulted in them generally feeling less comfortable and more conscious about their teeth. The strong desire to enhance their dental appearance and have a more esthetic smile was commonly related to being able to smile naturally, the widespread use of social media, the importance of photographs and professional benefits, and the desire to feel better about themselves after treatment.

“I did it to have straight teeth. So, just to have a nice smile, and a part of it is how I look in pictures” (Participant 13: male, 57 years old, salesman, RA).

“I found it really upsetting to look at pictures of myself, where my mouth was open. I felt like I could not smile” (Participant 21: female, 31 years old, civil engineer, FL).

The pressure of social appearance on participants, particularly because of social media and internet applications, further contributed to the way participants felt about themselves.

“The thing with social media, that you just constantly see photos of yourself, like with other people who have got straight teeth. It is like oh my teeth look ridiculous” (Participant 17: female, 49 years old, teacher, FL).

The nature of the participants’ work, which entails being frequently exposed to the public, proved to be another factor in their desire to undergo orthodontic treatment.

“I was feeling more self-conscious about my teeth especially as I had a lot of speaking in public at conferences and on video so obviously; in those situations, you feel more self-conscious” (Participant 14: male, 48 years old, freelance researcher, RA).

For some participants, seeking orthodontic treatment was attributed to growing older or reaching certain milestones, but in those instances, it was merely a secondary motivator, as mentioned below:

“I think subconsciously turning 40 maybe made me want to sort my teeth out. I do not know. It is a big milestone” (Participant 18: female, 40 years old, virologist, FL).

Most participants perceived that their dental appearance negatively influenced the way people perceived them, which motivated them to undergo treatment. Teasing and negative comments during social interactions with friends, peers, and family in their home, school, university, and/or work environment were examples provided by the participants. Moreover, being less dissimilar to others would, in turn, lead to them fitting into their social group better.

“My grandchildren said: ‘Oh, is that your angry tooth, nana?’ I thought, ‘Oh no.’ So, that was a part of having the treatment done; I did not want to have an angry tooth” (Participant 1: female, 66 years old, retired, FC).

“I guess as you get older the more you notice things about it like all the people around you have got straight teeth” (Participant 17: female, 49 years old, teacher, FL).

By undertaking orthodontic treatment, some perceived that they would be remedied from the negative impacts they had received in regard to their dental appearance, as exemplified by a male participant from the RA group below:

“It is probably psychological; from a very young age, my front 2 teeth were very prominent. I was teased at school they used to call me Bugs Bunny” (Participant 13: male, 57 years old, salesman, RA).

Dental health-related issues were discussed in regard to reducing the risk of deterioration of dental and oral health and functional impairment.

Participants expressed concerns about the risk of their dental and oral health condition worsening without orthodontic treatment, as reported below:

“I noticed erosions in my teeth, and I was told by my dentist because my teeth are grinding on each other; it is going to get worse; so, I panicked and said immediately sign me up for treatment” (Participant 5: male, 38 years old, financial advisor, FC).

A few participants reflected that their malocclusion was returning, attributing this to their suboptimal retainer wear after previous orthodontic treatment, thus motivating them to seek treatment before the problem became more complex.

“I noticed they were becoming more and more crooked; I never had a retainer when I had braces as a teenager, so was quite a lot of slippages” (Participant 20: female, 40 years old, performer/teacher, FL).

Some participants associated the deterioration of their dental appearance with aging, being a strong motivator for seeking professional help, as highlighted below:

“My teeth were pretty wonky, all over the place, and I think they were just getting worse with age” (Participant 6: male, 30 years old, IT specialist, FC).

Participants reported that one of the primary reasons for undergoing orthodontic treatment was to enhance functionality, such as improving their ability to eat and clean their teeth properly.

“I could only eat properly on 1 side of my mouth” (Participant 2: female, 52 years old, recruitment consultant, FC).

“The main reason why I am doing it is because I have had a lot of issues with my gums; I have had 3 gum grafts, and just having straight teeth enables you to floss better” (Participant 12: female, 28 years old, IT specialist, RA).

One participant went further and pointed out how her inability to clean her teeth had led to financial implications because of more regular visits to the hygienist, thus reporting that having orthodontic treatment would benefit her.

“I thought I might get braces to make my teeth a bit easier to clean because I used to go to the hygienist every 2 or 3 months, and it is expensive” (Participant 3: female, 46 years old, specialist vet, FC).

A combination of social influence and appliance features was found to influence the participants’ decision to select a particular appliance. Figure 2 illustrates these 2 major themes and the 5 subthemes that emerged from the data analysis.

