ORIGINAL Farzanegan ARTICLE et al
Evaluation of Health Related Quality of Life Changes After Initial Orthodontic Treatment Fahimeh Farzanegana/Farzin Heravib/Masoud Ramezanic Purpose: To evaluate the changes of Oral Health Related Quality of Life (OHRQoL) in patients after the placement of a fixed orthodontic appliance. Materials and Methods: This prospective study consisted of 148 adolescents (97 girls and 51 boys) between the ages of 14 and 17 who were patients of an orthodontic clinic. OHRQoL was assessed by a modified questionnaire that evaluated four domains: oral symptoms, functional limitations as well as emotional and social well-being in three time frames: before bonding and banding (T0), two months after initiating orthodontic treatment (T1) and six months after initiating orthodontic treatment (T2). The repeated measures test was used to compare the relative changes of OHRQoL among the different time frames. Results: There were no significant differences between the levels of OHRQoL and its domains for boys or girls at any time point. The overall level of OHRQoL decreased significantly at T1 relative to T0; however, the emotional well-being domain improved at T1 in comparison to T0. At T2, the OHRQoL level increased significantly relative to T0 in all domains. Conclusion: The patients’ quality-of-life level decreased by initiating orthodontic treatment; however, during that period, emotional well-being increased. As orthodontic treatment progressed, the quality of life level increased. Key words: oral-health related quality of life, orthodontic treatment, patient assessment Oral Health Prev Dent 2015;13:143-147 doi: 10.3290/j.ohpd.a33087
E
valuating the changes in quality of life is a vital part of measuring the effect of treatment in many clinical settings. Considerable evidence exists which shows that oral disorders including malocclusions may have a significant impact on physical, social and psychological well-being (Shaw et al, 1980; Dolan and Gooch, 1997; Hetherington et al, 1999; Oliveira and Sheiham, 2004; Fernandes et al, 2006; Heravi et al, 2011); therefore, improving the quality of life of patients has become one of
a
Assistant Professor, Department of Orthodontics, Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran. Fahimeh Farzanegan: Experimental design, wrote the manuscript, performed statistical evaluation, contributed substantially to discussion.
b
Assistant Professor, Department of Orthodontics, Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran. Idea, hypothesis, proofread the manuscript.
c
Dentist, Mashhad, Iran. Distributed the questionnaires to the patients and collected them at evaluation timepoints.
Correspondence: Dr. Farzin Heravi, Department of Orthodontics, School of Dentistry, Vakilabad Blvd, Azadi Sqr, Mashhad, Iran. Tel: +98-511-882-9501, Fax: +98-511-882-9500. Email: [email protected]
Vol 13, No 2, 2015
Submitted for publication: 28.07.12; accepted for publication: 26.05.13
the goals of orthodontic treatment. Since there is no evidence-based data available to support the relationship between malocclusions and increasing incidence of caries (Helm and Petersen, 1989; Heesterman, 1993), periodontal diseases (Addy et al, 1988; Polson et al, 1988), TMJ disorders (Luther, 1998) and traumatic dental injuries (Koroluk et al, 2003), improving patients’ quality of life has become the major goal of orthodontic treatments. In the last decade, researchers have been more interested in assessing the effects of malocclusion on oral-health related quality of life (OHRQoL) (FosterPage et al, 2005; Johal et al, 2007; Locker et al, 2007; de Oliveira et al, 2008; Heravi et al, 2011). Moreover, some researchers have investigated the impact of orthodontic treatments on the quality of life (Zhang et al, 2008; Chen et al, 2010; Liu et al, 2011). Zhang et al (2008) proved that patients’ OHRQoL was worse during the initial 6-month phase of orthodontic treatment, but it was better in the emotional well-being domain when compared to the pre-treatment phase. Liu et al (2011) reported the impact of the initial 18-month phase of fixed orthodontic treatment
