Self-esteem and its influence on the inclination toward esthetic dental treatments: a cross-sectional study

Abstract

Background

Facial attractiveness, influenced by dental esthetics, impacts self-perception and social interactions. The rise of social media has further fueled the demand for cosmetic dental treatments. This study aimed to examine the influence of self-esteem on the inclination of dentists, dental students, and laypeople toward esthetic dental treatments.

Methods

This cross-sectional study involved 410 participants, including dentists, dental students, and laypeople, selected through convenience sampling. Data were collected using a questionnaire that captured sociodemographic characteristics, oral hygiene status, previous experience with esthetic treatments, inclinations toward esthetic dental treatments, and self-esteem levels using the Rosenberg Self-Esteem Scale (RSES). The questionnaire, created on the Porsline© website, was distributed via social media platforms. Data were analyzed using SPSS version 21, employing the Chi-square test and logistic regression, with a p-value of less than 0.05 considered statistically significant.

Results

The RSES showed that 16.3% of participants had low self-esteem, while 83.7% had high self-esteem. Among participants with previous cosmetic procedures, 84.3% expressed interest in pursuing additional treatments compared to 47.7% of those without such experience (P < 0.01). Among dental professionals, 38.3% of high and 37.5% of low self-esteem individuals expressed interest in cosmetic treatments (P = 0.42), while among laypeople, 66.6% of high and 82.2% of low self-esteem individuals indicated interest (P = 0.04). Regardless of profession, 66.7% of individuals with low self-esteem and 55.4% of those with high self-esteem expressed interest in esthetic treatments (P = 0.08). RSES scores varied significantly across age groups, with participants aged > 45 years showing the highest scores (P = 0.03). Regression analysis indicated that laypeople were more likely to seek esthetic dental treatments than dentists or dental students (OR = 3.02, 95% CI = 1.88–4.83). Participants with a history of esthetic dental treatments were also more likely to pursue further procedures (OR = 5.39, 95% CI = 2.97–9.77).

Conclusions

Self-esteem significantly correlates with laypeople’s inclination toward cosmetic dental treatments. Dentists and dental students tend to express less interest in such procedures, likely due to their understanding of potential long-term complications. Additionally, individuals with prior experience in esthetic dental treatments showed greater interest in pursuing further treatments.

Background

Facial attractiveness impacts various societal outcomes, such as partner selection, forming friendships, securing employment, and even court sentencing [1]. Dental health is a critical factor in facial beauty and can influence how individuals perceive others’ personality traits [2]. Dental esthetics significantly affect a person’s quality of life by shaping self-perception, social behavior, and psychological well-being [3]. These factors, coupled with the growth of social media, have led to an increased demand for dental esthetic treatments. As media platforms expand, the desire to enhance one’s smile has driven the popularity of cosmetic dental procedures [4, 5].

Self-esteem refers to an individual’s perception of their own worth [6]. It represents the belief that one is “good enough.” Individuals with high self-esteem inherently value their individuality and feel confident in their worth [7]. Cosmetic dental procedures, such as veneers, not only improve physical appearance but also boost self-esteem [3, 8]. Conversely, dissatisfaction with dentofacial esthetics is associated with greater psychosocial stress and reduced self-esteem [7].

The Rosenberg Self-Esteem Scale (RSES) is a widely used tool for assessing self-esteem by evaluating feelings of personal value and self-respect [9]. It has been established as a reliable and valid measure across diverse populations, including Iranian samples [10,11,12,13]. The RSES is positively correlated with self-confidence, academic performance, and physical appearance and negatively associated with anxiety and depression [11].

The decision to undergo cosmetic procedures is influenced by personal traits, societal pressures, and the accessibility of medical services. Factors such as demographics, physical and psychological health, societal norms, and the influence of social media play critical roles [14]. Studies across regions highlight the impact of self-perception and societal expectations on body appreciation and cosmetic treatments. A large-scale study across 65 countries found that nations such as Malta, Taiwan, and Bangladesh had the highest body appreciation scores, while India and Australia ranked among the lowest. Men reported higher body appreciation than women, with the lowest scores observed among individuals identifying as another gender. Body appreciation remained relatively stable throughout adulthood, peaking in middle and older ages. Higher body appreciation was positively associated with life satisfaction, rural residence, and single status. Nationally, greater cultural distance from Western, Educated, Industrialized, Rich, Democratic (WEIRD) norms and higher income inequality were linked to elevated body appreciation scores [15]. Furthermore, the increased availability of cosmetic services has made such procedures more accessible, further fueling their popularity [16,17,18]. This convergence of personal and external factors explains the rising trend in cosmetic treatments [14].

