Patients’ satisfaction with dental esthetics

Gili R. Samorodnitzky-Naveh, Selly B. Geiger

and Liran Levin
J Am Dent Assoc 2007;138;805-808

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R E S E A R C H

Patients’ satisfaction with dental esthetics

Gili R. Samorodnitzky-Naveh, DMD; Selly B. Geiger, DMD; Liran Levin, DMD

ntil recently, restorative

U
D
dentistry considered
mostly functional
ABSTRACT ✷
J
A A

✷
®
demands (for example,

N
Background. Esthetics has become an important

CON
repairing the destructive

IO
issue in modern society, as it seems to define one’s

T
effects of dental caries). However,

A
N

I
character. In the past, functional demands were the U C

with the decrease in caries preva- A ING EDU 4

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main consideration in dental treatment. Today, with RT
lence,1-3 the focus has shifted gradu- ICLE
the decrease in caries prevalence, the focus has shifted
ally from functional dentistry per se
toward dental esthetics. The authors conducted a study to evaluate the
to esthetic dentistry. As a result,
factors influencing patients’ satisfaction with their dental appearance
the perception of tooth appearance
and with the results of esthetic treatment.
in modern society could influence
Methods. The authors surveyed a population of 407 adults (mean age,
the changes in patients’ needs.4
21 years). They distributed a questionnaire regarding satisfaction with
Several authors have reported
current dental esthetics and previous esthetic treatments.
discrepancies between the treat-
Results. Of the 407 subjects, 152 (37.3 percent) were dissatisfied with
ment needs perceived by patients
their dental appearance. Tooth color was the primary reason for dissatis-
and those assessed by dental profes-
faction (133 [89.3 percent] of 149 subjects), followed by poor tooth align-
sionals.5-9 Osterberg and colleagues10
ment (36 [23.7 percent] of 152 subjects), although 110 (27 percent) of the
reported that esthetic rather than
407 subjects had received orthodontic treatment. The authors found no
functional factors determine a
correlation between patients’ satisfaction with their dental appearance
patient’s subjective need to replace
and having undergone any procedure to whiten their teeth. Nevertheless,
missing teeth. Many patients find
134 (88.2 percent) of the dissatisfied subjects reported that they would
the six anterior teeth indispensable
like to undergo this procedure.
but will accept edentulous spaces in
Conclusions. Tooth color was a major factor with regard to dental
posterior regions.11-17 In our beauty-
esthetics. Most subjects were interested in improving their appearance
conscious society, a smile has great
and whitening their teeth.
impact. When a patient’s smile is
Clinical Implications. When planning treatment, dentists should
destroyed by dental disease, the
take into consideration esthetic objectives in addition to function, struc-
result often is loss of self-esteem
ture and biology. This requires the clinician to rely on several disciplines
and damage to his or her overall
in dentistry to deliver the highest level of dental care, which should lead
physical and mental health.18
to a higher level of patient satisfaction.
Because most areas of dentistry
Key Words. Esthetics; tooth whitening; tooth fracture; orthodontic
deal increasingly with esthetics, we
treatment; caries.
conducted this study to evaluate the
JADA 2007;138(6):805-8.
factors that influence patients’ sat-
isfaction with dental esthetics and
the impact of basic dental treat- Dr. Samorodnitzky-Naveh is a clinical instructor, Department of Oral Rehabilitation, The Maurice and
ments on their satisfaction with Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Israel, and Medical Corps, Israel
their dental appearance. Defense Forces.
Dr. Geiger is a lecturer, Department of Oral Rehabilitation, The Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Israel.
SUBJECTS, MATERIALS Dr. Levin is a clinical instructor, Department of Oral Rehabilitation, The Maurice and Gabriela Gold-
AND METHODS schleger School of Dental Medicine, Tel Aviv University, Israel, and Unit of Periodontology, Department
of Oral and Dental Sciences, Rambam Medical Center, Haifa, Israel. Address reprint requests to Dr.
The study population consisted of Levin, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv,
407 adults (242 men [59.4 percent], Israel 69978, e-mail “liranl@post.tau.ac.il”.

