ORIGINAL ARTICLE

Does psychological well-being influence

oral-health-related quality of life reports in
children receiving orthodontic treatment?
Shoroog Agou,a David Locker,b Vanessa Muirhead,c Bryan Tompson,d and David L. Streinere
Toronto, Ontario, Canada

Introduction: Although the associations between oral biologic variables such as malocclusion and oral-health-
related quality of life (OHRQOL) have been explored, little research has been done to address the influence of
psychological characteristics on perceived OHRQOL. The aim of this study was to assess OHRQOL outcomes
in orthodontics while controlling for individual psychological characteristics. We postulated that children with
better psychological well-being (PWB) would experience fewer negative OHRQOL impacts, regardless of
their orthodontic treatment status. Methods: One hundred eighteen children (74 treatment and 44 on the waiting
list), aged 11 to 14 years, seeking treatment at the orthodontic clinics at the University of Toronto, participated in
this study. The child perception questionnaire (CPQ11-14) and the PWB subscale of the child health question-
naire were administered at baseline and follow-up. Occlusal changes were assessed by using the dental
aesthetic index. A waiting-list comparison group was used to account for age-related effects. Results: Although
the treatment subjects had significantly better OHRQOL scores at follow-up, the results were significantly
modified by each subject’s PWB status (P \0.01). Furthermore, multivariate analysis showed that PWB
contributed significantly to the variance in CPQ11-14 scores (26%). In contrast, the amount of variance
explained by the treatment status alone was relatively small (9%). Conclusions: The results of this study
support the postulated mediator role of PWB when evaluating OHRQOL outcomes in children undergoing ortho-
dontic treatment. Children with better PWB are, in general, more likely to report better OHRQOL regardless of
their orthodontic treatment status. On the other hand, children with low PWB, who did not receive orthodontic
treatment, experienced worse OHRQOL compared with those who received treatment. This suggests that chil-
dren with low PWB can benefit from orthodontic treatment. Nonetheless, further work, with larger samples and
longer follow-ups, is needed to confirm this finding and to improve our understanding of how other psychological
factors relate to patients’ OHRQOL. (Am J Orthod Dentofacial Orthop 2011;139:369-77)

