Received: 5 April 2017 | Revised: 14 July 2017 | Accepted: 20 November 2017

DOI: 10.1111/jerd.12362

RESEARCH ARTICLE

Development and validation of a new condition-specific

instrument for evaluation of smile esthetics-related quality
of life

Ema Saltovic1 | Vlatka Lajnert2 | Sabina Saltovic3 | Daniela Kovacevic Pavicic2 |

Andrej Pavlic4 | Stjepan Spalj4

1
Department of Restorative Dentistry and
Endodontics, School of Medicine, University
Abstract
of Rijeka, Croatia
Objective: Orofacial esthetics raises psychosocial issues. The purpose was to create and validate
2
Department of Prosthodontics, School of
new short instrument for psychosocial impacts of altered smile esthetics.
Medicine, University of Rijeka, Croatia
3
Psychology Unit, Rijeka First Croatian High Materials and Methods: A team of an orthodontist, two prosthodontists, psychologist, and a den-
School, Croatia tal student generated items that could draw up specific hypothetical psychosocial dimensions (69
4
Department of Orthodontics, School of items initially, 39 in final analysis). The sample consisted of 261 Caucasian subjects attending local
Medicine, University of Rijeka, Croatia
high schools and university (26% male) aged 14 to 28 years that have self-administrated the
Correspondence designed questionnaire. Factorial analysis, Cronbach’s alpha, Pearson correlation, paired samples
Stjepan Spalj, Department of Orthodontics, t-test and analysis of variance were used for analyses of internal consistency, construct validity,
School of Medicine University of Rijeka, responsiveness, and test–retest.
Kresimirova 40, 51000 Rijeka, Croatia.
Email: stjepan.spalj@medri.uniri.hr Results: Three dimensions of psychosocial impacts of altered smile esthetics were identified: den-
tal self-consciousness, dental self-confidence and social contacts that can be best fitted by 12
Funding information
items, 4 items in each dimension. Internal consistency was good (a in range 0.85–0.89). Good sta-
University of Rijeka, Grant Number:
13.06.2.1.53. bility in test–retest was confirmed. In responsiveness testing, tooth whitening induced increase in
dental self-confidence (P 5 0.002), but no significant changes in other dimensions.

Conclusion: The new instrument, Smile Esthetics-Related Quality of Life (SERQoL), is short and
has proven to be a good indicator of psychosocial dimensions related to perception of smile
esthetics.

Clinical significance
Smile Esthetics-Related Quality of Life questionnaire might have practical validity when applied in
esthetic dental clinical procedures.

KEYWORDS
esthetics, psychosocial, quality of life

1 | INTRODUCTION Despite these theories, the influence of orofacial esthetics on person’s

Physical attractiveness, particularly facial attractiveness, plays an impor-
tant role in a one’s psychosocial development. An average facial
appearance is considered the most appealing because of the good
genetic structure according to the evolutional theory and similarity
with the basic facial prototype in line with the cognitive theory.1,2
psychosocial development varies depending on cultural characteristics
and social environment which are subject to change depending on a
time period and sociocultural surroundings.1
Orofacial deformity does not represent only a dysfunction but
could have an influence on one’s quality of life (QoL); self-confidence,
self-esteem, body image, behavior, and social life.3–7 It can possibly

160 | V
C 2017 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2018;30:160–167.
SALTOVIC ET AL. | 161

TA BL E 1 Final factor matrix of the questionnaire

Item F1 (DSCf) F2 (SC) F3 (DSCs)

I like to see my teeth in photographs. 0.84

I feel proud of the appearance of my teeth and smile. 0.83

When I smile, I like to show my teeth. 0.82

I think that my smile is trustworthy. 0.78

I do not enjoy company of other people because I am thinking about 0.88

the appearance of my teeth and smile much.