JADA, Vol. 138 http://jada.ada.org June 2007 805

Copyright ©2007 American Dental Association. All rights reserved.
R E S E A R C H

TABLE 1 esthetic treatments such as orthodontic

Subjects’ self-reported estimation of tooth treatment, tooth whitening and ante-
appearance. rior restorations. The survey also asked
patients to report impairments in tooth
QUESTION PERCENTAGE OF SUBJECTS (N = 407) appearance (for example, crowding,
Yes No dental caries, restorations, malalign-
Are you satisfied with your 62.7 37.3 ment, tooth fractures). To ensure
tooth appearance? anonymity, the clinic staff did not
Are you satisfied with your 43.0 57.0 record subjects’ names on the question-
tooth color? naires. All subjects answered the ques-
Do you feel your teeth are 18.8 81.2 tionnaire (for a 100 percent response
crowded? rate).
Do you feel your teeth are 23.2 76.8 We collected and analyzed the data
poorly aligned? by using statistical software (SPSS ver-
Do you feel your teeth are 16.4 83.6 sion 11.0, SPSS, Chicago).
protruding?

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RESULTS
Do you suffer from dental 22.8 77.2
caries in your anterior As shown in Table 1, more than 60 per-
teeth?
cent of subjects were satisfied overall
Do you have nonesthetic 15.0 85.0 with their dental appearance. Never-
restorations in your anterior
teeth? theless, only 175 subjects (43 percent)
were satisfied with their tooth color.
Do you have fractures in 19.7 80.3
your anterior teeth? Table 1 also shows subjects’ responses
with regard to specific esthetic con-
Are you hiding your teeth 13.8 86.2
while smiling? cerns, such as tooth malalignment.
Among the 152 subjects (37.3 percent)
TABLE 2 who were dissatisfied with their dental
appearance, 133 (89.3 percent) of 149
Subjects’ self-reported previous esthetic reported that tooth color was the
dental treatments. reason. Women were more satisfied
PREVIOUS TREATMENT PERCENTAGE OF SUBJECTS (N = 407) than men with their general tooth
Yes No
appearance (65.4 percent versus 59.8
percent, respectively; P = .04). More
Orthodontic Treatment 27.0 73.0
men than women reported having frac-
Tooth Whitening 13.1 86.9 tured anterior teeth (21.9 percent
Crowns on Anterior Teeth 9.9 90.1 versus 15.7 percent, respectively;
P = .03). Overall, 56 subjects (13.8 per-
Anterior Tooth Implant 3.9 96.1
cent) reported that they hid their teeth
Root Canal Treatment in 15.2 84.8 when smiling.
Anterior Teeth
Table 2 shows subjects’ previous
esthetic dental treatments. One hun-
165 women [40.5 percent]), 18 through 26 years of dred ten subjects (27 percent) reported having
age (mean [± standard deviation] age, 21 ± 3.5 received orthodontic treatment, with more women
years), who had appointments at a military than men reporting that they received this treat-
dental clinic. There was no common background ment (36.5 percent versus 19.6 percent; P < .001).
regarding place of birth, education or socioeco- Thirty-six (23.7 percent) of the 152 subjects who
nomic setting. The Ethics Committee of the were dissatisfied with their dental appearance
Medical Corps, Israel Defense Forces, approved reported being dissatisfied with the alignment of
the study. their teeth (26 of these subjects reported having
The survey addressed patients’ satisfaction received orthodontic treatment). More women
with regard to dental esthetics issues, such as than men reported that they had undergone tooth
satisfaction with tooth appearance, color and whitening (17 percent versus 11.2 percent, respec-
alignment, as well as satisfaction with previous tively; P < .03). When asked about dental treat-

806 JADA, Vol. 138 http://jada.ada.org June 2007

Copyright ©2007 American Dental Association. All rights reserved.
 R E S E A R C H

ments they would like to receive (Table TABLE 3

3), most subjects were interested in Subjects’ desired esthetic dental treatments.
improving their tooth appearance and
TREATMENT PERCENTAGE OF SUBJECTS (N = 407)
in whitening their teeth. Of the sub-
jects who reported being dissatisfied Yes No
with the general appearance of their Improvement in Tooth 77.4 22.6
teeth, 88.2 percent said they would like Appearance (General)

to have their teeth whitened. Tooth Whitening 81.8 18.2

Stepwise logistic regression revealed
Teeth Alignment 31.5 68.4
that subjects’ general dissatisfaction
with the appearance of their teeth was Crowns on Anterior Teeth 13 87

influenced mostly by tooth color (odds

ratio = 13.1; P < .001), followed by TABLE 4
self-reported poorly aligned teeth,
hiding teeth when smiling and self-
Factors influencing general dissatisfaction
reported caries in anterior teeth (Table with tooth appearance.