Orthodontic appliance choice was strongly influenced by those the participants interacted with before the treatment, including their clinicians, family members, and friends.

The patient-orthodontist professional relationship was reported to be an influential factor in selecting orthodontic appliances by most participants. Some participants went further and reported that good rapport and trust in their clinician’s guidance and recommendations were imperative to make their decisions.

“I based my decision on the consultation with the orthodontist; he is an expert. I trust what he says” (Participant 2: female, 52 years old, recruitment consultant, FC).

Past orthodontic treatment experiences of family and friends were reported by many as either positive or negative motivational factors for selecting a particular appliance. Successful past experiences described as being pain-free effectively influenced the participant’s decision to select a particular orthodontic appliance.

“Because my sister had it and she had a good experience, and her teeth are similar to mine” (Participant 10: female, 24 years old, university student, RA).

In contrast, experiences involving unpleasant esthetics and eating difficulties were mentioned by the fixed appliances group as factors for not selecting RAs:

“I saw a friend with Invisalign. There were bubbles everywhere personally; I did not see the appeal” (Participant 5: male, 38 years old, financial advisor, FC).

“My friend had Invisalign; he was taking it out to eat. I just remember thinking, oh God, I could not do that, definitely not” (Participant 17: female, 49 years old, teacher, FL).

As participants were asked to articulate their reasoning behind their choice of treatment modality, different aspects of the appliances’ features were reported, including the esthetic appearance, perceived effectiveness of the appliance, and pragmatic considerations.

Esthetic appliance appearance was universally framed as the primary reason for selecting the type of appliance. The desire to choose an appliance as discrete as possible was reported across all 3 groups of participants.

“One thing about ceramic braces is that you know, it is much harder to see” (Participant 6: male, 30 years old, IT specialist, FC).

Along the same lines, participants talked about the impact of the selection of the appliance on their self-image. The ability to smile more naturally was commonly reported as the reason for selecting a less visible orthodontic appliance.

“I am a person who smiles a lot; so, if the braces that are visible were the only option, I would not have done it” (Participant 12: female, 28 years old, IT specialist, RA).

The nature of their work, which involves constant interaction with people, was noted by participants from the RA and FL appliance groups as a decisive factor in selecting a more esthetic and less visible appliance, as mentioned below:

“The appearance of the brace was very important; especially being patient facing all the time with my job it makes a difference, the more discrete they are” (Participant 9, female, 25 years old, receptionist at dental practice, RA).

“Because of my job; it requires being in front of the camera; so, it was very important to me to have them as masked as possible” (Participant 18: female, 40 years old, virologist, FL).

In contrast, the more “visible” FC appliances that required a longer duration of treatment were less popular among a few participants of the RA group.

“I did not really feel comfortable going a visible brace because I thought if it is going to be a 2-year process” (Participant 15: male, 18 years old, university student, RA).

Perceived effectiveness of orthodontic appliances was another reason to select their orthodontic appliances, as reported by participants in the fixed appliances groups (FC and FL). Some participants preferred fixed appliances as a treatment option; these decisions were partly influenced by their clinicians’ recommendations and/or findings from their research in that they were more effective in the treatment of their malocclusion.

“I was doing my research; it seemed like for underbites, train tracks were the best way to go, and having my mouth in the proper place was more important to me than the esthetics of the braces” (Participant 3: female, 46 years old, specialist vet, FC).

“We were looking at train tracks; basically, we were only looking at fixed appliances because all of the orthodontists had said to me, ‘Yeah, do not do Invisalign, it is not going to work for you’…” (Participant 21: female, 31 years old, civil engineer, FL).

Pragmatic considerations were mainly reported by participants from the RA group as the main reason for selecting their appliance. Several benefits of this appliance were discussed in the interviews, including the ability to remove the appliances at any time, the lack of restrictions on the types of foods consumed, and remote monitoring, which required fewer visits to the dentist.

“The convenience factors the fact that had I gone back to New York; the orthodontist was able to still monitor me from New York and worst-case scenario; he would ship me stuff so it was a doable option” (Participant 11, female, 47 years old, entrepreneur, RA).

“The ability to take it out was very attractive to me; you can retain complete freedom while also going through this process” (Participant 18: female, 40 years old, virologist, FL).

Wearing clear aligners and FC or FL appliances impacts participants’ quality of life either positively or negatively and in some both. Functional and psychosocial factors emerged from the data analysis as the strong influencers on patients’ treatment experience. The 2 major themes and 6 subthemes are illustrated in Figure 3 . Each of these is described in more detail in the following paragraphs.