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Theses & Dissertations
Boston University Theses & Dissertations
2016
Quality of life in adult orthodontic
patients
Neely, Martha Lucia
http://hdl.handle.net/2144/18305
Boston University
BOSTON UNIVERSITY
HENRY M. GOLDMAN SCHOOL OF DENTAL MEDICINE
THESIS
QUALITY OF LIFE IN ADULT ORTHODONTIC PATIENTS
by
MARTHA LUCIA NEELY
D.D.S, National University of Colombia 1997
D.M.D, Boston University Henry M. Goldman School of Dental Medicine, 2013
Submitted in partial fulfillment of the requirements for the degree of
Master of Science in Dentistry
In the Department of Orthodontics and Dentofacial Orthopedics
2016
Approved by:
First Reader
______________________________________________________
Dr. Judith A. Jones, DDS, MPH, DScD
Professor and Assistant Dean for Faculty Development
Director, Center for Clinical Research
Boston University Henry M. Goldman School of Dental Medicine
Second Reader
______________________________________________________
Dr. Leslie A. Will, Chair and Anthony A. Gianelly Professor in
Orthodontics
Director of the Advanced Specialty Education Program in
Orthodontics
Boston University Henry M. Goldman School of Dental Medicine.
Third Reader
______________________________________________________
Dr. Astha Singhal, BDS, MPH, PhD
Assistant Professor
Department of Health Policy and Health Services Research
Boston University Henry M. Goldman School of Dental Medicine
Reader Approval Page
ACKNOWLEDGEMENTS
I would like to thank:
Drs. Judith Jones and Leslie Will for their continued support over the past years. Their
guidance and support were influential throughout my research. I appreciate their efforts
tremendously and their willingness to always help.
Dr. Raffi Miller for his support of this research project. This study would not have been
possible without his fundamental project ideas, time and dedication.
Dr. Astha Singhal for her expertise, kindness and supportive nature as a contributing
reader of this thesis.
Sharron Rich for her statistical expertise. Without her help and continuous support, the
data would have remained unanalyzed and therefore statistically meaningless.
Carol Nicholson, Kendrick Smaellie and all pre-doctoral students that contributed by
recruiting patients, without their help this project would not have been possible.
All the patients that participated in this project, without their help this project would not
have been successful.
I would also like to give a huge thanks to the entire faculty in the Department of
Orthodontics and Dentofacial Orthopedics at Boston University Goldman School of
Dental Medicine. Their knowledge and clinical expertise is something that I will
remember for the rest of my life. I hope to honor them by practicing my profession in the
same manner I was taught while I serve my patients and community.
Additionally, I would also like to thank and congratulate my co-residents for their help
with my project and their dedication throughout the last three years.
Finally, I would like to thank my husband and family for their love, support, guidance
and commitment during the past years while I was pursuing my dream of becoming an
Orthodontist. This achievement belongs to you.
iii
QUALITY OF LIFE IN ADULT ORTHODONTIC PATIENTS
MARTHA LUCIA NEELY
Boston University, Henry M. Goldman School of Dental Medicine, 2016
Major Professor: Dr. Leslie A. Will, Chair and Anthony A. Gianelly Professor in
Orthodontics, Director of the Advanced Specialty Education Program in Orthodontics at
Boston University Henry M. Goldman School of Dental Medicine.
ABSTRACT
Objective: To examine Teen Oral Health-related Quality of Life (TOQL) for use in adults
receiving orthodontic treatment and assess validity and reliability by age-group.
Methods: Teenagers ages 10-18 years and adults 18 years and over completed surveys at
the Orthodontic Clinic at Boston University. The survey consisted of sociodemographic
information, dental behavior questions, and the TOQL instrument. (Wright, Spiro, Jones,
& Rich, n.d.) Malocclusion severity was assessed using the Index of Orthodontic
Treatment Need (IOTN).
Results: 161 teens and 146 adults participated; teens had a mean age of 13 years and
adults 32 years. Subjects represented both genders and diverse racial and ethnic
backgrounds. In general, scores overall and by domains were higher for adults than for
teens, signifying a greater effect on the quality of life. Mean TOQL scores were worse
(17.55) in adults than in teens (11.92, p<0.01); emotional and social domains scores were
higher for adults (p<0.001).Construct validity was supported by strong association of
TOQL scores with self-reported oral health (p<0.0001). Cronbach’s alpha was higher in
adults (0.75 in adults compared to 0.68 in teens) and for all the domains.
Conclusion: Adults who come for orthodontic treatment report that they are more
affected by their malocclusion as compared to teens. Total TOQL score and the
emotional and social domains are significantly higher for adults than teens. The project
suggests that TOQL is a valid and reliable way to measure impact of malocclusion in
quality of life in both adults and teens.
iv
TABLE OF CONTENTS
READER APPROVAL PAGE ................................................................................................ II
ACKNOWLEDGEMENTS ........................................................................................... III
ABSTRACT ................................................................................................................... IV
TABLE OF CONTENTS ................................................................................................ V
LIST OF TABLES ......................................................................................................... VI
LIST OF FIGURES ....................................................................................................... VII
REVIEW OF THE LITERATURE ................................................................................. 1
HYPOTHESIS AND OBJECTIVES ............................................................................ 13
MATERIALS AND METHODS .................................................................................. 14
Design and IRB: ........................................................................................................ 14
Sample Selection and Enrollment Criteria: .............................................................. 14
Study Procedures: ..................................................................................................... 15
Outcomes of interest: ................................................................................................ 15
Predictors: ................................................................................................................ 17
Data Analyses: .......................................................................................................... 21
RESULTS ..................................................................................................................... 22
DISCUSSION AND CONCLUSIONS ......................................................................... 36
Conclusions: ............................................................................................................. 40
APPENDIX ................................................................................................................... 41
REFERENCES ............................................................................................................. 55
CURRICULUM VITAE ............................................................................................... 63
v
LIST OF TABLES
TABLE 1 LITERATURE REVIEW SUMMARY…………….……..……………9
TABLE 2 DEMOGRAPHICS.…...…….…………..………………….…….…….23
TABLE 3 SCORE IMPACT FOR DIFFERENT DOMAINS…………….……..26
TABLE 4 TOQL BY GROUPS…………….……………………………….….….29
TABLE 5 SCALE RELIABILITY OF TOQL (CRONBACH ALPHA)..……....30
TABLE 6 MULTIPLE REGRESION ANALYSIS…………………………...…..31
vi
LIST OF FIGURES
FIGURE 1 TOQL SCORES BY STUDY GROUP……………………………….32
FIGURE 2 IMPACT BY STUDY GROUP……………………………….……….35
vii
REVIEW OF THE LITERATURE
Oral health influences the patients’ wellbeing from different perspectives, such as
psychological, social, and functional health. These aspects are referred to as oral health–
related quality of life.
Many definitions have been given to “quality of life’’ over the years. Becker et al.
defined it as ‘‘a person’s sense of well-being that stems from satisfaction or
dissatisfaction with the areas of life that are important to him/her” (Becker, Diamond, &
Sainfort, 1993).
The World Health Organization defined quality of life as ‘‘people’s perception of their
position in life in the context of the culture and value systems in which they live and in
relation to their goals, expectations, standards, and concerns.’’(“World Health
Organization. Measuring quality of life: the development of the world health organization
quality of life instrument (WHOQOL). ,” n.d.)
Other authors further define oral health-related quality of life (OHQoL) as the extent to
which oral and perioral conditions impact people’s life and enable an individual to eat,
speak and socialize without active disease, discomfort or embarrassment and which
contributes to their general well-being. (“Department of Health. An oral health strategy
for England. London, United Kingdom: HMSO; 1994.,” n.d.).
1
Conditions affecting oral health, such as malocclusion, are very prevalent in our society,
and they have consequences not only for physical well-being but also impair quality of
life by affecting function, appearance, interpersonal relationships, socializing, self-esteem
and psychological well-being (Masood, et al., 2014).
Data from the National Health and Nutrition Examination Survey (NHANES III) and
western European studies suggest that two-thirds to three-fourths of adults possess some
form of malocclusion. Further, the proportion of adults seeking orthodontic treatment in
the United States has increased dramatically in the last four decades (Buttke & Proffit,
1999).
Adults seek orthodontic treatment for a wide variety of reasons including esthetic, social,
functional and psychological concerns. In addition, orthodontics may facilitate other
dental treatment. For example, crowded or misaligned teeth may make it more
complicated for patients to control plaque accumulation, leading to increased incidence of
caries and periodontal disease. Orthodontists are also important members of
interdisciplinary teams because they can contribute in multiple ways. For example, in a
mutilated dentition, an orthodontist can help by establishing a favorable crown to root
ratio, correcting vertical orientation so that occlusal forces are transmitted along the long
axis of the tooth, obtaining better position of teeth that have drifted after extractions or
bone loss, insufficient tooth structure due to fractures or excessive wear, and crossbite or
misalignment of anterior teeth. In addition, successful placement of implants to support
restorations is often easier and more predictable if adjacent teeth are first repositioned.
