==== Front PLoS One PLoS One plos PLOS ONE 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0287235 PONE-D-23-06321 Research Article People and places Geographical locations South America Brazil People and places Geographical locations Europe European Union Finland Medicine and Health Sciences Public and Occupational Health Behavioral and Social Aspects of Health Biology and Life Sciences Psychology Psychometrics Social Sciences Psychology Psychometrics Biology and Life Sciences Psychology Social Psychology Social Sciences Psychology Social Psychology Biology and Life Sciences Psychology Psychological Attitudes Social Sciences Psychology Psychological Attitudes Research and Analysis Methods Mathematical and Statistical Techniques Statistical Methods Multivariate Analysis Principal Component Analysis Physical Sciences Mathematics Statistics Statistical Methods Multivariate Analysis Principal Component Analysis People and Places Population Groupings Ethnicities European People Finnish People Aesthetic dental treatment, orofacial appearance, and life satisfaction of Finnish and Brazilian adults Aesthetic dental treatment, orofacial appearance, and life satisfaction https://orcid.org/0000-0003-1514-5758 Campos Lucas Arrais Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Resources Validation Visualization Writing – original draft 1 2 3 4 * Campos Juliana Alvares Duarte Bonini Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Writing – review & editing 5 https://orcid.org/0000-0001-9214-5378 Marôco João Formal analysis Funding acquisition Methodology Software Supervision Writing – review & editing 6 7 https://orcid.org/0000-0002-7938-1701 Peltomäki Timo Conceptualization Data curation Funding acquisition Investigation Methodology Project administration Resources Supervision Visualization Writing – review & editing 1 2 3 8 1 Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland 2 Department of Ear and Oral Diseases, Tampere University Hospital, Tampere, Finland 3 Faculty of Health Sciences, Institute of Dentistry, University of Eastern Finland, Kuopio, Finland 4 School of Dentistry, Campus Araraquara, São Paulo State University (UNESP), São Paulo, Brazil 5 School of Pharmaceutical Sciences, São Paulo State University (UNESP), São Paulo, Brazil 6 William James Center for Research (WJCR), ISPA-Instituto Universitário, Lisbon, Portugal 7 Flu Pedagogy, Nord University, Bodø, Norway 8 Department of Oral and Maxillofacial Diseases, Kuopio University Hospital, Kuopio, Finland Mafla Ana Cristina Editor Universidad Cooperativa De Colombia - Pasto, COLOMBIA Competing Interests: The authors have declared that no competing interests exist. * E-mail: lucas.arraisdecampos@tuni.fi 29 6 2023 2023 18 6 e02872356 3 2023 1 6 2023 © 2023 Campos et al 2023 Campos et al https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Aims To study the probability of seeking/undergoing aesthetic dental treatment (ADT) and compare self-perception of orofacial appearance (OA) based on sex, age, and monthly income; and to estimate the impact of OA on life satisfaction (LS) among Finnish and Brazilian adults, considering the indirect effect of receiving ADT and the moderating effects of those sociodemographic variables. Methods This was an online cross-sectional study. Orofacial Esthetic Scale (OES), Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) and Satisfaction with Life Scale (SWLS) were used. Probability of seeking/receiving ADT was calculated using logistic regression and odds ratio (OR). OA scores were compared according to sociodemographic characteristics (ANOVA, α = 5%). Structural equations models estimated the impact of OA on LS. Results 3,614 Finns [75.1% female, 32.0 (SD = 11.6) years] and 3,979 Brazilians [69.9% female, 33.0 (SD = 11.3) years] participated in the study. Women were more likely to receive ADT than men in both countries (OR>1.3). However, no statistically or practical significant differences were observed in OA between sexes (p>0.05 or p<0.05, ηp2 = 0.00–0.02). In Finland, demand for ADT (OR = 0.9–1.0) and OA scores (p>0.05) were the same among different ages and monthly income. In Brazil, younger individuals (OR>1.6) and those with higher monthly income (OR>2.7) were more likely to receive ADT, while those with lower income had a greater psychosocial impact of OA (p<0.05; ηp2>0.07). Individuals who were more satisfied with their own OA and had less psychosocial impact from OA had higher levels of LS (β = 0.31–0.34; p<0.01; explained variance: 9.8–13.1%). Conclusion Demand for ADT is influenced by sociodemographic and cultural factors. Greater societal pressure on physical appearance is observed among women in Western countries. In countries with high socioeconomic inequalities, consumerism and social prestige are involved in this demand. Self-perception of orofacial appearance plays a significant role in individuals’ subjective well-being. Therefore, the planning of aesthetic treatments in the orofacial region should consider the patient’s perceptions and social context. http://dx.doi.org/10.13039/501100001807 Fundação de Amparo à Pesquisa do Estado de São Paulo 2018/06739-1 https://orcid.org/0000-0003-1514-5758 Campos Lucas Arrais http://dx.doi.org/10.13039/501100001807 Fundação de Amparo à Pesquisa do Estado de São Paulo 2019/19590-9 Campos Juliana Alvares Duarte Bonini http://dx.doi.org/10.13039/501100002322 Coordenação de Aperfeiçoamento de Pessoal de Nível Superior 001 https://orcid.org/0000-0003-1514-5758 Campos Lucas Arrais the State funding for university-level health research, Tampere University Hospital, Wellbeing services county of Pirkanmaa, Finland 9AC074 https://orcid.org/0000-0002-7938-1701 Peltomäki Timo This study received financial support from São Paulo Research Foundation (FAPESP) (grant number#2018/06739-1) awarded to LAC and (grant number #2019/19590-9) awarded to JADBC. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) (grant number 001), awarded to LAC. This study was partly financially supported by the State funding for university-level health research, Tampere University Hospital, Wellbeing services county of Pirkanmaa, Finland (grant number 9AC074) awarded to TP. