International Dental Journal 2020; 70: 321–327

SCIENTIFIC RESEARCH
REPORT doi: 10.1111/idj.12574

Psychosocial impact of dental aesthetics on dental patients

Lucas Arrais Campos1, Mariana Andrade Costa1, Fernanda Saullome Sampaio Bonaf
e1,
Jo~
ao Mar^oco2 and Juliana Alvares Duarte Bonini Campos3
1
School of Dentistry, S~ao Paulo State University (UNESP), Araraquara, Brazil; 2William James Center for Research (WJCR), University
Institute of Psychological, Social, and Life Sciences (ISPA), Lisbon, Portugal; 3School of Pharmaceutical Sciences, S~ao Paulo State University
(UNESP), Araraquara, Brazil.

Objective: This study aimed to evaluate the contribution of demographic and clinical characteristics on the psychosocial
impact of dental aesthetics of dental patients. Methods: The psychosocial impact of dental aesthetics was assessed by the
Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ). Data validity was estimated using confirmatory factor
analysis (CFA). Reliability was assessed using standardised Cronbach’s alpha coefficient (a). A structural model was
developed to assess the contribution of demographic and clinical characteristics to the results. The fit of the model was
evaluated and the z test (a = 5%) was used to estimate the significance of the contributions (b). Results: A total of 505
dental patients (80% female; age: 36.3, SD = 11.4) participated in the study. Data showed adequate validity (CFA: v2/
df = 3.3, Tucker–Lewis index [TLI] = 0.92, comparative fit index [CFI] = 0.92 and root mean square error of approxi-
mation [RMSEA] = 0.07) and reliability (a = 0.77–0.92). The fit of the structural model was adequate (v2/df = 2.8,
TLI = 0.89, CFI = 0.91, RMSEA = 0.06). People of a lower economic level, with incomplete dentition, who did not
undergo previous aesthetic dental treatment, and who did not like their own smile showed greater psychosocial impact
of dental aesthetics. Conclusions: Demographic and clinical characteristics should be considered in the evaluation of the
impact of dental aesthetics on individuals’. Moreover, PIDAQ is an alternative tool for clinical evaluation of the psy-
chosocial impact of dental aesthetics because it provides valid and reliable data.

Key words: Dental aesthetics, psychometrics, validation studies, factor analysis, structural equation modelling

parameters and patient expectations and, on the other

INTRODUCTION
hand, to understand the real need for the desired pro-
Physical appearance has an important impact on peo- cedures. Moreover, as the perceptions of dentists and
ple’s lives and orofacial aesthetics can play a major patients are often different, a thorough evaluation of
role, especially concerning social interactions1–3. the treatment need and patient expectations is impor-
Therefore, the perception of characteristics such as tant for a satisfactory outcome7,8.
teeth color, shape, size, position, and exposal might Therefore, the assessment of the psychosocial
become psychosocially important regardless of impact of dental aesthetics might be relevant for
whether there is a relevant functional or aesthetic patient management and treatment planning8. For this
impairment1,4,5. purpose, the Psychosocial Impact of Dental Aesthetics
A direct consequence of this concern with appear- Questionnaire (PIDAQ) was developed9. The PIDAQ
ance is the greater demand for aesthetic dental treat- has four domains of psychosocial impact (dental self-
ments, such as prosthetic dental bleaching and confidence, social impact, psychological impact, and
orthodontics2,3,6. However, treatment plans should be aesthetic concern)9 and although originally developed
based on clinical needs and a detailed investigation of for orthodontics, the instrument has been used in sev-
the reasons leading to the perceived ‘negative’ appear- eral clinical and epidemiological contexts7,10–14.
ance7. This is important, on the one hand, to achieve In addition, the characteristics that influence the
treatment success taking into account both clinical psychosocial impact of dental aesthetics should be
© 2020 FDI World Dental Federation 321
Campos et al.

