Assessment of oral health-related quality of life in Nigerian children using the Child Perceptions Questionnaire (CPQ 11-14)

kolawole 15-03-2011 11:12 Pagina 55 K.A. Kolawole, O.D. Otuyemi, A.M. Oluwadaisi Department of Child Dental Health Faculty of Dentistry, Obafemi Awolowo University. Ile-Ife Nigeria e-mail: kkole@oauife.edu.ng Assessment of oral health-related quality of life in Nigerian children using the Child Perceptions Questionnaire (CPQ 11-14) ABSTRACT Aim The study objective was to examine the impact of oral health and disease on the quality of life of a population sample of 11 to 14-year-old children in Ile-Ife, Nigeria using the Child Perceptions Questionnaire (CPQ11-14). The hypothesis was that children with more severe malocclusions and greater caries experience would have higher CPQ scores indicating worse quality of life. Methods A random sample of school children were selected to participate in this study. Two hundred and forty eight children duly completed the CPQ11-14 and were examined for malocclusion and dental caries using the Dental Aesthetic Index (DAI) and DMFT index. Results Overall CPQ 11-14 scores ranged from 0 to 81 with a mean of 23.44 ± 17.19. There was no distinct gradient in mean CPQ scores across the DAI categories of malocclusion. Children with high caries experience according to the DMFT also did not have higher CPQ scores. Significant correlations were observed between the overall CPQ11-14 and domain scores and global ratings of oral health and overall well-being. No statistically significant associations were found between the clinical and overall CPQ scores. Conclusion The results indicate that the presence of malocclusion and dental caries did not have a significant impact on the quality of life of the Nigerian children using the CPQ11-14. The CPQ11-14 may be unable to discriminate between children in various malocclusion categories in all population groups. The relationship of reported quality of life and malocclusion is probably mediated by other factors. Keywords: Children; Oral health; Quality of life. Introduction Psychologists, sociologists, orthodontists and other dental researchers have sought the demonstration of an association between malocclusion and psychosocial well- being. The past few years have witnessed a great surge of interest in the assessment of the social and psychological impact of malocclusion. The goals of the investigators include demonstrating the importance of dental aesthetics in social and psychological life, as well as identifying the specific features or traits that define the negative impact of malocclusion [Cons et al.,1986]. Malocclusions are appreciable deviations from the ideal that may be considered aesthetically and functionally unsatisfactory [Houston and Tulley, 1986] i.e. those irregularities of the teeth beyond the acceptable range of normal. They are a reflection of the natural variations that occur in any biological system. Physical appearance has been found to have implications for an individual s psychological development [Stricker, 1980]. Malocclusions can adversely affect an individual personal self-concept and self-esteem not only during adolescence but also in adulthood. Children with malocclusions are more likely to be the victims of teasing, name calling and physical bullying [DiBiase and Sandler, 2001]. Children who are stigmatised or ridiculed by peers come to view themselves as inadequate [Shaw et al., 1979]. An understanding of the physical, social and psychological effects of malocclusion is important as it provides an insight into the consequences of malocclusion, i.e. the effects of malocclusion if left untreated and the benefits of orthodontic care [O Brien et al., 1998; Cunningham and Hunt, 2001]. Although there is little agreement on the definition of quality of life, it has been defined as a person s sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him/her [Becker et al., 1993]. Health contributes to quality of life and the true impact of health and disease on life is known as health-related quality of life (HRQL). The purpose of a HRQL instrument is not just to measure the presence and severity of disease symptoms but also show the impact of the illness and/or the intervention on the individual and in some cases to study unmet patient needs [Bennett and Phillips, 1999] The Child Perceptions Questionnaire (CPQ11-14), was developed by Jokovic et