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data AvailabilityAll relevant data are within the paper and its Supporting information files. Data Availability All relevant data are within the paper and its Supporting information files. ==== Body pmcIntroduction Since ancient times, societies have valued physical appearance, which today remains to be an important characteristic that can affect various aspects of an individual’s life [1, 2]. Orofacial appearance (teeth and face) is a notable feature of physical appearance and is strongly related to interpersonal relations [1]. This is because orofacial region plays a large role in the process of communication, identification, and self-identity construction [1, 3, 4]. From the orofacial appearance, impressions are also quickly formed regarding an individual’s personality and moral and social characteristics [4, 5]. Despite their limited accuracy, these impressions have a place in social behavior and routine decision making, resulting in privileges or disadvantages based on orofacial appearance [5]. An individual who is aware of this can then adopt body-altering behaviors, aiming to obtain a good-looking appearance based on self-perception and socially established standards [1]. Undergoing aesthetic procedures [6], including aesthetic dental treatments, are among these behaviors. With progress advancing in the field of aesthetic dental treatments, studies over the last two decades have stated a growing demand for these treatments [7–10]. Although this statement is widely recognized and reported in clinical dental practice, there are limited studies [9–12] that provide specific quantification of desire or demand for aesthetic dental treatments across different populations. Samorodnitzky-Naveh et al. [9] conducted a survey with 407 18-26-year-old dental patients in Israel, of whom 77.4% desired to improve their dental appearance. Wulfman et al. [10] found that 38.0% of French seniors sample (n = 3,868, age≥55 years) expressed a desire to change their smile, with women and younger part of the sample expressing a greater desire. In a study conducted on 31-year-old Brazilians (n = 536) in 2018, Silva et al. [11] found that 85.9% reported being interested in tooth whitening treatment. This finding by Silva et al. [11] is similar to that by Campos et al. [12] in 2022, in which study 81.9% of a Brazilian general population sample (age≥18 years, n = 1,468) reported having sought aesthetic dental treatment. In the same study [12], a Finnish sample (n = 3,636, age ≥18 years) was also investigated: less than half (40.6%) reported having sought such a treatment. It seems that demand for aesthetic dental treatment is influenced by cultural [12] and sociodemographic factors [9, 10] such as sex, age, and economic level, and should be taken into account when the demand is scrutinized. It is also important to consider that demand refers to a behavior adopted based on an individual’s perspectives and perceptions. In dentistry, self-perception of orofacial appearance stands out [1, 12], being one of the main dimensions of oral health-related quality of life (OHRQoL) and can represent a reason why dental treatment is sought [13, 14]. Therefore, including the self-perception of orofacial appearance in research on demand for aesthetic dental treatment is important. Because the dimensions of OHRQoL cannot be directly measured, the use of specific means, psychometric scales, are necessary [14, 15]. The Orofacial Esthetic Scale (OES) [15–17] and the Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ) [15, 18, 19] are two scales that evaluate self-perception of orofacial appearance and have shown good indicators of validity and reliability in different populations. Estimating the impact of the orofacial appearance dimension of OHRQoL on well-being of individuals with different cultural backgrounds is another important point to be considered. This information may be useful not only for advancing scientific evidence and contributing to the formation of professionals with a more holistic view of their patients [1], but also for fostering discussion about the social role of dentistry. Campos et al. [1] observed in a sample of Brazilian individuals aged 18 to 40 (n = 1,940) that orofacial appearance, measured by OES and PIDAQ, explained 9.9 to 14.3% of the variance in life satisfaction (cognitive aspect of subjective well-being). Although the orofacial appearance occupies a prominent space in an individual’s life [1, 12–14], to the best of our knowledge no other studies have evaluated their direct contribution to subjective well-being in general populations, which would be relevant for the development of a patient-centered treatment plan [1]. Self-perception of orofacial appearance may vary according to different sociodemographic characteristics, such as sex, age, and socioeconomical level [16, 20, 21]. These characteristics may therefore also have an effect on how orofacial appearance impacts subjective well-being. Thus, it is relevant to investigate the differences in orofacial appearance according to sociodemographic characteristics and evaluate their moderating role on the relationship between orofacial appearance and well-being. Cultural and social values can also influence the role of these sociodemographic variables in the demand for aesthetic dental treatment and the perception of orofacial appearance, as well as its impact on well-being. Therefore, to identify coherences and specificities, it is worthwhile to extend this investigation to countries with significant sociocultural differences initially. Finland and Brazil are examples of countries with such sociocultural discrepancies. Finland has one of the closest levels of gender equality [22], low inequality between different socioeconomic classes [23], and similar living conditions of its population. Brazil, on the other hand, has high inequality and different living conditions among different sociodemographic groups [22, 23], which affects access to health treatments, especially aesthetic dental treatment, since it is provided in the private sector. Moreover, the value attributed to physical appearance varies between these countries, with physical appearance carrying much more importance in social interactions and behaviors for Brazilians [12]. Thus, studying both countries simultaneously is a good starting point for cross-national comparisons. The objectives of this study were 1. to study the probability of Finnish and Brazilian adults of seeking and undergoing aesthetic dental treatment according to sex, monthly income, and age, 2. to compare the self-perception of orofacial appearance in Finland and Brazil according to sex, monthly income, and age, and 3. to estimate the impact of self-perception of orofacial appearance on life satisfaction in Finnish and Brazilian adults, taking into consideration the indirect effect of receiving aesthetic dental treatment and the moderating effects of sex, monthly income, and age on this impact. Methods Study design and sampling This was a cross-sectional study with snowball non-probability sample selection. Finnish and Brazilian individuals over the age of 18 years were invited to participate in the study. The selection of Brazil and Finland for the study was based on their sociocultural differences, as well as the convenience of the researchers whose work is located in these countries. Initially the invitation was sent to students and staff from universities in Finland and Brazil. Then, snowball strategy was used to recruit more participants. Because the data were collected during the pandemic, this sampling strategy was the most feasible to address the aims of the study. The minimum sample size was calculated following the proposal by Hair et al. [24], who recommend a minimum of 10 participants per parameter to be estimated in the structural model. In the present study, 28 parameters were considered a priori to be estimated in the model. Thus, the