2
Orthodontic treatment also helps to achieve the best balance between dental and facial
esthetics, ideal occlusal relationships and long-term dentoalveolar stability. In today's
society, a person's dentition is an important component of facial attractiveness, which can
markedly affect his or her self-esteem and self-image.(Buttke & Proffit, 1999)
The oral and facial region is a very important area and it draws the most attention in
verbal and non-verbal communication and interpersonal interactions. As a result, patients
who seek orthodontic treatment may be more concerned with improving their appearance
and social acceptance than they are with improving their oral function or health.
Improving these aspects of quality of life is an important reason for undergoing
orthodontic treatment and the primary motivator. For clinicians, understanding the
physical, social, functional and psychological implications of malocclusion on oral
health-related quality of life should be very important, as it can give us information on
the effects of malocclusion on people’s lives and may provide a clearer reason why
people seek orthodontic treatment. (Hassan & Amin, 2010).
It can be argued that the traditional focus of dental care has been on treating the
pathology, rather than take a holistic view of the person and their concerns. Before the
1970s the patient’s quality of life was not a consideration in dentistry. In 1972, Thomas
Elwood published one of the first studies that looked at quality of life in relation to old
age (Elwood, 1972). This led to an increase in research involving quality of life as it
related to various health conditions, such as, obesity, respiratory disease, pain, and
epilepsy. Since that time, the social impact of dental disease, and the relationship
3
between dental conditions and quality of life have been assessed widely (Cohen & Jago,
1976; Reisine, 1988a, 1988b; Shaw et al., 1980). Several studies have examined quality
of life, oral health-related quality of life and its relation to oral health (Fassil & Hayes,
2010; Filstrup et al. unpublished; Reisine, et al., 1988b; Shaw et al., 1980) They have
generally shown that diminished oral health has a negative impact on quality of life.
Fewer studies, though, have examined quality of life and its relation to malocclusion, or
more specifically, the correlations between treatment of malocclusion through
orthodontic treatment, and quality of life (Shaw et al., 1980).
Shaw et al. were among the first to highlight the need to investigate the benefits of
orthodontic treatment in relation to social effects in their compiled articles from 1980 to
2007. They compared the dental and psychosocial status of people who received, and did
not receive, orthodontic treatment as teenagers and follow them for 20 years. They found
little objective evidence to support that orthodontic treatment improves psychological
well-being and self-esteem. (Shaw, et al; 1980; Shaw, et al., 1986; Shaw, et al., 2007a).
Although several early studies began to assess some of the relationships in question, they
did not look specifically at how malocclusion affects quality of life or oral health-related
quality of life, or how orthodontic treatment can change these outcome measures (Arrow,
et al., 2011; Liu, et al., 2009; Shaw, et al., 2007; Taylor, et al., 2009) . Although other
researchers have begun to assess these relationships, the results have been mixed thus far.
Taylor et al. and Arrow et al. conducted two different cohort studies and found a limited
association between malocclusion and quality of life or psychosocial factors. In general,
4
orthodontic treatment did not appear to be associated with oral health-related quality of
life. (Taylor, et al., 2009; Arrow, et al., 2011). Similarly, Johal et al. found no difference
in scores for oral health impact profile when measured before and after orthodontic
treatment (Johal, et al., 2014). On the other hand, a systematic review published by Liu et
al. in 2009 showed a modest association between malocclusion, orthodontic treatment
need and quality of life. Some of the weaknesses they noted in the available research at
the time were the lack of standardized assessment and a relative weakness in strength of
evidence (Liu et al., 2009).
Other studies have assessed relationships between the severity of malocclusion, different
treatment modalities, and quality of life. Kiyak’s longitudinal research (2008) on the
impact of conventional and surgical orthodontics on quality of life examined the
association between oral health-related quality of life and severity and type of
malocclusion, as well as the impact of treatment and patient characteristics on quality of
life. They found evidence that patients’ main interests are on the esthetic and social
aspects and they are the motive for seeking orthodontic treatment. Patients with severe
malocclusion appear to have poorer oral health-related quality of life than patients with
less critical treatment need in these domains. Furthermore, oral function did not appear to
have as great an effect on patients’ as the severity or visibility of the malocclusion.
Orthodontic intervention was found to enhance some aspects of oral health-related
quality of life, particularly esthetics, but not necessarily social acceptance. One of the
most important remarks in this article is the emphasis on the importance of clinicians
having a clear understanding, before initiating treatment, of their patients' quality of life
5
and their expectations about improvements in specific domains of quality of life (Kiyak,
2008).
Many other authors have contributed to our knowledge in oral health-related quality of
life. They have reported that patients with malocclusion may have physical pain as well
as psychological discomfort and disability. They feel self-conscious or tense, have
difficulty relaxing, and may be somewhat irritable with other people. It has been also
found that patients show significant changes in physical health and mental health quality
of life and had improved disease-specific health-related quality of life, psychological
status and anxiety irrespective of the severity of the malocclusion after orthodontic
treatment. (Choi, et al., 2010; Rusanen, et al., 2010; Azuma et al., 2008; Hassan & Amin,
2010).
In 2010, Feu reported on a cross-sectional study of Brazilian adolescents aged 12-15
years). He reported that teens who sought orthodontic treatment had a higher possibility
of reporting worse oral health quality of life than did those who had never sought
treatment, and that severely compromised esthetics was a better predictor of worse oral
health quality of life than the act of seeking orthodontic treatment. (Feu et al., 2010).
Other studies have also found the importance of malocclusion and orthodontic treatment
in individual’s quality of life, such as Palomares et al. (2012), who found that subjects
with no history of orthodontic treatment had a significantly poorer oral health-related
quality of life that patient who had received orthodontic treatment. They conducted their
6
study on young Brazilian adults, who had completed orthodontic treatment and compared
them with untreated subjects in need of orthodontic treatment who were waiting for
treatment. (Palomares, et al., 2012).
More recent studies have also determined the negative effect of malocclusion in health
related quality of life. Several authors have concluded that malocclusion has a significant
negative impact on oral health-related quality of life and its domains. They also found
that participants with high treatment needs and who are more unsatisfied with dental
esthetics were more likely to report more oral effects and a significantly greater negative
impact on the overall oral health-related quality of life score. They also found that when
orthodontic treatment was completed, oral health-related quality of life was increased to
levels similar to normal occlusion (Kang & Kang, 2014; Masood et al., 2013; Silvola et
al., 2014).
In their 2014 systematic review, Zhou, et al. reviewed four different data bases and
supplemented this with manual searches for articles the impact of orthodontic treatment
on quality of life published between 1960 and December 2013. They proposed a modest
association between orthodontic treatment and quality of life. The majority of studies
evaluated by them showed correlation between orthodontic treatment and quality of life
no matter what measurement was applied (Zhou, et al, 2014).
In 2015, similar studies by Choi et al. and Chen et al. concluded that malocclusion has a
significant negative impact on oral health-related quality of life, especially for the
7
psychological discomfort and psychological disability domains and cause limited oral
function, pain, and social disability in young adults (Choi, et al., 2015; Chen, et al.,
2015).
8
Table 1. Literature review summary
Author
Year
Age
Group/
Mean age
17.342.5/25.4
Measure Used
Findings
Azuma et
al.
2008
The subjective Oral Health Status
indicator (SOHSI), The
orthognathic Quality of life
Questionnaire (OQLQ) and The
Recognition and Satisfaction scale
modified (RSS-M)
Oral health impact profile/ IOTN
dental health component
Improvement in the disease specific
HRQOL and state of anxiety of patients
with malocclusion after surgical
correction irrespective of the severity
before surgery.
Chen et
al.
2015
1825/28.8
Choi et
al.
2010
23.94
Short Form Health Survey (SF-36),
Short Form Oral Health Impact
Profile (OHIP-14), and the
Orthognathic Quality of Life
Questionnaire (OQLQ)
Significant improvement in QoL
occurred after combined orthodonticsurgical treatment,
as demonstrated by significant decrease
in OHIP scores and OQLQ scores.
Claudino
et al.
2013
18-21
Dental Aesthetic Index (DAI) and
oral aesthetic self-perception as
indicated by the Oral Aesthetic
Subjective Impact Scale (OASIS)
A high prevalence of malocclusion was
observed. Adults with severe
malocclusion had a higher prevalence of
poorer oral aesthetic self-perception.
Frejman
et al.
2013
27.56
Specific questionnaires oral
health-related quality of life, selfesteem, and depression
Patients with dentofacial deformities
had a more negative oral health-related
quality of life and a lower self-esteem
compared with controls.
Hassan
et al.
2010
21-25
DC of IOTN and the short version
of oral health impact profile
questionnaire
The impact of malocclusion on OHRQOL
of young adults was very important and
is imperative a patient-based evaluation
of oral health status and oral health
needs.
