Eur Arch Paediatr Dent DOI 10.1007/s40368-014-0172-6
ORIGINAL SCIENTIFIC ARTICLE
Effect of malocclusion among adolescents on family quality of life L. G. Abreu • C. A. Melgac¸o • M. H. N. G. Abreu E. M. B. Lages • S. M. Paiva
•
Received: 15 November 2014 / Accepted: 17 December 2014 European Academy of Paediatric Dentistry 2015
Abstract Aim To evaluate the effect of malocclusion among adolescents on their families’ oral health-related quality of life (OHRQoL). Methods A consecutive sample of 125 parents/caregivers of Brazilian adolescents was chosen. Participants were asked to answer the Brazilian version of the Family Impact Scale (FIS). The main independent variable was adolescents’ malocclusion, which was measured with the Dental Aesthetic Index. Gender, age, and family monthly income were the other independent variables. Data analysis involved descriptive statistics, Mann–Whitney test, and univariate and multiple logistic regression. Results Among the 125 participants initially admitted to the present study, two were excluded so that 123 parents/caregivers participated providing a response rate of 98.4 %. The overall FIS score revealed a more frequent effect for families of adolescents who presented malocclusion (P = 0.005). Significant findings were also observed for parental emotions (P = 0.022), family conflict
L. G. Abreu C. A. Melgac¸o E. M. B. Lages S. M. Paiva Department of Paediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, MG 31270-901, Brazil L. G. Abreu (&) Rua Maranhao, 1447/1101, Funcionarios, Belo Horizonte, MG 30150-331, Brazil e-mail: [email protected] M. H. N. G. Abreu Department of Community and Preventive Dentistry, School of Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, MG 31270-901, Brazil
(P = 0.010), and financial burden (P = 0.010) subscales. When the independent variables family monthly income and malocclusion were inserted together in the regression model, families with a monthly income of \5 Brazilian minimum wages (approximately US$ 325.00 per month) were more likely to have a worse OHRQoL, and families whose adolescents presented malocclusion were 3.55 more likely to have a poorer quality of life than those families whose adolescents did not present malocclusion. Conclusions Families of adolescents with malocclusion were more likely to report a worse OHRQoL. Keywords Family Adolescent Malocclusion Parents Caregivers Quality of life
Introduction The concept of oral health-related quality of life (OHRQoL) concerns the effect of oral outcomes on individuals’ daily functioning, well-being, and overall quality of life (Sischo and Broder 2011). In recent years, OHRQoL assessment has become an important component of the evaluation of health services. Indeed, policy-makers and funders have used quality of life measures to guide programmes and rehabilitation efforts (Allen 2003). The importance of assessing patients’ perceptions of health as well as the presence or absence of disease lies in the need to obtain reliable data to promote health and to better allocate public resources (Schwappach 2002). It has been widely recognised that malocclusion has a negative effect on adolescents’ OHRQoL, especially in terms of satisfaction with appearance (Marques et al. 2006, 2009). The aesthetic effect of malocclusion has a significant influence on the psychological well-being and
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social interactions among individuals (Marques et al. 2009). In some cases, it can also result in a limitation of the adolescents’ functions (Dawoodbhoy et al. 2013). There is evidence that a more severe malocclusion, such as open bite, can reduce chewing performance. Moreover, the presence of a diastema has a modest effect on speech capabilities (Martins-Ju´nior et al. 2012). Adolescents affected by oral disorders often turn to their families for support and assistance to treat and relieve dental symptoms (Bendo et al. 2014). In these cases, the family is indirectly affected by adolescents’ oral conditions in the form of a negative effect on daily activities, emotions, and financial issues that can ultimately lead to family conflict (Locker et al. 2002). Oral diseases are not merely a therapeutic challenge for paediatric dentists, but also have far-reaching effects on those who share the household and care for young individuals (Thomson and Malden 2011). To the best of our knowledge, the Family Impact Scale (FIS) (Locker et al. 2002) is the most appropriate instrument available to determine the impact of children’s and adolescents’ oral conditions on their family’s quality of life. However, few studies (Malden et al. 2008; Antunes et al. 2014) have made use of this tool, and its administration in different populations from different locations is still required (Abanto et al. 2012). Moreover, the effect of malocclusion among adolescents on their family’s quality of life has been poorly investigated thus far (Barbosa and Gavia˜o 2009). Therefore, the aim of this study was to evaluate the effect of malocclusion on the families of adolescent individuals. The null hypothesis for this study is that there is no difference in OHRQoL between families whose adolescents presented with malocclusion and those who did not.
Materials and methods Subjects, setting, period of recruitment, and eligibility criteria A consecutive sample of adolescents and their parents/caregivers was selected out of a group of children who sought the dental screening programme of the Department of Paediatric Dentistry and Orthodontics of the Federal University of Minas Gerais in September 2013. This programme consists of an oral examination of adolescents referred to the School of Dentistry to discover whether or not they need orthodontic treatment. Parents/caregivers of adolescents needed to be literate and fluent in Brazilian Portuguese. The exclusion criteria were adolescents with untreated dental caries, a history of dental trauma and poor gingival health, those with craniofacial anomalies and syndromes, and those who had undergone any dental treatment within the last 3 months.
