ORIGINAL ARTICLE

Effect of malocclusion on adults seeking

orthodontic treatment
Martha L. Neely,a Raffi Miller,b Sharron E. Rich,c Leslie A. Will,d Wanda G. Wright,e and Judith A. Jonesf
Lunenberg, Boston and Cambridge, Mass, East Greenwich, RI, Greenville, NC, and Detroit, Mich

Introduction: Our objective was to examine the Teen Oral Health-related Quality of Life (TOQOL) questionnaire
for use in adults receiving orthodontic treatment and assess validity and reliability by age group. Methods: Teen-
agers from 10 to 18 years and adults 18 and over completed surveys at the orthodontic clinic at Boston Univer-
sity. The survey consisted of sociodemographic information, dental behavior questions, and the TOQOL
instrument. Malocclusion severity was assessed using the Index of Orthodontic Treatment Need. Results: Over-
all, 161 teens and 146 adults participated. The mean ages were 13 years for the teens and 32 years for the
adults. Subjects were represented by both sexes and diverse racial and ethnic backgrounds. In general, scores
overall and by domains were higher for adults than for teens, signifying a greater effect of the malocclusion on the
quality of life. Mean TOQOL scores as well as emotional and social domain scores (P\0.001) were worse (17.6)
in adults than in teens (11.9; P \0.01). Construct validity was supported by strong a association of TOQOL
scores with self-reported oral health. The Cronbach alpha was higher in adults overall and for all domains
(0.75 in adults compared with 0.68 in teens). Conclusions: Adults who come for orthodontic treatment appear
to be more affected by their malocclusion than are teens. The total TOQOL score and the emotional and social
domains were significantly higher for adults. The total TOQOL score and the emotional and social domains were
significantly higher (worse) for adults than teens. This project suggested that TOQOL may be a useful way to
measure the impact of malocclusion on the quality of life in both adults and teens. (Am J Orthod Dentofacial
Orthop 2017;152:778-87)

O
ral health-related quality of life is the extent to with consequences for not only physical well-being but
which oral and perioral conditions affect people's also impairment of quality of life by affecting function,
lives and general health, including diet, speech, appearance, interpersonal relationships, socializing,
and well-being.1 self-esteem, and psychological well-being.3 It is not sur-
Conditions affecting oral health, such as malocclu- prising, therefore, that the proportion of adults seeking
sion, are prevalent in our society. Data from the Third orthodontic treatment in the United States has increased
National Health and Nutrition Examination Survey and dramatically in recent decades.
western European studies suggest that two thirds to Adults seek orthodontic treatment for a wide variety
three fourths of adults have some form of malocclusion,2 of reasons including esthetic, social, functional, and psy-
chological concerns. The orofacial region is an important
a
Private practice, Lunenberg, Mass and East Greenwich, RI. area that draws attention in verbal and nonverbal
b
Departments of Pediatric and General Dentistry, Goldman School of Dental
communication and interpersonal interactions. In to-
Medicine, Boston University, Boston, Mass; The Forsyth Institute, Cambridge,
Mass. day's society, a person's dentition is an important
c
Department of Health Policy and Health Services Research, Goldman School of component of facial attractiveness, which can markedly
Dental Medicine, Boston University, Boston, Mass.
d affect his or her self-esteem and self-image.2 In addition,
Department of Orthodontics and Dentofacial Orthopedics, Goldman School of
Dental Medicine, Boston University, Boston, Mass. orthodontics may facilitate other dental treatment.
e
Department of Foundational Sciences and Research, School of Dental Medicine, Improving these aspects of quality of life is an important
East Carolina University, Greenville, NC.
f reason for undergoing orthodontic treatment. For clini-
Goldman School of Dental Medicine, Boston University, Boston, Mass; Detroit
Mercy Dental, Detroit, Mich. cians, understanding the physical, social, functional, and
All authors have completed and submitted the ICMJE Form for Disclosure of psychological implications of malocclusion on oral
Potential Conflicts of Interest, and none were reported.
health-related quality of life is important, since it can
Address correspondence to: Leslie A. Will, 100 East Newton Street, Boston, MA
02118; e-mail, [email protected]. inform us about the effects of malocclusion on people's
Submitted, June 2016; revised and accepted, April 2017. lives and suggest why they seek orthodontic treatment.4
0889-5406/$36.00
Before the 1970s, the patient's quality of life was not
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2017.04.023 a consideration in dentistry. In 1972, Elwood5 published

