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Effect of malocclusion severity on oral health-related quality of life and food

intake ability in a Korean population

Article in American Journal of Orthodontics and Dentofacial Orthopedics · January 2016

DOI: 10.1016/j.ajodo.2015.08.019

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ORIGINAL ARTICLE

Effect of malocclusion severity on oral

health–related quality of life and food
intake ability in a Korean population
Sung-Hwan Choi,a Jung-Suk Kim,b Jung-Yul Cha,c and Chung-Ju Hwangd
Seoul and Seongnam, Korea

Introduction: The aim of this study was to evaluate the effect of malocclusion severity on oral health–related
quality of life and food intake ability in adult patients, controlling for sex, age, and the type of dental clinic visited.
Methods: The sample consisted of 472 Korean patients (156 male, 316 female) with a mean age of 21.1 (SD,
8.6) years in a dental hospital and a private clinic. The correlations between the Korean version of the Oral Health
Impact Profile-14 (OHIP-14K), subjective food intake ability (FIA) for 5 key foods, and Index of Orthodontic
Treatment Need-Dental Health Component (IOTN-DHC) were investigated. Results: The mean IOTN-DHC
and OHIP-14K scores were significantly higher for the dental hospital patients than for the private clinic
patients (IOTN-DHC, P \0.001; OHIP-14K, P \0.05). Malocclusion severity was significantly higher in male
than in female subjects (P \0.001). Older patients perceived their oral health–related quality of life more
negatively than did the teens (P \0.001). As the severity of the malocclusion increased, oral health–related
quality of life and masticatory function worsened (OHIP-14K, P \0.001; FIA, P \0.05). Conclusions: As the
severity of the malocclusion and the age of the patients increased, oral health–related quality of life and masti-
catory function relatively deteriorated. This finding provides evidence that severe malocclusions are associated
with lower quality of life and less masticatory efficiency in older patients. (Am J Orthod Dentofacial Orthop
2016;149:384-90)

P
eople with a severe malocclusion can be less self- by esthetic improvement after orthodontic treatment as
confident in social relationships because of their well as improvement in oral function.1,2
dentition and facial morphology, since a severe Previous epidemiologic investigations on oral health
malocclusion can affect how a person is perceived in a have depended on clinical indexes, such as the Commu-
negative manner throughout his or her entire life. von nity Periodontal Index of Treatment Needs or the De-
Wezel et al1 reported that facial satisfaction is a signifi- cayed, Missing, and Filled teeth index.3 Consequently,
cant predictor for all expectations of orthodontic treat- these studies have limitations because of the emphasis
ment in subjects 17 years and older. Thus, patients only on the presence or absence of oral disease. To over-
with a severe malocclusion expect psychological comfort come these limitations, the oral health–related quality of
life (OHRQoL) index was introduced and has recently
a
Fellow, Department of Orthodontics, The Institute of Cranial-Facial Deformity, gained more attention. OHRQoL is defined as the
College of Dentistry, Yonsei University, Seoul, Korea. “absence of physical and psychological negative effects
b
Private practice, Seongnam, Korea. by oral health status in daily life and self-confidence
c
Associate professor, Department of Orthodontics, The Institute of Cranial-Facial
Deformity, College of Dentistry, Yonsei University, Seoul, Korea. about the maxillofacial region.”4 Patients desire ortho-
d
Professor, Department of Orthodontics, The Institute of Cranial-Facial dontic treatment to gain psychological stability by func-
Deformity, College of Dentistry, Yonsei University, Seoul, Korea. tional and esthetic improvements instead of merely
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported. treating oral disease.5 Thus, OHRQoL may be the most
Supported by a research grant from the Korean Association of Orthodontists appropriate method to measure the necessity for and
Foundation. the results of orthodontic treatment.6-9
Address correspondence to: Chung-Ju Hwang, Department of Orthodontics, The
Institute of Cranial-Facial Deformity, College of Dentistry, Yonsei University, A person's self-perceived masticatory function has a
50-1 Yonsei-ro, Seodaemun-gu, Seoul 120 752, Korea; e-mail, [email protected]. great effect on his or her daily life.10 An improvement
Submitted, May 2015; revised and accepted, August 2015. in masticatory function by orthodontic treatment can
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists. maintain the healthy status of patients via the intake
http://dx.doi.org/10.1016/j.ajodo.2015.08.019 of various foods and improvement in their quality of
384
Choi et al 385

