Download Oral health-related quality of life and orthodontic treatment seeking

ORIGINAL ARTICLE
Oral health-related quality of life and orthodontic
treatment seeking
Daniela Feu,a Branca Helo!ısa de Oliveira,b Marco Antônio de Oliveira Almeida,c H. Asuman Kiyak,d
and José Augusto M. Miguele
Rio de Janeiro, Brazil, and Seattle, Wash
Introduction: The aim of this study was to assess oral health-related quality of life (OHQOL) in adolescents
who sought orthodontic treatment. A comparison between these adolescents and their age-matched peers
who were not seeking orthodontic treatment provided an assessment of the role of OHQOL in treatment
seeking. Methods: The sample consisted of 225 subjects, 12 to 15 years of age; 101 had sought orthodontic
treatment at a university clinic (orthodontic group), and 124, from a nearby public school, had never undergone
or sought orthodontic treatment (comparison group). OHQOL was assessed with the Brazilian version of the
short form of the oral health impact profile, and malocclusion severity was assessed with the index of orthodontic treatment need. Results: Simple and multiple logistic regression analysis showed that those who
sought orthodontic treatment reported worse OHQOL than did the subjects in the comparison group
(P \0.001). They also had more severe malocclusions as shown by the index of orthodontic treatment need
(P 5 0.003) and greater esthetic impairment, both when analyzed professionally (P 5 0.008) and by selfperception (P \0.0001). No sex differences were observed in quality of life impacts (P 5 0.22). However,
when the orthodontic group was separately evaluated, the girls reported significantly worse impacts
(P 5 0.05). After controlling for confounding (dental caries status, esthetic impairment, and malocclusion
severity), those who sought orthodontic treatment were 3.1 times more likely to have worse OHQOL than
those in the comparison group. Conclusions: Adolescents who sought orthodontic treatment had more
severe malocclusions and esthetic impairments, and had worse OHQOL than those who did not seek orthodontic treatment, even though severely compromised esthetics was a better predictor of worse OHQOL than
seeking orthodontic treatment. (Am J Orthod Dentofacial Orthop 2010;138:152-9)
T
here is increasing recognition that oral disorders
can have a significant impact on physical, social,
and psychological well-being.1-5 This has
resulted in greater clinical focus on improving quality
of life as a major objective of dental care for dental
conditions that are not life threatening.2,4-6
The importance of evaluating oral health-related
quality of life (OHQOL) among orthodontic patients
relates to the impact of dental esthetics on social
a
Specialist in Orthodontics, Department of Orthodontics, Rio de Janeiro State
University, Rio de Janeiro, Brazil.
b
Associate professor, Department of Preventive and Community Dentistry, Rio
de Janeiro State University, Rio de Janeiro, Brazil.
c
Chairman, Department of Orthodontics, Rio de Janeiro State University, Rio de
Janeiro, Brazil.
d
Professor, Department of Oral & Maxillofacial Surgery; adjunct professor,
Department of Psychology, University of Washington, Seattle.
e
Associate professor, Department of Orthodontics, Rio de Janeiro State University, Rio de Janeiro, Brazil.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Daniela Feu, R Moacir Avidos, no 156/apto 804, Praia do
Canto, Vitória, E.S., Cep: 29055-350; e-mail, [email protected].
Submitted, May 2008; revised and accepted, September 2008.
0889-5406/$36.00
Copyright ! 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.09.033
152
acceptance and self-concept. It has been shown that
those with malocclusion can develop feelings of selfconsciousness and shame about their dental condition
or feel shy in social contexts, and also their body selfconcept because of facial appearance might be negatively affected.2,7-11 Nevertheless, a malocclusion can
be perceived differently by the affected person,4,12,13
and a person’s self-awareness of the malocclusion might
not be related to its severity.12,14,15
Therefore, when evaluating the impact of a malocclusion, it is important to consider the different domains
that can be affected and their relationships to personality traits and psychosocial factors. Some people with
a severe malocclusion are satisfied with or indifferent
to their dental esthetics, whereas others are concerned
about minor irregularities.16,17
Assessing the effect of oral disorders and conditions
on quality of life can be of great value to researchers,
health planners, and oral health care providers.18,19
Several instruments have been designed to measure
dental outcomes in terms of the impact on quality-oflife of changes in oral health. Among these, the oral
health impact profile (OHIP) and its short form
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 2
(OHIP-14) are widely used. The original 49-item OHIP
was developed by Slade and Spencer,20 based on the
OHQOL conceptual model of Locker,21 derived from
the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps. It
was designed to be applied to diverse oral conditions.
