Patient satisfaction after orthodontic treatment : a systematic review

Objetivo: Realizar uma revisão sistemática da literatura sobre os fatores que levam à satisfação ou não do paciente pós-tratamento ortodôntico. Material e Métodos: Esta revisão sistemática foi registrada no PROSPERO (CRD42013004528). Quatro bancos de dados, bem como as listas de referências e citações das publicações incluídas foram pesquisados de acordo com as diretrizes do PRISMA, produzindo 6.387 títulos e resumos. Dois revisores realizaram a coleta de dados independentemente e um terceiro revisor foi incluído, se não houvesse consenso. Resultados: Nove artigos (2.742 participantes) permaneceram após a extração e interpretação dos dados. Um total de 14 resultados foram extraídos dos relatórios e foram agrupados em 4 temas que foram julgados semelhantes: tratamento, estética, função e bem-estar social. Os principais resultados baseados na frequência do tamanho de efeito foram: autopercepção da estética dos dentes (44%); harmonia dos dentes com outras estruturas da face (44%); alinhamento dos dentes anteriores (33%); maior conforto, ausência de dor e melhora na mastigação/ alimentação (33%); bem-estar social (33%); tratamento valeu a pena (33%). Conclusão: Apesar dos poucos trabalhos encontrados e do valor questionável da qualidade de alguns, a evidência aponta que o principal fator que leva à satisfação dos pacientes está relacionado à melhora estética dos próprios dentes. A mastigação, a ausência de dor, o bem-estar social e a maneira como o tratamento foi conduzido foram destacados como razões para a satisfação do paciente pós-tratamento ortodôntico. AbstRAct

and (3) conduct a metasummary of the results found.

Protocol and registration
This systematic review was written in accordance with the items described in the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) and was registered in the International Register of Prospective Systematic Reviews (Prospero), under number CRD42013004528.

Eligibility criteria
The following inclusion criteria were considered: (1) articles that presented the experimental method of a qualitative or opinion survey study; (2) articles that reported the factors related to post orthodontic treatment satisfaction; (3) studies whose subjects were patients with a minimum age of 18 years, who had concluded orthodontic treatment, and (4) studies whose subjects presented with skeletal facial pattern I, II or III.The following exclusion criteria were considered: (1) studies whose research subjects were oral health technicians, doctors, nurses or dental students; (2) patients who had undergone orthognathic surgery.

Literature search
To search for studies, the following electronic databases were consulted: Pubmed, Lilacs, Web of Science and Scopus, without limitation on date, in the English and Portuguese languages.The reference lists of the retrieved studies were searched for additional publications, and the citations were also analyzed using Google Scholar.The authors of included studies were contacted by email for the identification of additional studies.

Search strategy
For the search strategy, the PICO format [25] and the following terms were used: "Patient", "Patients", "Client", "Clients", "After orthodontic

INtRoDuctIoN
T here is a high percentage of individuals with malocclusion who need orthodontic treatment [1][2][3] and the demand for professional help frequently occurs for esthetic reasons, irrespective of the patient's functional and structural conditions [4][5][6].There has been a growing number of professionals in this area, [7,8] and concern about the satisfaction of individuals who will have this treatment performed, or are undergoing it, has become a reason for investigation [9][10][11][12][13][14][15][16].
According to one study, approximately 34% of patients are satisfied with the treatment, 62% are partially satisfied, and 4% are not satisfied with the treatment they received [11].For a good treatment, orthodontists must evaluate the individual as a whole, listen to his/her point of view and concept of esthetics [10,17,18].The risks arising from professional practice have increased over the last few years in some countries such as the United States [19,20] and it is important for all the care relative to a good professional/patient relationship to be taken, before, during and after conclusion of the treatment.The professional's work must be based on ethical principles, and dental schools must include the topic in the curricular proposals, because the professional/patient relationship is one of the factors of success in dental practice [10,20,21].Furthermore, no professional should make promises about treatment, so as not to generate expectations in the patient, which may perhaps not be possible to attain.
Although there are studies that relate orthodontics with facial and oral esthetic aspects, [22][23][24] patient satisfaction has had relatively limited coverage in the literature.Systematic reviews may help to improve the quality of care offered by orthodontists.In this context, the objectives of this study were: (1) to conduct a systematic review of the literature, of qualitative and opinion surveys, (2) ask the question: What are the factors that lead to patient satisfaction as regards the result of orthodontic treatment?therapy", "After orthodontic treatment", "After Orthodontic Therapeutics" and "Post orthodontic treatment", as well as their Mesh and Entry terms (Table 1).The terms related to the type of study of the articles that should be included were not used, because "Qualitative Research" was introduced as a Mesh term by Pubmed, only in the year 2003, and therefore we excluded studies prior to this date, from the study.a third reviewer (USGS) was consulted before a final decision was reached.