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Table 1 Means and standard deviations of QoL overall and domain scores at three different time points Oral symptom Sex
N
Female 97
Male
Total
51
0
2
Functional limitation Emotional well-being 6
0
12.03 14.40 9.42 9.50 ±8.38 ±8.38 ±6.49 ±8.00 15.17 ±9.37
18.92 ±10.6
11.13 ±7.77
2 13.76 ±9.06
6
0
2
6
0
2
9.13 23.09 21.89 14.6 8.96 10.49 ±7.18 ±12.60 ±10.35 ±7.54 ±12.48 ±6.38
10.5 14.19 8.96 23.27 22.01 13.7 ±8.27 ±8.56 ±6.91 ±14.61 ±12.38 ±9.04
13.11 15.95 10.01 9.87 13.91 148 ±8.83 ±9.44 ±6.98 ±8.08 ±8.86
Social well-being
8.70 ±7.82
Quality of life
6
0
2
6
4.02 53.59 60.55 37.25 ±4.70 ±29.81 ±25.93 ±19.39
9.84 ±6.04
3.94 57.72 64.98 37.78 ±4.67 ±35.68 ±32.58 ±24.78
9.07 23.15 21.93 14.3 8.87 10.27 ±7.07 ±13.28 ±11.05 ±8.07 ±11.07 ±6.25
3.99 55.02 62.08 37.43 ±4.67 ±31.89 ±28.36 ±21.32
0: baseline, pretreatment; 2: two months after starting treatment; 6: six months after starting treatment.
on adulthood OHRQoL. They found that the greatest deterioration in OHRQoL occurred in the early phase of treatment, but with ongoing treatment, the detrimental effects to OHRQoL decreased. Chen et al (2010) evaluated the impact of fixed orthodontic appliance therapy on OHRQoL and reported that these treatments could improve Chinese patients’ OHRQoL. Since there is only limited data on an Iranian population on the effects of treatment with fixed orthodontic appliances on OHRQoL (Heravi et al, 2011) and because of the discrepancies between these results and those of the studies mentioned above, the present study was performed to assess the effect of a 6-month time period after starting orthodontic treatment on the oral-health related quality of life.
Table 2 Comparison of QoL overall and domain scores at three different time points Time (month)
2
6
Oral symptoms
0
0.0001*
0.00001*
Functional limitations
0
Emotional well-being
0
Social well-being
0
Quality of life
2
0.0001* 0.00001*
2 0.074
2
2
0.0001* 0.0001*
0.407
0.0001*
0.000*
0.0001*
2 0
0.181 0.0001*
0.0001* 0.0001*
0: baseline, pretreatment; 2: two months after starting treatment; 6: six months after starting treatment. *Statistically significant.
MATERIALS AND METHODS In this longitudinal prospective study, 148 adolescents (97 females and 51 males) seeking treatment at the Orthodontic Clinic of the Mashhad University of Medical Sciences, Iran, participated in our study. They were between 14 and 17 years old and they presented with no previous orthodontic treatment or history of any systemic diseases. They had finished other dental treatment before starting orthodontic therapy. OHRQoL was assessed by a self-administered questionnaire given at three different times: baseline, one week before orthodontic treatment (T0); 2 months (T1) and 6 months (T2) after starting orthodontic treatment. After screening, 218 patients were recruited to fill out the questionnaire. At T1, 180 patients were followed-up to answer the questionnaire, but at T2, only 148 patients participated in this phase (non-response due to missed appointments). The study was approved by the Research Ethics Committee of the Mashhad University of Medical Sciences. A questionnaire was developed by adopting items from OHRQoL questionnaires such as the
144
CPQ 11-14, OHIP and OIDP. The validity and reliability of this questionnaire was approved in an earlier study (Fernandes et al, 2006). The questionnaire used here consisted of 43 questions categorised into four domains: oral symptoms, functional limitations, and emotional and social well-being. A maximum time of 20 min was allowed for each participant to answer the questions. Responses to each item were scored on a 5-point Likert scale: 0 = never; 1 = hardly ever; 2 = occasionally; 3 = fairly often; and 4 = very often or every day. The sum total of these scores yields the level of the patient’s OHRQoL. Higher scores indicate a lower level of OHRQoL and vice versa. After data collection, the scores of each domain were summed up. The Kolmogorov-Smirnov test was used to validate the normal distribution of data. Normally distributed data were analysed by the repeated measure test and the Bonferroni correction of pairwise comparisons. Statistical signifi cance was set at p < 0.05.
