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The psycho-social impact of malocclusions and treatment expectations of

adolescent orthodontic patients

Article  in  The European Journal of Orthodontics · December 2015

DOI: 10.1093/ejo/cjv093

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 European Journal of Orthodontics, 2016, 593–601
doi:10.1093/ejo/cjv093
Advance Access publication 26 December 2015

Original article

The psycho-social impact of malocclusions

and treatment expectations of adolescent
orthodontic patients
Eugene Twigge*, Rachel M. Roberts**, Lisa Jamieson***,
Craig W. Dreyer**** and Wayne J. Sampson*****
*Department of Orthodontics, **School of Psychology, ***Australian Research Centre for Population Oral Health,
****Department of Orthodontics and *****Department of Orthodontics, The University of Adelaide, Australia

Correspondence to: Craig W. Dreyer, School of Dentistry, Faculty of Health Sciences, The University of Adelaide, Adelaide
5005, Australia. E-mail: craig.dreyer@adelaide.edu.au

Summary
Objectives:  To evaluate the short- and long-term orthodontic treatment (OT) expectations,
malocclusion severity, and oral health-related quality of life (OHRQoL) status of adolescent patients
using qualitative and quantitative methodology.
Materials and methods:  Adolescents (n  =  105; 42 males and 63 females) aged between 12 and
17  years participated in this interview and questionnaire-based study. The Psychosocial Impact
of Dental Aesthetics Questionnaire (PIDAQ) and the Oral Impacts on Daily Performances (OIDP)
scale evaluated OHRQoL status. Study casts were analysed using the Dental Aesthetics Index (DAI)
and the Index of Complexity, Outcome and Need (ICON). Mann–Whitney test and Spearman’s
correlations tested various univariate variables.
Results:  With similar index-determined OT need (DAI, P = 0.371 and ICON, P = 0.932) females tended
to have worse OHRQoL status (PIDAQ scores, P-values ranged from 0.006 to 0.0001 and scores
for the OIDP question related to smiling, laughing, and showing teeth without embarrassment,
P-value = 0.015). Occlusal index scores did not have statistically significant associations with the
OHRQoL scales. Better dental appearance was expected by 85 per cent of the adolescents in the
short-term and by 51 per cent in the long-term after OT. The associated psycho-social expectations
were: 1.  improved dental self-confidence, 2.  positive psychological impact/improved self-worth,
and 3. positive social impact.
Conclusions:  Female adolescent patients tended to experience worse psycho-social impacts
related to their malocclusions compared with males with similar index-determined OT need.
Index-determined OT need scores did not correlate with the OHRQoL scales. Adolescent patients
expected OT to improve their dental appearance and QoL aspects.

Introduction the psycho-social well-being of individuals (5). Importantly, the

above study used quality of life (QoL) instruments that do not meas-
The smile is considered a dynamic feature of facial and overall
ure oral health directly.
attractiveness and dental aesthetics is considered important for
The motive for OT might change between adolescence to adult-
self-esteem (1–4). A  prospective 20  year evaluation of the psycho-
hood and adolescents might face pressures from social norms which
social benefits of orthodontic treatment (OT) showed that OT may
could increase the desire for OT as an aesthetic adjustment strat-
improve self-esteem; however, many factors influence and maintain
egy rather than ‘true’ need (6, 7). This could explain why the dental