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Sample size calculation Sample size calculation was performed using the Epi Info 6.04 software (Centers for Disease Controls and Prevention, Atlanta, GA, USA). It was based on a 95 % confidence interval (CI), 80 % power, 20 % expected outcome (negative self-rated health) in the group of families of adolescents without malocclusion, 20:40 ratio between the number of families of adolescents with malocclusion and families of adolescents without malocclusion, and 2.5 minimal relative risk (Kirkwood and Stern 2003). The sample size required for the analysis consisted of 99 individuals. This scenario was increased by 25 % to compensate for eventual refusals and losses. All in all, a total of 125 individuals were asked to take part in the present study. Ethical issues This study received approval from the Human Ethics Research Board of the Federal University of Minas Gerais in compliance with the ethical standards of the Brazilian National Committee of Ethics on Research (CONEP). All parents/caregivers and their adolescents received information on the objectives of the study and signed a statement of informed consent. Parents/caregivers and adolescents were told that if they did not agree to participate in the present study, their refusal would not affect their future care provided by the Federal University of Minas Gerais in any way. Measures of OHRQoL and data sources The outcome examined in this study was the effect of malocclusion on the adolescents’ families. The OHRQoL assessment used was the FIS, which was developed in Canada (Locker et al. 2002) and cross-culturally adapted and validated to be applied to the Brazilian population (Goursand et al. 2009). This instrument consists of 14 items divided into four subscales: parental/family activity (PA), parental emotions (PE), family conflict (FC), and financial burden (FB). The questions refer only to the frequency with which events occurred over the previous 3 months (Table 1). Each item included five response options: ‘‘never’’ = 0, ‘‘once or twice’’ = 1, ‘‘sometimes’’ = 2, ‘‘often’’ = 3, and ‘‘every day or almost every day’’ = 4. A ‘‘don’t know’’ response was also allowed. The overall FIS score and the score for individual subscales were calculated as a simple sum of the response codes. The overall score ranged from 0 to 56, with a higher score being indicative of a greater degree of effect of an adolescent’s oral condition on his/her family (Locker et al. 2002). Parents/caregivers answered the questionnaire separately from their sons/daughters, so as to ensure that the latter did not influence the responses of the former. As
Eur Arch Paediatr Dent Table 1 Family Impact Scale items distributed among the four subscales
Parental/family activity During the past 3 months, how often… Have you or the other parent taken time off work? Has your child required more attention from you or the other parent? Have you or the other parent had less time for yourselves or other family members? Has your sleep or that of the other parent been disrupted? Have family activities been interrupted? Parental emotions During the past 3 months, how often… Have you or the other parent been upset? Have you or the other parent felt guilty? Have you or the other parent worried that your child will have fewer life opportunities? Have you felt uncomfortable in public places? Family conflicts During the past 3 months, how often… Has your child argued with you or the other parent? Has your child been jealous of you or other family members? Has your child’s condition caused disagreement or conflict in the family? Has your child blamed you or the other parent? Financial burden During the past 3 months, how often… Has your child’s condition caused financial difficulties for your family?
previously mentioned, the questions of the tool addressed the frequency of events regarding problems with adolescents’ teeth, lips, jaws, or mouth considering a self-reported recall of the last 3 months. Thus, the administration of the questionnaires was limited to parents/caregivers of adolescents with no dental disease other than malocclusion and no dental treatment in a period of time shorter than the interval described above, thereby avoiding any bias that could have occurred if the 3-month period had not been considered. Clinical oral examination Data on malocclusion were collected through the Dental Aesthetic Index (DAI) (Jenny and Cons 1996). The DAI consists of ten parameters of dentofacial anomalies related to both clinical and aesthetic aspects. Those parameters include missing visible teeth, crowding, spacing, diastema, largest maxillary anterior irregularity, largest mandibular anterior irregularity, anterior maxillary overjet, anterior mandibular overjet, anterior open bite, and antero-posterior molar relation. The results of each parameter was multiplied by the respective round coefficient and then summed. A constant value of 13 was added to this sum to obtain the final score. Four grades of malocclusion were established with priorities and orthodontic treatment recommendations assigned to each grade: normal or minor malocclusion/no treatment is needed (B25); definite malocclusion/treatment
is elective (26–30); severe malocclusion/treatment is highly desirable (31–35); handicapping malocclusion/ treatment was mandatory (C36). In this study, malocclusion was dichotomised as: absent (B25) and present ([25) (Tak et al. 2013). The research team consisted of two orthodontists who participated in a calibration process for malocclusion evaluation using the DAI. Theoretical and clinical exercises were coordinated by an orthodontist with more than 20 years of experience. The theoretical component involved a discussion on the criteria for the diagnosis of malocclusion as well as an analysis of study models. The clinical component involved the examination of 15 adolescents who were not included in the main study. Examinations were carried out by each of the two researchers for the calculation of the inter-examiner agreement. Those 15 adolescents were re-examined 10 days later for the calculation of the intra-examiner agreement. Cohen’s kappa values ranged from 0.84 to 0.90 for both inter- and intra-examiner agreement. Pilot study Following the calibration process, a pilot study was conducted to test the methodology of the study and the comprehension of the questionnaire. Adolescents included in the pilot study were not included in the main sample. The results of this pilot study showed no misunderstanding
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regarding the questionnaire and changes in the method were deemed unnecessary.