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Farzanegan et al II
20
Oral symptoms
18
S
S
16 14 S
12
male
S 10
Functional limitations
I
14 S
S 12 S
male
S
10 female
female 8
8 0
2 month
0
6
III
2 month
IV NS
female
22.5
10
20.0 S 17.5 female
15.0
male
12.5 0
2 month
6
Social well-being
Emotional well-being
6
NS
male NS
8 S 6
4 0
2 month
6
V 65 S
OHRQL
60
male S
S
55 female
S
50 45 40 35 0
2 month
6
RESULTS One hundred forty-eight of 218 patients completed the OHRQoL questionnaire at all 3 times during the study. Ninety-seven participants were female (67%) and their mean age was 15.8 years. The mean age of male patients was 16.1 years. There was no significant difference in the OHRQoL or its domain scores between the two sexes at any time. Table 1 illustrates means and standard deviations of OHRQoL and its domains.
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Fig 1 Changes in I. oral symptoms, II. functional limitations, III. emotional well-being, IV. social well-being and V. OHRQoL over a 6-month period. The mean difference is significant at the 0.05 level. S: significant; NS: not significant.
After using the repeated measure analysis, it became clear that changes in OHRQoL and its domains were significant during this period. Table 2 shows the results of the Bonferroni test. The overall OHRQoL score and the scores of oralsymptom and functional-limitation domains signifi cantly increased from T0 to T1. The score of the emotional well-being domain decreased during this period, but not significantly. The changes of the social well-being domain were not statistically signifi cant (Table 2 and Fig 1).
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Comparing the T2 phase with T1, a significant decrease was found in the OHRQoL scores and its domains. Moreover, at T2, the scores of the domains were lower than their equivalents at T0, and in the oral-symptoms, social and emotional wellbeing domains, these differences were significant (Table 2).
DISCUSSION Many orthodontists believe that by initiating orthodontic treatment, their patients become happier. On the other hand, difficulties faced by patients may become apparent after the placement of orthodontic appliances. In this study, our aim was to assess different aspects of the orthodontic patients’ QoL during the first 6 months after initiating orthodontic treatment in 147 patients. For this purpose, we used a modified questionnaire that was proven to be reliable and valid in a previous study on 14- to 17-year-old adolescents in an Iranian population (Heravi et al, 2011). We found no significant difference between male and female participants. This finding was consistent with the results of previous studies (Chen et al, 2010; Liu et al, 2011). Therefore, the results of both sexes were pooled. Significant changes in OHRQoL were observed in this study during the initial 6-month phase of orthodontic treatment, which supports the findings of other studies that found treatment with fixed orthodontic appliances to have a negative impact on OHRQoL (Bernabe et al, 2008; Zhang et al, 2008; Liu et al, 2011; Chen et al, 2010). The overall OHRQoL scores at T0 (before treatment) were lower than T1 (at 2 months). This implies that during the initial phase of orthodontic treatment, the level of OHRQoL decreased, concurring with findings by Zhang et al (Zhang et al, 2008). However, the results of Chen et al (2010) showed that OHRQoL scores at 1 month after starting orthodontic treatment were similar to pre-treatment scores. At the T2 phase (6 months after orthodontic therapy began), the level of OHRQoL increased even beyond that at T0. This result is in contrast to Liu (Liu et al, 2011), who concluded that the level of QoL 18 months after orthodontic treatment began was comparable with pre-treatment, but at 6 and 12 months, the level of QoL was lower than at T0. These differences are in part due to different questionnaires that were used in these studies. In addition, a cultural difference may be assumed to be the cause of this disagreement.
