The Saudi Journal of Medical Insights

Background: Malocclusion affects over half of the global population, with profound functional, aesthetic, and
psychosocial consequences. Orthodontic treatment offers effective intervention, yet access remains strikingly uneven
across populations, with socioeconomic status (SES) consistently identified as a critical determinant.
Objective: This systematic review comprehensively examines the influence of socioeconomic status on the decision to
undergo orthodontic treatment, synthesizing evidence from diverse geographic and healthcare contexts.
Methods: A systematic literature search was conducted across PubMed/MEDLINE, Scopus, Web of Science, Embase,
and the Cochrane Library (2021–2026). Studies were included if they examined the relationship between SES indicators
and orthodontic treatment outcomes. Two independent reviewers performed study selection, data extraction, and risk of
bias assessment using ROBINS-I and adapted Newcastle-Ottawa Scale tools. Narrative synthesis was employed due to
substantial heterogeneity.
Results: Seven studies encompassing multiple countries (China, France, Finland, Saudi Arabia, Australia, Nigeria,
Romania) were included. Findings revealed that SES significantly influences treatment decisions in multiple contexts,
though relationships varied across healthcare systems. Cost consistently emerged as the primary perceived barrier among
lower-income groups. Notably, low SES was not correlated with greater treatment complexity but was strongly associated
with lower patient cooperation, evidenced by increased bracket debondings, missed appointments, and treatment
abandonments. Geographic disparities compounded socioeconomic disadvantages, with reduced service availability in
lower SES areas.
Conclusion: Socioeconomic status significantly influences orthodontic treatment access, decisions, and outcomes, with
cost and cooperation representing critical mediating factors. Reducing disparities requires multi-level approaches
encompassing policy reform, healthcare system strengthening, and patient-centred clinical practice.