Original Article

Effect of orthodontic treatment on oral healthrelated quality of life

Daniela Feua; Jose Augusto M. Miguelb; Roger K. Celestec; Branca Heloisa Oliveirad
ABSTRACT Objective: To assess changes in oral healthrelated quality of life (OHQoL) in children undergoing fixed orthodontic treatment and compare it to that of two groups not receiving treatment. Materials and Methods: Two hundred eighty-four subjects aged 1215 years were followed for 2 years; 87 were undergoing treatment at a university clinic (TG), 101 were waiting for treatment at this clinic (WG), and 96 were attending a public school and had never sought treatment (SG). OHQoL was assessed using the Oral Health Impact Profile (OHIP-14). All subjects were examined and interviewed at baseline (T1), 1 year later (T2), and 2 years later (T3). OHIP-14 scores were analyzed using negative binomial regression in generalized estimating equations for correlated data. Results: During the follow-up period, the WG and TG OHIP-14 scores showed a statistically significant increase and decrease, respectively (P , .001). At T1, the TG had an OHIP-14 score that was 1.9 times higher than that of the SG; however at T3, the TG score was 60% lower than the initial score of the SG. Adjusting for age, gender, dental health status (DMFT), socioeconomic position, malocclusion severity, and self-perceived esthetics did not change the effect of orthodontic treatment on OHQoL. Conclusion: Fixed orthodontic treatment in Brazilian children resulted in significantly improved OHQoL after 2 years. (Angle Orthod. 2013;83:892898.) KEY WORDS: Oral healthrelated quality of life; Orthodontic treatment; Patient assessment

INTRODUCTION The increasing emphasis on the need for evidencebased health services requires that the evaluation of the effectiveness of orthodontic treatment employ outcome measures that are important to the patient and the clinician.1 Thus, studying oral healthrelated quality of life (OHQoL) in orthodontic patients may provide information that will help clinicians and public
a Specialist in Orthodontics, MSc in Orthodontics, PhD student, Rio de Janeiro State University, Rio de Janeiro, Brazil. b Adjunct Professor, Department of Orthodontics, Rio de Janeiro State University, Rio de Janeiro, Brazil. c Adjunct Professor, Department of Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. d Associate Professor, Department of Preventive and Community Dentistry, Rio de Janeiro State University, Rio de Janeiro, Brazil. Corresponding author: Dr Daniela Feu, Rua da Gre cia 85, apt 1101, Barro Vermelho Vitoria ES Brazil 29057-660 (e-mail: danifeutz@yahoo.com.br).

Accepted: January 2013. Submitted: October 2012. Published Online: April 17, 2013 G 2013 by The EH Angle Education and Research Foundation, Inc.
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health planners improve the quality of orthodontic care.2 Recent studies have shown that malocclusion is associated with poor OHQoL.3,4 Studies have also shown that, depending on the phase of the treatment, orthodontic treatment may either compromise or improve OHQoL.5,6 Studies indicating that patients are less likely to report negative impacts on OHQoL after completing orthodontic treatment often have important limitations (ie, they may be cross-sectional or may not include a comparison group).57 Data suggesting the positive effects of orthodontic treatment on OHQoL continue to be inconclusive.2,8,9 Shaw et al.9 questioned whether behavioral differences between people who sought and did not seek orthodontic treatment in their study could have influenced their results. The objective of this prospective study was to assess whether fixed orthodontic appliance therapy affected OHQoL in children by comparing them with two groups of untreated individuals. The influence of the patients dental health status, esthetic impairment, socioeconomic status, and malocclusion severity on OHQoL was examined.
DOI: 10.2319/100412-781.1