Table 2 Socio-demographic characteristics of Brazilian sample and adolescents’ orthodontic need Number (%)
Family monthly income Adolescents’ gender
Family income was assessed in terms of the Brazilian minimum wage (BMW), a standard for this type of evaluation. Family income was calculated by adding the monthly wages of all economically active members of the family and dividing this sum by the current BMW, which corresponded to approximately US$ 325.00 per month at the time of data collection. For statistical analysis, family income was dichotomised as: families with a monthly income equal or lower than 5 BMWs and families with a family income higher than 5 BMWs. Statistical analysis Data were entered and processed for analysis using the Statistical Package for Social Sciences (SPSS for Windows, version 17.0, SPSS Inc., Chicago, IL, USA). Data analysis included descriptive statistics as well as the Kolmogorov–Smirnov test to examine the assumption of normality, which was not confirmed. Thus, the Mann– Whitney test was used to evaluate differences in the subscale and overall FIS scores between parents/caregivers of adolescents who presented malocclusion and those parents/caregivers whose adolescents did not present malocclusion. Univariate and multiple logistic regression models were carried out with the overall FIS score as the dependent variable (dichotomised by the median). The independent variable was whether or not adolescents presented with a malocclusion, with gender, age, and family’s monthly income included as potential confounders. Variables with a P value of \0.20 in the univariate analysis were included in a multiple logistic regression model using the ‘‘enter’’ method. The level of significance was set at P \ 0.05.
Results A total of 123 families of adolescents participated in this study providing a response rate of 98.4 %. The reason for non-participation was that two accompanying persons were not the adolescents’ parents/caregivers and, therefore, were unable to answer the FIS. Demographic data of the sample are displayed in Table 2. Table 3 shows data on the FIS overall and subscale scores for each group. The scores were significantly higher among families of adolescents who presented malocclusion than those families whose ado malocclusion for the overall (P = 0.005) score, as well as for the PE (P = 0.022), FC
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Male
60 (48.8)
Female
63 (51.2)
Adolescents’ age (years) 11
59 (48.0)
12
64 (52.0)
Family income (BMW/month) Up to 1 BMW
20 (16.3)
From 1 to 3 BMWs
66 (53.7)
From 3 to 5 BMWs
26 (21.1)
From 5 to 9 BMWs
09 (7.3)
More than 9 BMWs
02 (1.6)
Malocclusion assessment Absent
40 (32.5)
Present
83 (67.5)
BMW Brazilian minimum wage
(lescents did not presentP = 0.010), and FB (P = 0.010) subscale scores. Data from the univariate and multiple logistic regressions are shown in Table 4. In the univariate analysis, the variables gender (P = 0.860) and age (P = 0.427) proved to be statistically insignificant. However, the variable family income was significantly associated with the FIS overall score (P = 0.007). The odds ratio suggested that families with a monthly income of more than 5 BMWs were less likely to have a poorer OHRQoL than families with a monthly income lower than 5 BMWs. In addition, the odds ratio suggested that families of adolescents who presented with any malocclusion were 3.38 times more likely to have a worse OHRQoL than those families whose adolescents did not present with a malocclusion (P = 0.002). When the variables malocclusion and family income were inserted together in the regression model, the former remained statistically significant (P = 0.002), despite the influence of the latter. In the multiple logistic regression, the odds ratio suggested that families of adolescents with malocclusion and families with a monthly income of \5 BMWs were more likely to have a worse OHRQoL than families of adolescents without malocclusion and families with a monthly income of more than 5 BMWs, respectively.
Discussion In the present evaluation, families of adolescents with malocclusion achieved a higher overall FIS score, suggesting that the presence of malocclusion on adolescents
Eur Arch Paediatr Dent Table 3 Mean, SD, median, minimum, and maximum values of overall and subscale FIS scores among families of adolescents with and without malocclusion Range of possible FIS scores
Adolescents without malocclusion
Adolescents with malocclusion
N = 40
N = 83
Mean (SD)
Median
Min–Max
Mean (SD)
Median
P value*
Min–Max
PA
0–20
2.48 (2.54)
2.00
0–10.0
3.63 (3.46)
2.00
0–12.0
0.131
PE
0–16
0.98 (1.52)
0.00
0–6.0
1.89 (2.27)
1.00
0–8.0
0.022
FC
0–16
1.15 (1.73)
0.00
0–7.0
2.36 (2.68)
1.00
0–10.0
0.010
FB
0–4
0.15 (0.42)
0.00
0–2.0
0.58 (0.91)
0.00
0–3.0
0.010
OL
0–56
4.75 (5.09)
3.00
0–25.0
8.46 (7.06)
6.00
0–26.0
0.005
PA parental activity, PE parental emotions, FC family conflicts, FB financial burden, OL overall, SD standard deviation, Min minimum, Max maximum * Mann–Whitney test Table 4 Univariate and multiple logistic regression models for dependent variable, overall FIS, considering malocclusion and potential confounders as independent variables Variables
Lesser impact FIS 0–3, N (%)
Greater impact FIS 4–26, N (%)
Unadjusted OR (95 % CI)
P value*
Adjusted OR (95 % CI)
P value
Male
21 (17.1)
39 (31.7)
0.94 (0.44–1.95)
0.860
–
–
Female
23 (18.7)
40 (32.5)
19 (15.5)
40 (32.5)
0.74 (0.35–1.55)
0.427
–
–
12 25 (20.3) Family income (BMW)
39 (31.7) 0.17 (0.04–0.71)
0.007
0.16 (0.04–0.68)
0.013
3.38 (1.53–7.47)
0.002
3.55 (1.56–8.05)
0.002
Gender
Age 11
[5
08 (6.5)
03 (2.4)
B5
36 (29.3)
76 (61.8)
Yes
22 (17.9)
61 (49.6)
No
22 (17.9)
18 (14.6)
Malocclusion
OR odds ratio, CI confidence interval * Chi-square test
has a considerable negative impact on their families. The results of the multiple logistic regression showed that adolescents’ malocclusion predisposes their family members to a greater chance of experiencing a negative impact on their quality of life, regardless of potential confounding variables, such as monthly income. This study makes a unique contribution to scientific knowledge, as it is the first investigation to use a validated tool for the measurement of OHRQoL and provide such evidence in sample of Brazilian adolescents. It has been suggested that adolescents’ oral and orofacial conditions have a detrimental effect on their families (Locker et al. 2002). Previous reports measured the impact of dental caries and dental trauma on the OHRQoL of children’s and adolescents’ families (Abanto et al. 2012; Bendo et al. 2014). Findings provided by those Brazilian studies supported the
hypothesis that families of adolescents with dental trauma are also more likely to report a negative impact on their quality of life than families of adolescents with no signs of dental trauma (Bendo et al. 2014). In addition, the OHRQoL of families of children who present dental caries is poorer when compared with families of children with no dental caries (Abanto et al. 2012). On the other hand, treating young individuals’ oral problems resulted in substantial improvements for the household (Malden et al. 2008). In fact, the treatment of dental caries in young children is associated with a positive achievement in OHRQoL for their families (Thomson and Malden 2011). Moreover, therapy with fixed appliances has a positive impact on the families of adolescent patients with significant improvements appearing mostly in parental activities and parental emotions (Abreu et al. 2014).