A
s orthodontic outcome research continues to health-related quality of life (OHRQOL).3 OHRQOL is de-
move away from the traditional biomedical fined as the absence of negative impacts of oral condi-
model1 toward a biopsychosocial perspective,2 tions on social life and a positive sense of dentofacial
more attention is being given to the concept of oral- self-confidence.4 Studies with reliable OHRQOL mea-
sures have identified differences between treated and un-
From the University of Toronto, Toronto, Ontario, Canada.
a
Assistant professor of orthodontics, Faculty of Dentistry, King Abdulaziz treated orthodontic patients.5-9 For example, a Brazilian
University. study of 1675 adolescents indicated that children who
b
Professor, Faculty of Dentistry. had completed orthodontic treatment reported fewer
c
Graduate Student, Faculty of Dentistry.
d
Associate professor, Faculty of Dentistry. OHRQOL impacts than those who were never treated.5
e
Professor, Department of Psychiatry and Baycrest Center. These differences were mostly related to socio-
Based on a thesis submitted by the first author to the school of graduate studies, emotional aspects of well-being such as smiling, laugh-
University of Toronto, in partial fulfillment of the requirements for the PhD degree.
A preliminary report was presented at the International Association of Dental ing, and showing teeth without embarrassment.8,9
Research meeting in Toronto in 2008. Such differences between treated and untreated
The authors report no commercial, proprietary, or financial interest in the prod- subjects are expected in light of studies emphasizing the
ucts or companies described in this article.
Reprint requests to: Shoroog Agou, Faculty of Dentistry, University of Toronto, importance of dentofacial esthetics in daily social
124 Edward St, Toronto, Ontario, Canada M5G 1G6; e-mail, sagou@kau.edu.sa. interactions. For instance, an unattractive dentition has
Submitted, January 2009; revised and accepted, May 2009. been associated with teasing, bullying,10,11 and negative
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists. OHRQOL impacts.5,11-13 Improving dental esthetics
doi:10.1016/j.ajodo.2009.05.034 and, subsequently, psychological well-being (PWB) are
369
370
frequently stated reasons for seeking orthodontic treat-
ment during childhood and adolescence.14,15 However,
the bulk of evidence denoting the relative stability of
PWB undermines this assumption.16-19 Furthermore, no
studies have described how OHRQOL and PWB change
during orthodontic treatment.
Attempts to correlate OHRQOL reports with clinical
orthodontic indicators, on the other hand, have often
reached equivocal conclusions.20-23 In many of these
studies, children reporting worse OHRQOL were not
consistently those with worse malocclusions. It is
possible that some children with a severe malocclusion
are more emotionally resilient to the challenges caused
by their condition. Hence, accurate interpretation of
OHRQOL measures requires an understanding of not
only their psychometric properties, but also the
contextual factors that might influence their
assessments of health and well-being.24 A recent
long-term study evaluating psychosocial outcomes in
orthodontics suggested that analyzing the effects of
orthodontic treatment on psychological health without
considering intervening factors might lead to invalid
conclusions about the efficacy of treatment.19 This
was corroborated by cross-sectional reports recognizing
the effects of innate personality traits on children’s per-
ceptions of dentofacial esthetics25-27 and patients’
evaluations of the impact of their health on daily
functioning.28-30
Contemporary models of diseases and disorders and
their consequences, which integrate both biologic and
psychologic aspects of health, support this holistic
thinking paradigm.31 For example, according to the
model of Wilson and Cleary,32 health-related quality of
life outcomes experienced by a patient are determined
not only by the nature and severity of the disease or
disorder, but also by the patient’s characteristics and
his or her environment. A thorough examination of the
orthodontic OHRQOL literature with the Wilson-Cleary
model as the conceptual framework showed that, for
the most part, studies have focused on the associations
between biologic variables and OHRQOL,23,33,34 with
little emphasis on the psychological characteristics of
children receiving orthodontic treatment.35 This is sur-
prising, since research has shown that determinants of
health-related quality of life are mainly psychological.36
Hence, psychological factors such as PWB are certainly
important mediators of OHRQOL.37
Since the relationship between psychological factors
and OHRQOL is largely unexamined in orthodontic pa-
tients, this study was undertaken to answer the question:
do individual psychological characteristics affect chil-
dren’s OHRQOL reports? The specific objectives of this
longitudinal investigation were to explore the effect of
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Agou et al
PWB on reported OHRQOL in children receiving ortho-
dontic treatment and to compare this effect with a sam-
ple of untreated waiting-list controls. We hypothesized
that children with better PWB would experience fewer
negative impacts, regardless of their orthodontic treat-
ment status. According to this hypothesis, the children’s
assessment of OHRQOL would be influenced by their
PWB. To demonstrate this mediating role of PWB, we
compared OHRQOL in children with high and low PWB
scores. We expected that OHRQOL outcomes would
not change for those in the high PWB group but might
change for those in the low group.
Since medical research has shown that psychological
variables are likely to affect the more subjective domains
of quality of life reports, we expected that the influence
of PWB would be more pronounced for the more subjec-
tive social and emotional dimensions of the OHRQOL
measure used in this study than for the more objective
dimensions addressing functional limitations and oral
symptoms.38
MATERIAL AND METHODS
In this study, we used a 2-group before-and-after de-
sign to assess changes in OHRQOL after orthodontic
treatment. Patients receiving treatment were the focal
group of interest, whereas patients awaiting treatment
comprised the comparison group.
To be eligible, a child had to be fluent in English and
have good general health. Children with severe dentofa-
cial deformities were excluded. Parents’ consents and
children’s assents were obtained, and the Research