Quality assessment
In order to evaluate the quality of the opinion surveys, an adaptation was made of the checklist proposed by Bennett et al. [26], in the article "Reporting guidelines for survey research: an analysis of published guidance and reporting practices".Even articles presenting low quality were included.Later an evaluation was made of the weight of this article.
The quality assessment of included surveys considered the inclusion of the following items: I) research question justification; II) explicit research question; III) clear objectives; IV) description of the methods used to analyze data; V) method used to administer the research instrument (questionnaire); VI) place and date of the study; VII) method described well enough to be replicated; VIII) reliability of evidence; IX) validity of evidence; X) method used to verify data entry; XI) use of codification; XII) sample size calculation; XIII) method for selecting the sample; XIV) description of the study population; xv) description of the research instrument; XVI) description of the research instrument development; xvii) instrument pre-test; XVIII) instrument reliability and validity; xix) scoring method; xx) informed consent obtained; XXI) ethics approval; and XXII) evidence of ethical treatment of research participants; and XXIII) sample representativeness.
The items above were verified and classified as definitely present (yes), partially or unclearly present (not clear), or definitely not present (no).Studies that presented a prevalence of "yes" answers (> 50%) in the quality assessment were deemed to have a low risk of bias, studies that did not clearly present many of the items assessed were classified to have a moderate risk of bias, while studies that presented a prevalence of "no" answers (> 50%) were considered to have a high risk of bias.

Study selection
Two reviewers (LYK and RSST) independently read all retrieved titles, abstracts, and full-text articles.If one assessor regarded a publication as having met the inclusion criteria, the full text was obtained.Abstracts considered as potentially eligible, as well as those that did not supply enough information, were reserved for the assessment of the full-text article.Any differences concerning eligibility after the full text was evaluated were resolved through consensus, and when differences still persisted, Patient satisfaction after orthodontic treatment: a systematic review

Data extraction
Two reviewers (LYK and RSST) independently conducted data extraction.Items of general information were collected from the studies, such as authors and year of publication.The following specific characteristics were collected: objective, study design, place where research was conducted, the intervention, number of participants in the sample, inclusion and exclusion criteria, characteristics of the participants, manner of data collection, data analysis, main outcomes/results and conclusions of authors.
The percentage of participants who contributed to each of the topics was calculated, and the mean was determined for similar responses in each study.After this, the total of similar responses of all the studies was calculated, which was reported as a percentage.

Data analysis
For data analysis, a qualitative metasummary [27] was used, which is an approach directed toward quantitative aggregation of the synthesis of both qualitative and opinion surveys.This involves extraction, grouping and formatting of the results, and calculation of frequency and intensity effect sizes.
After extraction of the results of the studies included, and grouping of the relevant findings, topics were created -concise representations, those broader in scopeeliminating redundancies, however, preserving the complexity of their contents.Whenever possible, examples of citations of participants were extracted.For coding the topics, we used the Software ATLAS.ti7 -Qualitative Data Analysis.
To evaluate the magnitude of the conclusions obtained, the frequency and intensity effect sizes were calculated of themes that had been included by over 25% of the studies.For this purpose, the number of studies that presented a certain therm (minus the results derived from a study with a common base and that would represent a duplication of the same conclusion) was divided by the total number of studies.In addition, by means of percentage, the representativeness of each topic within each study was pointed out.

