Originl Article Effect of orthodontic tretment on orl helth relted qulity of life Dniel Feu ; Jose Augusto M. Miguel ; Roger K. Celeste c ; Brnc Helois Oliveir d ABSTRACT Ojective: To ssess chnges in orl helth relted qulity of life (OHQoL) in children undergoing fixed orthodontic tretment nd compre it to tht of two groups not receiving tretment. Mterils nd Methods: Two hundred eighty-four sujects ged 12 15 yers were followed for 2 yers; 87 were undergoing tretment t university clinic (TG), 101 were witing for tretment t this clinic (WG), nd 96 were ttending pulic school nd hd never sought tretment (SG). OHQoL ws ssessed using the Orl Helth Impct Profile (OHIP-14). All sujects were exmined nd interviewed t seline (T1), 1 yer lter (T2), nd 2 yers lter (T3). OHIP-14 scores were nlyzed using negtive inomil regression in generlized estimting equtions for correlted dt. Results: During the follow-up period, the WG nd TG OHIP-14 scores showed sttisticlly significnt increse nd decrese, respectively (P,.001). At T1, the TG hd n OHIP-14 score tht ws 1.9 times higher thn tht of the SG; however t T3, the TG score ws 60% lower thn the initil score of the SG. Adjusting for ge, gender, dentl helth sttus (DMFT), socioeconomic position, mlocclusion severity, nd self-perceived esthetics did not chnge the effect of orthodontic tretment on OHQoL. Conclusion: Fixed orthodontic tretment in Brzilin children resulted in significntly improved OHQoL fter 2 yers. (Angle Orthod. 2013;83:892 898.) KEY WORDS: Orl helth relted qulity of life; Orthodontic tretment; Ptient ssessment INTRODUCTION The incresing emphsis on the need for evidencesed helth services requires tht the evlution of the effectiveness of orthodontic tretment employ outcome mesures tht re importnt to the ptient nd the clinicin. 1 Thus, studying orl helth relted qulity of life (OHQoL) in orthodontic ptients my provide informtion tht will help clinicins nd pulic Specilist in Orthodontics, MSc in Orthodontics, PhD student, Rio de Jneiro Stte University, Rio de Jneiro, Brzil. Adjunct Professor, Deprtment of Orthodontics, Rio de Jneiro Stte University, Rio de Jneiro, Brzil. c Adjunct Professor, Deprtment of Preventive nd Socil Dentistry, Fculty of Dentistry, Federl University of Rio Grnde do Sul, Porto Alegre, Brzil. d Associte Professor, Deprtment of Preventive nd Community Dentistry, Rio de Jneiro Stte University, Rio de Jneiro, Brzil. Corresponding uthor: Dr Dniel Feu, Ru d Gréci 85, pt 1101, Brro Vermelho Vitori ES Brzil 29057-660 (e-mil: dnifeutz@yhoo.com.r). Accepted: Jnury 2013. Sumitted: Octoer 2012. Pulished Online: April 17, 2013 G 2013 y The EH Angle Eduction nd Reserch Foundtion, Inc. helth plnners improve the qulity of orthodontic cre. 2 Recent studies hve shown tht mlocclusion is ssocited with poor OHQoL. 3,4 Studies hve lso shown tht, depending on the phse of the tretment, orthodontic tretment my either compromise or improve OHQoL. 5,6 Studies indicting tht ptients re less likely to report negtive impcts on OHQoL fter completing orthodontic tretment often hve importnt limittions (ie, they my e cross-sectionl or my not include comprison group). 5 7 Dt suggesting the positive effects of orthodontic tretment on OHQoL continue to e inconclusive. 2,8,9 Shw et l. 9 questioned whether ehviorl differences etween people who sought nd did not seek orthodontic tretment in their study could hve influenced their results. The ojective of this prospective study ws to ssess whether fixed orthodontic pplince therpy ffected OHQoL in children y compring them with two groups of untreted individuls. The influence of the ptients dentl helth sttus, esthetic impirment, socioeconomic sttus, nd mlocclusion severity on OHQoL ws exmined. 892 DOI: 10.2319/100412-781.1