life.11 Masticatory function can be evaluated by subjec-

Table I. Characteristics of the subjects
tive and objective methods. Subjective methods measure
masticatory function using a questionnaire or an inter- Private Hospital Total P value
view to determine food intake ability (FIA) of various Total 244 (51.7) 228 (48.3) 472 (100)
types of foods. Clinically, the FIA questionnaire was Sex \0.001
Female 188 (59.5) 128 (40.5) 316 (66.9)
developed as a simple and easy method to assess subjec-
Male 56 (35.9) 100 (64.1) 156 (33.1)
tive masticatory function.12 Age (y) 0.057
The aim of this study was to investigate the effects of Teens 97 (45.3) 117 (54.7) 214 (45.3)
malocclusion severity on OHRQoL and chewing ability. 20-29 111 (57.2) 83 (42.8) 194 (41.1)
The Korean version of the Oral Health Impact Profile- 30-39 28 (60.9) 18 (39.1) 46 (9.7)
Over 40 8 (44.4) 10 (55.6) 18 (3.8)
14 (OHIP-14K) survey was used to evaluate OHRQoL,
and the FIA questionnaire was used to evaluate chewing Values are presented as number (%). P values were calculated with
ability in patients who came for orthodontic treatment. the chi-square test.
The null hypothesis was that malocclusion severity was
not correlated with OHRQoL and FIA in patients, con-
trolling for sex, age, and type of dental clinic visited. 0, never; 1, hardly ever; 2, occasionally; 3, fairly often;
and 4, very often. The OHIP-14K total score was calcu-
MATERIAL AND METHODS lated as the sum of the 14 scores, generating scores from
This study was a cross-sectional evaluation of 472 0 to 56, with higher scores indicating poor OHRQoL.
patients aged 21.1 6 8.6 years who visited the Depart- To evaluate subjective masticatory ability, the FIA
ment of Orthodontics at Yonsei University Dental Hospi- self-assessed questionnaire requested the patients'
tal in Seoul, Korea, and private clinics in Gyeonggi masticatory abilities for 5 key foods (dried cuttlefish,
province from April 2012 to January 2014. In this study, raw carrots, peanuts, cubed white radish kimchi, and
228 patients were from the dental hospital, and 244 pa- caramel) according to previous studies.15,16 The
tients were from the private practices (316 female, 156 subjects answered the FIA questionnaires using a 5-
male) (Table I). point Likert scale: cannot chew at all (1 point), difficult
Patients with the following conditions were excluded to chew (2 points), cannot say either way (3 points), can
from this study: (1) severe dentofacial anomalies, chew some (4 points), and can chew well (5 points). The
including cleft lip and palate; (2) current or past history total FIA score was calculated as the average of the 5 key
of orthodontic treatment and orthognathic surgery; and foods, which generated scores from 5 to 25, with higher
(3) serious medical conditions for which they had been scores indicating good chewing ability. A lower score
hospitalized in the past 3 months, or patients taking indicated poor chewing ability.
medications. These criteria were used to form a homoge- The Dental Health Component of the Index of Ortho-
neous group by excluding factors affecting the partici- dontic Treatment Need (IOTN-DHC) involves an assess-
pants' quality of life. This study was performed with ment of the following 10 malocclusion traits: overjet,
the understanding of each participant, and written reverse overjet, overbite, open bite, crossbite, crowding,
informed consent was obtained from each subject. impeded eruption, cleft lip and palate defects or other
This study followed the guidelines of the Declaration craniofacial anomalies, Class II and Class III buccal oc-
of Helsinki and was approved (2-2013-0052) by the clusions, and hypodontia.17 The IOTN-DHC consists of
institutional review board of Yonsei University Dental 5 grades. Grades 1 and 2 describe conditions that do
Hospital. not require treatment or require minimal treatment.
Data were collected in face-to-face interviews. Dur- Grade 3 describes a moderate or borderline need for
ing the interviews, the patients provided information treatment. Grades 4 and 5 describe conditions that
on their sex and age. OHRQoL was assessed using the require treatment.
OHIP-14K questionnaire, which was previously trans- For the OHIP-14K and the FIA questionnaire, the reli-
lated and validated.13 All 14 OHIP-14K questions asked ability of internal consistency was verified by measuring
how frequently the patient had experienced an adverse the Cronbach a coefficient. Forty people who did not
effect from oral conditions during the preceding participate in this study were randomly selected and reex-
3 months.14 The 14 questions covered these 7 domains amined 2 weeks after their initial examination. The Cron-
of oral health: functional limitation, physical pain, psy- bach a values were 0.860 for the OHIP-14K and 0.886 for
chological discomfort, physical disability, psychological the FIA questionnaire. The IOTN-DHC was measured by
disability, social disability, and handicap. The responses 2 trained and calibrated orthodontists (J-S.K., J-Y.C.).
were recorded with a Likert-type scale coded as follows: To assess interexaminer and intraexaminer reliability,

