Evaluation of Self Contentment with Dental Appearance and Preference to Treatment to Improve Esthetics

Introduction: Oral health not only comprises of mere absence of oral disease and dysfunction but also includes dental appearance for overall facial beauty as it has influence on person’s self confidence and social life. Dental aesthetic comprises of tooth color, shape, alignment and position of the teeth in the dental arches. For the rewarding outcome of the treatment, clinician need to understand the root of dissatisfaction with present aesthetic and desired treatment to enhance the aesthetic that will assist in development of treatment plan. Materials and Methods: Pre-tested structured questionnaire was used in 349 subjects from previous studies with slight modification for data collection. The questionnaire was divided into three parts, first part recorded the demographic data, second part consisted of the patients’ view regarding satisfaction of the dental appearance and third part consist of the Likert scale where participants will rate the satisfaction level regarding their general appearance. Results: A relationship between gender (P<0.05), education (P=0.006) and overall satisfaction of the general appearance of the teeth was seen. Males were found to be more satisfied than females and people with higher education were more satisfied with their general dental appearance.For majority of the participants, choice of treatment to improve the aesthetic was teeth whitening (37.25%) followed by orthodontic treatment (29.80%), then dental crown, veneers (27.29%). The least favoured treatment by the participants is denture (5.16%) to improve the aesthetic. Conclusions: Dissatisfaction with the color, alignment, teeth appearance and condition are the main reasons for the patients to seek aesthetic treatment.


Introduction
I n last few decades people have become more concerned about their dental appearance, aesthetics and smile. Oral health not only comprises of mere absence of oral disease and dysfunction but also includes dental appearance for overall facial beauty as it has infl uence on person's self confi dence and social life. 1 Dental aesthetics plays a major role in overall beauty of the face. 2 The patients seeking treatment to the Prosthodontists and Orthodontists are mainly for the aesthetic purpose. There is remarkable eff ect on perceived oral health related quality of life due to minor inconsistencies in dental esthetics. [3][4][5] Dental aesthetic comprises of tooth colour, shape, alignment and position of the teeth in the dental arches. 2,6-7 These factors are infl uenced by individual's personal choice, socio-demographic factors, cultural background, age, sex and education level. Female are reportedly more concerned about the dental aesthetics compared to male. Concern for dental aesthetics decreases with increase in age and education level. 8 While restoring the dental aesthetics, creating natural appearance is the prime task in all fi eld of dentistry especially for Prosthodontists and restorative dentists. 9 Advancement in technology and development of the dental materials has led to availability of numerous treatment options and excellent result fulfi lling the aesthetic demand of the patients. 10 To fulfi l the aesthetic demand of the patient clinician should have knowledge about the dental aesthetic expectation of the patient. As there may be variation in perception of aesthetics between patient and clinician which could create diff erences during treatment if not properly recognized. 11 Dental professionals should be familiar with the psychological spark of treatment demands, the eff ect of aesthetic treatment in patients' satisfaction, and subsequently the impact of treatment in successful outcome. 12 Patients' demand and preference for the specifi c type of treatment to improve the dental aesthetics are still not studied and explored suffi ciently. Various studies have found varying level of satisfaction among diff erent populations like 79.4% in Nigeria, 13 71.1% in Turkey, 14 67.6% in Jordan, 15 and 69.60% in Iran. 16 Therefore, for the rewarding outcome of the treatment, clinician need to understand the root of dissatisfaction with present aesthetic and desired treatment to enhance the aesthetics which will assist in development of treatment plan. 17 The aim of this study was to evaluate theself contentment with dental appearance and preference to treatment to improve esthetics in the people coming to Devdaha Medical College and Research Institute, Nepal.

Materials and Methods
A descriptive cross-sectional study was conducted on the patients and attendant attending dental OPD of Devdaha Medical College and Research Institute over a period of 10 months (September2019-July2020). The sample size was 384, which was determined using the formula- The participants who were 18 years or older with no history of medical conditions or diseases and received no dental treatment for last six months were included in the study. The study was approved by Institutional Review Committee of Devdaha Medical College and Research Institute. Brief explanation of study was given to each participant and verbal and written consent was obtained before commencing the study.
The pre-tested structured questionnaire was used from previous studies by Tin-Oo et al 7 with slight modifi cation for data collection.
The questionnaire was divided into three parts, fi rst part recorded the demographic details of the participants (name, age, sex, marital status, education), second part recorded participants' view regarding satisfaction of the dental appearance, colour, crowding, teeth alignment, protrusion, caries in front teeth, unaesthetic fi lling, fracture in front teeth and patient's desire to undergo treatment to improve appearance of the teeth and third part consisted of the Likert scale where the participants will rate the satisfaction level regarding general appearance. The questionnaires were administered to the participants and the investigators were available all the time to resolve any queries. The response time to complete the questionnaire was approximately ten minutes. This process continued until the desired sample size was achieved.
After completing the questionnaire, the data was coded, enter into the excel sheet and statistical analysis was done using SPSS version 21. The descriptive statistics (mean, median, standard deviation, frequency, percentage frequency) and chi square test at the signifi cant level of p<0.05 were analyzed. During the data collection phase, participants were ensured about the confi dentiality about their identity and response. The incomplete questionnaires were excluded from the fi nal Performa during the data entry phase that led to total number of participants 349 in the study.

