Research Article

Patient’s Expectation of Orthodontic Treatment at a

Tertiary Health Facility in Lagos, Nigeria

Dr Oyapero Afolabi,1 Dr Ogunbanjo Ogunbiyi B,2 Dr Adegbite Kikelomo O,3 Dr Ajisafe Olawande A4
1
Consultant, Dept of Community Dentistry, Consultant Orthodontist, 4Senior Registrar
2,3

Dept of Child Dental Health, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria

Correspondence: Dr Oyapero Afolabi Email: [email protected]

ABSTRACT
Introduction: An understanding of the expectations and attitude of patients is a prerequisite for appropriate behavioural and
clinical management.

Objective: To assess patients’ expectations of orthodontic treatment and relationship of gender to this expectation among
Nigerian patients.

Materials & Method: The descriptive study comprised of patients attending the orthodontic clinic at Lagos State University
Teaching Hospital (LASUTH), Nigeria for the first time. A structured questionnaire was used to obtain the socio-demographic
information and responses to questions on their expectation of orthodontic treatment.

Result: Majority of the respondents had higher expectations on aesthetic outcome of orthodontic treatment than the functional
outcomes. They expected to have better smile, teeth straightened and have confidence socially. The lowest mean scores were
obtained in the domains of improvement in career and making speech easier. Females had significant higher scores than male
participants in all domains explored with the mean highest score in the domain of better smiles; while the highest male mean
score was in the domain of straightened teeth.

Conclusion: Orthodontics relies heavily on patient cooperation for a successful end result. It is recommended that the
orthodontist agrees with the patient on realistic expected treatment outcomes before the treatment commences so that they
are not disappointed with the final appearance.

Keywords: malocclusion, orthodontic treatment, patient expectation

INTRODUCTION outcomes have thus become an accepted endpoint in

clinical practice in recent years, as the patient’s experience
Orthodontics is the area of dentistry concerned with the and preference has grown.
supervision, guidance and correction of the growing
dentofacial structures by the application of forces and/or An understanding of patients’ expectations and attitude
the stimulation and redirection of the functional forces within is a prerequisite for appropriate behavioural and clinical
the craniofacial complex. Orthodontic treatment also has a management. Increasingly, patient-centred measures are
significant impact on psychosocial aspect of the patients. It 1 used to assess these subjective attributes in assessing
has been estimated that about 80% of orthodontic patients orthodontic need and in determining the outcomes of
seek treatment out of aesthetic concern rather than the orthodontic care.6-7 Assessment of patients’ expectations
health and function. 2
Patients and their parents expect is central to understanding the oral health needs, patient
orthodontic treatment to result in well-aligned teeth and satisfaction with treatment, and ultimately the perceived
improvement in overall facial appearance.3 They also expect overall quality of health systems.8 To a large extent, patients’
the treatment to improve their dental, and facial aesthetics4 expectation of orthodontic treatment depends on the
and consequently their popularity and social acceptance. In 5 perception of their own dentofacial aesthetics9 and on the
orthodontic treatment planning, a strong focus on normative continuous feedback they receive from their peers. Hence,
assessments and an objective evaluation of the patients’ their decision to seek orthodontic treatment appears to be
treatment needs by established metric standards could lead motivated by social norms and culture in their reference
to an inadvertent overlooking of the patient’s expectations group and the society. Societal standards on facial beauty/
concerning the treatment. Quality of life and patient-oriented appearance and expectations are thus intrinsically linked

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 Afolabi O, Ogunbiyi OB, Kikelomo AO, Olawande AA : Patient’s Expectation of Orthodontic Treatment at a Tertiary Health Facility in Lagos, Nigeria