ORTHODONTIC TREATMENT AND QUALITY OF LIFE 893 MATERIALS AND METHODS Prticipnts This study ws pproved y the Ethics Reserch Committee of Pedro Ernesto Hospitl, Rio de Jneiro Stte University (1417 CEP/HUPE). Prents received letter descriing the study nd requesting consent for their children to prticipte. A totl of 318 children ged 12 15 yers were followed for 2 yers in Rio de Jneiro, Brzil. They were seprted into the following three groups: tretment group (TG), witing group (WG), nd school group (SG). Children in the TG nd WG were selected from list of 216 children (n 5 225, nine refusls, 96% response rte) who sought orthodontic tretment t the University in 2006. Only children who hd never undergone orthodontic tretment were eligile. The 92 children who strted tretment etween April nd Decemer 2006 composed the TG. The 124 children who were not selected for tretment were plced on witing list nd were followed eginning in April 2006. Ptients were selected for tretment y professors in the orthodontics clinic of Rio de Jneiro Stte University sed on the eductionl needs nd resources of the clinic nd the ptient s type of mlocclusion, independent of mlocclusion severity. This selection ws independent of the reserch nd ws not influenced y it. The professors responsile for the selection of ptients for tretment were unwre of the reserch. Children in the WG could e clled t ny time to egin tretment, nd upon tretment initition they were immeditely excluded from the study nd considered loss to the smple. Orthodontic tretment ws gurnteed to ll ptients in the WG. The SG included ll 12- to 15-yer-old children (n 5 124) enrolled in pulic school ner the university in 2006 who hd never undergone or sought orthodontic tretment. This school hs dentl clinic run y the university t which undergrdute students, supervised y fculty memers of the dentl school, regulrly provide free primry dentl cre. Children identified s needing specilized cre re referred for tretment to the pproprite deprtments of the university. Prents of the SG children were sent questionnire, ttched to the consent form, to determine whether their children hd lredy sought or undergone orthodontic tretment. Twenty-two of these schoolchildren were excluded ecuse their prents did not return the consent form or reported tht the child hd undergone or previously sought orthodontic tretment. Therefore, the SG consisted of 102 children (82.3% response rte). This group ws smpled to represent children who hd ccess to pulicly funded orthodontic tretment ut did not seek it, regrdless of the severity of their mlocclusion. The comprility etween the perceived OHQoL in this group nd tht in the TG nd WG ws ssessed using sttisticl regression methods, controlling for potentil confounding fctors. A power clcultion ws performed sed on oserved vlues in which the Orl Helth Impct Profile (OHIP-14) score decresed y 8.79 points (stndrd devition [SD] 5 5.92, n 5 87) over time in the TG, wheres it incresed y 0.87 points (SD 5 1.21, n 5 101) in the WG nd y 0.10 points (SD 5 1.24, n 5 96) in the SG. Assuming norml distriution, this study therefore hd 100% power to detect sttisticlly significnt difference t n lph of 1% y compring chnges in the TG with those in the SG nd WG. This smple size hd power of 96.2% to detect difference etween WG nd SG. Vriles nd Their Mesurement Dt were collected through self-completed questionnires nd dentl exms conducted y one trined orthodontist. The children completed three sets of interviews nd clinicl evlutions t seline (T1), fter 1 yer (T2), nd fter 2 yers (T3). OHQoL ws mesured with the OHIP-14, 10 which is considered vlid nd relile instrument nd is lso responsive to chnges in orl helth conditions. 11 The Brzilin version of the OHIP-14 hs shown good psychometric properties when pplied to dults 11 nd dolescents. 12 14 OHIP-14 scores were clculted y summing the response codes for the 14 items. Consequently, the totl scores could rnge from 0 to 56, with higher scores indicting poorer OHQoL. Socioeconomic sttus ws mesured with the Brzil Economic Clssifiction Criteri. 15 These criteri clssify households into eight ctegories ccording to the eductionl level of the hed of the house, whether hired mid works in the house, nd the numer of home pplinces, crs, toilets, nd wshing mchines. The ctegories rnge from A to E: A nd B indicte high socioeconomic sttus, C signifies medium socioeconomic sttus, nd D nd E re ssocited with low socioeconomic sttus. After the children completed the questionnires, clinicl exmintions were performed. Mlocclusion severity nd esthetic impirment were mesured using the Dentl Helth Component (DHC) nd the Aesthetic Component (AC), respectively, of the Index of Orthodontic Tretment Need (IOTN). 16 Esthetic impirments were lso evluted y the children themselves (AC Self-Perception). The IOTN is time-efficient, vlidted, nd relile method. 17 Dentl helth sttus ws determined using the DMFT clssifiction (decyed/ missing/filled teeth). 18