778
Neely et al 779

one of the first studies that looked at quality of life in health-related quality of life and its component do-
relation to old age. This led to an increase in research mains. Patients with high treatment needs and who
involving quality of life as it related to various health are more dissatisfied with dental esthetics were more
conditions such as, obesity, respiratory disease, pain, likely to report greater oral effects and a significantly
and epilepsy. Since that time, the social impacts of greater negative impact on the overall oral health-
dental disease and the relationship between dental con- related quality of life score. They also found that when
ditions and quality of life have been assessed widely.6-9 orthodontic treatment was completed, oral health-
Several studies have examined quality of life, and oral related quality of life increased to levels similar to per-
health-related quality of life and its relationship to oral sons with a normal occlusion.21-23
health.8-11 They have generally shown that diminished Zhou et al24 proposed a modest association be-
oral health has a negative impact on quality of life. tween orthodontic treatment and quality of life. The
Fewer studies, though, have examined quality of life majority of studies they evaluated showed significant
and its relationship to malocclusion or, more correlations between orthodontic treatment and quality
specifically, the correlations between orthodontic of life no matter what measurement was used. Choi
treatment and quality of life.9 et al25 and Chen et al26 concluded that malocclusion
Few early studies looked specifically at how maloc- has a significant negative impact on oral health-
clusion affects quality of life or oral health-related qual- related quality of life, especially for the psychological
ity of life, or how orthodontic treatment can change discomfort and psychological disability domains, and
these outcomes.12-15 Although other research has can cause limited oral function, pain, and social
begun to assess these relationships, the results have disability in young adults.
been mixed thus far, with some studies reporting that Most studies of adult orthodontic patients
orthodontic treatment did not appear to be associated relating their malocclusion and oral health-related
with oral health-related quality of life.12,15,16 In quality of life found that malocclusion in adults
contrast, a systematic review by Liu et al13 showed a has a remarkable impact on oral health-related qual-
modest association between malocclusion, orthodontic ity of life.25-28 Patients report lower levels of self-
treatment need, and quality of life. Some weaknesses esteem and are self-conscious due to their negative
they noted in the available research were the lack of dental esthetic perception and social appearance.
standardized assessment and a relative weakness in Some of the most commonly perceived oral impacts
strength of evidence. in adults are physical pain as well as psychological
Other studies have assessed relationships between discomfort and disability. Once orthodontic treat-
the severity of malocclusion, different treatment modal- ment finishes, studies have shown that adults
ities, and quality of life. Kiyak17 found evidence that pa- reported improvement in disease-specific health-
tients' main motives for seeking orthodontic treatment related quality of life, anxiety, esthetic self-
are esthetic and social concerns. Patients with severe perception, and overall improvement in psychological
malocclusion appear to have poorer oral health-related discomfort and disability.24,29 However, most
quality of life than those with less critical treatment research in this area has focused on the impact of
needs in these domains. Furthermore, oral function did orthodontic treatment on the quality of life in
not appear to have as great an effect on patients as children rather than adults. This is in part because
the severity or visibility of the malocclusion. Orthodontic children make up the majority of orthodontic
intervention was found to enhance some aspects of oral patients.24 However, as more adults seek correction
health-related quality of life, particularly esthetics, but of their malocclusions, investigation into the oral
not necessarily social acceptance. health-related quality of life in adults is important
Other authors have reported that patients with for our understanding of their experience with
malocclusion may have physical pain as well as psycho- malocclusion and why they seek treatment.
logical discomfort and disability. Patients with maloc- The aim of this study was to examine the validity and
clusion report feeling self-conscious or tense, have reliability of the Teen Oral Health-related Quality of Life
difficulty relaxing, and may be somewhat irritable with (TOQOL) instrument for adults receiving orthodontic
other people; they show significant improvements in treatment compared with teens.30 We hypothesized
physical health and mental health quality of life after or- that oral health-related quality of life in adults with
thodontic treatment irrespective of the severity of the malocclusion is worse than that of adults without
malocclusion.4,18-20 malocclusion, and that adults with malocclusion who
More recently, several authors have concluded that seek orthodontic treatment are more bothered by the
malocclusion has a significant negative impact on oral malocclusion than are teenagers.