Results
The search in the electronic databases PubMed, Web of Science, Scopus and Lilacs resulted in 6.387 references.After removal of the duplicates and evaluation of the titles and abstracts, 67 articles were considered potentially eligible.After analysis of the references and citations of complete texts in Google Scholar, another three articles were selected, totaling 70 articles.61 articles were excluded for the following reasons: 23 articles did not present the experimental method of a qualitative or opinion survey; 29 articles presented patients under the age of 18 years; in three articles the research subject was a dental student or health technician/ or other areas of health; four articles did not report patient satisfaction after orthodontic treatment, and the complete texts of two articles were not made available.No article reported on subjects who had been submitted to orthognathic surgery.On conclusion of the evaluation, nine opinion surveys [9,13,15,16,18,[28][29][30][31] fulfilled the inclusion criteria and were included in the systematic review.No qualitative study was found.Figure 1, in a flow diagram, summarizes the process of selection of the articles.
In total, 2.742 individuals participated in the primary studies.The geographic distribution of the place where the studies were conducted was as follows: Germany (1 study), Brazil (3 studies), Holland (1 study), Spain (1 study), Sweden (1 study) and Finland (1 study).There was 1 study that involved Germany and Holland.The studies may be visualized in greater details in Table 2.
Patient satisfaction after orthodontic treatment: a systematic review  With the quality assessment the risk of bias of the studies included was verified.Studies in which there was prevalence of "yes" in the quality evaluation, were considered with low risk of bias.Studies in which many of the items evaluated were not clearly presented, were classified with moderate risk of bias.Studies in which there was prevalence of "no" were classified with high risk of bias. 4 articles were considered with low risk [13,15,16,30], 4 with medium risk [9,28,29,31] and one with high risk of bias [18].After analysis and coding of the 9 articles, two categories of analysis were created: one related to the patient, and the other related to the professional conducts.

Patient Category
In this category, three topics emerged with a set of related sub-topics: -Esthetics: factors related to alignment of anterior teeth, self-perception of the esthetics of teeth and harmony of teeth in relation to other structures of the face.
-Function: absence of pain, oral comfort and improvement in chewing/eating.
-Social well-being: promotion of selfawareness with regard to oral and general health, improvement in body image as a whole, improvement in shyness and satisfaction with general oral health.
As regards esthetics, after conclusion of orthodontic treatment, 44% of the articles developed esthetic self-perception of their teeth, 33% with regard to factors related to tooth alignment and 44% began to compare the harmony of the teeth in relation to other structures of the face.With regard to function, 33% of the articles reported greater comfort, absence of pain and improvement in chewing/ eating.A higher level of social well-being was pointed out by 33% of the articles, and approximately 22% reported orthodontic treatment promoted self-awareness as regards oral and general health, in addition to improving shyness and promoting satisfaction of general oral health.

Professional Category
The topic analyzed in this category was: -Treatment: course of treatment, time necessary for treatment to be adequate, whether treatment was worth it, and whether the patient received attention and care from the orthodontist.
The course of treatment was as expected for 22% of the articles.Adequate time spent on treatment, not very extended or very short, was pointed out as a factor contributing to the satisfaction of 22% of the articles.Over 33% of those involved reported orthodontic treatment was worth it.In addition, 11% reported satisfaction after treatment, when they received attention and care from the orthodontist and his/her team.Table 3 presents the frequency of effect size of each topic found for each category of analysis.
The intensity of effect size was calculated to evaluate the impact of studies and their conclusions on the results of synthesis.The article that presented the highest frequency of intensity; that is, presented the largest number of topics, was the study of Riedmann [28], with over 46%, followed by Maia [15] with 33%, Varela [9] also with 29%, Oliveira; Tavares; Freitas [30] 26%, Njio [13] and Tuominen [18] with 18%, Klages [29] and Berset [31] with 13.3% and Palomares [16] with 6.6%.
Patient satisfaction after orthodontic treatment: a systematic review