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The PE, FC, and FB subscale scores were significantly higher for the families whose adolescents presented malocclusion, suggesting a greater negative impact on OHRQoL. With respect to the PE subscale, parents were upset and felt guilty because they were worried about being blamed for their sons’/daughters’ dental health (Amin et al. 2006). Another point of concern in the PE subscale is related to the parents’ feeling of discomfort in public places due to their sons’/daughters’ oral conditions (Abanto et al. 2011). The results of the present study regarding the FB subscale are in accordance with the findings of two previous investigations, which evaluated the family effect of oral disorders on a group of adolescents with dental caries and a group of adolescents with malocclusion (Locker et al. 2002; Goursand et al. 2009). The proportion of those reporting financial difficulties as a result of adolescent’s oral condition was higher for the latter. The data suggest that the nature of the family impact varied across clinical groups and was worse in the orthodontic sample (Locker et al. 2002). This fact may reflect the pattern of funding for orthodontic services in Brazil. In this country, orthodontic treatment is not provided free at either private offices or in the university setting (Rosenbach et al. 2000). The nature of family impact may also vary due to the characteristics of the oral conditions. While dental caries is more related to pain and discomfort and to the symptomatic domains of quality of life, malocclusion has strong implications for psychosocial domains, rather than those that influence oral health (Abanto et al. 2011). Concerning the FC subscale, results also concur with those reported in a previous study (Bendo et al. 2014). Conflict may happen when adolescents experience oral disorders and family members have different views and beliefs about their oral health. The results of this study, however, must be interpreted taking into consideration its limitations. The first is inherent to the cross-sectional design, which only collected data at a single point or over a short period of time. Thus, associations identified in this study should not be interpreted as a causal relationship (Levin 2006). However, given the lack of assessments of the effect of malocclusion on the families of adolescents, the present investigation can be considered a preliminary insight into this issue (Grimes and Schulz 2002). The second is the use of a generic rather than a specific OHRQoL tool. While the former evaluates the quality of life, generally allowing comparisons among different populations, the latter focuses on problems relevant to that disease. Their specific nature makes them more sensitive to subtle, but clinically important changes in oral health (Cunningham and Hunt 2001). The lack of specificity of the FIS as well as the low overall scores in both groups may also raise the question whether the statistically
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significant results have clinical relevance and make a real difference to individuals’ lives (Brignardello-Petersen et al. 2013). Finally, the present sample of parents/caregivers was limited to the clinic of a single university. Therefore, the generalisation of results in this study should be viewed with caution and not considered fully representative of the Brazilian population (Oliveira and Nadanovsky 2005). The findings described herein provide helpful information for clinical practice and public policy decisions. Conditions affecting oral health, including malocclusion, can be considered a public health problem because they are highly prevalent (Petersen et al. 2005) and may have negative consequences on the daily lives of affected individuals and their families (Kramer et al. 2008; Marques et al. 2009). OHRQoL research can be used to guide public policies, which can be useful in increasing the productivity of the health-care system and, ultimately, in helping to eradicate disparities in oral health (Sischo and Broder 2011). Measures of OHRQoL may also be important in clinical practice in terms of identifying needs, selecting therapies, and monitoring patient progress (Locker 1996). Future research is needed to understand how this impact influences adolescent families’ OHRQoL over time and to determine whether or not the provision of orthodontic treatment has a positive effect on the families of adolescent patients (Strauss and Cassell 2009; Ukra et al. 2013). Future studies should also evaluate the effect of different malocclusion severity levels on the quality of life of adolescents’ families. The collection of further data from different locations is also warranted in an attempt to verify the technical properties of FIS and to confirm and extend the results on family impact reported herein (Locker et al. 2002). One possible suggestion would be to conduct population-based studies to provide external validity and make it possible to extrapolate the findings to the general population as a whole (Bendo et al. 2014). Considering that the FIS is a short instrument, its use in epidemiological surveys is feasible, and it can also be included as an indicator for broader uses, such as political, research, public health, and clinical actions (Abanto et al. 2012).
Conclusions Families of Brazilian adolescents who presented malocclusion were more likely to report a poorer OHRQoL than families of adolescents with no malocclusion. The main negative impacts regarded parental emotions, family conflict, and financial burden. Acknowledgments This study was supported by the National Council for Scientific Development (CNPq), the Coordination for the Improvement of Higher Level Education Personnel (CAPES), and the State of Minas Gerais Research Foundation (FAPEMIG), Brazil.
Eur Arch Paediatr Dent Conflict of interest of interest.