Kang et
al.
2014
18-39
Short form of the Oral Health
Impact Profile (OHIP-14) and
Psychosocial Impact of Dental
Aesthetics Questionnaire (PIDAQ).
Malocclusion has a negative impact on
OHRQoL, but this could be improved in
adults through orthodontic treatment.
Klages
2004
24.6
Aesthetic Component (AC) of the
Index of Orthodontic Treatment
Need (IOTN)
Dental aesthetics had a direct effect in
OHRQOL. Self-consciousness is related
to social appearance and appearance
disapproval.
9
Malocclusion has a significant negative
impact on OHRQoL. This is greatest for
the psychological discomfort and
psychological disability domains. The
orthodontic treatment of malocclusion
improves OHRQoL of patients.
Author
Year
Age
Group/
Mean age
1630/18.5
Measure Used
Findings
Liu et al.
2011
Short-form Oral Health Impact
Profile (OHIP-14) and United
Kingdom oral health-related
quality of life measure (OHQoLUK). Study casts were assessed for
OTN by: Dental Aesthetic Index
(DAI), Index of Orthodontic
Treatment Need (IOTN)-Aesthetic
Component (IOTN-AC) and Dental
Health Component (IOTN-DHC)
and Index of Complexity, Outcome
and Need (ICON).
Orthodontic treatment need was
associated with OHRQoL. The
magnitude of the statistical difference
between those with and without an
orthodontic treatment need was larger
when OHRQoL was assessed using
OHQoL-UK compared to OHIP-14
Liu et al.
2011
Adults
Short form of the Oral Health
Impact Profile (OHIP-14) and the
United Kingdom oral healthrelated quality of life (OHQoL-UK)
Changes in OHRQoL occur during fixed
orthodontic appliance therapy. During
the earlies phase greater deterioration
in OHRQoL occurs. With ongoing
treatment, the detrimental effects to
OHRQoL are reduced.
Masood
et al.
2013
15-25
Oral Health Impact Profile (OHIP14) and the Index of Orthodontic
Treatment Need- Dental Health
Component (IOTN-DHC).
Malocclusion has a significant negative
impact on OHRQoL and its domains.
This is greatest for the psychological
discomfort domain.
Johal et
al
2015
Adults
Oral Health Impact Profile (OHIP14) and Rosenberg self-esteem
scale
No difference in scores for the Oral
Health Impact Profile (OHIP-14) when
measured immediately before and after
orthodontic treatment.
Palomar
es et al.
2012
18-30
Index of Orthodontic Treatment
Need (DC and AC)
Young adults who received orthodontic
treatment had significantly better oral
health-related quality of life scores after
treatment completion, than untreated
subjects.
Rusanen
et al.
2009
1664/35.5
Oral Health Impact Profile (OHIP)14
Patients with severe malocclusions
report high levels of oral impacts.
Physical pain as well as psychological
discomfort and disability were the most
commonly perceived oral impacts.
Being self-conscious, feeling tense,
having difficulties in relaxing, and being
somewhat irritable with other people
were more common in females than in
males.
10
Author
Year
Age
Group/M
age
18-64/38
Measure Used
Findings
Rusanen
et al.
2012
Oral Health Impact Profile(OHIP14), the intensity of facial pain
using a Visual Analogue Scale
(VAS), TMD with Helkimo ’ s
clinical dysfunction index (Di), and
occlusal characteristics with the
Peer Assessment Rating (PAR)
Patients with severe malocclusion who
also have TMD and facial pain more
often have impaired oral health-related
quality of life.
Silvola et
al.
2014
1861/37.4
Oral Health Impact Profile (OHIP14) and the Aesthetic Component
of the Index of Orthodontic
Treatment Need.
Improvement in esthetic due to
treatment of severe malocclusion
improves oral health–related quality of
life, particularly by decreasing
psychological discomfort and
psychological disability.
Choi et
al.
2015
1832/22.4
Oral Health Impact Profile (OHIP14) and the Index of Orthodontic
Treatment Need DC.
Malocclusion is a key factor associated
with poor quality of life caused by
limited oral function, pain, and social
disability in young adults.
The table above show some of the most relevant studies done on the quality of life in
adult orthodontic patients. Even though one of the studies did not find any difference in
quality of life before or after orthodontic treatment, most of the studies have found that
malocclusion in adults has a remarkable impact on oral health-related quality of life.
Patients report lower levels of self-esteem, are self-conscious due to their negative dental
aesthetic perception and social appearance disapproval, have difficulty relaxing, and
become somewhat irritable. Some of the most commonly perceived oral impacts in adults
are physical pain as well as psychological discomfort and disability.
11
Once orthodontic treatment was finished, studies show that adults report improvement in
disease-specific health-related quality of life, anxiety, aesthetic self-perception and
overall improvement in the psychologic discomfort and disability.
In summary, most of the research in this area has focused on the impact of orthodontic
treatment on the quality of life in children rather than adults. This is in part because
children make up the majority of orthodontic patients. (Zhou et al., 2014). However,
more adults are seeking correction for their malocclusion, so investigation into the oral
health-related quality of life in adults is important for our understanding of adults’
experience with malocclusion and why they seek treatment. We hypothesized that oral
health-related quality of life in adults with malocclusion is worse than that of adults
without malocclusion. We also hypothesized that adults with malocclusion who seek
orthodontic treatment are more bothered by the malocclusion than teenagers seeking
orthodontic treatment as they have accumulated insults for a longer period of time and for
that reason they are willing to pay for their own treatment and go through it with all of its
personal and social implications. However, our review did not find any article or study
that compares oral health-related quality of life in adult and teenaged orthodontic
patients.
12
HYPOTHESIS AND OBJECTIVES
The aim of this study was to examine the validity and reliability of Teen Oral Healthrelated Quality of Life (TOQL) for adults receiving orthodontic treatment as compared to
teenagers. Using the TOQL, we assessed the impact of malocclusion on OHRQOL
among adults who seek orthodontic treatment, and compared it to teenagers seeking
orthodontic treatment and teenagers in the community who did not seek orthodontic
treatment. Finally, we explored and described the reasons behind adults seeking
orthodontic treatment later in life.
For comparison with teenagers, we used existing data from a previous study of teens at
Boston University Henry M. Goldman School of Dental Medicine.
This current paper is the first part of a longitudinal study. In this paper, we describe
baseline data and test the following hypothesis:
H0: There is no difference in oral health-related quality of life between adults seeking
orthodontic treatment, teenagers seeking orthodontic treatment and teenagers not seeking
orthodontic treatment.
13
MATERIALS AND METHODS
Design and IRB:
This is a cross-sectional study of adults’ perception of the impact of their teeth and/or
mouth on their oral health-related quality of life. The results were compared to data from
a previous unpublished study by Mahaffey et al. (2011) who evaluated quality of life in
teenagers seeking orthodontic treatment and compared results with that from teenagers in
the community (Mahaffey, Will, Wright, Rich, & Jones, n.d.). In addition to the QOL
instrument, both adult and teenaged patients were asked to rate the aesthetic appearance
of their teeth relative to the Aesthetic Component (AC) of the Index of Orthodontic
Treatment Need (IOTN).
This project was approved by the Internal Review Board at Boston University Medical
Campus. All participants gave written informed consent.
Sample Selection and Enrollment Criteria:
The patients selected for this study were adults aged 18 years or older, who were
classified as Grade 2 or greater (worse) category of the Dental Component (DC) of the
IOTN by calibrated examiner (PI). Patients with mental or physical disabilities were
excluded from the study. In addition, non-English speaking patients were excluded from
the study because translation services were not readily available. All patients who
satisfied the above listed inclusion criteria and were seeking comprehensive or limited
orthodontic treatment were invited to participate.
14
Study Procedures:
Patients who presented to the orthodontic clinic at Boston University Henry M. Goldman
School of Dental Medicine for treatment were screened preliminarily for eligibility at or
after their records appointment. If qualified based on their IOTN, they were asked to
participate at their following appointment before appliances were placed. At that time,
patients who consented were asked to complete the adult version of the TOQL. Also, an
Oral Health Screening form was completed at this time by the PI. This form was used to
assess the current oral health status of the participants. Data from the surveys and
screening forms were then compiled and analyzed. Data from previous teen study by
Mahaffey et al. was used to compare results (Mahaffey et al., n.d.). At the completion of
orthodontic treatment, participants will be surveyed again to assess changes in quality of
life and oral health-related quality of life.