DIscussIoN
In qualitative surveys, interviews with open questions are used, within an itinerary that allows a great deal of flexibility, and in which there is a vast possibility of responses.This allows a certain topic to be analyzed in depth.Whereas opinion surveys, because of using closed and more structured questions, allow a less diverse spectrum of responses.Therefore, the first aspect drawing attention in this review is that the production of qualitative surveys seeking to find out the opinion of patients about orthodontic treatment received is limited.On the other hand, despite the final number of opinion surveys having been relatively small, it must be pointed out that the number could have been larger if studies with subjects under the age of 18 years, who had been through some orthodontic experience, had been included.These articles were not included in the study, because this is the age from which the subject has the autonomy to judge the result of his/her treatment.As from this age range, the number of indications for treatment with the use of mobile appliances is lower.
The qualitative survey has been an important complement to quantitative data.Facial beauty is defined to a far larger extent by the set of characteristics rather than harmony among the skeletal parts only, and it does not seem to interest patients that the angles and proportions of their face are within a "pattern of normality", if this pattern does not suit their ethnic and individual characteristics.
Among the topics identified, the factor presenting the highest frequency was esthetics on conclusion of orthodontic treatment.This reflects the increasing esthetic demand among a large portion of individuals who seek orthodontists nowadays [22,32,33].The majority of adults who seek orthodontic treatment for themselves and their children do so for esthetic reasons [32].
A higher level of social well-being was pointed out by 33% of the articles, and approximately 22% reported orthodontic treatment promoted self-awareness as regards oral and general health, in addition to improving their own body image and shyness.From the professional point of view, this is a reflection of good attendance of the patient, so that he/she accepts being submitted to the entire treatment once again, because he/she believes the treatment will bring satisfactory results, and improve his/her general health and social life.According to this thinking, one study showed that over 92% of patients reported that if they were to take the decision once again, they would submit to orthodontic treatment again [4].Birkeland [32], in his study, showed orthodontists play a significant role in the decision about treatment, whether it is by means of the information transmitted, or related to cost-benefit and counseling of the patient.All this reflects a good professional code of ethics.
The article that presented the highest frequency of intensity; that is, presented the largest number of topics, was the study of Riedmann [28].There was significant difference in the frequencies found, however, not every article that presented a high frequency of effect size, presented low risk of bias.This is due to the diversity of topics found and their potential clinical relevance.
All the results of the research showed the importance of knowing about the factors that lead to the satisfaction of patients after orthodontic treatment.This is related to the professional's conduct, which has great influence on the decision to adhere to treatment, and consequently reflects the contribution made by the professional to planning, during treatment and follow-up of the patients, who related great esthetic and/or functional changes due to the use of the corrective orthodontic appliance [10,11,13,20,21].The publication of systematic review studies, as well as others that synthesize research results is an important step towards evidencebased practice.The final aim of this process is to improve the quality of care offered by health professionals.

coNclusIoN
In spite of the few studies and questionable value of quality of some, the evidence points out the main factor that leads to the satisfaction of patients is the improvement in esthetics.By this study, we could also conclude that masticatory function, absence of pain, social well-being and the way treatment was conducted were pointed out as reasons for post orthodontic treatment satisfaction.

Table 1 -
Search strategy in different electronic databases

Table 2 -
Distribution of studies according to gender, age, place where research was conducted *N/I: Not informedFigure 1 -Flow diagram showing Process of study selection.

Studies Sample Size (total) Men Women Age, mean or range Country Index used
(2)z Dent Sci 2017 Apr/Jun;20(2)