|Year : 2017 | Volume
| Issue : 2 | Page : 69-74
Orthodontic treatment need and self-perceived psychosocial impact of dental esthetics in a university adult population in Malaysia
Sneha Ravindranath1, James Tan Shou En2, Allan Pau Kah Heng3
1 Senior Lecturer, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
2 BDS Student, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
3 Associate Dean, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
|Date of Submission||02-Nov-2016|
|Date of Acceptance||17-Jan-2017|
|Date of Web Publication||17-Apr-2017|
School of Dentistry, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur
Source of Support: None, Conflict of Interest: None
Objectives: The aims of this study were to (1) determine the orthodontic treatment need in a university adult population, (2) estimate the self-perceived need for orthodontic treatment, and (3) to assess the self-reported psychosocial well-being and its association with treatment need. Subjects and Methods: Eighty-seven adults (20–70 years of age) comprising academic and corporate staff from a health science university participated in this study. The esthetic component of index of orthodontic treatment need (AC of IOTN) was used to determine the orthodontic treatment need, and a simple questionnaire was used for data on sociodemographics and self-perceived need. Psychosocial well-being was measured through the self-rated Psychosocial Impact of Dental Aesthetics Questionnaire. Data was analyzed using nonparametric Kruskal–Wallis tests with statistical significance set as P < 0.05. Results: Thirteen people (14.9%) had an orthodontic treatment need by AC of IOTN, whereas 40 (46%) perceived a need for orthodontic treatment. Age, gender, ethnicity, or marital status was not associated with treatment need. Those who had no need for treatment measured by the AC of IOTN scored significantly higher on the dental self-confidence (DSC) domain (P = 0.009) and significantly lower in the psychosocial impact domain (P = 0.048) when compared to those with treatment need. The self-perceived need was significantly associated with DSC (P = 0.000), social impact (P = 0.002), psychosocial impact (P = 0.003) as well as the esthetic concern domain (P = 0.012). Conclusion: The orthodontic treatment need perceived by the adults in this study was higher with significant impact on the psychosocial well-being. Orthodontic treatment for the patient based on the assessment of psychosocial impact would be beneficial in addressing patient's perspectives of treatment need.
Keywords: Adult orthodontics, esthetics, orthodontic treatment need, perception, psychosocial impact
|How to cite this article:|
Ravindranath S, En JT, Heng AP. Orthodontic treatment need and self-perceived psychosocial impact of dental esthetics in a university adult population in Malaysia. J Indian Orthod Soc 2017;51:69-74
|How to cite this URL:|
Ravindranath S, En JT, Heng AP. Orthodontic treatment need and self-perceived psychosocial impact of dental esthetics in a university adult population in Malaysia. J Indian Orthod Soc [serial online] 2017 [cited 2018 Apr 19];51:69-74. Available from: http://www.jios.in/text.asp?2017/51/2/69/204609
| Introduction|| |
Increasingly, more adults are seeking orthodontic treatment, and the key motivating factor has been the desire for improvement in dental appearance., The Third National Health and Nutrition Examination Survey showed that up to two-thirds of American adults had some types of malocclusion . The orthodontic treatment need of adults has been reported to be as high as 62% in Germans aged 18–39 years, 39% in Dutch adults aged 15–74 years, and 11% in Swedish adults aged over 20 years. Studies conducted on smaller cohorts of young adults in university , and male army recruits  reported treatment need ranging from 32.6% to 50.1%. Clearly, there is a clinician-determined need for orthodontic treatment in the adult population. However, the treatment need defined by various orthodontic indices measuring the normality of occlusion may not necessarily reflect the patient perceived need for treatment which is dependent on an interplay of factors including dental esthetics, psychological, social, and cultural factors. Recent studies have indicated that there is discord between the clinician-defined treatment need and patient-perceived need., Thus, moving beyond normative indices and incorporating psychosocial measures of perceived need would complement estimates of normative need.,
However, several factors affect the provision and uptake of orthodontic treatment. The uptake of orthodontic services in countries using normative indices for treatment need assessment was largely dependent on the dentist–population ratio and incorporation of psychosocial measures reflecting the perceived need did not affect treatment provision., On the other hand, a recent cross-sectional study in four specialist practices demonstrated that age, marital status, and oral health-related quality of life significantly predicted the uptake of orthodontic treatment among adults.