identified before treatment. Thus, a more individu- replaced by ‘color’, as follows: ‘24. I like my tooth
alised treatment plan can be established, meeting the color’. A 5-point Likert type scale was used for
expectations of the patient. Some studies have shown responses (0: I do not agree, 1: I agree a little, 2: I
that sex10,11,15–19 and age12,19 may affect the impact somewhat agree, 3: I agree a lot, 4: I totally agree).
of dental aesthetics, however, other authors did not The Portuguese version of the PIDAQ proposed by Sar-
find this relationship7,8,20,21. Regarding clinical char- denberg et al.5 was used. For the cultural adaptation,
acteristics, studies indicate that more compromised three people (one Brazilian researcher, one Portuguese
dental aesthetics have greater psychosocial researcher, and one Portuguese language teacher) anal-
impact7,8,16,18,20. ysed its adequacy to the orthographic agreement estab-
Thus, considering the use of the PIDAQ in dental lished among the Portuguese-speaking countries in
clinics, this study evaluated the contribution of clini- 2009. Then, a pilot study (25 individuals, 88%
cal and demographic characteristics on the psychoso- women, mean age of 44.7, SD = 15.4) was carried out
cial impact of dental aesthetics. to verify the individuals’ understanding of the items.
The content validity ratio (CVR) was estimated to
verify the essentiality of each item for evaluation of
METHODS
domains, as proposed by Lawshe24. Participants at
this stage included eight specialists in dental aesthetics
Study design
who classified each item of the instrument into ‘essen-
This was an observational cross-sectional study. tial’, ‘useful but not essential’, and ‘unnecessary’. To
Adults aged between 18 and 59 years who sought evaluate the significance of the CVR, a proposal pre-
care at the university clinics (periodontology, den- sented by Wilson et al.25 was used, considering
tistry, emergency, prosthodontics, oral medicine and a = 5%.
surgery) were invited to participate in 2016 and 2017. Data validity was estimated using confirmatory fac-
People with severe cognitive impairment were tor analysis (CFA) considering the following indices:
excluded. v2/df ≤5.0, Tucker–Lewis index (TLI) and compara-
The sample size was calculated based on the recom- tive fit index (CFI) ≥0.9, and root mean square error
mendation of Hair et al.22 that suggest at least five of approximation (RMSEA) <0.1026,27. Reliability
subjects per parameter of the model to be elaborated. was assessed using standardised Cronbach’s alpha
Considering that the largest model to be tested (struc- coefficient (a ≥ 0.70)26.
tural model) has 60 parameters, the minimum sample
size required was 300.
Structural model
To estimate the contribution of demographic and clin-
Study variables
ical characteristics to the psychosocial impact of den-
Demographic information such as sex, age, marital tal aesthetics, a structural model was developed.
status, work activity (no/yes), and economic level Therefore, the general psychosocial impact factor (sec-
were collected. The economic level was estimated ond order factor) was considered the dependent vari-
using Brazilian Economic Classification Crite- able. The variables sex (0 = male, 1 = female), work
ria (Brazilian Market Research Association [ABEP])23. activity (0 = no, 1 = yes), economic level (1 = D/E,
The clinical characteristics collected were presence of 2 = C, 3 = B, 4 = A), oral status (0 = partial denti-
teeth (complete dentition/partial dentition), use of tion, 1 = complete dentition), use of dental prostheses
dental prostheses (no/yes), previous dental aesthetics (0 = no, 1 = yes), current or previous aesthetics dental
treatment (no/yes), and if the individual likes his or treatment (0 = no; 1 = yes), if the person liked his or
her own smile (no/yes). Finally, the PIDAQ was com- her smile (0 = no, 1 = yes), and age were the indepen-
pleted. dent variables.
The fitting of the structural model was evaluated
using the previously cited indexes (v2/df, CFI, TLI,
Measuring instrument
and RMSEA).26 The trajectories (b) were estimated
The PIDAQ is composed of 23 items distributed in and evaluated with the z-test. A significance level of
four domains (Table 1), and a general domain called 5% and a stepwise procedure were used; independent
‘Psychosocial Impact’ can also be added. For the pre- variables with significant (P < 0.05) b were main-
sent study, an item was added in the self-confidence tained in the final model26,27.
domain based on the importance that teeth color might The analyses were performed in IBM SPSS Statistics
have on dental esthetics13. The new item was based on 22 (IBM Corp., Armonk, NY, USA) and AMOS 22.0
the original item 23 but with the word ‘position’ (IBM Corp., Armonk, NY, USA) software.