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Evaluating the domains of OHRQoL showed that the scores of oral symptoms after a two-month period increased, but decreased after 6 months to a level lower than at T0. This finding is in agreement with Zhang et al (2008) and McGrath et al (2004). This was also the same for functional limitations. These findings make sense, since after bracket placement, patients may experience a period of oral pain, especially during mastication, which can be the cause of an increase in the scores in these domains. Values at T2 showed a significant decrease in scores. It could be that patients have become accustomed to the situation and feel more comfortable with their oral functions – even much more than in the T0 phase. The emotional and social well-being criteria did not change significantly during the first two months after bracket placement. However, during this period, in contrast to the scores of other domains, the scores of emotional well-being decreased. This fact implies that in a patient with malocclusion, even bracket placement could improve their emotional well-being. This finding is in exact agreement with the results of Zhang et al (2008). The questionnaire (CPQ) used in that study is very similar to the questionnaire used in the present study. Comparing the results of our study with the results of Zhang et al (2008), it was of interest that the mean scores of OHRQoL and its domains in our study were lower than those in the Zhang et al study. Moreover, the score of the emotional well-being domain was about a fifth of that in Zhang et al’s study. These differences can be interpreted by the differences in overall QoL level between the two populations and differences in their cultures. In the T2 phase, scores of these two domains decreased remarkably. This phenomenon can be due to the patient’s wish to improve their appearance. This information can be useful to inform patients of the likely effect of orthodontic treatment on their lives and thus can give them realistic expectations of treatment.
CONCLUSION Although the quality of life of patients diminished after placement of orthodontic appliances, six months later, all aspects of quality of life underwent a significant improvement, so that, aside from functional limitations, the final QoL level measured was even better than before treatment began.
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REFERENCES 1. Addy M, Griffiths GS, Dummer PM, Kingdon A, Hicks R, Hunter ML et al. The association between tooth irregularity and plaque accumulation, gingivitis and caries in 11–12 year old children. Eur J Orthod 1988;10:76–83. 2. Bernabe E, Sheiham A, de Oliveira CM. Impacts on daily performances related to wearing orthodontic appliances. Angle Orthod 2008;78:482–486. 3. Chen M, Wang DW, Wu LP.Fixed orthodontic appliance therapy and its impact on oral health-related quality of life in Chinese patients.Angle Orthod 2010;80:49–53. 4. de Oliveira C, Sheiham A, Tsakos G, O’Brien K. Oral healthrelated quality of life and the IOTN index as predictors of children’s perceived needs and acceptance for orthodontic treatment. Br Dent J 2008;207:1–5. 5. Dolan TA, Gooch BF. Dental health questions from the Rand Health Insurance study. In: Slade GD, editor. Measuring oral health and quality of life, ed 2. Chapel Hill, NC: University of North Carolina, 1997:8–31. 6. Fernandes MJ, Ruta DA, Ogden GR, Pitts NB, Ogston SA. Assessing oral health-related quality of life in general dental practice in Scotland: validation of the OHIP-14. Community Dent Health 2006;34:53–62. 7. Foster-Page LA, Thomson WM, Jokovic A, Locker D. Validation of the child perceptions questionnaire (CPQ 11-14). J Dent Res 2005;84:649–652. 8. Heesterman R: The future provision of orthodontic services [editorial]. Community Dent Health 1993;10:107–110. 9. Helm S, Petersen PE: Causal relation between malocclusion and caries. Acta Odont Scand 1989;47:212–221. 10. Heravi F, Farzanegan F, Tabatabaee M, Sadeghi M. Do malocclusions affect the oral health-related quality of life? Oral Health Prev Dent 2011;9:229–233. 11. Hetherington EM, Parke RD, LockeVO. Child psychology: a contemporary viewpoint, ed 5. New York: McGraw-Hill, 1999.