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4). We should point out, however, that FACTOR ODDS RATIO P VALUE
hiding teeth when smiling is a reflec-
Are you satisfied with your tooth 13.1 < .001
tion of dissatisfaction, not a cause of it. color? (Answered “No”)

DISCUSSION Do you feel your teeth are poorly 6.5 < .001
aligned? (Answered “Yes”)
Esthetics has become an important
Are you hiding your teeth while 3.2 .003
aspect of dentistry. Until about the last smiling? (Answered “Yes”)*
two decades, clinicians considered
Do you suffer from dental caries in 2 .03
esthetics to be far less important than your anterior teeth? (Answered “Yes”)
function, structure and biology. Today,
* Hiding teeth while smiling is a reflection of dissatisfaction, not a cause of it.
however, if a treatment plan does not
include a clear view of its esthetic
impact on the patient, the outcome could be disas- was influenced mainly by tooth color.
trous.4 Clinicians should begin a treatment plan We found that women were more satisfied with
with well-defined esthetic objectives, and they the general appearance of their teeth than were
then should consider the impact of the planned men. In a survey of attitudes regarding dental
treatment on function, structure and biology. esthetics, Vallittu and colleagues27 found that
Such planning requires the clinician to rely on tooth appearance was more important to women
several disciplines (such as prosthodontics, peri- than to men. We should point out, however, that
odontics and orthodontics) to deliver the highest our cohort consisted of more men than women
level of dental care to the patient. because of the military setting of the study.
The main objective of our study was to report We conducted this study in a young cohort
patients’ esthetic perceptions of their teeth. Dif- (mean age, 21 years) of subjects who arrived at
ferences in esthetic perceptions among dentists, the dental clinic for a scheduled meeting. We can
dental students and laypeople have been exam- assume that most of the subjects had received
ined in the literature. Generally, studies have dental treatment in the past. This might have
found that dentists are more sensitive with contributed to the discrepancy we found between
regard to identifying deviations from the so-called overall satisfaction with tooth appearance (62.7
ideal appearance than are laypeople.9,19-24 percent) and satisfaction with tooth color (43 per-
Carlsson and colleagues25 and Wagner and col- cent). Nevertheless, 13.8 percent of subjects
leagues26 found that people who were not dentists reported that they hid their teeth when smiling.
had a stronger preference for white teeth than did A major goal of dental treatment should be to re-
dentists. In addition, Vallittu and colleagues27 establish esthetics and enable patients to feel con-
reported that various groups of patients had dif- fident about smiling without having to hide their
ferent attitudes toward the appearance of their teeth. (However, it is possible that some patients
teeth. In our study, subjects’ self-reported satis- may be overly sensitive about the appearance of
faction with the general appearance of their teeth their teeth and do not need whitening or other

