Influence of quality of life, self-perception, and self ...

ORIGINAL ARTICLE

Influence of quality of life, self-perception, and self-esteem on orthodontic treatment need Patr!ıcia R. dos Santos,a Marcelo de C. Meneghim,b Glaucia M. B. Ambrosano,b Mario Vedovello Filho,c and Silvia A. S. Vedovelloc Araras and Piracicaba, S~ao Paulo, Brazil Introduction: In this study, we aimed to assess the relationship between normative and perceived orthodontic treatment need associated with quality of life, self-esteem, and self-perception. Methods: The sample included 248 schoolchildren aged 12 years. The normative aspect of orthodontic treatment was assessed by the Dental Health Component and the Aesthetic Component of the Index of Orthodontic Treatment Need. The subjects were further evaluated for their oral health-related quality of life, self-esteem, and self-perception of oral esthetics. The Aesthetic Component of the Index of Orthodontic Treatment Need was considered as the response variable, and generalized linear models estimated by the GENMOD procedure (release 9.3, 2010; SAS Institute, Cary, NC). Model 1 was estimated with only the intercept, providing the basis for evaluating the reduction in variance in the other models studied; then the variables were tested sequentially, considering P #0.05 as the criterion for remaining in the model. Results: In the model, self-perception and self-esteem were statistically significant in relation to the perceived need for treatment. The normative need was significantly associated with the outcome variable and was not influenced by independent variables. Conclusions: The normative need for orthodontics treatment was not overestimated by the perceived need, and the perceived need was not influenced by sex and the impact on quality of life. (Am J Orthod Dentofacial Orthop 2017;151:143-7)

M

alocclusion is a public health problem with high prevalence in different populations,1-6 causing physical and psychological implications, influencing oral health-related quality of life.7-11 Social interactions are also influenced by malocclusion, affecting the way persons are perceived and how they perceive themselves.12 Therefore, their self-perception of oral health plays an important role in understanding the influence of malocclusion on quality of life.13-17 In childhood, physical and psychosocial changes contribute to the formation of a child's understanding,

a Araras Dental School, Centro Universit!ario Herm!ınio Ometto - Uniararas, Araras, S~ao Paulo, Brazil. b Department of Community Dentistry, Piracicaba Dental School, University of Campinas, Piracicaba, S~ao Paulo, Brazil. c Department of Orthodontics, Araras Dental School, Centro Universit!ario Herm!ınio Ometto - Uniararas, Araras, S~ao Paulo, Brazil. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Silvia A.S. Vedovello, Av. Dr. Maximiliano Baruto, 500, Jardim Universit!ario, Araras, S~ao Paulo 13607-339, Brazil; e-mail, [email protected]. Submitted, November 2015; revised and accepted, June 2016. 0889-5406/$36.00 ! 2017 by the American Association of Orthodontists. All rights reserved. http://dx.doi.org/10.1016/j.ajodo.2016.06.028

so that about 8 years of age, he or she has criteria regarding self-perception similar to those of adults. At this stage, children have also been shown to be more concerned about what others think of them, and this reflects directly on their self-esteem.18-21 The association between normative indicators and evaluation of the perceived impact of malocclusion on quality of life allows identifying patients with greater orthodontic treatment needs.15,17,22 Although orthodontic treatment need is usually identified through normative aspects, it is important to identify the needs that young people perceive regarding their occlusal conditions, increasingly influenced by behavioral and social factors.21-27 In this context, the aim of this study was to evaluate the relationship between normative and perceived orthodontic treatment needs, and assess its association with quality of life, self-esteem, and self-perception. MATERIAL AND METHODS