© The Author 2015. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
593
For permissions, please email: journals.permissions@oup.com
594
appearance concerns of adolescents are considered to be highly criti-
cal (8). In these circumstances, constructs such as self-esteem might
transiently improve. In contrast, other studies have found the ben-
efits of OT to impact individuals beyond better dental aesthetics and
that the QoL gains are long lasting (1, 9). Consequently, self-esteem
is considered a product of life experiences that develop as a person
matures (10). Huang conducted a meta-analysis of longitudinal stud-
ies to investigate the self-esteem mean-level changes from childhood
to adulthood. Self-esteem was considered a relatively stable con-
struct and the author compared self-esteem changes to a ‘treadmill’.
In other words, self-esteem changes had a tendency to relapse back
to an inherent self-esteem level (11).
Orthodontic treatment need is measured clinically using occlusal
indices that give priority to the most handicapping malocclusions.
An association reportedly exists between malocclusion severity and
dental appearance dissatisfaction (12). However, this is not a consist-
ent observation (13, 14) Therefore, it is not surprising that Albino
et  al. found that the perceived psycho-social impact of occlusal
features more strongly predicted OT need than severity (15). Two
commonly employed indices are the Dental Aesthetics Index (DAI)
(16) and the Index of Complexity, Outcome and Need (ICON) (17).
These indices are not designed to measure patient perceptions and
QoL. In contrast, some patients desire OT as a consequence of self-
perceived poor dental appearance and related psycho-social impacts
(18, 19).
A number of oral health-related quality of life (OHRQoL)
instruments have been developed. The Psychological Impact
of Dental Aesthetics Questionnaire (PIDAQ) was developed as
an OHRQoL psychometric instrument to evaluate perceived
impacts of dental aesthetic concerns on young adult ortho-
dontic patients (20). The Oral Impacts on Daily Performances
(OIDP) scale was developed by Adulyanon et  al. in 1996 for
Thai adults and subsequently applied to different populations
and languages (21–23). The OIDP is based on a modified World
Health Organization (WHO) model and quantifies oral impacts
by evaluating the frequency and severity scores for different
daily activities (24, 25).
The discrepancy between index-determined OT need (objective)
and patient-perceived (subjective) OT need highlights the importance
of communication in orthodontics. Kiyak stated: ‘It behooves the
general dentist and orthodontist to listen carefully to each patient’s
understanding of his or her malocclusion and its impact on QoL
domains, including oral function, appearance, social acceptance and
emotional well-being’ (26).
Female adolescent patients may experience worse psycho-social
impacts compared with males having similar index-determined OT
need. However, the evidence is inconclusive (12, 27). The media tend
to emphasise the importance of appearance in relation to identity,
attractiveness, and success and there is increasing sexualization
and objectification of male and female bodies in the media (28).
Therefore, the impact of malocclusion on gender could change over
time and should be evaluated.
During adolescence, young people develop their social iden-
tity, self-image, and self-worth (29) and are least capable of mak-
ing objective and detached assessments of their appearance (30). In
addition, body image and dental appearance awareness increases
with age (31) and could explain why dental appearance dissatisfac-
tion increases with increasing age (32). However, this has been an
inconsistent finding in the literature (33). Appearance perceptions
may change over time (29) and, therefore, adolescent perceptions
should be evaluated.
European Journal of Orthodontics, 2016, Vol. 38, No. 6
Social and appearance norms set by friends and peers may
impact on individuals significantly, especially when these norms are
enforced through teasing (34, 35). Moreover, appearance norms and
the ‘beauty culture’ are upheld in the media (36). Parents often feel
obligated to provide the best care for their children and tend to be
more critical of their child’s teeth. Therefore, parents may initiate OT
and have a stronger desire for OT than their child (37). There may be
a strong link between OT desire and expectations. It is not surprising
that children and their parents expect OT to improve oral health,
function, and self-esteem (38). In addition, parents may expect more
improved self-image, oral function, and social life compared with
their children (39). There is limited qualitative information available
on patient and parent OT expectations.
A recent systematic review encouraged future research to com-
bine qualitative and quantitative methodology to provide new
insights on how malocclusions might affect the OHRQoL of chil-
dren and adolescents (40). Therefore, the aims of the present study
were to evaluate adolescent patients’ OT expectations, malocclusion
severity, and OHRQoL status by assessing two subjective and two
objective measures and using qualitative methodology. The study
sought answers to the following questions:
1. Are there any gender differences related to DAI, ICON, PIDAQ,
and OIDP scores?
2. What are the associations between OHRQoL status of individu-
als (measured by PIDAQ and OIDP) and respective DAI or ICON
scores?
3. What are the short- and long-term OT expectations of adolescent
patients?
Materials and methods
Approval for this cross-sectional and interview-based study was
granted by the Women’s and Children’s Health Network, Human
Research Ethics Committee WCHN HREC (HREC/13/WCHN/133).
The sample comprised eligible adolescent patients, between
12 and 17 years, referred for specialist OT at the Adelaide Dental
Hospital (ADH) where eligibility for OT was determined by a valid
South Australian health care concession card (41) and relevant clini-
cal factors (Figure 1). Subjects were recruited during the consultation
process prior to OT (Figure 2) and access to specialist OT was not
influenced by an unwillingness to participate.
The purpose of the research project and the procedures involved
with the interviews were discussed with each patient and parent/
guardian. All were given a detailed information sheet, including a
copy of the consent form. Participation was voluntary, no incen-
tives were offered and there was an opportunity to ask questions
related to the study. Written consent was obtained, including the use
of existing study casts, but patients were free to withdraw consent
at any stage.
All interviews were conducted in a room annexed to the ortho-
dontic clinic. The interviews took approximately 30 minutes to
complete and consisted of questionnaires and audio-recorded face-
to-face discussions (Figure 2).
Each participant was instructed to answer all questions indepen-
dently and research staff were available to address possible queries
without coaching. Subsequently, open-ended questions related to
their OT expectations were asked. These questions were printed in
the questionnaire booklet as a template. An Olympus DS 4000™
digital audio-recorder was used to record patient responses and
recordings were coded to protect the privacy of patients at data entry
and reporting.
E. Twigge et al. 595

Figure 1.  Flowchart explaining the selection criteria to receive public funded OT. IOTN, Index of Orthodontic Treatment Need (42); DAI, Dental Aesthetic Index (16).

Figure 2.  Participant recruitment and interview component flowchart. ICON (Index of Complexity, Outcome and Need) (17) PIDAQ (Psychosocial Impact of Dental
Aesthetic Questionnaire) (20), OIDP (Oral Impacts on Daily Performances) (21).

Two quantitative scales, PIDAQ (20) and OIDP (21), were self-confidence subscale scores were reverse-scored/converted to
applied to assess patient-perceived OHRQoL impacts asso- allow all of the questions to score in a positive direction. For
ciated with their malocclusion. The PIDAQ questions were OIDP questions, the wordings were derived from the adult (21)
asked in accordance with Klages et  al. (20). The PIDAQ dental and child-OIDP (43) scales. Positive answers to OIDP questions
596 European Journal of Orthodontics, 2016, Vol. 38, No. 6

