This study is considered the first in which the effect of fake braces on OHRQoL has been evaluated. The results have shown that changes in OHRQoL occurred with wearing braces for fashion only. Fake braces group had significantly greater negative effects on functional limitation and physical disability. Nevertheless, fake braces group reported significantly positive impacts on psychological discomfort and disability.
Along with factors such as long treatment period and discomfort of the appliances, the high cost is one of the main concerns of orthodontic devices6. Currently, braces have become symbols of wealth and fashion accessories in some parts of Southeast Asia. The problem is that as fashion braces emerged as a statement of financial status, they have been advertised and sold through social media by unqualified personnel. In addition, the quality of the orthodontic brackets is low and cases of metal toxicity from those braces have been reported10. Investigating the impact of those non-therapeutic braces on quality of life is as important as studying uncovering potential health risks because deeper understanding of the consequences of fashion braces will enable the patients to provide informed consent, give them realistic expectations and provide a more accurate analysis of cost and benefits of the devices11. This study, therefore, was conducted to assess the impact of fashion braces on OHRQoL with the hope of filling the gap of knowledge about fake braces and educating the public about the effects of fake braces.
Overall, the total OHIP scores showed no significant differences among the three groups of subjects. Interestingly, both fashion and therapeutic braces groups showed lower levels of psychological discomfort, psychological disability, social disability and handicap than the control group. This is consistent with a previous study that showed decrease in all these criteria over time in individuals with conventional or self-ligating orthodontic devices12. Considering these OHIP domains consisted of questions regarding topics such as self-consciousness, embarrassment and dissatisfaction with life, this result suggests that wearing braces, therapeutic or fashion, could improve a person’s psychological and social well-being. These results concur with other studies underscoring the positive effects of orthodontic interventions on OHRQoL as well4,13. Compared to the therapeutic braces group, the fashion braces group showed even lower levels of psychological discomfort and psychological disability, which means that fashion braces may indeed help people feel more confident and satisfied with themselves.
Despite the psychological and social benefits, both fashion and therapeutic braces groups showed greater functional limitation and physical disability than the control group, which is supported by a recent study that found a worsening trend in patients’ OHRQoL during orthodontic treatments5. In particular, fashion braces group showed significantly greater deterioration in these two criteria than the control group. In other words, people with fashion braces had more problems pronouncing words, felt sense of taste worsened, had unsatisfactory diets and had to interrupt meals due to their braces. People may prioritize the psychological benefits obtained by wearing fashion braces, but it is worth thinking about what the long-term physical and functional consequences will be.
The high cost of orthodontic treatment is one of the main considerations in terms of patient treatment decisions, so it is important to investigate the relationship between family income and OHRQoL. In this study, family income showed negative correlation with all OHIP domains except for functional limitation, psychological discomfort and social disability. The low-income group showed higher OHIP domain level as well as total OHIP score when compared to high-income group. Simply put, low-income subjects suffered from more problems than high-income subjects did. Even when high-income subjects were compared to average-income subjects, negative correlations between income and physical disability, handicap and total OHIP score were observed. High-income individuals reported fewer problems eating and functioning in life while wearing braces. This was in consensus with a previous study conducted in Sweden that showed significant association between poor OHRQoL and low income as well as having no economic resources14. These results suggest that high-income subjects generally had fewer problems with their braces perhaps because they had more resources to properly address the difficulties when needed. For instance, they may have been able to visit their orthodontists more often to have therapeutic braces adjusted. Subjects with high family income may have had higher quality braces installed on their teeth from the beginning as well.
In this study, cross-sectional design was utilized as it is illegal to do a prospective study on fashion braces in Saudi Arabia and private dental centers were unwilling to cooperate. One main drawback of this study was that non-probability population sampling was used. Since the survey was distributed online as a Google form questionnaire via social media including What’s App, Twitter, Facebook, Instagram and Snapchat, not all residents in Saudi Arabia had an equal chance of being selected as participants in this study. For instance, the mean age of the subjects who responded to the survey was 26.6 years old, which suggested that the younger population is more likely to use these types of social media to express their opinions. Moreover, there was not an equal representation of the three groups as more than 60% of the participants did not wear any braces while less than 5% of the subjects had braces for fashion purposes. Since this survey was conducted as a pilot study with a small sample size, it is not safe to assume that the sample fully represents the target population. The results should be accepted with the realization that the study may lack representation of the population.
Despite the limitations, there were interesting results observed in this study in terms of the distribution of the samples. More than 70% of the subjects in the fashion braces group had education below the university level whereas more than 70% of the subjects in the therapeutic braces or control group had university level education. This conforms with the conclusion that the patients’ educational level had direct influence on their knowledge and behavior regarding the main oral diseases and preventive measures15. It also supports a previous study in London that found low educational level has an independent negative impact on OHRQoL in older people16. People who have university level education may be more knowledgeable about the therapeutic effects of conventional braces and detrimental effects of fake braces, so they may be more likely to avoid fashion braces. People who have university level education are also more likely to have enough resources to afford therapeutic braces instead of fashion braces.
In terms of family income, the subjects of this study were somewhat equally divided between three groups of income less than average, average and more than average. Since fashion braces are cheaper versions of braces, it is not surprising that the majority of subjects in the fashion braces group had family income less than the national average in Saudi Arabia. This agrees with a previous study in which more than half the respondents came from a low-income family and the results showed that they thought fake braces could be a cheaper and faster alternative to conventional orthodontic appliances7. Many people from low-income families are unaware of the high fees and long duration of orthodontic treatments, needless to say the potential health risks posed by fake brace. They also have a strong desire to follow the trend of wearing braces as a symbol of financial status.