The items in the original 49-item version and in the
short form, OHIP-14, are grouped into 7 domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability,
social disability, and handicap.20,22 The OHIP and the
OHIP-14 were originally developed for use with elderly
patients, but both have been successfully used to measure the impact of oral problems in adolescents in the
United States,23 Brazil,2,24,25 Myanmar,26 and Chile.27
The Brazilian version of OHIP-1419,28 has shown
good psychometric properties, similar to those of the
original instrument, when tested in young women19
and in 12-year-old schoolchildren.24
The aims of this study were to assess OHQOL in
Brazilian adolescents aged 12-15 who sought orthodontic treatment in the Department of Orthodontics at Rio
de Janeiro State University in Brazil and to measure
the impacts of malocclusion severity, esthetic impairment, sex, age, and socioeconomic status on their
OHQOL. A comparison between these adolescents
and age-matched peers who were not seeking orthodontic treatment provided an assessment of the role of
OHQOL in treatment seeking.
MATERIAL AND METHODS
Permission to undertake the survey was obtained
from the Ethics Research Committee of Rio de Janeiro
State University. Parents received a letter describing the
study and requesting consent for their children to
participate.
The sample consisted of 225 adolescents (ages,
12-15 years) divided into 2 groups: the orthodontic
group and the comparison group. All 101 children
between 12 and 15 years of age who were scheduled
for orthodontic treatment evaluation in the Department
of Orthodontics of Rio de Janeiro State University in
2006 were eligible to participate in the orthodontic
group. Because 9 parents did not allow their children
to participate in the study (8.8% loss; 77.7% girls,
22.3% boys), the orthodontic group had a final number
of 92 children. The comparison group initially comprised all 124 age-matched children from a public
school near the university clinic. Their parents were
sent a questionnaire, attached to the consent form,
asking whether their children had already sought or
undergone orthodontic treatment. Twenty-two children
Feu et al
153
were excluded because they did not return the consent
form or reported having had or sought orthodontic
treatment. Therefore, the comparison group consisted
of 102 children (17.7% of loss; 63.4% girls, 36.6%
boys).
This sample size was sufficient to estimate a prevalence of oral impacts of 25% in the comparison group
and a difference between this group and the orthodontic
group, with a power of 80% at a significance level of
0.05.16
Data on variables and their measurement were
collected through interviews, self-completed questionnaires, and dental screenings performed by an orthodontist (D.F.). The questionnaires included a measurement
of OHQOL, the Brazilian shortened version of the
OHIP-14.19 During the interviews, a measurement of
socioeconomic status was used, the Brazil economic
classification criteria.29 This classifies people into 5
socioeconomic categories according to the educational
level of the head of the household, consumer goods
owned (eg, VCRs, DVDs, color TVs), and access to
household help. For our statistical analysis, the 5 socioeconomic categories were divided into high (A and B)
and low (C-E) social classes.
After the children were interviewed and had finished
filling out the questionnaires, clinical examinations
were conducted to assess orthodontic treatment need
and dental health status. Malocclusion severity and
orthodontic esthetic impairment were measured by using, respectively, the dental health component (DHC)
and the aesthetic component (AC) of the index of orthodontic treatment need (IOTN).30 Esthetic impairment,
measured by IOTN-AC was also evaluated by the children themselves (AC self-perception). Dental health
status was determined with the decayed, missing and
filled teeth index (DMFT) and the World Health Organization diagnostic criteria.31
Students in the comparison group were examined in
their school’s dental office, under conditions similar to
those at the university where the orthodontic group
was examined, and by the same orthodontist. The examiner had been determined as being trained in the use of
the IOTN index by a researcher (gold standard) with
broad experience with this occlusal index (J.A.M.).
The gold standard had been previously determined for
IOTN assessment during a course at the University of
Manchester in the United Kingdom. The training process included examination of 20 plaster casts by both
the examiner and the researcher, and subsequent comparison of their results. To assess intraexaminer reliability, 26 children were reinterviewed and reexamined 7 to
10 days after the first assessments (15 from the comparison group and 11 from the orthodontic group).