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780 Neely et al

MATERIAL AND METHODS health screening form was also completed at this time
This was a cross-sectional study of adults' percep- by the principal investigator. This form was used to
tions of the impact of their teeth and mouth on their assess the current oral health status of the participants.
oral health-related quality of life. The results were Data from the surveys and screening forms were then
compared with data from teenagers seeking orthodontic compiled and analyzed.31 At the completion of ortho-
treatment and from teenagers in the community.31 In dontic treatment, participants will be surveyed again
addition to the quality of life instrument, both adult to assess changes in quality of life and oral health-
and teenaged patients were asked to rate the esthetic related quality of life.
appearance of their teeth relative to the Aesthetic Questions were asked in 2 parts, and the impact was
Component of the Index of Orthodontic Treatment calculated by a scoring program. The first part of the
Need (IOTN).32 This project was approved by the Institu- question asked how often the patients' oral health both-
tional Review Board at Boston University. All partici- ered them, and the second asked how severely they were
pants gave written informed consent. bothered. Numeric values were assigned to every possible
The patients selected for this study were adults aged response as follows: 0, did not happen; 1, once in a while;
18 years or older who were judged to fall into the grade 2 2, some of the time; and 3, all the time. Severity values
or greater (worse) category of the Dental Component of were 0, did not happen; 1, never bothered; 2, bothered
the IOTN. Patients with mental or physical disabilities a little bit; 3, somewhat bothered; and 4, very bothered.
were excluded from the study. Scoring was done in the manner of Wright et al.1 An
All patients who satisfied the inclusion criteria and impact score was created by multiplying the frequency
were seeking comprehensive or limited orthodontic scores by the bother score; impact scores thus ranged
treatment were invited to participate. from 0 to 12. The impact scores were recoded on a scale
The primary outcomes of interest were overall oral of 1 to 13 by adding 1 to each score; missing values were
health-related quality of life as related to the patients' coded as zero. Means and sums were calculated for each
malocclusion. The oral health-related quality of life domain and for the overall instrument. The overall score
was measured using the TOQOL, developed by Wright was calculated as the sum of the impact values, minus
et al,30 who demonstrated its validity and reliability in the number of items, divided by the maximum value of
a diverse sample of 13- to 18-year-old adolescents. an item times the number of items, minus the number
The TOQOL assesses oral health-related quality of life of items, times 100.
in 5 domains: role, oral health, social, emotional, and The Dental Component of the IOTN (completed by
physical. Each item in each domain is explored by asking the principal investigator) consists of a classification sys-
a question beginning, “Due to problems with your teeth tem from grades 1 to 5, with grade 1 indicating no treat-
and mouth, how often in the past 3 months have ment need up to grade 5 indicating great treatment
you.?” The role domain assesses how the state of the need.32 The Dental Component was used to assess the
patients' oral condition impacts their ability to pay presence and severity of malocclusion, and hence ortho-
attention at school or work, missing work or school, dontic treatment need. The numbers of decayed,
and their ability to sleep. The oral health domain assesses missing, or filled teeth were also assessed from patient
bad breath, bleeding gums, food caught between teeth, records. The Aesthetic Component of the IOTN consists
and mouth sores. The social domain assesses the impact of a visual classification system from grade 1 to 10 using
of the patients' current oral state on social pressures and a series of photos, with grade 1 indicating mild esthetic
interactions, such as worrying about opinions of others concerns and grade 10 major esthetic concerns. The pa-
in regard to their appearance and comfort with smiling. tient was asked to score the severity of the malocclusion
The emotional domain assesses whether their oral health by selecting the photo that looked the most like his or her
upsets or worries them, and the physical domain mea- mouth from the IOTN picture format.
sures difficulty eating and oral pain. For each item, the In addition, other potential confounding factors were
respondents are asked how often they are bothered assessed: age, insurance status, education, and oral
and how severely they are bothered. health.
Patients who came to the orthodontic clinic for treat-
ment were screened preliminarily for eligibility based on Statistical analysis
initial records. If they qualified based on their IOTN, they Data from the survey were double entered into a
were asked to participate at their next appointment database, cleaned, and analyzed using software (version
before appliances were placed. At that time, those who 9.3; SAS, Cary, NC). The characteristics of the sample
consented were asked to complete the TOQOL. An oral population were described with respect to age, sex,

