Tin-Oo et al. BMC Oral Health 2011, 11:6
http://www.biomedcentral.com/1472-6831/11/6
RESEARCH ARTICLE
Open Access
Factors influencing patient satisfaction with
dental appearance and treatments they desire
to improve aesthetics
Mon Mon Tin-Oo*, Norkhafizah Saddki, Nurhidayati Hassan
Abstract
Background: We assessed factors influencing patients’ satisfaction with their dental appearance and the
treatments they desired to improve dental aesthetics.
Methods: A cross-sectional study was performed out among 235 adult patients who visited the Hospital Universiti
Sains Malaysia dental clinic. A structured, interviewer-guided questionnaire was used to identify patient satisfaction
with their general dental appearance, cosmetic elements and desired treatments.
Results: The 235 patients consisted of 70 males (29.8%) and 165 females (70.2%), of mean age 31.5 years (SD 13.0).
Of these patients, 124 (52.8%) were not satisfied with their general dental appearance. In addition, 132 patients
(56.2%) were not happy with the color of their teeth, 76 (32.3%), regarded their teeth were poorly aligned, 62
(26.4%), as crowded and 56 (23.4%) protruded. Dissatisfaction with tooth color was significantly higher in female
than in male patients (odds ratio [OR] of 1.99 (95% confidence interval [CI] 1.13-3.50). Tooth whitening was the
treatment most desired by patients (48.1%). Results of multiple logistic regression analysis showed that patient
dissatisfaction with general dental appearance was significantly associated with female gender (OR = 2.18; 95% CI:
1.18-4.03), unhappiness with tooth color (OR = 3.05; 95% CI: 1.74-5.34) and the opinion that their teeth protruded
(OR = 2.91, 95% CI: 1.44-5.91).
Conclusions: Most patients in this study were not satisfied with their dental appearance with a greater percentage
of females expressing dissatisfaction than males. An age was not associated with satisfaction. Unhappiness with
tooth color and feelings of having protruding teeth also had a significant negative influence on patient satisfaction
with general dental appearance.
Background
Dental appearance is an important feature in determining the attractiveness of a face, and thus plays a key role
in human social interactions. Among the significant factors affecting overall dental appearance are tooth color,
shape, and position; quality of restoration; and the general arrangement of the dentition, especially of the anterior teeth [1]. Furthermore, an aesthetically pleasing
smile was found to depend on tooth color, size, shape,
and position, upper lip position, visibility of teeth and
amount of gingival display [2]. Although each factor
may be considered individually, all components must act
* Correspondence: monmonto@kb.usm.my
School of Dental Sciences, Universiti Sains Malaysia, Health Campus, 16150
Kubang Kerian, Kelantan, Malaysia
together to create a harmonic and symmetric entity that
produces the final aesthetic effect [1].
In general, people desire for pearly white teeth. Thus,
tooth color is one of the most important factors determining satisfaction with dental appearance [1,3]. Selfsatisfaction with tooth color decreases with increasing
severity of discoloration [4,5]. White teeth have been
positively correlated with high ratings of social competence, intellectual ability, psychological adjustment and
relationship status [6]. Alternatively, untreated dental
caries, non-aesthetic or discolored anterior teeth restorations and missing anterior teeth usually lead to dissatisfaction with dental appearance [3,7-9]. Furthermore,
treatments improving dental aesthetics have been found
to increase patient quality of life and psychological
status [10,11].
© 2011 Tin-Oo et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Tin-Oo et al. BMC Oral Health 2011, 11:6
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Malocclusion is a common oral disorder, although
treatment needs and demands vary. In some populations, tooth misalignments are not regarded as serious
enough to necessitate treatment [12-14], whereas, in
other populations, the need for orthodontic treatment
may be very high [15,16]. There is general agreement
that people are motivated to seek orthodontic treatment
because of the negative physical, psychological and
social impacts of malocclusion, but studies of the effects
of malocclusion and its treatment on people’s lives have
yielded inconsistent results [17,18]. These discrepancies
may be due to various interpretations of physical, psychological and social impact and lack of standardized
methods to measure these quality of life constructs [17].