322 © 2020 FDI World Dental Federation

 Psychosocial impact of dental aesthetics

Table 1 Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ)

Factor Item Portuguese version† English version‡

Dental self- it4 Eu tenho orgulho dos meus dentes I am proud of my teeth
confidence it7 Eu gosto de mostrar meus dentes quando eu sorrio I like showing my teeth when I smile
it12 Eu fico contente quando eu vejo meus dentes no espelho I am happy about seeing my teeth in the mirror
it17 As pessoas acham meus dentes bonitos Other people like my teeth
it21 Eu estou satisfeito com a apar^encia dos meus dentes I am content with the look of my teeth
it23 Eu acho a posicß~ao dos meus dentes muito boa I like my tooth position
it24 Eu acho a cor dos meus dentes muito boa§ I like my tooth color§
Social impact it2 Eu me contenho/controlo quando sorrio; assim, meus dentes n~ao When I smile, I sometimes try not to reveal my
aparecem muito teeth completely
it5 Se eu n~ao conhecßo bem as pessoas, algumas vezes eu me If I don’t know someone well, I imagine what they
preocupo com o que elas podem achar dos meus dentes might think about my teeth
it9 ~ es
Eu tenho receio de que outras pessoas possam fazer observacßo I sometimes fear others might tease me because of
desagrad
aveis sobre os meus dentes my teeth
it14 De alguma forma eu fico inibido nos encontros sociais por causa I occasionally feel a little self-conscious toward
dos meus dentes others because of my teeth
it15 Eu as vezes me pego colocando minha m~ao na frente da minha I would sometimes like to put my hand in front of
boca para esconder meus dentes my mouth in order to hide my teeth.
it13  vezes eu acho que as pessoas est~ao olhando fixamente para
As I sometimes have the feeling that people are giving
meus dentes me funny looks when they see my teeth
it19 Coment
arios sobre os meus dentes me irritam mesmo que seja de Stupid jokes about my teeth upset me, even if they
brincadeira are only said in fun
it22 Eu as vezes me preocupo com o que pessoas do outro sexo I sometimes fear that other boys (or girls) might
pensam sobre meus dentes think my teeth are ugly
Psychological it3 Eu sinto inveja dos dentes bonitos de outras pessoas I sometimes envy friends whose teeth are more
impact beautiful
it6 Eu fico um pouco incomodado quando vejo os dentes de outras If I compare my own teeth with others‘, I may get
pessoas upset
it10  vezes eu fico um pouco triste com a apar^encia dos meus
As The look of my teeth sometimes makes me a bit
dentes unhappy
it11 Eu acho que a maioria das pessoas que eu conhecßo tem dentes I think that most of my friends have more beautiful
melhores do que os meus teeth
it16 Eu me sinto mal quando eu penso na apar^encia dos meus dentes I sometimes feel ashamed because of my tooth
position
it20 Eu gostaria que meus dentes tivessem uma apar^encia melhor I sometimes wish my teeth would look better
Aesthetic it1 Eu n~ao gosto de ver meus dentes no espelho I don’t like my teeth when I look at myself in the
concern mirror
it8 Eu n~ao gosto de ver meus dentes em fotos I dislike seeing my teeth on pictures of me
it18 Eu n~ao gosto de ver meus dentes quando eu assisto a um v
ıdeo I don’t like my teeth when I see myself in a video
em que eu aparecßo
†
Portuguese version of Psychosocial Impact of Dental Aesthetic Questionnaire proposed by Sardenberg et al. [5].
‡
English version of Psychosocial Impact of Dental Aesthetic Questionnaire proposed by Klages et al. [9].
§
Item added in this study.

Procedures and ethical aspects 36.27 (SD = 11.37) years. The sample characteristics
are shown in Table 2.
Individuals undergoing treatment at the University
The majority of participants were women and had
dental clinic were invited to participate in the study
work activity. Most had partial dentition, were not
by a researcher who approached patients in the wait-
using dental prostheses, were receiving or had had
ing room. The instrument was self-completed in gen-
aesthetic dental treatment, and reported liking their
eral, however, support was provided if anyone had
own smile.
difficulty filling out the questionnaire or preferred to
Descriptive statistics of the participant responses to
be interviewed. Thus, 72.4% of the data were col-
the items of the PIDAQ and the CVR are shown in
lected through self-completion and 27.6% by means
Table 3. No severe violation of normality was
of an interview. This study was approved by the
observed in the responses (skewness <3 and kurto-
Ethics Committee on Human Research.
sis <7 in absolute values). Items 6, 11, 16, 18, and 21
were not considered essential by the specialists. The
RESULTS data showed adequate validity (CFA: v2/df = 3.3,
TLI = 0.92, CFI = 0.92, and RMSEA = 0.07) and
A total of 623 people were invited to participate in
reliability (a = 0.77–0.92). The structural model fit,
this study. However, 118 were excluded because they
considering all the independent variables, was accept-
did not either meet the inclusion criteria (n = 29) or
able (v2/df = 2.8, TLI = 0.89, CFI = 0.91,
respond to all items of the instrument and demo-
RMSEA = 0.06). However, not all independent
graphic questionnaire (n = 89). The mean age was
© 2020 FDI World Dental Federation 323
Campos et al.