were followed with frequency and severity questions suggested by Participants represented different ethnic groups: Anglo-
Adulyanon et al. (21). Australian (75 per cent), Vietnamese (6 per cent), Iraqi (3 per cent),
Two open-ended questions, which were audio-recorded for tran- Greek (2 per cent), Filipino (2 per cent), Cambodian (2 per cent),
scription, were asked: other (10 per cent) and came from 48 different Adelaide metro-
politan areas and 15 country areas. The majority of patients (69
1. “What immediate benefits do you expect from orthodontic treat- per cent) had OT need defined as ‘highly desirable’ or ‘mandatory’
ment like braces?” according to the DAI (Table 1). The use of ICON cut-offs for sever-
2. “What benefits do you expect from orthodontic treatment like ity and complexity scores, 94 per cent of the cases needed OT, and
braces in the long-term?” 69.5 per cent of cases were either difficult or very difficult (Table 1).
The DAI (16) and ICON (17) instruments were used to measure There were no statistically significant differences between male
objective OT need. The first author (ET) was calibrated to the ‘gold’ and female DAI (P = 0.371) and ICON (P = 0.932) scores (Table 2).
standard in the use of the DAI and ICON indices. Fifteen study casts Therefore, any differences found between male and female sub-
were randomly selected by a third party using a random number jective OT need would not be attributable to different malocclu-
generator program to test intra-rater repeatability. The first author sion severities. There were significant differences between males
was blinded to the process and repeated the study cast measurements and females for all PIDAQ variables (P-value ranged from 0.006
at least weeks after the initial measurements. Using Bland-Altman to 0.0001) as well as one OIDP question related to smiling, laugh-
plots for DAI and ICON, 12 out of 15 measurements were within ing, and showing your teeth without embarrassment (question 5,
1 SD for the DAI (SD of 1.6 ) and 10 out of 15 measurements were P  =  0.015) (Table  3). None of the participants considered their
within 1 SD for ICON (SD of 5.1 ). Twenty consecutive participants mouth or teeth to impact upon one OIDP daily performance: ‘car-
were asked to repeat the OIDP and PIDAQ questionnaires at least 2 rying out major work or social role’ such as studying or doing
weeks after the initial interview. Thirteen participants returned the homework.
questionnaires. The test–retest agreement for OIDP was 92 per cent When PIDAQ variables were correlated to OIDP variables, DAI
using a binary approach. PIDAQ test–retest scores were all within 2 and ICON, only OIDP questions five and eight related to smiling,
SDs of the mean using Bland-Altman plots (SD of 2.8). laughing, and showing teeth without embarrassment (r  =  0.54–
The overall Cronbach alpha (CA) for OIDP was 0.59 and ranged 0.67, P ≤0.0001) and enjoying contact with people (r = 0.19–0.29,
from 0.46 to 0.62 for the individual questions. The overall CA for P  =  0.05–0.002) respectively as well as the OIDP total score
PIDAQ was 0.94, the CA for the subscales were: dental self-confi- (r  =  0.35–0.43, P  =  0.003 to <0.0001) showed significance for all
dence (0.87), social impact (0.88), psychological impact (0.82), and PIDAQ variables. The two OIDP questions considered the psycho-
aesthetic concern (0.91). social impact malocclusion had on individuals (Table 4).
There were no statistically significant associations between OIDP
variables, DAI and ICON scores, except between ICON and OIDP
Data analysis
totals (r = 0.19, P = 0.05) and between DAI and ICON total scores
Categorical data were analysed for associations using the Mann–
(r = 0.51, P ≤ 0.001) (Table 5).
Whitney test. Numerical data were analysed for associations using
The content analysis results are summarized in Figure 3 and are
Spearman’s correlations. Significance was set at P = 0.05 and correla-
discussed under separate headings.
tion strengths were interpreted according to Cohen. (44) The statisti-
cal analyses were completed using SAS V9.3 (SAS Institute Inc., Cary,
North Carolina, USA). Regarding the qualitative data, the first author Table 1.  Distribution of the orthodontic treatment need and treat-
(ET) transcribed the recorded answers to the two open-ended ques- ment complexity according to the DAI and ICON scores. Modified
tions for content analysis. The aim of content analysis was to gain from Jenny and Cons (45) and Richmond (46). DAI, Dental Aesthet-
insight into perceived short- and long-term treatment expectations ics Index; ICON, Index of Complexity, Outcome and Need.
of adolescent orthodontic patients. Without a starting hypothesis, the
DAI total score
aim was to generate a theory derived from empirical data based on (severity level) n (%) Treatment need definition
the two open-ended questions. Participants’ responses were analysed,
coded, compared, and conceptualized. Similar descriptions were ≤25 6 5.7 No or slight treatment need
grouped into categories to identify general patterns within the data. 26–30 30 28.6 Treatment is elective
The first (ET) and second (RR) authors applied the content analysis 31–35 33 31.4 Treatment is highly desirable
methodology independently. They used the interview responses of 15 ≥36 36 34.3 Treatment is mandatory
       
participants and there was excellent agreement between the authors.
ICON total score n (%) Treatment need definition
(severity level)
Results
<43 6 5.7 Elective need
From December 2013 to August 2014, 411 new patients aged between ≥43 99 94.3 Treatment need
12 and 17 years presented for an orthodontic consultation. Of these,        
105 volunteered to participate in the study, but five refused consent to
ICON total score n (%) Complexity definition
have their voice recorded and were excluded from the content analy- (complexity level)
sis. None of the questionnaire questions remained unanswered.
Forty-two male and 63 female patients aged 12.3–17.8  years <29 1 1 Easy
29–50 14 13.3 Mild
participated.
51–63 17 16.2 Moderate
The mean age ( X ) and standard deviation for males were ( X
64–77 32 30.5 Difficult
15.5 years; SD 1.4 years) and for females were ( X 15.4 years; SD >77 41 39 Very difficult
1.5 years).
E. Twigge et al. 597

Expected short-term (only) benefits
Better oral function and oral hygiene
Eight per cent of patients thought that OT would improve oral func-
tion such as better speech, better chewing, or the prevention of tooth
grinding. Similarly, a number of patients thought that OT would
help them clean their teeth better (7 per cent). Quotes from the inter-
views support this:
‘…Hopefully, with me stop grinding, it may stop the irri-
tating weird biting and stuff’.