I avoid going out because I am burdened by the appearance of my teeth and smile. 0.88

When I meet other people, I tend to cover my mouth. 0.82

I think people avoid me because of the look of my teeth. 0.79 0.31

I worry about other people giving insulting remarks about my teeth. 0.84

I cannot relax because I am thinking about the appearance of my teeth and smile. 0.82

I feel discomfort because of the appearance of my teeth and smile. 0.32 0.74

I am somewhat sad because of the appearance of my teeth and smile. 20.47 0.69

Total variance explained (%) 25.6 25.3 22.5

Cronbach’s a 0.87 0.89 0.85

Interitem correlations (range) 0.62 0.66 0.60

(0.57–0.69) (0.56–0.74) (0.55–0.74)

DSCf—Dental self-consciousness, SC—Social contacts, DSCs—Dental self-confidence.

lead to various stages of depression, anxiety, emotional instability, and
8
introversion. Consequently, people are more often seeking improve-
ment of dental esthetics than improvement of oral function and
health.9,10 The majority consider that they will enhance their QoL by
improving their orofacial appearance. The perception of a person’s facial
appearance is often related to the concern about other people’s opinions
and reactions. Therefore, even small imperfections in dental esthetics
have an influence on a person’s fear of social negative reactions that cre-
ate insecurities with own appearance. 11
The QoL is a multidimensional
concept which includes the subjective perception of functional, emo-
12,13
tional, and social aspects of a person’s life and a sense of self. There-
one short, unidimensional, measuring satisfaction, and other long and
multidimensional.15,16 Construction of such an instrument is a complex
process that includes psychological and statistical methods often above
the scope of dental clinician. It aims to produce a reliable instrument
(accurate, reproducible, and consistent from one testing occasion to
another) and valid instrument that can accurately measure the concept it
is supposed to measure. The purpose of this research was to create and
validate a new multidimensional but short condition-specific instrument
for patient reported outcome measures of psychosocial impacts of
altered smile esthetics. Hypotheses were that the new instrument will
be stable and have the possibility to detect problems related to impaired

fore, the instruments measuring QoL in form of questionnaires have a esthetics and also to detect changes after the correction of problems.

wide use ranging from expectations to satisfaction with care. Incorpora-

tion of QoL measures in dental practice intend to improve patient-
dentist communication in relevant issues addressed and discussed, pro-
motes patient’s active participation in treatment planning and evaluating
the treatment outcome. They might be helpful in detecting and observ-
ing the differences between patient’s and doctor’s opinions and percep-
tions and in documenting the psychosocial changes during and after the
treatment process. The QoL measures have an important aspect, as they
are able to represent the patient’s psychosocial perception in numerical
form, so it is highly important to relate the objective treatment need
evaluated by the dentist with the subjective need perceived by the
patient. Condition-specific instruments have more advantages than
generic ones as they are adjusted to specific conditions and have lower
sensitivity degree, thus having a better detection of the effects.12,14 A
few instruments focusing on smile esthetics were recently developed,
2 | MATERIALS AND METHODS
A team of four experts; an orthodontist, two prosthodontists and psy-
chologist, and a dental student attending the final semester generated
items that could draw up specific hypothetical dimensions. Items for
the new instrument were chosen by reviewing available literature in
consideration with suggestions of team members. Additionally, dental
students were asked to suggest items related to the perception of oro-
facial esthetics and the QoL. Each team member suggested and
explained which item should be included, changed or excluded accord-
ing to his or her professional experience. The first version of the ques-
tionnaire was created by the panel and contained 39 items out of the
primary 69. In the pilot study, the first version of the questionnaire was
administrated by 30 persons whose task, other than completing it, was
162 | SALTOVIC ET AL.

