Self-Perception of Brazilian Adolescents who need Orthodontic Treatment

Objective: To evaluate the self-perception of adolescents regarding the need to undergo orthodontic treatment. Material and Methods: It was performed a cross-sectional study. The sample (n = 200) was composed of adolescents aged 11 to 18 years, of both sexes, divided into 2 groups (G1 – in treatment group, G2 beginner group). A structured questionnaire was divided into three categories for data collection: teeth, face, and symptomatology. Considering the age group, data were tabulated and the first measures of central tendency and dispersion (mean, median, standard deviation, minimum value and maximum value), frequencies, and percentages for other variables were calculated. Student’s t-test, Chi-square test, Fisher’s exact were used to compare the groups for the age group and other variables at a 5% significance level. Results: The mean age was 15.47 (SD = 1.56) years, 59% of the individuals were women. The main reason for deciding to wear orthodontic appliances was due to necessity and malpositioned teeth (94.5%) and for other reasons (5.5%), with no significant difference between G1 and G2 groups (p>0.05); 20.5% wanted their front teeth to be longer/shorter, and 18.5% wanted their upper teeth to be moved forward/backward. There was no significant difference between the groups in the categories "what would you like to change in your appearance" and "pain and discomfort" (p<0.05). Conclusion: Esthetics related to dental positioning of the upper incisors greatly influenced motivation of the adolescents to seek orthodontic treatment. Skeletal anomalies and pain symptomatology had little influence on the adolescent perception.


Introduction
The perception of facial appearance plays a fundamental role in the assessment of personal attractiveness and development of the individuals' self-esteem, greatly affecting mental health and social behavior, with significant implications in the areas of education, professional and personal life.
Studies have shown that the perception of one's appearance involves several aspects that are not always related to the actual intensity of facial deformity or severity of malocclusion [1,2].
Two key factors seem to strongly influence the decision of adolescents to undergo orthodontic treatment.The first one is related to fashion and socializing with friends, and the second to patient motivation, which is closely related to the patients' perception of their own esthetic appearance, more frequently affecting women [3,4].Other studies have observed that approximately 70% of patients acknowledge feeling discomfort regarding their own appearance, of which 30% of dissatisfaction causes great insecurity and evident disadvantages in social life [5][6][7].
Data from the National Epidemiological Survey (SB Brazil, 2010) pointed out that occlusion problems affect 38.8% of the adolescents aged 12.Of these, 19.9% of the problems are mild.However, 19.0% have severe or very severe malocclusion, conditions that require immediate treatment and are a priority in public health programs [1].
The commitment of orthodontists or general practitioners is of paramount importance during the first consultation to understand patients' expectations regarding treatment and adapt them to real therapeutic possibilities.It was found that 70% of patients in treatment were satisfied with the results and said to be well informed about the treatment they were undergoing [8][9][10].
The time spent to understand the patients' true interests should be valued, and it is extremely important to explain the objectives, possibilities and limitations of orthodontic treatment [11].The best way to gain trust and obtain patient cooperation is by giving importance to interpersonal relationships and, consequently, investing in the professional-patient relationship [12][13][14].
Thus, the self-perception of adolescents in relation to orthodontic treatment may facilitate the planning and the choice of the best orthodontic mechanics for this age group.Thus, the purpose of this study was to evaluate the self-perception of adolescents regarding the need for orthodontic treatment.

Study Design
The research was a cross-sectional, quantitative, descriptivea and epidemiological study.The study was conducted in the municipality of Irecê, Bahia, 478 km from the city of Salvador, with a population of 73,380 inhabitants, HDI 0.691, and a GDP of 832,726,000.07[15].

Sampling
The convenience sample consisted of 200 patients aged 11-18 years from a private orthodontic clinic who met the inclusion criteria and were divided into two groups: patients undergoing treatment (G1) and those who were undergoing clinical assessment for orthodontic treatment (G2).The inclusion criteria of the study were as follows: no previous orthodontic treatment, random choice of the establishment for treatment, without referral from another professional.

Data Collection
Data collection was performed using the questionnaire proposed by Arnett and Worley [12] that contains a list of conditions so that patients can identify their complaints.The items of the questionnaire were divided into 3 categories: 1) teeth, 2) face, and 3) symptoms.According to the authors, adolescents seeking orthodontic treatment generally desire changes in one of these categories.
The questionnaire was self-administered and groups G1 and G2 answered it without the interference of the professional, allowing them to identify their complaints and specify which category troubled them more, thus assessing how adolescents observed facial and dental abnormalities.The questionnaires were applied during patient consultation, and the collection was held from August to October 2016.

Data Analysis
The measures of central tendency and dispersion for age (mean, median, standard deviation, minimum and maximum values) and the frequencies and percentages for the other variables were calculated.Student's t-test was used to compare the groups regarding age and the Chi-square or Fisher's exact test for the other variables.The level of significance was 5% for all applied tests.All analyses were conducted using R software, version 3.2.2(www.r-project.org).

Ethical Aspects
The study was approved by the Research Ethics Committee of São Leopoldo Mandic (Protocol No. 1612085).All participants signed the informed consent term.