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Neely et al 781

Table I. Demographics
Label Category Adult Teen orthodontics P Teen control
n 307 146 161 303
Mean age (y) 32.45 13.04 \0.001 15.1
Sex Female 63.01% 47.83% 0.008 54.13%
Male 36.99% 52.17% 45.87%
Dental insurance Medicaid 15.49% 47.47% \0.001 57.64%
None 29.58% 6.96% 8.33%
Other 12.68% 3.80% 0.00%
Private 42.25% 41.77% 34.03%
Race group Asian 16.90% 5.16% 0.002 4.01%
Black/African-American 15.49% 18.71% 32.11%
Hispanic/Latino 28.87% 26.45% 22.74%
White/Caucasian 34.51% 36.13% 40.13%
Other/mixed 4.23% 13.55% 1%
Overall health group Excellent/very good/good 97.93% 94.41% 0.113
Fair/poor 2.07% 5.59%
Health of teeth/mouth group Excellent/very good/good 69.86% 78.26% 0.093 85.71%
Fair/poor 30.14% 21.74% 14.29%
Health of teeth/mouth Better/same 90.28% 96.88% 0.018 94.67%
compared to 1 year ago
Worse 9.72% 3.13% 5.33%
Teeth (n) 27.24 26.71 0.072 27.68
Aesthetic Component of IOTN 3.54 4.43 0.002
IOTN index 3.34 3.24 0.34
IOTN group 2,3 65.07% 57.76% 0.19
4,5 34.93% 42.24%