variables had a significant contribution, and therefore, Table 3 Descriptive statistics of the participant
the model was refined (Table 4). responses to the items of the PIDAQ and the CVR
During model refinement, it was observed that the
Item Mean Median Standard Skewness Kurtosis CVR†
variables ‘use of dental prostheses’ and ‘work activity’ deviation
were at the limit of significance and, because of the
it1 1.19 1 1.45 0.88 0.64 0.75
large sample size used, these variables were removed it2 1.19 0 1.52 0.89 0.80 1.00
in the subsequent analyses. In the final model the vari- it3 1.01 0 1.48 1.16 0.26 1.00
ables that remained were economic level, dentition it4 1.49 1 1.53 0.54 1.21 0.75
it5 1.06 0 1.48 1.04 0.50 1.00
status, dental aesthetics treatment, and appreciation it6 0.66 0 1.22 1.74 1.66 0.50
of own smile. it7 1.59 1 1.57 0.42 1.39 1.00
it8 1.26 0 1.57 0.79 1.01 1.00
it9 1.15 0 1.58 0.90 0.89 1.00
DISCUSSION it10 1.48 1 1.58 0.55 1.30 0.75
it11 1.44 1 1.53 0.54 1.25 0.50
The present study demonstrated that data obtained by it12 1.47 1 1.53 0.53 1.24 0.75
it13 1.11 0 1.47 0.95 0.65 1.00
PIDAQ has adequate validity and reliability for it14 1.10 0 1.50 0.99 0.60 1.00
Brazilian adult dental patients. A significant contribu- it15 0.75 0 1.35 1.53 0.75 1.00
tion to the psychosocial impact of dental aesthetics it16 1.23 0 1.54 0.78 1.01 0.50
it17 0.81 0 1.22 1.35 0.67 1.00
was found for economic level, dentition status, dental it18 1.08 0 1.51 1.01 0.59 0.50
aesthetic treatment, and appreciation of own smile. it19 1.10 0 1.57 0.97 0.78 0.75
Several studies have used the PIDAQ but few have it20 2.66 3 1.51 0.65 1.13 1.00
it21 1.21 1 1.44 0.82 0.73 0.50
evaluated the validity and reliability of data in a simi- it22 1.08 0 1.50 1.00 0.61 1.00
lar sample or context as was done in this study8,9. it23 1.53 1 1.53 0.44 1.31 1.00
Although the PIDAQ was originally developed for it24 1.11 0 1.39 0.94 0.48 1.00

*PIDAQ, Psychosocial Impact of Dental Aesthetics; CVR, content

validity ratio.
†
CVR8;0,05 = 0.693.

Table 2 Distribution [n (%)] of participants accord-

ing to their characteristics
orthodontic patients9, the present study showed that
Characteristic n (%) its use in different contexts is feasible.
Sex The inclusion of an item to the model (Item 24,
Female 404 (80.0) self-confidence domain, Table 1), was based on the
Male 101 (20.0) relevance that teeth color can have on the psychoso-
Marital status
Single 191 (37.8) cial impact of dental esthetics13. With such an item,
Widowed 7 (1.4) the possibilities for the use of the PIDAQ are
Married 262 (51.9) extended to different clinical contexts. During the
Divorced 45 (8.9)
Economic level† CFA, we verified that this item presented good facto-
A 29 (5.7) rial loading (kit24 = 0.61), indicating that teeth color
B 185 (36.7) is relevant for the ‘self-confidence’ domain. Therefore,
C 256 (50.7)
D/E 35 (6.9) the maintenance of this item is recommended when
Work activity applying the PIDAQ in clinical contexts other than
No 179 (35.4) orthodontics.
Yes 326 (64.6)
Oral status The CFA showed adequate validity of data obtained
Complete dentition 203 (40.2) by PIDAQ considering the four domains and the gen-
Partial dentition 302 (59.8) eral domain ‘psychosocial impact’, reinforcing the the-
Use of dental prostheses
No 369 (73.1) ory underlying the instrument development, which
Yes 136 (26.9) states that the model evaluates a global aspect of the
Current or previous aesthetics dental treatment psychosocial impact of dental aesthetics. Thus, the
No 144 (28.5)
Yes 361 (71.5) decision whether to use the domains separately or the
Do you like your smile? general domain should be based on the desired out-
No 162 (32.1) come. By using this tool, a better assessment of
Yes 343 (67.9)
patients’ expectations and needs can be carried out
†
Brazilian Economic Classification Criteria23, mean income per stra- allowing individualised clinical management and treat-
tum: A = R$20,888.00 (U$5,722.74); B = R$4,852.00-R$9,254.00
(U$1,329.32-U$2,535.34); C = R$1,625.00-R$2,705.00 (U$445.20- ment.
U$741.10); D-E = R$768.00 (U$210.41). Estimated from the Cen- The demographic and clinical characteristics that
tral Bank of Brazil (U$1.00 = R$3.65) in 05/23/2018. presented a significant contribution to the model were
324 © 2020 FDI World Dental Federation
 Psychosocial impact of dental aesthetics

