Introduction

In Chile, the prevalence of caries and periodontal diseases has declined in people under the age of 20¹. However, dento-maxillary anomalies, affecting 38.29% of children aged 6 and 53% of children aged 12, have not significantly decreased over time².

Therefore, corrective orthodontic treatment with brackets is an option to address these anomalies, because it improves aesthetics and therefore patients’ quality of life³. However, the use of these appliances in an area as sensitive as the oral cavity may cause discomfort⁴, and there often appear oral ulcers^5-6 and pain, especially in the first few months⁷.

The information on the first three months of orthodontic treatment is essential for the clinical trial, and as mentioned above, the appearance of pain and functional limitations in this period may disappoint certain patients, affecting their motivation, cooperation spirit, and it may even lead them to abandon the treatment^7-8.

Marques et al.⁹ show that approximately 16% of patients experience a degree of discomfort when using fixed orthodontic appliances, which has a negative impact on their quality of life. However, in the study conducted by Gacitúa et al.¹⁰ in Santiago de Chile, there was a significant difference in level of satisfaction between the first and second evaluations, the latter yielding the best result. However, there was no follow-up after the first month.

Given this background, the aim of this study is to assess the level of satisfaction with the use of fixed orthodontic appliances in users attending health centers in Valdivia and Paillaco in 2017.

Materials and methods

An observational cross-sectional study was conducted between May and October of 2017. The target population were patients who had started treatment with fixed orthodontic appliances in public and private health centers in Paillaco and Valdivia.

The sample size was designed considering the results of Gacitúa et al.¹⁰, who found an average overall satisfaction score before the orthodontic treatment of 27.2 points (SD ± 4.48); our hypothesis posits a difference between the first and third checkups in the scale average: 31.2 points (SD ± 4.48). Considering a power level of 0.9 and an alpha error of 0.05, and 25% of additional observations in case there is no follow-up, a sample size of 34 users was estimated. This was calculated using Stata software, version 10.0 (StataCorp USA).

The study included patients over 9 and under 25 of both sexes, who could read and write in Spanish, and who voluntarily accepted to participate in the study, following the required protocols in the case of minors.

The users included in this study had fixed appliances, with MBT or Roth prescription metal brackets¹¹, and were diagnosed with moderate or severe negative dento-maxillary discrepancy¹². Users with additional orthodontic appliances like transpalatal arches, lingual arches, mini implants and Quad Helix were also included.

Users excluded from the study; users who needed conventional orthodontic treatment and also surgical treatment, presence of mild negative dentomaxillary discrepancy, users of removable and/or fixed dentures, presence of periodontal disease, chronic diseases, those undergoing analgesic therapy, presence of some type of temporomandibular disorder¹³, oral pathology causing pain, speech disorder and those with some type of condition that might prevent them from completing the survey autonomously.

To measure satisfaction, the questionnaire developed by Gacitúa et al.¹⁰⁾ was used. It included ten statements, which were grouped in three areas: oral hygiene (OH), comfort (CF) and aesthetic self-perception (ASP); each with a certain number of questions, three for OH, four for CF and three for ASP. According to the literature, these are essential elements in orthodontic treatment^9,14. Each question has a value between 0 and 5 in alternatives with Likert format (5: very satisfied, 4: satisfied, 3: acceptable, 2: dissatisfied, and 1: very dissatisfied). Non-answers were awarded a 0 value. The total score of the questionnaire ranges between 0 and 50 points, where a higher score indicated greater satisfaction.

The invitation to participate in the study was made to patients in the centers described, which was approved by the Ethics Committee of the Valdivia Health Service. In the case of users under 18, their permission was requested and their representatives had to sign an informed consent.

The surveys were administered by two researchers (G.F. and S.A.) who were calibrated by administering it to ten patients who had already completed their treatment with fixed orthodontic appliances. The first survey was administered one month after the installation of the fixed appliances, which was the first checkup. The following surveys were administered in the two subsequent checkups, corresponding to the second and third months. At the time of installation, all the patients were instructed on the necessary care regarding hygiene, eating and potential discomfort.