race and ethnicity, insurance, education, and treatment study.31 Subjects in both groups represented diverse
need. TOQOL scores for adults seeking orthodontic racial and ethnic backgrounds. In both groups, white
treatment were computed overall and by individual do- subjects represented the greatest proportion of the sam-
mains, and were compared with scores of teenagers un- ple followed by Hispanics/Latinos. Demographic charac-
dergoing and not undergoing orthodontic treatment teristics of the sample are shown in Table I.
from previous studies using t tests and chi-square Most patients (97%) reported that their general
tests.1,31 Additionally, TOQOL scores by groups were health was excellent, very good, or good. The distribu-
obtained using generalized linear modeling. tion by age group showed similar findings: 98% of
Simple and multiple linear regressions examined the adults and 94% of teens reported excellent, very good,
relationships between TOQOL as the dependent variable or good overall health.
and IOTN scores, after adjusting for other covariates. As In regard to their self-rated oral health, fewer (74%)
a test of construct validity, the TOQOL scores were reported excellent, very good, or good health, whereas
compared across IOTN groups and self-reported oral the remaining (26%) reported fair or poor oral health.
health. In addition, discriminant validity was estimated The distribution by age showed that 70% of adults re-
by comparing teens and adults needing orthodontic ported excellent, very good, or good oral health, and
treatment with data on teens surveyed in the schools. 78% of teens reported excellent, very good, or good.
Cronbach's alpha was computed overall and for each With respect to dental insurance, in the teen group,
domain of the TOQOL for adults and teenagers to 47% of the sample were on Medicaid, followed by
examine the reliability (internal consistency) of the in- 42% with private insurance; 11% responded “none” or
strument. Finally, a 3-way comparison of TOQOL scores “other.” This was different from the adult group, where
among adult orthodontic, teen orthodontic, and teen 42% of the sample had private insurance, followed by
control groups was done using generalized linear none or other at 42%, and Medicaid at 15%. The differ-
modeling, adjusting for age, IOTN, race, and sex. ences in terms of insurance were statistically significant
with a P value \0.001.
RESULTS The IOTN was divided by group as shown in Table I.
A total of 307 subjects participated in this study: 146 The group of teen patients with IOTN scores of 2 or 3
adults who were recruited and 161 teens from a previous represented 58% of the sample as compared to 65% of

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782 Neely et al

Table II. Scores for the domains in the teen and adult groups
Mean scores and impacts % yes

Mean (SD) Range Adult Teen P Adult Teen P

TOQOL score (17 items) 14.59 (11.86) 0-65.69 17.55 11.92 \0.001
Emotional domain 12.78 (18.48) 0-100 16.55 9.4 \0.001
Oral problems 13.11 (12.71) 0-62.5 14.61 11.75 0.054
Physical domain 11.16 (16.02) 0-100 12.49 9.97 0.174
Role domain 3.78 (7.85) 0-66.67 3.85 3.72 0.886
Social domain 28.09 (25.60) 0-100 35.3 21.6 \0.001
Emotional domain
Impact depressed 0.88 (2.05) 0-12 1.2 0.59 0.01 31.94% 14.91% 0.001
Impact feel angry/upset 1.64 (2.70) 0-12 2.06 1.27 0.012 47.89% 34.78% 0.021
Impact feel worried 2.07 (2.94) 0-12 2.71 1.5 \0.001 65.03% 45.91% \0.001
Oral health domain
Impact bad breath 1.26 (2.06) 0-12 1.17 1.34 0.461 35.42% 52.17% 0.003
Impact bleeding gums 1.45 (2.40) 0-12 1.73 1.2 0.056 46.90% 44.72% 0.703
Impact food between teeth 2.79 (2.93) 0-12 3.23 2.39 0.014 78.62% 86.25% 0.079
Impact mouth sores 0.80 (1.44) 0-8 0.88 0.72 0.341 32.41% 33.33% 0.865
Physical domain
Impact difficult eating food like 1.08 (2.25) 0-12 1.33 0.86 0.074 33.79% 25.63% 0.118
Impact trouble eating hot/cold/hard 1.58 (2.52) 0-12 1.73 1.44 0.32 43.75% 41.61% 0.707
Impact pain 1.35 (2.09) 0-12 1.44 1.27 0.465 40.97% 45.96% 0.38
Role domain
Impact hard to pay attention 0.41 (1.26) 0-12 0.56 0.27 0.054 21.38% 10.56% 0.009
Impact miss school/work 0.48 (1.25) 0-8 0.38 0.58 0.158 11.89% 30.63% \0.001
Impact trouble sleeping 0.46 (1.42) 0-12 0.43 0.48 0.742 15.28% 16.77% 0.723
Social domain
Impact crocked teeth/spaces 5.14 (4.27) 0-12 5.83 4.53 0.008 79.02% 86.96% 0.065
Impact worried less attractive 2.78 (3.61) 0-12 3.93 1.76 \0.001 72.22% 46.58% \0.001
Impact not want to smile/laugh 2.59 (3.55) 0-12 3.34 1.91 \0.001 61.11% 47.83% 0.02
Impact unhappy with looks 3.00 (3.46) 0-12 3.94 2.16 \0.001 79.86% 54.66% \0.001