In addition to patients’ views on esthetic dental treatments, the perspectives of dental professionals also play a significant role. Patients and dentists share similar valuations in esthetic scenarios, particularly regarding the significance of missing anterior teeth, though other aspects of treatment may reveal differing perspectives [19]. Practitioners report increased office productivity through cosmetic dentistry and greater personal satisfaction from performing esthetic procedures valued by their patients [20].

Given the impact of esthetic dental treatments on self-esteem, this study used the RSES to investigate the relationship between self-esteem and the inclination toward cosmetic dental treatments among dentists, dental students, and laypeople. The null hypothesis assumed that self-esteem levels do not significantly influence this inclination and that there are no significant differences between dental professionals and laypeople.

Methods

This study presents findings from a larger investigation into the effects of social media on individuals’ tendencies toward esthetic dental treatments [21]. While the larger study focused on evaluating the effect of social media activity on participants’ willingness to undergo esthetic dental treatments, this study examines how self-esteem influences their willingness and explores whether dental knowledge is a contributing factor. In brief, this cross-sectional research took place in Iran from July to August 2022. An online questionnaire assessed how different factors, including self-esteem, influence individuals’ inclination toward esthetic dental procedures [21]. The study was approved by the Research Ethics Committee at Shahid Beheshti University of Medical Sciences under reference number IR.SBMU.DRC.REC.1400.132. Informed consent was obtained on the initial page of the online questionnaire. Participants were provided with detailed information about the study’s objectives, procedures, and their rights. They voluntarily agreed to participate by completing the consent form. To ensure privacy, all questionnaires were anonymized and linked only to a specific code. The study complied with the Declaration of Helsinki, and the findings were reported following the STROBE checklist.

To determine the sample size, the proportion of individuals interested in receiving esthetic dental treatments was estimated to be around p = 60%. This proportion was anticipated with a 95% confidence interval in the population and an expected error of approximately d = 5%. As a result, based on the formula $\:N=\frac{{z}^{2}p(1-p)}{{d}^{2}}$, a sample size of N=369 was required for this study. Considering that around 10% of participants may not complete the questionnaires, the sample size was increased to 410 (calculated as $\:\frac{369}{(1-0.1)}=410$). The inclusion criteria were being over 18 years of age and using at least one social media platform from Instagram, Telegram, and WhatsApp.

The main outcome variable was the willingness to undergo esthetic dental treatments (yes or no), while the primary explanatory variable was self-esteem (high or low), assessed using the RSES questionnaire. Covariates included sex (male or female), education level (university degree, high school diploma or lower), prior experience with cosmetic dental procedures (yes or no), profession (dentist/dental student or layperson), and oral hygiene status (frequency of brushing and flossing).

The Farsi version of the RSES questionnaire utilized in this study was originally translated and developed by Shapurian et al. [10] in 1987, with its reliability and validity established at that time. Esthetic treatments were defined as ceramic or composite veneers, bleaching, or any procedures aimed at altering the appearance of teeth without a therapeutic rationale. This questionnaire was developed using the Porsline© website (www.porsline.ir), and the link was shared publicly on Instagram, Telegram, and WhatsApp. Porsline© ensures confidentiality and data integrity through SSL encryption, restricted access to personal information, and user consent for support services. User data, including survey responses, remains user-owned, is not shared with third parties, and is promptly deleted upon request. These measures uphold stringent data privacy standards [22].

The RSES questionnaire had 10 statements and was scored as follows: a positive response to each of statements 0 to 5 was given a score of + 1 and a negative response a score of -1. Conversely, a positive response to each of the statements from 6 to 10 was given a score of -1 and a negative response a score of 1+. The sum of these scores was calculated. A total score higher than zero indicated high self-esteem, while a score lower than zero suggested low self-esteem. The maximum possible score (+ 10) represented very high self-esteem, while the minimum possible score (-10) indicated extremely low self-esteem. Suppose a participant responds positively to two statements and negatively to three statements out of statements 0 to 5, their total score for this section would be -1. Similarly, if the participant responds positively to one statement and negatively to four statements out of statements 6 to 10, their score for this section would be -3. Adding these together, the final score would be -4, which indicates low self-esteem. The original and translated versions of the RSES questionnaire are provided as Additional Files 1 and 2.

The data were analyzed using SPSS Version 21 (IBM Corp., Armonk, NY). For statistical analysis, the Chi-square test was employed. A p-value of less than 0.05 was deemed to represent statistical significance. An adjusted logistic regression analysis was performed, reporting odds ratios (OR) and 95% confidence intervals (95% CI) to assess the influence of various variables on individuals’ willingness to undergo esthetic dental treatments while controlling for covariates. A separate logistic regression analysis was conducted to evaluate the influence of different variables on participants’ self-esteem scores.