154 Feu et al
Statistical analysis
The data were analyzed by using software (version
7.0, StataCorp, College Station, Tex). Simple and multiple stepwise regression analyses, as well as chi-square
and t tests, were used to evaluate the effects of esthetic
impairment, malocclusion severity, sex, age, and socioeconomic status on OHQOL. Significance levels were
set at 0.05. Kappa statistics were used to test the consistency between the examiner’s scores and the gold standard scores, and for intraexaminer reliability. To test the
stability and internal consistency of the OHIP-14, the
intraclass correlation coefficient (ICC) and the Cronbach reliability coefficient a were used, respectively.
For OHIP-14 analysis, ordinal responses were coded
from 0 for ‘‘never’’ to 4 for ‘‘very often,’’ and all 14
ordinal responses were summed to produce an overall
OHIP score that could range from 0 to 56, with higher
scores indicating poorer OHQOL.
IOTN-AC scores range from 1 to 10 and for analytical purposes; subjects with scores greater than 5 were
considered to have an esthetic orthodontic treatment
need. For the DHC scores (range, 1-5), subjects with
scores greater than 3 were considered to have an objective orthodontic treatment need. These determinations
of orthodontic treatment needs were based on the cutoff
points for index dichotomization of Mandall et al,14
which had been used in previous studies.14,32-34
RESULTS
For both the DHC (kappa, 0.70) and the AC (kappa,
0.68) components of the IOTN, the examiner had good
agreement with the gold standard. Intraexaminer
reliability was very good (kappa, 0.98 for AC [95%
CI, 0.96-1.0]; kappa, 0.96 [95% CI, 0.90-1.0] for
DHC; and kappa, 1.0 for DMFT), indicating substantial
consistency of the clinical measurements.3 The ICC for
the OHIP-14 was 0.97 (95% CI, 0.95-0.99) and the
kappa coefficient for the AC self-perception was 0.93
(95% CI, 0.90-1.0). Test-retest reliability values for
the OHIP-14 and the AC self-perception were similar
between the orthodontic and comparison groups. The
internal consistency of the OHIP-14 showed a satisfactory Cronbach coefficient a of 0.73 (95% CI lower limit,
0.68).
Statistically significant differences between the orthodontic and comparison groups were found for socioeconomic status, malocclusion severity, and esthetic
impairment. The orthodontic group included more children at the high socioeconomic level and fewer at the
low level (P 5 0.002). This group also had significantly
higher DHC, AC examiner, and AC self-perception
scores on the IOTN, indicating more severe
American Journal of Orthodontics and Dentofacial Orthopedics
August 2010
malocclusions and greater normative and selfperceived treatment needs than did those in the comparison group. However, the 2 groups did not differ for age,
sex, and dental health status (DMFT). These findings
are shown in Table I.
In this study, the OHIP-14 values had an asymmetric
distribution in a favorable direction (ie, higher frequency of low OHIP-14 scores indicating relatively
high OHQOL), with scores ranging from 0 to 31. In
the statistical analysis, OHIP scores were transformed
into a dichotomous variable by using a cutoff value of
9, the median for the whole sample35 (n 5 194). Thus,
OHIP-14 scores higher than 9 were considered to reflect
more negative OHQOL, and those lower than or equal to
9 indicated more favorable OHQOL.
OHIP-14 scores were substantially higher in the orthodontic group, and the girls had significantly higher
OHIP-14 scores than did the boys in that group
(P 5 0.05). Adolescents who had sought orthodontic
treatment also had higher OHQOL scores in all 7
OHIP-14 domains. In both groups, the domains that
were most negatively affected were psychological discomfort (35.8%) and psychological disability (38.0%).
Furthermore, severe malocclusion (DHC scores of 4
and 5), normative and self-perceived esthetic impairment (AC scores .5), and poor dental health (DMFT
.5) were also statistically associated with more negative OHQOL. No statistically significant associations
were found between socioeconomic status, sex, age,
and OHQOL. These findings are given in Table II.
Multivariate analysis was used to adjust the relationship between orthodontic treatment seeking and
OHQOL.36 All potential confounding variables that
showed an association (eg, malocclusion severity, decay
experience, and orthodontic treatment needs) with the
outcome variable (ie, more severe impact: OHIP-14
score .9) in the bivariate analyses were included in
the model.4,35-38 Initially, subjects in the orthodontic
group were 4.6 times more likely to report a negative
impact on their quality of life than those in the
comparison group. After controlling for DMFT, DHC,
AC examiner, and AC self-perception, adolescents
who sought orthodontic treatment still were 3.1 times
more likely to report worse OHQOL than those from
the comparison group, who did not seek orthodontic
treatment. Severely normative and self-perceived
esthetic impairment were stronger predictors of worse
OHQOL than treatment seeking (Table III).