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Table II. Descriptive statistic values by IOTN-DHC, OHIP-14, and FIA questionnaire according to the type of clinic
Total Private Hospital P value
IOTN-DHC n (%) \0.001*
Grade 1 39 (8.3) 38 (15.6) 1 (0.4)
Grade 2 94 (19.9) 72 (29.5) 22 (9.6)
Grade 3 137 (29.0) 69 (28.3) 68 (29.8)
Grade 4 134 (28.4) 65 (26.6) 69 (30.3)
Grade 5 68 (14.4) 0 (0.0) 68 (29.8)
Median 3 3 4
Mean rank 175.67 301.60 \0.001y
OHIP-14
Total 8.32 (7.35) 7.55 (5.89) 9.15 (8.59) 0.019
Functional limitation 0.61 (0.68) 0.56 (0.60) 0.68 (0.75) 0.057
Physical pain 0.78 (0.82) 1.46 (1.48) 0.83 (0.89) 0.189
Psychological discomfort 0.94 (0.96) 1.08 (1.08) 1.60 (1.63) 0.002
Physical disability 0.61 (0.78) 1.10 (1.41) 0.67 (0.85) 0.104
Psychological disability 0.45 (0.63) 0.88 (1.18) 0.46 (0.67) 0.733
Social disability 0.45 (0.67) 0.83 (1.18) 0.49 (0.75) 0.241
Handicap 0.33 (0.60) 0.57 (0.99) 0.38 (0.67) 0.093
FIA 22.15 (3.82) 22.24 (3.95) 22.07 (3.69) 0.625
Data are presented as means and standard deviations unless otherwise noted. Group comparisons were performed with the independent t test unless
otherwise noted.
*P values were calculated with the chi-square test; yP values were calculated with the Mann-Whitney U test.

the kappa values were 0.99 for interrater reliability and RESULTS
0.988 and 0.99 for intrarater reliability.18 There were sex differences in patients between the
dental hospital and the private clinics. The proportion
Statistical analysis of female patients in private clinics was greater than in
All statistical analyses were performed with SPSS the dental hospital (P \0.001). However, there was no
software for Windows (version 21.0; SPSS, Chicago, statistically significant difference in age between the 2
Ill). The Kolmogorov-Smirnov test was applied to clinics (Table I).
confirm the data distribution and normality. Malocclusion severity was significantly greater in the
Descriptive analyses, including the means and stan- dental hospital patients (mean rank, 301.60) than in the
dard deviations, were performed with respect to general private clinic patients (mean rank, 175.67) (P \0.001)
characteristics, including sex and age, type of orthodon- (Table II). The proportion of patients with severe maloc-
tic clinic visited (dental hospital or private clinic), IOTN- clusion was significantly higher in the dental hospital
DHC, OHIP-14K, and FIA questionnaire. The chi-square than in the private clinic (P \0.001). One hundred
test, Mann-Whitney U test, independent t test, or 1-way thirty-seven patients (60.1%) in the dental hospital
analysis of variance was used to evaluate the differences were scored at grades 4 and 5. Patients in the dental hos-
in the IOTN-DHC, OHIP-14K, and FIA questionnaire ac- pital had significantly greater mean OHIP-14K total
cording to sex, age, and type of orthodontic clinic. scores than did the patients in the private clinics
Spearman rank correlation coefficients were used to (P \0.05).
examine relationships between the variables. To assess Malocclusion severity was significantly higher in
the strength of the correlation, r .0.50 was considered male subjects (mean rank, 279.75) than in female sub-
to indicate a moderate to strong correlation, and jects (mean rank, 215.15) (P\0.001) (Table III). The pro-
r \0.50 indicated a weak correlation.19 Multiple linear portion of male patients with a severe malocclusion was
regression analysis was used to investigate the effects significantly higher than female patients (P \0.001).
of malocclusion severity on quality of life and mastica- Ninety males (57.7%) were scored at grades 4 and 5.
tory function, controlling for sex, age, and type of dental There was no difference in total OHIP-14K scores and
clinic. The selected independent variables for sex and the subdomains between the sexes.
type of clinic were categorized on the basis of data dis- Among the questions regarding quality of life, pa-
tributions to facilitate analytic analyses as follows: sex tients in their teens positively assessed their OHRQoL
(female, 0; male, 1) and type of clinic (private, 0; dental in 6 subdomains except for the physical pain domain.
hospital, 1). In contrast, other age groups had a relatively negative

