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/lp/ou_press/oral-health-related-quality-of-life-among-children-with-excessive-450VvZSN0i
- Publisher
- Oxford University Press
- Copyright
- © The Author(s) 2018. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
- ISSN
- 0141-5387
- eISSN
- 1460-2210
- DOI
- 10.1093/ejo/cjy033
- Publisher site
- See Article on Publisher Site
Abstract
Summary Objectives To compare Oral health-related quality of life (OHRQoL) among 9-year-old children with excessive overjet (EO) to children with unilateral posterior crossbite (UPC) and children with normal occlusion (NO). Materials and methods The study sample sourced from 19 Public Dental Service Clinics in Sweden. Reported are baseline data originating from two controlled trials, one regarding UPC and the other focusing on EO. The NO children derive from the same trials. The UPC group comprised 93 children (45 boys and 48 girls), the EO group 71 children (36 boys and 35 girls), and the NO group 65 children (32 boys and 33 girls). In conjunction to a clinical examination, all children completed the Child Perceptions Questionnaire (CPQ8-10) for evaluation of OHRQoL. The CPQ8-10 comprises 25 questions grouped into four domains: oral symptoms, functional limitations, emotional, and social well-being. Validated questions about pain in the jaws and face were also included. Results The total mean CPQ score was 5.1 for the UPC, 7.4 for the EO, and 4.4 for the NO group, showing a significant difference between the UPC and EO (P = 0.048) and between EO and NO group (P = 0.012). These differences remained when adjusted for the confounders’ caries, trauma, enamel defects, and headache. No difference between UPC and NO was found. The EO children also reported significantly higher scores in the domains emotional and social well-being (P = 0.039 and P = 0.012). Limitations The study would be strengthened if a longitudinal design had been performed. Conclusion Children with EO reported significantly lower OHRQoL compared to children with UPC or NO. The children generally reported low CPQ scores that imply an overall fairly good OHRQoL. Introduction The World Health Organization (WHO) states that oral health is essential to both general health and quality of life. Good oral health implies being free from diseases and disorders that could limit a person’s capacity in biting, chewing, smiling, speaking, or negatively affect psychosocial well-being (1). One of the most frequent oral conditions is malocclusions and frequency ranges between 39 and 93%, whereas some of the most common specific malocclusions are excessive overjet (EO) with Class II malocclusion and unilateral posterior crossbite (UPC) (2–5). Several indices exist to assess orthodontic treatment need in terms of the severity of a malocclusion. However, a person’s self-perception of the malocclusion may not always be related to malocclusion severity, and outcomes related to patients’ values or perceptions of malocclusions are often lacking. A recent systematic review confirmed that orthodontic research seems to have overlooked patient values among children while there have been many studies measuring morphological differences (6). Therefore, to include the patient’s perspective is as important as clinical registrations when making decisions regarding treatments or performing research (6,7). Consequently, to incorporate patient’s perspectives enables a wider evaluation of treatment need, and furthermore, treatment success (8). The term used when evaluating patient’s perceptions of psychosocial well-being and oral health is oral health-related quality of life (OHRQoL). Self-report questionnaires are commonly used to register and evaluate patients’ perspective. A common instrument used in child populations is the Child Perceptions Questionnaire (CPQ) (9), and this instrument enables assessment of the OHRQoL of children in order to provide additional information when making clinical decisions or evaluating the success of treatments or interventions. In a recent systematic review (10), it was found that malocclusions have negative effects on children’s and adolescent’s OHRQoL, and especially if the malocclusions were present in the aesthetic zone. However, a majority of the high-quality studies originated from Brazil, and an additional finding was the lack of OHRQoL studies with European origin. It is known that OHRQoL may differ between