Malocclusion among adolescents : qualitative and quantitative studies of the impact on oral health and daily life

Though not considered pathological conditions, malocclusions and their impact have traditionally been assessed from a professional point of view. This could be due to their multifactorial aetiology and the great variation in their severity. Interceptive orthodontic treatments are undertaken during childhood often to reverse an unfavourable development, whereas corrective treatment is performed to adjust established deviations. Orthodontic treatment is, however, predominately optional and provided for the convenience of the individual. Therefore, it is important to involve the patients in the process of assessing treatment need. To do so, detailed knowledge of patient views of the condition and of its impact on their daily life are needed. In Sweden, dental health care is free-of-charge for children and adolescents. However, due to limited public resources, subsidized orthodontic care is only offered to those with the greatest need. Thus, treatment priority determination is critical. Current modes for assessing treatment need and decision priority are based on normative occlusal indices, which do not account for patient values. In addition, findings of systematic reviews that use generic instrument to evaluate the impact of malocclusion on Quality of Life are inconclusive. These shortcomings reveal the limitations of these approaches. Thus, the aims of this thesis were to (i) examine the effect of malocclusions on the everyday lives of adolescents, (ii) explore the relationship between professionally assessed treatment need and patient demand for treatment, and (iii) develop a condition-specific instrument that would help improve treatment need evaluations. The present thesis comprises three papers. Paper I was a qualitative investigation using grounded theory for data collection and analysis. It elucidated how malocclusions affect the daily lives of adolescents and how adolescents cope with malocclusion-related distress. Paper II was a cross-sectional, quantitative prediction study based on a subpopulation of Swedish adolescents and used survey and dental record data. In Paper II, path analysis explored the structural relationship between a set of self-assessed measures and treatment need and demand. Paper III was a methodological prediction study that used the same dataset as Paper II. Here, a prediction equation based on regression analysis was presented to test the validity of the measures in the newly developed Demand for Orthodontic Treatment Questionnaire (DOTQ). The overall findings were that internal and external factors repeatedly remind adolescents with malocclusion of their condition. Consequently, adolescents develop strategies, such as “hiding one’s teeth” and “striving for a cure”, to handle the negative feelings associated with the condition. Self-assessed demand for treatment was significantly correlated with professionally assessed treatment need. Further, the DOTQ measures are reliable and intercorrelated. It was demonstrated that self-assessed demand for treatment is a strong predictor of professionally assessed treatment need. Finally, cross-validation confirmed the predictive validity of the DOTQ. Thus, the DOTQ seems to be a promising instrument for predicting orthodontic treatment need. In clinical praxis, dental professionals who treat adolescents with malocclusions should be aware of various strategies that these patients use to deal with their condition, and which potentially lead to irrational behaviours. Patients often become frustrated when treatment need assessment becomes lengthy and delays treatment start. The perceived discrepancy between the professional focus on health aspects and the adolescent focus on aesthetics is unsatisfying in adolescent eyes. Thus, instruments able to evaluate patient perception would be helpful, and recommended, in assessments of orthodontic treatment need and treatment decision priority. Here, the DOTQ could become a useful consultation tool. ABSTRACT Though not considered pathological conditions, malocclusions and their impact have traditionally been assessed from a professional point of view. This could be due to their multifactorial aetiology and the great variation in their severity. Interceptive orthodontic treatments are undertaken during childhood often to reverse an unfavourable development, whereas corrective treatment is performed to adjust established deviations. Orthodontic treatment is, however, predominately optional and provided for the convenience of the individual. Therefore, it is important to involve the patients in the process of assessing treatment need. To do so, detailed knowledge of patient views of the condition and of its impact on their daily life are needed. In Sweden, dental health care is free-of-charge for children and adolescents. However, due to limited public resources, subsidized orthodontic care is only offered to those with the greatest need. Thus, treatment