Patients’ general satisfaction with the appearance of anterior maxillary teeth

Page 520 VOJNOSANITETSKI PREGLED Vojnosanit Pregl 2017; 74(6): 520–525. UDC: 616.31:111.852 https://doi.org/10.2298/VSP151110248L ORIGINAL ARTICLE Patients’ general satisfaction with the appearance of anterior maxillary teeth Zadovoljstvo pacijenata izgledom prednjih gornjih zuba Vlatka Lajnert*, Daniela Kovačević Pavičić*, Hrvoje Pezo†, Aleksandra Stevanović‡, Tatjana Jović*, Damir Šnjarić§, Edin Muhić║ ‡ University of Rijeka, Faculty of Dental Medicine, *Department of Prosthodontic, Department of Psychiatry, Rijeka, Croatia; †Private Dental Practice, Zagreb, Croatia; § Private Dental Practice, Rijeka, Croatia; ║Private Dental Practice, Sarajevo, Bosnia and Herzegovina Abstract Apstrakt Background/Aim. Dental appearance plays an important role in practically all personal social interactions. The main factors that define the dental appearance are tooth colour, shape and position, quality of restoration, and the general position of the teeth in arch, especially in the anterior region. The aim of this study was to evaluate the impact of dental status (tooth shape, fracture, dental and prosthetic restorations and presence of plaque) on patient's satisfaction with the dental appearance, controlling for the age and gender. Methods. A total of 700 Caucasian subjects (439 women) aged 18–86 (median 45 years) participated in the cross-sectional study. Study included clinical examination and self-administrated questionnaire based on selfperceived aesthetics and satisfaction with the appearance of their maxillary anterior teeth. Results. A regression analysis demonstrated that presence of dental plaque, tooth fracture, composite fillings and crowns had significant independent contribution and were negative predictors of satisfaction with teeth appearance. Participants with presence of plaque on upper teeth (p < 0.001), fractures (p = 0.005), composite fillings (p < 0.001) and crowns (p = 0.032) were less satisfied than those without it. Model explains 12% or variance of general satisfaction with the appearance of maxillary frontal teeth (p < 0.001) and the major contributors are composite fillings (5.3%) and plaque (3.2%). Tooth shape, age and gender were not significant predictors of satisfaction. Conclusion. Satisfaction with the teeth appearance is under the influence of many factors with significant negative influence of presence of dental plaque, fractures, composite restorations, and crowns. Uvod/Cilj. Izgled zuba igra važnu ulogu u praktički svim kontaktima jedne osobe. Glavni faktori koji definišu izgled zuba su boja, oblik i pozicija zuba, kvalitet restauracije i položaj zuba u zubnom luku, posebno u prednjem delu. Cilj ovog rada bio je da se utvrdi uticaj životnog doba, pola, frakture zuba i plak indeksa na zadovoljstvo pacijenta izgledom zuba. Metode. U istraživanju je učestvovalo 700 ispitanika u životnom dobu 18–86 godina (medijana 45 godina). Istraživanje je bilo bazirano na kliničkom pregledu i ispunjavanju upitnika koji je uključivao pitanja bazirana na samoproceni zadovoljstva izgledom gornjih prednjih zuba. Rezultati. Regresijska analiza je pokazala da dentalni plak, frakture zuba, kompozitni ispuni i krunice imaju statistički značajan uticaj i da su negativni prediktori zadovoljstva izgledom zuba. Ispitanici s plakom na gornjim prednjim zubima (p < 0,001), frakturom (p = 0,005), kompozitnim ispunima (p < 0,001) i krunicama (p = 0,032) bili su manje zadovoljni od ispitanika bez njih. Model objašnjava 12% varijanse generalnog zadovoljstva izgledom gornjih prednjih zuba (p < 0,001) kao i najveći učinak imaju kompozitni ispuni (5,3%) i plak (3,2%). Oblik zuba, životno doba i pol nisu bili značajni prediktori zadovoljstva. Zaključak. Zadovoljstvo izgledom zuba je pod uticajem mnogih faktora, a negativan uticaj imaju prisustvo zubnog plaka, fraktura, kompozitnih ispuna i krunica. Key words: esthetics, dental; patient satisfaction; surveys and questionnaires; age factors; dental plaque; dental restoration, permanent. Ključne reči: estetika, stomatološka; bolesnik, zadovoljstvo; ankete i upitnici; životno doba, faktor; zub, plak; zub, trajni ispuni. Correspondence to: Vlatka Lajnert, University of Rijeka, Faculty of Dental Medicine, Department of Prosthodontic, Krešimirova 40, 51 000 Rijeka, Croatia. Phone: +385 51 345 633. E-mail: vlatkamikic@yahoo.com Vol. 74, No 6 VOJNOSANITETSKI PREGLED Introduction In the past, restorative dentistry considered mostly functional demands, but with the decrease in caries prevalence, interest in dental aesthetics has increased rapidly among both patients and dentists 1–4. Nowadays, public appearance plays an extremely important role in both advertising