Table III illustrates both unadjusted and adjusted
values for DMFT, AC self-perception, AC examiner,
DHC, and socioeconomic status and demonstrates their
effects in negatively influencing OHQOL independently of other variables.38
Feu et al
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 2
Table I.
155
Distribution of sociodemographic characteristics, and IOTN, DMFT, and OHIP-14 scores
Comparison group
Socioeconomic status
A or B
C
D
Sex
Male
Female
Age† (mean y)
DMFT†
IOTN-AC examiner
Score 1-4
Score 5-7
Score 8-10
IOTN-AC self-perception
Score 1-4
Score 5-7
Score 8-10
IOTN-DHC
Score 1-3
Score 4-5
Total sample
Orthodontic group
Total
P*
n
(%)
n
(%)
n
0.002
19
66
17
(18.6)
(64.7)
(16.6)
49
41
2
(53.2)
(44.5)
(2.17)
60
115
19
(30.9)
(59.3)
(9.8)
0.246
60
42
13.5
1.2
(57.7)
(42.3)
(0.1)
(0.1)
46
46
13.2
1.7
(50)
(50)
(0.1)
(0.2)
106
88
13.6
1.4
(54.6)
(45.4)
(0.1)
(0.1)
0.008
71
26
5
(69.6)
(25.4)
(4.9)
47
36
9
(51.1)
(39.1)
(9.78)
118
62
14
(60.8)
(32.0)
(7.2)
0.000
99
3
0
(97.0)
(2.9)
-
59
23
10
(64.1)
(25.2)
(10.7)
158
26
10
(81.4)
(13.4)
(5.2)
0.000
76
26
102
(74.5)
(25.5)
(52.58)
40
52
92
(43.5)
(56.5)
(47.42)
116
78
194
(59.8)
(40.2)
(100)
0.320
0.793
(%)
*For ratio comparisons of proportions, the chi-square test was used and, for average means, the t test; †Line values refer to mean scores and
percentages of standard deviation.
DISCUSSION
This cross-sectional study is one of the few in Brazil
to assess the relationship between OHQOL and orthodontic treatment needs in adolescents with reliable
and valid instruments: the OHIP-14 and the
IOTN.4,19,24,39,40 In the future, this will allow for
comparisons with similar studies conducted in other
countries, helping to identify cross-cultural differences
in OHQOL and esthetic perceptions. The sample was
not intended to represent the entire population of
12- to 15-year-old Brazilians but, rather, to give an overview of children seeking orthodontic services at a university clinic in a large urban center of Brazil.
The OHIP-14 was developed for older adults, but Ferreira et al24 found that its Brazilian version had good psychometric properties, similar to those of the original
instrument, when testing the questionnaire with a group
of 12-year-olds. The OHIP-14 has been successfully applied to adolescents by many authors4,23-25,27,41 because
adolescents 12 years of age and above are capable of
abstract thinking, reasoning about timing of past events,
and correlating them with good or bad experiences.3
One might expect that a measurement instrument especially developed for children, such as the child oral health
impact profile42 and the child perceptions questionnaire,43 could provide a more accurate picture of the OHQOL in this adolescent population, but, when this study
was conducted, those instruments had not been translated
into Brazilian Portuguese and validated.
Most articles in the literature state that more females
than males seek dental treatment, but the proportions of
boys and girls who sought orthodontic treatment at our
university clinic during the recruitment period for this
study were almost the same.12,23,44,45 More girls did
not obtain their parents’ consent to take part, so that
the orthodontic group ended up with equal numbers of
boys and girls. The situation was similar in the study
of Patel et al46: because of lack of parental consent,
the number of girls in the study was even lower than
the number of boys. Nevertheless, we cannot rule out
the possibility that this might have biased our results.
