The psycho-social impact of malocclusions and treatment expectations of adolescent orthodontic patients

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1 European Journal of Orthodontics, 2016, doi: /ejo/cjv093 Advance Access publication 26 December 2015 Original article The psycho-social impact of malocclusions and treatment expectations of adolescent orthodontic patients Eugene Twigge*, Rachel M. Roberts**, Lisa Jamieson***, Craig W. Dreyer**** and Wayne J. Sampson***** *Department of Orthodontics, **School of Psychology, ***Australian Research Centre for Population Oral Health, ****Department of Orthodontics and *****Department of Orthodontics, The University of Adelaide, Australia Correspondence to: Craig W. Dreyer, School of Dentistry, Faculty of Health Sciences, The University of Adelaide, Adelaide 5005, Australia. Summary Objectives: To evaluate the short- and long-term orthodontic treatment (OT) expectations, malocclusion severity, and oral health-related quality of life (OHRQoL) status of adolescent patients using qualitative and quantitative methodology. Materials and methods: Adolescents (n = 105; 42 males and 63 females) aged between 12 and 17 years participated in this interview and questionnaire-based study. The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) and the Oral Impacts on Daily Performances (OIDP) scale evaluated OHRQoL status. Study casts were analysed using the Dental Aesthetics Index (DAI) and the Index of Complexity, Outcome and Need (ICON). Mann Whitney test and Spearman s correlations tested various univariate variables. Results: With similar index-determined OT need (DAI, P = and ICON, P = 0.932) females tended to have worse OHRQoL status (PIDAQ scores, P-values ranged from to and scores for the OIDP question related to smiling, laughing, and showing teeth without embarrassment, P-value = 0.015). Occlusal index scores did not have statistically significant associations with the OHRQoL scales. Better dental appearance was expected by 85 per cent of the adolescents in the short-term and by 51 per cent in the long-term after OT. The associated psycho-social expectations were: 1. improved dental self-confidence, 2. positive psychological impact/improved self-worth, and 3. positive social impact. Conclusions: Female adolescent patients tended to experience worse psycho-social impacts related to their malocclusions compared with males with similar index-determined OT need. Index-determined OT need scores did not correlate with the OHRQoL scales. Adolescent patients expected OT to improve their dental appearance and QoL aspects. Introduction The smile is considered a dynamic feature of facial and overall attractiveness and dental aesthetics is considered important for self-esteem (1 4). A prospective 20 year evaluation of the psychosocial benefits of orthodontic treatment (OT) showed that OT may improve self-esteem; however, many factors influence and maintain the psycho-social well-being of individuals (5). Importantly, the above study used quality of life (QoL) instruments that do not measure oral health directly. The motive for OT might change between adolescence to adulthood and adolescents might face pressures from social norms which could increase the desire for OT as an aesthetic adjustment strategy rather than true need (6, 7). This could explain why the dental The Author Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please journals.permissions@oup.com 593

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

3 E. Twigge et al. 595 Figure 1. Flowchart explaining the selection criteria to receive public funded OT. IOTN, Index of Orthodontic Treatment Need (42); DAI, Dental Aesthetic Index (16). Figure 2. Participant recruitment and interview component flowchart. ICON (Index of Complexity, Outcome and Need) (17) PIDAQ (Psychosocial Impact of Dental Aesthetic Questionnaire) (20), OIDP (Oral Impacts on Daily Performances) (21). Two quantitative scales, PIDAQ (20) and OIDP (21), were applied to assess patient-perceived OHRQoL impacts associated with their malocclusion. The PIDAQ questions were asked in accordance with Klages et al. (20). The PIDAQ dental self-confidence subscale scores were reverse-scored/converted to allow all of the questions to score in a positive direction. For OIDP questions, the wordings were derived from the adult (21) and child-oidp (43) scales. Positive answers to OIDP questions