‘Besides benefits like being able to clean them and being able
Table  2. Associations involving gender, ICON scores and DAI to eat and have better speech, I think it will definitely impact
scores using the Mann–Whitney test. DAI, Dental Aesthetics Index; how I  react and, you know, socialise with people. Even
ICON, Index of Complexity, Outcome and Need. though I  am awkward by personality, I  think having teeth
Sex Mean Std. Dev Median Min Max P-value that are not worrying me will make me less likely to back out
of situations where I might be able to accomplish something’.
DAI scores Female 33.7 5.7 32.8 23.8 48 0.371
Male 36.3 9.3 33.4 23.3 59.4 ‘If I  do not get braces, some teeth will probably rot
ICON scores Female 71.1 16.9 73 38 114 0.932 (decay), because I will not be able to clean them properly’.
Male 70.2 17.9 69.5 17 97

Expected long-term (only) benefits

Table 3.  Associations involving gender and PIDAQ and OIDP vari- Prevent future problems with teeth
ables using the Mann–Whitney test for categorical data. PIDAQ, A number of participants thought that OT would help prevent the
Psychosocial Impact of Dental Aesthetics Questionnaire; OIDP, Oral deterioration of their dentition in the long-term (22 per cent). This
Impacts on Daily Performances. category included patients with agenesis of permanent teeth who
did not want ongoing dental treatment or maintenance. In addition,
Variable Female (N = 63) Male (N = 42) P-value
some participants thought that OT would provide motivation to
Mean Std. Dev Mean Std. Dev   look after their teeth better. Quotes from the interviews support this:

PIDAQ: dental self- 17.1 4.9 14.8 3.9 0.006* ‘If I have a better bite, my teeth will probably not wear
confidence down that much and I will therefore have less problems
PIDAQ: social impact 14.3 8 9.2 5.8 0.001* in the future’.
PIDAQ: psychological 15.2 5.1 12.1 3.7 0.0005*
impact ‘I will be able to keep my teeth for longer and my mouth
PIDAQ: aesthetic 8 3.8 5.4 3.1 0.0002* will stay healthier and it will help me to keep them in bet-
concern
PIDAQ total score 54.6 18.8 41.4 12.7 0.0001*
ter shape as I will have more motivation’.
OIDP Q1 1.1 3 1.4 3.5 0.379
OIDP Q2 1 3.4 1.7 4.4 0.902 Avoid getting braces later
OIDP Q3 4 6.9 2 4.3 0.252 Some participants thought that getting braces now (during adoles-
OIDP Q4 0.9 3.4 1.3 3.9 0.465 cence) was easier or better compared with having braces as an adult
OIDP Q5 7 8.1 3.2 6.1 0.015* (8 per cent). For some adolescents, having OT now would allow
OIDP Q6 1.7 4.4 0.3 0.9 0.189 them to live life without worrying about the straightness of their
OIDP Q7 0 0 0 0 0
teeth or have OT later. Quotes from the interviews support this.
OIDP Q8 1.7 4.3 0.5 1.9 0.13
OIDP total 8.7 10.4 5.3 5.7 0.372 ‘I do not have to get braces as an adult.’
‘I will not have to worry, at the back of my head all the
*Statistically significant.
time, that I need to get them (teeth) done’.

Table 4.  Spearman’s correlation was applied to assess the univariate associations between PIDAQ variables, OIDP questions, DAI and ICON
scores. DAI, Dental Aesthetics Index; ICON, Index of Complexity, Outcome and Need; PIDAQ, Psychosocial Impact of Dental Aesthetics
Questionnaire; OIDP, Oral Impacts on Daily Performances.

Variable OIDP Q1 OIDP Q2 OIDP Q3 OIDP Q4 OIDP Q5 OIDP Q6 OIDP Q7 OIDP Q8 OIDP total DAI ICON

PIDAQ: dental self-confidence 0.03 0.09 0.16 0.02 0.58 0.1 0 0.29 0.35 0.13 0.16
P-value 0.73 0.34 0.1 0.86 <0.0001* 0.32 0 0.002* 0.0003* 0.18 0.1
PIDAQ: social impact 0.05 0.08 0.15 0.07 0.58 0.05 0 0.26 0.39 0.05 0.14
P-value 0.62 0.4 0.12 0.46 <0.0001* 0.59 0 0.01* <0.0001* 0.59 0.17
PIDAQ: psychological impact 0.01 0.03 0.18 0.03 0.54 0.02 0 0.19 0.37 -0.03 0.18
P-value 0.9 0.75 0.07 0.78 <0.0001* 0.84 0 0.05* 0.0001* 0.8 0.07
PIDAQ: aesthetic concern 0.003 0.06 0.13 0.12 0.57 0.08 0 0.25 0.37 0.03 0.01
P-value 0.98 0.52 0.18 0.22 <0.0001* 0.41 0 0.01* <0.0001* 0.77 0.93
PIDAQ total 0.02 0.07 0.17 0.07 0.67 0.06 0 0.29 0.43 0.06 0.15
P-value 0.81 0.48 0.09 0.49 <0.0001* 0.53 0 0.003* <0.0001* 0.55 0.13

*Statistically significant.
598 European Journal of Orthodontics, 2016, Vol. 38, No. 6