countries and societies, since a self-perceived measure can be dependent upon the context of the child (11, 12). Furthermore, there are no studies that explicitly investigate how the specific malocclusions UPC with functional shift and EO may affect the OHRQoL in young children. It has been reported that if UPC with functional shift, i.e. a forced guidance of the mandible where the mandible deviates to the crossbite side, is left untreated adverse effects on the temporomandibular joints, pain in the masticatory system, and altered facial growth including facial asymmetry can occur (13–15). In addition, EO, especially without complete lip seal, has greater risk of dental trauma (5, 16) and can also be associated with bullying (17). Since pain, abnormal facial appearance, and bullying are related to specific malocclusions, it is important to investigate what influence specific different malocclusions may have on the OHRQoL in children. Likewise, it is important in this context to include children with normal occlusion (NO) and with no or mild orthodontic treatment need as controls in the evaluations. Therefore, the aim of this study was to investigate the OHRQoL among 9-year-old children in mixed dentition and compare the OHRQoL of children with UPC to children with EO as well as with children with NO with no or mild orthodontic treatment need. The hypothesis was that children with EO have lower OHRQoL than children with UPC with functional shift or children with no or mild orthodontic treatment need since EO occur in the aesthetic zone. Subjects and methods The study sample of the children was sourced from 19 Public Dental Service Clinics in Sweden. The sample was comprised of baseline data from children that origin from two different controlled trials, one regarding UPC with functional shift and the other focusing on EO combined with Class II malocclusion. Both trials also include children with NO and with no or mild orthodontic treatment need. To ensure the representativeness of the sample, all children were selected from clinics located in different socioeconomically areas, and the clinics were located in communities ranging from 10 000 up to 140 000 inhabitants. The inclusion criteria considering the UPC group were consecutive children, boys and girls, in the mixed dentition (between 8 and 10 years of age), with UPC with functional shift of more than 1 mm, including the first permanent molars and a Class I occlusion. In addition, no sucking habits or ceased sucking habits should have been evident at least 1 year before the trial was started. The inclusion criteria for the group of patients with EO were consecutive children, boys, and girls, in the mixed dentition (between 8 and 10 years of age), with EO (≥6 mm) and first permanent molars in Class II malocclusion. Furthermore, no sucking habits or ceased sucking habits should have been evident at least 1 year before the trial was started. The inclusion criteria for the normal group were consecutive children, boys and girls, in the mixed dentition (between 8 and 10 years of age), with NO and with no or mild orthodontic treatment need, i.e. Index of Orthodontic Treatment Need – Dental health Component (IOTN-DHC) (18) of 1 or 2. The exclusion criteria were craniofacial syndromes, children who had previously undergone orthodontic treatment, or severe crowding of teeth (extraction of teeth necessary). All children and their parents were invited to attend and were asked to give their informed consent before entering the trial. The trial protocol and informed consent form were approved by the Regional Ethical Review Board in Lund (Dno: 2012/650) and Linköping (Dno: 2012/302–31), Sweden. Data collection took place from December 2013 to April 2017. CPQ8-10 questionnaire To evaluate the OHRQoL among the children in the three groups, the CPQ8-10 (19), which is validated for children 8–10 years of age, was used. The CPQ 8-10, comprise 25 questions grouped into four domains: oral symptoms (OS), functional limitations (FL), emotional well-being (EW), and finally social well-being (SW). Each question has five answering possibilities, i.e. ‘never’ (scoring 0), ‘once or twice’ (scoring 1), ‘sometimes’ (scoring 2), ‘often’ (scoring 3), and ‘every day or almost every day’ (scoring 4). The domains were added in order to produce a total score. The questionnaire also contained two global self-ratings of oral health using a four-point scale