Children who had sought orthodontic treatment had
more severe malocclusion, greater esthetic impairment
(according to both their own and the examiners’ evaluations), and more negative OHQOL impacts. These
results are not surprising, since these conditions are
expected to predict a child’s interest in treatment. It has
been shown that deviant dental appearance is a reason
for teasing by peers at school and in other social
situations.47 Also, children in the orthodontic group
belonged to higher-income families, with expectations
of self-image enhancement after orthodontic treatment
tending to be higher, and this might have influenced their
esthetics self-perceptions.39,47
156 Feu et al
Table II.
American Journal of Orthodontics and Dentofacial Orthopedics
August 2010
Associations between sociodemographic characteristics, IOTN, DMFT, and OHIP-14
OHIP \9 (higher OHQOL)
P*
Socioeconomic position
A or B
C
D
Sex
Male
Female
Group
Comparison
Orthodontic
IOTN-AC self-perception
Score 1-4
Score 5-7
Score 8-10
IOTN-AC examiner
Score 1-4
Score 5-7
Score 8-10
IOTN-DHC
Score 1-3
Score 4-5
DMFT†
Age† (y)
Total
Odd ratio (95% CI)
OHIP .9 (lower OHQOL)
Total
n
(%)
n
(%)
n
(%)
0.99
1
1.05 (0.47-2.33)
1.77 (0.46-6.73)
36
81
13
(66.6)
(66.9)
(68.4)
18
40
6
(33.4)
(33.1)
(31.6)
60
115
19
(100)
(100)
(100)
0.22
1.65 (0.55-2.26)
75
55
(70.8)
(62.5)
31
33
(29.2)
(37.5)
106
88
(100)
(100)
0.00
4.66 (1.35-5.70)
84
46
(82.3)
(50.0)
18
46
(17.7)
(50.0)
102
92
(100)
(100)
0.00
1
4.0 (1.7-9.5)
26.6 (6.2-216.1)
118
11
1
(74.7)
(42.3)
(10.0)
40
15
9
(25.3)
(57.7)
(90.0)
158
29
10
(100)
(100)
(100)
0.00
1
2.6 (1.8-6.8)
5.11 (3.3-8.7)
91
23
7
(77.7)
(37.1)
(53.84)
26
39
6
(22.3)
(62.9)
(46.16)
117
62
13
(100)
(100)
(100)
0.00
3.28 (1.76-3.12)
0.05
0.08
1.24 (1.0-1.5)
0.84 (0.62-1.14)
90
40
1.2
13.7
130
(77.6)
(51.3)
(0.1)
(0.1)
(67.0)
26
38
1.7
13.4
64
(22.4)
(48.7)
(0.2)
(0.1)
(33.0)
116
78
1.4
13.6
194
(100)
(100)
(0.1)
(0.1)
(100)
*For ratio comparisons, the chi-square test was used and, for averages, the t test; †Lines values refer to mean scores and percentages.
Multivariate analysis showed that adolescents from
the group that sought orthodontic treatment were 3.1
times more likely to have negative impacts on their
quality of life, independent of their decay experience,
severity of the malocclusion, and esthetic impairment.
This supports other researchers’ findings in various populations—that quality of life outcomes are related not
only to health and disease factors but also to subjective
experiences and feelings about these factors.3,5,7,13,21,48-51
This result shows the influence of individual
personality traits on OHQOL, which cannot be
ignored and might, to some extent, explain why some
patients are concerned about minor malocclusions
and demand orthodontic intervention, whereas others
accept a major deviation from the norm quite happily
because it does not cause a negative impact on daily
living.
Corroborating these findings, Bernabé et al52 found
that many adolescents with normative orthodontic treatment need experienced no impacts on OHQOL. Likewise, Oliveira and Sheiham4 found that a high
percentage of Brazilian adolescents who were determined to have orthodontic treatment, and were scored
with the IOTN, had no overall oral health impact.
The multivariate analysis also showed that children
with higher esthetic scores (ie, severely compromised
esthetics), as evaluated by the examiner, were 3.9 times
more likely to have negative impacts than those with no
or minor esthetic treatment needs, independently of
other variables. Self-perceived esthetics were even
more predictive of negative OHQOL impacts; adolescents with higher AC self-perception scores were 11.7
times more likely to have negative OHQOL impacts
than those with lower self-perception scores (ie, more
favorable perceived esthetics). Similarly, Oliveira and
Sheiham4 found that Brazilian adolescents who did
not report negative OHQOL impacts were 2.5 times
more likely to be satisfied with their dental appearance
than those who had a negative oral impact. These results
support the findings of Kok et al,53 who found a correlation between negative quality of life impacts and dental
esthetic self-perceptions.