minimum sample size required for each country was 280 participants. However, a larger number of participants were recruited to increase the variability and coverage of the data for the study populations. Demographic information was collected on sex (male, female, or other/not informed), age, marital status (single, married/common law/stable relationship, divorced, widower), monthly income, and whether the individual has sought or received any aesthetic dental treatment (no, yes). Although age was collected in years it was categorized according to the 25th, 50th, 75th, and 90th percentiles when considering the samples from both countries simultaneously (1: <23 years, 2: 23├ 29 years, 3: 29├ 39 years, 4: 39├ 52 years, and 5: ≥52 years). The monthly income was collected based on information from Statistics Finland [25] and Centro de Políticas Sociais–FGV Social (Brazil) [26] and was stratified into the following categories: Finland– 1: <2,500 €, 2: 2,500├ 5,000 €, 3: 5,000├ 7,500 €, 4: 7,500├ 10,000 €, 5: ≥10,000 €; Brazil– 1: 0.50 [30, 31]. The reliability of the data was assessed using Cronbach’s alpha coefficient (for OES) or ordinal alpha coefficient (for PIDAQ and SWLS) and values > 0.70 were considered adequate [30, 31]. Measurement invariance was tested to verify whether it would be possible to compare the mean scores obtained using the scales between subsamples according to variables of interest (sex, monthly income categories, and age categories) [32]. Multigroup analysis considering CFI difference (ΔCFI) between configural and metric models (metric invariance) and between metric and scalar models (scalar invariance) was performed between the subsamples of each country. Reductions in CFI smaller than 0.01 were indicative of measurement invariance. The analyses were conducted in the R program (R Core Team, 2022) using the “lavaan” [33] and “semTools” [34] packages. The responses to the items within each scale demonstrated a distribution that closely approximated the normal distribution, as well as evidence of multivariate normality (Finland–OES: |sk| ≤ 1.2, |ku| ≤ 1.9, kum/cr = 0.4; PIDAQ: |sk| ≤ 2.6, |ku| ≤ 6.5, kum/cr = 1.0; SWLS: |sk| ≤ 1.1, |ku| ≤ 1.0, kum/cr = 0.3; Brazil–OES: |sk| ≤ 1.3, |ku| ≤ 1.7, kum/cr = 0.4; PIDAQ: |sk| ≤ 2.9, |ku| ≤ 3.8, kum/cr = 1.1; SWLS: |sk| ≤ 1.3, |ku| ≤ 1.8, kum/cr = 0.3). The fit of the factor models of the scales was adequate to the Finnish and Brazilian samples, attesting the validity and reliability of the data (S1 Table). The models also showed adequate fit to the subsamples data (CFI ≥ 0.94, TLI≥ 0.90, RMSEA ≤ 0.13, SRMR ≤ 0.06, α ≥ 0.82). Metric or scalar measurement invariance was observed among the subsamples of each country according to sex, monthly income categories, and age category (S1 Table) making it possible to directly compare the mean scores [32]. Data analysis Descriptive analysis was performed to characterize the sample according to the country. The prevalence and 95% Confidence Interval (95%CI) of the participants who have sought and received aesthetic dental treatment were estimated and compared using z test (α = 5%) according to the sex, monthly income category, and age category. Logistic regression model was conducted separately according to the country and the odds ratio with 95%CI was calculated to verify the relationship of these sociodemographic variables with seeking and receiving aesthetic dental treatment. Sex (reference category (rc): male), monthly income category (rc: <2,500€/ 0.95, Explained Common Variance (ECV) > 0.85, and Mean of Item Residual Absolute Loadings (MIREAL) < 0.30 [36]. Values of UniCo > 0.98, ECV > 0.89, and MIREAL < 0.27 were observed in Finnish and Brazilian sample. Therefore, these results suggest and confirm the possibility of treating the OES and PIDAQ factors scores as one dimension called Orofacial Appearance. PCA was performed using program Factor 11.05 for Windows [37]. In the structural model, the Orofacial Appearance dimension was considered as independent variable and the dimension of life satisfaction assessed by SWLS was the dependent variable. The variable ‘received aesthetic dental treatment’ was inserted in the model as intermediate variable (indirect effect) between orofacial appearance and life satisfaction. The criteria for indirect effect were verified [38, 39] and bootstrap simulation analysis for Sobel’s test was used for the evaluation of indirect effect path estimates [31]. Moderation analysis was conducted to estimate the moderating role of sex (1 = male, 2 = female), monthly income (Finland: 1 = <2,500 €, 2 = 2,500├ 5,000 €, 3 = 5,000├ 7,500 €, 4 = 7,500├ 10,000 €, 5 = ≥10,000 €; Brazil: 1 = 1.0) for different sociodemographic classes. In contrast, in Finland, the OR for age and economic level classes appears close to the alignment of the value 1. 10.1371/journal.pone.0287235.g002 Fig 2 Odds ratio (OR) with 95% confidence Interval (95%CI) for seeking and receiving aesthetic dental treatment according to sex, monthly income, and age. Note. Reference category: sex = male; monthly income = <2,500€ / 0.17). Therefore, the models were refined by excluding this variable, as well as those sociodemographic variables. The refined model presented adequate fit to the samples (Finnish Sample: CFI = 0.97, TLI = 0.95, RMSEA = 0.087, SRMR = 0.068; Brazilian Sample: CFI = 0.97, TLI = 0.96, RMSEA = 0.076, SRMR = 0.047). The orofacial appearance presented a significant impact on life satisfaction in both countries (Table 4). Individuals who are more satisfied with their own orofacial appearance and who perceive less of a psychosocial impact of dental aesthetic have higher life satisfaction. The model showed an explained variance for life satisfaction of 9.8% in the Finnish sample and 13.1% for the Brazilian sample. 10.1371/journal.pone.0287235.t004 Table 4 Path estimates of the structural models elaborated to assess the impact of orofacial appearance on life satisfaction, the moderation role of sex, monthly income, and age, and the indirect effect of have received aesthetic dental treatment on this impact. Finnish sample Brazilian sample Path estimate B β SE p-value B β SE p-value Completed model OA → LS (β1) 0.52 0.45 0.16 0.002 0.47 0.44 0.10 <0.001 ADT → LS (β2) 0.04 0.01 0.04 0.279 0.13 0.05 0.04 0.002 Sex → LS (β3) 0.33 0.11 0.05 <0.001 0.12 0.04 0.02 0.007 MI → LS (β4) 0.21 0.22 0.02 <0.001 0.37 0.30 0.02 <0.001 Age → LS (β5) -0.01 -0.07 <0.01 <0.001 0.01 0.08 <0.01 <0.001 Sex*OA → LS (β6) -0.12 -0.18 0.07 0.099 -0.07 -0.11 0.04 0.101 MI*OA → LS (β7) -0.01 -0.03 0.02 0.523 -0.02 -0.06 0.02 0.159 Age*OA → LS (β8) <0.01 0.03 <0.01 0.621 <0.01 -0.01 <0.02 0.790 OA → ADT (β9) -0.01 -0.04 0.01 0.030 0.01 0.03 0.01 0.104 Sex → ADT (β10) 0.06 0.05 0.02 0.001 0.11 0.10 0.02 <0.001 MI → ADT (β11) <0.01 <0.01 0.01 0.845 0.05 0.12 0.01 <0.001 Age → ADT (β12) <0.01 <0.01 <0.01 0.995 <0.01 -0.08 <0.01 <0.001 Indirect effect # OA → ADT → LS (β9*β2) <0.01 <0.01 <0.01 0.384 <0.01 <0.01 <0.01 0.166 Refined model † OA → LS (β1) ‡ 0.34 0.31 0.02 <0.001 0.38 0.36 0.02 <0.001 B: non-standardized