Brazilian adolescents' perception of the orthodontic appliance: A qualitative study Anderson Barbosa de Almeida, Isabel Cristina Gonc ¸ alves Leite, and Girlene Alves da Silva Juiz de Fora, Brazil Introduction: Orthodontic treatment has a significant impact on the quality of life and self-esteem of adolescents, with emotional and behavioral implications. The objective of this research was to understand Brazilian adolescents' perception of the orthodontic treatment. Methods: A qualitative research study was car- ried out through content analysis of data collected from 142 adolescents using the word-association technique (WAT), followed by 8 focus groups with 71 of these students. Results: The most recurrent words on the WAT demonstrated a positive esthetic impact of the orthodontic appliance, both for the adolescents' self- assessment and in the assessment of friends. Several themes were identified in the qualitative analysis, with the esthetic benefit of orthodontic treatment and the esthetic impact of the appliance being the most relevant positive points. The most-cited negative aspect in the study was the pain associated with the treatment, followed by the discomfort and trauma caused by the fixed appliance. Conclusions: Orthodontic treatment has a positive esthetic impact for Brazilian adolescents, with improvement of their self-image. Fixed orthodontic appliances have an immediate positive impact on appearance and are an important factor in behavioral relationships among Brazilian adolescents, particularly owing to their association with social status. The understanding of the sociobehavioral aspects involved in orthodontic treatment is of fundamental importance for the clinical relationship between patient and professional. (Am J Orthod Dentofacial Orthop 2019;155:490-7) M alocclusion is one of the most frequent oral health problems in the world, behind only dental caries and periodontal disease. 1 Maloc- clusion has a negative impact on children's, adolescents', and adults' self-esteem and quality of life, with signifi- cant consequences in their psychosocial, affective, and professional relationships. 2-4 Orthodontic treatment has shown improvements in quality of life and self- esteem, demonstrating its influence on emotional and behavioral aspects. 5-8 The perception of the need for orthodontic treatment and its impact on quality of life have been evaluated mainly with the use of quantitative research methods. 6,9-11 However, particularities related to the use of an orthodontic appliance in the imaginations of adolescents may go unnoticed by such research methods, raising the importance of complementarity between the approaches of quantitative and qualitative research. Evidence-based dentistry has its roots in epidemi- ology, whereas qualitative methods have their founda- tions in social sciences and therefore have had a limited impact on dental literature. However, implemen- tation of an evidence-based practice will depend criti- cally on the circulation of knowledge among research centers, professionals, and the population, a process that can be positively influenced by qualitative research. 12 Although qualitative research is increasingly used in the health area, there are still few studies that have explored its potential in the various medical and dental specialties. 13 The word-association technique (WAT) is a projective technique that allows the apprehension of mental pro- jections of a social group in a spontaneous way, and gives evidence of unconscious elements through mani- festations of behavior in reactions or evocations. 14 On the other hand, the focus group is a method that helps in understanding how different perceptions and Department of Collective Health, Faculty of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil. All authors have completed and submitted the ICMJE Form for Disclosure of Po- tential Conflicts of Interest, and none were reported. Address correspondence to: Anderson Barbosa de Almeida, Avenida Bar~ ao do Rio Branco 2555/601, Centro, Juiz de Fora, MG, Brazil; e-mail, anderjfalmeida@ gmail.com. Submitted, May 2017; revised and accepted, May 2018. 0889-5406/$36.00 Ó 2019 by the American Association of Orthodontists. All rights reserved. https://doi.org/10.1016/j.ajodo.2018.05.020 490 ORIGINAL ARTICLE