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Does Orthodontic Treatment Affect Patients’ Quality of Life?

Key words: quality of life, OHRQoL, psychology and orthodontics, patient expectations, esthetics and orthodontics

	Abstract

Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

 
The oral-facial region is usually an area of significant concern for the individual because it draws the most attention from other people in interpersonal interactions and is the primary source of vocal, physical, and emotional communication. As a result, patients who seek orthodontic treatment are concerned with improving their appearance and social acceptance, often more than they are with improving their oral function or health. Enhancing these aspects of quality of life is an important motive for undergoing orthodontic treatment. Regardless of age, patients’ and their parents’ or caregivers’ expectations about improvements in oral function, esthetics, social acceptance, and body image are important for both general dentists and orthodontists to consider when advising patients about these procedures and during the treatment process. This review of research on the impact of conventional and surgical orthodontics on quality of life examines 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. The article will emphasize the importance of clinicians’ having a clear understanding, before initiating treatment, of their patients’ quality of life and their expectations about improvements in specific domains of quality of life.

The following review of research on the impact of malocclusion and its treatment on oral health-related quality of life (OHRQoL) will examine the evidence for and against this association. Studies that have tested the link between OHRQoL domains and the severity, type, and treatment of malocclusion will be discussed, as well as characteristics of the individual that may influence these associations.

OHRQoL is generally assessed subjectively, although some researchers have discussed the feasibility of parents’ reporting this for children younger than age ten. In general, parents underestimate the impact of oral conditions on their children’s emotional and social quality of life. However, there is greater agreement between parents and children in observable aspects of quality of life, such as physical functioning.⁵

	Impact of Orthodontic Treatment on OHRQoL

Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

 
Several studies have examined how orthodontic treatment affects OHRQoL. Most researchers have found differences between treated and untreated patients, but scores tend to be skewed toward favorable quality of life, even among patients with severe mal-occlusion. In a study of 1,675 adolescents in Brazil, researchers administered two OHRQoL scales and assessed malocclusion with an objective measure, the Index of Orthodontic Treatment Need (IOTN).⁶ Youths who had completed orthodontic treatment reported fewer oral health impacts than their peers who were currently under treatment (1.85 times less) and fewer than those who were never treated (1.43 times less). Significant differences emerged in three areas related to socioemotional well-being: smiling, laughing, and showing teeth without embarrassment.

Youths with high clinical need (using the IOTN) reported 2.65 times more dental impacts on the OHRQoL measures than did children with lower need. Children with acceptable or ideal occlusion and their parents reported higher OHRQoL than those with any degree of malocclusion, specifically children who had increased overjet (>6 mm) or anterior spacing greater than 1.5 mm between adjacent teeth.⁷ To date, no differences have been found between types of malocclusion.^7,8

It is noteworthy that OHRQoL scales that measure different components of this concept have found differences between children with malocclusion vs. acceptable occlusion on emotional and social well-being, but not on oral symptoms and functional limitations.⁸ It is therefore not surprising that scores on the oral function domain of OHRQoL do not improve dramatically with orthodontic treatment. Indeed, this lack of perceived improvement in oral function appears to be an objectively verifiable outcome; a recent review of the impact of malocclusion and its treatment on several areas of quality of life concluded that conventional orthodontics without surgery generally does not improve patients’ chewing efficiency or self-reported masticatory ability. Nor does it affect objectively assessed speech articulation.⁹ Currently, the most widely used measure of OHRQoL in children is the Child Oral Health Quality of Life Questionnaire (COHQOL).^10,11 It was developed for the express purpose of assessing OHRQoL outcomes related to clinical trials and intervention studies among children ages six to fourteen. It includes a Parental-Caregiver Perceptions Questionnaire (P-CPQ), to obtain parents’ proxy ratings of their children’s OHRQoL, and the Child Perceptions Questionnaire (CPQ). The latter has slightly different questions in the forms designed for ages six to seven, eight to ten, and eleven to fourteen. The CPQ_11–14 form, for example, is comprised of thirty-six items that represent four health domains: oral symptoms, functional limitations, emotional well-being, and social well-being.