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Choi et al 387

Table III. Descriptive statistical values by IOTN-DHC, OHIP-14, and FIA questionnaire according to sex
Total Female Male P value
IOTN-DHC n (%) \0.001*
Grade 1 39 (8.3) 35 (11.1) 4 (2.6)
Grade 2 94 (19.9) 70 (22.2) 24 (15.4)
Grade 3 137 (29.0) 99 (31.3) 38 (24.4)
Grade 4 134 (28.4) 78 (24.7) 56 (35.9)
Grade 5 68 (14.4) 34 (10.8) 34 (21.8)
Median 3 3 4
Mean rank 215.15 279.75 \0.001y
OHIP-14K
Total 8.32 (7.35) 8.25 (7.26) 8.47 (7.55) 0.759
Functional limitation 0.61 (0.68) 0.60 (0.66) 0.63 (0.72) 0.643
Physical pain 0.78 (0.82) 0.78 (0.85) 0.78 (0.75) 0.930
Psychological discomfort 0.94 (0.96) 0.94 (0.94) 0.92 (1.01) 0.849
Physical disability 0.61 (0.78) 0.59 (0.79) 0.65 (0.75) 0.407
Psychological disability 0.45 (0.63) 0.46 (0.63) 0.42 (0.62) 0.489
Social disability 0.45 (0.67) 0.45 (0.67) 0.46 (0.68) 0.873
Handicap 0.33 (0.60) 0.31 (0.59) 0.37 (0.63) 0.309
FIA 22.15 (3.82) 22.12 (3.88) 22.22 (3.72) 0.798
Data are presented as means and standard deviations unless otherwise noted. Group comparisons were performed with the independent t test unless
otherwise noted.
*P values were calculated with the chi-square test; yP values were calculated with the Mann-Whitney U test.

Table IV. Descriptive statistical values by IOTN-DHC, OHIP-14, and FIA questionnaire according to age
Total Teensa 20–29b 30–39c Over 40d P value Post hoc
IOTN-DHC
Median 3 3 3 3 3
Mean rank 194.86 211.52 221.5 258.97 0.006 d.b,c.a*
OHIP-14K
Total 8.32 (7.35) 6.90 (6.46) 9.04 (7.58) 11.76 (8.85) 8.83 (7.21) \0.001 c.b,d.a
Functional limitation 0.61 (0.68) 0.55 (0.64) 0.64 (0.71) 0.87 (0.70) 0.47 (0.63) 0.021 c.a,b.d
Physical pain 0.78 (0.82) 0.75 (0.77) 0.75 (0.85) 1.09 (0.86) 0.67 (0.87) 0.057
Psychological discomfort 0.94 (0.96) 0.73 (0.87) 1.12 (1.01) 1.10 (1.07) 1.00 (0.79) \0.001 b,c.d.a
Physical disability 0.61 (0.78) 0.48 (0.73) 0.66 (0.77) 0.91 (0.96) 0.67 (0.79) 0.003 c.b,d.a
Psychological disability 0.45 (0.63) 0.33 (0.54) 0.52 (0.66) 0.71 (0.74) 0.44 (0.62) \0.001 c.b,d.a
Social disability 0.45 (0.67) 0.37 (0.60) 0.48 (0.72) 0.67 (0.70) 0.56 (0.73) 0.031 c.b,d.a
Handicap 0.33 (0.60) 0.24 (0.53) 0.36 (0.60) 0.53 (0.81) 0.61 (0.72) 0.003 d.c.a,b
FIA 22.15 (3.82) 22.43 (3.41) 22.31 (3.69) 20.85 (4.70) 20.61 (6.08) 0.021 a.c

Data are presented as means and standard deviations unless otherwise noted. P values were calculated with 1-way ANOVA and the Scheff
e test
unless otherwise noted.
*Kruskal-Wallis test with the Bonferroni correction.