Ethics Board of the University of Toronto, Ontario,
Canada, approved all study procedures. Subjects were
not offered incentives or compensation for participating
in the study. The treatment subjects were consecutively
recruited from the graduate orthodontic clinic at the
University of Toronto during their first assessment visit.
The control subjects were consecutively recruited from
the Faculty of Dentistry clinics during their first ortho-
dontic screening visit. All 11- to 14-year-old subjects
who met the eligibility criteria were recruited by the first
author (S.A.).
All children completed the child perception question-
naire (CPQ11-14) and the PWB subscale of the child
health questionnaire at baseline (T1) and follow-up
(T2). The questionnaires were completed by the children
unassisted by parents or investigators. The dental
aesthetic index (DAI) was used to determine the clinical
severity of the malocclusion. Table 1 summarizes the
main study variables. Age and sex were recorded because
of their potential associations with outcome and explan-
atory variables. The treatments were completed at the
graduate orthodontic clinic as routinely prescribed with
Agou et al
fixed appliance therapy. On average, treatment lasted for
26 months. The T2 data were collected at the first reten-
tion check appointment for the treatment subjects and
after an equivalent time interval for the control subjects.
The CPQ11-14 is a child OHRQOL instrument. The
age-specific questionnaire (11-14 years) consists of 37
items, grouped into 4 domains: oral symptoms (OS),
functional limitations (FL), emotional well-being
(EWB), and social well-being (SWB). Each item asks
about the frequency of events, as applied to the teeth,
lips, and jaws, in the previous 3 months. The response
options were “never,” “once or twice,” “sometimes,” “of-
ten,” and “every day or almost every day.” Additive scale
and subscale scores for the CPQ11-14 were calculated by
summing the item response codes. Although the instru-
ment was designed to yield an overall score, a separate
score can be generated for each subscale. Higher scores
signify worse OHRQOL. The validity, reliability, and re-
sponsiveness of this measure have been established in
various settings.6,21,23,33,39-42 This measure examines
the impacts of oral conditions on children’s EWB and
SWB; nonetheless, it is important not to confuse these
2 domains with the more generic PWB. EWB and SWB
focus specifically on the impacts of oral health
conditions of children’s daily functioning, whereas
PWB takes into account the effect of all aspects of
health and daily life on well-being.
The children’s PWB was measured by using the PWB
subdomain of the child health questionnaire, which is
a widely used and validated self-report instrument.43
The 16-item PWB scale measures the frequency of
both negative and positive feelings. The items capture
anxiety, depression, and happiness. Frequency is mea-
sured by using a 5-level continuum that ranges from
“all of the time” to “none of the time.” The scores
were calculated according to the user’s manual.44 Higher
scores indicate better PWB; a score of a 100, for
example, indicates that the child feels peaceful, happy,
and calm all of the time. In contrast, lower scores indi-
cate that the child has feelings of anxiety and depression.
Specific instructions confirming the generic nature of
the measure were added at the beginning of the
questionnaire.
The severity of each treatment and control subjects’
orthodontic condition was assessed from study models
taken at T1 and T2 and by using the DAI.45 Although
other treatment-need indexes such as the index of or-
thodontic treatment need and the index of complexity,
outcome, and need are available, the DAI was chosen be-
cause it incorporates the social acceptability of a child’s
dental appearance. The rating is based on the measure-
ment of 10 occlusal traits; each trait is multiplied by
a weight derived from the judgment of laypersons. The
American Journal of Orthodontics and Dentofacial Orthopedics
371
Table I. Main study variables and their interpretations
CPQ11-14 Child perception questionnaire
Lower CPQ11-14 scores represent better OHRQOL
OS Oral symptoms
Lower CPQ11-14 scores represent better OHRQOL
FL Functional limitations
Lower CPQ11-14 scores represent better OHRQOL
EWB Emotional well-being
Lower CPQ11-14 scores represent better OHRQOL
SWB Social well-being
Lower CPQ11-14 scores represent better OHRQOL
PWB Psychological well-being
Lower PWB scores represent worse psychological
well-being
DAI Dental aesthetic index
Lower DAI scores represent better occlusion
products are summed, and a constant is added to give
a DAI score. DAI scores range from 13 (the most accept-
able) to 100 (the least acceptable). The DAI ratings were
recorded by 3 trained and calibrated examiners. Intra-
examiner and interexaminer reliabilities were evaluated
by having the raters independently assess a random
10% sample of the models and then reassessing the
models after a 1-week interval. Intraexaminer reliability
for the DAI raters was high with intraclass correlation co-
efficients of 0.96, 0.91, and 0.97, respectively. The inter-
examiner reliability was also high (intraclass correlation
coefficient of 0.81).
Statistical analysis
The data were analyzed by using SPSS software
(version 16, SPSS, Chicago, Ill). Data analyses included
descriptive statistics, and bivariate and multivariate
analyses. Paired t tests were used to assess within-
group changes over time for the treatment and control
groups. The P value for all tests was set at \0.05.
Analysis of covariance (ANCOVA) models were then
used to explore between-group differences. The first
goal was to evaluate the relationship between the
provision of orthodontic treatment and the changes in
OHRQOL, represented by overall and individual
CPQ11-14 scores, while controlling for the CPQ11-14
scores at T1, age, and malocclusion severity. This analy-
sis plan, represented in model 1 (Table II), aims to
address whether there is a difference in reported OHR-
QOL between treatment and control subjects.
The second goal was to evaluate the role of PWB on
mediating OHRQOL outcomes by using a second AN-
COVA model (model 2 in Table II). This model addresses
whether there is a difference in OHRQOL scores between
treatment and control subjects and whether it remains
significant after controlling for PWB.
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Table II. Main study variables at T1 and T2 for the treatment and control groups
Group Treatment Control

