## 4 Discussion
### Personality and Attitudes Toward Orthodontic Treatment  
Personality traits are crucial in shaping patients' attitudes toward orthodontic treatment. Two studies have demonstrated how certain traits, such as agreeableness, openness, extraversion, conscientiousness, and neuroticism, influence the willingness to undergo treatment [52, 53]. Agreeableness is positively correlated with a greater acceptance of various treatment options [53], suggesting that cooperative and trusting individuals are more receptive to orthodontic care. Similarly, elevated extraversion has been linked to more positive attitudes toward treatment, with these patients often being more motivated and engaged, leading to better adherence to treatment protocols and improved overall experiences [52, 55, 66]. In addition, patients with high openness are more likely to perceive orthodontic treatment favorably [52, 63], promoting better compliance and outcomes [64, 66]. Patients open to new experiences may exhibit greater adaptability to the discomfort and lifestyle changes associated with orthodontic treatment, such as dietary restrictions and oral hygiene modifications [67]. In contrast, high neuroticism is associated with negative treatment attitudes [53], likely due to increased anxiety and reduced stress-coping \begin{table}
\begin{tabular}{c c c c c c} \hline \hline  & \multicolumn{4}{c}{**Outcomes**} \\ \cline{2-6}  & **Pain Perception** & **Attitude** & **Compliance** & **Satisfaction** & **OHRQoL** \\ \hline
**Number** & 5 studies & 5 studies & 4 studies [58, 59, 61, 60] & 2 studies [56, 64] & 4 studies [54, 55, 62] & 4 studies [56, 54, 55, 62] (511 patients) & 4 studies [54, 55, 62] (519 patients) & 4 studies [54, 55, 62] (519 patients) \\ \hline
**Study design** & \begin{tabular}{c} Observational studies \\ (mainly cross-sectional \\ and one study including \\ a short-term \\ prospective observation) \\ \end{tabular} & \begin{tabular}{c} Observational studies \\ studies \\ (cross-sectional) \\ \end{tabular} & \begin{tabular}{c} Observational studies \\ (mostly cross-sectional \\ and one longitudinal \\ observational study) \\ \end{tabular} & \
\begin{tabular}{c} Observational studies \\ studies \\ (cross-sectional) \\ \end{tabular} &
\begin{tabular}{c} Observational studies \\ studies \\ (cross-sectional) \\ \end{tabular} \\ \hline
**Risk of Bias** & Not serious & Not serious & Serious \({}^{\text{a}}\) & Not serious & Not serious \\ \hline
**Inconsistency** & Not serious & Not serious & Serious \({}^{\text{b}}\) & Serious \({}^{\text{b}}\) \\ \hline
**Indirectness** & Not serious & Not serious & Serious \({}^{\text{c}}\) & Not serious \\ \hline
**Imprecision** & Serious \({}^{\text{d}}\) & Serious \({}^{\text{d}}\) & Serious \({}^{\text{d}}\) & Serious \({}^{\text{d}}\) & Serious \({}^{\text{d}}\) \\ \hline
**Other** & None \({}^{\text{e}}\) & None \({}^{\text{e}}\) & None \({}^{\text{e}}\) & None \({}^{\text{e}}\) & None \({}^{\text{e}}\) \\ \hline
**Effect of direction** & \begin{tabular}{c} Higher neuroticism \\ and maladaptive traits \\ are associated with \\ increased \\ pain perception. \\ \end{tabular} & \begin{tabular}{c} Extraversion, \\ openness, and \\ conscientiousness \\ are associated with \\ more positive \\ treatment attitudes. \\ \end{tabular} & \begin{tabular}{c} Higher neuroticism \\ conscientiousness and \\ self-efficacy are \\ associated with \\ compliance, but some \\ studies show \\ mixed results. \\ \end{tabular} & \
\begin{tabular}{c} Higher neuroticism \\ is associated with \\ lower satisfaction; \\ \end{tabular} &
\begin{tabular}{c} Higher neuroticism \\ is associated with \\ poorer OHRQoL, \\ power \\ or theftsoQL, \\ while extraversion \\ and \\ and openness buffer \\ negative impacts. \\ \end{tabular} \\ \hline
**Overall** & \(\oplus\)OOO & \(\oplus\)OOO & \(\oplus\)OOO & \(\oplus\)OOO & \(\oplus\)OOO \\
**GRADE certainty** & Very low & Very low & Very low & Very low \\ \hline \hline \end{tabular}
\end{table} 
Table 5: Assessment of the certainty of evidence using the GRADE tool. abilities [52; 57; 68].