Several measures of OHRQoL have been developed for adult populations. Most of these grew out of studies that focused on the impact of caries, periodontal disease, and tooth loss and replacement among older adults. These include the General (formerly "Geriatric") Oral Health Assessment Index (GOHAI)^12,13 and the Oral Health Impact Profile (OHIP).¹⁴ The latter has been widely used and validated with diverse populations and in multiple languages. A shortened version of this scale (OHIP-14) contains all the original domains represented by the original forty-nine-item scale (e.g., physical pain, social disability, psychological discomfort, functional limitations) and has increasingly been applied to studies on the impact of dental conditions and their treatment among adults.^15–17

Researchers in New Zealand assessed the association between OHRQoL and malocclusion severity among 430 children ages twelve to thirteen who varied in their extent of malocclusion.¹⁸ Using the Child Perceptions Questionnaire for eleven- to fourteen-year-olds (CPQ_11–14), described above, the researchers observed a distinct OHRQoL gradient, with children in the "handicapping" category of malocclusion obtaining the highest (worst OHRQoL) scores and those in the "minor/no malocclusion" category scoring best. However, these differences emerged only on the emotional and social well-being domains (e.g., worrying about being different, being teased, avoiding smiling), not in oral symptoms or functional limitations (e.g., pain, difficulty chewing).

Consistent with these findings, a study of young adults in Florida who had or had not undergone orthodontics in the past ten years found that those with lower Peer Assessment Ratings of occlusion (PAR) scores (i.e., better occlusion) reported higher OHRQoL, using another measure of this concept for adults,¹⁹ in the areas of appearance (r=–.21, p<.005) and performance (r=–.25, p<.005), but less so in eating (r=–.17, p<.05). These patterns were more prominent in the untreated group, such that young adults with malocclusion who had not received orthodontic treatment reported lower oral health-related quality of life in several domains.²⁰ This is consistent with the findings of the study of Brazilian youths.⁶

	Patient Expectations for OHRQoL and Demographic Comparisons

Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

 
It appears that improved appearance and psychosocial function are important OHRQoL concerns for patients who seek orthodontic treatment.²¹ Among young adults in Finland, the primary motives for orthodontic treatment were to improve dental appearance and attitudes toward malocclusion, not necessarily oral function.²² In another study, researchers followed 197 adolescent orthodontic patients at the University of Hong Kong from pretreatment through six months of fixed-appliance therapy.²³ Despite children’s expectations of functional, emotional, and social problems during the course of treatment, these CPQ domains actually improved during the first six months of active orthodontic therapy. The authors did not measure post-treatment OHRQoL.

Patients ages eight to fourteen expect significant improvements in their social and psychological well-being and in their oral function, but less so in their general health. Parents consistently expect more improvement than their children in all domains. Ethnic differences have emerged, with non-Hispanic white children and their parents expecting greater improvement in appearance than other ethnic groups. Latino and African American children report higher expectations for improved social acceptance following treatment, and all three ethnic groups expect moderate levels of improvement in their oral function.^24–26 These findings suggest that children from diverse ethnic groups can benefit from orthodontic treatment, but it is important for dental providers to determine individual and ethnic differences in treatment expectations. These studies also demonstrate that, contrary to popular stereotypes, boys and girls do not differ in their expectations for improved appearance as a result of orthodontic treatment although, in these same studies of children anticipating interceptive treatment in the mixed dentition, girls reported significantly greater social expectations.

However, gender differences cannot always be predicted accurately. A comparison of three children anticipating interceptive orthodontics illustrates the importance of examining each patient’s perceptions and expectations.²⁷ The children in Figures 1–3 all qualified for orthodontic treatment under Medicaid because of severe overjet (12 mm, 14 mm, 13 mm, respectively). All had anterior crowding. The girl in Figure 1 (age ten years and four months) also had a 3 mm overbite and lip incompetence. The boy in Figure 2 (age eight years and seven months) had an openbite, while the boy in Figure 3 (age eight years and ten months) had a 5 mm overbite. Despite their remarkable similarities in objective indicators of malocclusion (i.e., severe overjet, anterior crowding, overbite, or open bite), these children differed in their treatment expectations. Most different was the girl in Figure 1, who reported high expectations for improved oral function but much lower expectations in the other domains. In contrast, the boy in Figure 2 reported highest expectations for improved appearance and low in other domains. The third child had high expectations for improved appearance and social function, but low for oral function; this boy’s expectations were diametrically opposite from what we found for the girl with similar treatment needs.