path estimate; β: standardized path estimate; SE: standard error; OA: orofacial appearance dimension; ADT: have received aesthetic dental treatment; LS: life satisfaction; MI: monthly income. β1 to β12: path estimates corresponding to Fig 1B. #Indirect effect assessed by Sobel’s test with bootstrap simulation. †Model refined by excluding the variables have received aesthetic dental treatment, sex, monthly income, and age (Fig 1C). ‡Explained variance for life satisfaction: Finnish sample = 0.098, Brazilian sample = 0.131. Discussion This study presents a screening of the prevalence of individuals seeking and undergoing esthetic dental treatment according to sociodemographic characteristics in Finnish and Brazilian population. Although an increase in demand for this treatment has been pointed out [7–10], there is a lack of specific data that allows comparisons across populations and sociodemographic groups. We also compared the self-perception of orofacial appearance according to sociodemographic characteristics and estimated its impact on subjective well-being in both populations. The results call attention to the importance of dental and medical practitioners, educators, and policy makers to know and deal with the sociodemographic and cultural aspects involved in aesthetic dental treatments. Women were more likely than men to seek and undergo aesthetic dental treatment in both samples. This is expected, since Western cultures are marked by patriarchy roots [41] and objectification of female body [42], resulting in more body-altering behaviors by women [42]. However, the scenarios in Brazil and Finland are different. Finland has strong and effective gender equality policies in different spheres of life, such as access to education and health, paid work, and political empowerment [43, 44] and it is the second most gender-equal country in the world [22]. Nevertheless, our results corroborate previous studies [44, 45] showing that social norms evoking greater aesthetic pressure on women persist even in Finland. In future discussions and reform on gender equality policies in Finland [43] it is necessary to include agendas aimed at reconstructing the still-imposed social norms of physical appearance between the sexes. In Brazil, with few and not so effective gender equality policies, there are social inequalities between the sexes [22], including low social representation of women in the society, wage gaps between the genders, and a high rate of violence against women [22, 46]. In this context, the greater physical appearance pressure on women, besides being considered a social norm, also becomes a tool for the men dominance and maintenance of inequalities [44]. Therefore, minimizing this pressure can be relevant, however, first and foremost, it is important that strong and effective policies are developed and promoted to build a safe, fair, and representative society for Brazilian women as well. No or very small differences without practical significance in the self-perception of the orofacial appearance (assessed by OES and PIDAQ) were observed between men and women. These results refute that the higher demand by women occurs because of a poorer self-perception of orofacial appearance than men. Rather, they support the idea that external factors and the internalization of social norms [41, 42, 44, 45], have a significant contribution in the difference in seeking aesthetic dental treatment between the sexes. In agreement with previous studies [16, 20, 21], no differences with practical significance were found in the perception of orofacial appearance between the age groups. Despite this, in Brazil, young people have sought and undergone more aesthetic dental treatments. An explanation for this is that Brazilians place a high value on appearance and it becomes a key component of social interactions [1, 2] and can be considered as a capital (aesthetic capital) [47]. In this regard, good looks based on beauty standards have a strong influence on one’s social acceptance and on obtaining job positions [2]. Therefore, young Brazilians may have a high demand for aesthetic dental treatment to fit into socially established beauty standards with the aim of achieving social insertion and even professional position. In Finland, although physical appearance also has an influence on many aspects of life [44, 47, 48], no difference in the demand for aesthetic dental treatment was observed between the age groups. This difference in relation to Brazil can be interpreted by speculating three different, but not mutually exclusive, hypotheses: 1. a lower value attributed to physical appearance in Finland than in Brazil. It may result in lower demand for aesthetic dental treatment, even though the perception of orofacial appearance is similar to the Brazilians [12]. 2. different beauty standards related to physical traits between countries. In Brazil, the ideal beautiful smile is close to that of the USA [49], which includes straight and very white teeth and explains the greater demand for smile-improving treatments. And 3. in Finland there is a social norm of equal opportunity for the population [48], so that Finns may be aware of discriminatory issues that violate it, such as those related to physical appearance [48]. In this way, many Finns may avoid adopting behaviors, including undergoing aesthetic treatment, that contribute to these issues. Despite the differences between Brazil and Finland, it is important to point out that aesthetic values, beauty standards, and behaviors to alter physical appearance have changed and become more similar among countries, especially Western ones, with increasing digitalization and the rise of social media [50]. Therefore, future cross-national studies in different age cohorts, including younger generations, are important for understanding attitudes toward orofacial appearance and aesthetic treatment. Our results may also not have captured the age-related consumption of aesthetic treatments for the rejuvenation purpose. This is because only intraoral treatments were considered as aesthetic dental treatment in the present study. Although some intraoral clinical features are associated with a more youthful appearance (e.g., gingival display and shape and length of incisors) [51], most treatments aiming at rejuvenation effect are extraoral, such as botulinum toxin and soft tissue filler injections [52]. Thus, we suggest that future studies investigate the relation of demand for different aesthetic treatments with self-perception of appearance in different populations and groups. The results regarding monthly income were also different between Finland and Brazil. It supports the idea that health treatments, especially aesthetic ones, can be associated with consumerism and social prestige [12, 53]. Finland is classified as a low socioeconomic inequality country between socioeconomic classes [23] and most Finns have similar living conditions and a democratic access to health care, regardless of socioeconomic classes. Brazil, in turn, is classified as a high-inequality country