priority determination is critical. Current modes for assessing treatment need and decision priority are based on normative occlusal indices, which do not account for patient values. In addition, findings of systematic reviews that use generic instrument to evaluate the impact of malocclusion on Quality of Life are inconclusive. These shortcomings reveal the limitations of these approaches. Thus, the aims of this thesis were to (i) examine the effect of malocclusions on the everyday lives of adolescents, (ii) explore the relationship between professionally assessed treatment need and patient demand for treatment, and (iii) develop a condition-specific instrument that would help improve treatment need evaluations. The present thesis comprises three papers. Paper I was a qualitative investigation using grounded theory for data collection and analysis. It elucidated how malocclusions affect the daily lives of adolescents and how adolescents cope with malocclusion-related distress. Paper II was a cross-sectional, quantitative prediction study based on a subpopulation of Swedish adolescents and used survey and dental record data. In Paper II, path analysis explored the structural relationship between a set of self-assessed measures and treatment need and demand. Paper III was a methodological prediction study that used the same dataset as Paper II. Here, a prediction equation based on regression analysis was presented to test the validity of the measures in the newly developed Demand for Orthodontic Treatment Questionnaire (DOTQ). The overall findings were that internal and external factors repeatedly remind adolescents with malocclusion of their condition. Consequently, adolescents develop strategies, such as “hiding one’s teeth” and “striving for a cure”, to handle the negative feelings associated with the condition. Self-assessed demand for treatment was significantly correlated with professionally assessed treatment need. Further, the DOTQ measures are reliable and intercorrelated. It was demonstrated that self-assessed demand for treatment is a strong predictor of professionally assessed treatment need. Finally, cross-validation confirmed the predictive validity of the DOTQ. Thus, the DOTQ seems to be a promising instrument for predicting orthodontic treatment need. In clinical praxis, dental professionals who treat adolescents with malocclusions should be aware of various strategies that these patients use to deal with their condition, and which potentially lead to irrational behaviours. Patients often become frustrated when treatment need assessment becomes lengthy and delays treatment start. The perceived discrepancy between the professional focus on health aspects and the adolescent focus on aesthetics is unsatisfying in adolescent eyes. Thus, instruments able to evaluate patient perception would be helpful, and recommended, in assessments of orthodontic treatment need and treatment decision priority. Here, the DOTQ could become a useful consultation tool. Populärvetenskaplig sammanfattning Allt fler barn och ungdomar vill ha tandreglering för att komma tillrätta med sina felställda tänder och bettavvikelser. Graden och konsekvensen av bettavvikelser kan variera påtagligt. Tandreglering kan till exempel göras för att avbryta en ogynnsam bettutveckling eller för att rätta till bettavvikelser i det permanenta bettet. I Sverige erbjuds, i enlighet med Tandvårdslagen, avgiftsfri tandreglering till de barn och ungdomar som anses ha störst behov av behandling. Begränsade allmänna resurser gör att prioriteringar måste göras. Då bettavvikelser inte betraktas som sjukdomstillstånd, görs en majoritet av dessa behandlingar i huvudsak av estetiska och psyko-sociala skäl och för att underlätta livssituationen för den enskilde patienten. Inte minst därför är det av stor vikt att patientens åsikter tas i beaktande vid bedömning av behandlingsbehov. I den kliniska vardagen används i dagsläget instrument som främst utgår ifrån tandläkarens professionella perspektiv och omdöme. Syftet med denna avhandling var därför:  Att kartlägga hur bettavvikelser påverkar ungdomars dagliga liv samt studera hur professionellt bedömt behandlingsbehov hänger samman med patientens behandlingsönskemål.  Att utforma och utvärdera ett instrument för prediktering, bedömning och prioritering av behovet av tandreglering som tar hänsyn till ungdomars uppfattning om bettavvikelse samt hur det påverkar oral hälsa, funktion, självkänsla och livskvalitet. Resultatet visar att ungdomar med bettavvikelser ofta blir påminda om detta, till följd av både extern och intern påverkan, som när de ser sig själva i spegeln, via medias inverkan eller till följd av kamraters påtryckningar. Många ungdomar utvecklar olika strategier för att kunna hantera sina tankar och känslor kopplade till sin bettavvikelse, såsom att hålla för munnen vid tal eller skratt, inte visa tänderna när de ler eller eftersträva tandreglering. Avhandlingen visar också att skalor och instrument som baseras på självskattning med fördel k