4 596 European Journal of Orthodontics, 2016, Vol. 38, No. 6 were followed with frequency and severity questions suggested by Adulyanon et al. (21). Two open-ended questions, which were audio-recorded for transcription, were asked: 1. What immediate benefits do you expect from orthodontic treatment like braces? 2. What benefits do you expect from orthodontic treatment like braces in the long-term? The DAI (16) and ICON (17) instruments were used to measure objective OT need. The first author (ET) was calibrated to the gold standard in the use of the DAI and ICON indices. Fifteen study casts were randomly selected by a third party using a random number generator program to test intra-rater repeatability. The first author was blinded to the process and repeated the study cast measurements at least weeks after the initial measurements. Using Bland-Altman plots for DAI and ICON, 12 out of 15 measurements were within 1 SD for the DAI (SD of 1.6 ) and 10 out of 15 measurements were within 1 SD for ICON (SD of 5.1 ). Twenty consecutive participants were asked to repeat the OIDP and PIDAQ questionnaires at least 2 weeks after the initial interview. Thirteen participants returned the questionnaires. The test retest agreement for OIDP was 92 per cent using a binary approach. PIDAQ test retest scores were all within 2 SDs of the mean using Bland-Altman plots (SD of 2.8). The overall Cronbach alpha (CA) for OIDP was 0.59 and ranged from 0.46 to 0.62 for the individual questions. The overall CA for PIDAQ was 0.94, the CA for the subscales were: dental self-confidence (0.87), social impact (0.88), psychological impact (0.82), and aesthetic concern (0.91). Data analysis Categorical data were analysed for associations using the Mann Whitney test. Numerical data were analysed for associations using Spearman s correlations. Significance was set at P = 0.05 and correlation strengths were interpreted according to Cohen. (44) The statistical analyses were completed using SAS V9.3 (SAS Institute Inc., Cary, North Carolina, USA). Regarding the qualitative data, the first author (ET) transcribed the recorded answers to the two open-ended questions for content analysis. The aim of content analysis was to gain insight into perceived short- and long-term treatment expectations of adolescent orthodontic patients. Without a starting hypothesis, the aim was to generate a theory derived from empirical data based on the two open-ended questions. Participants responses were analysed, coded, compared, and conceptualized. Similar descriptions were grouped into categories to identify general patterns within the data. The first (ET) and second (RR) authors applied the content analysis methodology independently. They used the interview responses of 15 participants and there was excellent agreement between the authors. Results From December 2013 to August 2014, 411 new patients aged between 12 and 17 years presented for an orthodontic consultation. Of these, 105 volunteered to participate in the study, but five refused consent to have their voice recorded and were excluded from the content analysis. None of the questionnaire questions remained unanswered. Forty-two male and 63 female patients aged years participated. The mean age ( X ) and standard deviation for males were ( X 15.5 years; SD 1.4 years) and for females were ( X 15.4 years; SD 1.5 years). Participants represented different ethnic groups: Anglo- Australian (75 per cent), Vietnamese (6 per cent), Iraqi (3 per cent), Greek (2 per cent), Filipino (2 per cent), Cambodian (2 per cent), other (10 per cent) and came from 48 different Adelaide metropolitan areas and 15 country areas. The majority of patients (69 per cent) had OT need defined as highly desirable or mandatory according to the DAI (Table 1). The use of ICON cut-offs for severity and complexity scores, 94 per cent of the cases needed OT, and 69.5 per cent of cases were either difficult or very difficult (Table 1). There were no statistically significant differences between male and female DAI (P = 0.371) and ICON (P = 0.932) scores (Table 2). Therefore, any differences found between male and female subjective OT need would not be attributable to different malocclusion severities. There were significant differences between males and females for all PIDAQ variables (P-value ranged from to ) as well as one OIDP question related to smiling, laughing, and showing your teeth without embarrassment (question 5, P = 0.015) (Table 3). None of the participants considered their mouth or teeth to impact upon one OIDP daily performance: carrying out major work or social role such as studying or doing homework. When PIDAQ variables were correlated to OIDP variables, DAI and ICON, only OIDP questions five and eight related to smiling, laughing, and showing teeth without embarrassment (r = , P ) and enjoying contact with people (r = , P = ) respectively as well as the OIDP total score (r = , P = to <0.0001) showed significance for all PIDAQ variables. The