“I think getting it done now is better than doing it after impact’ which increased. Quality of life expectations, associated
20 years”. with ‘better dental appearance’, varied from a single expectation to
any combination of expectations (Figure 4).
Expected short- and long-term benefits:
No perceived benefits Improved dental self-confidence
The percentage of participants who did not perceive any benefits It was expected that better dental appearance would improve ‘dental
from OT increased from short-term (11 per cent) to long-term (19 self-confidence’ in the short-term (overall 59 per cent, F 60 per cent,
per cent). and M 58 per cent) and in the long-term (overall 23 per cent, F 23 per
cent, and M 23 per cent). For many adolescents, the QoL impact of
poor dental appearance was related to daily activities such as smiling,
Better dental appearance
laughing, and talking. Poor dental appearance was perceived as restric-
Better dental appearance was the predominant short-term [85 per
tive and this affected the way they acted in public. Some of the coping
cent overall, females (F) 85 per cent, and males (M) 85 per cent] and
strategies employed were covering their smiles with their hands and
long-term (51 per cent overall, F 55 per cent, and M 45 per cent)
consciously avoiding smiling. Quotes from the interviews support this:
OT expectation. Better dental appearance was associated with three
aspects of QoL (‘improved dental self-confidence’, ‘positive psycho- ‘I will be more confident with my teeth and probably
smile more, I guess. In photos as well, I will look better’.
Table 5.  Spearman’s correlation was applied to assess the univari- ‘I will feel more confident about smiling in photos and
ate associations between OIDP variables, DAI and ICON scores.
I do not have to worry about not showing my teeth when
DAI, Dental Aesthetics Index; ICON, Index of Complexity, Outcome
and Need; OIDP, Oral Impacts on Daily Performances. I talk to people and I do not have to feel embarrassed or
uncomfortable. I  usually, without braces, I  do not show
Variable DAI total scores ICON total scores
my teeth and I  try to hide them. With braces, I  will be
OIDP Q1 −0.05 0.02 more confident showing my teeth and smile more often’.
P-value 0.62 0.85
OIDP Q2 0.03 0.12
P-value 0.76 0.21 Positive psychological impact (improved self-worth)
OIDP Q3 0.004 0.18 It was expected that better dental appearance would have ‘positive
P-value 0.97 0.07 psychological impact’ in the short-term (overall 50 per cent, F 49 per
OIDP Q4 −0.1 0.01 cent, and M 55 per cent) and in the long-term (overall 27 per cent,
P-value 0.31 0.94 F 33 per cent, and M 18 per cent). Poor dental appearance impacted
OIDP Q5 0.11 0.15 on some adolescents on a deeper and more personal level, affecting
P-value 0.26 0.14 the domains of self-worth and psychological well-being. Adolescents
OIDP Q6 0.14 0.12
expected OT to improve their dental appearance and, therefore, help
P-value 0.16 0.22
them to be bolder and more confident individuals. Some adolescents
OIDP Q7 0 0
P-value 0 0
expected less teasing and feelings of being judged. In addition, better
OIDP Q8 0.14 0.12 dental appearance was thought to induce feelings of happiness and
P-value 0.15 0.22 content and reduced feelings of stress and worry. Quotes from the
OIDP Total 0.05 0.19 interviews support this:
P-value 0.6 0.05*
DAI total score — 0.51 ‘Just instant better confidence and better self-esteem. Just
P-value — <0.001* as if relief has come over me, like as I  am happy about
them (teeth) and I do not have to worry about them any-
*Statistically significant.
more’.
‘It will give me more confidence in myself and boost my
self-esteem more.”

“Well, like self-esteem wise…I think it will be better

because, like my friends, like, some of my friends say stuff
about it (teeth) and that will not happen anymore’.