JADA, Vol. 138 http://jada.ada.org June 2007 807

Copyright ©2007 American Dental Association. All rights reserved.
R E S E A R C H
esthetic treatments.)
Tooth whitening was the most desirable treat-
ment reported by subjects in this study. This is a
simple and safe procedure. Because of the
increasing demand for improved esthetics, den-
tists should consider the procedure in patients’
overall treatment plans.
CONCLUSIONS
Subjects in this study considered tooth color to be
a major factor with regard to dental esthetics.
Most subjects reported that they were interested
in improving their tooth appearance and
whitening their teeth. Their general satisfaction
with tooth appearance was influenced mainly by
tooth color, followed by self-reported malaligned
teeth, hiding teeth when smiling and self-
reported caries in anterior teeth.
When planning treatment, dentists should con-
sider, along with the patient, esthetic objectives
in addition to function, structure and biology.
This requires the clinician to rely on several disci-
plines in dentistry to deliver the highest level of
dental care, which can lead to a higher level of
patient satisfaction. ■
1. Beltran-Aguilar ED, Barker LK, Canto MT, 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.
2. Levin L, Shenkman A. The relationship between dental caries
status and oral health attitudes and behavior in young Israeli adults. J
Dent Educ 2004;68(11):1185-91.
3. Samorodnitzky GR, Levin L. Self-assessed dental status, oral
behavior, DMF, and dental anxiety. J Dent Educ 2005;69(12):1385-9.
4. Spear FM, Kokich VG, Mathews DP. Interdisciplinary manage-
ment of anterior dental esthetics. JADA 2006;137(2):160-9.
5. Smith JM, Sheiham A. Dental treatment needs and demands of an
elderly population in England. Community Dent Oral Epidemiol
1980;8(7):360-4.
6. Palmqvist S, Soderfeldt B, Arnbjerg D. Self-assessment of dental
conditions: validity of a questionnaire. Community Dent Oral
Epidemiol 1991;19(5):249-51.
7. Vigild M. Denture status and need for prosthodontic treatment
among institutionalized elderly in Denmark. Community Dent Oral
808 JADA, Vol. 138 http://jada.ada.org June 2007
Copyright ©2007 American Dental Association. All rights reserved.
Epidemiol 1987;15(3):128-33.
8. Locker D, Slade G. Association between clinical and subjective
indicators of oral health status in an older adult population. Gerodon-
tology 1994;11(12):108-14.
9. Goldstein RE. Study of need for esthetics in dentistry. J Prosthet
Dent 1969;21(6):589-98.
10. Osterberg T, Hedegard B, Sater G. Variation in dental health in
70-year old men and women in Goteborg, Sweden: a cross-sectional epi-
demiological study including longitudinal and cohort effects. Swed
Dent J 1984;8(1):29-48.
11. Bjorn AL, Owall B. Partial edentulism and its prosthetic treat-
ment: a frequency study within a Swedish population. Swed Dent J
1979;3(1):15-25.
12. Tervonen T, Knuuttila M. Awareness of dental disorders and dis-
crepancy between ‘objective’ and ‘subjective’ dental treatment needs.
Community Dent Oral Epidemiol 1988;16(6):345-8.
13. Liedberg B, Norlen P, Owall B. Teeth, tooth spaces, and pros-
thetic appliances in elderly men in Malmo, Sweden. Community Dent
Oral Epidemiol 1991;19(3):164-8.
14. Schuurs AH, Duivenvoorden HJ, Thoden van Velzen SK, Verhage
F, Makkes PC. Value of the teeth. Community Dent Oral Epidemiol
1990;18(1):22-6.
15. Tervonen T. Condition of prosthetic constructions and subjective
Downloaded from jada.ada.org on December 18, 2010
needs for replacing teeth in a Finnish adult population. J Oral Rehabil
1988;15(5):505-13.
16. Owall BE, Taylor RL. A survey of dentitions and removable par-
tial dentures constructed for patients in North America. J Prosthet
Dent 1989;61(4):465-70.
17. Akeel R. Attitudes of Saudi male patients toward the replacement
of teeth. J Prosthet Dent 2003;90(6):571-7.
18. Ingber FK. You are never fully dressed without a smile. J Esthet
Restor Dent 2006;18(2):59-60.
19. Cochrane SM, Cunningham SJ, Hunt NP. A comparison of the
perception of facial profile by the general public and 3 groups of clini-
cians. Int J Adult Orthodon Orthognath Surg 1999;14(4):291-5.
20. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception
of dentists and lay people to altered dental esthetics. J Esthet Dent
1999;11(6):311-24.
21. Kerr WJ, O’Donnell JM. Panel perception of facial attractiveness.
Br J Orthod 1990;17(4):299-304.
22. Beyer JW, Lindauer SJ. Evaluation of dental midline position.
Semin Orthod 1998;4(3):146-52.
23. Brisman AS. Esthetics: a comparison of dentists’ and patients’
concepts. JADA 1980;100(3):345-52.
24. Shulman JD, Maupome G, Clark DC, Levy SM. Perceptions of
desirable tooth color among parents, dentists and children. JADA
2004;135(5):595-604.
25. Carlsson GE, Wagner IV, Odman P, et al. An international com-
parative multicenter study of assessment of dental appearance using
computer-aided image manipulation. Int J Prosthodont 1998;11(3):
246-54.
26. Wagner IV, Carlsson GE, Ekstrand K, Odman P, Schneider N. A
comparative study of assessment of dental appearance of dentists,
dental technicians, and laymen using computer-aided image manipula-
tion. J Esthet Dent 1996;8(5):199-205.
27. Vallittu PK, Vallittu AS, Lassila VP. Dental aesthetics: a survey
of attitudes in different groups of patients. J Dent 1996;24(5):335-8.