894 FEU, MIGUEL, CELESTE, OLIVEIRA Students from the SG were exmined in their school s dentl office under conditions similr to those t the university clinic t which children in the TG nd WG were exmined. The exminer ws trined in the use of the IOTN y senior resercher (gold stndrd). The senior resercher ws previously clirted for IOTN ssessment during course tken t the University of Mnchester. The trining process included the exmintion of set of 40 plster csts y oth the exminer nd the senior resercher nd susequent comprison of their results. To ssess intrexminer reliility, 26 dolescents were reinterviewed nd re-exmined within 7 10 dys of the first ssessment. Qudrtic weighted kpp vlues were used to clculte the reliility coefficient for DMFT (kpp 5 1), IOTN-DHC (kpp 5 0.94), nd IOTN-AC (kpp 5 0.98). The intrclss correltion coefficient (ICC) ws used for OHIP-14 (ICC 5 0.97). At seline, Cronch s lph for OHIP-14 ws 5 0.72 for the SG, 5 0.68 for the TG, nd 5 0.66 for the WG. Sttisticl Anlysis Differences in the distriution of covrites mong groups were tested using nonprmetric tests for repeted mesurements nd ordinl vriles when pproprite. All nlyses were crried out using Stt 9.2 (SttCorp LP, College Sttion, Tex). Significnce levels were estlished t.01. A preliminry nlysis showed tht OHIP-14 followed n overdispersed Poisson distriution; therefore, negtive inomil regression model ws used. 19 To ccommodte the temporl correltion etween the three ssessments, generlized estimting equtions with fixed coefficients nd first-order utoregressive covrince structure were pplied, 20 clustering ll oservtions within ech individul in temporl order (T1-T2-T3). The group vrile ws the exposure of interest. Gender, ge, DMFT, IOTN-AC, IOTN-DHC, IOTN Self-Perception, nd economic sttus were considered to e potentil confounders. Whether the scores of OHIP-14 vried over the follow-up period for time-independent vriles ws tested with n interction coefficient to evlute these vriles in comintion with the time vriles. The djusted model ws sed on ckwrd stepwise regression with P..20 for removl. RESULTS At seline, the three groups were comprle with respect to ge, gender, nd men DMFT. Esthetic impirment nd mlocclusion severity were less pronounced in the SG thn in the TG nd WG. The SG included more children from low- nd middleincome households thn did the TG nd WG (Tle 1). The dropout rtes were 5.4% in the TG, 18.5% in the WG, nd 5.9% in the SG. Of the 33 individuls tht dropped out, eight chnged ddresses, eight withdrew from the study, nd 17 from the WG were excluded ecuse they strted tretment. Therefore, our nlysis ws sed on 852 oservtions clustered mong 284 individuls (TG 5 87, WG 5 101, SG 5 96). Tle 1. Clinicl nd Sociodemogrphic Chrcteristics of Individuls, y Group, t Bseline SG WG TG Totl % (n 5 102) % (n 5 124) % (n 5 92) P Vlue Gender Mle 41.2% (42) 48.4% (60) 51.1% (47).35 Femle 58.8% (60) 51.6% (64) 48.9% (45) Brzil Economic Clssifiction Criteri A1 A2 0.0% (0) 2.4% (3) 3.3% (3),.01 B1 2.0% (2) 12.9% (16) 10.9% (10) B2 16.7% (17) 22.6% (28) 23.9% (22) C1 65.7% (67) 55.7% (69) 59.8% (55) C2 0.0% (0) 0.0% (0) 0.0% (0) D E 15.7% (16) 6.5% (8) 2.2% (2) Men (SD) Men (SD) Men (SD) P Vlue IOTN-DHC 3.0 (0.9) 3.4 (1.2) 3.5 (1.1),.01 IOTN-AC exminer 3.9 (1.8) 4.5 (2.0) 4.6 (2.0).02 IOTN-AC self-perceived 1.9 (1.1) 4.0 (2.1) 4.1 (2.1),.01 Age, y 13.7 (1.2) 13.7 (1.1) 13.4 (1.1).16 DMFT 1.3 (1.4) 1.4 (1.6) 1.5 (1.5).73 OHIP-14 5.5 (5.0) 10.8 (6.2) 10.4 (6.1),.01 Chi-squre test for differences mong groups or chi-squre test for differences in trends mong groups with ordinl vriles. Kruskl-Wllis test.