This cross-sectional study was conducted in municipal schools in Araras, S~ao Paulo, Brazil, with 12-yearold schoolchildren (138 boys, 110 girls). 143

dos Santos et al

144

The minimum sample calculated was 240 persons, considering a level of significance of 5%, test power of 80%, and minimum detectable odds ratio of 1.5. Excluded from the sample were children who had previously undergone, or were at present undergoing, orthodontic treatment; physical or intellectual limitations that would prevent the examination from being performed; and those whose parents did not authorize their participation, so that a sample of 248 schoolchildren was obtained. Data were collected in a clinical examination performed in the school environment, under natural light, using a wooden spatula and questionnaires that were answered by the children themselves. The outcome variable was the perceived need for orthodontic treatment, determined by the Aesthetic Component of the Index of Orthodontic Treatment Need (IOTN-AC). The IOTN-AC evaluates a person's psychosocial needs by means of a dental attractiveness scale illustrated by 10 color photographs that present a decreasing and continuous degree of attractiveness, in which photo 1 represents the most attractive dental arrangement and photo 10 the least attractive. The children made the evaluations by identifying the degree of esthetic compromise in the photographs of the scale similar to that of their own smile.28 Normative treatment need was assessed by using the Dental Health Component of the Index of Orthodontic Treatment Need (IOTN-DHC). The IOTN-DHC was performed by a duly calibrated examiner (P.R.D.), with experience in epidemiology and knowledge of orthodontics. By means of a scale of 5! in ascending order, the IOTN-DHC evaluates need, absence of teeth (including congenital absence and impacted teeth), overjet (positive or negative), anterior or posterior crossbite, crowding, overbite, and anterior or posterior open bite. Although all alterations were evaluated, only the severest are used as a basis for determining treatment needs; these were classified as without/little need (IOTN 1-2), moderate need (IOTN 3), or definite orthodontic treatment need (IOTN 4-5).28 To analyze the children's data, they were classified as without malocclusion (IOTN-DHC 1 and 2) and with malocclusion (IOTN-DHC 3, 4, and 5). The impact of malocclusion on the quality of life was evaluated by the Child Perceptions Questionnaire. This age-specific questionnaire (11-14 years) consists of 37 items, grouped into 4 domains: oral symptoms, functional limitations, emotional well-being, and social well-being. Each item asked about the frequency of events, as applied to the teeth, lips, and jaws, in the last 3 months. The response options were “never, once or twice, sometimes, often,” and “every day or almost

January 2017 " Vol 151 " Issue 1

every day.” The quality of life classification was dichotomized into “never, once or twice, sometimes, often” and worst impact (“every day or almost every day”). This instrument allows the score to be evaluated separately for each domain, but only the general score was used.29 Self-esteem was assessed with the Global Negative Self-evaluation. Each question contained 6 response options scored from 1 to 6: 1, does not apply at all; 2, does not apply well; 3, applies somewhat well; 4, applies fairly well; 5, applies well; and 6, applies exactly. The scores were added to obtain the average self-esteem score of each schoolchild; these were classified as high selfesteem or low self-esteem.30 Self-perception of oral esthetics was assessed by using the Oral Aesthetic Subjective Impact Scale (OASIS). The OASIS measures the impact of external influences in childhood by asking questions concerning the perceptions of others and themselves, as well as about their teeth. The schoolchildren had to answer 5 questions on a 7-point Likert scale, and points awarded to all questions were added to provide an overall oral esthetic impact score as perceived by each child. The scores for all questions and the value of the IOTN-AC were added to obtain the final sum of OASIS. This variable was dichotomized by the means as 0, positive selfperception (OASIS \14), and 1, negative selfperception (OASIS .14).31 Statistical analysis

After descriptive analysis of the data, multilevel, multiple logistic regression models were estimated by means of the PROC GENMOD procedure in a statistical program (release 9.3, 2010; SAS Institute, Cary, NC). The variables were sequentially tested in the models according to the study question, considering P #0.05 as the criterion for remaining in the model. Adjustment of the model was evaluated based on the lowest Corrected Akaike Information Criterion. Model 1 was estimated with the intercept only, serving as a basis for evaluating the reduction in residue in the remaining models studied. In models 2 and 3, the association between self-perception of the OASIS and the perceived treatment need (IOTN-AC) was analyzed, initially by the raw analysis (model 2) and afterward adjusted for possible confounding variables (sex, impact of malocclusion on quality of life, and self-esteem, model 3). The same procedure was performed for analysis of the association between normative orthodontic treatment need (IOTN-DHC) and the perceived orthodontic treatment need (IOTN-AC) in models 4 and 5.