TA BL E 2 Description of the sample

Variable AS 6 SD min–max

Dental self-consciousness 6.0 6 3.2 4–20

Social contacts 5.2 6 3.0 4–19

Dental self-confidence 15.2 6 3.9 5–24

Satisfaction with teeth appearance (05not at all–45very much) 2.8 6 0.8 0–4

Satisfaction with facial appearance (05not at all–45very much) 2.8 6 0.7 1–4

Self-reported treatment need (05not at all–45very much) 1.3 6 1.1 0–4

Self-esteem 43.6 6 4.6 22–50

Body image—teeth and smile important for body image (05strongly disagree–45strongly agree) 3.5 6 0.7 1–4

PIDAQ AC 1.8 6 2.5 0–9

PIDAQ PI 5.4 6 4.6 0–19

PIDAQ SI 3.3 6 4.6 0–22

PIDAQ DSC 16.0 6 4.6 2–24

OES 32.3 6 4.3 19–40

OHIP OFA 7.3 6 4.3 0–21

OHIP PSI 4.1 6 5.8 0–24

Lightness 75.13 6 2.29 68.70–82.30

Chroma 16.82 6 2.33 11.62–25.08

Translucency 2.57 6 1.89 0.22–12.26

ICON 19.3 6 11.1 7–52

IOTN AC subject 2.1 6 1.1 1–5

IOTN AC orthodontist 2.1 6 1.0 1–5

to give comments on the clarity of the items and/or suggest changes. A
Likert five point scale was used as a method of filling in the question-
naire (1—strongly disagree, 2—disagree, 3—neither agree nor disagree,
4—agree, 5—strongly agree.) 17 This type of scale was chosen as it was
familiar to participants (students and pupils) having in mind they had
had this type of evaluation during their education (scale from 1 to 5).
Upon reviewing the participants’ comments from the pilot study, the
final version of the questionnaire was created and self-administrated
by 261 Caucasian subjects (26% males). The convenience sample con-
sisted of adolescents and young adults attending local high schools
(N 5 94) and university aged 14 to 28 years (median 19, interquartile
range 18–22). All data was collected during 2015. The study was
approved by the Ethics Committee of School of Medicine University of
Rijeka (2170-24-01–15-04 and 2170-24-01–15-06) in accordance
with the 1964 Helsinki declaration and its later amendments. Informed
consent was obtained from all individual participants included in the
study. For minors parents’ informed consent was obtained.
Exploratory factor analysis (principal component with orthogonal
varimax rotation) was used to explore the latent structure of the new
questionnaire. After examining the factor analysis results, the items
which did not match with the content of a particular factor were
excluded and once again the exploratory factor analysis was made only
with the items that remained following the content evaluation.
Cronbach’s alpha and interitem correlations were used for the
analyses of internal consistency.
Construct validity was examined using Pearson’s correlations and
multiple linear regression analysis. The instruments used for construct
validity were the Rosenberg’s Self-Esteem Scale,18 Orofacial Esthetic
Scale (OES),19 Psychosocial Impact of Dental Aesthetics Questionnaire
(PIDAQ),20 Oral Health Impact Profile (OHIP),21 self-assessment of the
satisfaction with dental appearance and smile and self-assessment of
the importance of dental appearance and smile for the body image
which were evaluated using a Likert five point scale.
For the evaluation of relationship between dimensions of the
new questionnaire and clinical parameters, some participants were
intraorally examined to evaluate the degree of present malocclusion
using the Index of Orthodontic Treatment Need—Aesthetic Compo-
nent (IOTN AC) and Index of Complexity, Outcome and Need
22
(ICON.) Additionally, the elements of color in the L*a*b system23
were estimated on the reference tooth, maxillary right central inci-
sor, using a spectrophotometric instrument (SpectroShade 713000,
MHT, Verona, Italy). The tooth color was assessed three times,
without background, with white background, and with black back-
ground. Measurements were performed in a room with diffuse illu-
mination. Using these measurements, lightness (L*), chroma (C 5
[(a*)2 1 (b*)2]1/2) and translucency were calculated; translucency as
SALTOVIC ET AL. | 163

TA BL E 3 Construct validity estimated by Pearson correlations with known measures

