The Relationship between Orthodontic Treatment Need and Oral Health Related Quality of Life of School Children
Abdolreza Jamilian1a*, Alireza Darnahal1b, Sara Eslami2c, Bita Kiaee1d, Zinat Kamali3e, Letizia Perillo4f
- Department of Orthodontics, Tehran Dental Branch, Islamic Azad University, Tehran, Iran
- Department of Periodontics, Tehran Dental Branch, Islamic Azad University, Tehran, Iran
- National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Post Graduate Orthodontic Program, Departments of Orthodontics, Second University of Naples, Naples, Italy
a., f. DDS, PhD, Professor
b., d. DDS
c DDS, Assistant Professor
Professor Abdolreza Jamilian, DDS, PhD
No 2713, Vali Asr St. Tehran 1966843133, Iran
Tel: 0098-21-22011892; Fax: 0098-21-22022215
Objective: The aim of this study was to assess the effect of different orthodontic treatment needs on the oral health-related quality of life of young people aged 15-17.
Methods: 684 (343 boys and 341 girls) school children aged 15 to 17 years were selected at random from 12 schools to represent the four main areas of Tehran. Malocclusion of the subjects was determined with the Dental Health Component (DHC) of Index of Orthodontic Treatment Need (IOTN). Participants also completed the shortened version Oral Health Impact Profile questionnaire (OHIP-14). Chi-Square test was used to analyze the data
Results: 41 of the subjects had previous orthodontic treatment or were being treated at the time of study. 413, 172, and 58 of the subjects had little or no, borderline, and actual need for orthodontic treatment, respectively. Orthodontic treatment need significantly affected all daily activities in both male and female subjects.
Conclusions: Malocclusion has a negative impact on both physical and psychological aspects of the daily life of subjects who are in definite need for orthodontic treatment.
Keywords: Orthodontic Treatment Need; Oral Health Related Quality of Life; Malocclusion; psychology
Malocclusion in itself is neither a disease nor a life threatening condition; (1) nevertheless, the appearance of the mouth and a person’s smile plays a significant role in judgments regarding facial attraction. Thus, malocclusion has large physical, social, and psychological impact on the individual and society.(2-4) Quality of life (QoL) has been defined by the World Health Organization as ‘‘people’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.’’(5) Oral health-related quality of life (OHRQoL) is the extent to which oral and paraoral conditions impact one’s life. Recently, researchers and clinicians have focused more on the patients’ own perceptions of oral health status and oral health care systems to understand their needs, satisfaction with treatment, and ultimately the perceived overall quality of health systems.(6, 7) Understanding the impact of orthodontic treatment on quality of life is of great importance for many reasons. Informing the patients about the consequences and discomfort can lead to a better understanding. Informed consent gives the patients insight into the benefits and health gains associated with orthodontic treatment, which might help overcome problems associated with non-compliance.(8)
Recently, an Index of Treatment Need (IOTN) was proposed by Brook and Shaw(9) in the United Kingdom as a scoring system for estimating treatment need of patients with various degrees of malocclusion. The Dental Health Component (DHC) of the IOTN index places patients in five grades from “no need for treatment” to “extreme treatment need”. (Table 1) The IOTN has been used extensively in literature to evaluate actual and perceptive orthodontic treatment needs.(10, 11) The use of IOTN alone to establish orthodontic treatment need may be potentially problematic since some patients who have no psychosocial need for treatment would be perceived as requiring treatment. (12) The use of OHRQoL measures in addition to professional indices offers a potentially useful combination. Therefore, various studies have evaluated IOTN and its impact on OHRQoL. Masood et al(13) found that malocclusion has a significant negative impact on OHRQoL and its domains. Nevertheless, there was no reported difference in impact between male and females. Agou et al also found that the impact of malocclusion on quality of life is substantial in children with low self-esteem.(14) Nevertheless, some other authors did not find any relationship between malocclusion or orthodontic treatment need and OHRQoL.(15-17) Therefore, the aim of this study was to assess the effect of different orthodontic treatment needs on the OHRQOL of young adults.
Material and Methods:
This study received approval from the Human Research Ethics Committee of the IAU University of medical sciences. Twelve schools were randomly selected among all high schools in the east, west, north, south, and center of Tehran (Iran) and a random sample of 684 (343 boys and 341 girls) aged 15–17 year-olds attending these schools was selected (30 to 35 subjects were randomly selected from each school). Parents of sampled children were notified about the purposes of the study.