American Journal of Orthodontics and Dentofacial Orthopedics

dos Santos et al

RESULTS

A total of 248 children were examined (44.4% boys, 55.6% girls) aged 12 years. The normative assessment of malocclusion showed that 61.7% of them had no orthodontic treatment need; 27% had a moderate need, and only 11.3% had a definite treatment need. The descriptive data of the results are presented in Table I. Multilevel logistic regression analysis is presented in Table II. Model 1 was constructed as the intercept only. In model 2, only the variable self-perception (OASIS) was tested in the analysis, in which statistical significance (P \0.0001) was observed when related to the outcome variable (IOTN-AC). In model 3, this association was adjusted for other possible confounding variables (sex, impact of malocclusion on quality of life, and self-esteem), and only self-perception (P \0.0001) and self-esteem (P 5 0.0280) were statistically significant. In model 4, the normative evaluation made by the professional (IOTN-DHC) was tested, and coherence was observed with the evaluation perceived by the child (P\0.0001). When adjusted for the variables sex, impact on quality of life, and self-esteem in model 5, the evaluation of orthodontic treatment need remained significant (P \0.0001). Thus, children with a negative self-perception associated with low self-esteem perceived a real need for orthodontic treatment that was not influenced by sex and the impact of malocclusion on quality of life. DISCUSSION

The indication for orthodontic treatment is generally made by normative evaluation of occlusal conditions.4,9,13,26 However, the literature has demonstrated the importance of considering the diagnosis perceived by each person, as well as understanding the psychosocial implications of malocclusion.14-18,20,24-27,32,35 Since the main motivation for seeking orthodontic treatment is to improve esthetic appearance, studying patients' perceptions and the impacts of malocclusion on their quality of life is of utmost importance to prioritize the treatment need.17,22-24,33 Many studies have used the Dental Aesthetic Index to assess orthodontic treatment need17,22,23,34; however, this index overestimates malocclusion characteristics.34 In this sense and according to the literature, indicators such as IOTN intend to measure the severity of the malocclusion objectively, either as a deviation from normal occlusion or in terms of perceived treatment need.28,33,34 Thus, although orthodontic treatment need indexes have been devised to minimize the subjectivity associated with the diagnosis and referral

145

Table I. Need for treatment according to sex, based on

IOTN Dental Health Component IOTN IOTN 1-2 No/little need IOTN 3 Moderate need IOTN 4-5 Definite need Total

Aesthetic Component

Boys n (%) 67 (43.8)

Girls n (%) 86 (56.2)

Boys n (%) 101 (43.9)

Girls n (%) 129 (56.1)

25 (37.3)

42 (62.7)

5 (41.7)

7 (58.3)

18 (64.2)

10 (35.8)

4 (66.7)

2 (33.3)

110 (44.4)

138 (55.6)

110 (44.4)

138 (55.6)

assessment of malocclusion, they do not necessarily indicate the complexity of the treatment.4,34,35 Furthermore, they contain an esthetic component (IOTN-AC), which reflects the need perceived by patients, considering their subjective perception to identify a malocclusion.16,36 In this study, the IOTN-AC was used to assess the perceived need for treatment, and, despite being a subjective assessment, the influences of selfperception (OASIS) and self-esteem (Global Negative Self-evaluation) were also studied to contribute to understanding the psychological and social aspects of occlusal changes.4,32,35 The normative evaluation of malocclusion overestimates the perceived need for orthodontic treatment13,19,26; however, the results of this study suggest a different conclusion. One probable hypothesis is that some studies cited13,19 used the Dental Aesthetic Index which corresponds to an esthetic index applied in an exclusively normative manner, whose final score is given by the sum of different occlusal characteristics, overestimating orthodontic treatment need.34 Therefore, our results showed that children who selfdeclared as having treatment needs (IOTN-AC) were also diagnosed as having orthodontic treatment needs through the normative criterion (IOTN-DHC). Methodologies that use direct questions to evaluate the perceived need for malocclusion treatment overestimate the person's perception.37,38 We used instruments specifically developed to measure self-perception related to malocclusion, such as the IOTN-AC and OASIS, based on the fact that the person's understanding was not influenced. Moreover, the literature highlights that orthodontic treatment need identified by professionals has an impact on a person's quality of life,9,11,13,16,39 with greater emphasis on severe malocclusions.39-41 Nevertheless, there are no reports of the influence on the perceived need. In this study, the impact on quality of life did