The variables studied were sex, total score of the questionnaire and score of each area (OH, CF, ASP). The data were organized in a Google spreadsheet (Google Inc. USA.).

A descriptive statistics analysis using central tendency and dispersion measures was conducted. The Shapiro Wilk test was performed to determine the normality of the data. To establish differences between scores and the different health centers, the Friedman test was performed with a p<0.05 significance level, for which free-access statistical software R, version 3.4.1, was used.

Results

Thirty-six patients fulfilled the selection criteria. Follow-up could not be conducted with two of them, so the survey was correctly administered to 34 users. Twenty-one were women (61.8%) and 13 were men (38.2%). The average age was 14.1 (SD ± 3.5).

The total satisfaction score was 37.94 (SD ± 7.13) points for the first checkup, 40.56 (SD ± 6.35) for the second and 41.09 (SD ± 6.92) for the third. Table 1 shows the total satisfaction scores obtained per checkup in the health centers studied.

Table 1: Total overall satisfaction score according to checkup and health center 

C1: Checkup 1 C2: Checkup 2 C3: Checkup 3 SD: Standard Deviation MIN: Minimum value MAX: Maximum value

In oral hygiene, the mean obtained for women was 11 (SD ± 2.3) points for the first checkup, 11 (SD ± 2.5) points for the second, and 11 (SD ± 2.2) points for the third. Among men, the mean obtained was 11 (SD ± 2.5) points for the first checkup, 11 (SD ± 2.5) for the second and 12 (SD ± 3.0) for the third (Fig. 1).

Fig. 1: Scores obtained for oral hygiene (checkups 1, 2 and 3) after the application of the satisfaction questionnaire 

The scores obtained for comfort are seen in Fig. 2. The mean for women in the first checkup was 15 (SD ± 3.4) points, 16 (SD ± 2.8) points for the second, and 16 (SD ± 2.9) for the third. For men, the mean result was 14 (SD ± 3.8) points for the first checkup, 17 (SD ± 3.5) points for the second and 17 (SD ± 4.1) for the third.

Fig. 2: Scores obtained for comfort, (checkups 1, 2 and 3) after the application of the satisfaction questionnaire 

For aesthetic self-perception, the scores obtained are shown in Fig. 3. The mean for women in the first checkup was 13 (SD ± 2.7) points, 13 (SD ± 2.0) points for the second, and 14 (SD ± 1.5) for the third. The mean for men in the first checkup was 11 (SD ± 3.4) points, 13 (SD ± 2.5) points for the second, and 13 (SD ± 2.9) for the third.

Fig. 3: Scores obtained for aesthetic self-perception (checkups 1, 2 and 3) after the application of the satisfaction questionnaire 

There were no statistically significant differences (p>0.05) when comparing the total score of the surveys in the various checkups per health center, nor when assessing these results regarding satisfaction.

Discussion

Despite using different methods to assess satisfaction with the use of fixed appliances, the studies conclude that there is an impact on the user’s quality of life right after installation. Therefore, the aim of this study was to assess the level of satisfaction with the use of fixed orthodontic appliances in users attending health centers in Valdivia and Paillaco.

Regarding our results, an increase was found in the average total satisfaction score in all health centers after the checkups. In Paillaco, this increase was 3.3 points, 0.9 points for the public health center in Valdivia and 9.8 points in the private health center in Valdivia. These results suggest that satisfaction with the use of brackets is steady during the treatment or that it increases slightly during this period.

By contrasting these results with those obtained by Gacitúa et al. ¹⁰, who administered the same survey a week and a month after installation and reported a significant increase in satisfaction, greater than 10 points between these two instances, such values cannot be compared with those of this study since the surveys were administered for the first, second and third month after installation. This study showed an increase of 3.15 points between the first and third checkups, which is considerably lower. However, both results show an increase in average satisfaction with the use of fixed appliances.