Results
Among Correlation between the satisfaction with dental appearance and the satisfaction with tooth color with demographic variables are depicted in Table 2.
A signifi cant relationship between gender (P<0.05), education (P=0.006) and overall satisfaction of the general appearance of the teeth was seen. Male are more satisfi ed than female with their general appearance of teeth and people with higher education are more satisfi ed. There is also a signifi cant relationship between satisfaction of the teeth color and education level (P<0.05) and age group (P<0.05). Higher the education more satisfaction with the teeth color where as older the age less satisfi ed with the teeth color. Older people have more fracture in their anterior teeth that are statistically signifi cant (P<0.05).
Majority of the participants, choice of treatment to improve the aesthetic is teeth whitening (37.25%) followed by orthodontic treatment (29.80%), then dental crown, veneers (27.29%). The least favored treatment by the participants is denture (5.16%) to improve the aesthetic of their anterior dental aesthetic. In Likert scale ratings, 19.77% were very satisfi ed, 33.52% were satisfi ed, 16.33% were unsure, 24.07% were dissatisfi ed and 6.31% were very dissatisfi ed with their anterior dental aesthetic.

Discussion
For many years function, alleviation of pain and preserving the biology of the teeth were considered to be more important than the aesthetic. However with the time aesthetic has become one of the major concern and the treatment plan, without including aesthetic view of patient, may bring disastrous outcome. 18 The concept of aesthetics and perception towards the dental aesthetics vary from population to population and among the individuals in the population. 8 In this study 52.15% of the participants were satisfi ed with their general teeth appearance, among them 29.51% were male and 22.64% were female. This study is consistent with the study done by Al-Shahrani et al 19 and Al-Omiri et al 5 where females were more dissatisfi ed with their anterior esthetics and contrast to the study done by Afshar et al. 16 Various studies conducted in India(40.9%), 20 Malaysia (47.2%) 7 and Saudi Arabia (50%) 21 of the population satisfi ed with their anterior esthetic which was lower than our study whereas the study done in Turkey (57.3%), 4 Palestine(65%), 22 Jordan(65.5%) 23 and United Kingdom(76%) 24 shows the higher level of satisfaction. This study shows that satisfaction with dental appearance is infl uenced by many factors among which most relevant are personal preference, socioeconomic status and the cultural background.
Tooth colour is one of the prime factors that determined the satisfaction of overall dental appearance. In this study 63.32% of the participants were satisfi ed with their teeth colour which is consistent with the study done by Maghaireh et al 25 27 Higher the education more the satisfaction with the teeth colour may attributed to higher confi dence level and higher selfesteem level. 4,26 Malocclusion has prominent role in the anterior aesthetic. In this study 25.21% of the participants felt their teeth are crowded. This fi nding is similar to that of Tin-Oo (26.4%), 7 Afshar et al (22.9%) 16 and Al-Zarea. 5  The most preferred treatment in this study to improve aesthetics is tooth whitening which is the fi nding similar to the most preferred cosmetic dental treatment in Malaysia and Riyadh. 7,28 This suggests that satisfaction of anterior teeth aesthetics has strong co-relation with teeth color. 5 The second most preferred treatment is orthodontic treatment followed by crown and veneers to improve the aesthetics. The least preferred treatment is denture; this may be lesser subjects in higher age group and preference of fi xed treatment rather than removable prosthesis. In this study satisfaction with the general appearance evaluated by the patient in Likert scale has direct correlation with the satisfaction with the anterior teeth appearance. This result is persistent with the idea that teeth appearance has impact on general appearance 5,24 and contrast to the study where there is no relationship between the general appearance and teeth. 29 Diff erent in sample size, cultural background, personal preference and psychological impact might explain this confl ict in result.

Conclusions
Aesthetics is subjective idea and it is the combination of various qualities. It cannot be defi ned in any one dimension. Tooth shade play major role in the satisfaction with the anterior aesthetics followed by position and alignment of teeth in the arch. Dissatisfaction with the colour, alignment, teeth appearance and condition are the main reason for the patients to seek aesthetic treatment.