Currently, cosmetic dentistry has become an important aspect of dentistry. Tooth whitening treatments,
anterior teeth restoration, labial veneers crowns, and
orthodontic treatment are frequently demanded by
patients who interested in improving their dental
appearance [3]. We have assessed satisfaction with
dental appearance, desired treatments to improve dental
appearance, and factors that influence satisfaction with
dental appearance among adult patients who attended
the dental clinic at the Hospital Universiti Sains Malaysia (HUSM).
Methods
This cross sectional study was carried out from June 1,
2009 to January 31, 2010 among patients who attended
the HUSM dental clinic. All included patients were
newly registered adults >18 years old, who had not
received any dental treatment within the previous six
months, were able to understand the Malay language
and have no clear evidence of cognitive disturbances.
Sample size was calculated using the formula estimating
a single proportion with a requirement for 95% confidence [19]. The prevalence of dissatisfaction with dental
appearance was estimated to be 62.7% based on the
satisfaction with dental aesthetics among adult patients
attending a military dental clinic in Tel Aviv, Israel [3].
Considering the available resources, a sample size of 183
was selected with a precision of 0.07 (7%). To accommodate for a 30% non-response rate, 238 patients were
invited to participate in this study.
A systematic random sampling technique was used to
select the study sample. The sampling interval was
decided based on the estimated number of eligible
patients attending the clinic on a normal outpatient day,
with every tenth patient was invited to participate. No
possible biases regarding the selection of the study
population were anticipated and the samples were representative of the reference population. This study was
approved by the Research and Ethics Committee
(Human), Universiti Sains Malaysia.
Page 2 of 8
A structured, interviewer guided questionnaire
(Table 1) was used for data collection. The questionnaire consisted of questions on socio-demographic items
including sex, age, and level of education, as well as
questions on each patient’s satisfaction with his/her
then-current general dental appearance. Patients were
also asked about their satisfaction with tooth color, perceived malalignment of teeth (crowding, poorly aligned
or protruding), caries in anterior teeth, non-aesthetic
anterior tooth color restoration and presence of tooth
fracture. In addition, patients were asked to select the
aesthetic treatments they wished to undergo, including
orthodontic treatment, crowns, tooth whitening, tooth
color restorations and partial dentures.
Prior to this study the clarity of the questionnaire was
pre-tested on 15 patients who were not involved in the
study. Feedback regarding problems understanding and
answering the questionnaire was obtained and addressed.
Each patient provided written informed consent before
participation in this study.
Data were entered and analyzed using the Statistical
Package for Social Sciences (SPSS) for Windows software (version 12.0; SPSS Inc, Chicago). Descriptive statistics such as mean and standard deviation (SD) for
continuous variables and frequency and percentage for
categorical variables were determined. The chi-square
test was used to compare the sex, age, education levels
of patients who were and were not satisfied with their
dental appearance. The level of significance was set at
0.05.
Factors influencing patient satisfaction with dental
appearance were determined at both the univariate and
multivariate levels using simple logistic regression analysis and multiple logistic regression analysis, respectively.
Variables selected for inclusion in the multiple logistic
regression analysis model were selected using the forward stepwise logistic regression method. Following the
fit of the preliminary model, the importance of each
variable was verified. The interaction terms were
checked using the Likelihood Ratio (LR) test. Multicollinearity problems were was identified by the Variance
Inflation Factor (VIF) test.
The final model was assessed for fitness using the
Hosmer-Lemeshow goodness-of-fit test. The classification tables for sensitivity and specificity as well as the
area under the Receiver Operating Characteristic (ROC)
curve were also recorded to assess the model fitness.
Influential outliers were identified using Cook’s distance.
Data points above 1.0 were considered as influential
outliers.
Results
The demographic background of the patients and their
satisfaction with their dental appearance are shown in
Tin-Oo et al. BMC Oral Health 2011, 11:6
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Table 1 Questionnaire used in the study
Survey on patient satisfaction with dental appearance and desired treatment to improve aesthetics
1. Sex □Male □Female
3. Education level: □ Primary □ Secondary □ Post secondary □ Tertiary
2. Age:___________(years)
1.
Are you satisfied with the general appearance of your teeth?
□ Yes
□ No
2.
Are you satisfied with your tooth color?
□ Yes
□ No
3.
Do you feel your teeth are crowded?
□ Yes
□ No
4.
Do you feel your teeth are poorly aligned?