The authors declare that they have no conflict
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ORIGINAL SCIENTIFIC ARTICLE
Effect of malocclusion among adolescents on family quality of life L. G. Abreu • C. A. Melgac¸o • M. H. N. G. Abreu E. M. B. Lages • S. M. Paiva
•
Received: 15 November 2014 / Accepted: 17 December 2014 European Academy of Paediatric Dentistry 2015
Abstract Aim To evaluate the effect of malocclusion among adolescents on their families’ oral health-related quality of life (OHRQoL). Methods A consecutive sample of 125 parents/caregivers of Brazilian adolescents was chosen. Participants were asked to answer the Brazilian version of the Family Impact Scale (FIS). The main independent variable was adolescents’ malocclusion, which was measured with the Dental Aesthetic Index. Gender, age, and family monthly income were the other independent variables. Data analysis involved descriptive statistics, Mann–Whitney test, and univariate and multiple logistic regression. Results Among the 125 participants initially admitted to the present study, two were excluded so that 123 parents/caregivers participated providing a response rate of 98.4 %. The overall FIS score revealed a more frequent effect for families of adolescents who presented malocclusion (P = 0.005). Significant findings were also observed for parental emotions (P = 0.022), family conflict
L. G. Abreu C. A. Melgac¸o E. M. B. Lages S. M. Paiva Department of Paediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, MG 31270-901, Brazil L. G. Abreu (&) Rua Maranhao, 1447/1101, Funcionarios, Belo Horizonte, MG 30150-331, Brazil e-mail: [email protected] M. H. N. G. Abreu Department of Community and Preventive Dentistry, School of Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, MG 31270-901, Brazil
(P = 0.010), and financial burden (P = 0.010) subscales. When the independent variables family monthly income and malocclusion were inserted together in the regression model, families with a monthly income of \5 Brazilian minimum wages (approximately US$ 325.00 per month) were more likely to have a worse OHRQoL, and families whose adolescents presented malocclusion were 3.55 more likely to have a poorer quality of life than those families whose adolescents did not present malocclusion. Conclusions Families of adolescents with malocclusion were more likely to report a worse OHRQoL. Keywords Family Adolescent Malocclusion Parents Caregivers Quality of life
Introduction The concept of oral health-related quality of life (OHRQoL) concerns the effect of oral outcomes on individuals’ daily functioning, well-being, and overall quality of life (Sischo and Broder 2011). In recent years, OHRQoL assessment has become an important component of the evaluation of health services. Indeed, policy-makers and funders have used quality of life measures to guide programmes and rehabilitation efforts (Allen 2003). The importance of assessing patients’ perceptions of health as well as the presence or absence of disease lies in the need to obtain reliable data to promote health and to better allocate public resources (Schwappach 2002). It has been widely recognised that malocclusion has a negative effect on adolescents’ OHRQoL, especially in terms of satisfaction with appearance (Marques et al. 2006, 2009). The aesthetic effect of malocclusion has a significant influence on the psychological well-being and
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social interactions among individuals (Marques et al. 2009). In some cases, it can also result in a limitation of the adolescents’ functions (Dawoodbhoy et al. 2013). There is evidence that a more severe malocclusion, such as open bite, can reduce chewing performance. Moreover, the presence of a diastema has a modest effect on speech capabilities (Martins-Ju´nior et al. 2012). Adolescents affected by oral disorders often turn to their families for support and assistance to treat and relieve dental symptoms (Bendo et al. 2014). In these cases, the family is indirectly affected by adolescents’ oral conditions in the form of a negative effect on daily activities, emotions, and financial issues that can ultimately lead to family conflict (Locker et al. 2002). Oral diseases are not merely a therapeutic challenge for paediatric dentists, but also have far-reaching effects on those who share the household and care for young individuals (Thomson and Malden 2011). To the best of our knowledge, the Family Impact Scale (FIS) (Locker et al. 2002) is the most appropriate instrument available to determine the impact of children’s and adolescents’ oral conditions on their family’s quality of life. However, few studies (Malden et al. 2008; Antunes et al. 2014) have made use of this tool, and its administration in different populations from different locations is still required (Abanto et al. 2012). Moreover, the effect of malocclusion among adolescents on their family’s quality of life has been poorly investigated thus far (Barbosa and Gavia˜o 2009). Therefore, the aim of this study was to evaluate the effect of malocclusion on the families of adolescent individuals. The null hypothesis for this study is that there is no difference in OHRQoL between families whose adolescents presented with malocclusion and those who did not.
Materials and methods Subjects, setting, period of recruitment, and eligibility criteria A consecutive sample of adolescents and their parents/caregivers was selected out of a group of children who sought the dental screening programme of the Department of Paediatric Dentistry and Orthodontics of the Federal University of Minas Gerais in September 2013. This programme consists of an oral examination of adolescents referred to the School of Dentistry to discover whether or not they need orthodontic treatment. Parents/caregivers of adolescents needed to be literate and fluent in Brazilian Portuguese. The exclusion criteria were adolescents with untreated dental caries, a history of dental trauma and poor gingival health, those with craniofacial anomalies and syndromes, and those who had undergone any dental treatment within the last 3 months.