industry and media in general since it affects other people’s perception in numerous daily situations 1, 5. Therefore in the last two decades esthetics in dental practice has become just as important as functional, structural and biological characteristics. Dental appearance is a leading feature in determining the overall attractiveness of one’s face, thus playing an important role in practically all personal social interactions. Principal factors which define the dental appearance are tooth colour, its shape and position, quality of restoration, and the general positioning of the teeth in arch (crowding, diastemas), which is especially important in the anterior region 6, 7. The overall appearance of the dentition may be influenced by gender, age and education level. Moreover, genderrelated differences play quite a significant role in aesthetic dentistry, since it has been demonstrated that women and men seem to have different approaches and needs in their pursuit of a more favorable dental appearance 8, 9. Consequently, it is very difficult to address individual needs with specific guidelines or a unique systematic approach that will undoubtedly lead to consistent results 10, 11. In general, patients want white Hollywood teeth. Thus, tooth colour is absolutely one of the most important factors determining patient satisfaction with their smile 1, 6, 7, 12, 13. In fact, bright teeth have been related to high social skills, intelligence, prestige, ability to balance conflicting needs, and relationship status 14. Alternatively, untreated dental caries, discoloured front teeth restorations and missing teeth in the anterior region are sources of displeasure and lack of satisfaction 1, 15–17. Malocclusion is a common oral finding. Regardless of its high frequency, treatment needs and demands vary depending on cultural and personal differences. In some populations, tooth misalignments are not regarded as serious defects which would necessitate treatment, either orthodontic or prosthetic 18 while, in other populations, with high standards of dental appearance the need for orthodontic treatment may similarly be quite pronounced 19. There is a general agreement in the literature that people who are motivated to seek orthodontic treatment of malocclusion do so prompted by its negative physical, psychological and social impacts. However, the studies focusing on the effects of malocclusion and consequences of its treatment on people's lives have offered inconsistent and confusing results 20. As mentioned before, the harmonious smile is defined not only by the dental esthetic elements – shape, position, and color of the teeth – but also by the gingival (soft) tissues. Gingival health defined by colour, margins and visibility is the essential component of an attractive smile 21. Since the aesthetics is an important dimension in dental practice, and it is a result of a pleasing composition of many elements modified by individual preferences, cultural influences, sociodemographic factors and self-perceived need for Lajnert V, et al. Vojnosanit Pregl 2017; 74(6): 520–525. Page 521 dental treatments, the aim of this study was to determine the predictors of patients' satisfaction with esthetic appearance of their maxillary anterior teeth. Methods A total of 700 Caucasian subjects from Rijeka region, Croatia, (aged 18-86; median 45 years) participated in the cross-sectional study (439 women). Sampling procedure included convenient sample – consecutive voluntary blood donors at the Department of Transfusion Medicine University Hospital Rijeka, subjects at regular annual check-ups at the Institute for Public Health Rijeka, and patients seeking treatment at the University Dental Clinic Rijeka. All the participants included in the study gave written informed consent to the survey procedures, which were approved by the Ethical Committee of the Rijeka University Faculty of Medicine. The inclusion criteria were individuals with all six anterior teeth present in the upper jaw; while exclusion criteria were: evidence of gingival inflammation or hyperplasia, observable gingival recession, observable occlusal wear, active orthodontic therapy by edgewise appliances, temporary crowns in prosthetic rehabilitation, progressive endodontic therapy, usage of splints for the treatment of temporomandibular disorders and participants with craniofacial syndromes. Study included clinical examination and Aesthetic Questionnaire. The Aesthetic Questionnaire was selfadministrated and comprised five questions related to satisfaction with dental appearance in general (tooth colour, shape, position in a dental arch and appearance of gingiva of maxillary anterior teeth). Assessments were made using a three-point scale with