Figure  3.  Content analysis showing the overall short- and long-term
expectations of OT and for males (M) and females (F). Some participants had
more than one short- or long-term expectation.
logical impact or improved self-worth’, and ‘positive social impact’)
(Figure  4). Perception of better dental appearance and improved
QoL decreased from short- to long-term except for ‘positive social
Positive social impact
It was expected that better dental appearance would have ‘positive
social impact’ in the short-term (overall 23 per cent, F 22 per cent,
and M 25 per cent) and in the long-term (overall 18 per cent, F 18 per
cent, and M 18 per cent). Some adolescents expected OT to improve
not only the appearance of their teeth but also their social life, rela-
tionships, ability to interact, and to make better first impressions.
In addition, better looking teeth were thought to make them more
presentable for work-related interviews with a better chance of get-
ting a job. Some participants thought that better dental appearance
E. Twigge et al.
Figure  4.  The overall short-term and long-term QoL expectations of
adolescents associated with better dental appearance after OT.
would make them fit in better, be more acceptable, make them more
attractive and be more confident going out in public. Quotes from
the interviews support this:
‘I think socially definitely beneficial, because like I said before,
I feel it (teeth) make me look younger than I actually am, so
it (braces) will help me look more mature, probably, I can say,
more accepted, maybe a little bit more attractive, yah’.
‘I will have confidence talking in front of people and I will
feel better when I  am working. I  want to be a barista,
so that means I have to serve people coffees and I…they
are going to look at me and I will have to smile and they
(teeth) will be nice’.
Discussion
The present study evaluated the orthodontic perceptions of 12- to
17-year-old adolescent patients and aimed to address three research
questions. Two OHRQoL scales (PIDAQ and OIDP) and two
occlusal indices (DAI and ICON) were utilized to address these
questions. Statistically significant associations were shown between
PIDAQ variables and OIDP questions; however, the strength of the
correlations varied from small to large. The OIDP question five
related to smiling, laughing, and showing teeth without embarrass-
ment showed large correlations. In addition, OIDP question eight
related to enjoying contact with other people showed small correla-
tions and OIDP final scores showed medium correlations. For these
variables, the two OHRQoL scales were comparable. Although the
occlusal indices have different scoring criteria, ICON and DAI were
able to identify malocclusions with similar OT need. Therefore, the
association between ICON and DAI final scores were statistically
significant.
The PIDAQ is an orthodontic-specific psychometric OHRQoL
scale developed to measure dental appearance impacts and per-
ceptions of young adults (20). However, the OIDP is a descriptive
OHRQoL scale which is not specifically designed for orthodontic
patients (21). This could explain the low OIDP CA values. In addi-
tion, the adolescent patients, in the present study, are predominantly
dentally fit. Males and females had similar index-determined occlusal
scores (DAI and ICON total scores); however, females had statisti-
cally higher OHRQoL scores (all PIDAQ scores) and scores for
one OIDP question related to smiling, laughing, and showing teeth
without embarrassment (OIDP question five). The fact that only
one OIDP question (which related to the psycho-social impact of
poor dental appearance) showed a gender difference, illustrates how
index/scale selection can influence study outcomes and conclusions
599
and potentially introduce bias. Therefore, it appears that malocclu-
sions of similar severity might have significantly more psycho-social
impact on females compared with males. This confirms results of a
study by Christopherson et al. who used the Index of Orthodontic
Treatment Need (IOTN) and a modified version of the Michigan
Oral Health-Related Quality of Life Scale - Child version (27) to
assess the objective, subjective, and self-assessed OT need. Girls were
found to experience worse OHRQoL and desire OT more compared
with boys with similar index-determined OT need.
The age range between the participants was only 5  years.
Therefore, correlations with age were not a primary outcome
measure and the results were not included in the tables. However,
there were no statistically significant associations between
OHRQoL status (measured using PIDAQ and OIDP) and increas-
ing age. Therefore, the present study does not agree with pre-
vious reports that dental appearance dissatisfaction increases
(decreased OHRQoL) with increasing age (32). However, the pre-
sent study is supported by Marques et al. who also used the OIDP
in a larger sample of Brazilian schoolchildren but of a younger
age range (33). The authors found that OHRQoL status was not
age-dependent.
Although the DAI and ICON index scores were statistically sig-
nificant, there were no statistically significant associations between
OHRQoL variables and occlusal index scores, except OIDP total
scores and ICON total scores. However, the association was small.
Therefore, a discrepancy exists between subjective and objective
(index-determined) OT need. This is consistent with the report by de
Oliveira and Sheiham, who used IOTN, OIDP, and the Oral Health
Impacts Profile (OHIP-14) (14).
Although the present study revealed that females had a worse
OHRQoL status compared with males having similar index-
determined occlusal scores, there was no conclusive evidence that
higher index-determined occlusal scores (increased severity) caused
worse OHRQoL experiences. This could be explained by the fact
that no controls were used to compare results and the correlation
between OIDP and ICON final scores was small. Therefore, on a
group level, the inference was that poor dental appearance could
have OHRQoL impacts on some adolescents, especially the psy-
cho-social domains. On an individual level, the present study used
qualitative methodology to gain insight into how malocclusions
might affect adolescents.
The qualitative results indicated that most adolescent patients
expected ‘better dental appearance’ in the short- and long-term after
OT. In addition, ‘better dental appearance’ included psycho-social
benefits such as ‘improved dental self-confidence’, ‘positive psycho-
logical impact/improved self-worth’, and ‘positive social impact’.
Interestingly, the perceived expectations decreased from short- to
long-term, except for ‘positive social impact’. The qualitative results
indicated that participants did not expect OT to have a long-lasting
effect on psycho-social aspects such as dental self-confidence and
self-esteem. This was in concordance with previous studies (5, 11).
The adolescents in the present study expected better dental
appearance to have a positive social impact in the long-term, rather
than in the short-term. The short-term OT expectations of 12- to
17-year-old adolescents might be to acquire better dental appear-