the adult group. The mean esthetic component scores or upset about their teeth or mouth (P 5 0.02), and
were 4.43 in teens and 3.54 in adults. The difference 46% of teens vs 65% of adults felt worried about their
was statistically significant (P 5 0.002). teeth or mouth (P \0.001).
In general, scores overall and by domains were higher In the oral health domain, bad breath was a concern
for adults than for teens, signifying greater effects of oral for 52% of teens vs 35% of adults. This may have been
conditions on the quality of life, as seen in Table II. The related to poor oral hygiene, which is common in teens.
mean overall TOQOL scores (17 items) were worse (17.5) Also, food between the teeth concerned 86% of teens
in adults than in teens (11.9; P\0.01); emotional domain and 79% of adults.
scores were 16.5 in adults vs 9.4 in teens (P \0.01), and The bivariate effects of sociodemographic, self-
the social domain scores were 35.3 for adults vs 21.6 for reported oral health, and dental factors on TOQOL are
teens (P\0.01). The oral, physical, and role domains were shown in Table III. Notable is that the fair/poor oral
also worse in adults, but the differences were not statisti- health group had a worse mean TOQOL (19.9) than the
cally significant. excellent/very good/good oral health group (12.7;
Almost a third (31%) of teens and 12% of adults re- P \0.0001), supporting construct validity.
ported having missed school or work due to a problem in Although it was not statistically significant, the mean
their teeth or mouth. In addition, 46% of teens and 72% TOQOL score of the patients in the IOTN 4/5 group
adults felt worried about their attractiveness, and 55% (15.6) was worse than those in the IOTN 2/3 group
of teens and 80% of adults felt unhappy with their looks (13.9). In addition, female subjects reported a worse
(P \0.001). mean TOQOL (16.3) than did male subjects (12.4).
There were also some differences on other items. Reliability (internal consistency) was measured using
Twice as many (32%) adults vs (15%) teens described the Cronbach alpha as shown in Table IV. The Cronbach
feeling depressed about their teeth or mouth alpha was higher in adults for all domains (TOQOL, 17
(P \0.001), 48% of adults vs 35% of teens felt angry items; 0.75 in adults compared with 0.68 in teens).

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Neely et al 783

Table III. TOQOL by groups Table V. Multiple regression analysis

Mean Variable Parameter SE P value
Variable Category TOQL P value Adult 5.93 1.34 \0.001
Age group Adult 17.55 \0.001 IOTN 4 or 5 2.08 1.40 0.138
Teen 11.92 Black/Hispanic/other 2.44 1.38 0.079
IOTN group 2 or 3 13.91 0.214 Female 2.79 1.35 0.040
4 or 5 15.64 R2, adjusted 0.0879
Health of teeth/mouth Excellent/very good/ 12.74 \0.001
group good
Fair/poor 19.89 differences were found. Similarly, the TOQOL score,
Sex Female 16.32 0.005
Male 12.47
crooked teeth, and feeling depressed were significantly
different between the groups (P \0.001).30
The emotional domain scores were 19.8 for adults,
17.9 for orthodontically treated teens, and 14.7 for the
Table IV. Scale reliability of TOQOL (Cronbach alpha) control teens (P \0.001). Similarly, the emotional
Age group domain component scores for “feeling depressed” were
16.6 for adults, 9.4 for the treated teens, and 6.4 for
Total Adult Teen
the control teens (P\0.001). Overall scores for the social
Total 0.7337 0.7510 0.6862
Emotional 0.6400 0.6665 0.5769
domain were 31.1 for adults, 16.2 for the treated teens,
Oral health 0.7249 0.7290 0.7104 and 6.6 for the control teens (P \0.001).
Physical 0.6900 0.6966 0.6591 For the impact scores by study group (Fig 2), the
Role 0.6905 0.6930 0.6492 comparison of the 3 groups showed worse impacts in
Social 0.6887 0.7441 0.5649 the adult group in the different domains and individual
All scores reported are standardized (not raw). items as shown in Figure 2.