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Sample size calculation Sample size calculation was performed using the Epi Info 6.04 software (Centers for Disease Controls and Prevention, Atlanta, GA, USA). It was based on a 95 % confidence interval (CI), 80 % power, 20 % expected outcome (negative self-rated health) in the group of families of adolescents without malocclusion, 20:40 ratio between the number of families of adolescents with malocclusion and families of adolescents without malocclusion, and 2.5 minimal relative risk (Kirkwood and Stern 2003). The sample size required for the analysis consisted of 99 individuals. This scenario was increased by 25 % to compensate for eventual refusals and losses. All in all, a total of 125 individuals were asked to take part in the present study. Ethical issues This study received approval from the Human Ethics Research Board of the Federal University of Minas Gerais in compliance with the ethical standards of the Brazilian National Committee of Ethics on Research (CONEP). All parents/caregivers and their adolescents received information on the objectives of the study and signed a statement of informed consent. Parents/caregivers and adolescents were told that if they did not agree to participate in the present study, their refusal would not affect their future care provided by the Federal University of Minas Gerais in any way. Measures of OHRQoL and data sources The outcome examined in this study was the effect of malocclusion on the adolescents’ families. The OHRQoL assessment used was the FIS, which was developed in Canada (Locker et al. 2002) and cross-culturally adapted and validated to be applied to the Brazilian population (Goursand et al. 2009). This instrument consists of 14 items divided into four subscales: parental/family activity (PA), parental emotions (PE), family conflict (FC), and financial burden (FB). The questions refer only to the frequency with which events occurred over the previous 3 months (Table 1). Each item included five response options: ‘‘never’’ = 0, ‘‘once or twice’’ = 1, ‘‘sometimes’’ = 2, ‘‘often’’ = 3, and ‘‘every day or almost every day’’ = 4. A ‘‘don’t know’’ response was also allowed. The overall FIS score and the score for individual subscales were calculated as a simple sum of the response codes. The overall score ranged from 0 to 56, with a higher score being indicative of a greater degree of effect of an adolescent’s oral condition on his/her family (Locker et al. 2002). Parents/caregivers answered the questionnaire separately from their sons/daughters, so as to ensure that the latter did not influence the responses of the former. As
Eur Arch Paediatr Dent Table 1 Family Impact Scale items distributed among the four subscales
Parental/family activity During the past 3 months, how often… Have you or the other parent taken time off work? Has your child required more attention from you or the other parent? Have you or the other parent had less time for yourselves or other family members? Has your sleep or that of the other parent been disrupted? Have family activities been interrupted? Parental emotions During the past 3 months, how often… Have you or the other parent been upset? Have you or the other parent felt guilty? Have you or the other parent worried that your child will have fewer life opportunities? Have you felt uncomfortable in public places? Family conflicts During the past 3 months, how often… Has your child argued with you or the other parent? Has your child been jealous of you or other family members? Has your child’s condition caused disagreement or conflict in the family? Has your child blamed you or the other parent? Financial burden During the past 3 months, how often… Has your child’s condition caused financial difficulties for your family?
previously mentioned, the questions of the tool addressed the frequency of events regarding problems with adolescents’ teeth, lips, jaws, or mouth considering a self-reported recall of the last 3 months. Thus, the administration of the questionnaires was limited to parents/caregivers of adolescents with no dental disease other than malocclusion and no dental treatment in a period of time shorter than the interval described above, thereby avoiding any bias that could have occurred if the 3-month period had not been considered. Clinical oral examination Data on malocclusion were collected through the Dental Aesthetic Index (DAI) (Jenny and Cons 1996). The DAI consists of ten parameters of dentofacial anomalies related to both clinical and aesthetic aspects. Those parameters include missing visible teeth, crowding, spacing, diastema, largest maxillary anterior irregularity, largest mandibular anterior irregularity, anterior maxillary overjet, anterior mandibular overjet, anterior open bite, and antero-posterior molar relation. The results of each parameter was multiplied by the respective round coefficient and then summed. A constant value of 13 was added to this sum to obtain the final score. Four grades of malocclusion were established with priorities and orthodontic treatment recommendations assigned to each grade: normal or minor malocclusion/no treatment is needed (B25); definite malocclusion/treatment
is elective (26–30); severe malocclusion/treatment is highly desirable (31–35); handicapping malocclusion/ treatment was mandatory (C36). In this study, malocclusion was dichotomised as: absent (B25) and present ([25) (Tak et al. 2013). The research team consisted of two orthodontists who participated in a calibration process for malocclusion evaluation using the DAI. Theoretical and clinical exercises were coordinated by an orthodontist with more than 20 years of experience. The theoretical component involved a discussion on the criteria for the diagnosis of malocclusion as well as an analysis of study models. The clinical component involved the examination of 15 adolescents who were not included in the main study. Examinations were carried out by each of the two researchers for the calculation of the inter-examiner agreement. Those 15 adolescents were re-examined 10 days later for the calculation of the intra-examiner agreement. Cohen’s kappa values ranged from 0.84 to 0.90 for both inter- and intra-examiner agreement. Pilot study Following the calibration process, a pilot study was conducted to test the methodology of the study and the comprehension of the questionnaire. Adolescents included in the pilot study were not included in the main sample. The results of this pilot study showed no misunderstanding
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regarding the questionnaire and changes in the method were deemed unnecessary.