two OIDP questions considered the psychosocial impact malocclusion had on individuals (Table 4). There were no statistically significant associations between OIDP variables, DAI and ICON scores, except between ICON and OIDP totals (r = 0.19, P = 0.05) and between DAI and ICON total scores (r = 0.51, P 0.001) (Table 5). The content analysis results are summarized in Figure 3 and are discussed under separate headings. Table 1. Distribution of the orthodontic treatment need and treatment complexity according to the DAI and ICON scores. Modified from Jenny and Cons (45) and Richmond (46). DAI, Dental Aesthetics Index; ICON, Index of Complexity, Outcome and Need. DAI total score (severity level) n (%) Treatment need definition No or slight treatment need Treatment is elective Treatment is highly desirable Treatment is mandatory ICON total score (severity level) n (%) Treatment need definition < Elective need Treatment need ICON total score (complexity level) n (%) Complexity definition < Easy Mild Moderate Difficult > Very difficult

5 E. Twigge et al. 597 Expected short-term (only) benefits Better oral function and oral hygiene Eight per cent of patients thought that OT would improve oral function such as better speech, better chewing, or the prevention of tooth grinding. Similarly, a number of patients thought that OT would Table 2. Associations involving gender, ICON scores and DAI scores using the Mann Whitney test. DAI, Dental Aesthetics Index; ICON, Index of Complexity, Outcome and Need. Sex Mean Std. Dev Median Min Max P-value DAI scores Female Male ICON scores Female Male Table 3. Associations involving gender and PIDAQ and OIDP variables using the Mann Whitney test for categorical data. PIDAQ, Psychosocial Impact of Dental Aesthetics Questionnaire; OIDP, Oral Impacts on Daily Performances. Variable Female (N = 63) Male (N = 42) P-value Mean Std. Dev Mean Std. Dev PIDAQ: dental self * confidence PIDAQ: social impact * PIDAQ: psychological * impact PIDAQ: aesthetic * concern PIDAQ total score * OIDP Q OIDP Q OIDP Q OIDP Q OIDP Q * OIDP Q OIDP Q OIDP Q OIDP total *Statistically significant. help them clean their teeth better (7 per cent). Quotes from the interviews support this: Hopefully, with me stop grinding, it may stop the irritating weird biting and stuff. Besides benefits like being able to clean them and being able to eat and have better speech, I think it will definitely impact how I react and, you know, socialise with people. Even though I am awkward by personality, I think having teeth that are not worrying me will make me less likely to back out of situations where I might be able to accomplish something. If I do not get braces, some teeth will probably rot (decay), because I will not be able to clean them properly. Expected long-term (only) benefits Prevent future problems with teeth A number of participants thought that OT would help prevent the deterioration of their dentition in the long-term (22 per cent). This category included patients with agenesis of permanent teeth who did not want ongoing dental treatment or maintenance. In addition, some participants thought that OT would provide motivation to look after their teeth better. Quotes from the interviews support this: If I have a better bite, my teeth will probably not wear down that much and I will therefore have less problems in the future. I will be able to keep my teeth for longer and my mouth will stay healthier and it will help me to keep them in better shape as I will have more motivation. Avoid getting braces later Some participants thought that getting braces now (during adolescence) was easier or better compared with having braces as an adult (8 per cent). For some adolescents, having OT now would allow them to live life without worrying about the straightness of their teeth or have OT later. Quotes from the interviews support this. I do not have to get braces as an adult. I will not have to worry, at the back of my head all the time, that I need to get them (teeth) done. Table 4. Spearman s correlation was applied to assess the univariate associations between PIDAQ variables, OIDP questions, DAI and ICON scores. DAI, Dental Aesthetics Index; ICON, Index of Complexity, Outcome and Need; PIDAQ, Psychosocial Impact of Dental Aesthetics Questionnaire; OIDP, Oral Impacts on Daily Performances. Variable OIDP Q1 OIDP Q2 OIDP Q3 OIDP Q4 OIDP Q5 OIDP Q6 OIDP Q7 OIDP Q8 OIDP total DAI ICON PIDAQ: dental self-confidence P-value <0.0001* * * PIDAQ: social impact P-value <0.0001* * <0.0001* PIDAQ: psychological impact P-value <0.0001* * * PIDAQ: aesthetic concern P-value <0.0001* * <0.0001* PIDAQ total P-value <0.0001* * <0.0001* *Statistically significant.