with regard to socioeconomic factors [23], including differences in the access to healthcare. Still, treatments solely or primarily intended to improve physical appearance, such as aesthetic dental treatments, are not offer by the Brazilian public health system and can only be accessed in private clinics at high cost. Our results show that Brazilians in middle and upper socioeconomic classes had more access to aesthetic dental treatment than the lower class, emphasizing the importance of income as a key factor in seeking and accessing dental treatments. Therefore, it is essential to consider economic conditions when studying the conditions that intervene in the search and undergoing of dental treatments. The results also reinforce the hypothesis that these treatments have high social and consumption values in countries with large social inequalities, such as Brazil [12]. It is also difficult to disassociate these values from the other results, which show that lower-income Brazilians had a higher negative social and psychological impact of dental aesthetics on their life. The relation of this impact with not having undergone aesthetic dental treatment may be associated with a dissatisfaction with a physical characteristic, as well as with an unfulfilled desire to consume and a consequent feeling of not belonging to higher socioeconomic classes. In accordance with previous studies [1, 54, 55], in which physical appearance was found to be an important contribution to one’s subjective well-being, our results showed that self-perception of orofacial appearance had a significant impact on life satisfaction. This perception contributed approximately one tenth to the life satisfaction of Brazilian and Finnish individuals. Having received aesthetic dental treatment did not have an indirect effect on this impact. Nevertheless, these results demonstrate how powerful the performance of the dentist can be in the re-establishment and/or promotion of their patient’s well-being. In some cases, the aesthetic dental treatments are well indicated, with an improvement of physical aspects and, consequently, of the self-perception of orofacial appearance. This may, in turn, provide psychological benefits and positively impacts the patient’s life satisfaction. However, this effect may not have been captured in our study since the sample consists of individuals from the general population, rather than patients with a specific orofacial condition. Thus, the results also suggest that the demand for aesthetic dental treatment is not always solely motivated by a desire to improve a single physical aspect, pointing to the potential risks that treatments carried out indiscriminately and without individualized planning may have. This is because, in some cases, the demand for aesthetic dental treatment may be associated with psychological symptoms or disorders (e.g., dysmorphic disorder) [56] or social pressures as discussed above. For these, performing the aesthetic treatment may not have a long-term benefit [1, 56] and may also contribute to worsening psychological symptoms or disorders and to the maintenance of social pressures and inequalities. As a result, no benefit, or even a negative impact on the patient’s well-being, may be observed. Present structural model analysis indicated that the impact of orofacial appearance on life satisfaction was similar between the countries and was not moderated by sociodemographic characteristics. This is comprehensible because orofacial region has peculiarities that transcend time, culture, and sociocultural characteristics [4]. Orofacial region not only serves as a tool for communication (both verbal and nonverbal) [1, 3], but also plays a crucial role in shaping one’s sense of self-identity through unique physical features [1, 4]. Keeping in mind the importance of individual needs and characteristics, aesthetic treatments in the orofacial region should be patient-centered including a detailed anamnesis, patient’s perceptions, and clinical examination identifying unique characteristics. In this way, the treatment can address physical issues that may enhance the sense of belonging and connect the patient to their social/cultural group [12, 53]. At the same time, the treatment will preserve their singularities, maintaining the sense of individuality and uniqueness [4]. Otherwise, the individual’s singular characteristics are not taken into account in the aesthetic treatment, often being altered or disguised. This alteration may negatively affect the patient by removing their sense of self-identity and lead to a lack of recognition of themselves [4], subsequently causing dissatisfaction with the treatment. The cross-sectional design was a limitation of the study since it does not allow for cause-and-effect inference of the structural model. The non-probability sampling and the online data collection can also be considered as a limitation [12], as they may hinder the generalizability of the results to the whole Finnish and Brazilian population. Trying to minimize these limitations, we used large sample sizes to obtain a comprehensive result that is close to the variability of the study population. We also attested to the validity and reliability of the data and used robust methods to elaborate the structural models. It is also noteworthy that the present study used life satisfaction as a measure of well-being. It deals only with the cognitive aspect of well-being from a hedonic perspective (focused on experiences of pleasure and enjoyment) [27–29]. However, well-being is a multidimensional concept, and other examples of its aspects are emotional well-being (hedonic perspective) and social and psychological well-being (eudaimonic perspective: focused on experiences of meaning and purpose) [55]. Therefore, it is important for future studies to examine the relationship between self-perception of physical appearance and other aspects of well-being in different cultures. Despite its limitations, the present study provides evidence that contributes to research on social determinants of health, include those conducted in Latin America [57, 58]. It also highlights the need for discussion and further investigation of the psychological, social, cultural, economic, and political factors related to aesthetic dental treatments and their implications for health across different countries. These efforts can identify and provide key elements for a better understanding of social determinants of health, which is crucial for the development of effective and equitable health policies and programs. This can lead to improved health outcomes for individuals and communities. Conclusion The demand for aesthetic dental treatment is influenced by sociodemographic and cultural factors, not just by self-perception of orofacial appearance. The findings indicate greater societal pressure on physical appearance among women in Finland and Brazil. They also suggest that consumerism and social prestige are involved in this demand in countries with high socioeconomic inequalities, such as Brazil. Self-perception of