to the quest for orthodontic treatment and are important The sample size was calculated using the formula for cross
parameters that can determine the success of orthodontic sectional studies: N=Zpq/d2. Using the prevalence of 88% for
treatment.10 expectation improved appearance from orthodontic treatment
from a reference study;16 a sample size of 82 was determined.
The successful outcome of orthodontic treatment requires not
One hundred and four participants were however recruited
only knowledge and technical competence on the part of the
for this study. Subjects who were ≥16 years of age and were
treating orthodontist but also considerable effort on the part attending the orthodontic clinic for the first time were included
of the patient.11 The behaviours expected of a patient such as in the study. Patients who had commenced orthodontic
keeping appointments, maintaining oral hygiene, adhering treatment and those who refused to give their informed consent
to dietary recommendations and wearing appliances may were excluded.
disturb established routine or interfere with social activities.12
Understanding the patient’s expectation can play a key role A structured interviewer-administered questionnaire was
in treatment planning by aiding the dentist to determine how used for data collection. The first part of the questionnaire
realistic the patient’s expectations are and also prepares obtained information on socio-demographic items including
the patients for the intricate aspects of the treatment that gender, age, level of education, as well as dental history.
will require their full cooperation. 13-14
Mismatch between the The second part obtained data on patients’ expectations of
patient’s desire and the service received is connected to orthodontic treatment. A visual analogue scale (VAS) marked
decreased satisfaction with treatment outcome. Patients at 10-mm intervals was used as the Likert response format for all
with inappropriately high expectations may be dissatisfied questions except questions assessing the expected duration of
with the optimal care while those with inappropriately low orthodontic treatment and the frequency of follow-up visits. The
expectations may be satisfied with deficient care. 15 maximum obtainable score for questions with Likert responses
was 10 indicating a high expectation while the lowest score was
Exploration of the expectation of patients about orthodontic 1 indicating a low expectation.
treatment has been reported by some authors but there is
paucity of data about orthodontic patients in Nigeria. The Data was analyzed using SPSS version 18 software. Frequency
objective of the study was to assess patients’ expectations of distribution tables were generated for all variables and
orthodontic treatment and the relationship of gender to this measures of central tendency and dispersion were computed
expectation among Nigerian patients. for numerical variables. Differences and associations were
considered statistically significant where the associated p-values
MATERIALS AND METHOD were ≤0.05.

A cross-sectional study was conducted at the Orthodontic Clinic RESULT

of Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos;
a tertiary care health facility in Nigeria. The study population A total of 104 respondents completed the questionnaire.
consisted of new patients registered at the Orthodontic clinic Majority of the respondents were female and from the Yoruba
of LASUTH. A simple random sampling technique using the tribe. Table 1 describes the ethnic group and gender of the
balloting method was used to determine the study subjects using respondents.
the attendance register for each clinic day as the sampling
Expectations of the respondents at their initial orthodontic
frame. Selected subjects were screened for eligibility by set
appointment
inclusion and exclusion criteria and those who met these criteria
and were willing to give their informed consent were included At the initial appointment, respondents expected
in the study. following commonest procedures: having a check-up and

Table 1: Characteristics of the study sample

Male Female Total
Ethnic Group
N % N % N %

Yoruba 30 28.8 45 42.3 75 72.1

Igbo 14 13.4 11 10.6 25 24.0

Hausa 1 0.9 1 0.9 2 1.9

Others 2 1.9 0 0 2 1.9

Total 47 45.2 57 54.8 104 100

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 Afolabi O, Ogunbiyi OB, Kikelomo AO, Olawande AA : Patient’s Expectation of Orthodontic Treatment at a Tertiary Health Facility in Lagos, Nigeria

Table 2: Expectation of the respondents at their initial orthodontic appointment

Mean values
p-Value
Male Female Total

Expectation at initial appointment

Have braces fitted 6.11 5.40 5.72 0.375

Have check-up and diagnosis 8.23 8.39 8.32 0.776

Have a discussion about treatment 7.89 8.33 8.13 0.438

Have X-rays 6.51 5.16 5.77 0.066

Have impressions 5.38 5.33 5.36 0.946

Have oral hygiene checked 7.23 7.54 7.40 0.626

Type of orthodontic treatment expected

Braces, don’t know what type 6.34 5.88 6.04 0.541

Train track braces 4.45 3.54 3.95 0.187

Teeth extracted 3.91 3.44 3.65 0.515

Jaw surgery 1.68 2.30 2.02 0.201

Perception about orthodontic treatment giving problem/pain. 4.43 2.49 3.37 0.001*