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12. Johal A, Cheung M, Marcene W. The impact of two different malocclusion traits on quality of life. Br Dent J 2007;202:E2. 13. Koroluk DL, Tulloch JFC, Phillips C. Incisor trauma and early treatment for Class II Division 1 malocclusion. Am J Orthod Dentofacial Orthop 2003;123:117–126. 14. Liu Z, McGrath C, Hägg U. Changes in oral health-related quality of life during fixed orthodontic appliance therapy: an 18-month prospective longitudinal study. Am J Orthod Dentofacial Orthop 2011;139:214–219. 15. Locker D, Jokovic A, Tompson B, Prakash P. Is the child perceptions questionnaire for 11–14 year olds sensitive to clinical and self-perceived variations in orthodontic status? Community Dent Oral Epidemiol 2007;35:179–185. 16. Luther F. Orthodontics and the temporomandibular joint: where are we now? Part 2. Functional occlusion, malocclusion and TMD. Angle Orthod 1998;68:305–318. 17. McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality of children: implications for research and practice. Community Dent Oral Epidemiol 2004;32:81–85. 18. Oliveira CM, Sheiham A. Orthodontic treatment and its impact on oral health-related quality of life in Brazilian adolescents. J Orthod 2004; 31:20–27. 19. Polson AM, Subtelny JD, Meitner SW, Polson AP, Sommers EW, Iker HP et al. Long-term periodontal status after orthodontic treatment. Am J Orthod Dentofacial Orthop 1988;93:51–58. 20. Sadowsky C, BeGole EA. Long-term effects of orthodontic treatment on periodontal health. Am J Orthod 1981;80:156–172. 21. Shaw WC, Addy M, Ray C. Dental and social effects of malocclusion and effectiveness of orthodontic treatment: a review. Community Dent Oral Epidemiol 1980;8:36–45. 22. Zhang M, McGrath C, Hägg U. Changes in oral health-related quality of life during fixed orthodontic appliance therapy. Am J Orthod Dentofacial Orthop 2008;133:25–29.
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Evaluation of Health Related Quality of Life Changes After Initial Orthodontic Treatment Fahimeh Farzanegana/Farzin Heravib/Masoud Ramezanic Purpose: To evaluate the changes of Oral Health Related Quality of Life (OHRQoL) in patients after the placement of a fixed orthodontic appliance. Materials and Methods: This prospective study consisted of 148 adolescents (97 girls and 51 boys) between the ages of 14 and 17 who were patients of an orthodontic clinic. OHRQoL was assessed by a modified questionnaire that evaluated four domains: oral symptoms, functional limitations as well as emotional and social well-being in three time frames: before bonding and banding (T0), two months after initiating orthodontic treatment (T1) and six months after initiating orthodontic treatment (T2). The repeated measures test was used to compare the relative changes of OHRQoL among the different time frames. Results: There were no significant differences between the levels of OHRQoL and its domains for boys or girls at any time point. The overall level of OHRQoL decreased significantly at T1 relative to T0; however, the emotional well-being domain improved at T1 in comparison to T0. At T2, the OHRQoL level increased significantly relative to T0 in all domains. Conclusion: The patients’ quality-of-life level decreased by initiating orthodontic treatment; however, during that period, emotional well-being increased. As orthodontic treatment progressed, the quality of life level increased. Key words: oral-health related quality of life, orthodontic treatment, patient assessment Oral Health Prev Dent 2015;13:143-147 doi: 10.3290/j.ohpd.a33087
E
valuating the changes in quality of life is a vital part of measuring the effect of treatment in many clinical settings. Considerable evidence exists which shows that oral disorders including malocclusions may have a significant impact on physical, social and psychological well-being (Shaw et al, 1980; Dolan and Gooch, 1997; Hetherington et al, 1999; Oliveira and Sheiham, 2004; Fernandes et al, 2006; Heravi et al, 2011); therefore, improving the quality of life of patients has become one of
a
Assistant Professor, Department of Orthodontics, Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran. Fahimeh Farzanegan: Experimental design, wrote the manuscript, performed statistical evaluation, contributed substantially to discussion.
b
Assistant Professor, Department of Orthodontics, Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran. Idea, hypothesis, proofread the manuscript.
c
Dentist, Mashhad, Iran. Distributed the questionnaires to the patients and collected them at evaluation timepoints.