ranging from ‘excellent’ to ‘poor’ and overall well-being using a four-point scale ranging from ‘not affected at all’ to ‘very much affected’. The total score ranged between 0 and 100, with subscale scores range of each domain from 0 to 20 (OS, FL, EW) or 40 (SW). If answer alternatives were not applicable for the child, the question was given the median input of the total score. The higher scores corresponded to poorer quality of life status. Finally, the children also answered validated questions about pain in the jaws and face (20). The questionnaire was filled out in conjunction to the clinical examination and the children were instructed to answer the questions without any support from their parents. However, all children had the opportunity to ask questions about the questionnaires, and if needed, to get support with reading the questions by clinical staff personnel. Clinical and dental record measures The clinical measures and the determinations were performed by two experienced orthodontists (JK, OS) following a prespecified protocol that was used to collect data about malocclusions, orthodontic treatment need, caries, enamel defects, incisors with or without lip closure, and if any trauma had occurred. Alginate impressions were taken of each child who participated in the trial and study casts were made and trimmed after index in central occlusion. Study casts were evaluated according to the method of Bjoerk et al. (21) in order to determine malocclusions in sagittal, vertical, and transversal relations as well as determination of crowding, spacing, tooth rotations, overjet, and overbite. Measurements of overjet and overbite were made with a stainless-steel ruler while crowding and spacing was determined by a digital sliding calipers (Digital 6, 8M007906, Mauser-Messzeug GmBH, Oberndorf/Neckar, Germany). All measurements were made to the nearest 0.5 mm. The dental health component of the index of orthodontic treatment need (IOTN-DHC) was used to rank the treatment need (18). This index classifies the treatment need into five grades: no need 1; mild/little need 2; moderate/borderline need 3; severe need 4; and extreme need 5. In combination with the clinical examination, dental records of the patients were used to support the determination of caries of the anterior teeth (the aesthetic zone, i.e. canine to canine in both arches). A caries lesion was characterized as caries identified by probing. Enamel defects were registered for permanent teeth and in the evaluation dichotomized into the presence of quantitative decay of enamel (hypoplasia) or qualitative alteration in the transparence (opacity) of the enamel, and no enamel defect. Reporting of perceived trauma was affirmed by the dental records and in the investigations dichotomized into trauma or not. Calibration of operators Before diagnostics and study cast evaluations in this trial, 20 study casts from patients not included in this study were separately examined by the observers. Ten patients with UPC and 10 patients with EO were evaluated. In each patient, 26 decisions had to be performed according to a pre-set protocol regarding diagnostic parameters, malocclusion traits, measurements of overjet, and overbite as well as determination of treatment need according to IOTN-DHC. The two independent observers (JK, OS), made 26 decisions in each of the 20 study casts. Consequently, each observer had to carry out 520 decisions, and concordance between the observers was reached in 97.1% of the decisions. The inter-examiner disagreements of 2.9% were resolved by discussions to reach consensus. Most of the disagreements dealt with determination of treatment need according to IOTN-DHC. Sample size estimation and statistical analysis The criterion for significance (alpha) was set at 0.05. The test was two-tailed, which means that an effect in either direction was interpreted. With a proposed sample size of 60 in each group, the trial had a power of 81.6 % (1 − beta) to yield a statistically significant result. This computation assumed that the difference in proportions was 0.25 (25 % difference of quality of life between the groups). The difference of 25% was selected as the smallest difference in the sense that any smaller difference would not be of clinical or substantive significance. It was also assumed that this effect size was reasonable in the sense that an effect of this magnitude could be anticipated in this