Outcomes of interest:
The primary outcomes of interest were overall oral health-related quality of life, and
overall quality of life as related to the patients’ malocclusion. The oral health-related
quality of life was measured using the TOQL. The TOQL was developed by Wright et
al., who demonstrated its validity and reliability in a diverse sample of 13-18 year old
adolescents. They used a sample of 363 adolescents in a cross sectional study and showed
the TOQL as a valid and reliable oral health-related quality of life measurement. (Wright,
15
Spiro, Jones, & Rich, under revision). The TOQL assesses oral health-related quality of
life in 5 domains; role, oral health, social, emotional, and physical. Role assesses how the
state of the patients’ oral condition impacts their ability to pay attention at school or
work, and their ability to sleep. The oral health domain assesses bad breath, bleeding
gums, food caught between teeth, and mouth sores. The social domain assesses the
impact of the patients’ current oral state on social pressures and interactions, such as
having crooked teeth, worrying about opinions of others in regards to their appearance,
and comfort with smiling. The emotional domain assesses if their oral health upsets or
worries them, while the physical domain measured difficulty eating and oral pain.
The TOQL scores were calculated by a SAS (version 9.3) scoring program. Questions
were asked in two parts: how often the patient’s oral health bothered them, and how
severely they were bothered by it. Numerical values were assigned to every possible
response. The frequency responses were graded as follows: (0) did not happen, (1) once
in a while, (2) some of the time, and (3) all the time. Severity values were: (0) did not
happen, (1) never bothered, (2) bothered a little bit, (3) somewhat bothered and (4) very
bothered. These values represented the influence of how often and how bothered an
individual item is, so that the lower the point total, the less of a problem the item is. Then
the values of how often are multiplied by values of how bother and a range is obtained 012. Finally to compute scores on a scale ranging from 0-100, the following mathematical
formula was used:
SCORE=((Sum- # items)/(max value*#items-#items))*100.
16
Predictors:
The Dental Component (DC) of the IOTN (completed by PI) consists of a classification
system from Grades 1-5, with Grade 1 indicating no treatment need up to Grade 5
indicating “very great” treatment need. The DC of the IOTN was used to assess the
presence and severity of malocclusion, and hence orthodontic treatment need.
The references for classification were as follows:
GRADE 1 (none)
Extremely minor malocclusions including displacements < 1mm. (Only use for selection
of purpose)
GRADE 2 (little)
a) Increased overjet > 3.5mm but ≤ 6mm with competent lips.
b) Reverse overjet > 0mm but ≤ 1mm.
c) Anterior or posterior crossbite with ≤ 1mm discrepancy between retruded contact
position and intercuspal position.
d) Displacement of teeth > 1mm but ≤ to 2mm.
e) Anterior or posterior open bite > 1mm but ≤ 2mm.
f) Increased overbite ≥ to 3.5mm without gingival contact.
g) Prenormal or postnormal occlusions with no other anomalies. Includes up to half a
unit discrepancy
17
GRADE 3 (moderate)
a) Increased overjet > 3.5mm but ≤ 6mm with incompetent lips.
b) Reverse overjet > 1mm but ≤ 3.5mm.
c) Anterior or posterior crossbites with > 1mm but ≤ 2mm discrepancy between retruded
contact position and intercuspal position.
d) Displacement of teeth > 2mm but ≤ 4mm.
e) Lateral or anterior open bite > 2mm but ≤ 4mm.
f) Increased and complete overbite without gingival or palatal trauma.
GRADE 4 (great)
a) Increased overjet > 6mm but ≤ 9mm.
b) Reverse overjet > 3.5mm with no masticatory or speech difficulties.
c) Anterior or posterior crossbites with > 2mm discrepancy between retruded contact
position & intercuspal position.
d) Severe displacements of teeth > 4mm.
e) Extreme lateral or anterior open bites > 4mm.
f) Increased and complete overbite with gingival or palatal trauma.
g) Less extensive hypodontia requiring prerestorative orthodontics or orthodontic space
closure to obviate the need for a prosthesis.
h) Posterior lingual crossbite with no functional occlusal contact in one or both buccal
segments.
i) Reverse overjet > 1mm but < 3.5mm with recorded masticatory and speech difficulties.
j) Partially erupted teeth tipped and impacted against adjacent teeth.
18
k) Supplemental teeth.
GRADE 5 (very great)
a) Increased overjet > 9mm.
b) Extensive hypodontia with restorative implications (more than one tooth missing in
any quadrant) requiring prerestorative orthodontics.
c) Impeded eruption of teeth (with the exception of third molars) due to crowding,
displacement, the presence of supernumerary teeth, retained deciduous teeth and any
pathological cause.
d) Reverse overjet > 3.5mm with reported masticatory and speech difficulties.
e) Defects of cleft lip and palate.
f) Submerged deciduous teeth
The numbers of decayed, missing, and/or filled teeth were also assessed from extant
patient records.
The Aesthetic component consists of a classification system from grade 1-10, with grade
1 indicating mild aesthetic concerns up to grade 10 major aesthetic concerns. The
observer is meant to score the severity of their own malocclusion by selecting the photo
that looked the most like his or her mouth.
19
In addition, other potential confounding factors were assessed such as insurance status,
patient’s education, and oral health.
20
Data Analyses:
Data from the survey were double entered into a database and analyzed using SAS®
(Statistical Analyses Software, Version 9.3, Cary, NC). The characteristics of sample
population were described with respect to age, gender, race-ethnicity, insurance, patient’s
education and treatment need. Baseline TOQL scores for adults seeking orthodontic
treatment were computed overall and by individual domains, and were compared with
teenagers undergoing and not undergoing orthodontic treatment (from previous
studies)(Huntington et al., 2011; Mahaffey et al., n.d.; Wright et al., n.d.) using t-test and
chi-square. Additionally, TOQL by groups was obtained using Generalized Linear
Modeling (GLM).
Simple and multiple linear regressions examined the relationships between TOQL (as the
dependent variable) and IOTN scores, after adjusting for other covariates. As a test of
construct validity, the TOQL scores were compared across IOTN groups and selfreported oral health. In addition, discriminant validity was estimated by comparing teens
and adults needing orthodontic treatment with data on teens surveyed in the community.
Cronbach’s alpha was computed for each domain of the TOQL for adults and teenagers
to examine the reliability of the instrument.
Lastly, three way comparison between adult ortho, teen ortho and teen control was done
using Generalized Linear Modeling (GLM).
21
RESULTS
A total of 307 subjects participated in the present study: 161 TEEN ORTHO from a
previous study, 146 ADULTS ORTHO were recruited plus 303 CONTROL TEENS from
previous study. The TEEN ORTHO had a mean age of 13 years and 52% were male,
ADULTS ORTHO had a mean age of 32 and 37% were male and TEEN CONTROL had
mean age 15 and 46% were male. Demographic characteristics of the sample are shown
in Table 2.
22
Table 2 Demographic characteristics of adults seeking orthodontic treatment (ADULT
ORTHO), teens seeking orthodontic treatment (TEEN ORTHO) and teens in the
community not seeking orthodontic treatment (TEEN CONTROL)
Label
N
Mean age
Gender
Dental Insurance
Race Groups
Overall Health Group
(GH1)
Health of teeth/mouth
Group (OH1)
Health of teeth /mouth
compared to 1 year ago
# Teeth
Aesthetic component of
IOTN
IOTN index
IOTN Group
Categories
307
Female
Male
Medicaid
none
Other
Private
Asian
Black/ AfricanAmerican
Hispanic /Latino
White/Caucasian
Other/mixed
Excellent/ Very
Good/Good
Fair /Poor
Excellent/ Very
Good/Good
Fair /Poor
Better/same
Worse
2,3
4,5
ADULT
ORTHO
TEEN
ORTHO
p
146
32.45
63.01%
36.99%
15.49%
29.58%
12.68%
42.25%
16.90%
15.49%
161
13.04
47.83%
52.17%
47.47%
6.96%
3.80%
41.77%
5.16%
18.71%
28.87%
34.51%
4.23%
97.93%
26.45%
36.13%
13.55%
94.41%
0.113
2.07%
69.86%
5.59%
78.26%
0.093
30.14%
90.28%
9.72%
27.24
3.54
21.74%
96.88%
3.13%
26.71
4.43
3.34
65.07%
34.93%
3.24
57.76%
42.24%
<.001
0.008
<.001
0.002
TEEN
CONTROL
303
15.1
54.13%
45.87%
57.64%
8.33%
0.00%
34.03%
4.01%
32.11%
22.74%
40.13%
1%
0.018
0.072
.002
85.71%
14.29%
94.67%
5.33%
27.68
0.34
0.19
Subjects in all three groups represented diverse racial and ethnic backgrounds; in the
TEEN ORTHO group, White/Caucasian represented 36.1 % of the sample, followed by
Hispanic/Latinos (26.4%), Black/African Americans (18.7%), Asian (5.1%) and diverse
backgrounds (13.5%). In the ADULT ORTHO group White/Caucasian represented
23
34.5% of the sample, followed by Hispanics/Latinos (28.8%), Black/African American
(15.4%), Asian (16.9%) and diverse backgrounds (4.2%).