orofacial appearance plays a significant role in individuals’ subjective well-being. Therefore, to achieve success and promote well-being, the planning of aesthetic treatments in the orofacial region should also take into account the patient’s perspectives, perceptions, unique characteristics, and social context. Supporting information S1 Table Psychometric indicators related to the fit of the factor models of Orofacial Esthetic Scale (OES), Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ), and Satisfaction with Life Scale (SWLS) to the samples. (DOCX) Click here for additional data file. S2 Table Descriptive statistics of the scores of Orofacial Esthetic Scale (OES) and Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ) dimensions and measures of sample adequacy (MSA) for principal component analysis (Finnish sample: n = 3,614; Brazilian sample: n = 3,979). (DOCX) Click here for additional data file. S3 Table Principal component analysis (PCA) and parallel analysis results for Finnish and Brazilian sample. (DOCX) Click here for additional data file. S1 File Data. Data underlying the finds described in this manuscript. (XLSX) Click here for additional data file. 10.1371/journal.pone.0287235.r001 Decision Letter 0 Mafla Ana Cristina Academic Editor © 2023 Ana Cristina Mafla 2023 Ana Cristina Mafla https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version0 25 Apr 2023 PONE-D-23-06321Aesthetic dental treatment, orofacial appearance, and life satisfaction of Finnish and Brazilian adultsPLOS ONE Dear Dr. Campos, Thank you for submitting your manuscript to PLOS ONE. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1:  The subject of this manuscript is of interest for research in several fields such as body image, mental health, and dentistry, as also for clinical practice. This is a well-written manuscript resulting from a robust method. Reading the text was very informative. I really enjoyed it. Below I present a few comments regarding some information I felt was lacking and some aspects that raised my curiosity. Introduction: 1. Some background on particular characteristics of Brazil and Finnish that might impact the studied variables might be informative for the readers. These countries are very different regarding the value placed on physical appearance, the access to health care, including dental treatments and aesthetic procedures, and the cost of the procedures – for example. Although some of these aspects were presented in the discussion section, I think it is important to state in the introduction what are the reasons (if any) to investigate these countries in a single study (and to compare them). Method: 2. What were the criteria used to categorize the variable income? 3. Did the participants receive some incentive to participate in the study? Did they receive information about the results of the study? 4. Since it was an online survey using snowball sampling, did the authors employ some strategy to confirm that the respondents were adults? 5. When examing the validity of the data using confirmatory factor analysis, did the authors test data normality (both univariate and multivariate)? 6. For the analysis of logistic regression, how the reference categories of each variable were established? Reviewer #2:  This study is very interesting because it shows the importance of sociodemographic and psychological variables as predictors of the seek/undergoing aesthetic dental treatment. The sample size and the rigor of the statistical procedures represent a great strength of the work presented. The document shows four specific objectives however, there is no general objective that allows the articulation of all of them in such a way that the final purpose of the study presented can be identified. The fourth specific objective, "to conduct a cross-national study", is not essentially an objective, but rather an activity. It is already integrated into the specific objectives when the comparison between Brazilians and Finnish is mentioned. When reviewing the coherence and integration between the objectives of the study, it is identified that the first one relates sociodemographic variables with the probability of seeking and undergoing aesthetic dental treatment; the second objective relates sociodemographic variables to facial appearance; and the third objective relates OFA to SWL. However, it would be important to explore if the sociodemographic variables, OFA, and SWL are related to the probability of undergoing aesthetic dental treatment. This can be an alternative to the articulation of specific objectives. There is no clarity in the text of lines 70 and 71: "Individuals who were more satisfied and had less psychosocial impact from OA had higher levels of LS". What does the word "satisfied" refer to? It is necessary to clarify the criteria that were used to create the income ranges. It would be necessary to check if the income issue is comparable, in terms of what is required to live. The fact that the majority of Finnish are in quartile 1 may indicate a guarantee of living conditions, while in Brazil it may show inequities in income distribution. It is necessary to clarify in the text how the calculation of the effect size was made. Access to treatment may be mediated by economic conditions. The difference in OR behavior between those who seek and those who undergo aesthetic dental treatment shows the importance of income as a key factor, reason for which it must be considered in the study of the conditions that intervene in the search and realization of dental treatments. It is suggested to update Figure 3, which corresponds to the SEM, so that the final model evaluated is included. Finally, it is important to emphasize that the study of the conditions that promote the development of specific health results has been a topic developed from Latin American models known as critical epidemiology or the social determination of health, proposals that can provide new elements of understanding of how the social, cultural, economic, and political conditions interact so that results such as those discussed in the study are presented. In this regard, I respectfully suggest some references: Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev. Fac. Nac. Salud Pública 2013; 31(supl 1): S13-S27. Available: http://www.scielo.org.co/pdf/rfnsp/v31s1/v31s1a02.pdf Ruiz DC, Morales C. Social determination of the oral health disease process: a social-historical approach in four Latin American countries. Invest Educ Enferm. 2015; 33(2): 248-259. Available: http://www.scielo.org.co/pdf/iee/v33n2/v33n2a07.pdf Concha S. Determinación Social de la atención odontológica de las mujeres embarazadas de tres localidades de Bogotá. Tesis Doctoral. Bogotá: Universidad Nacional de Colombia. Available: https://repositorio.unal.edu.co/bitstream/handle/unal/55763/%281%2963317599.2015.pdf?sequence=1&isAllowed=y ********** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. 