Opinion about wearing braces giving problems 5.00 4.89 4.94 0.882

Problem with orthodontic treatment when eating 5.60 4.56 5.03 0.140

Orthodontic treatment to restrict what you can eat or drink 6.91 5.58 6.18 0.059

Opinion about how people will react to wearing brace 5.40 6.04 5.75 0.341
* Significant at p<0.05

diagnosis (8.32); having a discussion about their treatment though male respondents had higher mean scores in most of
(8.13) and having oral hygiene checked (7.40). Many of the the domains (Table 2).
respondents did not expect any problem or discomfort with the
Expectations on the duration of orthodontic treatment
wearing of braces and this domain was associated with a low
mean score (3.37). The least expected procedures were having
Majority of the respondents (34.6%) did not know the duration
teeth extracted (3.65) and having jaw surgery (2.02). There was
of orthodontic treatment while 15.4% expected the treatment
no significant difference between the mean scores of male
to take less than one year. Only 24% respondents felt that the
and female respondents in almost all domains explored even
treatment will take about 2 years (Figure 1).

Figure 1: Expectation on the duration of orthodontic treatment Figure 2: Expected frequency of Orthodontic review
appointment

40

23.08% 30.77%

30

Don’t know

> once every month

20
Frequency

Once every month

Once every six weeks

10
< once every 2 months
22.12%
16.35%
7.69%
0
Don’t <12 12 18 24 >24
Know

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 Afolabi O, Ogunbiyi OB, Kikelomo AO, Olawande AA : Patient’s Expectation of Orthodontic Treatment at a Tertiary Health Facility in Lagos, Nigeria

Table 3: Expectations on outcome of orthodontic treatment

Mean values
p-Value
Male Female Total

Straighten teeth 7.66 9.11 8.48 0.002*

Create better smile 7.51 9.32 8.50 0.000*

Make it easier to eat 5.87 8.00 7.04 0.001*

Make it easier to speak 5.51 7.91 6.83 0.000*

Make it easier to keep my teeth clean 6.23 7.77 7.08 0.012*

Improve my chance of good career 6.04 7.44 6.81 0.038*

Give confidence socially 6.06 9.19 7.77 0.000*

* * Significant at p<0.05

Expected frequency of orthodontic appointments Females had significant higher scores than male participants
in all domains explored with the highest female mean score
Over 30% of the respondents did not know the frequency of
obtained in the domain of better smiles (9.32); however the
their review appointment once the orthodontic treatment
highest male score was in the domain of straightened teeth
commenced, while 23% expected it to be every 2 months. Only
(7.66) (Table 3).
22% correctly estimated their review to be once every six weeks
(Figure 2). Association between gender and frequency/duration of
orthodontic treatment
Expectations on outcome of orthodontic treatment
There was no significant difference between the responses of
Majority of the respondents had higher expectations on aesthetic
male and female respondents on the expected duration of
outcome of orthodontic treatment than on the functional
Orthodontic treatment and also on the frequency of review
outcomes. They expected to have a better smile (8.50), have
appointments. However, a greater percentage of the male
their teeth straightened (8.40) and have confidence socially
respondents did not know the expected duration of the
(7.77). The lowest mean scores were obtained in the domains of
treatment (Table 4).
improvement in career (6.81) and making speech easier (6.83).

Table 4: Association between gender and frequency/duration of orthodontic treatment

Male Female Total Significance

Don’t know 20(19.2%) 16(15.4%) 36(34.6%)

< 1 year 3(2.8%) 13(12.6%) 16(15.4%)

1 year 3(2.8%) 5(4.8%) 8(7.7%) X2=8.026

How long orthodontic
p-Value=0.155
treatment take 1.5 years 2(1.9%) 4(3.9%) 6(5.8%)

2 years 14(13.5%) 11(10.5%) 25(24.0%)

> 2 years 5(4.9%) 8(17.6%) 13(12.5%)

Don’t know 15(14.4%) 17(16.4%) 32(30.8%)

>once monthly 12(11.5%) 5(4.8%) 17(16.3%)

X2=6.695
How often to attend
Once monthly 2(1.9%) 6(5.8%) 8(7.7%) p-Value=0.153
follow-up
Once every six weeks 9(8.7%) 14(13.4%) 23(22.1%)

≤ Once every two months 9(8.7%) 15(14.4%) 24(23.1%)

Total 47(45.2%) 57(54.8%) 104(100%)

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 Afolabi O, Ogunbiyi OB, Kikelomo AO, Olawande AA : Patient’s Expectation of Orthodontic Treatment at a Tertiary Health Facility in Lagos, Nigeria