Each patient was examined for orthodontic treatment need with IOTN. The examinations were conducted at school during the day, by one trained and calibrated dentist with the help of a tongue blade, mirror, probe and ruler; no radiographs were taken. The treatment needs of the patients were categorized as little or no treatment needed (IOTN 1 and 2), borderline need (IOTN 3), and definite need for treatment (IOTN 4 and 5). The subjects with previous orthodontic treatment were also categorized as a separate group. Examiner error was determined by re-examining 30 subjects after a period of at least two weeks. The error was non-significant.
The subjects were also asked to complete questionnaires incorporating the Short Form Oral Health Impact Profile measure (OHIP-14, a generic oral health–related QoL assessment).(18) The OHIP is designed to determine the perception of the social impact of oral disorders and has well-documented psychometric properties.(19) Responses to the 14 items of OHIP were recorded in a 5-point Likert scale (0= never, 1= hardly ever, 2= occasionally, 3 = fairly often, 4 = very often). The responses were dichotomized as “impact” and “no impact”. The responses of “never” and “hardly ever” were considered as “no impact” and “occasionally”, “fairly often”, and “very often” were considered as at least some oral health “impact”. The Statistical Package for Social Sciences, Version 20 (SPSS Inc. Chicago, Illinois, USA) was used to analyze the data. Chi-Square test was used to analyze the data and p-value was set at P < 0.05.
A total of 684 students (mean age16±0.8 years) from 12 secondary schools were examined. Table 2 shows that the samples included 343 male and 341 female subjects. Table 2 also shows the detailed distribution of subjects based on their IOTN grades. As can be seen in table 3, daily activities were associated with higher orthodontic treatment needs in both male and female subjects. Almost none of the subjects with no or little treatment need and borderline treatment need had problem pronouncing words; while 26 % of the male students and 30% of the female students of the definite need for treatment group had problem pronouncing words. (P<0.001) About 70% of the female subjects and 43% of the male subjects of the definite need for treatment group felt tense in their life; while, only 5% of the male subjects and 4% of the female subjects of the no or little treatment need group felt tense. Chi-square test showed that all daily activities were significantly affected by the treatment need.
This study showed that malocclusion has both physical and psychological impacts on male and female subjects who are in definite need for orthodontic treatment. The findings of this study corresponds with the study conducted by Hassan and Amin Hel(20). Their study results highlighted the impact of malocclusion on OHRQoL of young adults and emphasize the importance of patient-based evaluation of oral health status and oral health needs. However, they showed that orthodontic treatment needs did not significantly affect speech and word pronunciation. While similar to our study other researchers observed a strong association between speech disorders and dentofacial abnormalities.(21-24) The difference between this study and the study conducted by Hassan and Amin Hel (20) might be the difference between the ages of the subjects since in their study the subjects were 21 to 25 years old. In a wider age range Masood et al (13) assessed OHRQoL in young people aged 15–25, and the association between IOTN, sex, age and education level, and OHRQoL. Similar to our study, they found that malocclusion has a significant negative impact on OHRQoL and its domains. Likewise, they reported no difference in impact between males and females. With respect to the gender differences, the findings of our study were in contradiction with the study of de Oliveria and Sheiham (25), who reported that sex significantly affects the impact of malocclusion on OHRQOL, and women were 1.22 times more likely to have an impact than men.
Both IOTN and OHIP-14 are reliable instruments; nevertheless, they have some limitations. One of the major limitations of OHIP-14 is that it does not elicit the specific cause(s) of the impacts recorded, which can be related to a variety of oral health conditions and not necessarily the subject’s malocclusion. IOTN may be a relatively insensitive instrument to measure minor occlusal traits and irregularities which mostly affect patient appearance and about which a patient is deeply concerned.(26)
Malocclusion has a negative impact on both physical and psychological aspects of the daily life of subjects who are in definite need for orthodontic treatment. These impacts are similar for both male and female subjects.
Conflict of Interest and Sources for Funding:
- Mohlin B, al-Saadi E, Andrup L, Ekblom K. Orthodontics in 12-year old children. Demand, treatment motivating factors and treatment decisions. Swedish dental journal. 2002;26(2):89-98.
- Liu Z, McGrath C, Hagg U. The impact of malocclusion/orthodontic treatment need on the quality of life. A systematic review. The Angle orthodontist. 2009;79(3):585-591.