Table 2 Socio-demographic characteristics of Brazilian sample and adolescents’ orthodontic need Number (%)
Family monthly income Adolescents’ gender
Family income was assessed in terms of the Brazilian minimum wage (BMW), a standard for this type of evaluation. Family income was calculated by adding the monthly wages of all economically active members of the family and dividing this sum by the current BMW, which corresponded to approximately US$ 325.00 per month at the time of data collection. For statistical analysis, family income was dichotomised as: families with a monthly income equal or lower than 5 BMWs and families with a family income higher than 5 BMWs. Statistical analysis Data were entered and processed for analysis using the Statistical Package for Social Sciences (SPSS for Windows, version 17.0, SPSS Inc., Chicago, IL, USA). Data analysis included descriptive statistics as well as the Kolmogorov–Smirnov test to examine the assumption of normality, which was not confirmed. Thus, the Mann– Whitney test was used to evaluate differences in the subscale and overall FIS scores between parents/caregivers of adolescents who presented malocclusion and those parents/caregivers whose adolescents did not present malocclusion. Univariate and multiple logistic regression models were carried out with the overall FIS score as the dependent variable (dichotomised by the median). The independent variable was whether or not adolescents presented with a malocclusion, with gender, age, and family’s monthly income included as potential confounders. Variables with a P value of \0.20 in the univariate analysis were included in a multiple logistic regression model using the ‘‘enter’’ method. The level of significance was set at P \ 0.05.
Results A total of 123 families of adolescents participated in this study providing a response rate of 98.4 %. The reason for non-participation was that two accompanying persons were not the adolescents’ parents/caregivers and, therefore, were unable to answer the FIS. Demographic data of the sample are displayed in Table 2. Table 3 shows data on the FIS overall and subscale scores for each group. The scores were significantly higher among families of adolescents who presented malocclusion than those families whose ado malocclusion for the overall (P = 0.005) score, as well as for the PE (P = 0.022), FC
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Male
60 (48.8)
Female
63 (51.2)
Adolescents’ age (years) 11
59 (48.0)
12
64 (52.0)
Family income (BMW/month) Up to 1 BMW
20 (16.3)
From 1 to 3 BMWs
66 (53.7)
From 3 to 5 BMWs
26 (21.1)
From 5 to 9 BMWs
09 (7.3)
More than 9 BMWs
02 (1.6)
Malocclusion assessment Absent
40 (32.5)
Present
83 (67.5)
BMW Brazilian minimum wage
(lescents did not presentP = 0.010), and FB (P = 0.010) subscale scores. Data from the univariate and multiple logistic regressions are shown in Table 4. In the univariate analysis, the variables gender (P = 0.860) and age (P = 0.427) proved to be statistically insignificant. However, the variable family income was significantly associated with the FIS overall score (P = 0.007). The odds ratio suggested that families with a monthly income of more than 5 BMWs were less likely to have a poorer OHRQoL than families with a monthly income lower than 5 BMWs. In addition, the odds ratio suggested that families of adolescents who presented with any malocclusion were 3.38 times more likely to have a worse OHRQoL than those families whose adolescents did not present with a malocclusion (P = 0.002). When the variables malocclusion and family income were inserted together in the regression model, the former remained statistically significant (P = 0.002), despite the influence of the latter. In the multiple logistic regression, the odds ratio suggested that families of adolescents with malocclusion and families with a monthly income of \5 BMWs were more likely to have a worse OHRQoL than families of adolescents without malocclusion and families with a monthly income of more than 5 BMWs, respectively.
Discussion In the present evaluation, families of adolescents with malocclusion achieved a higher overall FIS score, suggesting that the presence of malocclusion on adolescents
Eur Arch Paediatr Dent Table 3 Mean, SD, median, minimum, and maximum values of overall and subscale FIS scores among families of adolescents with and without malocclusion Range of possible FIS scores
Adolescents without malocclusion
Adolescents with malocclusion
N = 40
N = 83
Mean (SD)
Median
Min–Max
Mean (SD)
Median
P value*
Min–Max
PA
0–20
2.48 (2.54)
2.00
0–10.0
3.63 (3.46)
2.00
0–12.0
0.131
PE
0–16
0.98 (1.52)
0.00
0–6.0
1.89 (2.27)
1.00
0–8.0
0.022
FC
0–16
1.15 (1.73)
0.00
0–7.0
2.36 (2.68)
1.00
0–10.0
0.010
FB
0–4
0.15 (0.42)
0.00
0–2.0
0.58 (0.91)
0.00
0–3.0
0.010
OL
0–56
4.75 (5.09)
3.00
0–25.0
8.46 (7.06)
6.00
0–26.0
0.005
PA parental activity, PE parental emotions, FC family conflicts, FB financial burden, OL overall, SD standard deviation, Min minimum, Max maximum * Mann–Whitney test Table 4 Univariate and multiple logistic regression models for dependent variable, overall FIS, considering malocclusion and potential confounders as independent variables Variables
Lesser impact FIS 0–3, N (%)
Greater impact FIS 4–26, N (%)
Unadjusted OR (95 % CI)
P value*
Adjusted OR (95 % CI)
P value
Male
21 (17.1)
39 (31.7)
0.94 (0.44–1.95)
0.860
–
–
Female
23 (18.7)
40 (32.5)
19 (15.5)
40 (32.5)
0.74 (0.35–1.55)
0.427
–
–
12 25 (20.3) Family income (BMW)
39 (31.7) 0.17 (0.04–0.71)
0.007
0.16 (0.04–0.68)
0.013
3.38 (1.53–7.47)
0.002
3.55 (1.56–8.05)
0.002
Gender
Age 11
[5
08 (6.5)
03 (2.4)
B5
36 (29.3)
76 (61.8)
Yes
22 (17.9)
61 (49.6)
No
22 (17.9)
18 (14.6)
Malocclusion
OR odds ratio, CI confidence interval * Chi-square test
has a considerable negative impact on their families. The results of the multiple logistic regression showed that adolescents’ malocclusion predisposes their family members to a greater chance of experiencing a negative impact on their quality of life, regardless of potential confounding variables, such as monthly income. This study makes a unique contribution to scientific knowledge, as it is the first investigation to use a validated tool for the measurement of OHRQoL and provide such evidence in sample of Brazilian adolescents. It has been suggested that adolescents’ oral and orofacial conditions have a detrimental effect on their families (Locker et al. 2002). Previous reports measured the impact of dental caries and dental trauma on the OHRQoL of children’s and adolescents’ families (Abanto et al. 2012; Bendo et al. 2014). Findings provided by those Brazilian studies supported the
hypothesis that families of adolescents with dental trauma are also more likely to report a negative impact on their quality of life than families of adolescents with no signs of dental trauma (Bendo et al. 2014). In addition, the OHRQoL of families of children who present dental caries is poorer when compared with families of children with no dental caries (Abanto et al. 2012). On the other hand, treating young individuals’ oral problems resulted in substantial improvements for the household (Malden et al. 2008). In fact, the treatment of dental caries in young children is associated with a positive achievement in OHRQoL for their families (Thomson and Malden 2011). Moreover, therapy with fixed appliances has a positive impact on the families of adolescent patients with significant improvements appearing mostly in parental activities and parental emotions (Abreu et al. 2014).