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Please note that Supporting Information files do not need this step. 10.1371/journal.pone.0287235.r002 Author response to Decision Letter 0 Submission Version1 14 May 2023 Dear Dr. Ana Cristina Mafla, Academic Editor PLOS ONE Thank you for reviewing our manuscript and considering the study for publication after the requested review. We are submitting a revised manuscript highlighting the changes and a clean version. Please kindly see below our response point-by-point to reviewers’ comments and suggestions. We hope that the responses and the revised manuscript address the reviewers' comments. Sincerely, The Authors Reviewer #1 •The subject of this manuscript is of interest for research in several fields such as body image, mental health, and dentistry, as also for clinical practice. This is a well-written manuscript resulting from a robust method. Reading the text was very informative. I really enjoyed it. Below I present a few comments regarding some information I felt was lacking and some aspects that raised my curiosity. -Response: Thank you. •Introduction: 1. Some background on particular characteristics of Brazil and Finnish that might impact the studied variables might be informative for the readers. These countries are very different regarding the value placed on physical appearance, the access to health care, including dental treatments and aesthetic procedures, and the cost of the procedures – for example. Although some of these aspects were presented in the discussion section, I think it is important to state in the introduction what are the reasons (if any) to investigate these countries in a single study (and to compare them). -Response: Thank you for your comment. We have added to the introduction some differences that justify the comparison between the countries (lines: 145-159) and also a sentence in the methods (lines: 172-174). •Method: 2. What were the criteria used to categorize the variable income? -Response: The categories for the monthly income variable were defined based on the recommendations and criteria of Statistics Finland and Centro de Políticas Sociais - FGV Social (Brazil). Both institutions are involved in research aimed at informing societal debates and the implementation of public policies. This information has been added to the manuscript (lines: 190-192). •3. Did the participants receive some incentive to participate in the study? Did they receive information about the results of the study? -Response: No, participation in the study was voluntary and anonymous in both countries, and participants did not receive any incentives to take part (information added in lines: 214-215). As data collection was anonymous and we did not have access to information that could identify individual participants during or after data collection, participants did not receive the study results directly. However, participants were provided with the researchers' contact information before and after the study to request additional information and the study results. Furthermore, we aim to disseminate our academic findings to the broader society using non-academic language. This is achieved through publication on the universities' institutional websites and through mainstream media, such as newspaper and magazine interviews. In Finland, results related to the findings have been discussed in two interviews for national journals and magazines. In Brazil, the results can be presented institutionally after the manuscript is published. •4. Since it was an online survey using snowball sampling, did the authors employ some strategy to confirm that the respondents were adults? -Response: Thank you for your question. We adhered to the guidelines and regulations set by the Data Protection Officer in Finland and the Research Ethics Committee in Brazil for online data collection. The only measure we took to ensure that respondents were adults was to include a question about their age and obtain their consent to participate in the study, which was obtained only after informing participants about the nature of the research and its inclusion criteria for adult individuals. •5. When examing the validity of the data using confirmatory factor analysis, did the authors test data normality (both univariate and multivariate)? -Response: Yes, the assumption of normality (both univariate and multivariate) was attested for the CFA. We have added this information and results to the manuscript (lines: 243-249 and 266-270). •6. For the analysis of logistic regression, how the reference categories of each variable were established? -Response: The reference categories for the independent variables were established based on previous studies that identified the groups with the lowest prevalence of seeking/undergoing esthetic treatments (information added in lines: 287-289). Reviewer #2 •This study is very interesting because it shows the importance of sociodemographic and psychological variables as predictors of the seek/undergoing aesthetic dental treatment. The sample size and the rigor of the statistical procedures represent a great strength of the work presented. -Response: Thank you. •The document shows four specific objectives however, there is no general objective that allows the articulation of all of them in such a way that the final purpose of the study presented can be identified. -Response: Thank you for your comment. The addition of an objective integrating the relationship between orofacial appearance, satisfaction with life, demographic variables, and receiving aesthetic dental treatment undoubtedly brings coherence and improves the manuscript. Please see below for our modifications and additions. •The fourth specific objective, "to conduct a cross-national study", is not essentially an objective, but rather an activity. It is already integrated into the specific objectives when the comparison between Brazilians and Finnish is mentioned. -Response: The reviewer is correct. Therefore, we have removed this fourth objective. •When reviewing the coherence and integration between the objectives of the study, it is identified that the first one relates sociodemographic variables with the probability of seeking and undergoing aesthetic dental treatment; the second objective relates sociodemographic variables to facial appearance; and the third objective relates OFA to SWL. However, it would be important to explore if the sociodemographic variables, OFA, and SWL are related to the probability of undergoing aesthetic dental treatment. This can be an alternative to the articulation of specific objectives. -Response: Thank you for the comment. We appreciate it and agree that adding an objective that integrates sociodemographic variables, orofacial appearance, life satisfaction, and aesthetic treatment makes the manuscript more coherent. To elaborate this new objective, we considered that the "dental aesthetic treatment" variable was obtained through a question asking whether the participant had received this treatment. We also noted that that "life satisfaction", measured by SWLS, refers to the overall life satisfaction at the time of filling out the survey (after the participant