Most (96.8%) of the patients reported their overall health as being excellent, very good,
or good. The remaining 3.9% patients reported their overall health as fair or poor. The
distribution by age group showed similar findings: 97.9% ADULTS ORTHO reported
excellent, very good or good overall health and the remaining 2% fair or poor; in the
TEEN ORTHO group distribution for reported overall health was 94.4% for excellent,
very good or good and 5.5% fair or poor.
In regards to their oral health, fewer (74.3%) reported excellent, very good, or good
health, while the remaining (25.7%) reported fair or poor overall health. The distribution
by age showed that 69.8% ADULT ORTHO reported excellent, very good or good oral
health and 30.1% fair or poor, while 78.2% of TEEN ORTHO reported excellent, very
good or good and 21.7% fair and poor.
With respect to dental insurance; in the TEEN ORTHO group 47.4% of the sample were
on Medicaid, followed by 41.7% with private insurance, while 10.8% responded ‘none’
or ‘other’. This was different from the ADULT ORTHO group, where 42.2% of the
sample had private insurance, followed by none/other at 42.2%, and Medicaid at 15.4%.
The differences in terms of insurance were statistically significant with a P value < .001.
24
The IOTN was divided by group as shown in Table 1. The average IOTN grade was 3.29,
between a moderate and great need for orthodontic treatment. There was no difference
between the means of the ADULT ORTHO group (3.34) versus in the TEEN ORTHO
group (3.24). By category, in the teens the IOTN 2/3 group represented 57.7 % of the
sample, and IOTN 4/5 was 42.2%. In the adult group IOTN 2/3 represented 65% and
IOTN 4/5 (34.9%).
The esthetic component score in TEEN ORTHO was 4.43 and 3.54 in ADULT ORTHO.
The difference was statistically significant with a P value .002.
25
Table 3. The scores for different domains in the teen and adult groups.
Mean (sd)
TOQL score (17 items)
Emotional domain (EMO)
Oral problems (OHL)
Physical Domain (PHY)
Role Domain (ROL)
Social domain (SOC)
Impact depressed (EMO)
Impact feel angry/upset (EMO)
Impact feel worried (EMO)
Impact bad breath (OHL)
Impact bleeding gums (OHL)
Impact food between teeth (OHL)
Impact mouth sores (OHL)
Impact difficult eating food like
(PHY)
Impact trouble eating
hot/cold/hard (PHY)
Impact pain (PHY)
Range
14.59 (11.86)
MEAN SCORES &
IMPACTS
ADULT
TEEN
p
ORTHO ORTHO
17.55
11.92
<.001
065.69
12.78(18.48)
0-100
16.55
13.11(12.71)
0-62.5 14.61
11.16(16.02)
0-100
12.49
3.78(7.85)
03.85
66.67
28.09(25.60)
0-100
35.3
Emotional Domain
0.88(2.05)
0-12
1.2
1.64(2.70)
0-12
2.06
2.07(2.94)
0-12
2.71
Oral Health Domain
1.26(2.06)
0-12
1.17
1.45(2.40)
0-12
1.73
2.79(2.93)
0-12
3.23
0.80(1.44)
0-8
0.88
Physical Domain
1.08(2.25)
0-12
1.33
1.58(2.52)
1.35(2.09)
Impact hard to pay attention (ROL)
Impact Miss school/work (ROL)
Impact trouble sleeping (ROL)
0.41(1.26)
0.48(1.25)
0.46(1.42)
Impact crocked teeth/spaces (SOC)
Impact worried less attractive
(SOC)
Impact not want to smile /laugh
(SOC)
Impact unhappy w/ looks (SOC)
5.14(4.27)
2.78(3.61)
% YES
ADULT
ORTHO
TEEN
ORTHO
p
9.4
11.75
9.97
3.72
<.001
0.054
0.174
0.886
21.6
<.001
0.59
1.27
1.5
0.01
0.012
<.001
31.94%
47.89%
65.03%
14.91%
34.78%
45.91%
<.001
0.021
0.001
1.34
1.2
2.39
0.72
0.461
0.056
0.014
0.341
35.42%
46.90%
78.62%
32.41%
52.17%
44.72%
86.25%
33.33%
0.003
0.703
0.079
0.865
0.86
0.074
33.79%
25.63%
0.118
1.73
1.44
0.32
43.75%
41.61%
0.707
0-12
1.44
Role Domain
0-12
0.56
0-8
0.38
0-12
0.43
Social Domain
0-12
5.83
0-12
3.93
1.27
0.465
40.97%
45.96%
0.38
0.27
0.58
0.48
0.054
0.158
0.742
21.38%
11.89%
15.28%
10.56%
30.63%
16.77%
0.009
<.001
0.723
4.53
1.76
0.008
<.001
79.02%
72.22%
86.96%
46.58%
0.065
<.001
0-12
2.59(3.55)
0-12
3.34
1.91
<.001
61.11%
47.83%
0.02
3.00(3.46)
0-12
3.94
2.16
<.001
79.86%
54.66%
<.001
26
In general, overall scores and domain-specific scores were higher for ADULT ORTHO
than for TEEN ORTHO, signifying greater effects of oral conditions on the quality of
life.
The mean overall TOQL scores (17 items) were worse (17.5) in ADULT ORTHO than in
TEEN ORTHO (11.9, p<0.01); emotional domain scores were 16.5 in ADULT ORTHO
compared with 9.4 in TEEN ORTHO (p<0.01) and the social domain score was 35.3 for
ADULTS ORTHO compared with 21.6 for TEEN ORTHO (p<0.01). The oral, physical
and role domains were also worse in ADULT ORTHO but the differences were not
statistically significant.
It is also important to note the significance of some of the questions asked in the survey.
30.6% TEEN ORTHO and 11.8 % of ADULT ORTHO report having missed school or
work due to a problem in their teeth or mouth. In addition, 46.5% of TEEN ORTHO and
72.2% ADULT ORTHO felt worried about their attractiveness, and 54.6% of TEEN
ORTHO and 79.8% ADULT ORTHO felt unhappy with their looks (p<.001).
There were also some differences on other items that were statistically significant: 31.9%
of ADULT ORTHO versus 14.9% TEEN ORTHO described feeling depressed (p .001);
47.8% of ADULT ORTHO versus 34.7% of TEEN ORTHO felt angry or upset about
their teeth or mouth (p .02) and 45.9% TEEN ORTHO versus 65% ADULT ORTHO felt
worried about their teeth or mouth (p.001).
27
In the oral health domain it is important to notice the following impacts which
represented a problem for TEEN ORTHO more than for ADULT ORTHO: bad breath
was a concern for 52.1% TEEN ORTHO and 35.4% ADULTS ORTHO. Most likely this
was related to poor oral hygiene which is very common in many teens. Also, food
between teeth concerned 86.2% of TEEN ORTHO and 78.6% of ADULT ORTHO.
TEEN ORTHO on the other hand, reported more mouth sores, pain in their teeth or
mouth, trouble sleeping, crooked teeth and spacing.
Bivariate effects of sociodemographic, self-reported oral health and dental factors on
TOQL are shown in Table 4.
28
Table 4 describes TOQL by groups.
Variable Name
AGEGROUP
IOTN_GROUP
Health of
teeth/mouth Group
(OH1)
GENDER
RACE GROUP
INSURANCE
Category
Adult
Teen
2 or 3
4 or 5
Excellent/ Very
Good/Good
Fair /Poor
Female
Male
Asian
Black/ African-American
Hispanic /Latino
White/Caucasian
Other/mixed
Medicaid
None
Other
Private
Mean
TOQL
17.55
11.92
13.91
15.64
12.74
19.89
16.32
12.47
13.76
16.41
15.55
12.89
15.09
13.58
15.07
16.82
14.71
P
<.001
0.214
<.001
0.005
0.396
0.66
As mentioned before, the mean TOQL was worse in ADULT ORTHO (17.5) than in
TEEN ORTHO (11.9 p<.0001). Also important to note from this table, the mean for selfreported oral health (OH1) by group fair/poor oral health group have a worse mean
TOQL (19.9) than the excellent/very good/good oral health group (12.7 p<.0001),
supporting construct validity of the TOQL instrument.
Although not statistically significant, the IOTN 4/5 group reported a worse mean TOQL
(15.6) than the IOTN 2/3 group (13.9). In addition, females reported a worse mean TOQL
29
(16.3) than males (12.4), and Black/African Americans (16.4) reported the worst mean
TOQL followed by Hispanic/Latinos (15.5), Asians (13.7) and Whites/Caucasians (12.8).
Reliability (internal consistency) was measured using Cronbach’s alpha. Table 5 shows
that Cronbach’s alpha (estimation of reliability of a psychometric test) was higher in
ADULT ORTHO for all the domains (TOQL 17 items for ADULT ORTHO 0.75
compared to 0.68 in TEEN ORTHO).