- van Wyk PJ, Drummond RJ. Orthodontic status and treatment need of 12-year-old children in South Africa using the Dental Aesthetic Index. SADJ : journal of the South African Dental Association = tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging. 2005;60(8):334-336, 8.
- Perillo L, Femminella B, Farronato D, Baccetti T, Contardo L, Perinetti G. Do malocclusion and Helkimo Index >/= 5 correlate with body posture? Journal of oral rehabilitation. 2011;38(4):242-252.
- The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Social science & medicine. 1995;41(10):1403-1409.
- Barbosa TS, Gaviao MB. Oral health-related quality of life in children: part II. Effects of clinical oral health status. A systematic review. International journal of dental hygiene. 2008;6(2):100-107.
- Ballini A, Cantore S, Fatone L, Montenegro V, De Vito D, Pettini F, et al. Transmission of nonviral sexually transmitted infections and oral sex. The journal of sexual medicine. 2012;9(2):372-384.
- Sergl HG, Klages U, Zentner A. Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 1998;114(6):684-691.
- Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. European journal of orthodontics. 1989;11(3):309-320.
- Perillo L, Masucci C, Ferro F, Apicella D, Baccetti T. Prevalence of orthodontic treatment need in southern Italian schoolchildren. European journal of orthodontics. 2010;32(1):49-53.
- Jamilian A, Toliat M, Etezad S. Prevalence of malocclusion and index of orthodontic treatment need in children in Tehran. Oral health & preventive dentistry. 2010;8(4):339-343.
- Kok YV, Mageson P, Harradine NW, Sprod AJ. Comparing a quality of life measure and the Aesthetic Component of the Index of Orthodontic Treatment Need (IOTN) in assessing orthodontic treatment need and concern. Journal of orthodontics. 2004;31(4):312-318; discussion 00-1.
- Masood Y, Masood M, Zainul NN, Araby NB, Hussain SF, Newton T. Impact of malocclusion on oral health related quality of life in young people. Health Qual Life Outcomes. 2013;11:25.
- Agou S, Locker D, Streiner DL, Tompson B. Impact of self-esteem on the oral-health-related quality of life of children with malocclusion. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2008;134(4):484-489.
- O’Brien C, Benson PE, Marshman Z. Evaluation of a quality of life measure for children with malocclusion. Journal of orthodontics. 2007;34(3):185-193; discussion 76.
- de Oliveira CM, Sheiham A, Tsakos G, O’Brien KD. Oral health-related quality of life and the IOTN index as predictors of children’s perceived needs and acceptance for orthodontic treatment. British dental journal. 2008;204(7):1-5; discussion 384-385.
- Zhang M, McGrath C, Hagg U. The impact of malocclusion and its treatment on quality of life: a literature review. International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children. 2006;16(6):381-387.
- Ravaghi V, Farrahi-Avval N, Locker D, Underwood M. Validation of the Persian short version of the Oral Health Impact Profile (OHIP-14). Oral health & preventive dentistry. 2010;8(3):229-235.
- Slade GD. Assessing change in quality of life using the Oral Health Impact Profile. Community dentistry and oral epidemiology. 1998;26(1):52-61.
- Hassan AH, Amin Hel S. Association of orthodontic treatment needs and oral health-related quality of life in young adults. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2010;137(1):42-47.
- Vallino LD, Tompson B. Perceptual characteristics of consonant errors associated with malocclusion. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 1993;51(8):850-856.
- Pahkala R, Laine T, Narhi M. Associations among different orofacial dysfunctions in 9-11-year-olds. European journal of orthodontics. 1995;17(6):497-503.
- Perillo L, Castaldo MI, Cannavale R, Longobardi A, Grassia V, Rullo R, et al. Evaluation of long-term effects in patients treated with Frankel-2 appliance. European journal of paediatric dentistry : official journal of European Academy of Paediatric Dentistry. 2011;12(4):261-266.
- Jamilian A, Perillo L, Rosa M. Missing upper incisors: a retrospective study of orthodontic space closure versus implant. Progress in orthodontics. 2015;16(1):2.
- de Oliveira CM, Sheiham A. Orthodontic treatment and its impact on oral health-related quality of life in Brazilian adolescents. Journal of orthodontics. 2004;31(1):20-27; discussion 15.
- Bernabe E, Sheiham A, Tsakos G, Messias de Oliveira C. The impact of orthodontic treatment on the quality of life in adolescents: a case-control study. European journal of orthodontics. 2008;30(5):515-520.