ORTHODONTIC TREATMENT AND QUALITY OF LIFE 895 During the follow-up period, the TG showed significnt improvement in OHQoL, dentl esthetics, nd dentl occlusion. In the WG nd SG, OHQoL worsened, wheres esthetic self-perception, esthetic impirment, nd mlocclusion severity remined the sme (Tle 2). In the TG, 44 ptients (50.5%) hd finished orthodontic tretment t the end of the follow-up period. At T3, the men OHIP-14 score ws 0.3 in ptients who hd hd the fixed pplince removed; it ws 3.0 in those who hd not. The IOTN-DHC nd IOTN-AC scores were lso higher mong those who did not finish tretment (P,.001). The WG (P,.001) nd SG (P 5.05) showed smll increses in their OHIP-14 scores, indicting worsened OHQoL during the evlution period. By contrst, the TG hd significnt reduction in its OHIP-14 scores (P,.001). Self-perceived esthetics nd normtive mesurements of IOTN did not chnge significntly in the SG nd WG, lthough these scores decresed significntly over time in the TG (P,.001). A univrite negtive inomil regression nlysis showed tht gender nd ge were not ssocited with OHIP-14 scores. Teengers of lower economic sttus hd worse OHQoL compred to those of highest economic sttus, lthough the difference ws not sttisticlly significnt. In ivrite nlysis, n increse of 1 point on the scle of the IOTN-AC (exminer score) ws ssocited with 1.25-fold increse in the OHIP-14 score. This ssocition ws not significnt fter djustment. Interctions of ge nd Tle 2. Medin Scores of Clinicl Time-Dependent Vriles During the Follow-up Period, y Group Mesure/Group T1 T2 T3 P Vlue OHIP-14 SG (n 5 96) 4 5 5.05 WG (n 5 101) 10 10 11,.001 TG (n 5 87) 9.5 8 0,.001 IOTN-AC self-perceived SG (n 5 96) 2 2 2.79 WG (n 5 101) 4 4 4.08 TG (n 5 87) 4 3 1,.001 IOTN-AC exminer SG (n 5 96) 4 4 4.95 WG (n 5 101) 4 4 4.97 TG (n 5 87) 4 3 1,.001 IOTN-DHC SG (n 5 96) 3 3 3.86 WG (n 5 101) 3.5 4 4.98 TG (n 5 87) 4 2 1,.001 Results re limited to those with completed dt over time. Friedmn test for rnking vriles with repeted mesurements. P vlues represent differences etween ny pir of yers of follow-up, not trend. gender with time were tested, which reveled no significnt ssocitions. Multiple regression nlyses, which used OHQoL mesured y the OHIP-14 s the outcome, showed tht self-perceived IOTN-AC, DMFT, nd IOTN-DHC were independently ssocited with OHIP-14 scores. In this model, the eneficil effect of orthodontic tretment on OHQoL ws reduced ut remined significnt (Tle 3). In the undjusted model, the OHIP-14 score of the TG prior to tretment ws 91% higher (reltive risk [RR] 5 1.91) thn the score of the SG prior to tretment, lthough it ws 70% lower fter 2 yers (RR 5 0.30). In the djusted model, the TG Tle 3. Undjusted nd Adjusted Associtions Between OHIP-14 Score nd Covrites During 2 Yers of Follow-up from Negtive Binomil Regression in Generlized Estimting Eqution Models Group SG Undjusted Score Rtios (95% CI ) P Vlue Adjusted Score P Rtios (95% CI ) Vlue T1 1,.01 1,.01 T2 1.11 (1.06 1.16) 1.10 (1.05 1.15) T3 1.02 (0.97 1.07) 1.00 (0.96 1.04) WG T1 2.04 (1.64 2.53),.01 1.73 (1.38 2.16),.01 T2 2.11 (1.70 2.61) 1.76 (1.41 2.21) T3 2.20 (1.78 2.71) 1.82 (1.45 2.29) TG T1 1.91 (1.53 2.39),.01 1.52 (1.21 1.91),.01 T2 1.69 (1.38 2.08) 1.83 (1.48 2.27) T3 0.30 (0.19 0.46) 0.38 (0.24 0.61) Gender Femle 1.31 Mle 1.09 (0.92 1.30) Brzil Economic Clssifiction Criteri A1 A2 1.04 c B1 1.65 (0.91 2.98) B2 1.75 (1.03 2.97) C1 1.66 (0.98 2.82) C2 1.29 (0.74 2.25) D E 1.46 (0.83 2.56) IOTN-DHC 1.40 (1.32 1.49),.01 1.18 (1.10 1.26),.01 (1 5 points) IOTN-AC 1.25 (1.21 1.30),.01 exminer (1 10 points) IOTN-AC 1.22 (1.18 1.25),.01 1.06 (1.03 1.09),.01 selfperceived (1 10 points) Age, y 0.98 (0.91 1.07).70 DMFT 1.06 (1.01 1.12).03 1.07 (1.01 1.12).014 CI indictes confidence intervl. Only vriles with P,.20 were retined in the stepwise ckwrds regression model eginning with ll vriles in the model. c P vlue for liner trend.