had undergone the aesthetic treatment). Thus, we have decided to keep life satisfaction as dependent variable, and include aesthetic dental treatment in the SEM. Based on the data, we believe that the model that considers the indirect effect of the treatment variable on the impact of orofacial appearance on life satisfaction is the most coherent and theoretically plausible. This model also maintains moderation role of sociodemographic variables on this impact and includes a direct path from these variables to treatment. We remain open to any other suggestions the reviewer may have. We have modified and/or added information in the objectives (lines: 56-57 and 163-166), methods (lines: 324-327, 335-337; Fig. 1), results (lines: 422-430; Table 4), and discussion (lines: 546-554). •There is no clarity in the text of lines 70 and 71: "Individuals who were more satisfied and had less psychosocial impact from OA had higher levels of LS". What does the word "satisfied" refer to? -Response: We added information to make it clearer (“Individuals who were more satisfied with their own OA…”; line: 72) •It is necessary to clarify the criteria that were used to create the income ranges. It would be necessary to check if the income issue is comparable, in terms of what is required to live. The fact that the majority of Finnish are in quartile 1 may indicate a guarantee of living conditions, while in Brazil it may show inequities in income distribution. -Response: The categories for the monthly income variable were defined based on the recommendations and criteria of Statistics Finland and Centro de Políticas Sociais - FGV Social (Brazil). Both institutions are involved in research aimed at informing societal debates and the implementation of public policies considering the reality of each country. This information has been added to the manuscript (lines: 190-192). Following Reviewer 1's comment, we have added a paragraph to the introduction highlighting the differences between the countries, including differences in living conditions and inequalities among socioeconomic classes (lines: 150-155). Additionally, we have included in the text that the results point to these differences and that income categories are not directly comparable (lines: 355-360). •It is necessary to clarify in the text how the calculation of the effect size was made. -Response: The calculation of effect sizes has been added to the Methods (lines: 300-301 and 341). Thank you. •Access to treatment may be mediated by economic conditions. The difference in OR behavior between those who seek and those who undergo aesthetic dental treatment shows the importance of income as a key factor, reason for which it must be considered in the study of the conditions that intervene in the search and realization of dental treatments. -Response: Thank you for the comment. We add some sentences in discussion to reinforce this idea of the importance of income as a key factor in seeking and accessing dental treatments (lines: 529-533). •It is suggested to update Figure 3, which corresponds to the SEM, so that the final model evaluated is included. -Response: Figure 1 has been updated according to the new proposed aim and adding the final refined model. •Finally, it is important to emphasize that the study of the conditions that promote the development of specific health results has been a topic developed from Latin American models known as critical epidemiology or the social determination of health, proposals that can provide new elements of understanding of how the social, cultural, economic, and political conditions interact so that results such as those discussed in the study are presented. In this regard, I respectfully suggest some references: Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev. Fac. Nac. Salud Pública 2013; 31(supl 1): S13-S27. Available: http://www.scielo.org.co/pdf/rfnsp/v31s1/v31s1a02.pdf Ruiz DC, Morales C. Social determination of the oral health disease process: a social-historical approach in four Latin American countries. Invest Educ Enferm. 2015; 33(2): 248-259. Available: http://www.scielo.org.co/pdf/iee/v33n2/v33n2a07.pdf Concha S. Determinación Social de la atención odontológica de las mujeres embarazadas de tres localidades de Bogotá. Tesis Doctoral. Bogotá: Universidad Nacional de Colombia. Available: https://repositorio.unal.edu.co/bitstream/handle/unal/55763/%281%2963317599.2015.pdf?sequence=1&isAllowed=y -Response: Thank you for the comment. We have added a final paragraph to the discussion, as well as the suggested references that we had access, emphasizing the contribution of our study and the importance of investigating this topic. (lines: 595-602) Attachment Submitted filename: Response to Reviewers.docx Click here for additional data file. 10.1371/journal.pone.0287235.r003 Decision Letter 1 Mafla Ana Cristina Academic Editor © 2023 Ana Cristina Mafla 2023 Ana Cristina Mafla https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version1 2 Jun 2023 Aesthetic dental treatment, orofacial appearance, and life satisfaction of Finnish and Brazilian adults PONE-D-23-06321R1 Dear Dr. Lucas Arrais Campos, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Ana Cristina Mafla Academic Editor PLOS ONE 10.1371/journal.pone.0287235.r004 Acceptance letter Mafla Ana Cristina Academic Editor © 2023 Ana Cristina Mafla 2023 Ana Cristina Mafla https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 21 Jun 2023 PONE-D-23-06321R1 Aesthetic dental treatment, orofacial appearance, and life satisfaction of Finnish and Brazilian adults Dear Dr. Campos: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Ana Cristina Mafla Academic Editor PLOS ONE ==== Refs References 1 Campos LA , Campos JADB , Silva WRD , Peltomaki T , Pinto ADS , Maroco J . Impact of body and orofacial appearance on life satisfaction among Brazilian adults. PLoS One. 2022;17 (11 ): e0275728. doi: 10.1371/journal.pone.0275728 36331912 2 Pithon MM , Nascimento CC , Barbosa GC , Coqueiro RS . Do dental esthetics have any influence on finding a job? 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Braz Oral Res. 2018;32 : e12. doi: 10.1590/1807-3107bor-2018.vol32.0012 29538477 12 Campos LA , Campos J , Kamarainen M , Silvola AS , Maroco J , Peltomaki T . Self-perception of orofacial appearance: Brazil-Finland cross-national study. Acta Odontol Scand. 2022;80 (8 ): 626–34. doi: 10.1080/00016357.2022.2077432 35622953 13 John MT . Foundations of oral health-related quality of life. J Oral Rehabil. 2021;48 : 355–9. doi: 10.1111/joor.13040 32658317 14 Campos LA , Peltomaki T , Maroco J , Campos J . Use of Oral Health Impact Profile-14 (OHIP-14) in Different Contexts. What Is Being Measured? Int J Environ Res Public Health. 2021;18 (24 ): 13412. doi: 10.3390/ijerph182413412 34949018 15 Campos LA , Kamarainen M , Silvola AS , Maroco J , Peltomaki T , Campos JADB . Orofacial Esthetic Scale and Psychosocial Impact of Dental Aesthetics Questionnaire: development and psychometric properties of the Finnish version. 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