Among the various instruments used to assess oral health-related quality of life, the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) is reported as specific to the orthodontic aspects of quality of life in young adults. This 23-item self-rating questionnaire has been validated and applied in several populations.,,,
The published research on the orthodontic treatment need of Asian adults and its association with psychosocial impact of dental esthetics is limited. The aims of this study were to (1) determine the normative orthodontic treatment need in a university adult population using the esthetic component of the index of orthodontic treatment need (AC of IOTN) and (2) investigate its association with self-reported psychosocial impact of dental esthetics.
| Subjects And Methods|| |
Study design and sample
Institutional research ethics approval was obtained for this cross-sectional study. The sampling population comprised employees of a health sciences university, both academic and corporate. All employees were provided with information about the study and invited to participate through e-mail. Those wearing dentures replacing anterior teeth or currently undergoing orthodontic treatment were excluded from the study. Participants who had or may have undergone orthodontic treatment in the past were not excluded, but this information was obtained in the questionnaire. Potential participants were assured confidentiality and consent was obtained from those who volunteered.
A questionnaire asking for information on sociodemographics, history of orthodontic treatment, self-perceived need, and the 23-item PIDAQ was e-mailed to the participants with a link to an online survey tool (SurveyMonkey ®). The demographic information collected was age, sex, occupation, namely academic or corporate, ethnicity, and marital status. The self-perceived need was obtained by a simple question, “Do you think you need orthodontic treatment?” with responses of “yes,” “no,” or “maybe.” The PIDAQ consisted of four subscales, namely, dental self-confidence (DSC, 6 items), social impact (SI, 8 items), psychological impact (PI, 6 items), and esthetic concern (AC, 3 items). A 5-point Likert scale, with responses of 0 = not at all; 1 = a little; 2 = somewhat; 3 = strongly; and 4 = very strongly was used.
A face-to-face meeting was arranged with the participants after completion of the questionnaire. A frontal smile photograph of the anterior dentition was taken using the Shofu EyeSpecial C-II camera with the patient smiling with sufficient anterior teeth display. The photographs were graded using the AC of IOTN by an orthodontist who was blinded to the questionnaire responses. Photographs scoring 1–4 represented “no need for treatment,” 5–7 “borderline need,” and 8–10 “definite need for treatment” on esthetic grounds. The AC of IOTN was chosen as it reflects the esthetic impairment which is the primary reason for seeking orthodontic treatment among adults. It has also been shown to be consistent with the patient's rating based on the category criterion., The examiner rating of AC of IOTN is shown to have a predictive probability of 75.7% for the uptake of orthodontic services and is, hence, a reliable tool for epidemiological survey purposes.
PASW Statistics version 18.0 (IBM Inc., Armonk, NY, USA) was used for the data analysis. Chi-square test was applied to evaluate any significant differences between the treatment need based on the demographic variables. Tests of normality showed that the data were not normally distributed. Therefore, the PIDAQ subscale scores were compared with the normative and self-perceived treatment need using nonparametric Kruskal–Wallis tests. A probability at the 5% level or less (P ≤ 0.05) was considered statistically significant.
| Results|| |
A total of 87 adults aged 20–70 years consented to participate in this study. According to the AC of IOTN assessment of participants' photographs, only three (3.4%) had a definite need and ten (11.5%) had a borderline need. However, self-perceived need was reported by 29 (33.3%) participants. Age, gender, and ethnicity were not statistically significantly associated with the photographic assessment of AC of IOTN or self-perceived treatment need [Table 1]. However, 14 (56.0%) corporate staff reported treatment need compared to 15 (24.2%) academic staff (P = 0.014).
|Table 1: Association of demographic variables with the normative and self--perceived orthodontic treatment need|
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Age was not associated with expressions of PIDAQ domains, whereas females scored statistically significantly higher mean ranks for the SI (P = 0.0003), PI (P = 0.024), and AC (P = 0.023) domains when compared to males. Corporate staff tended to report statistically significantly higher SI (P = 0.005), PI (P = 0.006), and AC (P = 0.000) mean ranks than reported by academics. Participants who were single or divorced were more likely to have a higher SI (P = 0.037) and PI (P = 0.004) when compared to the married participants and participants who were married were also more likely to report higher DSC (P = 0.026). Among the racial groups, Malays were more likely to express SI (P = 0.009) and PI (P = 0.004) when compared to Chinese, Indians, and others [Table 2].