possible answers 'dissatisfied' = 1, 'moderately satisfied' = 2, or 'completely satisfied' = 3. To test psychometric properties of this five-item Aesthetic Questionnaire the preliminary investigation was conducted which included 70 individuals who answered the 5 questions from the Questionnaire. Plaque index was determined using the method described by O'Leary et al. 22 in 1972. Plaque levels were assessed on four tooth surfaces. Presence or absence of plaque was noted with „+“ and „- “. In univariate analyses subjects were divided into 3 age groups: young age < 35 years; middle aged, 35–54 and old, ≥ 55 years. To examine the differences in several aspects of dental satisfaction in respect to gender a series of χ2-tests were performed within each age group (p < 0.05). The multiple linear regression analysis was made to evaluate influence of presence of plaque, tooth shape (1 = ovoid; 2 = triangle and 3 = quadratic), fracture (0 = absent; 1 = present), composite fillings and crowns on maxillary anterior teeth on satisfaction with dental appearance, while controlling for the gender and age. For this purpose the variable plaque was introduced as a dichotomous variable: 0 = subject with no plaque or 1 = subject with plaque present on at least one tooth. Similar was done for presence of fractures, fillings and crowns. The data were analyzed using a statistical software package SPSS 10.0 (SPSS 10.0; SPSS Inc., Chicago, IL, USA). Page 522 VOJNOSANITETSKI PREGLED Results In the young age group most of the participants were moderately satisfied with the appearance and most of them were completely satisfied with colour, shape, position and gingiva of their teeth. As presented in the Table 1, there were no significant differences in gender in observed variables of dental satisfaction. Participants from the middle age group were mostly completely satisfied with the appearance, colour, shape, position and Vol. 74, No 6 gingiva. However, several gender differences in satisfaction were obtained. Men and women from middle age group had a significantly different appraisal of satisfaction with the shape (χ2 = 10.175, p = 0.006) of their teeth with 61.4% of women being completely satisfied with the shape compared to 39.7% of men, and with 28.6% men dissatisfied with the shape compared to 12.6% of women (Table 2.) Also, there was a significant difference in satisfaction with the position of teeth between men and women in the middle age group (χ2 = 5.961, p = 0.05). Table 1 Results of χ2-test for satisfaction with different dental aspects between men (n = 79) and women (n = 180) in the young group (< 35 years) Variable Appearance male female total Colour male female total Shape male female total Position male female total Gingiva male female total Dissatisfied Moderately n (%) n (%) Completely satisfied n (%) 17 (33.3) 34 (19) 51 (19.8) 31 (39.2) 83 (45.8) 114 (43.8) 31 (39.2) 63 (35.2) 94 (36.4) 12 (15.2) 37 (20.6) 49 (18.9) 29 (36.7) 68 (37.8) 97 (37.5) 38 (48.1) 75 (41.7) 113 (43.6) 11 (13.9) 19 (10.6) 30 (11.6) 24 (30.4) 68 (37.8) 92 (35.5) 38 (48.1) 75 (41.7) 113 (43.6) 16 (20.3) 31 (17.2) 47 (18.1) 19 (24.1) 60 (33.3) 79 (30.5) 44 (55.7) 89 (49.4) 133 (51.4) 8 (10.1) 26 (14.4) 34 (13.1) 19 (24.1) 37 (20.6) 56 (21.6) 19 (24.1) 3 (20.6) 56 (21.6) χ2 df p 0.963 2 0.618 1.373 2 0.503 1.552 2 0.460 2.247 2 0.325 1.096 2 0.578 Note: % within the gender. Table 2 Results of χ2-test for satisfaction with different dental aspects between men (n = 63) and women (n = 127) in the middle age group (36–54 years) Variable Appearance male female total Colour male female total Shape male female total Position male female total Gingiva male female total Dissatisfied Moderately n (%) n (%) Completely satisfied n (%) 19 (30.2) 28 (22) 47 (24.7) 26 (41.3) 40 (31.5) 66 (34.7) 18 (28.6) 59 (46.5) 77 (40.5) 15 (23.8) 24 (18.9) 68 (35.8) 28 (44.4) 40 (31.5) 68 (35.8) 20 (31.7) 63 (49.6) 83 (43.7) 18 (28.6) 16 (12.6) 34 (17.9) 20 (31.7) 33 (26) 53 (27.9) 25 (39.7) 78 (61.4) 103 (54.2) 18 (28.6) 23 (18.1) 41 (21.6) 19 (30.2) 28 (22) 47 (24.7) 26 (41.3) 76 (59.8) 102 (53.7) 14 (22.2) 18 (14.2) 32 (16.8) 15 (23.8) 23 (18.1) 38 (20) 34 (54) 86 (67.7) 120 (63.2) χ2 df p 5.602 2 0.061 5.543 2 0.063 10.175 2 0.006 5.961 2 0.051 3.564 2 0.168 Note: % within the gender. Lajnert V, et al. Vojnosanit Pregl 2017; 74(6): 520–525. Vol. 74, No 6 VOJNOSANITETSKI PREGLED Again, women were more frequently completely satisfied with the position of their teeth compared to men, while men were more frequently dissatisfied with the position compared to women (Table 2). As presented in Table 3, participants from the old age group were mostly completely satisfied with the appearance, shape, position, and gingiva and moderately