Dental Self- Social Dental Self-

Consciousness Contacts Confidence

Dental self-consciousness r 1 0.660 20.619

P <0.001 <0.001

Social contacts r 0.660 1 20.416

P <0.001 <0.001

Dental self-confidence r 20.619 20.416 1

P <0.001 <0.001

PIDAQ AC r 0.577 0.368 20.540

P <0.001 <0.001 <0.001

PIDAQ PI r 0.568 0.297 20.484

P <0.001 <0.001 <0.001

PIDAQ SI r 0.595 0.380 20.384

P <0.001 <0.001 <0.001

PIDAQ DSC r 20.439 20.218 0.671

P <0.001 0.009 <0.001

OES r 20.460 20.179 0.633

P <0.001 0.033 <0.001

OHIP OFA r 0.524 0.264 20.482

P <0.001 0.001 <0.001

OHIP PSI r 0.548 0.260 20.450

P <0.001 0.002 <0.001

Self-esteem r 20.202 20.093 0.299

P 0.015 0.270 <0.001

Satisfaction with teeth appearance (05not at all–45very much) r 20.332 20.176 0.533
P <0.001 0.036 <0.001

Satisfaction with facial appearance (05not at all–45very much) r 20.119 20.067 0.294
P 0.155 0.426 <0.001

Self-reported need for treatment of teeth and smile (05not at all–45very much) r 0.287 0.121 20.307
P <0.001 0.151 <0.001

Body image—teeth and smile important for body image r 20.235 20.264 0.323
(05strongly disagree–45strongly agree)
P 0.005 0.001 <0.001

a relation of the result on the white (w) and black (b) background
(TL 5 [(L*w-L*b)2 1 (a*w-a*b)2 1 (b*w-b*b)2]1/2).
Test–retest included a repeated administration of the instrument
by 30 subjects in one-week period without any dental interventions.
Responsiveness testing was conducted on 30 participants using in-
office tooth whitening method. Whitening gel containing 38% hydro-
gen peroxide (Signal Fast Professional Plus Set, Signal, Unilever, Argen-
tina) was applied and photoactivated in duration of 30 minutes (Signal
Easy Lamp Plus, Signal, Unilever, Argentina). Color of the teeth was
assessed by a spectrophotometer before and after bleaching, and the
difference due to bleaching was calculated by formula DE* 5
(DL*21Da*21Db*2)1/2. Paired samples t-test and intraclass correlation
coefficient (ICC) were used for analysis of responsiveness and test–
retest. Statistical software SPSS 20 (IBM Corp, Armonk, USA) was used
in statistical analysis.
3 | RESULTS
3.1 | Internal Consistency
Several models in factorial analysis were tested controlling for Cron-
bach a and interitem correlations. The final version of the question-
naire contains 12 items grouped in three dimensions (Dental self-
consciousness, Dental self-confidence, and Social contacts), and in total
accounts for 73.4% of variance (Table 1). Internal consistency was
good (a in 0.85–0.89 range with average interitem correlation in the
164 | SALTOVIC ET AL.

TA BL E 4 Pearson correlations for estimation of linear relation change did not increase linearly the degree of self-confidence. Other
between dimensions and clinical parameters— degree of dimensions were not capable of detecting a change after teeth
malocclusion and elements of color
whitening.
Dental Dental
self- Social self-
consciousness contacts confidence
4 | DISCUSSION
IOTN AC subject r 0.333 0.113 20.300
P 0.003 0.320 0.007
Newly created questionnaire is a valid short instrument for patient
IOTN AC orthodontist r 0.121 20.028 20.216 reported outcome measures of psychosocial impacts of altered smile
P 0.288 0.806 0.058
esthetics. The instrument covers the emotions and behaviors previ-
ICON r 20.034 20.145 20.167 ously recognized as important and dominant in several existing QoL
P 0.764 0.206 0.145 instruments.20,21,24,25 These contents are embarrassment, shame, sad-

Lightness r 20.021 20.055 0.058 ness, worry, frequent preoccupation about own appearance, pride,
P 0.815 0.544 0.526 enjoyment in company of other people, and avoidance of social con-
tacts because of own appearance. Some statements, that is, items are
Chroma r 0.069 0.088 20.089
P 0.448 0.335 0.326 not similar to the present questionnaires and those reflect anxiety—the
inability to relax due to thinking about own appearance, self-
translucency r 20.005 20.066 20.041
confidence—attitude that one’s smile increases trust, and social
P 0.953 0.467 0.652