Table 4 Complete structural model considering demographic and clinical variables (independent variables) of the
psychosocial impact of dental aesthetics (second-order hierarchical model) and refined models using stepwise pro-
cedure
Characteristic

Sex Age Economic Work Oral Use of dental Aesthetics dental Like own
level activity status prostheses treatment smile

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

E.V., explained variance; SE, standard error; bs, b standardised.

economic level, dentition status, dental aesthetics It is known that the body is perceived differently by
treatment, and being pleased with own smile. The men and women and by different age groups31, which
influence of economic level on the psychosocial could be extrapolated to dental appearance. However,
impact of dental aesthetics has been studied before. the concept evaluated by the PIDAQ is the psychoso-
Contrary to our findings, Bellot-Arc
ıs et al.20 did not cial impact of appearance, and not the perception of
observe a significant difference among social classes. appearance. That is, the different perception of dental
This disparity can be attributed to the different meth- aesthetics of different sexes and age groups does not
ods used for economic level classification, different mean greater impact of aesthetics on people’s lives,
samples or contexts of the studies, and methodologies which might explain the lack of sex and age influence
used to evaluate the psychosocial impact. However, in our study.
other authors found that people from a lower eco- On the other hand, seeking dental aesthetics treat-
nomic level are more influenced by dental appear- ment and appreciating one’s own smile indicated
ance28,29, indicating that income might directly affect greater influence of dental appearance on people’s
access to health services. Furthermore, individual lives. When undergoing an aesthetic procedure and a
health-related psychological and psychosocial troublesome feature is modified or eliminated, the
resources, such as ability to build coping strategies, patient perception of the feature also changes, and his
adequate social support, and social control, seem to or her expectation is fulfilled by the treatment32. Lik-
vary among different economic levels30, justifying the ing the one’s own smile, however reduces the psy-
results found in the present study. chosocial impact that dental aesthetics can exert on
Age and sex did not significantly contribute to the someone’s life16.
psychosocial impact of dental aesthetics in the present Participants missing one or more teeth had an
sample. Although our findings are in agreement with increased psychosocial impact of dental aesthetics,
other studies7,8,21, the subject is controversial4,10–12,19. while the use of a prosthesis did not contribute to this
© 2020 FDI World Dental Federation 325
Campos et al.

impact. Although no studies were found on the psy- committee and with the 1964 Helsinki declaration
chosocial impact of tooth loss, it is known that tooth and its later amendments. The Ethics Committee on
loss greatly affects oral health-related quality of life Human Research of the School of Dentistry of S~ao
and the impact is greater with increasing number and Paulo State University.
location of missing teeth33.
As for limitations, this study did not perform a
Informed consent
detailed clinical evaluation of the participants, which
could provide relevant data to establish associations All individuals who participated in the study agreed and
with the psychosocial impact of dental aesthetics and signed the written informed consent form previously
help confirm the validity of PIDAQ. Thus, future approved by the Ethics Committee on Human Research
studies should include more detailed clinical exams to of the School of Dentistry of S~ao Paulo State University
explore these associations. In addition, the cross-sec- (CAAE Registry No. 53584016.0.0000.5416).
tional design of the study does not allow the establish-
ment of a cause-and-effect relationship. However, this
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