ORTHODONTIC TREATMENT AND QUALITY OF LIFE

893 it, regardless of the severity of their malocclusion. The comparability between the perceived OHQoL in this group and that in the TG and WG was assessed using statistical regression methods, controlling for potential confounding factors. A power calculation was performed based on observed values in which the Oral Health Impact Profile (OHIP-14) score decreased by 8.79 points (standard deviation [SD] 5 5.92, n 5 87) over time in the TG, whereas it increased by 0.87 points (SD 5 1.21, n 5 101) in the WG and by 0.10 points (SD 5 1.24, n 5 96) in the SG. Assuming a normal distribution, this study therefore had 100% power to detect a statistically significant difference at an alpha of 1% by comparing changes in the TG with those in the SG and WG. This sample size had a power of 96.2% to detect a difference between WG and SG. Variables and Their Measurement Data were collected through self-completed questionnaires and dental exams conducted by one trained orthodontist. The children completed three sets of interviews and clinical evaluations at baseline (T1), after 1 year (T2), and after 2 years (T3). OHQoL was measured with the OHIP-14,10 which is considered a valid and reliable instrument and is also responsive to changes in oral health conditions.11 The Brazilian version of the OHIP-14 has shown good psychometric properties when applied to adults11 and adolescents.1214 OHIP-14 scores were calculated by summing the response codes for the 14 items. Consequently, the total scores could range from 0 to 56, with higher scores indicating poorer OHQoL. Socioeconomic status was measured with the Brazil Economic Classification Criteria.15 These criteria classify households into eight categories according to the educational level of the head of the house, whether a hired maid works in the house, and the number of home appliances, cars, toilets, and washing machines. The categories range from A to E: A and B indicate high socioeconomic status, C signifies medium socioeconomic status, and D and E are associated with low socioeconomic status. After the children completed the questionnaires, clinical examinations were performed. Malocclusion severity and esthetic impairment were measured using the Dental Health Component (DHC) and the Aesthetic Component (AC), respectively, of the Index of Orthodontic Treatment Need (IOTN).16 Esthetic impairments were also evaluated by the children themselves (AC Self-Perception). The IOTN is a time-efficient, validated, and reliable method.17 Dental health status was determined using the DMFT classification (decayed/ missing/filled teeth).18
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MATERIALS AND METHODS Participants This study was approved by the Ethics Research Committee of Pedro Ernesto Hospital, Rio de Janeiro State University (1417 CEP/HUPE). Parents received a letter describing the study and requesting consent for their children to participate. A total of 318 children aged 1215 years were followed for 2 years in Rio de Janeiro, Brazil. They were separated into the following three groups: treatment group (TG), waiting group (WG), and school group (SG). Children in the TG and WG were selected from a list of 216 children (n 5 225, nine refusals, 96% response rate) who sought orthodontic treatment at the University in 2006. Only children who had never undergone orthodontic treatment were eligible. The 92 children who started treatment between April and December 2006 composed the TG. The 124 children who were not selected for treatment were placed on a waiting list and were followed beginning in April 2006. Patients were selected for treatment by professors in the orthodontics clinic of Rio de Janeiro State University based on the educational needs and resources of the clinic and the patients type of malocclusion, independent of malocclusion severity. This selection was independent of the research and was not influenced by it. The professors responsible for the selection of patients for treatment were unaware of the research. Children in the WG could be called at any time to begin treatment, and upon treatment initiation they were immediately excluded from the study and considered a loss to the sample. Orthodontic treatment was guaranteed to all patients in the WG. The SG included all 12- to 15-year-old children (n 5 124) enrolled in a public school near the university in 2006 who had never undergone or sought orthodontic treatment. This school has a dental clinic run by the university at which undergraduate students, supervised by faculty members of the dental school, regularly provide free primary dental care. Children identified as needing specialized care are referred for treatment to the appropriate departments of the university. Parents of the SG children were sent a questionnaire, attached to the consent form, to determine whether their children had already sought or undergone orthodontic treatment. Twenty-two of these schoolchildren were excluded because their parents did not return the consent form or reported that the child had undergone or previously sought orthodontic treatment. Therefore, the SG consisted of 102 children (82.3% response rate). This group was sampled to represent children who had access to publicly funded orthodontic treatment but did not seek