T AB LE 5 Comparison of dimensions between categories of

elements of tooth color
range of 0.60–0.66). Further exclusion of any other items would not
Std.
increase Cronbach a. Characteristics of the sample are presented in N Mean Deviation P*
Table 2.
DSCs Chroma low 14.5 15 5.33 2.02
medium 77 5.47 2.52
14.6–19.7
3.2 | Construct Validity and Correlation with Clinical high 19.8 11 4.36 1.21 0.350
Parameters
SC low 14.5 15 4.00 0.00
Social contacts measure the construct that is the most similar to Social medium 77 4.35 0.93
14.6–19.7
Impact (SI) of PIDAQ (r 5 0.380; P < 0.001; Table 3). Dental self-
high 19.8 11 4.00 0.00 0.167
confidence measures the construct that is similar to OES, Dental self-
DSCf low 14.5 15 14.73 3.60
confidence (DSC) of PIDAQ, body image, satisfaction with teeth and
medium 77 14.23 3.78
facial appearance, self-reported need for dental treatment and to some 14.6–19.7
extent self-esteem. Dental self-consciousness measures the construct high 19.8 11 14.73 3.10 0.839
similar to Aesthetic Concern (AC), SI and Psychological Impact of DSCs Lightness low 72.7 19 5.63 2.69
PIDAQ, Orofacial Appearance (OFA) and Psychosocial Impact (PSI) of medium 72 5.25 2.29
OHIP. 72.8–77.4
high 77.5 12 5.33 2.35 0.824
Normative degree of malocclusion was not in correlation with the
new QoL dimensions but the self-perceived malocclusion increased the SC low 72.7 19 4.63 1.61
medium 72 4.15 0.43
degree of dental self-consciousness (r 5 0.333; P 5 0.003) and
72.8–77.4
decreased the degree of dental self-confidence (r 5 20.300; P 5 0.007; high 77.5 12 4.33 0.65 0.070
Table 4). A correlation between new dimensions and color parameters
DSCf low 72.7 19 13.32 3.51
was not observed (Tables 4 and 5). medium 72 14.69 3.80
72.8–77.4
high 77.5 12 14.00 2.83 0.325
3.3 | Stability and Responsiveness
DSCs Translucency low <5.8 97 5.32 2.38
Good test–retest reliability was presented (ICC 5 0.690-0.970; Table 6) high 5.8 6 5.50 2.07 0.856
with small measurement error and paired differences mean. When con-
SC low <5.8 97 4.26 0.83
sidering the sample size, the percentage of differences between test high 5.8 6 4.33 0.52 0.827
and retest within limits of agreement was appropriate.
DSCf low <5.8 97 14.39 3.48
In the responsiveness testing, the Dental self-confidence dimen-
high 5.8 6 13.83 6.31 0.719
sion was capable of detecting a change in dental self-confidence after
teeth whitening (P 5 0.002; Table 7), but increase in the degree of color *ANOVA.
SALTOVIC ET AL. | 165

TA BL E 6 Test–retest reliability (N 5 30)

Paired differences
ICC (95% CI) MEa SDCb mean (95% CI) P LOAc

DSCs 0.744 (0.527–0.870) 0.9 2.6 0.0 (-0.5 to 0.5) 0.889 22.5 to 2.6 (96.7%)

SC 0.690 (0.447–0.839) 0.4 1.1 20.1 (-0.3 to 0.1) 0.326 21.2 to 1.0 (93.3%)

DSCf 0.970 (0.934–0.986) 0.6 1.7 20.3 (-0.7 to (-0.0)) 0.048 22.1 to 1.4 (96.7%)
a
Measurement error (ME) was calculated as square root of the residual variance.
b
Smallest detectable change (SDC) was calculated as 1.96*冑2*ME.
c
Limits of agreement (LOA) were calculated as paired differences mean 6 1.96 * standard deviation of differences between two measurements
(presented with percentage of differences between test and retest that are within limits of agreement).

