June 13, 2022

Orthodontic Experiences and Outcomes: What do our patients think?

We are all aware of the frenetic pace of life and our various commitments and priorities. We must find the time to talk and reflect. Perhaps the rate and focus of orthodontic research is a metaphor for our busy lives? There are lots of journals replete with publications. These papers often focus on our priorities- treatment efficiency and improved outcomes. Rarely do we seem to take stock of the impacts of our treatment on patients. Both in relation to the process of treatment and the outcomes of treatment. As a result, we have less reliable information on this fundamental aspect of orthodontics than perhaps we should.

This systematic review was carried out in New Zealand. The European Journal of Orthodontics published this study.

A qualitative meta-synthesis of research into patients’ past experiences and perceptions of orthodontic treatment outcomes

Hisham Mohammed, Ben K. Daniel, Michael Skilbeck, Reginald Kumar Jr., Jamin B. Halberstadt and Mauro Farella

Eur J. Orthod. 2022. doi: 10.1093/ejo/cjac008

What did they do?

They conducted a qualitative systematic review using meta-ethnography. They wanted identify key themes relating both to orthodontic experiences and outcome from the perspectives of orthodontic patients.

Inclusion Criteria:

The authors included data from primary studies reporting qualitative data from patients who had completed orthodontic treatment.


The authors performed a comprehensive literature search, including five electronic databases. They also searched for unpublished literature. Next, they assessed the quality of the primary studies using the Critical Appraisal Skills Programme (CASP) tool. Finally, they analysed the data using meta-ethnography. This involves seven steps to allow for a synthesis of findings from a range of primary studies.

What did they find?

They included and combined data from six primary studies.  Four were carried out in the UK, one in the USA, and one in Brazil, with adolescents and teenagers interviewed in three and adults in the other three studies. Importantly, they identified several key themes. These were related to past treatment experience, satisfaction with the outcome, and living with retainers. Specific points of interest include:

Treatment Experience:

  • Their relationships with clinical staff influenced their orthodontic experiences. Peer influence was variable.
  • Dietary changes and pain experience were both noted.

Satisfaction with Outcome:

  • They reported positive quality of life changes, improved confidence and self-esteem,
  • Improved appearance was the main driver for treatment and patients saw this as a critical benefit.
  • The patients equated straight teeth to healthy teeth and felt that there oral health had benefited.

Living with Retainers:

  • They reported challenges associated with retainer wear. These included, the need for better education around their importance and the challenge of long-term retainer wear.
What did I think?

I thought that this was an interesting study. Of course, I am biased as I have been involved in qualitative research studies, and I find some genuinely revelatory. The data were largely intuitive. However, it underlined some important aspects of treatment that we should not lose sight of. As is often the case, my enthusiasm is tempered a little by the yield from the review, with relatively few studies being included. Nevertheless, the authors have managed to give us some helpful insight into how our patients view what we do for them.

It was interesting to see that the main perceived benefit of orthodontics was a change in smile aesthetics. There were ‘downstream effects’ of this cosmetic change, including enhancing quality of life and self-esteem. Patients also referred to better function. This may not be consistent with objective findings. Interestingly, the authors linked this to ‘Pygmalion effects’ whereby high treatment expectations may improve performance or perception of performance.

Patients were relatively poorly versed in the need for retention, especially in the long term. As is so often the case, the findings concerning retention raised more questions than were answered.

  • How do we prepare patients better for retention?
  • Can we educate them concerning the long-term implications?
  • How can we reduce the onus on retention many years following completion of active treatment?
What can we conclude?

Orthodontic treatment does entail negative effects in terms of social interaction, pain and dietary implications. However, these impacts seem counterbalanced by the perceived aesthetic benefits allied to related improvements in terms of quality of life and self-confidence. Nevertheless, the impacts of long-term retention are hard to overstate.

In a sense, this study allows us to pause for thought. It also reaffirms that while the treatment process has associated drawbacks, what we do is undoubtedly valued. Some solace as we put our feet up after a busy day….

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Have your say!

  1. Good work by the Kiwis.
    The final sentence of the report affirms the 2nd last paragraph. Patients desire the changes we can make and as a result we have busy days (which we want to put our feet up after …. ). If it were not the case we should not be busy.
    Defining and approaching treatment objectives is helpful in producing results worth retaining and worthy of our patients valuing our efforts and skills.

  2. In 2012, our 6 year old daughter’s paediatric dentist referred her to an orthodontist, who was going to do expansion and fixed appliances. When our family saw a presentation by a wildlife biologist on how squirrels hold a ROUND ACORN with BOTH HANDS to chew through the shell and protein TO ALIGN THE CONSTANTLY ERUPTING INCISORS, we decided to put her on a different path. Instead of going to the orthodontist, she SQUATTED LIKE A SQUIRREL, AND CHEWED A PROPORTIONATELY SIZED, ROUND APPLE BY HOLDING IT WITH BOTH HANDS like a squirrel-she enjoyed laughing about it-it was cute and funny. She chewed every day like a squirrel, evenly from the left, center and right sides, and after 8 months her overbite and overjet started to align normally like the squirrel, and her inter-molar width increased with More forward and width space for her tongue. Also-perfect posture.


  3. Interesting comment and observations about the Apple chewing! :
    In our valley of third generation of Orchard Growers, all of the kids, parents, grandparents, whether biological, adopted, or immigrants of various ethnic, genetic origins, Grow up among the rows of fruit trees, constantly Eating Apples and other Round Fruit with their Hands, outdoors in the fresh air without a fork or knife, from toddler to senior. They all have the most naturally, perfectly aligned, broad smiles and teeth without any intervention.

    It must be the Round Surface that aligns the teeth. And, it makes sense that cutting an Apple into a wedge shape for a child would wedge apart teeth that do not yet have any adjacent teeth to buttress. Chewing with only the dominant hand on the same side would align and stimulate only that side to grow bone, while ignoring the other side, allowing chaotic eruption of teeth with less bone, and more BAD OCCLUSION.

    Where are the clinical studies of chewing methods for stimulating better arch growth and alignment? Any profession that ignores the obvious, and does not study it to make sound recommendations for all of humanity, has its priorities backwards in favor of reacting with invasive appliances instead of preventing with natural food chewing.

    ALL methods for preventing bad bites and undergrown arches must be made available and shared with the public- and certainly, there is no harm in chewing a healthy, round apple, so there is no harm, and everything to gain from recommending it for children. It’s better to get them addicted to apple chewing everyday than junk food, obesity diets.


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