al. [2002] to produce a measure that conforms to contemporary concepts of child health. It has discriminative and evaluative properties and is applicable to children with various dental and orofacial disorders. It forms one component of the Child Oral Health Quality of Life Questionnaire (COHQOL) which consists of a parental caregiver perception Questionnaire, a family impact Scale and three age-specific questionnaires. It is a 37 item measure encompassing four domains: oral symptoms, functional limitations, emotional and social well-being. The use of the CPQ11-14 among different populations has shown that it is able to distinguish between individuals and groups with poor and better OHRQoL [Foster Page, 2005; Brown and Al-Khayal, 2006]. The aim of this study was therefore to examine the impact of oral health and disease on the quality of life of a population sample of 11 to 14-year-old children in Ile- Ife Nigeria using the CPQ11-14. The hypothesis was that children with more severe malocclusions and greater caries experience would have higher CPQ scores. 55

kolawole 15-03-2011 11:12 Pagina 56 KOLAWOLE K.A., OTUYEMI O.D. AND OLUWADAISI A.M. Materials and methods A sample of 252 children aged 11-14 years was randomly selected from junior secondary schools in Ife central Local government area of Osun state Nigeria, and invited to participate in the study. The sample size was determined as 184. A previous study by Jokovic et al. [2002] gave a mean of 26.3 and a standard deviation of 16.7. Given an expected minimum difference of 8, a power of 0.90 and a significance level of 0.05, a minimum sample size of 184 subjects was needed. Ethical approval was obtained from the Obafemi Awolowo University Teaching Hospital Ethics Committee. Consent was obtained from the appropriate school authority, the children and their parents. The CPQ 11-14 was administered in English and each child completed it independently. The first two questions on the CPQ 11-14 are the global ratings of the child s oral health and the extent to which the oral/orofacial condition affected his/ her well-being, worded as follows. Would you say that the health of your teeth, lips and mouth is.. and How much does the condition of your teeth lips and jaws and mouth affect your life overall? A 5- point response format ranging from Excellent = 0 to poor = 4 and from Not at all = 0 to Very much = 4 respectively is offered for these ratings. The remaining questions are organised into four health domains. Oral symptoms (n = 6), functional limitations (n = 9) emotional well-being (n = 9) and social well-being (n = 13). The questions ask about the frequency of events in the previous three months in relation to the child s oral/orofacial condition. The response options are Never = 0, Once/twice =1; Sometimes = 2; Often = 3; Everyday/ almost every day = 4. An overall CPQ11-14 score was computed by addition of scores for all items in the domains. Scores for each domain were also computed. Dental examination was done by one examiner (KAK). None of the selected children had undergone or was undergoing orthodontic treatment. Examination for dental caries was done using the World Health Organization (WHO) criteria [1997]. The total number of decayed, missing and filled teeth (DMFT) was determined for each child, followed by an orthodontic examination. Orthodontic assessment was based on the Dental Aesthetic Index (DAI) [Cons et al., 1986]. The DAI is an index designed specifically to measure dental aesthetics, which has the ability to recognise conditions that deviate from societal accepted norms for dental appearance and have the potential for causing a psychosocial handicap. The theoretical concept underlying the DAI predicts that the more a person s dental appearance deviates from excellent the more likely it is that the person will experience social handicaps and therefore request orthodontic treatment. The WHO, in order to address the issue of non-uniformity in methods for assessing malocclusion, incorporated a description of the DAI in its 7 th edition of Basic Methods for Oral Health Surveys [1997]. The DAI consists of 10 components. Scores for each occlusal trait were determined by direct measurement. The multiplication of these scores by the weighting factor, summation of these products, and the addition of a constant produced the total DAI score. The scores were used to categorise the children into 4 groups: a) no/slight treatment need; b) treatment need; c) treatment highly desirable; d) treatment mandatory. Data entry and analysis were done on an IBMcompatible personal computer. The SPSS version 11.0 was used to determine the range, mean DAI score, total CPQ and domain scores. ANOVA was used to compare the mean CPQ scores of the children in various malocclusion well-being groups. The relationship between the global ratings on oral health and well-being and the overall CPQ score were determined using correlation coefficient tests. The association between the DMF and DAI scores and the overall CPQ and domain scores were also determined using correlations. Results Of the 252 school children sampled in this study, 248 questionnaires were complete enough for analysis. Incomplete questionnaires were excluded. There were 126 female and 122 male participants. The mean age was 12.54 ± 1.08 (Table 1). Scores for the CPQ 11-14 ranged from 0 to 81. There were three participants with floor effects, i.e. a score of zero, but none with ceiling effect, i.e. maximum score. The mean score was 23.44 ± 17.19. The mean for male and female were 22.70 and 24.17 respectively (Table 2, 3). There was no significant difference between them. The mean score was higher for the females in all domains except the emotional wellbeing domain, which was not statistically significant. About 72.5% of the children reported experiencing oral symptoms in the past three months, 56.9% functional limitations, 63.3% reported emotional and 65.3% social impacts. The mean DAI score was 26.39. The scores were 26.51 Male Female Total Number (%) 122 (49.2) 126 (50.8) 248 (100) Mean age (SD) 12.49 (1.09) 12.59 (1.07) 12.54 (1.082) Malocclusion Mean DAI score 26.51 (6.75) 26.27 (6.60) 26.39 (6.66) Treatment need Number (%) Minor/none 63 (51.6) 70 (55.6) 133 (53.6) Definite 31 (25.4) 28 (22.2) 59 (23.8) Severe 18 (14.8) 12 (9.5) 30 (12.1) Handicapping 10 (8.2) 16 (12.7) 26 (10.5) Dental caries Number (%) DMFT = 0 113 (92.6) 118 (93.7) 231 (93.1) DMFT = 1 6 (4.9) 8 (6.3) 14 (5.7) DMFT = 2 3 (2.5) 0 (0) 3 (1.2) TABLE 1 - Percentage distribution by sex, categories of malocclusion and caries severity. 56

kolawole 15-03-2011 11:12 Pagina 57 USE OF CPQ 11-14 IN NIGERIAN CHILDREN Number Mean score Range of observed of items Mean (SD)* scores Total scale 37 23.44 (17.19) 0-81 Subscales Oral symptoms 6 5.27 (3.66) 0-18 Functional limitations 9 4.77 (4.74) 0-24 Emotional well-being 9 6.30 (6.01) 0-28 Social well-being 13 7.10 (6.73) 0-27 *Standard deviation TABLE 2 - Descriptive data on CPQ and subscales. Mean Overall CPQ score Mean CPQ Domain Scores Oral symptoms Functional limitations Emotional Well-being Social Well-being Sex Mean (S.D) Male 22.70 (15.33) 5.07 (3.39) 4.57 (4.62) 6.34(5.63) 6.72 (6.14) Female 24.17 (18.85) 5.46 (3.90) 4.97 (4.82) 6.27(6.39) 7.47 (7.26) Dental caries category Mean (S.D) DMFT = 0 23.55 (17.24) 5.25 (3.70) 4.70 (4.70) 6.43(6.09) 7.16 (6.70) DMFT = 1 18.57 (13.12) 5.21 (3.19) 4.36 (3.63) 3.64(3.69) 5.36 (6.71) DMFT = 2 38.00 (26.22) 6.00 (3.61) 12.33(7.77) 9.00(6.93) 10.67(9.87) p value 0.194 0.941 0.020 0.179 0.408 Malocclusion category (DAI) Mean (S.D) Minor 25.11(18.65) 5.65 (3.81) 5.12 (5.17) 6.37(6.15) 7.97(7.33) Definite 20.19 (14.53) 4.47(3.44) 4.29 (4.34) 5.95(6.04) 5.47(5.93) Severe 20.47(14.02) 4.53(3.09) 3.90 (3.38) 5.80(5.31) 6.23(5.61) Handicapping 25.77 (17.56) 6.00(3.69) 5.08 (4.66) 7.35(6.19) 7.35(5.84) p value 0.192 0.091 0.486 0.752 0.102 TABLE 3 - Overall CPQ and Domain Mean scores by sex, caries severity and categories of malocclusion. GLOBAL RATING SCORE Oral health Overall well-being DAI DMFT R p value R p value R p value R p value Total scale 0.295 0.000 0.444 0.000-0.019 0.760-0.022 0.729 Subscales Oral symptoms 0.319 0.000 0.490 0.000-0.060 0.346 0.018 0.775 Functional limitations 0.266 0.000 0.386 0.000-0.025 0.691 0.062 0.329 Emotional well-being 0.291 0.000 0.352 0.000 0.062 0.334-0.070 0.271 Social well-being 0.162 0.011 0.282 0.000-0.064 0.313-0.036 0.575 R=Spearman s correlation coefficient TABLE 4 - Correlations between overall CPQ and Domain scores, global ratings of oral health and overall well-being and DAI and DMFT scores. and 26.27 for male and female respectively (Table 1). The difference was not significant. There was also no significant gender difference in the distribution into treatment categories according to the DAI. There was no distinct gradient in