Correspondence: Dr. Farzin Heravi, Department of Orthodontics, School of Dentistry, Vakilabad Blvd, Azadi Sqr, Mashhad, Iran. Tel: +98-511-882-9501, Fax: +98-511-882-9500. Email: [email protected]
Vol 13, No 2, 2015
Submitted for publication: 28.07.12; accepted for publication: 26.05.13
the goals of orthodontic treatment. Since there is no evidence-based data available to support the relationship between malocclusions and increasing incidence of caries (Helm and Petersen, 1989; Heesterman, 1993), periodontal diseases (Addy et al, 1988; Polson et al, 1988), TMJ disorders (Luther, 1998) and traumatic dental injuries (Koroluk et al, 2003), improving patients’ quality of life has become the major goal of orthodontic treatments. In the last decade, researchers have been more interested in assessing the effects of malocclusion on oral-health related quality of life (OHRQoL) (FosterPage et al, 2005; Johal et al, 2007; Locker et al, 2007; de Oliveira et al, 2008; Heravi et al, 2011). Moreover, some researchers have investigated the impact of orthodontic treatments on the quality of life (Zhang et al, 2008; Chen et al, 2010; Liu et al, 2011). Zhang et al (2008) proved that patients’ OHRQoL was worse during the initial 6-month phase of orthodontic treatment, but it was better in the emotional well-being domain when compared to the pre-treatment phase. Liu et al (2011) reported the impact of the initial 18-month phase of fixed orthodontic treatment
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Table 1 Means and standard deviations of QoL overall and domain scores at three different time points Oral symptom Sex
N
Female 97
Male
Total
51
0
2
Functional limitation Emotional well-being 6
0
12.03 14.40 9.42 9.50 ±8.38 ±8.38 ±6.49 ±8.00 15.17 ±9.37
18.92 ±10.6
11.13 ±7.77
2 13.76 ±9.06
6
0
2
6
0
2
9.13 23.09 21.89 14.6 8.96 10.49 ±7.18 ±12.60 ±10.35 ±7.54 ±12.48 ±6.38
10.5 14.19 8.96 23.27 22.01 13.7 ±8.27 ±8.56 ±6.91 ±14.61 ±12.38 ±9.04
13.11 15.95 10.01 9.87 13.91 148 ±8.83 ±9.44 ±6.98 ±8.08 ±8.86
Social well-being
8.70 ±7.82
Quality of life
6
0
2
6
4.02 53.59 60.55 37.25 ±4.70 ±29.81 ±25.93 ±19.39
9.84 ±6.04
3.94 57.72 64.98 37.78 ±4.67 ±35.68 ±32.58 ±24.78
9.07 23.15 21.93 14.3 8.87 10.27 ±7.07 ±13.28 ±11.05 ±8.07 ±11.07 ±6.25
3.99 55.02 62.08 37.43 ±4.67 ±31.89 ±28.36 ±21.32
0: baseline, pretreatment; 2: two months after starting treatment; 6: six months after starting treatment.
on adulthood OHRQoL. They found that the greatest deterioration in OHRQoL occurred in the early phase of treatment, but with ongoing treatment, the detrimental effects to OHRQoL decreased. Chen et al (2010) evaluated the impact of fixed orthodontic appliance therapy on OHRQoL and reported that these treatments could improve Chinese patients’ OHRQoL. Since there is only limited data on an Iranian population on the effects of treatment with fixed orthodontic appliances on OHRQoL (Heravi et al, 2011) and because of the discrepancies between these results and those of the studies mentioned above, the present study was performed to assess the effect of a 6-month time period after starting orthodontic treatment on the oral-health related quality of life.
