The increase in average life expectancy and national income has led to an increase in the number of middle-aged or old adult patients receiving orthodontic treatment.1 Traditionally, the “so-called” adult orthodontic treatment has implied the treatment of adult patients in their 20s and early 30s, rather than adolescents. This notion of “adult patients” has been gradually changing to include middle-aged or old adult patients.23 These changes have been reported worldwide.456 The main reasons behind this change in perception are the improved capacity of the profession to treat problems and the patients' desire to maintain their natural teeth and improve their function as well as appearance.7

Middle-aged and old adult patients are more likely to have periodontal problems, as well as bone turnover rates and psychological profiles that differ from younger patients.89101112 Information about the limitations and possibilities of orthodontic treatment, which may differ from those of younger patients, should be provided to these patients. This, in turn, requires accurate estimation of the patients' perceptions toward treatment. Therefore, it is necessary to investigate the motivation of patients for seeking orthodontic treatment and to analyze the barriers preventing them from starting orthodontic treatment according to different age groups. However, few studies have investigated the perceptions toward and demand for orthodontic treatment among middle-aged adult patients in Korea.131415

The rate of starting orthodontic treatment may be decided not only by the severity or prevalence of malocclusion, but also by other background factors, such as age, sex, and socioeconomic status.16171819 It would be intriguing to analyze the influence of background factors, such as age, sex, and area of living, on the perceptions toward orthodontic treatment. Therefore, this questionnaire study aimed to assess the overall frequencies of positive perception towards orthodontic treatment among adults categorized according to age, sex, and area of living, and to identify barriers or negative perceptions preventing them from receiving orthodontic treatment.

Among the 598 participants, 368 (61.5%) were women and 230 (38.5%) were men. The percentage of participants in their 20s, 30s, 40s, and 50s was 22.7%, 16.1%, 22.1%, and 23.7%, respectively. Table 1 summarizes the age and sex of the respondents.

Korea is faced with a large aging population and declining birth rate. In this “aging society,” orthodontists are witnessing a recent increase in the number of middle-aged or older patients visiting their practices.1520 These patient groups may have different subjective needs for orthodontic treatment than do younger patients, because they are concerned not only about their dental esthetics but also functional ability to maintain their teeth longer. They may also have a different status of the so-called “mature” dentition,2 with signs of aging, periodontal disease, multiple old dental restorations, and other medical problems.

The vast majority of studies on the need for orthodontic treatment have been conducted on children and adolescents.21 In questionnaire-centered studies, children self-perceived a higher treatment need than was professionally assessed on esthetic grounds. The demand for orthodontic treatment, however, is difficult to assess in children,22 and it will considerably change with increasing age. Moreover, the self-perception of treatment need in older adults may be different from the treatment need evaluated by orthodontic experts.2123 Livas and Delli21 have indicated that adults persistently underestimated the definitive treatment need as determined in terms of dental health.

In a practice survey conducted in 2010 by Lim,1 56.2% of respondents considered that less than 5% of total patients was accounted for orthodontic patients aged over 40 years, followed by 5–10% in 26.5% of respondents. This meant that in most orthodontic clinics, patients aged over 40 years accounted for less than 10% of the total number of patients. However, surprisingly, the result of this study demonstrated that even respondents in their 40s and 50s showed considerably high interest towards orthodontic treatment (46.2% and 45.1%, respectively). Among the younger patients in their 20s, over half of the respondents (63.2%) had a positive interest (Figure 1). Although the need for and interest towards orthodontic treatment may be different among adults, this finding indicated that older adults have a high interest towards and subjective need for orthodontic treatment.

It is generally known that women have a higher interest towards orthodontic treatment than do men.17242526 This study showed similar results in that women (52.2%) had a significantly higher rate of interest than did men (42.6%) in the total sampled population (Figure 2 and Table 2). However, no statistically significant differences were observed between the sexes in any of the age groups, indicating that participants of both sexes even over the age of 40 years had the same level of interest towards orthodontic treatment. This result may explain the recent increase in the number of middle-aged male patients visiting orthodontic clinics.

When the respondents were divided by the area of living, no significant difference was observed in the percentage of interest between Seoul and Gyeonggi areas, as well as between the subdivided areas. For this reason, the percentage of positive interest in orthodontic treatment was compared by the area of living. These results may imply that the socioeconomic level and health awareness among the participants are equally high regardless of their area of living in the capital area in Korea.

The chief complaint is a patient's self-reported primary reason for presenting for medical care. Chief complaints may be used to quantify, analyze, and plan for emergency care and provide valuable information on acute care needs where there are crucial data gaps. The need for standardization of chief complaint data in orthodontics has not yet been raised. The results of this study indicated that the order of priority of chief complaints had a definite trend in the different age groups. In younger adult patients in their 20s and 30s, protrusion, crowding, and asymmetry had higher priorities (Table 3). However, in older patients, spacing and secondary crowding had higher priorities. Spacing and secondary crowding may be the consequence of the reduced support provided by the affected periodontium.2728 This may also indicate that older patients are more concerned about malocclusion due to oral diseases. The important point is that they may be aware of the malalignment of their teeth, but are unaware of the status of the periodontium and their treatment need in terms of periodontal and other diseases. In the Korea National Health and Nutrition Examination Survey of 2015, the prevalence rate of periodontitis among participants in their 50s was approximately 54% in males and 31% in females, and the percentage increased with age. These results may emphasize the importance of disease control during orthodontic treatment in middle-aged patients.

Among the barriers that prevent the middle-aged patients from starting orthodontic treatment, treatment fee and long treatment time had high priorities (Table 4). In addition, the result of this study demonstrated that patients aged over 40 years tend to think that they are too old for orthodontic treatment and that treatment may do more harm than good. These results certainly indicate that more information should be provided to the public that proper orthodontic treatment accompanied with oral and systemic disease control do more good than harm.

Despite its interesting findings, the study has some limitations. It would have been better if this study had been conducted with a larger number of participants with more equal sex distribution. In addition, it would have been better if this study had been conducted outside the dental hospital. However, this study aimed to maintain a common background of the respondents (i.e., patients and accompanying guests) to form a group that was aware of the importance of dental health. Moreover, the study center is located in one of busiest areas of Seoul and in an affluent neighborhood, which will help minimize the effects of economic factors of the respondents. A future study combining multicenter surveys would be helpful in understanding the demands of older adults and their misunderstandings regarding orthodontic treatment. Data from such larger surveys would be required in the future to ensure orthodontists remain updated about adult orthodontic treatment and the use of interdisciplinary treatment approaches.