field of research. The data were statistically analyzed by using the IBM SPSS Statistics version 24. Means between groups were compared using ANOVA. Chi-square analysis and Fisher’s exact test were used to determine difference between groups regarding categorical data. General linear model in combination with Tukey’s test were performed when corrections were made for the following background/confounding variables: gender, caries, enamel defects, headache, and trauma. Differences with probabilities of less than 5% (P < 0.05) were considered to be statistically significant. Results Sample characteristics In the UPC group, there were 93 children, 45 boys and 48 girls, with a mean age of 9.1 years (SD 1.02) whereas in the EO group 71 children, 36 boys and 35 girls, with a mean age of 9.5 years (SD 0.53) participated. The NO group consisted of 65 children, 32 boys and 33 girls, with a mean age of 9.4 years (SD 1.01). Thus, the gender distribution between the groups was similar but a small albeit significant difference between the UPC and EO groups regarding age was found (P = 0.025). All children in the UPC and NO group had Class I molar relation while all in the EO group showed Class II division 1 malocclusion. A significant larger overjet (P < 0.001) and overbite (P <0.001) was found in the EO group compared to the UPC group, 8.2 (SD 1.50) and 3.7 mm (SD 1.40) versus 3.1 (SD 1.29) and 2.3 mm (SD 1.43). The overjet and overbite were 3.2 mm (SD 1.11) and 3.0 mm (SD 1.12) in the NO group. There was also a significant larger overjet (P < 0.001) in the EO compared to the NO group. Consequently, significantly more children without lip closure (P < 0.001) were found in the EO group (Table 1). No significant differences were revealed in overjet and overbite between the UPC and NO group. Table 1. Descriptive data for the three groups of children: excessive overjet (EO), unilateral posterior crossbite (UPC), and normal occlusion (NO). EO N = 71 UPC N = 93 NO N = 65 Group differences N % N % N % Gender Boys 36 50.7 45 48.4 32 49.2 No group differences Girls 35 49.3 48 51.6 33 50.8 P = 0.985 (C) IOTN 5 15 21.1 EO versus UPC P < 0.001 (F) 4 56 78.9 18 19.4 EO versus NO P < 0.001 (F) 3 75 80.6 UPC versus NO P < 0.001 (F) 2 7 10.8 1 58 89.2 Lips EO versus UPC P < 0.001 (F) With closure 50 70.4 92 99 65 100 EO versus NO P < 0.001 (F) Without closure 21 29.6 1 1 0 0 UPC versus NO P = 1.00 (F) Caries 0 0 0 0 1 1.5 No group differences P = 0.284 (F) Trauma 5 7 3 3.2 2 3.1 No group differences P = 0.504 (F) Enamel defects 5 7 1 1.1 2 3.1 No group differences P = 0.143 (F) Headache 3 4.2 8 8.6 4 6.2 No group differences P = 0.558 (F) EO N = 71 UPC N = 93 NO N = 65 Group differences N % N % N % Gender Boys 36 50.7 45 48.4 32 49.2 No group differences Girls 35 49.3 48 51.6 33 50.8 P = 0.985 (C) IOTN 5 15 21.1 EO versus UPC P < 0.001 (F) 4 56 78.9 18 19.4 EO versus NO P < 0.001 (F) 3 75 80.6 UPC versus NO P < 0.001 (F) 2 7 10.8 1 58 89.2 Lips EO versus UPC P < 0.001 (F) With closure 50 70.4 92 99 65 100 EO versus NO P < 0.001 (F) Without closure 21 29.6 1 1 0 0 UPC versus NO P = 1.00 (F) Caries 0 0 0 0 1 1.5 No group differences P = 0.284 (F) Trauma 5 7 3 3.2 2 3.1 No group differences P = 0.504 (F) Enamel defects 5 7 1 1.1 2 3.1 No group differences P = 0.143 (F) Headache 3 4.2 8 8.6 4 6.2 No group differences P = 0.558 (F) C: Chi-squared test; F: Fisher’s exact test. View Large Table 1. Descriptive data for the three groups of children: excessive overjet (EO), unilateral posterior crossbite (UPC), and normal occlusion (NO). EO N = 71 UPC N = 93 NO N = 65 Group differences N % N % N % Gender Boys 36 50.7 45 48.4 32 49.2 No group differences Girls 35 49.3 48 51.6 33 50.8 P = 0.985 (C) IOTN 5 15 21.1 EO versus UPC P < 0.001 (F) 4 56 78.9 18 19.4 EO versus NO P < 0.001 (F) 3 75 80.6 UPC versus NO P < 0.001 (F) 2 7 10.8 1 58 89.2 Lips EO versus UPC P < 0.001 (F) With closure 50 70.4 92 99 65 100 EO versus NO P < 0.001 (F) Without closure 21 29.6 1 1 0 0 UPC versus NO P = 1.00 (F) Caries 0 0 0 0 1 1.5 No group differences P = 0.284 (F) Trauma 5 7 3 3.2 2 3.1 No group differences P = 0.504 (F) Enamel defects 5 7 1 1.1 2 3.1 No group differences P = 0.143 (F) Headache 3 4.2 8 8.6 4 6.2 No group differences P = 0.558 (F) EO N = 71 UPC N = 93 NO N = 65 Group differences N % N % N % Gender Boys 36 50.7 45 48.4 32 49.2 No group differences Girls 35 49.3 48 51.6 33 50.8 P = 0.985 (C) IOTN 5 15 21.1 EO versus