Time T1 T2 T1 T2

Original baseline Retained baseline Follow-up Original baseline Retained baseline Follow-up
(n 5 98) (n 5 74) (n 5 74) (n 5 101) (n 5 44) (n 5 44)

Mean, (SD), Mean, (SD), Mean, (SD), Mean, (SD), Mean, (SD), Mean, (SD),
Variable range range range range range range
CPQ11-14 21.05 (15.09) 21.63 (14.19) 16.16 (10.99)* 24.07 (16.15) 24.07 (16.15) 23.14 (17.97)
1.00-68.00 3.00-68.00 0.00-44.00 3.00-80.00 3.00-80.00 2.00-73.00
OS 5.58 (3.40) 5.75 (3.37) 5.26 (3.15) 5.93 (3.24) 6.07 (3.59) 6.34 (3.69)
0.00-17.00 1.00-17.00 0.00-13.00 0.00-16.00 0.00-16.00 0.00-15.00
FL 5.09 (4.15) 5.27 (4.15) 5.41 (4.26) 5.92 (4.95) 5.36 (4.69) 4.82 (4.57)
0.00-21.00 0.00-21.00 0.00-18.00 0.00-23.00 0.00-22.00 0.00-17.00
EWB 5.19 (5.09) 5.29 (5.14) 2.51 (2.96)* 6.83 (5.59) 6.75 (5.45) 6.82 (7.56)
0.00-24.00 0.00- 24.00 0.00-12.00 0.00-22.00 0.00-22.00 0.00-29.00
SWB 5.18 (5.39) 5.32 (5.46) 2.99 (3.59)* 6.01 (6.12) 5.89 (6.13) 5.16 (6.34)
0.00-27.00 0.00-27.00 0.00-17.00 0.00-29.00 0.00-29.00 0.00-27.00
PWB 80.66 (10.09) 79.78 (9.29) 81.68 (10.52) 78.33 (12.98) 78.05 (11.7) 78.84 (13.39)
51.56-100 54.69-98.44 46.88-98.44 28.13-98.44 48.44-98.44 43.75-100
DAI 34.21 (8.18) 33.72 (7.78) 22.49 (2.86)* 36.53 (8.89) 36.25 (7.25) 33.56 (7.14)
17.00-58.40 17.00-58.40 17.30-30.10 20.00-74.80 25.80-53.80 23.60-44.40

*Paired t statistics significant at P \0.01.