satisfied with colour of their teeth. There were no significant gender differences in dental satisfaction in this age group (Table 3). Page 523 der model. Multiple regression provide us this opportunity. This is demonstrated in present study. Although there is a different satisfaction with teeth appearance between genders in some age groups in univariate models, in general gender and age are not principal, significant or even highly influential factors of satisfaction in multiple model. Dental appearance is adversely affected by abnormalities and deviations in the oral region 12. In this study we investigated satisfaction with dental appearance in relation to age, gender, pres- Table 3 Results of χ2-test for satisfaction with different dental aspects between men (n = 119) and women (n = 132) in the old age group (> 55 years) Variable Appearance male female total Colour male female total Shape male female total Position male female total Gingiva male female total Dissatisfied Moderately n (%) n (%) Completely satisfied n (%) 27 (22.7) 25 (18.9) 52 (20.7) 41 (34.5) 53 (40.2) 94 (37.5) 51 (42.9) 54 (40.9) 105 (41.8) 31 (26.1) 30 (22.7) 61 (24.3) 46 (38.7) 53 (40.2) 99 (39.4) 42 (35.3) 49 (37.1) 91 (36.3) 12 (10.1) 25 (18.9) 37 (14.7) 48 (40.3) 45 (34.1) 93 (37.1) 59 (49.6) 62 (47) 121 (48.2) 15 (12.6) 29 (22) 44 (17.5) 44 (37) 44 (33.3) 88 (35.1) 60 (50.4) 59 (44.7) 119 (47.4) 21 (17.6) 21 (15.9) 42 (16.7) 29 (24.4) 33 (25) 62 (24.7) 69 (58) 78 (59.1) 147 (58.6) χ2 df p 1.024 2 0.599 .378 2 0.828 4.076 2 0.130 3.800 2 0.150 .136 2 0.934 Note: % within the gender In order to further examine dental satisfaction, a regression analyses were performed with dominant shape, dominant plaque, at least one fracture on upper incisors, at least one composite fillings on upper incisors, at least one crowns on upper incisors, age, and gender while dependent variable was satisfaction with dental appearance expressed as the average score on the Aesthetic Questionnaire (Table 4). The results showed that the model explains 12% of variance of dental satisfaction. Dental plaque, tooth fracture, composite fillings and crowns have significant independent contribution and are negative predictors. Participants with presence of plaque on upper teeth, fractures, composite fillings and crowns were less satisfied than those without it. The major contributors were composite fillings (5.3%) and plaque index on upper incisors (3.2%). Discussion Numerous factors are influencing satisfaction with itsown dental esthetics and this study may help dentists to pay increased attention to the factors of patients' concern. Some factors are to some extent interrelated, complemented, share the same variance, or reduce the effects of the other factor. Therefore they should be explored simultaneously in a broaLajnert V, et al. Vojnosanit Pregl 2017; 74(6): 520–525. ence/absence of composite fillings and crowns, plaque index and tooth fracture. Table 4 Regression analyses for dental satisfaction Parameter Dominant shape Dominant plaque Fracture Composite filling Crowns Age Gender Beta 0.046 -0.183 -0.101 -0.247 -0.083 0.257 0.489 R2 = 0.122 F = 13.747 p = 0.000 p 0.197 0.000 0.005 0.000 0.032 0.797 0.625 Limited number of documented literature was present on influence of different factors on satisfaction in Croatian population. This study would help subjects to show their satisfaction with dental appearance and it may help dentists to pay increased attention to the factors of patient concern. Gender and age Contrary to our findings some evidence exist that apart from visible dental features, perception of dental appearance Page 524 VOJNOSANITETSKI PREGLED is modified by cultural factors and individual preferences, varying between individuals and cultures and changing over time and with age 5, 6, 23–25. It appears that men regard dental appearance as more important than women 24, but females tend to be more satisfied with the general appearance of their teeth 1. Results of our study showed that in the age group between 36 and 54 years, men are significantly less satisfied with the dental appearance, tooth shape and tooth position and achieved a significantly lower score on the average satisfaction of teeth in relation to women. This is likely due to strong impact of the media which portray men and women of all ages as needing to look younger and more attractive. Indeed, a study of 160 people of six different age strata ranging from 13 to 64 years showed that personal satisfaction with tooth colour was age-independent 12. Although younger usually have healthier teeth, and less frontal restoration and discolorations they may be more concerned with slight imperfections. On contrary older people, in general, are more likely