View larger version (82K): [in this window] [in a new window]   Figure 1. Child (age ten years and four months) anticipating interceptive orthodontics

View larger version (80K): [in this window] [in a new window]   Figure 2. Child (age eight years and seven months) anticipating interceptive orthodontics

View larger version (84K): [in this window] [in a new window]   Figure 3. Child (age eight years and ten months) anticipating interceptive orthodontics

In a series of studies examining children and adults undergoing conventional and surgical orthodontics, we have consistently found expectations for improved social acceptance and esthetics to be as high as or higher than oral function expectations. However, post-treatment self-reports generally reveal greater satisfaction with esthetic and oral function outcomes than with social outcomes.^26,27 Findings from our ongoing study of children undergoing interceptive orthodontics funded by Medicaid illustrate this pattern among children and their parents (see Table 1).²⁷

The possibility that this emphasis on esthetics is a universal phenomenon is supported by a study of patients aged nine through twenty who were seeking orthodontic treatment at a university clinic in Amsterdam. The researchers found that older teens and young adults expected greater improvement in their appearance than did adolescent patients, but no age differences emerged in concerns about functional problems. Indeed, these youths did not expect their oral function to improve as much as their general health and appearance. Dissatisfaction with one’s dental appearance was the best predictor of expectations in the areas of improved appearance and dental health among the young adults in this sample, but dissatisfaction with their facial appearance in general did not predict treatment expectations.²⁹

This review of studies that have assessed ethnic, gender, and age differences in OHRQoL expectations reveals that improved esthetics or appearance is a greater motive for young patients than improvements in oral function. While some ethnic and gender differences exist in OHRQoL expectations, there is a consistent pattern of expecting greater improvement in esthetics and social acceptance than in oral function among both children and their parents.

	Esthetics as a Component of OHRQoL

Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

 
Facial and dental attractiveness represents an important element of quality of life for patients seeking orthodontic treatment. Indeed, the review of OHRQoL studies in the previous section demonstrates that the socioemotional domain of quality of life (smiling, showing teeth without embarrassment, being teased about appearance) plays a significant role in the decision to undergo conventional or surgical orthodontics and is recognized by the orthodontist as a primary benefit of treatment.³⁰

Researchers have consistently found that facial attractiveness affects interpersonal success, particularly in school and employment settings. Attractive children and adults generally receive more favorable judgments and academic and performance reviews than do unattractive individuals. This in turn results in greater self-confidence among those high in attractiveness.³¹ The appearance of teeth and the smile are critical components of facial attractiveness.^28,32 The media and society in general reinforce this message that "beauty is good." Movie and television heroes have attractive teeth, in contrast to villains with crooked and discolored teeth. Models in television and magazine ads often display teeth that are not only perfectly aligned but also bleached and with ideal proportions. Not surprisingly, these popular images can generate self-criticism and dissatisfaction in the general population, especially among adolescents.^33,34

This may be one reason why patients’ primary area of concern regarding their body image is their teeth and, to a lesser extent, their mouth. Using a body image scale expanded from one introduced by Secord and Jourard,³⁵ we have found a consistent pattern of moderate to high satisfaction with other parts of the body, but much lower self-ratings of the face among patients seeking conventional or surgical orthodontics. There is a striking difference between patients’ satisfaction with their faces as opposed to other parts of their bodies when assessed before they undergo treatment. This is particularly true for self-ratings of teeth and mouth appearance among both children and adults who seek conventional and surgical orthodontics. The latter are more critical about their facial profile as well. Even among children as young as age eight or nine, self-consciousness about the appearance of their teeth is striking, in contrast to satisfaction with their overall body image and moderate acceptance of their facial appearance in general.

Following treatment with fixed appliances or after combined orthodontic/surgical procedures, patients report significant improvements in these body-image domains, but only slight or no change in other body components because their self-ratings in these other areas remain high.^25,27,36,37 As shown in Table 2, significant changes in facial image were observed from pre- to post-orthodontic therapy among children undergoing interceptive treatment in the mixed dentition, but not in overall body image.²⁷ In fact, self-ratings of teeth appearance improved to the level of other body features after orthodontic treatment. In a follow-up of young adults who had undergone one- or two-phase treatment five to ten years earlier and their peers who never received treatment, the "teeth" component of body image was higher in the two treatment groups (p<.001) than among untreated volunteers. However, the groups did not differ on other body image items.²⁰

	Perceived Treatment Need vs. OHRQoL

Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

Researchers in Norway also administered the Aesthetic Component (AC) of the IOTN to children, in this case 359 children in Bergen schools (mean age 10.6) who had not undergone orthodontic treatment.³⁹ Study models were scored by orthodontists using the AC and the Dental Health Component (DHC) of the IOTN. In contrast to the findings by Kok et al. in the UK,³⁸ these children rated themselves significantly more favorably on the AC than did orthodontists (p<.05). However, both studies found that children with the worst malocclusion (Grade 5 on the DHC) were not always concerned about their condition. In the Norwegian sample, 52.4 percent of children with DHC Grade 5 and 46.5 percent in DHC Grade 4 expressed no cares about their status. Parents were far more likely to express concerns about their child’s malocclusion: 68 percent of those whose children had been rated 4 or 5 on the DHC indicated that they were concerned. These findings highlight the importance of assessing children’s perceptions of their dental esthetics, quality of life, and treatment needs separately from that of their parents or orthodontist or general dentist.