894 Students from the SG were examined in their schools dental office under conditions similar to those at the university clinic at which children in the TG and WG were examined. The examiner was trained in the use of the IOTN by a senior researcher (gold standard). The senior researcher was previously calibrated for IOTN assessment during a course taken at the University of Manchester. The training process included the examination of a set of 40 plaster casts by both the examiner and the senior researcher and a subsequent comparison of their results. To assess intraexaminer reliability, 26 adolescents were reinterviewed and re-examined within 710 days of the first assessment. Quadratic weighted kappa values were used to calculate the reliability coefficient for DMFT (kappa 5 1), IOTN-DHC (kappa 5 0.94), and IOTN-AC (kappa 5 0.98). The intraclass correlation coefficient (ICC) was used for OHIP-14 (ICC 5 0.97). At baseline, Cronbachs alpha for OHIP-14 was a 5 0.72 for the SG, a 5 0.68 for the TG, and a 5 0.66 for the WG. Statistical Analysis Differences in the distribution of covariates among groups were tested using nonparametric tests for repeated measurements and ordinal variables when appropriate. All analyses were carried out using Stata 9.2 (StataCorp LP, College Station, Tex). Significance levels were established at .01. A preliminary analysis showed that OHIP-14 followed an overdispersed Poisson distribution; therefore, a

FEU, MIGUEL, CELESTE, OLIVEIRA

negative binomial regression model was used.19 To accommodate the temporal correlation between the three assessments, generalized estimating equations with fixed coefficients and a first-order autoregressive covariance structure were applied,20 clustering all observations within each individual in temporal order (T1-T2-T3). The group variable was the exposure of interest. Gender, age, DMFT, IOTN-AC, IOTN-DHC, IOTN Self-Perception, and economic status were considered to be potential confounders. Whether the scores of OHIP-14 varied over the follow-up period for time-independent variables was tested with an interaction coefficient to evaluate these variables in combination with the time variables. The adjusted model was based on a backward stepwise regression with P . .20 for removal. RESULTS At baseline, the three groups were comparable with respect to age, gender, and mean DMFT. Esthetic impairment and malocclusion severity were less pronounced in the SG than in the TG and WG. The SG included more children from low- and middleincome households than did the TG and WG (Table 1). The dropout rates were 5.4% in the TG, 18.5% in the WG, and 5.9% in the SG. Of the 33 individuals that dropped out, eight changed addresses, eight withdrew from the study, and 17 from the WG were excluded because they started treatment. Therefore, our analysis was based on 852 observations clustered among 284 individuals (TG 5 87, WG 5 101, SG 5 96).

Table 1. Clinical and Sociodemographic Characteristics of Individuals, by Group, at Baseline SG Total Gender Male Female A1A2 B1 B2 C1 C2 DE 41.2% 58.8% 0.0% 2.0% 16.7% 65.7% 0.0% 15.7% Mean (SD) IOTN-DHC IOTN-AC examiner IOTN-AC self-perceived Age, y DMFT OHIP-14
a b

WG (n 5 102) (42) (60) (0) (2) (17) (67) (0) (16) % 48.4% 51.6% 2.4% 12.9% 22.6% 55.7% 0.0% 6.5% Mean (SD) (0.9) (1.8) (1.1) (1.2) (1.4) (5.0) 3.4 4.5 4.0 13.7 1.4 10.8 (1.2) (2.0) (2.1) (1.1) (1.6) (6.2) 3.5 4.6 4.1 13.4 1.5 10.4 (n 5 124) (60) (64) (3) (16) (28) (69) (0) (8) % 51.1% 48.9% 3.3% 10.9% 23.9% 59.8% 0.0% 2.2%

TG (n 5 92) (47) (45) (3) (10) (22) (55) (0) (2) P Valuea .35

Brazil Economic Classification Criteria ,.01

Mean (SD) (1.1) (2.0) (2.1) (1.1) (1.5) (6.1)

P Valueb ,.01 .02 ,.01 .16 .73 ,.01

3.0 3.9 1.9 13.7 1.3 5.5

Chi-square test for differences among groups or chi-square test for differences in trends among groups with ordinal variables. Kruskal-Wallis test.