view of their quality of life. In particular, with regard to IOTN-DHC and the OHIP-14K (r, 0.135; P \0.01). A
psychological discomfort, the OHRQoL was assessed weak negative relationship was observed between the
negatively in patients in their 20s or older compared IOTN-DHC and the FIA questionnaire (r, 0.141;
with patients in their teens (P \0.001). Regarding the P \0.01). Age and the IOTN-DHC also had a weak pos-
FIA questionnaire, masticatory function was signifi- itive relationship (r, 0.174; P \0.01) (Table V).
cantly higher in patients in their teens than in those in To investigate factors affecting the OHIP-14K and
their 30s (teens: mean, 22.43 6 3.41; 30s: mean, the FIA questionnaire, multiple linear regression analysis
20.85 6 4.70) (P \0.05) (Table IV). was performed using sex, age, type of clinic, and the
Spearman rank correlation coefficients were deter- IOTN-DHC as independent variables. R-square ranged
mined to evaluate the relationships among the IOTN- from 0.027 to 0.065, indicating that this association
DHC, OHIP-14K, FIA questionnaire, and other variables. was weak, although it was significant. On the basis of
A weak positive relationship was found between the the adjusted analysis, older patients were more negative

American Journal of Orthodontics and Dentofacial Orthopedics March 2016
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388 Choi et al

Table V. Correlations among IOTN-DHC, OHIP-14, FIA questionnaire, and other variables
Age Sex Clinic IOTN-DHC OHIP-14 FIA
IOTN-DHC 0.174y 0.230y 0.476y 1 0.135y 0.141y
OHIP-14 0.208y 0.003 0.109* 0.135y 1 0.360y
FIA 0.113* 0.001 0.07 0.141y 0.360y 1

Sex (female, 0; male, 1); clinic type visited (private, 0; hospital, 1). *P \0.05; yP \0.01.

selected, then the functional limitation domain of the

Table VI. Summary of adjusted multivariate regres-
OHIP-14K was also significantly different between pri-
sion analyses predicting OHIP-14 total and FIA ques-
vate clinics and the dental hospital.
tionnaire
Malocclusions were more severe in the male patients.
Variable B 95% CI P value This finding is consistent with previous studies from other
Dependent variable: OHIP-14 total countries.20,21 However, the proportion of females was
(constant) 0.821 1.867, 3.509 0.549 greater than that of males (female, 66.9%; male, 33.1%)
Age 0.184 0.107, 0.260 \0.001
in this study, although their malocclusions were
IOTN-DHC 1.133 0.570, 1.696 \0.001
Dependent variable: FIA generally milder compared with males. These results
(constant) 24.671 23.245, 26.096 \0.001 suggest that subjective psychosocial factors account for
Age 0.059 1.000, 0.019 0.004 the predominance of females seeking orthodontic
IOTN-DHC 0.395 0.693, 0.096 0.010 treatment, and little physical or anatomic basis may
exist for this sex difference.21,22 Females not only are
about OHRQoL (regression coefficient [B] 5 0.184; 95% more likely to receive orthodontic treatment, but also
confidence interval [CI], 0.107, 0.260; P \0.001) and are perceived to need orthodontic treatment more than
FIA (B 5 0.059; 95% CI, 1.000, 0.019; P \0.01). males by referring dentists.23,24
A grade increase in the IOTN-DHC, an OHIP-14K total In this study, no significant difference was found in
score greater than 1.133 (B 5 1.133; 95% CI, 0.570, OHRQoL or masticatory function between the sexes
1.696; P \0.001), and a score lower than 0.395 on (Table III). This result coincides with the study of Feu
the FIA questionnaire (B 5 0.395; 95% CI, 0.693, et al25 in which no sex difference was found among fac-
0.096; P \0.05) can be expected to represent deterio- tors where malocclusion affects quality of life. The FIA
rating conditions. In other words, as the severity of questionnaire mean score of patients with malocclusion
malocclusion increased, masticatory function and was 22.15 6 3.82 (Table IV). This indicates that the mal-
OHRQoL worsened (Table VI). occlusions of the patients who participated in this study
were not sufficiently severe to cause many oral func-
DISCUSSION tional problems in daily life.
With regard to the type of dental clinic, malocclu- In this study, most patients sought orthodontic treat-
sions were more severe in patients who visited the dental ment to improve esthetics rather than functional prob-
hospital than in those who visited a private practice lems. This result agrees with previous studies in which
(Table II). This may be because patients with a severe orthodontic patients suffered more from esthetic prob-
malocclusion decided to obtain treatment at the dental lems and social relationships than from functional
hospital by themselves, considering the severity. Alterna- discomfort.1,6 These findings were also supported by a
tively, the patient might have been transferred from the previous study in which 80% of the orthodontic
private practice because of the difficulty, although or- patients desired esthetic improvement instead of
thodontic treatment at a dental hospital is more expen- functional improvement.26 However, the masticatory
sive, and the wait time is longer until the start of abilities of patients in their 30s were also significantly
treatment compared with private clinics in Korea. lower than those of patients in their teens. Chewing ef-
Moreover, patients in dental hospitals had poor OHR- ficiency decreases as people age. This study was not per-
QoL, including the psychological discomfort domain of formed on a general population but in patients in their
the OHIP-14K, compared with those in private clinics. 30s or older, who may tend to be more dissatisfied
However, functional limitation refers to restrictions in with their chewing ability (Table IV).
bodily function, such as chewing difficulty, which was Spearman correlation analysis of each variable
not significantly different between the 2 clinics.10 This showed that as the severity of the malocclusion
may be due to the sample issue. If proper samples were increased, the OHRQoL was negatively affected and