RESULTS slightly higher but not significantly different from those

Of the 118 study subjects in this study, 50% were
girls and 76% were white, with a mean age of 12.9 years
(SD, 0.98) at T1. According to published DAI categories,
44.2% of the overall sample had handicapping
malocclusions, 25.7% had severe malocclusions, 23.9%
had definite malocclusions, and 6.2% had minor maloc-
clusions.45
Although follow-up data were successfully obtained
from 118 subjects (74 treatment and 44 control), 199
children were recruited at the start of the study. To
ensure that the relatively large percentage of dropouts
(40.71%) did not compromise the comparability of T1
characteristics between the treatment and control
groups, the data of the original and the retained subjects
for the treatment and control groups were contrasted in
Table II. The statistics indicated that all variables studied
were comparable for both groups at T1. Hence, the sub-
jects lost to follow-up did not influence the distribution
of these variables.
Table II also summarizes the T2 data for the treat-
ment and control subjects, with a guide to interpreting
these scores in Table I. The CPQ11-14, EWB, SWB, and
DAI scores for the treatment subjects were the only vari-
ables that changed significantly over the study period. In
contrast, these scores did not change significantly for the
control group. As expected, PWB scores remained rela-
tively constant over time for both the treatment and
control subjects. Furthermore, these PWB scores were
reported for normal schoolchildren.43
As mentioned earlier, ANCOVA models were used to
test the differences in reported OHRQOL between the
treatment and control subjects. Treatment status was
entered into the ANCOVA model as a fixed factor and
tested for overall effect on CPQ11-14 overall and sub-
scales scores at follow-up. For each scale, the first model
controlled for age, T1 scores, and initial severity of mal-
occlusion (DAI), and the second model also controlled
for PWB. Table III provides a summary of the ANCOVA
models and the total amount of variance explained by
each model.
The results indicated a significant difference in over-
all CPQ11-14, SWB, and EWB scores between the treat-
ment and control subjects (P \0.05). However, after
considering PWB as a covariate, the effect of providing
orthodontic treatment was no longer significant, as
measured by the overall CPQ11-14 and SWB scores
(P 5 0.23). EWB was the only scale with the difference
between treatment and control subjects remaining sig-
nificant after controlling for clinical and psychological
confounders. To illustrate the results, the adjusted
mean CPQ11-14, SWB, and, EWB scores for the treat-
ment and control groups are presented in Table IV.
The contribution of DAI scores was not significant,
with exception of the SWB subscale. DAI scores signifi-
cantly contributed to the variance in SWB scores in
both ANCOVA models. In addition, age effects were

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Agou et al 373

Table III. ANCOVA models showing contribution of covariates to overall and subscale (T2) CPQ11-14 scores
(T2) CPQ11-14 (T2) EWB (T2) SWB (T2) FL (T2) OS

Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 Model 1 Model 2
F statistics F F F F F F F F F F
Age 0.57 5.79y .023 1.59 0.00 1.60 3.17 6.80y 1.41 5.79*
Baseline scores 6.51y 7.81y 1.89 2.09 6.52* 7.10y 5.27* 5.23* 3.45 3.77
DAI 0.58 0.39 0.21 0.11 4.85* 4.88* 0.00 0.03 0.27 0.58
PWB — 27.09y — 22.15y — 18.07y — 7.14y — 13.97y
Treatment status 4.17* 1.31 14.97y 10.17y 3.62* 1.29 1.47 3.29 1.77 0.31
Corrected model 3.79y 8.9y 5.02y 9.08y 4.78y 7.88y 2.73* 3.71y 2.01 4.46y
Adjusted R2 0.09 0.26 0.13 0.27 0.12 0.24 0.06 0.11 0.04 0.14
Model 1 controls for age, DAI, baseline scores, and treatment status; model 2 controls for all variables in model 1 in addition to PWB status.
*P \0.05; yP \0.01.

evident for the overall CPQ11-14, OS, and FL subscales.