dos Santos et al


624.8691 625.1050 809.8991

Estim, Estimate of regression model coefficient; OASIS, Oral Aesthetic Subjective Impact Scale; CPQ11-14, Child Perceptions Questionnaire; GSE, Global Negative Self-evaluation; IOTN-DHC, Dental Health Component of Index of Orthodontic Treatment Need; AICC, Corrected Akaike Information Criterion.

0.0107 0.0640 781.5163

\0.0001

0.0276 0.0039 0.0295 0.0109 0.0143 0.0051 0.0384 0.0647 784.2325

0.6040 0.1926 0.1939 \0.0001

SE 0.0546 Estim 0.6407 SE 0.0313 Estim 0.5620

SE 0.0407 0.0022 0.0172 0.0027 0.0218 P value \0.0001 \0.0001 SE 0.0308 0.0022 Variable Intercept OASIS Sex (REF:M) CPQ11-14 GSE IOTN-DHC AICC

Estim 0.4113

SE 0.0148

P value \0.0001

Estim 0.9238 0.0483

Model 2 Model 1

Table II. Generalized linear models for IOTN-AC as response variable

Estim 0.8780 0.0499 0.0138 0.0017 0.0478

Model 3

P value \0.0001 \0.0001 0.4212 0.5293 0.0280

Model 4

P value \0.0001

Model 5

P value \0.0001

146

not influence the children's perceptions of the need for orthodontic treatment. The literature reports the impact of malocclusion on a subject's self-esteem.14,15 With this methodology, we investigated the influence of self-esteem on the perceived need for orthodontic treatment, demonstrating this association. Children with the worst selfesteem had greater perceived needs for treatment. One differential of this study was the use of a multilevel model in the analysis of factors concerning the relationship between normative and self-perceived treatment needs. Multilevel models are appropriate for the analysis of hierarchical data. The oral health data model is rather complex, since these data generally do not have a normal distribution. Furthermore, we used a technique that gives better estimates and substantive meanings to data clustering in comparison with traditional regression analysis. The application of generalized linear models has been satisfactorily used in multilevel analyses.42,43 On the other hand, this was a crosssectional study, and we sought inferences with regard to causal factors without, however, establishing a temporal relationship; this could be a limitation of the study. The results of this study show the importance of appreciating adequate criteria to identify patients' perceptions related to orthodontic treatment need. CONCLUSIONS

The normative need for orthodontics treatment was not overestimated by the children's perceptions. Factors such as sex and quality of life did not influence these perceptions. REFERENCES 1. Thilander B. Dentoalveolar development in subjects with normal occlusion. A longitudinal study between the ages of 5 and 31 years. Eur J Orthod 2009;32:109-20. 2. Mtaya M, Brudvik P, Astrom AN. Prevalence of malocclusion and its relationship with sociodemographic factors, dental caries, and oral hygiene in 12- to 14-year-old Tanzanian schoolchildren. Eur J Orthod 2009;31:467-76. 3. Borzabadi-Farahani A, Borzabadi-Farahani A, Eslamipour F. Malocclusion and occlusal traits in an urban Iranian population. An epidemiological study of 11- to14-year-old children. Eur J Orthod 2009;31:477-84. 4. Borzabadi-Farahani A. An insight into four orthodontic treatment need indices. Prog Orthod 2011;12:132-42. 5. Brasil Minist!erio da Sa! ude. Projeto SBBrasil 2010: Pesquisa Nacional de Sa! ude Bucal: Resultados Principais. Bras!ılia: Minist!erio da Sa! ude; 2011. 6. Dimberg L, Lennartsson B, Arnrup K, Bondemark L. Prevalence and change of malocclusions from primary to early permanent dentition: a longitudinal study. Angle Orthod 2015;85:728-34. 7. Seehra J, Newton JT, Dibiase AT. Interceptive orthodontic treatment in bullied adolescents and its impact on self-esteem and oral-health-related quality of life. Eur J Orthod 2012;35:615-21.