□ Yes
□ No
5.
Do you feel your teeth are protruding?
□Yes
□ No
6.
7.
Do you have dental caries in your front teeth?
Do you have non-aesthetic fillings in your front teeth?
□ Yes
□ Yes
□ No
□ No
8.
Do you have fractures in your front teeth?
□ Yes
□ No
9.
Do you wish to undergo these treatments to improve the appearance of your teeth?
a. Orthodontic treatment to realign teeth
□ Yes
□ No
b. Tooth whitening
□ Yes
□ No
c. Dental crowns
□ Yes
□ No
d. Tooth coloured fillings
□ Yes
□ No
e. Dentures
□ Yes
□ No
Table 2. Of the 235 patients, (70.2%) were female. Ages
ranged from 18 to 62 years with a mean age of 31.5
years (SD 13.0). We found that (52.8%) of these patients
were not happy with their general dental appearance,
with dissatisfaction with tooth color being the most
common (56.2%). In addition, some patients regarded
their teeth as poorly aligned (32.3%), crowded (26.4%),
and protruding (23.4%). Others reasons for dissatisfaction include self-reported presence of caries (43.4%),
non-aesthetic restorations (30.6%), and tooth fractures
(15.3%). Patients also answered questions about the
treatments they desired to improve their appearance
(Table 3). We found that 48.1% wished to have their
teeth whitened, followed by restoration of tooth color
(18.3%), dentures (16.2%), orthodontic treatment
(14.0%), and dental crowns (11.5%).
Table 4 shows a comparison between the 111 patients
who were and the 124 who were not satisfied with their
general dental appearance. We found that satisfaction
with dental appearance differed significantly between
males and females. In addition, dissatisfaction with
tooth color and perception that of having protruding
teeth had significant negative impacts on patient satisfaction with general dental appearance. No other dental
problem or condition was associated with patient satisfaction with general dental appearance.
Simple logistic regression analysis of factors influencing
patient satisfaction with dental appearance found no significant associations between patient satisfaction and age,
education level, perception of having crowded and poorly
aligned teeth, self-reported dental caries, non-aesthetic
restorations, and fractures of the anterior teeth (Table 5).
However, dissatisfaction with general dental appearance
was significantly associated with female gender (OR =
2.70, 95% CI: 1.51-4.82), with unhappiness with tooth
color (OR = 3.35, 95% CI: 2.01-5.92) and with regarding
their teeth as protruding (OR = 3.42, 95% CI: 1.75-6.71).
Multivariable logistic regression analysis showed that
female gender (OR = 2.18, 95% CI: 1.18-4.03), unhappiness with tooth color (OR = 3.05, 95% CI: 1.74-5.34) and
the opinion who felt that their teeth were protruded (OR
= 2.91, 95% CI: 1.44-5.91) were significant independent
determinants of patient satisfaction with general appearance (Table 6). Possible two-way interactions between
factors were not significant, and there was no multicollinearity problem. The preliminary final model was
checked for fitness. The result of HosmerLemeshow goodness-of-fit test was not significant (p =
0.631, df = 4) and the area under the ROC curve was
0.714, suggesting that the model was fit. The sensitivity
and specificity of this model were 64.9% and 64.5%
respectively. These results indicated that satisfaction with
general dental appearance could be predicted correctly in
64.7% of these patients. When we assessed the contribution of each outlier, we found that none was influential.
Further analyses were performed to evaluate the perceptions of different groups of patients about the color
of their teeth. Table 7 shows the distribution of
responses by the socio-demographic background (age,
sex and education level) between the103 patients who
were and the 132 patients who were not satisfied with
their tooth color. Results of the chi-square test showed
that satisfaction with tooth color differed significantly
between male and female patients whereas none of the
other background variables was significant. Both simple
and multiple logistic regression analyses showed that
dissatisfaction with tooth color was significantly higher
in female than in males (OR = 1.99; 95% CI: 1.13-3.50).