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The PE, FC, and FB subscale scores were significantly higher for the families whose adolescents presented malocclusion, suggesting a greater negative impact on OHRQoL. With respect to the PE subscale, parents were upset and felt guilty because they were worried about being blamed for their sons’/daughters’ dental health (Amin et al. 2006). Another point of concern in the PE subscale is related to the parents’ feeling of discomfort in public places due to their sons’/daughters’ oral conditions (Abanto et al. 2011). The results of the present study regarding the FB subscale are in accordance with the findings of two previous investigations, which evaluated the family effect of oral disorders on a group of adolescents with dental caries and a group of adolescents with malocclusion (Locker et al. 2002; Goursand et al. 2009). The proportion of those reporting financial difficulties as a result of adolescent’s oral condition was higher for the latter. The data suggest that the nature of the family impact varied across clinical groups and was worse in the orthodontic sample (Locker et al. 2002). This fact may reflect the pattern of funding for orthodontic services in Brazil. In this country, orthodontic treatment is not provided free at either private offices or in the university setting (Rosenbach et al. 2000). The nature of family impact may also vary due to the characteristics of the oral conditions. While dental caries is more related to pain and discomfort and to the symptomatic domains of quality of life, malocclusion has strong implications for psychosocial domains, rather than those that influence oral health (Abanto et al. 2011). Concerning the FC subscale, results also concur with those reported in a previous study (Bendo et al. 2014). Conflict may happen when adolescents experience oral disorders and family members have different views and beliefs about their oral health. The results of this study, however, must be interpreted taking into consideration its limitations. The first is inherent to the cross-sectional design, which only collected data at a single point or over a short period of time. Thus, associations identified in this study should not be interpreted as a causal relationship (Levin 2006). However, given the lack of assessments of the effect of malocclusion on the families of adolescents, the present investigation can be considered a preliminary insight into this issue (Grimes and Schulz 2002). The second is the use of a generic rather than a specific OHRQoL tool. While the former evaluates the quality of life, generally allowing comparisons among different populations, the latter focuses on problems relevant to that disease. Their specific nature makes them more sensitive to subtle, but clinically important changes in oral health (Cunningham and Hunt 2001). The lack of specificity of the FIS as well as the low overall scores in both groups may also raise the question whether the statistically
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significant results have clinical relevance and make a real difference to individuals’ lives (Brignardello-Petersen et al. 2013). Finally, the present sample of parents/caregivers was limited to the clinic of a single university. Therefore, the generalisation of results in this study should be viewed with caution and not considered fully representative of the Brazilian population (Oliveira and Nadanovsky 2005). The findings described herein provide helpful information for clinical practice and public policy decisions. Conditions affecting oral health, including malocclusion, can be considered a public health problem because they are highly prevalent (Petersen et al. 2005) and may have negative consequences on the daily lives of affected individuals and their families (Kramer et al. 2008; Marques et al. 2009). OHRQoL research can be used to guide public policies, which can be useful in increasing the productivity of the health-care system and, ultimately, in helping to eradicate disparities in oral health (Sischo and Broder 2011). Measures of OHRQoL may also be important in clinical practice in terms of identifying needs, selecting therapies, and monitoring patient progress (Locker 1996). Future research is needed to understand how this impact influences adolescent families’ OHRQoL over time and to determine whether or not the provision of orthodontic treatment has a positive effect on the families of adolescent patients (Strauss and Cassell 2009; Ukra et al. 2013). Future studies should also evaluate the effect of different malocclusion severity levels on the quality of life of adolescents’ families. The collection of further data from different locations is also warranted in an attempt to verify the technical properties of FIS and to confirm and extend the results on family impact reported herein (Locker et al. 2002). One possible suggestion would be to conduct population-based studies to provide external validity and make it possible to extrapolate the findings to the general population as a whole (Bendo et al. 2014). Considering that the FIS is a short instrument, its use in epidemiological surveys is feasible, and it can also be included as an indicator for broader uses, such as political, research, public health, and clinical actions (Abanto et al. 2012).
Conclusions Families of Brazilian adolescents who presented malocclusion were more likely to report a poorer OHRQoL than families of adolescents with no malocclusion. The main negative impacts regarded parental emotions, family conflict, and financial burden. Acknowledgments This study was supported by the National Council for Scientific Development (CNPq), the Coordination for the Improvement of Higher Level Education Personnel (CAPES), and the State of Minas Gerais Research Foundation (FAPEMIG), Brazil.
Eur Arch Paediatr Dent Conflict of interest of interest.
The authors declare that they have no conflict
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