896 FEU, MIGUEL, CELESTE, OLIVEIRA score fter 2 yers ws 62% (RR 5 0.38) lower thn the score of the SG t the eginning. Chnges in the OHIP-14 dimensions reported during the study were found to follow similr nd corresponding pttern of chnges in the overll scores in the TG, WG, nd SG. Scores on dimensions 2, 3, nd 5 of the OHIP-14 contriuted the most to children s overll scores. Dimension 1 nd 2 scores t T2 were higher thn t ny other time in the TG, nd dimensions 3 nd 5 contriuted the most, oth to the impct reduction in TG t T3 nd to impct worsening in WG (Tle 4). DISCUSSION The min finding of this study ws tht OHQoL improved significntly following orthodontic tretment. However, dolescents who did not receive tretment (WG nd SG) showed slight increse in their OHIP- 14 scores, even though no chnges occurred in the severity of their clinicl mlocclusion or in esthetic selfperception. The clinicl significnce of the 1-point increse in the OHIP-14 scores of the WG nd the SG is difficult to estlish ecuse there re no criteri for determining whether n individul with specific OHIP score is mildly, modertely, or severely compromised y his orl disorders. 21 Two control groups (WG nd SG) were used to prevent ehviorl influences in our results. Previous studies 3,9,22 showed tht ehviorl differences etween children who do nd do not seek tretment seem to ply n importnt role in influencing their OHQoL. OHIP-14 scores were reltively stle in the SG during the oservtion period. Thus, the seline scores of the SG, representing children from the generl popultion who could hve een included in the TG or the WG if they hd sought tretment, were used for comprisons etween the groups t T3. OHIP-14 scores were similr in the TG nd WG t the eginning of the study. However, fter 2 yers, the OHQoL of children who hd undergone orthodontic tretment hd chnged significntly (P,.001). Notly, the OHIP-14 scores in the TG dropped drmticlly (62%) nd were thus lower thn the scores in the SG t the eginning. Children who were still witing for tretment showed sttisticlly significnt increse in their OHIP-14 scores (P,.001). This significnt increse in the OHIP-14 scores in the WG my hve occurred ecuse of the psychosocil disdvntges tht children with perceived mlocclusions cn experience in their dily lives 2,3 ; this is especilly pprent, ecuse the dimensions of psychologicl discomfort nd psychologicl disility contriuted the most to OHQoL worsening in the WG (Tle 4). It ws possile to further explore the reltionship etween finishing orthodontic tretment nd OHQoL, ecuse not ll of the ptients hd hd their fixed pplinces deonded fter 2 yers of follow-up. Ptients who lredy hd their fixed pplinces removed showed etter outcomes thn ptients who hd not, suggesting tht orthodontic tretment is not without potentilly hrmful effects on OHQoL, such s pin nd discomfort, s ws previously suggested y Chen et l. 5 nd Liu et l. 23 In the present study, ptients experienced worsened QoL during tretment ecuse of functionl limittions nd physicl pin (Tle 4). In ddition, 15- to 17-yer-olds usully consider rces to e unesthetic. 