Results

The online questionnaire was viewed by 740 individuals, and the required sample size of 410 was achieved through convenient sampling (55% response rate). Table 1 presents the detailed characteristics of participants. The RSES results revealed that 67 (16.3%) demonstrated low self-esteem, whereas 343 (83.7%) presented high self-esteem. The mean (± SD) score for self-esteem was 5.7 (± 4.9), within a range of -10 to + 10. Among all participants, 108 individuals (26.3%) had undergone esthetic dental procedures, and 235 (57%) expressed a desire to receive such treatments.

Table 1 Characteristics of participants

Table 2 presents participants’ willingness to undergo esthetic dental treatments categorized by their characteristics. It was observed that 53.2% of males and 59.9% of females expressed interest in esthetic treatments (P = 0.17). A higher proportion of participants over 45 years old (68.9%) showed interest in receiving esthetic dental treatments compared to younger age groups (P = 0.42). Participants with lower educational levels were significantly more interested in receiving esthetic treatments (62.3%) compared to those with university degrees (55.6%) (P = 0.002).

Table 2 The proportion of the 410 participants interested in pursuing esthetic dental services, grouped in different categories

Regardless of profession, 66.7% of individuals with low self-esteem and 55.4% of those with high self-esteem expressed an interest in receiving esthetic dental treatments (P = 0.08). Among the dentist/dental student group, 38.3% showed an inclination toward esthetic treatments. In contrast, among the general populace, 69.2% expressed a willingness to undergo esthetic treatments. The difference was found to be statistically significant (P < 0.01). Among dentists/dental students, the difference in willingness to undergo esthetic dental treatments was not significantly affected by the level of self-esteem (P = 0.42). Conversely, among the general population, 66.6% of the high self-esteem group and 82.2% of the low self-esteem group demonstrated an interest in esthetic treatments. The difference was statistically significant (P = 0.04).

The study also found that 84.3% of participants who had previously undergone esthetic treatments expressed a desire for further procedures, compared to 47.7% of those without prior experience (P < 0.01). While brushing frequency did not significantly influence the willingness to undergo esthetic dental treatments, differences were observed among participants with varying flossing intervals (P = 0.004).

Table 3 presents the regression analysis results assessing willingness to undergo esthetic dental treatments, adjusted for variables including sex, age, education, self-esteem, profession, history of previous esthetic dental treatments, and oral hygiene status. Two factors significantly influenced the likelihood of pursuing esthetic dental treatments: profession and history of previous esthetic treatments (P < 0.001 for both). In detail, laypeople were 3.02 times more likely to undergo esthetic treatments compared to dentists/dental students (95% CI = 1.88–4.83). Furthermore, participants with prior esthetic treatment experience were 5.39 times more interested in future treatments (95% CI = 2.97–9.77).

Table 3 Results of an adjusted regression analysis evaluating characteristics influencing willingness to undergo esthetic dental treatments

Table 4 highlights the mean RSES scores for participants across various categories. Participants over 45 years old had significantly higher self-esteem scores compared to younger age groups (P = 0.032). Moreover, significant differences in self-esteem scores were observed among participants with varying flossing intervals (P < 0.001). As shown in Table 5, the logistic regression analysis revealed that none of the adjusted variables, including sex, age, education, profession, history of or willingness to undergo esthetic dental treatments, or oral hygiene status, had a significant impact on participants’ RSES scores.

Table 4 The RSES scores of participants categorized by different characteristics

Table 5 Results of an adjusted regression analysis evaluating the association between participant characteristics and self-esteem scores

Discussion

This research aimed to explore how self-esteem influences the willingness of various individuals, including dentists, dental students, and laypeople, to undergo cosmetic dental procedures. The findings indicated that lower self-esteem and prior cosmetic treatment experience increased the likelihood of seeking esthetic dental procedures. Laypeople showed greater interest in these treatments compared to dental professionals, underscoring the influence of professional awareness on treatment preferences.