Tin-Oo et al. BMC Oral Health 2011, 11:6
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Table 2 Background of patients and satisfaction with
dental appearance (n = 235)
Table 3 Desired aesthetic dental treatments (n = 235)
Variables
Orthodontic treatment
Frequency (%)
Age group (years)
< 35
146 (62.1)
35 - 54
≥ 55
76 (32.3)
13 (5.5)
Sex
Male
70 (29.8)
Female
165 (70.2)
Education
Primary/Secondary
Post secondary/Tertiary
157 (66.8)
78 (33.2)
Satisfied with general dental appearance
No
124(52.8)
Yes
111 (47.2)
Dissatisfied with tooth color
No
Yes
103 (43.8)
132 (56.2)
Felt that teeth were crowded
No
173 (73.6)
Yes
62 (26.4)
Felt that teeth were poorly aligned
No
Yes
159 (66.7)
76 (32.3)
Felt that teeth protruded
No
180 (76.6)
Yes
55 (23.4)
Perceived dental caries
No
Yes
133 (56.6)
102 (43.4)
Perceived non-aesthetic restorations
No
163 (69.4)
Yes
72 (30.6)
Perceived fractures
No
Yes
199 (84.7)
36 (15.3)
Discussion
Attitudes and perceptions towards dental appearance
differ among populations and among individuals in a
population [20]. We found that of adults attending the
HUSM dental clinic, only 47.2% were satisfied with the
Variables
Frequency (%)
No
202 (86.0)
Yes
33 (14.0)
Tooth whitening
No
122 (51.9)
Yes
113 (48.1)
Dental crown
No
208 (88.5)
Yes
27 (11.5)
Tooth color restoration
No
192 (81.7)
Yes
43 (18.3)
Denture
No
197 (83.8)
Yes
38 (16.2)
appearance of their teeth, a lower percentage than in
previous studies of different populations. For example, a
study of 1,014 patients at a dental school in Ankara,
Turkey found that (57.3%) were satisfied with their dental appearance [7] as were 76% of stratified sample of
adults in the United Kingdom [21].
Perception towards dental appearance is determined by
cultural factors and individual preferences varying between
individuals and cultures and changing over time [1]. In
general, older people (age 55 and above) were more likely
than younger people to be satisfied with their dental
appearance [7,21], suggesting that the appearance of their
teeth is not as important to older than to younger individuals [20]. In this study, however, we found that age was
not associated with satisfaction with dental appearance
suggesting that dental appearance is becoming equally
important in both older and younger adults. This is likely
due to the strong impact of the media which portray men
and women of all ages as needing to look younger and
more beautiful. Indeed, a study of 180 people of six different age strata ranging from 13 to 64 years showed that
personal satisfaction with tooth color was age-independent
[22]. A study in Sweden of two large samples of 8,881 aged
50 years and 8,563 aged 60 years revealed that the majority
of respondents in both groups agreed that beautiful and
perfect teeth are very important [23]. Another study on
elderly aged 73 to 75 year old in Germany also showed
that the importance of dental appearance to overall
appearance was rated high by the subjects [24].
Tooth color is a critical factor influencing satisfaction
with smile appearance [1]. For example a study in the
Tin-Oo et al. BMC Oral Health 2011, 11:6
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Table 4 Profile of patients who were (n = 111) and were not (n = 124) satisfied with their general dental appearance
Satisfied
Yes (%)
n = 111
c2 statistics (df)
p value
1.135 (2)
0.567
11.631 (1)
0.001
1 331 (1)
0.249
20.873 (0)
< 0.001
0.459 (1)
0.498
1.872 (1)
0.171
13.666 (1)
< 0.001
0.002 (1)
0.962
0.082 (1)
0.775
0.000 (1)
0.999
No (%)
n = 124
Age group (years)
< 35
68 (61.3)
78 (62.9)
35 - 54
35 (31.5)
41 (33.1)
≥ 55
8 (7.2)
5 (4.0)
Sex
Male
45 (40.5)
25 (20.2)
Female
66 (59.5)
99 (79.8)
Primary/Secondary
70 (63.1)
87 (70.2)
Post secondary/Tertiary
41 (36.9)
37 (29.8)
No
66 (59.5)
37 (29.8)
Yes
45 (40.5)
87 (70.2)
No
84 (75.7)
89 (71.8)
Yes
27 (24.3)
35 (28.2)
No
80 (72.1)
79 (63.7)
Yes
31 (27.9)
45 (36.3)
No
97 (87.4)
83 (66.9)
Yes
14 (12.6)
41 (33.1)
No
63 (56.8)
70 (56.6)
Yes
48 (43.2)
54 (43.5)
No
78 (70.3)
85 (68.5)
Yes
33 (29.7)
39 (31.5)
No
94 (84.7)
105 (84.7)
Yes
17 (15.3)
19 (15.3)
Education
Dissatisfied with tooth color
Felt that teeth were crowded
Felt that teeth were poorly aligned
Felt that teeth protruded
Perceived dental caries
Perceived non-aesthetic restorations
Perceived fractures
United Kingdom found that the general public were dissatisfied with relatively mildly discoloured teeth indicating their concern about the color of their teeth [4].