Table 5 Scale reliability of TOQL table (Cronbach’s Alpha)
TOTAL
TOTAL
0.7337
AGE GROUP
ADULT
TEEN
0.7510
0.6862
EMOTIONAL
ORAL HEALTH
PHYSICAL
ROLE
SOCIAL
0.6400
0.7249
0.6900
0.6905
0.6887
0.6665
0.7290
0.6966
0.6930
0.7441
0.5769
0.7104
0.6591
0.6492
0.5649
All scores reported are standardized (not raw).
30
Table 6 multiple regression analysis
VARIABLE
Adult
IOTN 4,5
Black/Hispanic/Other
Female
Estimate
5.93
2.08
2.44
2.79
R2 – adjusted
0.0879
Standard Error
1.34
1.4
1.38
1.35
P-value
<.0001
0.1378
0.0786
0.0397
Bivariate analysis and multiple linear regressions modeling the TOQL scores as outcome
were done to find out what really affected quality of life and it was found that when
adjusted by age, IOTN, race and gender. ADULT ORTHO vs TEEN ORTHO was
significant with a (p <.0001), and Female vs Male was significant with a (p .0397).
Discriminant validity was estimated by comparing teens and adults needing orthodontic
treatment with data on teens surveyed in the schools (Table 2 control teen). Wright et al.
studied 303 teens with a mean age of 15.1. Fifty-four percent were female while 45.87%
were male. The distribution by race was 40.13% White/Caucasian, followed by 32.11%
Black/African American, 22.74% Hispanic/Latino, 4.01% Asian and 1% diverse
backgrounds. The representation by insurance was 57.64% Medicaid, 34.03% private and
8.33% none (Wright et al., under review for publication).
Comparison of the TOQL scores between the three groups (ADULT ORTHO patient,
TEEN ORTHO patient and TEEN CONTROL) was done. The results are represented in
fig 1.
31
Figure 1: TOQL scores by study group
TOQL SCORES BY STUDY GROUP
35
30
25
20
15
10
5
0
TOQL SCORE *
PHYSICAL DOMAIN
ROLE DOMAIN
ADULT ORTHO
TEEN ORTHO
ORAL HEALTH
DOMAIN
EMOTIONAL
DOMAIN *
SOCIAL DOMAIN *
TEEN CONTROL
TOQL scores for adults receiving orthodontic treatment were higher in all categories
compared with teens, whether undergoing orthodontic treatment or not.
The TOQL 15 score was significantly different between the three groups with 16.01 for
ADULT ORTHO, 10.66 for TEEN ORTHO and 8.38 for TEEN CONTROL (p<.001).
Also, when combining TOQL and other characteristics, such as, crooked teeth or feeling
depressed, some statistically significant values were found: the combination of the total
TOQL 17 score, crooked teeth, and feeling depressed were significantly different
32
between the groups with 17.55 for ADULT ORTHO, 11.92 for TEEN ORTHO, 8.21 for
TEEN CONTROL (p<.001). Similarly, TOQL 16 combined with crooked teeth was
significantly different with 18.01 for ADULT ORTHO, 12.36 for TEEN ORTHO and
8.47 for TEEN CONTROL (p<.001). In addition, TOQL 16 with feeling depressed only
was 15.64 for ADULT ORTHO, 10.3 for TEEN ORTHO and 8.11 for TEEN CONTROL
(p<.001).
The emotional and social domains in general had statistically significant differences with
each other. The emotional domain was 19.78 for ADULT ORTHO, 17.92 for TEEN
ORTHO and 14.74 TEEN CONTROL (p<.001). Similarly, emotional domain including
depressed was 16.55 for ADULT ORTHO, 9.4 TEEN ORTHO and 6.39 TEEN
CONTROL (p<.001). Scores for the social domain were 31.06 for ADULT ORTHO,
16.2 for TEEN ORTHO and 6.62 for TEEN CONTROL (p<.001). And social domain
with crooked teeth was 35.3 for ADULT ORTHO, 21.6 for TEEN ORTHO and 7.43 for
TEEN CONTROL (p<.001).
Looking at impact scores by study group (Fig 2), the comparison of the three groups
previously mentioned shows worse impacts in the ADULT ORTHO study groups with
respect to missing school/work, feeling upset, being worried, depressed, not smiling,
feeling less attractive, unhappy with looks and crooked teeth. In the role domain,
“missing school/work” was statistically significantly different between TEEN ORTHO
and TEEN CONTROL groups (p<.001). The scores for ADULT ORTHO were 0.38,
TEEN ORTHO 0.58 and TEEN CONTROL 0.20.
33
In the emotional domain, the scores for “feeling upset” was 2.06 in ADULT ORTHO,
1.27 in TEEN ORTHO and 0.60 in TEEN CONTROL, which were significantly different
between the three groups (p<.001). Similarly, the scores for “feeling worried” were 2.71
for ADULT ORTHO, 1.5 for TEEN ORTHO, and 1.21 for TEEN CONTROL, with both
teen groups being significantly different from the adults (P<.001). “Feeling depressed”
scores were 1.2 in ADULT ORTHO, 0.59 in TEEN ORTHO and 0.30 in TEEN
CONTROL, with both teen groups being significantly different from the adult (p<.001).
In the social domain, “not smiling” scores were 3.34 in ADULT ORTHO, 1.91 in TEEN
ORTHO and 1.07 in TEEN CONTROL, which were significantly different between the
three groups (p<.001). “Feeling less attractive” scores were 3.93 for ADULT ORTHO,
1.76 for the TEEN ORTHO and 0.68 for the TEEN CONTROL, significantly different
between the three groups (p<.001). “Feeling unhappy with looks” scores were 3.94 for
ADULT ORTHO, 2.16 for TEEN ORTHO and 0.64 TEEN CONTROL, statistically
significant between the three group (p<.001), and the “crooked teeth” scores were 5.83
for ADULT ORTHO, 4.53 for TEEN ORTHO and 1.62 for TEEN CONTROL, again
significantly different between the three groups (p<.001).
34
Figure 2: Impacts by study group
SIGNIFICANT IMPACTS BY STUDY GROUP
7
6
5
4
3
2
1
0
ADULT ORTHO
TEEN ORTHO
35
TEEN CONTROL
DISCUSSION AND CONCLUSIONS
Improving quality of life is the ultimate outcome of health care; it is now generally
accepted that malocclusion can have physical and psychological consequences. This
study was conducted to assess the impact of malocclusion on oral health-related quality
of life in adults seeking orthodontic treatment and compare it with teens who are either
seeking orthodontic care or not.
The results of this research are expressed as a comparison of the impact on oral healthrelated quality of life between teens seeking or not seeking orthodontic treatment and
adults seeking orthodontic treatment.
In general, the results of this research are consistent with previous studies that determined
that malocclusion has an impact in oral health-related quality of life. The systematic
review done by Zhou et al. (2014) found that the majority of the studies published and
included in their research found a positive correlation between orthodontic treatment and
quality of life, and an improvement in oral health-related quality of life after treatment as
compared to before or during treatment. They also found only one study where the oral
health-related quality of life was worse as compared to a control group with no
malocclusion and without orthodontic appliances. In this systematic review it is important
to note that the majority of oral health-related quality of life studies were done in children
(Zhou et al., 2014). It is also important to mention that our research did not evaluate oral
health-related quality of life during orthodontic treatment, so we could not address
36
whether oral health-related quality of life was better or worse during orthodontic
treatment.
Taylor et al. (2009) found that malocclusion and its treatment had little effect on the
overall quality of life; however, once treatment was completed and occlusion improved,
adolescents’ self-ratings of oral health improved. Patients in this study also reported
improvement in four areas of their lives (oral function, appearance, social function, and
health)”(Taylor et al., 2009). Similarly Johan (2015) found no difference in scores for
the oral health impact profile when measured immediately before and after orthodontic
treatment (Johal et al., 2014).
This study found that overall scores and domain scores were generally higher for
ADULT ORTHO than for TEEN ORTHO, suggesting a greater effect on the quality of
life among adults. Scores were particularly higher in the emotional and social domains.
This is similar to Chen et al. study that examined 250 Chinese orthodontic patients who
reported “to benefit psychologically from orthodontic treatment through improved facial
and dental appearance and increased self-confidence and improved esthetics”. Chen and
co-authors also found “that tenseness and self-consciousness were significantly correlated
to orthodontic treatment needs” (Chen et al., 2015). Similarly, Silvola et al. reported that
patients unsatisfied with dental esthetics were more likely to report more oral effects on
quality of life than those who were more satisfied. Finally, improvement in esthetic
satisfaction after treatment of severe malocclusion improved the oral health–related
37
quality of life and its dimensions of psychological discomfort and psychological
disability (Silvola et al., 2014).
In our study the main effects patients reported were missing work or school due to their
teeth/mouth and feeling worried, less attractive and unhappy with their looks. These
effects could be related with psychological aspects, however cannot be compare in the
same scale. Some of the problems encountered when comparing results from different
studies are due to the different ways used to measure the effects of malocclusion. “A
suggestion for future studies will be employ standardized assessments methods to
obtained outcomes that are uniform and easier to compare” (Zhou et al., 2014).