Several studies have demonstrated a link between self-esteem and the desire to improve dental appearance [8, 23, 24]. Davis et al. [8] examined the psychological effects of esthetic dental restorations using porcelain laminate veneers and found that such treatments positively impacted patients’ self-esteem. Akpasa et al. [24] focused on teenagers, revealing a strong correlation between self-esteem and perceptions of smile and dental esthetics. Teenagers with higher self-assessments of their smiles exhibited greater self-esteem than those with lower assessments. Similarly, Dos Santos et al. [23] confirmed the relationship between self-esteem and the perceived need for orthodontic treatment, finding that children with lower self-esteem were more likely to feel a heightened need for treatment. Furnham and Levitas [25] investigated motivations for seeking cosmetic surgery and found a negative correlation between self-esteem and the likelihood of undergoing cosmetic procedures, implying that individuals with lower self-esteem are more inclined toward such interventions. While their research primarily focused on surgical treatments, these findings suggest a similar trend for cosmetic dentistry. These studies reinforce the hypothesis that self-esteem is linked to the inclination toward cosmetic dental procedures. Improving dental esthetics can significantly enhance self-esteem, particularly for those dissatisfied with their dental appearance. This study revealed significant differences in the propensity to pursue esthetic dental treatments between laypeople with high and low self-esteem, with the latter group expressing greater interest. Interestingly, this difference was not significant among dentists and dental students.

Cultural differences play a significant role in shaping perceptions and priorities and, consequently, the interest in receiving esthetic dental treatments. According to a cross-cultural study by Nassani et al. [26], Iranians demonstrated lower utility values for scenarios involving missing anterior teeth compared to posterior teeth. This underscores a strong cultural emphasis on the esthetic and social significance of anterior teeth. Compared to UK participants, Iranian participants consistently assigned lower utility values to missing anterior teeth. This suggests that esthetics might hold a heightened cultural value in Iran, potentially influenced by societal expectations regarding appearance. Another study comparing Iranian and Turkish demographics showed that Iranian participants valued the functional aspects of posterior teeth less than Turkish participants despite similar cultural and religious backgrounds. This difference suggests that cultural norms within Iran may place relatively greater emphasis on esthetics over function [27].

The study also found that participants who had previously undergone cosmetic treatments were five times more likely to pursue additional treatments. This aligns with the broader understanding that individuals who have experienced the benefits of cosmetic dental treatments - such as enhanced dental esthetics and a boost in self-esteem - might be more willing to pursue further treatments to sustain or amplify these positive results.

An analysis of oral hygiene habits revealed potential associations with self-esteem and interest in esthetic treatments. Participants who flossed regularly and, paradoxically, those who never flossed reported the highest interest in esthetic treatments. Regular flossers may value oral health and esthetics, while non-flossers may harbor misconceptions that esthetic treatments like veneers serve as tooth shields that exempt them from maintaining oral hygiene. Previous studies have shown that individuals who floss daily exhibit higher self-confidence compared to those who do not floss [28]. This raises the assumption that the relationship might be bidirectional, where enhancing self-esteem could lead to better oral hygiene habits [29]. However, conflicting evidence exists, reporting no relationship between dental floss use and self-concept [30]. Overall, further research is needed to better understand the relationship between oral hygiene habits and self-esteem.

Based on the findings of this study, educational background may influence attitudes toward cosmetic dental interventions. The higher willingness toward esthetic dental treatments among individuals with lower educational levels could be attributed to differences in social priorities and perceptions of self-image. According to Rosenqvist et al. [31], there is an inverse relationship between educational level and dissatisfaction with physical appearance. Thus, individuals with lower educational attainment may place a greater emphasis on physical appearance to enhance social and professional interactions, potentially viewing cosmetic dental procedures to improve self-esteem or social standing. In contrast, those with higher education levels may prioritize other aspects of personal development and well-being, leading to a reduced interest in esthetic procedures. Moreover, individuals with higher education may have greater access to health information, which could foster a more cautious attitude toward elective treatments that do not serve a functional or therapeutic purpose [32].

The majority of the dentists/dental students involved in this study showed less interest in receiving esthetic dental treatments, while most laypeople were open to such procedures. This significant difference could be attributed to dentists’ greater awareness of the potential long-term complications of esthetic treatments, reducing their desire to pursue such services [33,34,35,36,37]. Furthermore, various factors may drive healthcare providers to influence patients’ decisions regarding the necessity of certain treatments, a phenomenon known as “supplier-induced demand.” Factors such as challenges with insurance companies, patients’ limited knowledge, and insufficient monitoring may drive healthcare providers to influence patients toward specific treatment modalities [38]. The personal interests of providers, such as the financial benefits associated with cosmetic treatments, may also play a role [20]. However, the current study presents a contrasting perspective to previous research conducted in Saudi Arabia. That particular study suggested that students in health-related fields are more influenced by social media, are more knowledgeable about the “Hollywood smile”, and are more likely to seek cosmetic dental care compared to students from other disciplines [39].

