An occasionally irregular blog about orthodontics

Does malocclusion influence quality of life?

Does malocclusion influence quality of life?

Does malocclusion influence quality of life?

The blog is a littler earlier this week because I have a busy week and I only have time today to write a  post. Several posts ago I commented that systematic reviews were being published in increasing numbers. Just when I thought that I covered all the recent reviews, another has recently been published. This is on the relationship between malocclusion and quality of life.When I saw this paper I was particularly interested because it provided information on what I feel is one of the most important areas in orthodontic research. This was also one of the “great unanswered questions” in orthodontics that I covered in this blog posting.

Having read the paper I think that it is important because it addresses the question of quality of life, which is one of the areas that we have not always measured well in research. This also interfaces well with last weeks blog on orthodontic outcomes.

Unknown-2 The Impact of Malocclusion on the quality of life among children and adolescents; A systematic review of quantitative studies.

Dimeborg L et al


European Journal of Orthodontics: 2014

Epub ahead of printDOI: 10.1093/ejo/cju046

I think that a good start to evaluating this paper is to use criteria that I used in my guide to reading a systematic review. The first feature to point out was that this was not a Cochrane Review and as a result is not going to be updated on a regular basis. This means that this is a “one off” snapshot of evidence.

The searches were carried out well and reported in sufficient detail to allow them to be repeated. The authors identified six publications. These were all cross sectional studies. In effect, the investigators compared the Oral Health Related Quality of Life (OHRQOL) of children with and without malocclusion. They also assessed the quality of the recommendations made using the GRADE approach and found that 4 papers were high quality and two were moderate. It was a little disappointing that they did not carry out a meta-analysis or attempt to calculate an effect from the studies. However, they did provide a detailed table outlining the findings of the papers.

They concluded that from these studies that malocclusion has a negative effect on oral health quality of life. This is an important and possibly clinically important finding.

 So what?

There are several factors that we need to consider about this review.

Firstly, the studies that they included were recently published. The studies used a cross sectional design and some may think that this is a problem, as the strength of evidence is not as high a trial. However, I have thought about this carefully and I feel that this is the only ethical study design that we can use to address this question. The authors also point out that this level of evidence is penalised by the GRADE assessment and they have addressed this in the discussion by pointing out that this is the only type of study design that we can carry out. I feel that they are entirely correct.

Another area that they discussed was that most of the studies were carried out in Brazil. As a result, the findings may not be entirely relevant to other parts of the World. While this may be an issue, the studies do provide useful pointer and until they are carried out in other countries we should accept their findings. It would surprise me if the results were different.

I had a careful look at the results table that showed the effects that they detected and this revealed some interesting finding. For example, in one paper they found that there was a high negative impact on OHRQOL in 42% of children without malocclusion and 57% of those with malocclusion. Furthermore, children with malocclusion were 1.3 (95% CI: 1.15-1.46) times more likely to experience a negative impact on OHQOL. In another study the malocclusion group had a 3.1 (95% CI: 1.5-6.3) times higher chance of reporting worse OHRQOL. Children with incisal crowding had a Risk Ratio of 1.5 (95% CI 1.2-1.9) when compared to children without crowding. This means that children with incisal crowding had a 50% greater risk of a negative impact than children with no malocclusion.

 A slight word of caution

While the results are useful to us as providers of orthodontic care, we also need to be cautious and we cannot assume that orthodontic treatment will OHRQOL. While some could argue that this is a reasonable assumption and I would  support this hypothesis, we currently have limited proof that orthodontic treatment improves oral health quality of life. The only way that we could obtain this is carry out a trial of children with malocclusion and randomise them to treatment and no treatment. We, clearly, cannot do this. As a result, we have to rely on weaker levels of evidence which result in a degree of uncertainty. Nevertheless, I feel that if we consider the balance of evidence against likely clinical gain, then I am beginning to believe that orthodontic treatment is likely to improve oral health quality of life. Has anyone any comments on this, we can have a heated debate?
Dimberg, L., Arnrup, K., & Bondemark, L. (2014). The impact of malocclusion on the quality of life among children and adolescents: a systematic review of quantitative studies The European Journal of Orthodontics DOI: 10.1093/ejo/cju046

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  1. Annalise McNair says:

    Hi Kevin, I haven’t had a chance to read this review but my instant thought on reading your blog was whether there is any difference in OHQoL between patients that qualify for treatment under IOTN and take it up and those that qualify and decide not to proceed with treatment. What do you think? Would it be worth or possible to investigate? Best wishes Annalise.

    • Kevin O'Brien says:

      Hi Annalise, I have gone back to the paper and some of the papers that they included. I looked to see if there was an effect of the more serious malocclusion on OHQoL but I could not find anything. This was probably because of low sample sizes. We are all aware of patients who have a severe malocclusion and decide not to have treatment and this group has always interested me because I sometimes wonder how they have got on. It certainly would be a worthwhile piece of research, perhaps offering cognitive behaviour therapy instead of orthodontics may have an effect?

      Best wishes: Kevin

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