Specific domains of the OHIP-14 were evaluated to
determine the most important negative impacts and their
correlations with other characteristics of the subjects.
The domains that were most affected in both groups
were psychological discomfort and psychological disability, which were also found to be related to esthetic
impairment in another study.54 Prahl-Andersen55 stated
that malocclusion might become enormously handicapping not because of the functional disability, but because it can adversely affect social relationships and
Feu et al
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 2
Unadjusted and adjusted odds ratio (OR)
values for predictors for OHIP-14 scores .9
Table III.
Unadjusted OR
(95% CI)
Comparison group
Orthodontic group
DMFT
IOTN-AC self-perception
Score 1-4
Score 5-7
Score 8-10
IOTN-AC examiner
Score 1-4
Score 5-7
Score 8-10
IOTN-DHC
Score 1-3
Score 4-5
1
4.6 (2.4-8.9)
1.2 (1.0-1.5)
1
4.0 (1.7-9.5)
26.6 (6.2-216.1)
Adjusted OR*
(95% CI)
1
3.1 (1.5-6.3)
1.2 (0.9-1.5)
1
2.5 (1.0-6.5)
11.7 (1.3-100.23)
1
2.6 (1.8-6.8)
5.1 (3.3-8.7)
1
1.7 (1.2-4.1)
3.9 (2.6-7.2)
1
3.28 (1.76-3.12)
1
1.95 (0.95-3.97)
157
OHQOL when scores exceeded 5, but high scores
were rare among the participants in this study.
The results showed that individual personality traits
probably have an influence on OHQOL, making negative
impacts not always exclusively dependent on malocclusion severity. Severely compromised esthetics had the
most important role in negative OHQOL, and their greatest impact was at the psychosocial level. Thus, orthodontists should be aware that both adolescent patients and
their parents might expect orthodontic treatment to
provide not only improved oral functioning, health, and
esthetics, but also enhancement of self-esteem and social
life.58 When these expectations are overblown, they might
not be met, leading to dissatisfaction with the treatment
outcome. The use of the OHQOL questionnaires as part
of the diagnosis procedures could help orthodontists to
identify and prevent these problems.
*Logistic regression model adjustment test was the goodness-of-fit
test of Hosmer and Lemeshow.38 P 5 0.35 showed good adjustment.
CONCLUSIONS
self-perceptions. The importance of these domains is
consistent with other studies in Brazil that evaluated
young adults who were seeking dental treatment and
also found psychological discomfort to be the most
negatively impacted domain.4,56
We found no sex differences in OHQOL when both
the orthodontic and the comparison groups were considered. This corroborates the studies of Birkeland et al,16
Hunt et al,57 and Bernabé et al.52 Nevertheless, when the
orthodontic group was evaluated alone, OHIP-14 scores
were higher in the girls, in concordance with other authors’ findings.4,10,18,22,58 These results suggest that
sex influences OHQOL among those who are worried
about esthetics and anticipating orthodontic treatment,
as Tulloch et al59 reported. Esperão60 also found that,
among Brazilians who sought orthognathic surgery,
OHQOL was poorer in female than in male patients.
Socioeconomic status did not negatively influence
quality of life outcomes in this sample; this is consistent
with the findings of other researchers.10,21,41,52,60-63
Locker21 and Shaw et al63 concluded that the negative
influence on OHQOL in subjects with lower socioeconomic status was because of poorer general oral health,
such as greater decay and periodontal disease. In our
study, the comparison group included 81.3% of subjects
with lower socioeconomic statuses (classes C-E), compared with 46.7% in the orthodontic group. Nevertheless, their OHQOL scores were generally more
favorable than those of the children in the orthodontic
group. Children in the comparison group received regular dental care during their school years, as evidenced by
their low DMFT scores, slightly lower than those of the
orthodontic group. DMFT had a negative influence on
In this cross-sectional study of Brazilian adolescents
(aged 12-15 years), those who had sought orthodontic
treatment had a higher chance of reporting worse
OHQOL than did those who had never sought treatment,
independently of dental caries status, malocclusion
severity, and esthetic impairment, whether selfperceived or evaluated by an orthodontist. Nevertheless,
severely compromised esthetics was a better predictor
of worse OHQOL than orthodontic treatment seeking.
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