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895 gender with time were tested, which revealed no significant associations. Multiple regression analyses, which used OHQoL measured by the OHIP-14 as the outcome, showed that self-perceived IOTN-AC, DMFT, and IOTN-DHC were independently associated with OHIP-14 scores. In this model, the beneficial effect of orthodontic treatment on OHQoL was reduced but remained significant (Table 3). In the unadjusted model, the OHIP-14 score of the TG prior to treatment was 91% higher (relative risk [RR] 5 1.91) than the score of the SG prior to treatment, although it was 70% lower after 2 years (RR 5 0.30). In the adjusted model, the TG

During the follow-up period, the TG showed significant improvement in OHQoL, dental esthetics, and dental occlusion. In the WG and SG, OHQoL worsened, whereas esthetic self-perception, esthetic impairment, and malocclusion severity remained the same (Table 2). In the TG, 44 patients (50.5%) had finished orthodontic treatment at the end of the follow-up period. At T3, the mean OHIP-14 score was 0.3 in patients who had had the fixed appliance removed; it was 3.0 in those who had not. The IOTN-DHC and IOTN-AC scores were also higher among those who did not finish treatment (P , .001). The WG (P , .001) and SG (P 5 .05) showed small increases in their OHIP-14 scores, indicating worsened OHQoL during the evaluation period. By contrast, the TG had a significant reduction in its OHIP-14 scores (P , .001). Self-perceived esthetics and normative measurements of IOTN did not change significantly in the SG and WG, although these scores decreased significantly over time in the TG (P , .001). A univariate negative binomial regression analysis showed that gender and age were not associated with OHIP-14 scores. Teenagers of lower economic status had worse OHQoL compared to those of highest economic status, although the difference was not statistically significant. In bivariate analysis, an increase of 1 point on the scale of the IOTN-AC (examiner score) was associated with a 1.25-fold increase in the OHIP-14 score. This association was not significant after adjustment. Interactions of age and
Table 2. Median Scores of Clinical Time-Dependent Variables During the Follow-up Period, by Groupa Measure/Group OHIP-14 SG (n 5 96) WG (n 5 101) TG (n 5 87) IOTN-AC self-perceived SG (n 5 96) WG (n 5 101) TG (n 5 87) IOTN-AC examiner SG (n 5 96) WG (n 5 101) TG (n 5 87) IOTN-DHC SG (n 5 96) WG (n 5 101) TG (n 5 87)
a

Table 3. Unadjusted and Adjusted Associations Between OHIP-14 Score and Covariates During 2 Years of Follow-up from Negative Binomial Regression in Generalized Estimating Equation Models Group SG T1 T2 T3 WG T1 T2 T3 TG T1 T2 T3 Gender Female Male 1 1.09 (0.921.30) .31 2.04 (1.642.53) ,.01 2.11 (1.702.61) 2.20 (1.782.71) 1.91 (1.532.39) ,.01 1.69 (1.382.08) 0.30 (0.190.46) 1.73 (1.382.16) ,.01 1.76 (1.412.21) 1.82 (1.452.29) 1.52 (1.211.91) ,.01 1.83 (1.482.27) 0.38 (0.240.61) 1 ,.01 1.11 (1.061.16) 1.02 (0.971.07) 1 ,.01 1.10 (1.051.15) 1.00 (0.961.04) Unadjusted Score P Ratios (95% CIa) Value Adjustedb Score P Ratios (95% CIa) Value

T1 4 10 9.5 2 4 4 4 4 4 3 3.5 4

T2 5 10 8 2 4 3 4 4 3 3 4 2

T3 5 11 0 2 4 1 4 4 1 3 4 1

P Valueb .05 ,.001 ,.001 .79 .08 ,.001 .95 .97 ,.001 .86 .98 ,.001

Brazil Economic Classification Criteria A1A2 1 .04c B1 1.65 (0.912.98) B2 1.75 (1.032.97) C1 1.66 (0.982.82) C2 1.29 (0.742.25) DE 1.46 (0.832.56) IOTN-DHC (15 points) IOTN-AC examiner (110 points) IOTN-AC selfperceived (110 points) Age, y DMFT
a b

1.40 (1.321.49) ,.01 1.25 (1.211.30) ,.01

1.18 (1.101.26) ,.01

1.22 (1.181.25) ,.01

1.06 (1.031.09) ,.01

0.98 (0.911.07) 1.06 (1.011.12)

.70 .03

1.07 (1.011.12)

.014

Results are limited to those with completed data over time. b Friedman test for ranking variables with repeated measurements. P values represent differences between any pair of years of follow-up, not trend.