Perception of tooth color is a complex phenomenon
that is influenced by many factors including lighting
conditions, the optical properties of teeth (translucency,
opacity, scattering of light, surface gloss), and the viewer’s visual experience [25]. We found that most
respondents (56.2%) were dissatisfied with the color of
their teeth in agreement with studies in populations in
other countries [3,5,7]. In agreement with previous
results, we found that, dissatisfaction with tooth color
may be the primary reason for dissatisfaction with
dental appearance [3].
The important contribution of tooth color to patients’
satisfaction with dental appearance was further highlighted
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Table 5 Factors influencing patients’ satisfaction with
dental appearance by simple logistic regression analysis
Variables
Crude
OR
95% CI
LR c2
(df)a
p
valuea
1.139 (2)
0.566
Table 6 Factors influencing patients’ satisfaction with
dental appearance by multiple logistic regression
analysis
Variables
Age group (years)
Adjusted
OR
95% CI
LR c2 (df) p
a
valuea
6.287 (1)
0.012
15.568 (1)
< 0.001
9.432 (1)
0.002
Sex
< 35
1.00
-
35 - 54
1.02
0.59-1.78 0.005 (1)b 0.941
Male
1.00
-
≥ 55
0.55
0.17-1.75 1.046 (1)b 0.306
Female
2.18
1.18-4.03
Male
1.00
-
Female
2.70
1.51-4.82
Sex
11.720 (1) 0.001
Satisfied with tooth
color
No
1.00
-
Yes
3.05
1.74-5.34
Education
Primary/Secondary
1.00
-
Post secondary/Tertiary
0.73
0.42-1.25
1.330 (1)
0.249
Felt that teeth
protruded
No
Yes
Dissatisfied with tooth color
a
No
1.00
-
Yes
3.35
2.01-5.92
21.156 (1) < 0.001
Felt that teeth were crowded
No
1.00
-
Yes
1.22
0.68-2.19
No
1.00
-
Yes
1.47
0.85-2.56
No
1.00
-
Yes
3.42
1.75-6.71
No
1.00
-
Yes
1.01
0.60-1.70
0.460 (1)
0.498
1.881 (1)
0.170
Felt that teeth were poorly
aligned
Felt that teeth protruded
14.217 (1) < 0.001
Perceived dental caries
0.002 (1)
0.962
former associated with greater attractiveness. In contrast
another study in Germany done by Höfel et al. [26] found
that perceptions of facial attractiveness were independent
of tooth color indicating that satisfaction with dental
appearance may not correlate positively with facial attractiveness. This finding underlines the influence of psychosocial attributes on the perception of attractiveness.
Many of the patients in this study reported having
dental caries and non-aesthetic restorations in their
front teeth, with and some reported having tooth fractures. All of these conditions will undoubtedly affect the
appearance of teeth, presumably leading to patient dissatisfaction with general dental appearance. Although our
Table 7 Socio-demographic background of patients who
were (n = 103) and were not (n = 132) satisfied with
their tooth colour
Variables
1.00
-
Yes
1.08
0.62-1.89
0.082 (1)
a
b
1.00
1.00
0.000 (1)
0.49-2.04
Satisfied
c2 statistics
(df)
p value
4.698 (2)
0.095
5.720 (1)
0.017
0.617 (1)
0.432
Yes (%) No (%)
n = 103 n = 132
0.775
Age group (years)
Perceived fractures
No
Yes
1.44-5.91
Likelihood Ratio (LR) test.
Perceived non-aesthetic
restorations
No
1.00
2.91
0.999
Likelihood Ratio (LR) test.