ance and to be socially accepted by friends and peers. Therefore, OT
may an aesthetic adjustment strategy during the adolescent years for
some adolescents. In the long-term, OT expectations might be related
to future events such as job interviews for which these individuals
would like to make a good first impression. This is in concord-
ance with a study on young adults who perceived dental aesthetics
600
important for employment prospects (29). Moreover, employers are
more likely to employ individuals with optimal dental aesthetics
(8). Therefore, adolescents’ desire for OT and better dental appear-
ance might be for immediate psycho-social needs as well as long-
term social needs. Interestingly, some adolescents do not expect any
short- or long-term benefits from OT. For these, the need for OT may
have been expressed by the referring dentist or the parent/guard-
ian and not the adolescent him/herself. In addition, these particular
adolescents may be satisfied with their current dental appearance
and function status. Future research could include the opinions of
parents/guardians regarding OT for their children using qualitative
methodology. Interestingly, there were no obvious gender differences
for most of the qualitative variables, especially the QoL expectations
associated with better dental appearance. This observation did not
support the quantitative results; however, a direct comparison was
not achievable as the qualitative and quantitative evaluations were
not analytically compatible.
The PIDAQ and OIDP scales were used in this study, although
use of adult OHRQoL instruments for children and adolescents has
not been recommended (47). Both PIDAQ and OIDP are commonly
used OHRQoL instruments in the literature and PIDAQ has been
used with adolescents (48, 49). In addition, no OHRQoL instru-
ment was available for orthodontic adolescent patients between 12
and 17 years when the study was conducted. A researcher was pre-
sent during all the interviews to ensure that all the questions were
understood. Moreover, if the adolescents were to be re-examined in
the future (longitudinally), most of the adolescents would be over
18 years and the same scales could be used.
The study had several limitations as the results were based on
cross-sectional data. A  follow-up study would be invaluable to
elicit the long-term effects. The present study did not formally test
the validity of PIDAQ and OIDP scales for South Australians. In
addition, little is known about the stability of these scales over
time and could be a study objective of future projects. Furthermore,
an orthodontic OHRQoL instrument, suitable for adolescents and
adults, would be a useful asset to the profession and would allow
future cross-sectional or longitudinal studies to be compared.
The strengths of the study include a qualitative evaluation of
patient perceptions regarding short- and long-term OT expectations.
In addition, two OHRQoL scales and two occlusal indices were used
to better interpret the subjective and objective ratings of treatment
need. The combination of qualitative and quantitative methodology
was able to provide useful information on how malocclusions affect
the OHRQoL of adolescent patients.
Conclusions
• With similar index-determined occlusal scores compared with
male adolescent patients, females tended to experience worse
OHRQoL. However, the short- and long-term QoL expectations
after OT was similar for both genders.
• There was statistically significant associations between DAI and
ICON index scores and were considered comparable. Similarly,
PIDAQ had statistically significant associations with two OIDP
questions related to the psycho-social impact of malocclusions and
the OIDP final scores. For these domains, PIDAQ and OIDP were
comparable. However, the correlation strength varied between
small and large.
• Subjective OT need measures (PIDAQ and OIDP) did not have
significant associations with objective OT need measures (DAI and
ICON).
European Journal of Orthodontics, 2016, Vol. 38, No. 6
• Better dental appearance was expected by 85 per cent of adoles-
cents in the short-term and 51 per cent of adolescents in the long-
term after OT. Different psycho-social expectations related to bet-
ter dental appearance were: (a) improved dental self-confidence,
(b) positive psychological impact/improved self-worth, and (c)
positive social impact.
• The present study promoted an individualized approach to ortho-
dontic patient management and the importance of good commu-
nication.
Acknowledgments
The authors would like to thank the Data Management and Analysis Centre
(DMAC) of the University of Adelaide for statistical support.
Funding
The authors would like to thank the Australian Society of Orthodontists,
Foundation for Research and Education (ASOFRE) for their financial support.
References
1. Palomares, N.B., Celeste, R.K., de Oliveira, B.H. and Miguel, J.A.M.
(2012) How does orthodontic treatment affect young adults’ oral health-
related quality of life? American Journal of Orthodontics and Dentofacial
Orthopedics, 141, 751–758.
2. Havens, D.C., McNamara, J.A., Jr, Sigler, L.M. and Baccetti, T. (2010) The
role of the posed smile in overall facial esthetics. The Angle Orthodontist,
80, 322–328.
3. Henson, S.T., Lindhauer, S.J., Gardner, W.G., Shroff, B., Tufekci, E. and
Best, A.M. (2011) Influence of dental esthetics on social perceptions of
adolescents judged by peers. American Journal of Orthodontics and
Dentofacial Orthopedics, 140, 389–395.
4. Shaw, W.C., Rees, G., Dawe, M. and Charles, C.R. (1985) The influence
of dentofacial appearance on the social attractiveness of young adults.
American Journal of Orthodontics, 87, 21–26.
5. Shaw, W.C., Richmond, S., Kenealy, P.M., Kingdon, A. and Worthington,
H. (2007) A 20-year cohort study of health gain from orthodontic treat-
ment: psychological outcome. American Journal of Orthodontics and
Dentofacial Orthopedics, 132, 146–157.
6. Sheats, R.D., Gilbert, G.H., Wheeler, T.T. and King, G.J. (1995) Pilot study
comparing parents' and third-grade schoolchildren's attitudes toward
braces and perceived need for braces. Community Dentistry and Oral Epi-
demiology, 23, 36–43
7. Trulsson, U., Strandmark, M., Mohlin, B. and Berggren, U. (2014) A quali-
tative study of teenagers’ decisions to undergo orthodontic treatment with
fixed appliances. Journal of Orthodontics, 29, 197–204.
8. Pithon, M.M., Nascimento, C.C., Barbosa, G.C.G. and da Silva Coque-
iro, R. (2014) Do dental esthetics have any influence on finding a job?
American Journal of Orthodontics and Dentofacial Orthopedics, 146,
423–429.
9. Tatarunaite, E., Playle, R., Hood, K., Shaw, W. and Richmond, S. (2005)
Facial attractiveness: a longitudinal study. American Journal of Orthodon-
tics and Dentofacial Orthopedics, 127, 676–682.
10. Helm, S., Kreiborg, S. and Solow, B. (1985) Psychosocial implications of
malocclusion: a 15-year follow-up study in 30-year-old Danes. American
Journal of Orthodontics, 87, 110–118.
11. Huang, C. (2010) Mean-level change in self-esteem from childhood
through adulthood: Meta-analysis of longitudinal studies. Review of Gen-
eral Psychology, 14, 250–260.