|Table 2: Comparison of mean ranks of Psychosocial Impact of the Dental Aesthetics Questionnaire domains between sociodemographic characteristics|
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Normative treatment need determined by AC of IOTN was found to be significantly associated with only the DSC (P = 0.015), whereas self-reported need was significantly associated with all the domains of PIDAQ [Table 3] and [Table 4].
|Table 3: Comparison of mean ranks of the Psychosocial Impact of Dental Aesthetics Questionnaire domains between normative need with esthetic component of index of orthodontic treatment need|
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|Table 4: Comparison of mean ranks of the Psychosocial Impact of Dental Aesthetics Questionnaire domains between self--perceived orthodontic treatment need|
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| Discussion|| |
This study was conducted to estimate the orthodontic treatment need of adults employed in a university in Malaysia. The key findings were that nearly half the sample self-perceived orthodontic treatment need whereas only 15% were considered having AC of IOTN need, and self-perceived was associated with all domains of the PIDAQ, whereas AC of IOTN need was associated with low DSC.
The prevalence of normative need estimated in the present study was much lower when compared to similar university cohorts where the treatment need was as high as 33%., Previous studies have reported variable self-reported need ranging from 8.8% to 28%; however, in the present study, it was much higher at 45%. The self-perceived need in adults is generally lower than the normative need determined by the clinician using the dental health component. The high self-perceived need reported in the present study may be due to the normative need determined by the AC of IOTN which estimates the esthetic impairment alone while most studies have used the dental health component. It must also be noted that the age range in this study was larger than such studies in a university setting which evaluated treatment need in young adults only. In addition, in our sampling design, we did not exclude participants who have undergone orthodontic treatment, and 23 (26.4%) participants had orthodontic treatment in the past. The rationale behind this was despite previous orthodontic treatment, there may still be a perceived unmet treatment need.,
The normative need determined by AC of IOTN was not associated with any of the sociodemographic variables, and participants with a normative need were more likely to report low DSC. This finding is expected as the DSC domain is related to the emotional impact of esthetic appearance of the teeth, and AC of IOTN primarily evaluates the esthetic appearance of the dentition. This finding corroborates with previous reports that demonstrate a linear association between severity of malocclusion assessed by IOTN and the psychosocial impact measured by PIDAQ., In contrast, Kolawole et al. reported a significant association of examiner-rated AC of IOTN with all PIDAQ domains except SI. In a Brazilian study, a significant association was found between the examiner-rated esthetic impairment based on the Dental Aesthetic Index and DSC and PI. A significant association of severity of malocclusion assessed by the dental health component of IOTN and psychosocial impact assessed by the Oral Health Impact Profile-14 (OHIP-14) in Malaysian young adults (15–25 years) seeking orthodontic treatment has been demonstrated with a significant impact on the psychological discomfort domain of OHIP-14.
In the present sample, corporate staff were more likely to express self-perceived treatment need. Although corporate staff were more likely to be female, gender was not associated with self-perceived need in this study, and this is inconsistent with previous research reported a higher self-perceived need among females.,, Older adults are less likely to express self-perceived treatment need, and in this study, a similar finding was noted although not significant with a higher self-perceived need in the 21–30 age group than the older age groups. Self-perceived treatment need was significantly associated with all domains of PIDAQ, and this upholds the findings by Klages et al. as well as a similar study in Chinese adults , that participants who reported a self-perceived treatment need also demonstrated a significant psychosocial impact of the malocclusion. However, in Spanish adolescents, self-perceived treatment need measured by AC of IOTN was a predictive variable of DSC, PI, and SI domain scores but not with the AC domain. This demonstrates the variable expression of the psychosocial impact of malocclusion in different population; however, a greater association of psychosocial impact measured by PIDAQ with self-perceived need than the normative need is apparent.