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Choi et al 389

masticatory efficiency deteriorated, although this corre- is a key factor associated with poor OHRQoL in young
lation was weak, with correlation coefficients ranging adults without orthodontic treatment, independent of
from 0.141 to 0.135 (Table V). The reason for this sociodemographic factors and other common oral
weak correlation between OHRQoL, masticatory func- diseases.9,41 Palomares et al38 also reported that young
tion, and malocclusion severity may be due to the Brazilian adults who received orthodontic treatment
following reasons: numerous clinical and psychological had significantly better OHRQoL scores in the retention
factors are related to OHRQoL and masticatory effi- phase after treatment than did untreated subjects.
ciency27,28; and although esthetics is an important Several limitations to this study should be considered
confounding factor in OHRQoL, the esthetic when interpreting these data. First, this was an associa-
component of the IOTN and the Index of Complexity, tion and cross-sectional study. We used a sample of con-
Outcome, and Need, which is based on the esthetic venience rather than a random population-based
component of the IOTN, were not assessed in this sample. Evidence regarding the negative effects of
study.19 Because we were assessing the patients' maloc- malocclusion severity on OHRQoL or masticatory func-
clusion severity, there was a discrepancy between the tion was lacking because of the cross-sectional design
dental health and the esthetic component grades of the of this study. This may limit the ability to extrapolate
IOTN, with only moderate agreement, and these findings these findings to the general population.42 Second, there
can be contradictory.18,29 This difference between the was no control group (subjects with no malocclusion or
dental health and esthetic components reflects that the mild malocclusions) in this study. Third, to assess
latter assesses the esthetic aspects of the malocclusion normative orthodontic treatment need, the IOTN-DHC
and highlights its subjective nature.29 If the dental health was used. However, the IOTN does not record all aspects
and esthetic components of the IOTN were assessed of malocclusion, and different indexes may have
together, then OHQRoL, FIA, and severity of the maloc- different thresholds or cutoff points for consideration
clusion would have higher correlations in this study. of orthodontic treatment need.29,43 In the future,
These reasons may be a limitation of this study to assess longitudinal studies are needed to assess the cause and
the correlations of OHRQoL, FIA, and malocclusion. effect, and to evaluate the relationship between
Multiple regression analysis showed that aging and malocclusion, OHRQoL, and FIA in a random sample
severity of the malocclusion had relatively negative ef- population. In addition, the esthetic component of the
fects on OHRQoL and masticatory function (Table VI). IOTN should be measured with the IOTN-DHC because
Negative effects of malocclusion on the quality of life esthetics could be an important confounding factor in
were reported in previous studies.30-32 However, other assessing the relationship between OHRQoL, FIA, and
previous studies reported that malocclusion severity malocclusion severity.
was not related to OHRQoL.33-35 These differences arise
from the following: (1) different measuring tools were CONCLUSIONS
used to measure OHRQoL36; and (2) the ages of the Malocclusions were more severe in patients who
experimental groups were different, and racial and cul- visited the orthodontic department of a dental hospital
tural differences may have also contributed to this differ- than in patients who visited private orthodontic clinics.
ence. The frequency of malocclusion and the degree of In older groups, particularly those in their 30s, mastica-
malocclusion severity may differ by race and culture.27 tory function was decreased, and negative perceptions
When assessing the effects of malocclusion severity, of OHRQoL were increased. As the severity of the maloc-
individual characteristics and sociopsychological factors clusion increased, OHRQoL worsened and masticatory
should be considered. Importantly, persons with poor efficiency deteriorated. This finding provides evidence
OHRQoL do not always seek or want orthodontic treat- that a severe malocclusion was associated with lower
ment.37,38 Stanford et al5 reported that a normal appear- quality of life and less masticatory efficiency in older
ance seems to include biological, psychological, and patients.
social elements. Patients do not seem to recognize ab-
normality solely as discrete variations from a prescribed REFERENCES
“normal” occlusion. Some people with severe malocclu- 1. van Wezel NA, Bos A, Prahl C. Expectations of treatment and satis-
sion are indifferent to dental esthetics or are content faction with dentofacial appearance in patients applying for ortho-
with their esthetics. In contrast, some people are dontic treatment. Am J Orthod Dentofacial Orthop 2015;147:
extremely sensitive to minor irregularities in their denti- 698-703.
2. Richards MR, Fields HW Jr, Beck FM, Firestone AR, Walther DB,
tion.39,40 However, rehabilitation of OHRQoL with Rosenstiel S, et al. Contribution of malocclusion and female facial
esthetic and functional improvements by orthodontic attractiveness to smile esthetics evaluated by eye tracking. Am J
treatment can be a practical goal because malocclusion Orthod Dentofacial Orthop 2015;147:472-82.