6 598 European Journal of Orthodontics, 2016, Vol. 38, No. 6 I think getting it done now is better than doing it after 20 years. Expected short- and long-term benefits: No perceived benefits The percentage of participants who did not perceive any benefits from OT increased from short-term (11 per cent) to long-term (19 per cent). Table 5. Spearman s correlation was applied to assess the univariate associations between OIDP variables, DAI and ICON scores. DAI, Dental Aesthetics Index; ICON, Index of Complexity, Outcome and Need; OIDP, Oral Impacts on Daily Performances. Variable DAI total scores ICON total scores OIDP Q P-value OIDP Q P-value OIDP Q P-value OIDP Q P-value OIDP Q P-value OIDP Q P-value OIDP Q7 0 0 P-value 0 0 OIDP Q P-value OIDP Total P-value * DAI total score 0.51 P-value <0.001* *Statistically significant. impact which increased. Quality of life expectations, associated with better dental appearance, varied from a single expectation to any combination of expectations (Figure 4). Improved dental self-confidence It was expected that better dental appearance would improve dental self-confidence in the short-term (overall 59 per cent, F 60 per cent, and M 58 per cent) and in the long-term (overall 23 per cent, F 23 per cent, and M 23 per cent). For many adolescents, the QoL impact of poor dental appearance was related to daily activities such as smiling, laughing, and talking. Poor dental appearance was perceived as restrictive and this affected the way they acted in public. Some of the coping strategies employed were covering their smiles with their hands and consciously avoiding smiling. Quotes from the interviews support this: I will be more confident with my teeth and probably smile more, I guess. In photos as well, I will look better. I will feel more confident about smiling in photos and I do not have to worry about not showing my teeth when I talk to people and I do not have to feel embarrassed or uncomfortable. I usually, without braces, I do not show my teeth and I try to hide them. With braces, I will be more confident showing my teeth and smile more often. Positive psychological impact (improved self-worth) It was expected that better dental appearance would have positive psychological impact in the short-term (overall 50 per cent, F 49 per cent, and M 55 per cent) and in the long-term (overall 27 per cent, F 33 per cent, and M 18 per cent). Poor dental appearance impacted on some adolescents on a deeper and more personal level, affecting the domains of self-worth and psychological well-being. Adolescents expected OT to improve their dental appearance and, therefore, help them to be bolder and more confident individuals. Some adolescents expected less teasing and feelings of being judged. In addition, better dental appearance was thought to induce feelings of happiness and content and reduced feelings of stress and worry. Quotes from the interviews support this: Just instant better confidence and better self-esteem. Just as if relief has come over me, like as I am happy about them (teeth) and I do not have to worry about them anymore. It will give me more confidence in myself and boost my self-esteem more. Well, like self-esteem wise I think it will be better because, like my friends, like, some of my friends say stuff about it (teeth) and that will not happen anymore. Figure 3. Content analysis showing the overall short- and long-term expectations of OT and for males (M) and females (F). Some participants had more than one short- or long-term expectation. Better dental appearance Better dental appearance was the predominant short-term [85 per cent overall, females (F) 85 per cent, and males (M) 85 per cent] and long-term (51 per cent overall, F 55 per cent, and M 45 per cent) OT expectation. Better dental appearance was associated with three aspects of QoL ( improved dental self-confidence, positive psychological impact or improved self-worth, and positive social impact ) (Figure 4). Perception of better dental appearance and improved QoL decreased from short- to long-term except for positive social Positive social impact It was expected that better dental appearance would have positive social impact in the short-term (overall 23 per cent, F 22 per cent, and M 25 per cent) and in the long-term (overall 18 per cent, F 18 per cent, and M 18 per cent). Some adolescents expected OT to improve not only the appearance of their teeth but also their social life, relationships, ability to interact, and to make better first impressions. In addition, better looking teeth were thought to make them more presentable for work-related interviews with a better chance of getting a job. Some participants thought that better dental appearance