Bivariate analysis and multiple linear regression DISCUSSION

modeling with TOQOL scores as outcomes tested which This study was conducted to assess the impact of
covariates affected quality of life. After adjustments for malocclusion on oral health-related quality of life in
age, IOTN, race, and sex, it was found that age and sex adults seeking orthodontic treatment, compared with
were significantly associated with TOQOL scores, as teens who were either seeking orthodontic care or not.
shown in Table V. Our results are expressed as a comparison of the impact
Discriminant validity was estimated by comparing on oral health-related quality of life between teens and
teens and adults needing orthodontic treatment with adults seeking orthodontic treatment.
data on teens surveyed in the schools (Table I, control In general, these results are consistent with previous
teens). Wright et al30 studied 303 teens with a mean studies that determined that malocclusion has an impact
age of 15 years (54% female, 46% male). The distribu- on oral health-related quality of life. In a systematic re-
tion by race was 40% white/Caucasian, followed by view, Zhou et al24 found that the most studies included
32% black/African American, 23% Hispanic/Latino, in their research found a positive correlation between or-
4% Asian, and 1% diverse backgrounds. The representa- thodontic treatment and quality of life and an improve-
tion by insurance was 58% Medicaid, 34% private, and ment in oral health-related quality of life after treatment
8% none. compared with before or during treatment. They found
Figure 1 depicts the comparison of the TOQOL scores only 1 study where the oral health-related quality of
among the 3 groups (adult orthodontic patients, teen or- life was worse compared with a control group with no
thodontic patients, and teen control). TOQOL scores for malocclusion and without orthodontic appliances. In
adults receiving orthodontic treatment were higher in all this systematic review, the majority of oral health-
categories compared with teens, whether undergoing related quality of life studies were done in children. We
orthodontic treatment or not. did not evaluate oral health-related quality of life during
The TOQOL scores were significantly different among orthodontic treatment, so we could not address whether
the 3 groups: 16 for adults, 10.7 for teens, and 8.4 for oral health-related quality of life changed during ortho-
control teens (P \0.001). Also, when combining TOQOL dontic treatment.
and other characteristics, such as, crooked teeth or We found that overall scores and domain scores were
feeling depressed, some statistically significant generally higher for adults than for teens, suggesting a

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784 Neely et al

Fig 1. TOQOL scores by study group.

Fig 2. Impacts by study group.

greater effect of orthodontic treatment need on the were more likely to report more oral effects than those
quality of life. Scores were particularly higher in the who were more satisfied. Finally, improvement in
emotional and social domains. This is similar to what esthetic satisfaction after treatment of severe malocclu-
Chen et al26 found in their study, as patients were re- sion improved the oral health–related quality of life and
ported “to benefit psychologically from orthodontic its dimensions of psychological discomfort and psycho-
treatment through improved facial and dental appear- logical disability.
ance and increased self-confidence and improved In our study, the main effects patients reported were
esthetics.” Chen et al also found tenseness and missing work or school due to their teeth or mouth and
self-consciousness were significantly correlated to feeling worried, less attractive, and unhappy with their
orthodontic treatment needs. Similarly, Silvola et al23 re- looks. These effects could be related to psychological as-
ported that patients dissatisfied with dental esthetics pects; however, they cannot be compared in the same