CI indicates confidence interval. Only variables with P , .20 were retained in the stepwise backwards regression model beginning with all variables in the model. c P value for linear trend. Angle Orthodontist, Vol 83, No 5, 2013

896 score after 2 years was 62% (RR 5 0.38) lower than the score of the SG at the beginning. Changes in the OHIP-14 dimensions reported during the study were found to follow a similar and corresponding pattern of changes in the overall scores in the TG, WG, and SG. Scores on dimensions 2, 3, and 5 of the OHIP-14 contributed the most to childrens overall scores. Dimension 1 and 2 scores at T2 were higher than at any other time in the TG, and dimensions 3 and 5 contributed the most, both to the impact reduction in TG at T3 and to impact worsening in WG (Table 4). DISCUSSION The main finding of this study was that OHQoL improved significantly following orthodontic treatment. However, adolescents who did not receive treatment (WG and SG) showed a slight increase in their OHIP14 scores, even though no changes occurred in the severity of their clinical malocclusion or in esthetic selfperception. The clinical significance of the 1-point increase in the OHIP-14 scores of the WG and the SG is difficult to establish because there are no criteria for determining whether an individual with a specific OHIP score is mildly, moderately, or severely compromised by his oral disorders.21 Two control groups (WG and SG) were used to prevent behavioral influences in our results. Previous studies3,9,22 showed that behavioral differences between children who do and do not seek treatment seem to play an important role in influencing their OHQoL. OHIP-14 scores were relatively stable in the SG during the observation period. Thus, the baseline

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scores of the SG, representing children from the general population who could have been included in the TG or the WG if they had sought treatment, were used for comparisons between the groups at T3. OHIP-14 scores were similar in the TG and WG at the beginning of the study. However, after 2 years, the OHQoL of children who had undergone orthodontic treatment had changed significantly (P , .001). Notably, the OHIP-14 scores in the TG dropped dramatically (62%) and were thus lower than the scores in the SG at the beginning. Children who were still waiting for treatment showed a statistically significant increase in their OHIP-14 scores (P , .001). This significant increase in the OHIP-14 scores in the WG may have occurred because of the psychosocial disadvantages that children with perceived malocclusions can experience in their daily lives2,3; this is especially apparent, because the dimensions of psychological discomfort and psychological disability contributed the most to OHQoL worsening in the WG (Table 4). It was possible to further explore the relationship between finishing orthodontic treatment and OHQoL, because not all of the patients had had their fixed appliances debonded after 2 years of follow-up. Patients who already had their fixed appliances removed showed better outcomes than patients who had not, suggesting that orthodontic treatment is not without potentially harmful effects on OHQoL, such as pain and discomfort, as was previously suggested by Chen et al.5 and Liu et al.23 In the present study, patients experienced worsened QoL during treatment because of functional limitations and physical pain (Table 4). In addition, 15- to 17-year-olds usually consider braces to be unesthetic.6,24 Because the

Table 4. Descriptive Analyses (Median Values) of the Seven Dimensions of OHIP-14a in TG, WG, and SG During 2 Years of Follow-up SG T1 Question 1 Question 2b Question 3c Question 4c Question 5d Question 6d Question 7e Question 8e Question 9f Question 10f Question 11g Question 12g Question 13h Question 14h Total OHIP-14 Score
b

WG T3 0.3 0.3 1.0 0.9 0.8 0.2 0.2 0.2 0.2 0.6 0.5 0.1 0.2 0.1 5.6 T1 0.8 0.3 0.9 1.0 1.9 1.1 0.2 0.2 0.5 2.0 1.1 0.3 0.6 0.0 10.8
c