to be satisfied with their dental appearance 12, 15, suggesting that the appearance of their teeth is not as important to older than to younger individuals 5. Visible dental features Dental appearance is adversely affected by abnormalities and deviations in the oral region 12 so those visible traits must be primarily sources of dissatisfaction. Our model included and investigated several dominant dental traits – presence/absence of composite fillings and crowns, tooth shape, presence of plaque and tooth fracture. As it is demonstrated the presence of composite fillings and plaque on maxillary anterior teeth are major factors influencing dissatisfaction with dental aesthetics, but also not to a large extent. Restorations – fillings and crowns Composite fillings are the most common restorations in maxillary anterior teeth because of their low price in comparison to the prosthetic restorations. Although composite restorations can be completed in a single treatment session with no added laboratory cost, this material is presently limited by several restrictions – inability to completely replicate natural tooth in colour and changes induced during time due to polymerization-induced shrinkage, low wear resistance and surface porosity, which may influence the patient’s level of satisfaction 26. Those limitations of composite materials may contribute to poorer aesthetics in time and induce decrease of satisfaction with dental appearance. Therefore these materials need to improve their performances. Younger people and women tend to expose more maxillary teeth than older and men 24, 25. The shortcoming of Vol. 74, No 6 present study was that it did not assess the quality of restorations as an element that could influence satisfaction. Still, probably people sometimes think that when they have some dental restoration their dental appearance is altered or less natural and they are to some extent dissatisfied. Dental appearance may influence social interactions and contribute to social selection 25. It also may reflect economic status 27. Wealthier people, even with worse oral health, are likely to have better frontal restoration, brighter and straighter teeth and a higher red-white esthetics. Perhaps that is why the presence of composite restorations, even well-made, may be a higher source of dissatisfaction than presence of fixed prosthetic restorations. Plaque Satisfaction with teeth appearance may reflect general attitude on health, particularly oral health. That explains why presence of plaque is regarded second-order factor in dissatisfaction. The presence of gingivitis was not assessed in this study, but plaque index highly positively correlates with gingivitis 28. Therefore it can be an indicator of periodontal health and oral health care. Quite expectedly, the increase of the degree of plaque index reduces the assessment of satisfaction with dental appearance. The participants who had a higher degree of plaque index reported a lower level of satisfaction with dental appearance. The plaque index was a statistically significant negative predictor of general satisfaction with their teeth (p < 0.001). Shape Tooth shape does not significantly influence satisfaction with teeth appearance. Still, it appears that incisor shape may be the key determinant of their esthetic preferences with round incisors perceived as the most esthetic 29. So to improve smile esthetics some mildly rounding the mesial and distal corners of square incisors can be done 30, 31. Many authors agree that the upper central incisors in particular are the key determinants in evaluating anterior dental aesthetics 24, 26, 27, 31. This can be taken as implying that these teeth probably play the subconsciously important role in people's judgements concerning dental aesthetics. Maxillary teeth are often the most visible during smile, although this feature is age- and gender related. Conclusion This study revealed that composite fillings and a presence of dental plaque in the anterior maxillary teeth are negative predictors to a self-perceived dental appearance. R E F E R E N C E S 1. Samorodnitzky-Naveh GR, Geiger SB, Levin L. Patients' satisfaction with dental esthetics. J Am Dent Assoc 2007; 138(6): 805−8. 2. Beltran-Aguilar E, Barker LK, Canto M, Dye BA, Gooch BF, Griffin SO, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis-United States, 1988-1994 and 1999-2002. MMWR Surveill Summ 2005; 54(3): 1−43. 3. Carlsson GE, Johansson A, Johansson AK, Ordell S, Ekbäck G, Unell L. Attitudes toward dental appearance in 50- and 60Lajnert V, et al. 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Received on November 10, 2015. Revised on November 12, 2015. Accepted on February 03, 2016. Online First September, 2016.