Our study found that the effects on the oral and physical domains were not statistically
significantly different. However, Choi et al. reported severe malocclusion as significantly
associated with functional limitation, physical pain, and social disability in young adults
(S.H. Choi et al., 2015). The results may differ due to the different scales and tools used
to measure quality of life.
Previous studies by Choi and Masood found that patients with severe malocclusions
reported a greater impact on oral health-related quality of life than those without severe
malocclusions; The magnitude of the association between oral health quality of life and
malocclusion was such that young adults with severe malocclusion had a 174% higher
oral health-related quality of life score than those without severe malocclusion, and their
scores on the functional limitation, physical pain, and social disability domains were
38
significantly correlated with malocclusion status. In addition, subjects reported functional
limitation, physical pain, and social disability about 2 times more often among those with
a severe malocclusion than among those without a severe malocclusion”(S.-H. Choi et
al., 2015; Y. Masood et al., 2013). In our study, IOTN 4/5 group reported worst mean
TOQL (15.7) than IOTN 2/3 group (13.7); however, the difference was not statistically
significant.
Females reported worse mean TOQL scores than males; this was not unexpected finding
since females are often more aware of their looks. However, this difference was not
statistically significant. Oliveria et al. reported that “sex significantly affects the impact
of malocclusion on oral health-related quality of life, and women were 1.22 times more
likely to have an impact than men” (de Oliveira & Sheiham, 2004). Unexpectedly, in
Hassan’s et al (2010) study women had nearly similar impacts of orthodontic treatment
needs on their daily activities as did the male orthodontic patients (Hassan & Amin,
2010). In our study female represented 62% of the sample and this might have influenced
our results.
This study is unique as it evaluate the impact of malocclusion on quality of life in adults
compared with teenagers. Our sample size (146 adults and 161 teenagers) is powerful
enough to give us a good indication of the differences in terms of the diverse domains
and impacts between teens and adults seeking for orthodontic treatment. In addition the
TOQL measuring tool was shown to be a reliable way to measure quality of life not only
in teenagers but also in adults.
39
There are some limitations in this study. Most shortcomings have to do with the
population who seek treatment at the dental school. In the teen groups (orthodontic and
non-orthodontic patients) Medicaid patients represent over 50% of the sample, while in
the adult ortho group, Medicaid patients are only 15% of the sample. Also it is important
to note that in the teen groups (orthodontic and non-orthodontic patient) some were the
children of faculty or staff at the dental school. On the other hand, the adult ortho
population included pre and post-doctoral students with very high dental IQ.
Additionally, in the adult ortho group the sample included 62% female while only 37%
males.
Conclusions: Adults who seek for orthodontic treatment appear to be more affected by
their malocclusion as compared to teens. The total score and the emotional and social
domains are significantly higher for adults than teens seeking orthodontic treatment. The
project suggests that TOQL is a valid and reliable way to measure impact of
malocclusion in quality of life in both adults and teens.
40
APPENDIX
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REFERENCES
Arrow, P., Brennan, D., & Spencer, a. J. (2011). Quality of life and psychosocial
outcomes after fixed orthodontic treatment: A 17-year observational cohort study.
Community Dentistry and Oral Epidemiology, 39(1), 505–514.
http://doi.org/10.1111/j.1600-0528.2011.00618.x
Azuma, S., Kohzuki, M., Saeki, S., Tajima, M., Igarashi, K., & Sugawara, J. (2008).
Beneficial effects of orthodontic treatment on quality of life in patients with
malocclusion. The Tohoku Journal of Experimental Medicine, 214(1), 39–50.
http://doi.org/10.1620/tjem.214.39
Becker, M., Diamond, R., & Sainfort, F. (1993). A new patient focused index for
measuring quality of life in persons with severe and persistent mental illness.
Quality of Life Research : An International Journal of Quality of Life Aspects of
Treatment, Care and Rehabilitation, 2(4), 239–51. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/8220359
Buttke, T. M., & Proffit, W. R. (1999). Referring adult patients for orthodontic treatment.
Journal of the American Dental Association (1939), 130(1), 73–9. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/9919034
Chen, M., Feng, Z.-C., Liu, X., Li, Z.-M., Cai, B., & Wang, D.-W. (2015). Impact of
malocclusion on oral health-related quality of life in young adults. The Angle
55
Orthodontist, 85(6), 986–91. http://doi.org/10.2319/101714-743.1
Choi, S.-H., Kim, B.-I., Cha, J.-Y., & Hwang, C.-J. (2015). Impact of malocclusion and
common oral diseases on oral health-related quality of life in young adults.
American Journal of Orthodontics and Dentofacial Orthopedics : Official
Publication of the American Association of Orthodontists, Its Constituent Societies,
and the American Board of Orthodontics, 147(5), 587–95.
http://doi.org/10.1016/j.ajodo.2014.12.025
Choi, W. S., Lee, S., McGrath, C., & Samman, N. (2010). Change in quality of life after
combined orthodontic-surgical treatment of dentofacial deformities. Oral Surgery,
Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, 109(1), 46–51.
http://doi.org/10.1016/j.tripleo.2009.08.019
Cohen, L. K., & Jago, J. D. (1976). Toward the formulation of sociodental indicators.
International Journal of Health Services : Planning, Administration, Evaluation,
6(4), 681–98. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/971976
de Oliveira, C. M., & Sheiham, A. (2004). Orthodontic treatment and its impact on oral
health-related quality of life in Brazilian adolescents. Journal of Orthodontics,
31(1), 20–7; discussion 15. http://doi.org/10.1179/146531204225011364
Department of Health. An oral health strategy for England. London, United Kingdom:
56
HMSO; 1994. (n.d.).
Elwood, T. W. (1972). Old age and the quality of life. Health Services Reports, 87(10),
919–31. Retrieved from
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1615983&tool=pmcentr
ez&rendertype=abstract
Fassil H, Hayes C, W. W. (2010). Sociodemographic Predictors of ECC and its Effect on
POQL.
Feu, D., de Oliveira, B. H., de Oliveira Almeida, M. A., Kiyak, H. A., & Miguel, J. A. M.
(2010). Oral health-related quality of life and orthodontic treatment seeking.
American Journal of Orthodontics and Dentofacial Orthopedics : Official
Publication of the American Association of Orthodontists, Its Constituent Societies,
and the American Board of Orthodontics, 138(2), 152–9.
http://doi.org/10.1016/j.ajodo.2008.09.033
Filstrup, S. L., Briskie, D., da Fonseca, M., Lawrence, L., Wandera, A., & Inglehart, M.
R. Early childhood caries and quality of life: child and parent perspectives. Pediatric
Dentistry, 25(5), 431–40. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/14649606
Hassan, A. H., & Amin, H. E.-S. (2010). Association of orthodontic treatment needs and
57
oral health-related quality of life in young adults. American Journal of Orthodontics
and Dentofacial Orthopedics : Official Publication of the American Association of
Orthodontists, Its Constituent Societies, and the American Board of Orthodontics,
137(1), 42–7. http://doi.org/10.1016/j.ajodo.2008.02.024
Huntington, N. L., Spetter, D., Jones, J. A., Rich, S. E., Garcia, R. I., & Spiro, A. (2011).
Development and validation of a measure of pediatric oral health-related quality of
life: the POQL. Journal of Public Health Dentistry, 71(3), 185–93.
http://doi.org/10.1111/j.1752-7325.2011.00247.x
Johal, A., Alyaqoobi, I., Patel, R., & Cox, S. (2014). The impact of orthodontic treatment
on quality of life and self-esteem in adult patients. The European Journal of
Orthodontics, 37(3), 233–237. http://doi.org/10.1093/ejo/cju047
Kang, J.-M., & Kang, K.-H. (2014). Effect of malocclusion or orthodontic treatment on
oral health-related quality of life in adults. Korean Journal of Orthodontics, 44(6),
304–11. http://doi.org/10.4041/kjod.2014.44.6.304
Kiyak, H. A. (2008). Does orthodontic treatment affect patients’ quality of life? Journal
of Dental Education, 72(8), 886–94. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/18676797
Liu, Z., McGrath, C., & Hägg, U. (2009). The impact of malocclusion/orthodontic
58
treatment need on the quality of life. A systematic review. The Angle Orthodontist,
79(3), 585–91. http://doi.org/10.2319/042108-224.1
Mahaffey, J., Will, L., Wright, W., Rich, S., & Jones, J. (n.d.). Orthodontic treatment
need is associated with Oral Health-related Quality of Life in Teens?
Masood, M., Masood, Y., Saub, R., & Newton, J. T. (2014). Need of minimal important
difference for oral health-related quality of life measures. Journal of Public Health
Dentistry, 74(1), 13–20. http://doi.org/10.1111/j.1752-7325.2012.00374.x
Masood, Y., Masood, M., Zainul, N. N., Araby, N. B., Hussain, S. F., & Newton, T.