Several studies show that women often care more about beauty and looks, tend to be more worried about their physical flaws, and are usually more critical about things related to appearance [40,41,42,43,44,45,46]. Current research also revealed that a higher proportion of females, compared to males, preferred esthetic treatments. However, this difference was not statistically significant. Contrastingly, the studies conducted by Afroz et al. [3] and Venete et al. [7] indicated that a significantly higher number of men, compared to women, were concerned about the appearance of their smiles and how others perceived them. Previous research on the Iranian population has shown no statistically significant differences in utility values between men and women, suggesting that esthetics and functionality may be weighted more equally across genders in the Iranian context [26, 27]. Although women have traditionally been the primary focus of esthetic studies and treatments, the increasing participation of men in cosmetic procedures challenges this historical trend. This shift suggests that gender-specific differences in esthetic priorities may be narrowing as societal acceptance of male engagement in esthetics increases. Gender-neutral societal expectations might also play a role in diminishing the observed differences in the study. Both men and women are increasingly exposed to similar cultural pressures regarding physical appearance, particularly in urban settings, which could lead to more homogenized attitudes toward esthetic treatments. Finally, both men and women prioritize esthetic treatments for reasons beyond simple beauty, such as social and professional advantages [47].

The definition of beauty varies across different age groups, as does the emphasis on esthetics. What may be considered attractive to younger individuals in a population may not necessarily appeal to older individuals within the same demographic [48]. Intercultural studies have shown that younger participants generally place greater importance on esthetics, particularly for anterior teeth. In contrast, older participants tend to exhibit a higher tolerance for tooth loss, likely reflecting differences in life experiences, societal norms, and expectations. In the Iranian population, younger participants assigned lower utility values to missing anterior teeth, emphasizing the importance of visible esthetics. This aligns with the younger generation’s focus on appearance, often shaped by modern societal pressures and media. Older individuals, however, displayed greater tolerance for missing teeth, particularly posterior ones, reflecting a generational shift in expectations where tooth loss is more readily accepted as a natural part of aging. Additionally, older participants assigned higher utility values to shortened dental arches compared to younger participants, suggesting they may prioritize functionality over esthetics​ [26, 27]. According to the literature, self-esteem levels fluctuate throughout aging, showing periods of increase, decrease, or stability [49]. Within the studied population, participants over 45 years old exhibited the highest self-esteem scores. Similarly, another study found that RSES scores peak during mid-adulthood, possibly due to stability and accomplishment in career, family, and personal development [49]. It is important to note that the patterns of self-esteem growth or decline are significantly influenced by socioeconomic and sociodemographic factors [50].

In terms of limitations, the unbalanced distribution of male and female participants may have introduced potential bias. Moreover, the current study might have unintentionally increased interest in esthetic procedures, as discussing the topic could spark curiosity about these services. Reliance on online questionnaires excluded individuals not using social networks, limiting the sample diversity. Additionally, the cross-sectional design poses a limitation, as it does not allow for determining the chronological sequence of variables. The questionnaire did not collect data on other potentially influential factors such as income level, occupation, and dental insurance coverage. Including these variables could have provided a more comprehensive understanding of the factors influencing the inclination toward esthetic dental treatments. Another limitation is the restriction of participants to individuals of Iranian nationality, as perceptions of beauty are influenced by ethnicity and cultural context. However, the growing inter-cultural exchanges facilitated by the internet, immigration, media, and arts are contributing to the emergence of a more homogenized global standard of beauty [51].

For future research, developing a questionnaire for individuals not active on social media and conducting a similar study with a larger and more diverse sample, including more participants in each age bracket, would be beneficial. Additionally, incorporating factors such as income level, occupation, dental insurance coverage, and self-rating of smiles would enhance the robustness and applicability of the findings. Categorizing self-esteem scores into multiple groups rather than binary classifications (low and high) is also recommended to assess whether additional trends or insights emerge.

Conclusion

This study demonstrates that self-esteem significantly influences the propensity to seek cosmetic dental treatments among laypeople, with individuals possessing lower self-esteem showing a greater inclination. Moreover, laypeople were notably more likely to pursue esthetic procedures than dental professionals, likely due to the latter’s awareness of potential complications and a more cautious approach to elective treatments. Additionally, prior experience with cosmetic treatments was associated with a higher likelihood of seeking further procedures, indicating the reinforcing impact of positive esthetic outcomes. The findings also suggest that social and educational factors shape attitudes toward cosmetic dentistry, with lower educational attainment correlating with a higher interest in esthetic interventions. These insights emphasize the need for a patient-centered approach that considers psychological and societal factors in addressing the demand for cosmetic dental treatments.