An occasionally irregular blog about orthodontics

Malocclusion, orthodontics and quality of life

By on December 15, 2014 in Personal opinion, Research Methods with 3 Comments
Malocclusion, orthodontics and quality of life

Malocclusion, orthodontics and quality of life?

One of the most important areas of orthodontic research that needs to be carried out is to clearly identify the effects of treatment. I have highlighted this in previous posts on the “the great unanswered questions” and “papers that have influenced me”.

When we consider this area, I feel that we can provide evidence that orthodontic treatment has an effect on problems arising from impactions, trauma and severe overjet, overbites and crowding. There is also no doubt that treatment improves the appearance of a persons teeth and it is reasonable to assume that this has a favourable effect on their quality of life. Unfortunately, the scientific proof of this concept is currently weak.

I was, therefore, very interested to find two papers in this months journals that are concerned with this area of research.  They are from teams in different parts of the World and I have illustrated this blog with pictures of the settings of the studies.  The first is from a team in Amman, Jordan.

images-19Impact of bullying due to dento-facial features on oral health related quality of life.
Iyad Al-Omari et al
AJO-DDO 2014;146: 134-9


When I read this paper I found that it was a further report on paper that I had previously discussed almost a year ago in this post.

I have looked back at this review I had commented “I wonder if the authors could have added value by including patient values in their study”. This second paper addresses this issue.

It is not clear if this new second paper represents an additional set of data collection or it simply contains an analysis of data that was originally collected and not reported; until now. Because these papers are related, it is worthwhile revisiting the first as part of this discussion.

What did they do?

The aim of the first paper was to

“Investigate the experience of bullying in a sample of schoolchildren in Jordan”.

The aim of the second was to

“Investigate whether their was a relationship between bullying and oral health quality of life (OHQoL) using the Child perception questionnaire (CPQ11-14)

The first study was a cross sectional investigation of 960 school children. In the new paper they calculated that they needed to evaluate OHQoL in 172 of the “bullied” and “non-bullied” groups that they identified in the first study. They then described how they enrolled 960 school children. I know that this is getting confusing!

I have decided to concentrate on their results for OHQoL for the bullied and non bullied children. They identified 379 participants who reported being bullied or not bullied about their teeth. They found that the total CPQ 11-14 were significantly greater for the participants who were bullied. That is they had a lower oral health quality of life.

What did I think?

I found this paper very difficult to interpret and it would have been much more understandable if these results had been presented as part of the original paper.

I would also like to refer to the original blog post, and Phil Benson made a comment that this incidence of bullying in this sample was high and this may be because the authors did not differentiate between bullying and teasing, which are different concepts.

Putting these issues aside, I think that there is something here and the findings echo other research in this area. I feel that we are moving towards being able state that a child with a visible malocclusion may be teased or bullied and this has an effect on their quality of life.

This leads us to the second paper from a team led from Sheffield, North of England.

Unknown-3Relationship between dental appearance, self esteem, socio economic status and oral health related quality of life in UK school children: A 3 year cohort study.

Philip Benson et al

EJO:2014 Advance access

DOI: 10.1093/ejo/cju076

The aim of their study was to

“Examine the relationship between the appearance of the teeth, dental health and oral health quality of life”.

The great thing about this study was that it was a longitudinal study in which they enrolled a group of 670 11-12 year old school children and followed them for three years. This was an ambitious and difficult study to carry out.

At each stage of data collection they measured

  • Oral Health Quality of Life
  • Self Esteem
  • Socio economic status
  • IOTN
  • DMFT.

At follow up 42% of the children had dropped out of the study, which is a problem as it  introduces some uncertainty into the data.

With the large number of variables and longitudinal nature of the data the statistical analysis was complex and I do not have the space to go into all the data here. The important findings were:

  1. IOTN DHC improved between T1 and T2 irrespective of orthodontic treatment for 35% of the children.
  2. The OHQoL improved over time
  3. The self esteem reduced
  4. The children with higher self esteem had a higher OHQoL
  5. Orthodontic treatment did not improve OHQoL

What did I think?

I thought that this was a very important study. It was interesting that IOTN improved over time, regardless of orthodontic treatment, on a population basis. I wonder if this is due to favourable facial growth. Nevertheless, this needs further investigation, as it is a clinically important  finding.

It was also interesting, and disappointing, that orthodontic treatment did not result in a significant improvement in Oral Health Quality of Life. However, I wonder if the study was sufficiently powered to answer this question as only 33 out of 171 children (19%) had been treated. The sample size calculation was based on an orthodontic treatment rate of 32%.

It was also great to see a study carried out in the community and not in dental schools or orthodontic clinics. This adds to the complexity and the generality of the findings.

Overall summary?

These two papers investigate similar issues and are both complex to interpret. My “soundbite” interpretation is that

  1. Visible malocclusion appears to influence quality of life
  2. At present we are not certain whether orthodontic treatment improves quality of life.
  3. This area clearly needs research

We could have a good discussion about this in the comments…
Al-Omari, I., Al-Bitar, Z., Sonbol, H., Al-Ahmad, H., Cunningham, S., & Al-Omiri, M. (2014). Impact of bullying due to dentofacial features on oral health–related quality of life American Journal of Orthodontics and Dentofacial Orthopedics, 146 (6), 734-739 DOI: 10.1016/j.ajodo.2014.08.011

Benson, P., Da’as, T., Johal, A., Mandall, N., Williams, A., Baker, S., & Marshman, Z. (2014). Relationships between dental appearance, self-esteem, socio-economic status, and oral health-related quality of life in UK schoolchildren: A 3-year cohort study The European Journal of Orthodontics DOI: 10.1093/ejo/cju076

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There Are 3 Comments

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  1. Peter Miles says:

    Hi Kevin; I thought you and the group may be interested in this open access article in the latest issue of the Korean Journal of Orthodontics investigating “Effect of malocclusion or orthodontic treatment on oral health-related quality of life in adults”. The article is open access at and in this adult sample of 860 subjects, they concluded that malocclusion has a negative impact on OHQoL as measured by both the Oral Health Impact Profile (OHIP-14) and Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ). The differences were statistically significant for both instruments and similar to the results by Al-Omari et al in terms of the OHIP-14 scores (Bullied = Malocclusion and those in treatment groups, Not-bullied = normal occlusion and those in retention groups).

  2. Has there been any research into other factors related to malocclusion which may affect the patient’s quality of life? For example, the restricted airway associated with most Class II malocclusions, OSA springs to mind, or the forward head posture, also associated with Class II cases, leading to stress on the muscles of the neck and back.

  3. andy pearson says:

    I’m just catching up on 2yrs of your blog but I’m not going to comment too much if I can help it. This one is interesting in that it indicates that IOTN improves with age. Now in my last 10 years of practicing I’m starting to wonder if we need a paradigm shift from early to late treatment. This would have certain advantages including: the treatment would be carried out on adults so the parents impact on decision making would be reduced ; There would be less unpredictable growth which can result in retreatment ; maybe there would be less need for treatment if iotn gets better in some cases.
    So, other than impactions which may worsen with time, how about not treating anyone (not just class 3s) until after the growth spurt?
    There would of course be less money in it.

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