(2013). Impact of malocclusion on oral health-related quality of life in young
people. Health Qual Life Outcomes, 11, 25. http://doi.org/10.1186/1477-7525-11-25
Palomares, N. B., Celeste, R. K., Oliveira, B. H. De, & Miguel, J. A. M. (2012). How
does orthodontic treatment affect young adults’ oral health-related quality of life?
American Journal of Orthodontics and Dentofacial Orthopedics, 141(6), 751–758.
http://doi.org/10.1016/j.ajodo.2012.01.015
Reisine, S. T. (1988a). The effects of pain and oral health on the quality of life.
Community Dental Health, 5(1), 63–8. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/3285973
59
Reisine, S. T. (1988b). The impact of dental conditions on social functioning and the
quality of life. Annual Review of Public Health, 9, 1–19.
http://doi.org/10.1146/annurev.pu.09.050188.000245
Rusanen, J., Lahti, S., Tolvanen, M., & Pirttiniemi, P. (2010). Quality of life in patients
with severe malocclusion before treatment. Eur J Orthod, 32(1), 43–48.
http://doi.org/10.1093/ejo/cjp065
Shaw, W. C., Addy, M., Dummer, P. M., Ray, C., & Frude, N. (1986). Dental and social
effects of malocclusion and effectiveness of orthodontic treatment: a strategy for
investigation. Community Dentistry and Oral Epidemiology, 14(1), 60–4. Retrieved
from http://www.ncbi.nlm.nih.gov/pubmed/3485508
Shaw, W. C., Addy, M., & Ray, C. (1980). Dental and social effects of malocclusion and
effectivenessof orthodontic treatment: a review. Community Dentistry and Oral
Epidemiology, 8(1), 36–45. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/6989548
Shaw, W. C., Richmond, S., Kenealy, P. M., Kingdon, A., & Worthington, H. (2007). A
20-year cohort study of health gain from orthodontic treatment: psychological
outcome. American Journal of Orthodontics and Dentofacial Orthopedics : Official
Publication of the American Association of Orthodontists, Its Constituent Societies,
and the American Board of Orthodontics, 132(2), 146–57.
60
http://doi.org/10.1016/j.ajodo.2007.04.009
Silvola, A.-S., Varimo, M., Tolvanen, M., Rusanen, J., Lahti, S., & Pirttiniemi, P. (2014).
Dental esthetics and quality of life in adults with severe malocclusion before and
after treatment. The Angle Orthodontist, 84(4), 594–9.
http://doi.org/10.2319/060213-417.1
Taylor, K. R., Kiyak, A., Huang, G. J., Greenlee, G. M., Jolley, C. J., & King, G. J.
(2009). Effects of malocclusion and its treatment on the quality of life of
adolescents. American Journal of Orthodontics and Dentofacial Orthopedics :
Official Publication of the American Association of Orthodontists, Its Constituent
Societies, and the American Board of Orthodontics, 136(3), 382–92.
http://doi.org/10.1016/j.ajodo.2008.04.022
World Health Organization. Measuring quality of life: the development of the world
health organization quality of life instrument (WHOQOL). . (n.d.). Retrieved
January 9, 2016, from http://www.who.int/mental_health/media/68.pdf
Wright, W., Spiro, A., Jones, J., & Rich, S. (n.d.). Development of the Teen Version of
the Pediatric Oral Health-related Quality of Life Instrument (POQL-T).
Consideration for Publication in the Journal of Public Health Dentistry.
Zhou, Y., Wang, Y., Wang, X., Volière, G., & Hu, R. (2014). The impact of orthodontic
61
treatment on the quality of life a systematic review. BMC Oral Health, 14, 66.
http://doi.org/10.1186/1472-6831-14-66
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CURRICULUM VITAE
MARTHA LUCIA NEELY, DDS, DMD.
781-853-9992
[email protected]
ACADEMIC TRAINING:
07/2013-05/2016 Resident Orthodontics and Maxillofacial Development. Henry M. Goldman
School of Dental Medicine Boston University, Boston MA. CAGS and MDS Orthodontics,
May 2016
08/2011- 05/2013 Advanced Standing Program for International Dentist. Henry M. Goldman
School of Dental Medicine Boston University, Boston MA. Doctor of Dental Medicine, May
2013.
06/1992- 06/1997 Graduate Nacional University of Colombia Odontologists (Ten Semesters),
Bogota, Colombia. Doctor in Dental Sciences, June 1997.
ORTHODONTIS WORK EXPERIENCE:
ORTHODONTICS ASSISTANT
10/ 2007- 03/2014: Doctor Brian Miller, Newton MA
Supervisor: Dr. Brian Miller
Phone: 617-9640073
ACADEMIC AND TEACHING APPOINTMENTS AND RESPONSABILITIES:
07/2008- 08/ 2011 Clinical Instructor: Health Policy and Health Services Research at Boston
University Henry M. Goldman School of Dental Medicine.
Clinical Instructor: Introduction Dental Practice
Supervisor: Dr. Michelle Henshaw
Phone: 617-638-5222
01/ 2004-06/ 2005 Teacher: Institute of Non Formal Education of the School Of Odontology
Alumni Association. National University of Colombia.
Supervisor: Dr. Fanny Bautista-Quintero, Phone: 57 1 2687179
Regular lectures and professor in charge of Biomaterials, Pediatric Dentistry, Operatory and
Index.
01/1996 -06/1996 Teaching Assistant: Integral Adult Pre-Clinic, third level. National
University of Colombia
63
06/1996-12/ 1996 Teaching Assistant: Integral Adult Clinic, first level. National University of
Colombia
HOSPITAL AND WORK APPOINTMENTS:
GENERAL DENTIST
03/2014- Present NORTH END WATERFRONT HEALTH CENTER/MGH Partners, Dentist.
Supervisor: Dr. Shirley Austin
Phone: 617-643-8070, Boston Ma
07/2008- 08/ 2011 Health Policy and Health Services Research at Boston University Henry M.
Goldman School of Dental Medicine.
Coordinator: Chelsea School Dental Program
Dentist: Chelsea School Dental Center
Supervisor: Dr. Michelle Henshaw
Phone: 617-638-5222
08/2000- 04/2007 OSDOKSALUD, Servicios Médicos Integrales, IPS
Supervisor: Dr. Oscar Cifuentes.
Phone: 57 1 8562256, Chocontá, Colombia
06/1998- 04/2007 School of Odontology Alumni Association, National University of Colombia,
Phone: 57 1 2687179
03/1999- 06/2003 Centro De Medicina Preventiva Eco-Vida, IPS
Supervisor: Dr. Miguel Alvarado.
Phone: 57 1 8574506, Tocancipá Colombia
08/ 2000 –03/ 2001 Centro Medico Global-Salud Sopo, IPS
Supervisor: Dr. Miguel Alvarado.
Phone: 57 1 8574506, Tocancipá Colombia
05/1998- 09/1999 Clinica Odontologica Nacional
Supervisor: Dr. Henry Zea.
Phone: 57 1 2237993
08/1997-02/ 1998 Dentist At The Coffee-Collectors Cooperative In Bolivar City, Antioquia,
Colombia
MAJOR ADMINISTRATIVE RESPONSIBILITIES:
07/2008- 08/ 2011 Coordinator of the BU/Chelsea School Dental Program.
Supervisor: Dr. Michelle Henshaw
Phone: 617-638-5222
08/2000-04/ 2007 Coordinator Of Dental Department: Osdoksalud, Servicios Médicos
Integrales, IPS
Supervisor: Doctor Oscar Cifuentes.
Phone: 57 1 8562256, Chocontá, Colombia.
64
HONORS AND AWARDS:
Elected member: Omicron Kappa Upsilon, National Dental Honor Society, 2013.
Predoctoral Oral Presentation Science Day Award Goldman School of Dental Medicine, 2013.
Postdoctoral Masters Oral Presentation Science Day Award Goldman School of Dental Medicine,
2011.
THESIS/DISSERTATION AND PUBLICATIONS:
Prevalence Of Post-Operative Neuropathies Associated To The Surgical Elimination Of Third
Lower Molars At The Surgery Clinics Of The National University Of Colombia In 1996
(Presented as a lecture at the Eighth Congress of Scientific Research in odontology, Cartagena,
1997 and published in annual publication “Association Colombiana de Facultades de
Odontologia” ACFO 1998)
Effects of Cuts in Medicaid on Dental-Related Visits and Costs at a Safety-Net Hospital
American Journal of Public Health (Impact Factor: 3.93). 06/2014; 104(6):e13-6
LICENSES AND CERTIFICATIONS
07/2013 Massachusetts Dental License
08/ 2008-05/2011 Massachusetts Faculty License.
07/1997 Licensed as a Dentist in Colombia, License No. 5-057198.
65