7 E. Twigge et al. 599 Figure 4. The overall short-term and long-term QoL expectations of adolescents associated with better dental appearance after OT. would make them fit in better, be more acceptable, make them more attractive and be more confident going out in public. Quotes from the interviews support this: I think socially definitely beneficial, because like I said before, I feel it (teeth) make me look younger than I actually am, so it (braces) will help me look more mature, probably, I can say, more accepted, maybe a little bit more attractive, yah. I will have confidence talking in front of people and I will feel better when I am working. I want to be a barista, so that means I have to serve people coffees and I they are going to look at me and I will have to smile and they (teeth) will be nice. Discussion The present study evaluated the orthodontic perceptions of 12- to 17-year-old adolescent patients and aimed to address three research questions. Two OHRQoL scales (PIDAQ and OIDP) and two occlusal indices (DAI and ICON) were utilized to address these questions. Statistically significant associations were shown between PIDAQ variables and OIDP questions; however, the strength of the correlations varied from small to large. The OIDP question five related to smiling, laughing, and showing teeth without embarrassment showed large correlations. In addition, OIDP question eight related to enjoying contact with other people showed small correlations and OIDP final scores showed medium correlations. For these variables, the two OHRQoL scales were comparable. Although the occlusal indices have different scoring criteria, ICON and DAI were able to identify malocclusions with similar OT need. Therefore, the association between ICON and DAI final scores were statistically significant. The PIDAQ is an orthodontic-specific psychometric OHRQoL scale developed to measure dental appearance impacts and perceptions of young adults (20). However, the OIDP is a descriptive OHRQoL scale which is not specifically designed for orthodontic patients (21). This could explain the low OIDP CA values. In addition, the adolescent patients, in the present study, are predominantly dentally fit. Males and females had similar index-determined occlusal scores (DAI and ICON total scores); however, females had statistically higher OHRQoL scores (all PIDAQ scores) and scores for one OIDP question related to smiling, laughing, and showing teeth without embarrassment (OIDP question five). The fact that only one OIDP question (which related to the psycho-social impact of poor dental appearance) showed a gender difference, illustrates how index/scale selection can influence study outcomes and conclusions and potentially introduce bias. Therefore, it appears that malocclusions of similar severity might have significantly more psycho-social impact on females compared with males. This confirms results of a study by Christopherson et al. who used the Index of Orthodontic Treatment Need (IOTN) and a modified version of the Michigan Oral Health-Related Quality of Life Scale - Child version (27) to assess the objective, subjective, and self-assessed OT need. Girls were found to experience worse OHRQoL and desire OT more compared with boys with similar index-determined OT need. The age range between the participants was only 5 years. Therefore, correlations with age were not a primary outcome measure and the results were not included in the tables. However, there were no statistically significant associations between OHRQoL status (measured using PIDAQ and OIDP) and increasing age. Therefore, the present study does not agree with previous reports that dental appearance dissatisfaction increases (decreased OHRQoL) with increasing age (32). However, the present study is supported by Marques et al. who also used the OIDP in a larger sample of Brazilian schoolchildren but of a younger age range (33). The authors found that OHRQoL status was not age-dependent. Although the DAI and ICON index scores were statistically significant, there were no statistically significant associations between OHRQoL variables and occlusal index scores, except OIDP total scores and ICON total scores. However, the association was small. Therefore, a discrepancy exists between subjective and objective (index-determined) OT need. This is consistent with the report by de Oliveira and Sheiham, who used IOTN, OIDP, and the Oral Health Impacts Profile (OHIP-14) (14). Although the present study revealed that females had a worse OHRQoL status compared with males having similar indexdetermined occlusal scores, there was no conclusive evidence that higher index-determined occlusal scores (increased severity) caused worse OHRQoL experiences. This could be explained by the fact that no controls were used to compare results and the correlation between OIDP and ICON final scores was small. Therefore, on a group level, the inference was that poor dental appearance could have OHRQoL impacts on some adolescents, especially the psycho-social domains. On an individual level, the present study used qualitative methodology to gain insight into how malocclusions might affect adolescents. The qualitative results indicated that most adolescent patients expected better dental appearance in the short- and long-term