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Neely et al 785

scale. Some problems encountered when comparing re- statistically significant. De Oliveira and Sheiham33
sults from different studies are due to the different ways reported that “sex significantly affects the impact of
used to measure the effects of malocclusion. It will be malocclusion on oral health related quality of life, and
helpful for future research to use standardized assess- women were 1.22 times more likely to have an impact
ment methods to obtain outcomes that are uniform than men.” Unexpectedly, in the study of Hassan and
and easier to compare.24 Amin,4 women had nearly similar impacts of orthodontic
We found that the effects on the oral and physical treatment needs on their daily activities as did the male
domains were not statistically significantly different. orthodontic patients.
However, Choi et al25 reported severe malocclusion to In our study, female subjects represented 62% of the
be significantly associated with functional limitation, sample, and there was concern that this might have
physical pain, and social disability in young adults. The influenced our results. To examine this further, we ran
results may differ because of the different methods the models by sex and found that adults had worse
used to measure quality of life. scores regardless of domain and sex. In the whole sam-
In previous studies, Choi et al25 and Masood et al22 ple, the TOQOL score and the emotional, oral health, and
found that patients with severe malocclusion reported social domain scores were significantly different by age
greater impacts on oral health-related quality of life group, with the adults having higher (worse) scores.
than those without severe malocclusion. The magni- When the sample was divided by sex, the TOQOL score
tude of the association between oral health-related as well as the emotional and social domains were still
quality of life and malocclusion was such that young significantly worse in the adult group. The oral health
adults with severe malocclusion had a 174% higher domain score was significantly different only in female
(worse) oral health-related quality of life score than subjects. Thus, the preponderance of female subjects
those without severe malocclusion, and their scores in the adult group did not change any nonsignificant
on the functional limitation, physical pain, and social values to significant.
disability domains were significantly correlated with Chen et al26 stressed the association between quality
malocclusion status. In addition, subjects with a severe of life and severe malocclusion, whereas our sample had
malocclusion reported functional limitation, physical a preponderance of adults with mild to moderate maloc-
pain, and social disability about 2 times more often clusions. However, there was no significant difference in
than those without a severe malocclusion. In our study, TOQOL scores between the group of adults with mild to
patients with IOTN scores of 4 or 5 reported a worse moderate malocclusion and the group with more severe
mean TOQOL score (15.7) than did the patients with malocclusion. It is possible that cultural differences be-
IOTN scores of 2 or 3. tween China and the United States accounted for the
It is hard to directly compare our results with many differences in the effect of malocclusion on the quality
other published studies for a variety of reasons. Shaw of life. Additionally, although we used the TOQOL with
et al14 looked at adults 20 years after their orthodontic 5 domains to measure the quality of life, Chen et al
treatment and concluded that “when self-esteem at used the oral health-related quality of life questionnaire
baseline was controlled for, orthodontic treatment had with 7 domains, so that mean scores from the 2 groups
little positive impact on psychological health and quality could not be directly compared.
of life in adulthood.” Clearly, some patients with poor This study is unique because we evaluated the impact
self-esteem when reporting for treatment will be far of malocclusion on quality of life in adults compared
more affected by their malocclusion, and we did not with teenagers. Our sample size (146 adults, 161 teen-
measure self-esteem. In addition, the psychologic mea- agers) was large enough to give us a good indication
sures were obtained through questionnaires and inter- of the differences in terms of the diverse domains and
views that may have brought out or emphasized impacts between teens and adults seeking orthodontic
different aspects than the TOQOL instrument that we treatment. In addition, the TOQOL measuring instru-
used. Finally, although the patients who received treat- ment was shown to be an internally consistent way to
ment did have a greater lasting improvement, it is not measure quality of life in teenagers and adults.
clear whether there was some relapse in alignment or oc- One important finding from our study was that,
clusion that might have led to their perhaps not having although the degree of malocclusion in the adults was
as great a benefit as expected. Unmet expectations by on average less severe than in the teens, the adults
themselves might result in patients not claiming a were more affected by their malocclusion. It may be
greater increase in the quality of life. that orthodontic treatment is common today for teens,
Female subjects had worse mean TOQOL scores than whereas adults who did not get treatment when growing
did male subjects; however, this difference was not up may have been bothered for many years before

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786 Neely et al

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