Regarding oral hygiene, in this study there was no significant increase in the scores, which can be attributed to the fact that clinicians were good motivators and educators, and also because patients understood the instructions given. With fixed orthodontic appliances, maintaining good hygiene and proper plaque removal become more difficult and require more time and frequency of brushing¹⁵, especially at the beginning of the treatment given the malocclusion present. As biofilm elimination is deficient, the prevalence of caries lesions increases as the treatment progresses^16,17, which could lead to a long-term negative effect regarding the degree of satisfaction of users of orthodontic appliances.

A similar trend was found for comfort, with a slight increase in the average score between the first and second checkup, which remained steady for the third, without significant differences between the groups. This means that patients better adapt to and feel more comfortable with the appliance over time. Wu et al.,¹⁸ had similar results, reporting an improvement in this area over time. Although both groups reached a level of satisfaction similar to that of the third checkup, men showed a slight increase in the score for this area, which is consistent with what Krishnan⁷ reports, who states that men might achieve higher levels of satisfaction than women.

The comfort dimension includes topics such as eating, pain, and phonation. Regarding eating, the potential changes experienced by users of fixed orthodontic appliances are widely documented: difficulty when eating and chewing certain types of harder foods⁵, which leads to eating smaller amounts and softer foods ⁶. One of the reasons for this change is the fact that certain foods adhere to the metal brackets, which makes it more difficult to preserve good oral hygiene¹⁵. Despite these difficulties, Johal et al.⁶ describe that as the treatment progresses, patients can adapt and resume their normal eating habits.

Regarding communication, as reported by Villanueva et al.¹⁹, phonation problems decrease considerably on the seventh day after installing the orthodontic appliance. In turn, Khattab et al.²⁰ note that phonation is negatively affected from the time of installation. However, in the following months, the patients did not experience any difficulty speaking or pronouncing words. Additionally, Martínez et al.²¹ indicate that 29.15% of phoneme production and perception is affected a month after installation.

Regarding pain, it increases between 4 and 24 hours after adjusting the fixed appliances, decreasing gradually and returning to normal on the seventh day⁹. These results are similar to those mentioned by Salmassian et al.⁴ regarding the reduction of pain over time.

Marques et al.⁹ state that younger patients have better tolerance to pain and are more adaptable to discomfort with the use of fixed appliances. Krishnan⁷ reached different results: adolescents reported the most pain, unlike preadolescents and adults. In this same study, regarding difference according to sex, women have greater levels of discomfort, ulcers and related pain than men do, while others find no significant differences.

When analyzing aesthetic self-perception, Feldens et al.²² say that one of the reasons to start orthodontic treatment is to improve aesthetics, which was more prevalent among women. This was also observed by Pachêco-Pereira et al.²³, who state that women have higher expectations than men regarding the treatment. This could explain the results of this study, where women’s level of satisfaction does not increase in the first three checkups, compared with men, who do show a slight increase in satisfaction after the second checkup.

This area remains controversial: on the one hand, patients find that using fixed appliances is not aesthetic²⁴, and on the other hand, the presence of brackets has not shown a negative impact on the aesthetic evaluation of the smile in patients with this type of appliance²⁵.

Within the limitations of our study, although the survey used¹⁰ provides a satisfaction questionnaire validated for the use of metal brackets, it has been used in few studies. It is also important to consider that this questionnaire has no cut-off value to determine patient dissatisfaction or satisfaction. Although we took all the necessary measures to avoid information biases, they might still be present.

Future studies could assess satisfaction over longer periods of treatment, in a more heterogeneous population, and consider more variables that differentiate each orthodontic treatment.

In conclusion, the level of satisfaction of users of brackets improves as orthodontic treatment progresses, both in the overall experience and for each area analyzed: oral hygiene, comfort and aesthetic self-perception.