DISCUSSION that majority of patients seek treatment to improve their smile

and their facial esthetics.24 People learn the concepts of facial
Malocclusion and dentofacial anomalies can produce immense attractiveness early in life and facial attractiveness is seen as a
physical, social, and psychological distress.17 Appreciation of social asset while lack of appeal is deemed a social liability.25-26
patients’ expectations of the orthodontic treatment and its Furthermore, even though epidemiological studies27 have
effect in quality of life is important. Unrealistic expectations about demonstrated that at least 70-75% of the population could
the orthodontic treatment process can influence treatment benefit from orthodontic treatment for occlusal malrelations,
compliance.18 Majority of the respondents in this study were such functional considerations are not necessarily linked to the
female. Some studies have observed that female adolescents need for treatment as it is perceived by patients. Rather, most
are more critical and anxious about their appearance than people view orthodontics as a means for improving dental-
males.19-20 The societal emphasis on the physical appearance facial appearance.
of females may be responsible for their higher demand for
orthodontic treatment. It has been projected that 80% of orthodontic patients seek
care for aesthetic, rather than for health or functional reasons.
The respondents in this study had realistic expectations about Similarly, psychological factors, rather than the severity of
most of the procedures they are expected to have at their initial malocclusion, decide demand for orthodontic treatment.28
appointment. Most of them expected to have check-up and Functional aspects of malocclusion such as inability to chew
diagnosis, discussion about their treatment and oral hygiene were not significantly associated with the desire for orthodontic
check at their initial appointment. Most of them did not expect treatment.29 It is recommended that the orthodontist agrees
to have an extraction or surgical procedures. with that patient on realistic expected treatment outcomes
before the management commences so that they are not
Similarly, many respondents did not expect any problem or
disappointed with the final appearance.
discomfort with the wearing of braces. In previous studies;
orthodontic patients expressed discomfort as the worst aspect Dental aesthetics was also found to be more important among
of orthodontic treatment, even though they categorized the women than men; and females had significant higher scores
discomfort as mild and of short duration. Orientation on the than male participants in all the domains explored with the
controlled use of painkillers and restriction in the ingestion of highest female mean score obtained in the domain of better
hard food on the days following the activations were enough smiles. This observation has been found to be responsible for lower
to minimize the aforementioned discomfort.21 Patients who are discontinuation rates of treatment for girls.30 The respondents
given adequate information regularly utilise dental services, and did not have a high expectation that orthodontic treatment
have more reasonable expectations of treatment outcomes22 will contribute to an improvement in their chance of a good
and greater satisfaction with the treatment. There is a need to career. This was in agreement with a previous study31 and this
educate patients before they commence the treatment with observation is not surprising since most of the respondents were
the appliances on the discomfort they will likely encounter. adolescents and were not in the employment age bracket.

Only 24% of the respondents had the right expectation about CONCLUSION
the duration of orthodontic treatment and the frequency of
review appointment. Orthodontic treatment relies heavily on Majority of the respondents in this study did not know the

patient cooperation for a successful outcome. The duration duration of orthodontic treatment nor the frequency of their

of treatment which includes the period of retention may thus review appointments. They however had higher expectations

affect the compliance of the patient if he/she is not adequately on the aesthetic outcome of orthodontic treatment than on the

counselled. British Orthodontic Society recommends that functional outcomes. The duration of treatment which includes

patients should obtain adequate information about their the period of retention may affect the compliance of the

proposed treatment, with a truthful estimate of the period patient if he/she is not adequately prepared. It is thus imperative

involved and the retention phase of the treatment. 23 that the patient receives adequate information on these
critical aspects of their treatment. It is also recommended that
Majority of the respondents had higher expectations on the the orthodontist agrees with the patients on realistic expected
aesthetic outcome of orthodontic treatment than on the treatment outcomes before the treatment commences so that
functional outcomes. Most of the participants indicated that they are not disappointed with the final appearance.
they expected orthodontic treatment to produce straighter
teeth, a better smile and a more pleasing social appearance.
OJN
This data was in agreement with previous studies that observed

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 Afolabi O, Ogunbiyi OB, Kikelomo AO, Olawande AA : Patient’s Expectation of Orthodontic Treatment at a Tertiary Health Facility in Lagos, Nigeria

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