It is also useful to understand the perceptions of general dentists compared to orthodontists regarding the benefits of treatment, since the former are often the first to assess and refer patients to orthodontists. A study of 139 general dentists and twenty-eight orthodontists in Northern Ireland found low concordance in ratings of the benefits of orthodontic treatment.³⁰ The top five benefits were consistent between the two groups: physical attractiveness, self-esteem, self-confidence, less teasing, and easier-to-clean teeth. However, general dentists attributed more oral health and functional benefits to orthodontic treatment than did specialists, who focused on the psychosocial benefits of treatment. It appears that orthodontists’ beliefs about the benefits of this treatment are more consistent with the beliefs of patients themselves.

As illustrated by several studies described in this review, the primary area of OHRQoL that patients seeking orthodontics are trying to improve is psychosocial, especially dental and facial appearance. Well-aligned teeth and an attractive smile are important to laypersons, perhaps more valued than improved oral function. This is probably good for the profession because evidence-based claims for the oral health benefits of orthodontic treatment, particularly its preventive effects, are not strong. Indeed, a recent review of frequent claims that orthodontics can reduce susceptibility to dental caries, periodontal disease, temporomandibular disorders, and traumatic dental injuries are not supported by careful longitudinal studies of individuals who do or do not obtain orthodontic treatment.⁴⁰

However, psychological benefits may also be less dramatic than generally assumed. A twenty-year observational study of 332 individuals (45 percent of whom obtained orthodontic treatment on their own during this period) between 1981 and 2001 who were between the ages of eleven and twelve at baseline found that self-esteem did not improve when baseline level of self-esteem was controlled, nor were untreated persons more likely than those who underwent orthodontic treatment to experience psychological disorders such as depression or social anxiety.⁴¹ However, those who had significant malocclusion and underwent orthodontic treatment during that period reported greater satisfaction with their dental occlusion and with their dental and general appearance. These patients also reported higher overall quality of life in their twenty-year assessment, compared with their peers who also had significant treatment needs but had not undergone treatment.

	Conclusions

Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

 
This review of the impact of malocclusion and its treatment on OHRQoL provides several consistent findings. There is ample evidence that patients focus primarily on esthetic and social aspects of OHRQoL as a motive for seeking orthodontic treatment; this is true for children as young as age eight and for adult patients. For the most part, patients with severe malocclusion appear to have poorer OHRQoL than patients with less critical treatment need in these domains, but not in OHRQoL related to oral function. The type of malocclusion (e.g., whether it is an overjet or overbite) does not affect patients’ OHRQoL as much as its severity or visibility. It should also be noted that individuals who rate themselves negatively on OHRQoL do not always want or seek treatment.

Undergoing orthodontic intervention has been found to enhance some aspects of OHRQoL, particularly esthetics, but not necessarily social acceptance. Psychological well-being as represented by self-esteem does not appear to be significantly affected over the long term. For most patients, treatment also does not have a significant salutary effect on objectively or subjectively assessed oral health status. A recent query of a potential patient to an orthodontist illustrates the dilemma faced by individuals who are referred by general dentists for preventive reasons: "My hygienist comments on my need for braces every time I come in, and with my old age creeping in, I don’t want to wait until it’s too late and damage my teeth, if I haven’t [done so] already."

These findings suggest that general dentists and orthodontists must communicate clearly with their patients about the pros and cons of orthodontic treatment, determine if a patient wants to undergo such treatment, and assess whether the expected benefits are realistic. The evidence from the available OHRQoL research suggests that esthetic and functional improvement is realistic, but the patient should not anticipate that treatment will enhance their self-esteem or prevent future caries, periodontal disease, or temporomandibular disorder (TMD). It behooves the general dentist and orthodontist to listen carefully to each patient’s understanding of his or her malocclusion and its impact on quality of life domains, including oral function, appearance, social acceptance, and emotional well-being. Only then can the process of patient education and informed consent be successfully completed.

	Author Information

Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

 
Dr. Kiyak is Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Washington, as well as Director of Geriatric Dentistry Programs and Director of the campus-wide Institute on Aging. Direct correspondence and requests for reprints to her at Box 357134, Seattle, WA 98195-7134; 206-543-5197 phone; 206-685-7222 fax; kiyak{at}u.washington.edu.

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Top Author information Abstract Impact of orthodontic treatment... Patient expectations for ohrqol... Esthetics as a component... Perceived treatment need vs.... Conclusions References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kiyak, H. A. Search for Related Content PubMed PubMed Citation Articles by Kiyak, H. A.