dos Santos et al

8. Chen M, Feng ZC, Liu X, Li ZM, Cai B, Wang DW. Impact of malocclusion on oral health-related quality of life in young adults. Angle Orthod 2015;85:986-91. 9. Sardenberg F, Martins MT, Bendo CB, Pordeus IA, Paiva SM, Auad SM, et al. Malocclusion and oral health-related quality of life in Brazilian school children. A population-based study. Angle Orthod 2013;83:83-9. 10. Peres KG, Peres MA, Thomson WM, Broadbent J, Hallal PC, Menezes AB. Deciduous-dentition malocclusion predicts orthodontic treatment needs later: findings from a population-based birth cohort study. Am J Orthod Dentofacial Orthop 2015;147: 492-8. 11. Pulache J, Abanto J, Oliveira LB, Bonecker M, Porras JC. Exploring the association between oral health problems and oral healthrelated quality of life in Peruvian 11- to 14- years-old children. Int J Paediatr Dent 2016;26:81-90. 12. Pithon MM, Nascimento CC, Barbosa GC, Coqueiro RS. Do dental esthetics have any influence on finding a job? Am J Orthod Dentofacial Orthop 2014;146:423-9. 13. Marques LS, Ramos-Jorge ML, Paiva SM, Pordeus IA. Malocclusion: esthetic impact and quality of life among Brazilian schoolchildren. Am J Orthod Dentofacial Orthop 2006;129:424-7. 14. Bradan SA. The effect of malocclusion and self-perceived aesthetics on the self-esteem of a sample of Jordanian adolescents. Eur J Orthod 2010;32:638-44. 15. Moura C, Cavalcanti AL, Gusm~ao ES, Soares RS, Moura FT, Santillo PM. Negative self-perception of smile associated with malocclusions among Brazilian adolescents. Eur J Orthod 2012; 35:483-90. 16. Benson PE, Da'as T, Johal A, Mandall NA, Williams AC, Baker SR, et al. Relationships between dental appearance, self-esteem, socio-economic status, and oral health-related quality of life in UK schoolchildren: a 3-year cohort study. Eur J Orthod 2015;37: 481-90. 17. Choi SH, Kim BI, Cha JY, Hwang CJ. Impact of malocclusion and common oral diseases on oral health-related quality of life in young adults. Am J Orthod Dentofacial Orthop 2015;147:587-95. 18. Bernab!e E, Tsakos G, Oliveira CM, Sheiham A. Impacts on daily performances attributed to malocclusion using the condition-specific feature of the oral impacts on daily performance index. Angle Orthod 2008;78:241-7. 19. Almeida AB, Leite IC, Melgaço CA, Marques LS. Dissatisfaction with dentofacial appearance and the normative need for orthodontic treatment: determinant factors. Dental Press J Orthod 2014;19:120-6. 20. Al-Omari IK, Al-Bitar ZB, Sonbol HN, Al-Ahmad HT, Cunningham SJ, Al-Omiri M. Impact of bullying due to dentofacial features on oral health-related quality of life. Am J Orthod Dentofacial Orthop 2014;146:734-9. 21. Taghavi Bayat J, Huggare J, Mohlin B, Akrami N. Determinants of orthodontic treatment need and demand: a cross-sectional path model study. Eur J Orthod 2016; http://dx.doi.org/10.1093/ejo/ cjw020 [Epub ahead of print]. 22. Feu D, de Oliveira BH, de Oliveira Almeida MA, Kiyak HA, Miguel JA. Oral health related quality of life and orthodontic treatment seeking. Am J Orthod Dentofacial Orthop 2010;138:152-9. 23. Agou S, Locker D, Muirhead V, Streiner DL, Tompson B, Streiner DL. Does psychological well-being influence oral-healthrelated quality of life reports in children receiving orthodontic treatment? Am J Orthod Dentofacial Orthop 2011;139:369-77. 24. Singh V, Hamdan A, Rock P. The perception of dental aesthetics and orthodontic treatment need by 10- to-11-year-old children. Eur J Orthod 2012;34:646-51.