Results
Table 1 shows the results for age and gender.The mean age of the sample was 15.47 years (SD = 1.56), minimum value of 11 and maximum of 18 years, and 59% of the sample was women.
There was no significant association (p>0.05) for the variables age and gender between those beginning treatment (G1) and those undergoing treatment (G2).
When asked about the main reason for deciding to wear orthodontic appliances, no participants answered because it was due to fashion or because friends wore them.Of the total sample, 94.5% answered that it was due to necessity, due to malpositioned teeth, and 5.5% answered that it was for other reasons, and there was no significant difference between those at the beginning of treatment those undergoing treatment (p>0.05), as shown in Table 2.  Most adolescents (88%) indicated that they wanted to correct their upper/lower front teeth, 81.5% of adolescents wanted to correct their upper teeth and 35.5% their lower teeth (Table 4).Of the total, 20.5% wanted their front teeth to be longer/shorter, and 18.5% wanted to move their upper teeth forward/backward, as shown in Table 3.As for what they wanted to change in their appearance, 26% pointed out that they wanted their cheeks to be bigger/smaller, 20% wanted a longer/shorter nose profile and 10% wanted their upper lip to be moved forward/backward.Among those who were beginning treatment, 14.3% wanted their lips to be closer/farther apart when teeth were touching, and among those undergoing treatment, 4.6% gave the same answer (p<0.05), as shown in Table 4.Of the total number of participants in the beginner group, 22% felt pain or discomfort in front of the ears, whereas in the group undergoing treatment this percentage was significantly lower (10.1%;p<0.05).Of the total sample, 64% felt tooth pain, with no significant difference between the groups (p>0.05).In the group undergoing treatment, 7.3% felt pain in the maxillary sinuses, whereas in the beginner group no participants chose this alternative (p<0.05)(Table 5).

Discussion
Collaboration of adolescents is difficult before orthodontic treatment and understanding how they perceive the use of the orthodontic appliance is a challenge for the orthodontist.
Corroborating the findings in the literature that show that women are more interested and willing to undergo orthodontic treatment, there were more women in this study than men [2,16].
The fewer number of men in the sample may be related to their lower demands regarding their own image, but also because they are less willing to comply with treatment rules.
Research indicates [3,17,18] that 40% of patients report being uncomfortable with malocclusion and 93% sought treatment mainly for esthetic reasons.Other reasons for treatment were related to masticatory difficulties, joint problems (11%), and speech difficulties (7%).In the present study, corroborating other studies [4,5,13], 94.5% of the patients perceived a need for esthetic but 22% felt a need to seek orthodontic treatment due to joint pain.
The perception of skeletal anomalies was of little importance in the sample studied, an average of 5%, which is in agreement with the results found in the literature that reveal that patients can cope well with serious anomalies feel extremely uncomfortable with minor problems such as malpositioned teeth or even small diastemas [9,19].
The perception of the study of adolescent patients who had severe discrepancies and surgical necessity realized that they were not interested in orthodontic treatment.Thus, it was concluded that the perceived low need was because these problems did not interfere directly in the facial aesthetics of adolescents.Considering that the perception about the characteristics of the dental aesthetic is significantly greater and that most of the adolescents who participated in this study valued the alterations of the upper and lower incisors, they questioned whether the patient's perception should be valued or not, thus changing the proposed treatment by the professional to be in tune with the patient's desire for change [16].
The greatest challenge for the orthodontist today is to accept the patient's main complaint as the most important factor that must be corrected.These factors should be found subjectively, and the professional should not only rely on diagnosis of cephalometric analyses and models or facial analyses [6,7,20,21].The use of cephalometry is essential for orthodontic planning and it is one of the determining factors for diagnosis.However, when orthodontists solely rely on this resource, it might prevent them from critically analyzing the case using visual evidence provided by clinical examination.The data showed that the perception of adolescents of their orthodontic problem is in agreement with this thought.
Morphological and clinical analyses are influenced by subjective personal preferences of each professional, placing less value on the adolescents' perceptions, increasing the chances of planning a treatment that will not be well accepted by the patient [8,10,14].These findings corroborate the results found in this study in which the adolescents stated that the decision to wear orthodontic appliances was due to necessity and malpositioned teeth.Therefore, the professional should take into consideration the concept of flexibility regarding facial and dental harmony, prioritize the patient's complaint and accept non-intervention in cases of correctable deviations, provided they are in accordance with adequate physiological occlusion and function, and occlusal and periodontal health [22][23][24].
Although 64% of the sample in this study complained of painful dental symptomatology, the number of individuals who mentioned some kind of pain was 47%.However, we cannot assure that pain was related to dental problems, but the results show how discomfort stimulates action toward seeking some type of treatment that can promote symptom relief [2,19,21].
The interest for public and/or private orthodontic treatment has increased over the last decades due to the need to correct malocclusion and esthetic demands of society.Professionals must understand the personal psychology of each patient by customizing treatment, explaining the limitations inherent to treatment, and valuing patients' reasons and complaints.
Although these results provide an overview of trends in esthetic perception and need for orthodontic treatment in the adolescent population, the limitation of the study was that the study population of sample was restricted to private practice.Another limitation was the cross-sectional design of the study that it makes it difficult to detect causality that leads to the problem.Thus, further studies including an adolescent population from different locations would provide a more significant representation of the adolescents' perception concerning their oral problems.The use of subjective indicators can contribute to the orthodontic treatment planning for adolescents in public and private health sectors [24,25].

Conclusion
Adolescents perceived that orthodontic treatment is a necessity and not a momentary fashion, and the main reason that led them to seek orthodontic treatment was esthetics related to the anterior teeth, with little perception of skeletal anomalies.