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3. Jamieson LM, Mejia GC, Slade GD, Roberts-Thomson KF. Risk fac- 24. Sheats RD, McGorray SP, Keeling SD, Wheeler TT, King GJ.
tors for impaired oral health among 18- to 34-year-old Austra- Occlusal traits and perception of orthodontic need in eighth grade
lians. J Public Health Dent 2010;70:115-23. students. Angle Orthod 1998;68:107-14.
4. Slade GD. Assessment of oral health-related quality of life. In: 25. Feu D, de Oliveira BH, de Oliveira Almeida MA, Kiyak HA, Miguel JA.
Inglehart MR, Bagramian RA, editors. Oral health-related quality Oral health-related quality of life and orthodontic treatment
of life. Chicago: Quintessence; 2002. p. 29-46. seeking. Am J Orthod Dentofacial Orthop 2010;138:152-9.
5. Stanford ND, Ip TB, Durham J. Adult orthodontic patients' views 26. Albino JE, Cunat JJ, Fox RN, Lewis EA, Slakter MJ, Tedesco LA.
regarding dentofacial normality: a qualitative study. Am J Orthod Variables discriminating individuals who seek orthodontic treat-
Dentofacial Orthop 2014;145:287-95. ment. J Dent Res 1981;60:1661-7.
6. de Oliveira CM, Sheiham A. Orthodontic treatment and its impact 27. Clijmans M, Lemiere J, Fieuws S, Willems G. Impact of self-esteem
on oral health-related quality of life in Brazilian adolescents. J Or- and personality traits on the association between orthodontic
thod 2004;31:20-7. treatment need and oral health-related quality of life in adults
7. Liu ZJ, McGrath C, H€agg U. Changes in oral health-related quality seeking orthodontic treatment. Eur J Orthod 2015;37:643-50.
of life during fixed orthodontic appliance therapy: an 18-month 28. Emodi-Perlman A, Yoffe T, Rosenberg N, Eli I, Alter Z, Winocur E.
prospective longitudinal study. Am J Orthod Dentofacial Orthop Prevalence of psychologic, dental, and temporomandibular signs
2011;139:214-9. and symptoms among chronic eating disorders patients: a
8. Zhang M, McGrath C, H€agg U. Changes in oral health-related qual- comparative control study. J Orofac Pain 2008;22:201-8.
ity of life during fixed orthodontic appliance therapy. Am J Orthod 29. Borzabadi-Farahani A. An insight into four orthodontic treatment
Dentofacial Orthop 2008;133:25-9. need indices. Prog Orthod 2011;12:132-42.
9. Choi SH, Kim BI, Cha JY, Hwang CJ. Impact of malocclusion and 30. Bernab
e E, Sheiham A, Tsakos G, de Oliveira CM. The impact of or-
common oral diseases on oral health-related quality of life in thodontic treatment on the quality of life in adolescents: a case-
young adults. Am J Orthod Dentofacial Orthop 2015;147:587-95. control study. Eur J Orthod 2008;30:515-20.
10. Lee IC, Yang YH, Ho PS, Lee IC. Chewing ability, nutritional status 31. Foster Page LA, Thomson WM, Jokovic A, Locker D. Validation of
and quality of life. J Oral Rehabil 2014;41:79-86. the child perceptions questionnaire (CPQ 11-14). J Dent Res 2005;
11. Appollonio I, Carabellese C, Frattola A, Trabucchi M. Dental status, 84:649-52.
quality of life, and mortality in an older community population: a 32. Heravi F, Farzanegan F, Tabatabaee M, Sadeghi M. Do malocclu-
multivariate approach. J Am Geriatr Soc 1997;45:1315-23. sions affect the oral health-related quality of life? Oral Health Prev
12. Jeong SH, Kang SM, Ryu JH, Kwon HK, Kim BI. Subjective food Dent 2011;9:229-33.
intake ability in relation to the mixing ability index in Korean 33. de Oliveira CM, Sheiham A, Tsakos G, O'Brien KD. Oral health-
adults. J Oral Rehabil 2010;37:242-7. related quality of life and the IOTN index as predictors of children's
13. Bae KH, Kim HD, Jung SH, Park DY, Kim JB, Paik DI, et al. Valida- perceived needs and acceptance for orthodontic treatment. Br