Age did not affect the PIDAQ domain scores in the present study. In contrast, in an Italian population, younger adults (18–30 years) had a higher SI, whereas older adults had a significant AC. Females reported a significantly higher SI, PI, and AC in this study. A higher PI was also shown among Spanish adolescent girls. Females are generally more concerned and critical of their dental appearance compared to males. In contrast, Kolawole et al. reported no difference in the PIDAQ domains between the genders. Corporate staff members also reported a significantly higher SI, PI, and AC. Studies comparing socioeconomic status have reported no significant association to treatment need, but there have been no studies associating treatment need with the occupation. This is an interesting finding as the nature of work of a person could be an important factor affecting his psychosocial need and thereby influencing the perceived need for treatment. There was a significantly higher SI and PI among the Malay ethnic group in this study. Ethnicity has shown not to affect self-perceived need as perceptions of dental esthetics of individuals in a similar social and cultural setting may not be very different. However, the SI and PI are subjective and may be related to other psychological dimensions such as self-consciousness. DSC was significantly higher in the “married/in a relationship group,” whereas the SI and PI were higher for the “single” group. This is an important finding as physical attractiveness could influence social interactions, and for those who are single, the psychosocial impact could be much higher.
It is not unexpected that normative need determined by AC of IOTN was significantly associated with DSC, but it is interesting to note that there was no significant association with SI, PI, or AC. This could reflect the variations in individual perceptions and coping behavior. In addition, the specificity of PIDAQ in assessing psychosocial impact of malocclusion as opposed to other dental ACs such as fluorosis, stains, or color of teeth is questionable. Conversely, the self-perceived need was associated with all PIDAQ domains reflecting the significant psychosocial impact in this group. This finding underscores the importance of incorporating patient perceptions in assessing orthodontic treatment needs. However, when the patient perceived need is higher than the normative need, unrealistic expectations from the orthodontic treatment should be verified. Patients presenting an overconcern about dental malalignment of minor clinical significance may be classified as displaying a syndrome of “appearance anxiety” or body dysmorphic disorder. Such psychological problems would have to be approached carefully and may even be beyond the scope of orthodontic interventions. The findings of this study should be considered in the context of its limitations. The sample size of the present study was small and, therefore, the results cannot be generalized, but the study gives an indication of the orthodontic treatment need and its association with psychosocial impact in the Malaysian adult population that has not yet been reported.
| Conclusion|| |
Self-perceived need in this study was higher than normative need determined by AC of IOTN. Self-perceived need was associated with all domains of the PIDAQ, whereas AC of IOTN need was only associated with DSC. The orthodontic treatment need of an adult population estimated by a normative index such as the AC of IOTN may underestimate the orthodontic treatment need and the impact of malocclusion on the psychosocial well-being of the population.
Financial support and sponsorship
This study was financially supported by the International Medical University Research Grant: BDS I-01/11 (08) 2014.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pabari S, Moles DR, Cunningham SJ. Assessment of motivation and psychological characteristics of adult orthodontic patients. Am J Orthod Dentofacial Orthop 2011;140:e263-72.
Jawad Z, Bates C, Hodge T. Who needs orthodontic treatment? Who gets it? And who wants it? Br Dent J 2015;218:99-103.
Proffit WR, Fields HW Jr., Moray LJ. Prevalence of malocclusion and orthodontic treatment need in the United States: Estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg 1998;13:97-106.
Bock JJ, Czarnota J, Hirsch C, Fuhrmann R. Orthodontic treatment need in a representative adult cohort. J Orofac Orthop 2011;72:421-33.
Burgersdijk R, Truin GJ, Frankenmolen F, Kalsbeek H, van't Hof M, Mulder J. Malocclusion and orthodontic treatment need of 15-74-year-old Dutch adults. Community Dent Oral Epidemiol 1991;19:64-7.
Salonen L, Mohlin B, Götzlinger B, Helldén L. Need and demand for orthodontic treatment in an adult Swedish population. Eur J Orthod 1992;14:359-68.
Bernabé E, Flores-Mir C. Orthodontic treatment need in Peruvian young adults evaluated through dental aesthetic index. Angle Orthod 2006;76:417-21.
Chu CH, Choy BH, Lo EC. Occlusion and orthodontic treatment demand among Chinese young adults in Hong Kong. Oral Health Prev Dent 2009;7:83-91.
Soh J, Sandham A. Orthodontic treatment need in Asian adult males. Angle Orthod 2004;74:769-73.