UPC P < 0.001 (F) 4 56 78.9 18 19.4 EO versus NO P < 0.001 (F) 3 75 80.6 UPC versus NO P < 0.001 (F) 2 7 10.8 1 58 89.2 Lips EO versus UPC P < 0.001 (F) With closure 50 70.4 92 99 65 100 EO versus NO P < 0.001 (F) Without closure 21 29.6 1 1 0 0 UPC versus NO P = 1.00 (F) Caries 0 0 0 0 1 1.5 No group differences P = 0.284 (F) Trauma 5 7 3 3.2 2 3.1 No group differences P = 0.504 (F) Enamel defects 5 7 1 1.1 2 3.1 No group differences P = 0.143 (F) Headache 3 4.2 8 8.6 4 6.2 No group differences P = 0.558 (F) C: Chi-squared test; F: Fisher’s exact test. View Large The prevalence of trauma, enamel defects, and headache were low in all three groups, and without any significant inter-group differences (Table 1). All children in the UPC group had moderate to severe treatment need indicating that the crossbite was of functional disturbing nature, i.e. a forced guidance of the mandible deviating the midline of the mandible to the crossbite side. In the EO group, all children had severe to extreme treatment need due to the EO, while in the NO group the children showed no or mild orthodontic treatment need (IOTN-DHC 1 or 2), Table 1. Furthermore, in each group there were few children with mild to moderate crowding or spacing in the aesthetic zone and with no inter-group differences. Oral health-related quality of life (OHRQoL) There were no dropouts, all questionnaires were completely filled in, and none had to be excluded due to missed data. The total CPQ mean score was 5.1 for the UPC group, 7.4 for the EO group, and 4.4 for the NO group. The EO group had significant higher total CPQ mean score than the UPC group (P = 0.048) and the EO group also had significantly higher total CPQ mean score than the normal group (P = 0.012), see Table 2 and Figure 1. No gender differences were found. Table 2. CPQ8-10 scores for the three groups; excessive overjet (EO), unilateral posterior crossbite (UPC), and normal occlusion (NO). CPQ total Oral symptoms (OS) Functional limitations (FL) Emotional well-being (EW) Social well-being (SW) Mean SD Mean SD Mean SD Mean SD Mean SD EO (N = 71) 7.4 8.2 3.9 2.7 1.2 1.8 1.2 2.4 1.2 3.2 UPC (N = 93) 5.1 5.1 3.3 2.7 0.9 1.6 0.5 1.2 0.5 0.8 NO (N = 65) 4.4 5.2 3.0 2.7 0.7 1.3 0.5 1.8 0.2 0.8 p-level when adjusted for possible confounders (caries, trauma, MIH, headache)a EO versus UPC EO versus UPC EO versus NO P = 0.048b P = 0.039b P = 0.012b EO versus NO P = 0.012b CPQ total Oral symptoms (OS) Functional limitations (FL) Emotional well-being (EW) Social well-being (SW) Mean SD Mean SD Mean SD Mean SD Mean SD EO (N = 71) 7.4 8.2 3.9 2.7 1.2 1.8 1.2 2.4 1.2 3.2 UPC (N = 93) 5.1 5.1 3.3 2.7 0.9 1.6 0.5 1.2 0.5 0.8 NO (N = 65) 4.4 5.2 3.0 2.7 0.7 1.3 0.5 1.8 0.2 0.8 p-level when adjusted for possible confounders (caries, trauma, MIH, headache)a EO versus UPC EO versus UPC EO versus NO P = 0.048b P = 0.039b P = 0.012b EO versus NO P = 0.012b aGeneral linear model. bTukey’s test. View Large Table 2. CPQ8-10 scores for the three groups; excessive overjet (EO), unilateral posterior crossbite (UPC), and normal occlusion (NO). CPQ total Oral symptoms (OS) Functional limitations (FL) Emotional well-being (EW) Social well-being (SW) Mean SD Mean SD Mean SD Mean SD Mean SD EO (N = 71) 7.4 8.2 3.9 2.7 1.2 1.8 1.2 2.4 1.2 3.2 UPC (N = 93) 5.1 5.1 3.3 2.7 0.9 1.6 0.5 1.2 0.5 0.8 NO (N = 65) 4.4 5.2 3.0 2.7 0.7 1.3 0.5 1.8 0.2 0.8 p-level when adjusted for possible confounders (caries, trauma, MIH, headache)a EO versus UPC EO versus UPC EO versus NO P = 0.048b P = 0.039b P = 0.012b EO versus NO P = 0.012b CPQ total Oral symptoms (OS) Functional limitations (FL) Emotional well-being (EW) Social well-being (SW) Mean SD Mean SD Mean SD Mean SD Mean SD EO (N = 71) 7.4 8.2 3.9 2.7 1.2 1.8 1.2 2.4 1.2 3.2 UPC (N = 93) 5.1 5.1 3.3 2.7 0.9 1.6 0.5 1.2 0.5 0.8 NO (N = 65) 4.4 5.2 3.0 2.7 0.7 1.3 0.5 1.8 0.2 0.8 p-level when adjusted for possible confounders (caries, trauma, MIH, headache)a EO versus UPC EO versus UPC EO versus NO P = 0.048b P = 0.039b P = 0.012b EO versus NO P = 0.012b aGeneral linear model. bTukey’s test. View Large Figure 1. View largeDownload slide CPQ8-10 total score for children with unilateral posterior crossbite (UPC), excessive overjet (EO), and normal occlusion (NO). A significant difference (P = 0.048) in mean total CPQ score between EO and UPC was found, there was also a difference between EO and NO (P = 0.012) but not for UPC and NO. Figure 1. View