Table 2 Comparison of QoL overall and domain scores at three different time points Time (month)
2
6
Oral symptoms
0
0.0001*
0.00001*
Functional limitations
0
Emotional well-being
0
Social well-being
0
Quality of life
2
0.0001* 0.00001*
2 0.074
2
2
0.0001* 0.0001*
0.407
0.0001*
0.000*
0.0001*
2 0
0.181 0.0001*
0.0001* 0.0001*
0: baseline, pretreatment; 2: two months after starting treatment; 6: six months after starting treatment. *Statistically significant.
MATERIALS AND METHODS In this longitudinal prospective study, 148 adolescents (97 females and 51 males) seeking treatment at the Orthodontic Clinic of the Mashhad University of Medical Sciences, Iran, participated in our study. They were between 14 and 17 years old and they presented with no previous orthodontic treatment or history of any systemic diseases. They had finished other dental treatment before starting orthodontic therapy. OHRQoL was assessed by a self-administered questionnaire given at three different times: baseline, one week before orthodontic treatment (T0); 2 months (T1) and 6 months (T2) after starting orthodontic treatment. After screening, 218 patients were recruited to fill out the questionnaire. At T1, 180 patients were followed-up to answer the questionnaire, but at T2, only 148 patients participated in this phase (non-response due to missed appointments). The study was approved by the Research Ethics Committee of the Mashhad University of Medical Sciences. A questionnaire was developed by adopting items from OHRQoL questionnaires such as the
144
CPQ 11-14, OHIP and OIDP. The validity and reliability of this questionnaire was approved in an earlier study (Fernandes et al, 2006). The questionnaire used here consisted of 43 questions categorised into four domains: oral symptoms, functional limitations, and emotional and social well-being. A maximum time of 20 min was allowed for each participant to answer the questions. Responses to each item were scored on a 5-point Likert scale: 0 = never; 1 = hardly ever; 2 = occasionally; 3 = fairly often; and 4 = very often or every day. The sum total of these scores yields the level of the patient’s OHRQoL. Higher scores indicate a lower level of OHRQoL and vice versa. After data collection, the scores of each domain were summed up. The Kolmogorov-Smirnov test was used to validate the normal distribution of data. Normally distributed data were analysed by the repeated measure test and the Bonferroni correction of pairwise comparisons. Statistical signifi cance was set at p < 0.05.
Oral Health & Preventive Dentistry
Farzanegan et al II
20
Oral symptoms
18
S
S
16 14 S
12
male
S 10
Functional limitations
I
14 S
S 12 S
male
S
10 female
female 8
8 0
2 month
0
6
III
2 month
IV NS
female
22.5
10
20.0 S 17.5 female
15.0
male
12.5 0
2 month
6
Social well-being
Emotional well-being
6
NS
male NS
8 S 6
4 0
2 month
6
V 65 S
OHRQL
60
male S
S
55 female
S
50 45 40 35 0
2 month
6
RESULTS One hundred forty-eight of 218 patients completed the OHRQoL questionnaire at all 3 times during the study. Ninety-seven participants were female (67%) and their mean age was 15.8 years. The mean age of male patients was 16.1 years. There was no significant difference in the OHRQoL or its domain scores between the two sexes at any time. Table 1 illustrates means and standard deviations of OHRQoL and its domains.
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Fig 1 Changes in I. oral symptoms, II. functional limitations, III. emotional well-being, IV. social well-being and V. OHRQoL over a 6-month period. The mean difference is significant at the 0.05 level. S: significant; NS: not significant.
After using the repeated measure analysis, it became clear that changes in OHRQoL and its domains were significant during this period. Table 2 shows the results of the Bonferroni test. The overall OHRQoL score and the scores of oralsymptom and functional-limitation domains signifi cantly increased from T0 to T1. The score of the emotional well-being domain decreased during this period, but not significantly. The changes of the social well-being domain were not statistically signifi cant (Table 2 and Fig 1).