Stanford ND, Ip TB, Durham J. Adult orthodontic patients' views regarding dentofacial normality: A qualitative study. Am J Orthod Dentofacial Orthop 2014;145:287-95.
Livas C, Delli K. Subjective and objective perception of orthodontic treatment need: A systematic review. Eur J Orthod 2013;35:347-53.
Ghijselings I, Brosens V, Willems G, Fieuws S, Clijmans M, Lemiere J. Normative and self-perceived orthodontic treatment need in 11- to 16-year-old children. Eur J Orthod 2014;36:179-85.
de Oliveira CM, Sheiham A. The relationship between normative orthodontic treatment need and oral health-related quality of life. Community Dent Oral Epidemiol 2003;31:426-36.
de Oliveira CM, Sheiham A, Tsakos G, O'Brien KD. Oral health-related quality of life and the IOTN index as predictors of children's perceived needs and acceptance for orthodontic treatment. Br Dent J 2008;204:1-5.
Mandall NA, Wright J, Conboy F, Kay E, Harvey L, O'Brien KD. Index of orthodontic treatment need as a predictor of orthodontic treatment uptake. Am J Orthod Dentofacial Orthop 2005;128:703-7.
Johal A, Joury E. What factors predict the uptake of orthodontic treatment among adults? Am J Orthod Dentofacial Orthop 2015;147:704-10.
Klages U, Claus N, Wehrbein H, Zentner A. Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults. Eur J Orthod 2006;28:103-11.
Lin H, Quan C, Guo C, Zhou C, Wang Y, Bao B. Translation and validation of the Chinese version of the psychosocial impact of dental aesthetics questionnaire. Eur J Orthod 2013;35:354-60.
Sardenberg F, Oliveira AC, Paiva SM, Auad SM, Vale MP. Validity and reliability of the Brazilian version of the psychosocial impact of dental aesthetics questionnaire. Eur J Orthod 2011;33:270-5.
Ngom PI, Attebi P, Diouf JS, Diop Ba K, Badiane A, Diagne F. Translation and cultural adaptation of a French version of the psychosocial impact of dental aesthetics questionnaire: PIDAQ. Orthod Fr 2013;84:319-31.
Spalj S, Lajnert V, Ivankovic L. The psychosocial impact of dental aesthetics questionnaire – Translation and cross-cultural validation in Croatia. Qual Life Res 2014;23:1267-71.
Grzywacz I. The value of the aesthetic component of the index of orthodontic treatment need in the assessment of subjective orthodontic treatment need. Eur J Orthod 2003;25:57-63.
Trivedi K, Shyagali TR, Doshi J, Rajpara Y. Reliability of aesthetic component of IOTN in the assessment of subjective orthodontic treatment need. J Adv Dent Res 2011;2:59-66.
Tuominen ML, Tuominen RJ. Factors associated with subjective need for orthodontic treatment among Finnish university applicants. Acta Odontol Scand 1994;52:106-10.
Bellot-Arcís C, Montiel-Company JM, Almerich-Silla JM. Psychosocial impact of malocclusion in Spanish adolescents. Korean J Orthod 2013;43:193-200.
Kolawole KA, Ayeni OO, Osiatuma VI. Psychosocial impact of dental aesthetics among university undergraduates. Int Orthod 2012;10:96-109.
Masood Y, Masood M, Zainul NN, Araby NB, Hussain SF, Newton T. Impact of malocclusion on oral health related quality of life in young people. Health Qual Life Outcomes 2013;11:25.
Svedström-Oristo AL, Pietilä T, Pietilä I, Vahlberg T, Alanen P, Varrela J. Acceptability of dental appearance in a group of Finnish 16- to 25-year-olds. Angle Orthod 2009;79:479-83.
Mandall NA, McCord JF, Blinkhorn AS, Worthington HV, O'Brien KD. Perceived aesthetic impact of malocclusion and oral self-perceptions in 14-15-year-old Asian and Caucasian children in greater Manchester. Eur J Orthod 2000;22:175-83.
Klages U, Zentner A. Dentofacial aesthetics and quality of life. Semin Orthod 2007;13:104-15.
[Table 1], [Table 2], [Table 3], [Table 4]