6,24 Becuse the Tle 4. Descriptive Anlyses (Medin Vlues) of the Seven Dimensions of OHIP-14 in TG, WG, nd SG During 2 Yers of Follow-up SG WG TG Difference finl initil T1 T2 T3 T1 T2 T3 T1 T2 T3 SG WG TG Question 1 0.3 0.4 0.3 0.8 0.8 0.9 0.7 1.3 0.1 0.0 0.1 20.6 Question 2 0.3 0.4 0.3 0.3 0.3 0.4 0.3 0.9 0.1 0.0 0.0 20.2 Question 3 c 1.0 0.9 1.0 0.9 0.9 0.9 0.9 2.4 0.5 0.0 0.0 20.3 Question 4 c 0.9 0.9 0.9 1.0 1.0 1.0 0.8 1.0 0.1 0.0 0.0 20.7 Question 5 d 0.8 0.8 0.8 1.9 1.9 2.0 1.9 0.7 0.2 0.0 0.2 21.6 Question 6 d 0.2 0.2 0.2 1.1 1.1 1.3 1.0 0.4 0.1 0.0 0.2 20.9 Question 7 e 0.2 0.3 0.2 0.2 0.2 0.2 0.3 0.1 0.0 0.0 0.0 20.2 Question 8 e 0.2 0.3 0.2 0.2 0.2 0.2 0.2 0.2 0.0 0.0 0.0 20.2 Question 9 f 0.2 0.2 0.2 0.5 0.5 0.5 0.4 0.2 0.0 0.0 0.0 20.3 Question 10 f 0.6 0.7 0.6 2.0 2.1 2.2 2.1 0.8 0.2 0.0 0.2 21.8 Question 11 g 0.5 0.6 0.5 1.1 1.1 1.2 1.2 0.6 0.1 0.0 0.1 21.0 Question 12 g 0.1 0.2 0.1 0.3 0.3 0.4 0.3 0.2 0.0 0.0 0.1 20.2 Question 13 h 0.2 0.2 0.2 0.6 0.7 0.7 0.5 0.3 0.1 0.0 0.0 20.5 Question 14 h 0.0 0.1 0.1 0.0 0.1 0.1 0.0 0.1 0.0 0.0 0.0 0.0 Totl OHIP-14 Score 5.5 6.1 5.6 10.8 1.3 12.0 10.4 9.2 1.6 0.1 1.2 28.8 OHIP-14 impct dimensions: functionl limittion, c physicl pin, d psychologicl discomfort, e physicl disility, f psychologicl disility, g socil disility, h hndicp.
ORTHODONTIC TREATMENT AND QUALITY OF LIFE 897 TG ptients were in this ge rnge t T3, it is lso possile tht the presence of the pplince resulted in IOTN-AC nd OHIP-14 scores tht were somewht higher thn expected. However, more studies re needed to clrify these findings. Improvement in the OHQoL of individuls who received orthodontic cre hs een previously reported. 5,6,25 Berné et l. 25 conducted cse-control study nd found tht Brzilin children with history of completed orthodontic tretment experienced fewer conditionspecific impcts on their dily lives ttriuted to mlocclusion thn did children with no history of tretment. De Oliveir nd Sheihm 6 conducted cross-sectionl study with 15- to 16-yer-old Brzilin children nd concluded tht those who hd completed orthodontic tretment hd etter OHQoL thn those currently undergoing tretment or those who hd never een treted. Chen et l. 5 followed 250 Chinese orthodontic ptients nd showed tht their OHQoL ws etter fter they completed tretment thn efore or during tretment. Nevertheless, one should e cutious when interpreting our results nd not conclude tht filure to otin orthodontic tretment during dolescence my hve detrimentl effect on QoL in dulthood, especilly for those with mild or moderte orthodontic needs. 9 Becuse prticipnts who entered the study were not llocted y chnce to either the TG or the WG ecuse of ethicl resons, it ws not possile to ensure tht the groups were lnced sed on chrcteristics tht were likely to lter the reltionship etween tretment nd outcome, thus minimizing potentil is. Imlnces in prognostic fctors etween groups in oservtionl studies cn e reduced y restriction or mtching nd cn e controlled for y sttisticl methods, s in this study. However, ecuse of the design of this study, we cnnot rule out the possiility of selection is. It my e expected tht the use of n instrument specificlly developed for children would provide more ccurte picture of the OHQoL of these ptients. However, t the time this study ws initited, none of the ville children s OHQoL instruments hd een trnslted into Brzilin Portuguese nd vlidted. CONCLUSIONS N Fixed orthodontic tretment improved OHQoL in 12- to 15-yer-old Brzilin children, resulting in 60% decrese in their OHIP-14 scores. N Those who sought ut did not receive tretment hd significntly worse OHIP-14 scores. N The psychologicl discomfort nd psychologicl disility dimensions contriuted most significntly to oth impct reduction nd impct worsening. ACKNOWLEDGMENT The source of support for this work ws the Ntionl Counsel of Technologicl nd Scientific Development (CNPq), Brzil, for Dniel Feu, nd Crlos Chgs Filho Foundtion (FAPERJ), Rio de Jneiro, Brzil, for Brnc H. Oliveir. REFERENCES 1. Hujoel PP. Levels of clinicl significnce. J Evid Bsed Dent Prct. 2004;4:32 36. 2. 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