largeDownload slide CPQ8-10 total score for children with unilateral posterior crossbite (UPC), excessive overjet (EO), and normal occlusion (NO). A significant difference (P = 0.048) in mean total CPQ score between EO and UPC was found, there was also a difference between EO and NO (P = 0.012) but not for UPC and NO. For the UPC group, the mean subscale score was 3.3 for OSs, 0.9 for FLs, and 0.5 for emotional and 0.5 for SW (Table 2). The corresponding data for the EO group was 3.9, 1.2, 1.2, 1.2, and for the NO group 3.0, 0.7, 0.5, and 0.2. The children with EO reported significantly higher scores in the domains EW compared to UPC-group (P = 0.039) and SW compared to NO-group (P = 0.012) (Table 2). For the domains OS and FL, no significant differences were detected between the groups. When corrections were made for the background variables/possible confounders; gender, caries, trauma, enamel defects, and headache, the significant difference between the groups still remained (Table 2). Headache was the only variable that showed significant negative impact on the OHRQoL and that in the domain OS (P < 0.05). Discussion This study analyzed the impact a UPC with functional shift or an EO may have on young children’s OHRQoL and comparisons were also made to children with no or mild orthodontic treatment need. The main finding was that children with EO reported a lower self-perceived OHRQoL when compared with children with unilateral posterior cross-bite or children with no or mild orthodontic treatment need. In addition, no difference in OHRQoL could be detected between children with UPC and children with no or mild orthodontic treatment need. These findings support our hypothesis and are accordance with earlier research stating that malocclusions in the aesthetic zone have a negative impact on OHRQoL (10). The negative impact was evident in the domains of SW and EW. Perhaps not an unexpected finding, but an important finding seen in the context of the young age of the patients. A somewhat surprising result was that children with UPC did not show reduced OHRQoL compared to children with no or mild orthodontic treatment need. The explanation may be that children with crossbite are not yet aware of their malocclusion, or that the functional disturbance associated has not yet caused any problems that have reflected in reduced OHRQoL among the children with UPC. Although the primary aim of this study was to compare children with EO and children with UPC as well as with children with NO, the children in the EO group also had significant increased overbite which may influence the OHRQoL. In addition, few children in each group without any inter-group differences showed small amount of crowding and spacing, having no influence on OHRQoL. Assessing OHRQoL, by the use of CPQ8-10, revealed generally low scores for the children participating in this study. This indicates that the children, even though the presence of malocclusions with severe to moderate orthodontic treatment need, perceive themselves of having an overall fairly good OHRQoL. It can also be underlined that there is no clear correlation or pattern between high IOTN scores and low OHRQoL (22). One possible explanation for the generally low CPQ scores found in this study is the low prevalence of caries among the children. Children with caries are more likely to show a reduced OHRQoL and when compared with dental trauma or malocclusions, caries may have as much as twice the negative impact on OHRQoL (23). A target has been set by WHO, namely by year 2020, the average amount of caries measured as decade filled teeth in European 12-year-olds should not exceed 1.5. This ambition has already been achieved in Sweden since the year 1995 (24). Accordingly, no caries was found in the aesthetic zone in any of the children participating in this study. Other important confounders that may impair OHRQoL are dental fear and dental pain (12). Age presents a negative correlation, as the risk for dental fear and potential behaviour management problems increases as the child’s age decreases (25). In this study, all young children had together with their parents voluntarily accepted to participate in an additional clinical examination including impressions for study casts and all children fulfilled the examinations and impressions without any problems. Thus, although not objectively verified, the children in this study did not show any