after OT. In addition, better dental appearance included psycho-social benefits such as improved dental self-confidence, positive psychological impact/improved self-worth, and positive social impact. Interestingly, the perceived expectations decreased from short- to long-term, except for positive social impact. The qualitative results indicated that participants did not expect OT to have a long-lasting effect on psycho-social aspects such as dental self-confidence and self-esteem. This was in concordance with previous studies (5, 11). The adolescents in the present study expected better dental appearance to have a positive social impact in the long-term, rather than in the short-term. The short-term OT expectations of 12- to 17-year-old adolescents might be to acquire better dental appearance and to be socially accepted by friends and peers. Therefore, OT may an aesthetic adjustment strategy during the adolescent years for some adolescents. In the long-term, OT expectations might be related to future events such as job interviews for which these individuals would like to make a good first impression. This is in concordance with a study on young adults who perceived dental aesthetics

8 600 European Journal of Orthodontics, 2016, Vol. 38, No. 6 important for employment prospects (29). Moreover, employers are more likely to employ individuals with optimal dental aesthetics (8). Therefore, adolescents desire for OT and better dental appearance might be for immediate psycho-social needs as well as longterm social needs. Interestingly, some adolescents do not expect any short- or long-term benefits from OT. For these, the need for OT may have been expressed by the referring dentist or the parent/guardian and not the adolescent him/herself. In addition, these particular adolescents may be satisfied with their current dental appearance and function status. Future research could include the opinions of parents/guardians regarding OT for their children using qualitative methodology. Interestingly, there were no obvious gender differences for most of the qualitative variables, especially the QoL expectations associated with better dental appearance. This observation did not support the quantitative results; however, a direct comparison was not achievable as the qualitative and quantitative evaluations were not analytically compatible. The PIDAQ and OIDP scales were used in this study, although use of adult OHRQoL instruments for children and adolescents has not been recommended (47). Both PIDAQ and OIDP are commonly used OHRQoL instruments in the literature and PIDAQ has been used with adolescents (48, 49). In addition, no OHRQoL instrument was available for orthodontic adolescent patients between 12 and 17 years when the study was conducted. A researcher was present during all the interviews to ensure that all the questions were understood. Moreover, if the adolescents were to be re-examined in the future (longitudinally), most of the adolescents would be over 18 years and the same scales could be used. The study had several limitations as the results were based on cross-sectional data. A follow-up study would be invaluable to elicit the long-term effects. The present study did not formally test the validity of PIDAQ and OIDP scales for South Australians. In addition, little is known about the stability of these scales over time and could be a study objective of future projects. Furthermore, an orthodontic OHRQoL instrument, suitable for adolescents and adults, would be a useful asset to the profession and would allow future cross-sectional or longitudinal studies to be compared. The strengths of the study include a qualitative evaluation of patient perceptions regarding short- and long-term OT expectations. In addition, two OHRQoL scales and two occlusal indices were used to better interpret the subjective and objective ratings of treatment need. The combination of qualitative and quantitative methodology was able to provide useful information on how malocclusions affect the OHRQoL of adolescent patients. Conclusions With similar index-determined occlusal scores compared with male adolescent patients, females tended to experience worse OHRQoL. However, the short- and long-term QoL expectations after OT was similar for both genders. There was statistically significant associations between DAI and ICON index scores and were considered comparable. Similarly, PIDAQ had statistically significant associations with two OIDP questions related to the psycho-social impact of malocclusions and the OIDP final scores. For these domains, PIDAQ and OIDP were comparable. However, the correlation strength varied between small and large. Subjective OT need measures (PIDAQ and OIDP) did not have significant associations with objective OT need measures (DAI and ICON). Better dental appearance was expected by 85 per cent of adolescents in the short-term and 51 per cent of adolescents in the longterm after OT. 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