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Comparing the T2 phase with T1, a significant decrease was found in the OHRQoL scores and its domains. Moreover, at T2, the scores of the domains were lower than their equivalents at T0, and in the oral-symptoms, social and emotional wellbeing domains, these differences were significant (Table 2).
DISCUSSION Many orthodontists believe that by initiating orthodontic treatment, their patients become happier. On the other hand, difficulties faced by patients may become apparent after the placement of orthodontic appliances. In this study, our aim was to assess different aspects of the orthodontic patients’ QoL during the first 6 months after initiating orthodontic treatment in 147 patients. For this purpose, we used a modified questionnaire that was proven to be reliable and valid in a previous study on 14- to 17-year-old adolescents in an Iranian population (Heravi et al, 2011). We found no significant difference between male and female participants. This finding was consistent with the results of previous studies (Chen et al, 2010; Liu et al, 2011). Therefore, the results of both sexes were pooled. Significant changes in OHRQoL were observed in this study during the initial 6-month phase of orthodontic treatment, which supports the findings of other studies that found treatment with fixed orthodontic appliances to have a negative impact on OHRQoL (Bernabe et al, 2008; Zhang et al, 2008; Liu et al, 2011; Chen et al, 2010). The overall OHRQoL scores at T0 (before treatment) were lower than T1 (at 2 months). This implies that during the initial phase of orthodontic treatment, the level of OHRQoL decreased, concurring with findings by Zhang et al (Zhang et al, 2008). However, the results of Chen et al (2010) showed that OHRQoL scores at 1 month after starting orthodontic treatment were similar to pre-treatment scores. At the T2 phase (6 months after orthodontic therapy began), the level of OHRQoL increased even beyond that at T0. This result is in contrast to Liu (Liu et al, 2011), who concluded that the level of QoL 18 months after orthodontic treatment began was comparable with pre-treatment, but at 6 and 12 months, the level of QoL was lower than at T0. These differences are in part due to different questionnaires that were used in these studies. In addition, a cultural difference may be assumed to be the cause of this disagreement.
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Evaluating the domains of OHRQoL showed that the scores of oral symptoms after a two-month period increased, but decreased after 6 months to a level lower than at T0. This finding is in agreement with Zhang et al (2008) and McGrath et al (2004). This was also the same for functional limitations. These findings make sense, since after bracket placement, patients may experience a period of oral pain, especially during mastication, which can be the cause of an increase in the scores in these domains. Values at T2 showed a significant decrease in scores. It could be that patients have become accustomed to the situation and feel more comfortable with their oral functions – even much more than in the T0 phase. The emotional and social well-being criteria did not change significantly during the first two months after bracket placement. However, during this period, in contrast to the scores of other domains, the scores of emotional well-being decreased. This fact implies that in a patient with malocclusion, even bracket placement could improve their emotional well-being. This finding is in exact agreement with the results of Zhang et al (2008). The questionnaire (CPQ) used in that study is very similar to the questionnaire used in the present study. Comparing the results of our study with the results of Zhang et al (2008), it was of interest that the mean scores of OHRQoL and its domains in our study were lower than those in the Zhang et al study. Moreover, the score of the emotional well-being domain was about a fifth of that in Zhang et al’s study. These differences can be interpreted by the differences in overall QoL level between the two populations and differences in their cultures. In the T2 phase, scores of these two domains decreased remarkably. This phenomenon can be due to the patient’s wish to improve their appearance. This information can be useful to inform patients of the likely effect of orthodontic treatment on their lives and thus can give them realistic expectations of treatment.
CONCLUSION Although the quality of life of patients diminished after placement of orthodontic appliances, six months later, all aspects of quality of life underwent a significant improvement, so that, aside from functional limitations, the final QoL level measured was even better than before treatment began.
Oral Health & Preventive Dentistry
Farzanegan et al
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