contacts—attitude that people will avoid someone because of their
appearance.
Multidimensionality of present new psychometric instrument is
demonstrated and impacts of altered smile esthetics are grouped into
three dimensions: Dental self-consciousness, Dental self-confidence,
and Social contacts. Internal consistency is appropriate, and does not
imply that some statements may be redundant.26,27 It also indicates
that there is an adequate number of items in each dimension, that the
items within the dimension measure the same psychological concept,
that is, construct and that the concept of each dimension is not hetero-
geneous.27 In psychology, a construct is a complex concept, such as
anger, personality, whose characteristics are not easily measurable and
may be dependent upon a subject’s mind. However, a clearly articu-
lated construct should allow different people to think similarly about
it.28 In simple words, items of present questionnaire that form the
same aspect of QoL demonstrated to have similar meaning, to measure
a similar idea, behavior, or attitude, which is a first step in guarantee od
validity.
Analysis of construct validity demonstrates that the new dimen-
sion—Dental self-consciousness measures esthetic concern and social
impact of dental esthetics to a certain extent. A similar dimension that
comprises reports of level of dissatisfaction with dental appearance
and tendency to focus on the public aspects of the self has been
described before.29 Public self-consciousness is an aspect of self-
consciousness and comprises being intensely aware of oneself as an
object of observation by others and uncomfortably nervous and embar-
rassed by what other people think.30 Self-evaluation may be influenced
by this psychological dimension because to some people even greater
impairments in esthetics do not represent problems, however, some
might be bothered by even slight deviations from the ideal.4
The new dimension Dental self-confidence measures to a great
extent satisfaction with orofacial esthetics and specifically self-
confidence arising from orofacial esthetics, and in some amount a con-
struct similar to self-esteem and body image. This is in accordance with
previous reports which imply that self-esteem may be influenced by
self-confidence in appearance, body esteem and self-perceived attrac-
tiveness and also mediated by romantic self-confidence.31 Self-esteem
is a pleasant feeling of high personal value and quality with self-
confidence probably being a prerequisite for its realization.32,33
The new brief dimension Social contacts, measures to a certain
extent concepts of social and psychosocial impact as well as orofacial
appearance, which are measured with instruments PIDAQ and OHIP.
Social impact is derived from possible problems in social interactions
caused by the negative perception of personal orofacial appearance.
However, this new subscale which measures the effect of dental
esthetics on social contacts has a clear designation of the construct
that exceeds the one from existing correlated subscales. Items from
that component could be significantly applicable in Croatian cultural
surroundings, where the society’s opinion is regarded more important
than individuals’, which has been previously reported.20
New instrument is able to detect some problems related to
impaired smile esthetics. The more harshly people perceive their maloc-
clusion the more concerned they are, and their self-confidence
decreases. However, the way clinician assesses the malocclusion is not
related to the new dimensions of QoL related to dental esthetics. Con-
cerning tooth color, persons with brighter teeth do not necessary have

TA BL E 7 Responsiveness testing (N 5 30)

Mean baseline Ratio of subjects Summary

score—mean Paired differences with increase of score range Standardized Standardized
follow up score mean (95% CI) score for 1 (%) at baseline effect sizea response meanb Pc rd Pd