tion of the Korean version of the oral health impact profile among Dent J 2008;204:1-5.
the Korean elderly. Community Dent Oral Epidemiol 2007;35:73-9. 34. Gururatana O, Baker SR, Robinson PG. Determinants of children's
14. Slade GD. Derivation and validation of a short-form oral health oral-health-related quality of life over time. Community Dent Oral
impact profile. Community Dent Oral Epidemiol 1997;25:284-90. Epidemiol 2014;42:206-15.
15. Kim BI, Jeong SH, Chung KH, Cho YK, Kwon HK, Choi CH. Subjec- 35. Taylor KR, Kiyak A, Huang GJ, Greenlee GM, Jolley CJ, King GJ.
tive food intake ability in relation to maximal bite force among Effects of malocclusion and its treatment on the quality of life
Korean adults. J Oral Rehabil 2009;36:168-75. of adolescents. Am J Orthod Dentofacial Orthop 2009;136:
16. Choi TH, Kim BI, Chung CJ, Kim HJ, Baik H, Park YC, et al. Assess- 382-92.
ment of masticatory function in patients with non-sagittal 36. Liu ZJ, McGrath C, H€agg U. Associations between orthodontic
occlusal discrepancies. J Oral Rehabil 2015;42:2-9. treatment need and oral health-related quality of life among
17. Brook PH, Shaw WC. The development of an index of orthodontic young adults: does it depend on how you assess them? Commu-
treatment priority. Eur J Orthod 1989;11:309-20. nity Dent Oral Epidemiol 2011;39:137-44.
18. Borzabadi-Farahani A, Borzabadi-Farahani A. Agreement between 37. Kiyak HA. Does orthodontic treatment affect patients’ quality of
the index of complexity, outcome, and need and the dental and life? J Dent Educ 2008;72:886-94.
aesthetic components of the index of orthodontic treatment 38. Palomares NB, Celeste RK, Oliveira BH, Miguel JA. How does or-
need. Am J Orthod Dentofacial Orthop 2011;140:233-8. thodontic treatment affect young adults' oral health-related qual-
19. Borzabadi-Farahani A, Borzabadi-Farahani A, Eslamipour F. The ity of life? Am J Orthod Dentofacial Orthop 2012;141:751-8.
relationship between the ICON index and the dental and aesthetic 39. Birkeland K, Boe O, Wisth P. Subjective evaluation of dental and
components of the IOTN index. World J Orthod 2010;11:43-8. psychological results after orthodontic treatment. J Orofac Orthop
20. Kataoka K, Ekuni D, Mizutani S, Tomufuji T, Azuma T, Yamane M, 1997;58:44-61.
et al. Association between self-reported bruxism and malocclusion 40. Klages U, Bruckner A, Zentner A. Dental aesthetics, self-awareness,
in university students: a cross-sectional study. J Epidemiol 2015; and oral health-related quality of life in young adults. Eur J Orthod
25:423-30. 2004;26:507-14.
21. Harris EF, Glassell BE. Sex differences in the uptake of orthodontic 41. Masood Y, Masood M, Zainul NN, Araby NB, Hussain SF,
services among adolescents in the United States. Am J Orthod Den- Newton T. Impact of malocclusion on oral health related quality
tofacial Orthop 2011;140:543-9. of life in young people. Health Qual Life Outcomes 2013;11:25.
22. Liepa A, Urtane I, Richmond S, Dunstan F. Orthodontic treatment 42. Borzabadi-Farahani A. A review of the oral health-related evidence
need in Latvia. Eur J Orthod 2003;25:279-84. that supports the orthodontic treatment need indices. Prog Orthod
23. Sheats RD, Gilbert GH, Wheeler TT, King GJ. Pilot study comparing 2012;13:314-25.
parents' and third-grade schoolchildren's attitudes toward braces 43. Borzabadi-Farahani A. A review of the evidence supporting the
and perceived need for braces. Community Dent Oral Epidemiol aesthetic orthodontic treatment need indices. Prog Orthod 2012;
1995;23:36-43. 13:304-13.

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Vol 149
Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
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