12. Moura, C., Cavalcanti, A.L., Gusmao, E.S., de Souza Coelho Soares, R.,
Cavalcante Moura, F.T. and Hordonho Santillo, P.M. (2013) Negative
self-perception of smile associated with malocclusions among Brazilian
adolescents. European Journal of Orthodontics, 35, 483–490.
13. Shaw, W.C. (1981) Factors influencing the desire for orthodontic treat-
ment. European Journal of Orthodontics, 3, 151–162.
 E. Twigge et al.
14. de Oliveira, C.M. and Sheiham, A. (2003) The relationship between nor-
mative orthodontic treatment need and oral health-related quality of life.
Community Dentistry and Oral Epidemiology, 31, 426–436.
15. Albino, J.E., Cunat, J.J., Fox, R.N., Lewis, E.A., Slakter, M.J. and Tedesco,
L.A. (1981) Variables discriminating individuals who seek orthodontic
treatment. Journal of Dental Residence, 60, 1661–1667.
16. Cons, N.C., Jenny, J. and Kohout, F.J. (1986) DAI: The Dental Aesthetic
Index. College of Dentistry, University of Iowa, Iowa City, IA.
17. Daniels, C. and Richmond, S. (2000) The development of the index of com-
plexity, outcome and need (ICON). Journal of Orthodontics, 27, 149–162.
18. Bernabé, E. and Flores-Mir, C. (2006) Orthodontic treatment need in Peru-
vian young adults evaluated through dental aesthetic index. The Angle
Orthodontist, 76, 417–421.
19. Hamdan, A.M., Al-Omari, I.K. and Al-Bitar, Z.B. (2007) Ranking den-
tal aesthetics and thresholds of treatment need: a comparison between
patients, parents, and dentists. European Journal of Orthodontics, 29,
366–371.
20. Klages, U., Claus, N., Wehrbein, H. and Zentner, A. (2006) Development
of a questionnaire for assessment of the psychosocial impact of dental aes-
thetics in young adults. European Journal of Orthodontics, 28, 103–111.
21. Adulyanon, S., Vourapukjaru, J. and Sheiham, A. (1996) Oral impacts
affecting daily performance in a low dental disease Thai population. Com-
munity Dentistry and Oral Epidemiology, 24, 385–389.
22. Tsakos, G., Marcenes, W. and Sheiham, A. (2001) Evaluation of a modified
version of the index of Oral Impacts On Daily Performances (OIDP) in elderly
populations in two European countries. Gerodontology, 18, 121–130.
23. Astrøm, A.N., Haugejorden, O., Skaret, E., Trovik, T.A. and Klock, K.S.
(2005) Oral impacts on daily performance in Norwegian adults: validity,
reliability and prevalence estimates. European Journal of Oral Sciences,
113, 289–296.
24. World Health Organization G. (1994) International Classification of
Impairments, Disabilities, and Handicaps: A  Manual of Classification
Relating to the Consequences of Disease. ERIC Clearinghouse, Geneva,
Switzerland.
25. Locker, D. (1988) Measuring oral health: a conceptual framework. Com-
munity Dental Health, 5, 3–18.
26. Kiyak, H.A. (2008) Does orthodontic treatment affect patients' quality of
life? Journal of Dental Education, 72, 886–894.
27. Christopherson, E.A., Briskie, D. and Inglehart, M.R. (2009) Objective,
subjective, and self-assessment of preadolescent treatment need--a func-
tion of age, gender, and ethnic/racial background? Journal of Public
Health Dentistry, 69, 9–17.
28. Reichert, T., Lambiase, J., Morgan, S., Carstarphen, M. and Zavoina, S.
(1999) Cheesecake and beefcake: no matter how you slice it, sexual explic-
itness in advertising continues to increase. Journalism and Mass Commu-
nication Quarterly, 76, 7–20.
29. Josefsson, E., Lindsten, R. and Hallberg, L.R. (2010) A qualitative study
of the influence of poor dental aesthetics on the lives of young adults. Acta
Odontologica Scandinavica, 68, 19–26.
30. Albino, J.E. (1983) Psychological aspects of oral conditions and treat-
ments. Clinical Preventive Dentistry, 5, 21–28.
31. Espeland, L.V. and Stenvik, A. (1991) Perception of personal dental
appearance in young adults: relationship between occlusion, awareness,
View publication stats
601
and satisfaction. American Journal of Orthodontics and Dentofacial
Orthopedics, 100, 234–241.
32. Bos, A., Hoogstraten, J. and Prahl-Andersen, B. (2003) Expectations of
treatment and satisfaction with dentofacial appearance in orthodontic
patients. American Journal of Orthodontics and Dentofacial Orthopedics,
123, 127–132.
33. Marques, L.S., Ramos-Jorge, M.L., Paiva, S.M. and Pordeus, I.A. (2006)
Malocclusion: esthetic impact and quality of life among Brazilian school-
children. American Journal of Orthodontics and Dentofacial Orthopedics,
129, 424–427.
34. Shaw, W., Meek, S. and Jones, D. (1980) Nicknames, teasing, harassment
and the salience of dental features among school children. Journal of
Orthodontics, 7, 75–80.
35. Seehra, J., Fleming, P.S., Newton, T. and DiBiase, A.T. (2011) Bullying in
orthodontic patients and its relationship to malocclusion, self-esteem and
oral health-related quality of life. Journal of Orthodontics, 38, 247–256.
36. Tiggemann, M. and Pickering, A.S. (1996) Role of television in adolescent
women's body dissatisfaction and drive for thinness. The International
Journal of Eating Disorders, 20, 199–203.
37. Hamdan, A.M. (2004) The relationship between patient, parent and clini-
cian perceived need and normative orthodontic treatment need. European
Journal of Orthodontics, 26, 265–271.
38. Bennett, M.E., Michaels, C., O'Brien, K., Weyant, R., Phillips, C. and Dry-
land K. (1997) Measuring beliefs about orthodontic treatment: a question-
naire approach. Journal of Public Health Dentistry, 57, 215–223
39. Tung, A.W. and Kiyak, H.A. (1998) Psychological influences on the timing
of orthodontic treatment. American Journal of Orthodontics and Dentof-
acial Orthopedics, 113, 29–39.
40. Dimberg, L., Arnrup, K. and Bondemark, L. (2015) The impact of maloc-
clusion on the quality of life among children and adolescents: a system-
atic review of quantitative studies. European Journal of Orthodontics, 37,
238–247.
41. www.humanservices.gov.au/customer/subjects/concession-and-health-
care-cards (2 December 2015, date last accessed)
42. Brook, P.H. and Shaw, W.C. (1989) The development of an index of ortho-
dontic treatment priority. European Journal of Orthodontics, 11, 309–320.
43. Gherunpong, S., Tsakos, G. and Sheiham, A. (2004) Developing and evalu-
ating an oral health-related quality of life index for children; the CHILD-
OIDP. Community Dental Health, 21, 161–169.
44. Cohen, J. (1988) Statistical Power Analysis for the Behavioural Sciences,
Lawrence Erlbaum, Hillsdale, MI, 2nd edn.
45. Jenny, J. and Cons, N.C. (1996) Establishing malocclusion severity levels on
the Dental Aesthetic Index (DAI) scale. Australian Dental Journal, 41, 43–46.
46. Richmond, S. (2005) Evaluating Effective Orthodontic Care. First Numerics,
Cardiff, United Kingdom.
47. O’Brien, C., Benson, P. and Marshman, Z. (2007) Evaluation of a quality of life
measure for children with malocclusion. Journal of Orthodontics, 34, 185–193.
48. de Paula Júnior, D.F., Santos, N.C., da Silva, E.T., Nunes, M.F. and Leles,
C.R. (2009) Psychosocial impact of dental esthetics on quality of life in
adolescents. The Angle Orthodontist, 79, 1188–1193.
49. Paula, D.F., Jr, Silva, É.T., Campos, A.C., Nuñez, M.O. and Leles, C.R. (2011)
Effect of anterior teeth display during smiling on the self-perceived impacts
of malocclusion in adolescents. The Angle Orthodontist, 81, 540–545.