mean CPQ scores across the various malocclusion categories according to the DAI. The highest mean CPQ score was obtained in the treatment category 4, i.e. treatment mandatory group. The treatment group 1 that represented minor/no need for orthodontic treatment had a mean score of 25.1. No gradient was observed in the mean CPQ domain scores according to the DAI treatment categories (Table 3). There was no significant difference when the overall CPQ and domain scores in the four malocclusion groups were compared. Ninety three percent of the sample had no caries experience and had a DMFT of 0, 5.7% had a DMFT of 1, while only 1.2% had a DMFT of 2 (Table 3). Although the highest CPQ score was obtained in the DMFT= 2 group, there was no gradient as the second highest score was obtained in the DMFT = 0 group (Table 3). There was no significant difference in CPQ scores between the DMFT groups except the functional limitation domain (p = 0.02). The relationship between overall CPQ score and global ratings on oral health and well-being revealed significant positive correlation (p =0.000). The correlation was better for overall well-being (r = 0.44) than the oral health rating (r = 0.29). Significant positive correlations were also observed between the scores for all health domains and global ratings of oral health and overall well-being. No statistically significant associations were found between the clinical and CPQ total scores (Table 4). The mean score for children reporting that their overall well-being was not at all affected by their oral 57

kolawole 15-03-2011 11:12 Pagina 58 KOLAWOLE K.A., OTUYEMI O.D. AND OLUWADAISI A.M. condition was 15.94 while for those reporting that it affected a lot or very much it was 36.68. Discussion There is an increasing recognition that oral disorders can have a significant impact on physical, social and psychological well-being although conflicting evidence exists [Zhang et al., 2006]. In relation to facial aesthetics it has been shown from the point of view of the patient that teeth were second in importance only to background facial appearance [Lew, 1993]. The oral health related quality of life measures have the potential to provide an understanding of the consequences of malocclusion if left untreated on the lives of individuals. In this study the mean overall CPQ score was 23.4 similar to 24.2 obtained by Brown and Al-Khayal in Saudi Arabia [2006] and 26.3 obtained in the original validation of the questionnaire by Jokovic et al. [2002], but quite different from the mean of 17.3 found in the study by Foster Page et al. in New Zealand [2005]. Zhang et al. [2008] found a mean of 20.5, which they considered low for a sample of orthodontic patients and suggested that despite needing orthodontic treatment, a subject s oral situation may have a modest impact on the quality of life. Unlike the studies in New Zealand, Canada and Saudi Arabia, there was no distinct gradient in mean CPQ and domain scores across the various categories of malocclusion according to the DAI. Research has shown that self-ratings of health items vary by race and education [Krause and Jay, 1994], and that evaluation of quality of life is also strongly influenced by the characteristics of an individual and his or her standards of reference [O Connor, 2004]. The result of this study implies that children in the worse treatment categories of malocclusion according to the DAI did not have worse OHRQoL than their counterparts who had minimal traits of malocclusion. Agou et al. [2008] in a study among Canadian children also could not conclusively state that increased malocclusion severity produced a direct increase in CPQ11-14 scores. This may be due to a number of reasons. Many orthodontic conditions are asymptomatic and relate to aesthetics rather than features like pain and discomfort, whereas pain is a common symptom that can impact quality of life [Zhang et al., 2006]. Unawareness of occlusal traits may also have been a factor. Various psychological, social, and cultural variables are known to be involved in an individual s awareness of a malocclusion. It is not every child with a malocclusion that is self-conscious about it, there is considerable variability of adjustment to the irregularity from total unawareness to deep concern [Shaw, 1981]. While some are unaware of pronounced malocclusion others may show great concern over a relatively mild irregularity [Gosney, 1986]. Unawareness may make it impossible for deviant occlusal traits to affect the psychosocial wellbeing of an individual. There is a possibility that the children were not able to accurately perceive their dental appearance. Perception of the aesthetic effects of malocclusions and the need and desire for treatment vary greatly in individuals. Accuracy of self-perception may even be particularly poor for young individuals. Studies indicate that children have limited ability to perceive their teeth accurately [Graber and Lucker, 1980; Shaw, 1981; Lindsay and Hodgkins, 1983; Holmes, 1992]. Previous studies have shown that Nigerian children have a tendency for them to overrate their dental appearance [Otuyemi et al., 1997; Kolawole et al., 2008]. Research has found that the relationship between reported OHRQoL and malocclusion is most likely mediated by other factors [Marshman et al., 2005]. The impact of oral conditions on individuals has been found to depend on their sense of self. An individual s sense of self is based on how adequately they perform in the domains of life that are important to them. Performance in unimportant areas has little impact on the self [Marshman et al., 2009]. For some their sense of self may be contingent on appearance, while others may relate importance to domains such as personality. Dental appearance did not appear to have been an important domain for these Nigerian children. This may explain lack of significant difference between children with no malocclusion and those with severe malocclusion traits. Stricker [1970] and Gosney [1986] had stated that the impact of dental appearance on the body image and self-concept is greater in persons who regard dental appearance as important than in those who do not consider it so. In Nigeria, availability and uptake of dental and orthodontic services is still very low. Individuals with malocclusion traits which are considered handicapping live their everyday lives without being bothered about it. When dental appearance is even regarded as important, other social pressures and the impact of poverty on the lives of people in developing countries like ours may not make oral health concerns a priority. Not many people have access to orthodontic care because it is expensive and unaffordable. Orthodontic services are provided on the basis of fee for service rendered even in government owned hospitals [Otuyemi, 2001]. Only five of the teaching hospitals in Nigeria provide orthodontic services. There was also no observed gradient in CPQ scores across the various DMFT groups. This may be due to the low prevalence of caries among the group of children studied: 93% had no caries experience, which is similar to previous reports from Nigeria. Significant correlations were observed between the global rating of oral health and the total CPQ score and domain scores. This is similar to the report by Brown and Al-Khayal [2006] in Saudi Arabia but different from that by Jokovic et al. [2002] in Canada. Significant correlations were also noted between the global rating of overall well-being and the total CPQ score and domain scores. This is similar to the findings of Jokovic et al. [2002] and Brown and Al-Khayal [2006]. There was however no association between global rating of overall well-being and social well-being in the latter study. No statistically significant associations were found between the clinical and CPQ total scores. This also differs from the study by Brown and Al-Khayal [2006], 58

kolawole 15-03-2011 11:12 Pagina 59 USE OF CPQ 11-14 IN NIGERIAN CHILDREN although direct comparisons between our study and theirs may not be possible because of the difference in the method of assessment of malocclusion. In the UK Marshman et al. [2005] were also not able to find any association between DMFT and CPQ scores. Correlations between DAI, DMFT scores and domain scores were also not significant; this agrees with reports by Brown and Al- Khayal [2006] who demonstrated a positive significant correlation only between the DMFT and oral symptoms, their malocclusion Index and social well-being. Conclusion The results of this study indicate that the presence of malocclusion and dental caries did not have a significant impact on the quality of life of the Nigerian children using the CPQ11-14. The CPQ11-14 is valid but may be unable to discriminate or distinguish between children with various severities of