signs of dental fear. As shown in Figure 1, one child in the EO group and one in the normal group reported obvious high CPQ scores. To prevent misinterpretations of the results, the statistical analyses were repeated without these outliers. The result prevailed, implying that the group with EO still without the outlier presented significantly higher total CPQ score and higher scores in the domains of emotional and functional well-being when compared with the other groups. There were rather few children reporting headache and there was no difference between the groups regarding the prevalence of headache. However, the only confounder in this study that exhibit to have a significant negative impact was headache. Hence, headache reduced OHRQoL, and especially for the domain OS. The impact of headache on OHRQoL is in accordance with other studies using the CPQ, however performed with older children (22). Migraine and tension-type headache are the most common types of headache in children, and can have a profound effect on the child, nevertheless the aetiology is usually medical or psychosocial (26). Self-perceived orthodontic treatment need differs for children from different cultures (27). OHRQoL might also be affected by confounders that may be dependent upon cultural or social context (11, 12). The need for studies from different countries has been advocated since most available research regarding children and their self-perceived OHRQoL has been conducted in Brazil (10). A potential demographic impact is displayed when the children in this study scored lower on the CPQ, i.e. reported better OHRQoL than Brazilian peers with no need for orthodontic treatment (28). Whether this is due to differences regarding confounders is unclear. The strengths of this study were the number of children participating and the well-defined groups including a NO group with no or mild orthodontic treatment need. Moreover, there were no dropouts in this study, and clinical routines ensured that the children were able to respond to the questionnaire without the involvement of parents. In addition, the children were recruited from several clinics located in different communities to ensure an appropriate socioeconomic scope. Finally, the examiners were calibrated before evaluating clinical data and the influence of possible confounders was low. The study would further be strengthened if psychological characteristics such as psychological well-being and self-esteem were incorporated. These dimensions have been shown to influence the OHRQoL for adolescents (29). Finally, a longitudinal study design would also strengthen the study. However, evaluating changes over time would mean postponing interventions for children with severe orthodontic treatment need. Conclusions Young children with EO reported significantly lower self-perceived OHRQoL compared to children with UPC with functional shift or children with NO and with no or mild orthodontic treatment need. No difference regarding self-perceived OHRQoL could be detected between children with UPC with functional shift when compared with children with NO and with no or mild orthodontic treatment need. However, despite the presence of malocclusions, the children generally reported low CPQ scores which imply an overall fairly good self-perceived OHRQoL. Funding This study was supported by the European Orthodontic Society Research Grant (2015) and the Region Halland and Region Östergötland, Sweden. Conflict of interest None to declare. Acknowledgements Our gratitude to the patients and their parents for participating in this study. References 1. http://www.who.int/oral_health/en/://www.who.int/oral_health/en/ ( 24 March 2017 , date last accessed). 2. Helm , S . ( 1968 ) Malocclusion in Danish children with adolescent dentition: an epidemiologic study . American Journal of Orthodontics , 54 , 352 – 366 . Google Scholar Crossref Search ADS PubMed 3. Thilander , B. and Myrberg , N . ( 1973 ) The prevalence of malocclusion in Swedish schoolchildren . Scandinavian Journal of Dental Research , 81 , 12 – 21 . Google Scholar PubMed 4. Thilander , B. , Pena , L. , Infante , C. , Parada , S.S. and de Mayorga , C . ( 2001 ) Prevalence of malocclusion and orthodontic treatment need in children and adolescents in Bogota, Colombia. 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The European Journal of Orthodontics – Oxford University Press
Published: Mar 29, 2019