Table IV. Observed and adjusted mean (T2) CPQ11-14,
Nonetheless, these effects were apparent only after con-
EWB, and SWB scores
trolling for PWB. The mediating role of PWB was further
examined by adding “group by PWB status” as an inter- Observed scores Adjusted scores
action term in a separate ANCOVA model (not included Scale Group Mean (SD) Mean (SE)
in Table III). The results were statistically significant CPQ11-14 Treatment 16.16 (10.99) 17.93 (1.44)*
with an F ratio of 7.01 (P \0.01) and an adjusted R2 Control 23.14 (17.97) 20.89 (1.90)*
of 26.8%. Since using normative reference groups is rec- EWB Treatment 2.51 (2.96) 2.99 (0.57)y
ommended to meaningfully interpret the results from Control 6.82 (7.56) 6.16 (0.76)y
SWB Treatment 3.03 (3.59) 3.48 (0.51)z
quality of life surveys,46 we dichotomized PWB around
Control 5.29 (6.44) 4.50 (0.68)z
the mode (76.6%), which approximates the population
norms published by Landgraf and Abetz43 and *Covariates appearing in the model were evaluated at the following
others.47-49 We then examined the CPQ11-14 scores in values: CPQ11-14, 22.47; DAI, 34.56, PWB, 80.52; yCovariates ap-
pearing in the model were evaluated at the following values: EWB,
the high and low PWB groups at T1 and T2. The direc- 5.70; DAI, 34.61; PWB, 80.43; zCovariates appearing in the model
tion of change was evaluated for both the treatment were evaluated at the following values: SWB, 5.38; DAI, 34.61;
and the control subjects (Table V). PWB, 80.43.

DISCUSSION
Although medical studies have stressed the impor-
tance of accounting for psychological parameters
when quality of life is used as a primary outcome, a crit-
ical analysis of orthodontic psychosocial outcome re-
search shows that most studies failed to do so.50,51
Hence, our results are timely, filling a research gap
identified by many researchers.3,52 To the best of our
knowledge, this is the first controlled longitudinal
study evaluating OHRQOL outcomes of orthodontic
treatment in light of pretreatment psychological
attributes. These results support the postulated
mediator role of PWB when evaluating OHRQOL
outcomes in children receiving orthodontic treatment.
The oral health impacts reported by our subjects were
not entirely dependent on the associated clinical condi-
tions. Rather, PWB influenced the participants’ perception
of oral health problems to a significant degree. Children
reporting better PWB were more likely to report better
OHRQOL regardless of their treatment status. As hypothe-
sized, the contribution of PWB to the variance in OHRQOL
was considerably greater for the SWB and EWB subscales,
compared with the OS and FL subscales (Table III).
The lack of significant changes in the PWB construct
over the study period conforms to the hedonic treadmill
theory, holding that well-being, for most people, is
a relatively constant state.18 These data add to the
bulk of evidence supporting this theory. The data also
agree with other studies that invalidated the assumption
that improving dental esthetics can have a significant
effect on a child’s PWB.17,53
This sample of Canadian children reported significant
reductions in negative oral impacts after orthodontic
treatment (mean CPQ11-14 reduction, 4.88; SD,
14.57) compared with control subjects of similar age,
sex, and dental condition (mean CPQ11-14 reduction,
0.93; SD, 21.72). These results concur with other studies
highlighting the positive effect of orthodontic treatment
on OHRQOL.5,8,9 For instance, CPQ11-14 scores im-
proved significantly after orthodontic treatment of chil-
dren in Hong Kong.9 Similarly, de Oliveira and Sheiham,5
in a cross-sectional study of 1675 schoolchildren, found