147

25. Tessarollo FR, Feldens CA, Closs LQ. The impact of malocclusion on adolescents' dissatisfaction with dental appearance and oral functions. Angle Orthod 2012;82:403-9. 26. Ghijselings I, Brodens V, Willems G, Fieuws S, Clijmans M, Lemiere J. Normative and self-perceived orthodontic treatment need in 11-to 16-year-old children. Eur J Orthod 2014;36:179-85. 27. Gavric A, Mirceta D, Jakobovic M, Pavlic A, Zrinski MT, Spalj S. Craniodentofacial characteristics, dental esthetics-related quality of life, and self-esteem. Am J Orthod Dentofacial Orthop 2015; 147:711-8. 28. Brook PH, Shaw WC. The development of an index of orthodontic priority. Eur J Orthod 1989;11:309-20. 29. Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral health-related quality of life. J Dent Res 2002;81:459-63. 30. Alsaker FD, Olweus D. Assessment of global negative selfevaluations and perceived stability of self in Norwegian preadolescents and adolescents. J Early Adolesc 1986;6:269-78. 31. Mandall NA, McCord JF, Blinkhorn AS, Worthington HV, O'Brien KD. Perceived aesthetic impact of malocclusion and oral self-perceptions in 14-15-year-old Asian and Caucasian children in greater Manchester. Eur J Orthod 2000;22:175-83. 32. Phillips C, Beal KN. Self-concept and the perception of facial appearance in children and adolescents seeking orthodontic treatment. Angle Orthod 2009;79:12-6. 33. Borzabadi-Farahania A, Borzabadi-Farahanib A. Agreement between the index of complexity, outcome, and need and the dental and aesthetic components of the index of orthodontic treatment need. Am J Orthod Dentofacial Orthop 2011;140:233-8. 34. Herkrath FJ, Rebelo MA, Herkrath AP, Vettore MV. Comparison of normative methods and the sociodental approach to assessing orthodontic treatment needs in 12-year-old schoolchildren. Oral Health Prev Dent 2013;11:211-20. 35. Borzabadi-Farahani A. A review of the oral health-related evidences that supports the orthodontic treatment need indices. Prog Orthod 2012;13:314-25. 36. Dawoodbhoy I, Delgado-Angulo EK, Bernab!e E. Impact of malocclusion on the quality of life of Saudi children. Angle Orthod 2013; 83:1043-8. 37. Marques LS, Barbosa CC, Ramos-Jorge ML, Pordeus IA, Paiva SM. Malocclusion prevalence and orthodontic treatment need in 1014-year-old schoolchildren in Belo Horizonte, Minas Gerais State, Brazil: a psychosocial focus. Cad Saude Publica 2005;21: 1099-106. 38. Almeida AB, Leite CG. Orthodontic treatment need for Brazilian schoolchildren: a study using the Dental Aesthetic Index. Dental Press J Orthod 2013;18:103-9. 39. Scapini A, Feldens CA, Ardenghi TM, Kramer PF. Malocclusion impacts adolescents' oral health-related quality of life. Angle Orthod 2013;83:512-8. 40. De Paula Junior DF, Santos NC, da Silva ET, Nunes MF, Leles CR. Psychosocial impact of dental esthetics on quality of life in adolescents. Angle Orthod 2009;79:1188-93. 41. Ukra A, Page LA, Thomson WM, Farella M, Smith AT, Beck V. Impact of malocclusion on quality of life among New Zealand adolescents. N Z Dent J 2013;109:18-23. 42. Aida J, Hanibuchi T, Nakade M, Hirai H, Osaka K, Kondo K. The different effects of vertical social capital and horizontal social capital on dental status: a multilevel analysis. Soc Sci Med 2009;69:512-8. 43. Nkansah-Amankra S, Luchok KJ, Hussey JR, Watkins K, Liu X. Effects of maternal stress on low birth weight and preterm birth outcomes across neighborhoods of South Carolina. 2000-2003. Matern Child Health J 2010;14:215-26.