TG T3 0.9 0.4 0.9 1.0 2.0 1.3 0.2 0.2 0.5 2.2 1.2 0.4 0.7 0.1 12.0
d

Difference final initial T3 0.1 0.1 0.5 0.1 0.2 0.1 0.0 0.0 0.0 0.2 0.1 0.0 0.1 0.0 1.6
e

T2 0.4 0.4 0.9 0.9 0.8 0.2 0.3 0.3 0.2 0.7 0.6 0.2 0.2 0.1 6.1

T2 0.8 0.3 0.9 1.0 1.9 1.1 0.2 0.2 0.5 2.1 1.1 0.3 0.7 0.1 1.3

T1 0.7 0.3 0.9 0.8 1.9 1.0 0.3 0.2 0.4 2.1 1.2 0.3 0.5 0.0 10.4

T2 1.3 0.9 2.4 1.0 0.7 0.4 0.1 0.2 0.2 0.8 0.6 0.2 0.3 0.1 9.2

SG 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1

WG 0.1 0.0 0.0 0.0 0.2 0.2 0.0 0.0 0.0 0.2 0.1 0.1 0.0 0.0 1.2
f

TG 20.6 20.2 20.3 20.7 21.6 20.9 20.2 20.2 20.3 21.8 21.0 20.2 20.5 0.0 28.8

0.3 0.3 1.0 0.9 0.8 0.2 0.2 0.2 0.2 0.6 0.5 0.1 0.2 0.0 5.5

a OHIP-14 impact dimensions: b functional limitation, disability, g social disability, h handicap.

physical pain,

psychological discomfort,

physical disability,

psychological

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897 ACKNOWLEDGMENT
The source of support for this work was the National Counsel of Technological and Scientific Development (CNPq), Brazil, for Daniela Feu, and Carlos Chagas Filho Foundation (FAPERJ), Rio de Janeiro, Brazil, for Branca H. Oliveira.

TG patients were in this age range at T3, it is also possible that the presence of the appliance resulted in IOTN-AC and OHIP-14 scores that were somewhat higher than expected. However, more studies are needed to clarify these findings. Improvement in the OHQoL of individuals who received orthodontic care has been previously reported.5,6,25 Bernabe et al.25 conducted a case-control study and found that Brazilian children with a history of completed orthodontic treatment experienced fewer conditionspecific impacts on their daily lives attributed to malocclusion than did children with no history of treatment. De Oliveira and Sheiham6 conducted a cross-sectional study with 15- to 16-year-old Brazilian children and concluded that those who had completed orthodontic treatment had a better OHQoL than those currently undergoing treatment or those who had never been treated. Chen et al.5 followed 250 Chinese orthodontic patients and showed that their OHQoL was better after they completed treatment than before or during treatment. Nevertheless, one should be cautious when interpreting our results and not conclude that failure to obtain orthodontic treatment during adolescence may have a detrimental effect on QoL in adulthood, especially for those with mild or moderate orthodontic needs.9 Because participants who entered the study were not allocated by chance to either the TG or the WG because of ethical reasons, it was not possible to ensure that the groups were balanced based on characteristics that were likely to alter the relationship between treatment and outcome, thus minimizing potential bias. Imbalances in prognostic factors between groups in observational studies can be reduced by restriction or matching and can be controlled for by statistical methods, as in this study. However, because of the design of this study, we cannot rule out the possibility of selection bias. It may be expected that the use of an instrument specifically developed for children would provide a more accurate picture of the OHQoL of these patients. However, at the time this study was initiated, none of the available childrens OHQoL instruments had been translated into Brazilian Portuguese and validated. CONCLUSIONS N Fixed orthodontic treatment improved OHQoL in 12to 15-year-old Brazilian children, resulting in a 60% decrease in their OHIP-14 scores. N Those who sought but did not receive treatment had significantly worse OHIP-14 scores. N The psychological discomfort and psychological disability dimensions contributed most significantly to both impact reduction and impact worsening.

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