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Table V. Mean T1 and T2 CPQ11-14 scores for the treatment and control groups based on PWB status
PWB status* Treatment status Mean CPQ11-14 at T1, (SD), range
Low PWB Treatment group (n 5 23)
Control group (n 5 19)
High PWB Treatment group (n 5 51)
Control group (n 5 25)
*High PWB, $76.6; low PWB, \76.6 (PWB was dichotomized around the mode based on published population norms).43,47-49
comparable treatment effects using other OHRQOL
measures.
In-depth analysis of our data, however, showed that
the effect of orthodontic treatment is less dramatic when
viewed in the context of the children’s psychological
profiles. The differences between the treatment and con-
trol subjects clearly diminished after accounting for PWB
(Table IV). Results from the multivariate analyses showed
that, for all scales, PWB explained additional variances in
the dependent variables (overall and subscale CPQ11-14
scores). For example, the ANCOVA models accounting
for PWB explained about a third of the variance in over-
all CPQ11-14, EWB, and SWB scores, with PWB contrib-
uting the most to the explanatory power. This was
observed for both the treatment and control subjects.
As expected, the PWB of the children in this study
influenced reports of OS and FL to a lesser extent.
The PWB results of this study help to clarify the find-
ings of earlier studies with the CPQ11-14 in orthodontic
patients; correlations between the CPQ11-14 and clini-
cal indexes were weak.6,23,40 A recent meta-analysis,
which concluded that determinants of quality of life
are mainly psychological, also supports this explana-
tion.38 Altogether, these results confirm the validity of
contemporary conceptual models of disease and its con-
sequences, and emphasize the importance of personal,
social, and environmental factors in mediating patient-
centered quality of life outcomes.32
Because some studies have affirmed the relationship
between malocclusion, orthodontic treatment, and
reported OHRQOL, it seemed important to control for
the initial severity of the malocclusion and treatment
status. Less than 10% of the variance in overall
CPQ11-14 scores was explained by the treatment status
alone, indicating a definite, but relatively small, effect.
The results support the findings of a long-term British
study that concluded that orthodontic treatment had lit-
tle positive impact on psychological health and quality
of life in adulthood, when self-esteem at baseline was
controlled for.53 Nevertheless, analyses of individual
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Agou et al
Mean CPQ11-14 at T2, (SD), range
24.00 (12.77) 22.22 (11.16)
6.00-54.00 6.00-44.00
21.68 (14.67) 30.00 (20.97)
5.00-63.00 5.00-73.00
20.88 (14.79) 14.69 (9.57)
3.00-68.00 3.00-39.00
25.88 (17.26) 17.92 (13.54)
3.00-80.00 2.00-51.00
CPQ11-14 subscales demonstrated that treatment ef-
fects varied across the 4 subscales. The EWB subscale
was the only one for which treatment effects remained
significant after adjusting for other clinical and psycho-
logical factors. Conversely, the SWB subscale was the
only scale to which the DAI scores made a significant
contribution, making this subscale the closest to corre-
spond to objective treatment needs.
The associations between psychological factors and
perceived social and emotional impacts of oral health
concur with what has been previously reported for chil-
dren, adolescents, and young adults.13,22,24-26,54-56
Overall, our study emphasizes the extent to which
psychological factors can modify children’s perceptions
of their actual oral health status.
A closer examination of the items comprising each
scale helps to explain these findings. The EWB subscale
focuses on internal feelings such as being worried, em-
barrassed, or concerned about looks. In contrast, the
SWB subscale consists of items assessing the impacts
of malocclusion on various social interactions, including
speaking in class, social activities, smiling, talking to
other children, and teasing by other children. It is also
important to consider that the data were collected
shortly after the end of treatment. It is not surprising
that orthodontic treatment did not have an immediate
effect on children’s SWB. Children might simply need
time to translate the emotional gains afer treatment to
their external environment. In general, the SWB and
EWB findings concur with past studies documenting
the negative effects of malocclusion on children’s
lives.10,57-59
In addition, treatment effects varied depending on
the child’s PWB. In our study, children with high PWB
scores were more likely to report significant improve-
ment in OHRQOL after treatment, compared with those
with low PWB scores (Table V). Evaluation of the overall
sample suggests that there is a trend for CPQ11-14
scores to improve over time regardless of treatment
status. Nevertheless, a closer evaluation of CPQ11-14
American Journal of Orthodontics and Dentofacial Orthopedics
Agou et al
scores per PWB group (Table V) shows that children with
low PWB who did not receive orthodontic treatment had
worse CPQ11-14 scores over time than those who
received treatment.
This change in behavior of the CPQ11-14 after ac-
counting for the PWB status highlights the importance
of considering the child’s psychological profile when