malocclusion in all population groups. Factors such as racial differences, characteristics of the individual, education and standards of reference may affect ratings of health items. Further studies in a clinical setting among children requiring orthodontic treatment may also be necessary. References Agou S. Locker D, Streiner D and Tompson B. Impact of self esteem on the oral health related quality of life of children with malocclusion. Am J orthod and Dentofacial Orthop 2008; 134: 484-489. Becker M, Diamond R, Sainfort F. A new patient focused index for measuring quality of life in persons with severe and persistent mental illness. Quality of life research 1993; 2: 239-251. Bennett ME, Phillips CL Assessment of health related Quality of life for patients with severe skeletal disharmony; a review of the issues. International Journal of adult orthodontics and orthognathic surgery 1999; 14: 65-75. Brown A and Al-Khayal Z.Validity and reliability of the Arabic Translation of the Child- oral-health-related quality of life questionnaire (CPQ 11-14) in Saudi Arabia. International Journal of Paediatric Dentistry 2006; 16: 405-411. Cons NC, Jenny J, Kohout FJ. DAI: The dental aesthetic index. Iowa City: University of Iowa.1986 Cunningham SJ, Hunt NP. Quality of life and its importance in Orthodontics. Journal of Orthodontics 2001; 28: 152-158 DiBiase AT, Sandler PJ. Malocclusion, orthodontics and bullying. Dental Update 2001; 28: 464-466. Foster Page LA, Thompson WM, Jokovic A, Locker D. Validation of the Child perceptions Questionnaire (CPQ 11-14) J Dent Res 2005; 84: 649-652 Gosney MBE. An Investigation into some of the factors influencing the desire for orthodontic treatment. British Journal of Orthodontics 1986; 13: 87-94. Graber LW, Lucker GW. Dental aesthetic self evaluation and satisfaction. American journal of Orthodontics and Dentofacial orthopaedics1980; 77: 163-173 Holmes A. The subjective need and demand for orthodontic treatment. British Journal of Orthodontics 1992; 19: 287-298. Houston WJB and Tulley WJ. A textbook of orthodontics.1986; Pg 2 Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life. J Dent Res 200281: 459-463 Kolawole KA, Otuyemi OD, Jeboda SO, Umweni AA. The need for orthodontic treatment in a school and referred population of Nigeria using the Index of Orthodontic Treatment Need (IOTN). Tropical Dental Journal 2008; 31:11-19 Krause NM, Jay GM. What do self-rated health items measure? Medical care 1994; 32: 930-942 Lew KK. Attitudes and perceptions of adults towards orthodontic treatment in an Asian community. Community Dentistry Oral Epidemiology1993; 21:31-35. Lindsay SJE, Hodgkins JFW. Children s perception of their own malocclusions. British Journal of Orthodontics1983; 10: 13-20 Marshman Z, Rodd H, Stern M et al. An evaluation of the Childs Perceptions Questionnaire in the UK. Community Dental Health 2005; 22:151-155. Marshman Z, Gibson BJ, Robinson PG. The impact of development defects of enamel on young people in the UK. Community Dentistry Oral Epidemiology 2009; 1: 45-57. O Brien K, Kay L, Fox D, Mandall N. Assessing oral health outcomes for orthodontics - measuring health status and Quality of life. Community Dental Health 1998; 5: 22-26. O Connor R. Measuring Quality of life in Health. Edinburgh: 2004 Churchill Livingstone Otuyemi OD, Ugboko VI, Adekoya- Sofowora CA et al. Unmet orthodontic treatment need in rural Nigerian adolescents. Community Dent Oral Epidemiol 1997; 25: 363-366. Otuyemi O.D. Orthodontics in Nigeria: journey so far and the challenges ahead. Journal of Orthodontics 2001; 28: 90-92. Shaw WC, Gbe MJ, Jones BM. The expectations of orthodontic patients in South Wales and St. Louis, Missouri. British Journal of Orthodontics 1979; 6:203-205 Shaw WC. Factors influencing the desire for orthodontic treatment. European Journal of Orthodontics 1981; 3:151-162. Stricker G. Psychological issues pertaining to malocclusion. American Journal of Orthodontics 1970 ;58: 276-283. World Health Organization Oral Health surveys. Basic methods. 4th ed. Geneva WHO.1997; 47-52. Zhang M, Mcgrath C and Hagg U. The Impact of malocclusion and its treatment on quality of life: a literature review. International Journal of paediatric Dentistry 2006;16; 381-387. Zhang M, Mcgrath C and Hagg U. Changes in oral health related quality of life during fixed orthodontic appliance therapy. Am J Orthod and Dentofacial Orthop 2008; 133: 25-29. 59