Wald test.
by our finding that tooth whitening was the aesthetic
treatment most desired by participants, a finding similar
to previous results [3]. In addition a study of 180 female
patients in South London [6] showed that whitened teeth
were preferred over teeth with original color with the
< 35
56 (54.4) 90 (68.2)
35 - 54
40 (38.8) 36 (27.3)
≥ 55
7 (6.8)
Male
39 (37.9) 31 (23.5)
Female
64 (62.1) 101 (76.5)
6 (4.5)
Sex
Education
Primary/Secondary 66 (64.1) 91 (68.9)
Post secondary/
Tertiary
37 (35.9) 41 (31.1)
Tin-Oo et al. BMC Oral Health 2011, 11:6
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patients in this study were not significantly affected by
any of those conditions a previous study [3] reported
that patient satisfaction with dental appearance was significantly influenced by self-reported caries in anterior
teeth, but not by other conditions. Further, decayed
anterior teeth were shown to have negative impact on
perceptions of facial attractiveness [6].
Patients with high levels of education were found to be
more satisfied with the color of their teeth than individuals
with lower academic achievement [5,7] as well as to have a
lower preference for white teeth [20]. These findings suggested that the higher self-satisfaction with tooth colour
observed in individuals with higher academic achievement
may reflect higher self-esteem [5,7]. Among our patients
the education level did not have impact on satisfaction
with tooth color or general dental appearance.
It is a commonly thought that women are more interested in their appearance than men. Indeed, female
patients were found to be more concerned with their
dental appearance than males [20] as well as to be more
critical in judging their dental appearance [24]. Similar
to previous results [3] we found that women expressed
greater dissatisfaction with dental appearance and tooth
color than men. In contrast study in Sweden found that
men regarded dental appearance as more important
than women [23] while other studies found that the differences were not significant [5,7]. Gender associated
differences in satisfaction with dental appearance may
require further investigations.
Increased labio-lingual inclination of the anterior teeth
may have caused some patients to regard that their
teeth as protruding, another factor that influenced
patient satisfaction with general dental appearance. We
found that, other tooth malalignments did not affect
patient satisfaction with general appearance, although
self-reported poorly aligned teeth and upper anterior
crowding have been found to be associated with patients
satisfaction [3,27]. These discrepancies highlighted the
wide individual variation in appreciation of acceptable
occlusal features. Individuals who perceived their profiles as being different from average were found more
likely to be dissatisfied with their facial appearance [28].
Poor tooth alignment and crowding are among the most
common malocclusion traits reported in the literature
[29-31], which may explain our finding of a lack of association between patients’ perceptions of having these
traits and satisfaction with general dental appearance.
This study was based entirely on self-reports by patients
through an interviewer guided questionnaire. We did not
attempt to correlate patient self assessments of their dental
problems and their dental records or to compare patients’
desired aesthetic treatments and professional assessments
of their needs. Furthermore, since the subjects of this
study were patients who came to the dental clinic for
Page 7 of 8
treatment, they would be expected to be more aware and
sensitive to their dental appearance.
Conclusions
Most patients in this study expressed dissatisfaction with
their dental appearance. Dissatisfaction was more common in females than in males. Unhappiness with tooth
color and feelings of having protruding teeth also had
significant negative influences on patient satisfaction
with their general dental appearance. The importance of
tooth color was further supported by our finding that
most patients would like to have their teeth whitened.
These results provide useful indications of the potential
demands for dental treatment, particularly aesthetic
treatment. In addition, understanding patients’ perceptions of their dental appearance is an important aspect
of patient management which may assist dentists in
planning treatments that are acceptable to the patients
leading to higher levels of patient satisfaction.
Acknowledgements
The authors acknowledge the staff of the Hospital Universiti Sains Malaysia
Dental Clinic, who facilitated the performance of this study.
Authors’ contributions
MMTO contributed to the design of the study, analyzed the data and wrote
the manuscript. NKS contributed to data analyses and interpretation, and
revised the manuscript. NH contributed to data acquisition and data
management. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 10 September 2010 Accepted: 23 February 2011
Published: 23 February 2011
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Cite this article as: Tin-Oo et al.: Factors influencing patient satisfaction
with dental appearance and treatments they desire to improve
aesthetics. BMC Oral Health 2011 11:6.
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