DSCs 6.1–5.4 0.7 (-0.3 to 1.7) 23.3 4–15 0.228 0.823 0.129 20.309 0.097

SC 4.4–4.2 0.3 (-0.2 to 0.7) 13.3 4–10 0.223 0.456 0.211 20.053 0.780

DSCf 13.8–14.8 20.9 (-1.5 to (-0.4)) 70.0 4–20 20.238 8.034 0.002 0.179 0.345
a
Standardized effect size5 (mean baseline score—follow up score)/(standard deviation of baseline score).
b
Standardized response mean 5 (mean baseline score—follow up score)/(standard deviation of baseline score—follow up score.
c
Paired samples t-test.
d
Pearson correlation coefficient with corresponding p value for correlation between change in DSCs, SC, and DSCf, and change in tooth color (DE) due
to bleaching.
166 | SALTOVIC
high self-confidence, low dental concern or no problems in social con-
tacts, neither do those with higher translucency and chroma. Also,
those with moderate lightness, chroma intensity and translucency do
not have more psychosocial issues than persons with high or low
chroma, translucency and lightness, and similar was reported previ-
ously.34 How laypeople perceive tooth color obviously differs from the
objective assessment. This implies that clinicians and patients do not
have the same perspective. Assessment of patients’ perspective could
be achieved with the new instrument.
It has been confirmed that the new psychometric instrument
has a good temporal stability. Thus, psychosocial issues addressed
will not change during time if no dental intervention in smile
esthetics is performed. One scalar point seems to be the cut-off for
error in measurement of psychosocial issues related to smile
esthetics. The smallest clinically relevant change that a patient
would identify as important in a dental treatment outcome is one
point for improvement in social contacts, two points for self-
confidence and three for self-consciousness.
Concerning the ability to detect changes after the correction of
problems of altered smile esthetics, tooth whitening made people more
self-confident with their dental esthetics, on a statistically significant
level. More than 2/3 of examinees reported change in self-confidence
after whitening, most (37%) with the increase of 2 or 3 scalar points.
Whitening demonstrated a low effect on other two dimensions, making
about 1=4 of examinees more self-consciousness and altering social rela-
tions only in 1/8. The relation between the amount of change in tooth
color and psychosocial issues is not linear. Therefore, solely increasing
the lightness of teeth or difference in teeth color by one unit will not
necessarily result in patients reporting proportional increase in self-
confidence, nor decrease in self-consciousness or problems in social
contacts. Furthermore, no clear curve trend was observed, meaning
that improvement in quality of life due to bleaching will not be clearly
evident after some color difference threshold is exceeded. Obviously,
there is a high interindividual variability in reports, subjectiveness in
assessment of outcomes of tooth whitening treatment and
suggestibility.
The QoL is a complex concept, and the same instruments can have
differently grouped items for various cultural surroundings,34,36 and a
multidimensional structure can be reduced when explored on a large
international sample.21 Therefore, the new characterization of psycho-
social dimensions emerged, such as Aesthetic Attitude or Orofacial
Appearance.34–37 Recently, efforts have been made into the process of
integration of existing OHRQoL instruments in order to develop a sim-
pler, yet psychometrically improved measurement.37
Present study included a relatively young population therefore
only malocclusion and tooth color was taken into consideration since
they basically have no or few prosthetic restorations that could raise
psychosocial issues related to altered smile esthetics. Therefore, as it
has clearly demonstrated the ability to detect dental issues and
changes due to clinical interventions, this new instrument could also be
tested in other age groups and on other components of smile esthetics
to understand which characteristics raise discomfort and could be suc-
cessfully solved.
ET AL.
5 | CONCLUSION
The new instrument, Smile Esthetics-Related Quality of Life (SERQoL),
is short and has proven to be a good indicator of psychosocial dimen-
sions related to perception of smile esthetics. It might have practical
validity when applied in dental clinical procedures.
ACK NOWLE DGME NT S
The authors do not have any financial interest in the companies
whose materials are included in this article. This research was partially
funded by the University of Rijeka (Project number: 13.06.2.1.53).
ORC ID
Daniela Kovacevic Pavicic http://orcid.org/0000-0002-8117-9203
Stjepan Spalj http://orcid.org/0000-0003-4836-3903
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How to cite this article: Saltovic E, Lajnert V, Saltovic S, Kova-
cevic Pavicic D, Pavlic A, Spalj S. Development and validation of
a new condition-specific instrument for evaluation of smile
esthetics-related quality of life. J Esthet Restor Dent.
2018;30:160–167. https://doi.org/10.1111/jerd.12362
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