evaluating OHRQOL outcomes in orthodontics. How-
ever, these results should be interpreted with caution
because of the small sample size in each group. Never-
theless, the effect of PWB on reported OHRQOL is worth
further investigation with larger samples and longer
follow-ups.
Information generated from this study will be of
great value to both clinical and policy-relevant research.
Researchers interested in capturing the multi-
dimensional aspects of oral health should consider the
PWB of their subjects when designing their studies.
Although some investigators might consider the PWB
variable as “noise,” it might also be an important
determinant of OHRQOL.37 Furthermore, the minor con-
tribution of DAI scores to the variances in the CPQ11-14
scores demonstrates the limitations of clinical indicators
in interpreting OHRQOL data.
Clinically, the results support the argument that or-
thodontists should include the psychological dimension
in their assessment when prioritizing treatment needs
and evaluating outcomes. Since children with low PWB
scores appeared to suffer more impacts from their
malocclusion, it seems logical to grant them priority
for orthodontic care. This could be achieved by using
proxy measures that reflect the children’s experiences,
such as the self-reported CPQ11-14. Nevertheless, worse
OHRQOL scores alone might not be sufficient to indicate
clinically worse oral health. Further work is needed to
refine existing OHRQOL measures to correspond more
closely to objective health needs. For example, results
from the CPQ11-14 subscale analyses can guide research
to develop short forms of this measure intended for
specific purposes.
There are some inherent limitations relevant to most
studies of orthodontic treatment. Since randomization is
difficult to achieve in orthodontics, a longitudinal
observational design offered the best and most feasible
alternative approach.19,60 Follow-up data confirmed
our preliminary findings and established directionality
between OHRQOL and PWB.61 The control group helped
to draw conclusions related to treatment effects rather
than changes stemming from the dynamic nature of psy-
chological constructs in growing children.62 Despite the
persistence of our recall efforts, this study was also lim-
ited by the relatively high attrition rate. This was mostly
because some waiting-list patients sought alternative
American Journal of Orthodontics and Dentofacial Orthopedics
375
care or relocated outside the city. Although it is possible
to assume that those who sought alternative treatment
were those with worse malocclusion or worse PWB, the
distribution of the main T1 characteristics between the
original and the retained subjects was comparable, at
least for the variables measured (Table II). Nevertheless,
the ANCOVA results should be interpreted with caution,
especially considering the lack of randomization and the
observational nature of this study.63
It is important to reconsider the current biomedical
and restricted paradigm on OHRQOL and to begin to
think about the series of processes by which social
and psychological factors influence OHRQOL reports.64
This study lays the ground for developing a conceptual
understanding of the interaction between reported
OHRQOL and a patient’s PWB. Although PWB ex-
plained the variance in CPQ11-14 to a reasonable
extent, the lack of comparable studies in the literature
makes it difficult to generalize the findings. Further-
more, the relatively low R2 values associated with the
models indicated that there could be other determi-
nants of OHRQOL. For instance, the direct contribution
of factors such as other oral health problems, social
support, and personality traits was not assessed in
this investigation. Hence, further work should be
attempted to study these factors with larger samples,
different age groups, and longer follow-ups to improve
the quantity and quality of orthodontic OHRQOL data.
The use of complex structural equation modeling or
path analysis can also add to our understanding of
how the various aspects of psychological health relate
to patients’ OHRQOL. Thus, an impetus for further
meaningful OHRQOL research in orthodontics will be
provided.
CONCLUSIONS
The findings of this study highlight the importance of
considering inherent psychological parameters in ortho-
dontic psychosocial research. More specifically, the
results support the mediator role of PWB when evaluat-
ing OHRQOL outcomes in children with a malocclusion.
Children with better PWB are, in general, more likely to
report better OHRQOL regardless of their orthodontic
treatment status. On the other hand, children with low
PWB, who did not receive orthodontic treatment,
experienced worse OHRQOL, compared with those who
received treatment. This suggests that children with
low PWB might benefit from orthodontic treatment,
but further work, with larger samples and longer
follow-ups, is needed to confirm this finding and to im-
prove our understanding of how other psychological
factors relate to patients’ OHRQOL.
March 2011
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376
The author would like to acknowledge the orthodontic
residents and staff at the university of Toronto for their
help with this study.
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