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Lucas Guimarães Abreu
IMPACTO DA MÁ OCLUSÃO E DO TRATAMENTO
ORTODÔNTICO NA QUALIDADE DE VIDA DE
ADOLESCENTES
Belo Horizonte
2015
Lucas Guimarães Abreu
IMPACTO DA MÁ OCLUSÃO E DO TRATAMENTO
ORTODÔNTICO NA QUALIDADE DE VIDA DE
ADOLESCENTES
Tese apresentada ao Programa de Pós-
Graduação da Faculdade de Odontologia da
Universidade Federal de Minas Gerais como
requisito parcial para a obtenção do título de
Doutor em Odontologia – área de concentração
em Odontopediatria.
Orientador: Prof. Dr. Saul Martins de Paiva
Co-orientadora: Profa. Dra. Elizabeth M. B. Lages
Faculdade de Odontologia
Universidade Federal de Minas Gerais
Belo Horizonte
Maio / 2015
FICHA CATALOGRÁFICA
D047
2015
T
Abreu, Lucas Guimarães
Impacto da má oclusão e do tratamento ortodôntico na
qualidade de vida de adolescentes /Abreu, Lucas Guimarães. –
2015.
141f. : il.
Orientador: Saul Martins de Paiva
Coorientadora: Elizabeth Maria Bastos Lages
Tese (Doutorado) – Universidade Federal de Minas Gerais,
Faculdade de Odontologia.
1. Qualidade de vida. 2. Má oclusão. 3. Adolescente. I. Paiva, Saul Martins de. II. Lages, Elizabeth Maria Bastos.
III. Universidade Federal de Minas Gerais. Faculdade de
Odontologia. IV. Título.
BLACK D047
Biblioteca da Faculdade de Odontologia - UFMG
Agradecimentos
Ao meu Orientador Professor Saul Martins de Paiva, pela confiança depositada em
mim durante estes anos. Saul, saiba que os frutos colhidos com este projeto, se
devem em grande parte, à sua participação. Sua capacidade para imprimir em um
orientando as qualidades para uma boa redação científica, além de sua experiência
e sua visão para explorar um assunto tão rico. Após um início difícil, pudemos
apresentar, em periódicos importantes, resultados muito interessantes e até
originais.
À minha Co-orientadora Professora Elizabeth Maria Bastos Lages, pela atenção,
dedicação e apoio durante o Mestrado e o Doutorado, principalmente na etapa árdua
de reunião dos participantes e na coleta de dados desta pesquisa. Elizabeth, vários
foram os dias que estivemos na clínica 8 desta faculdade. Naqueles momentos, eu
tive a oportunidade não somente de ter o seu apoio para uma das etapas mais
importantes deste trabalho, mas também de poder observá-la na orientação dos
alunos da escola e na condução de vários tratamentos nos cursos de graduação e
especialização.
À coordenadora da área de concentração em Odontopediatria Professora Isabela
Almeida Pordeus, exemplo de profissionalismo e persistência com a área de
concentração em Odontopediatria e com o Programa de Pós-Graduação em
Odontologia da Universidade Federal de Minas Gerais (UFMG). Isabela, saiba que
não foram raras, as vezes, em congressos ou encontros científicos, no Brasil e no
exterior, que eu me apresentava como aluno da Faculdade de Odontologia da
UFMG, e o seu nome era a referência que alguns dos meus interlocutores tinham
em Belo Horizonte.
Aos Professores da Faculdade de Odontologia da Universidade de Alberta, Maryam
Sharifzadeh-Amin e Carlos Flores-Mir, meus orientadores durante o estágio doutoral
no Canadá. Minha passagem por este país foi muito enriquecedora.
Aos Professores do Departamento de Odontopediatria e Ortodontia da Faculdade de
Odontologia da UFMG, Carolina de Castro Martins, Fernanda Morais Ferreira, José
Ferreira Rocha Júnior, Júnia Maria Cheib Serra Negra, Leonardo Foresti Soares de
Menezes, Miriam Pimenta Parreira do Vale, Patrícia Maria Pereira de Araújo Zarzar
e Sheyla Márcia Auad.
Aos Professores Alexandre Fortes Drummond e Henrique Pretti, coordenadores do
Curso de Especialização em Ortodontia da UFMG, por permitirem o meu acesso à
disciplina de Clínica Ortodôntica, onde foi feita a coleta de dados deste trabalho.
Ao Professor Mauro Henrique Nogueira Guimarães Abreu e ao Pós-Doutorando
Camilo Aquino Melgaço pela participação ativa neste projeto.
Às Pós-Doutorandas Ana Carolina Scarpelli, Cristiane Baccin Bendo e Milene Torres
Martins.
Aos colegas de Doutorado, Ana Paula Hermont, Cristina Miamoto, Fernanda
Bartolomeo Freire Maia, Maurício de Oliveira e Patrícia Drummond por estarem
juntos comigo nesta caminhada.
Aos colegas da Faculdade de Odontologia da Universidade de Alberta, Maryam
Elyasi, Parvaneh Badri, Aishah Alsumait, Mohammad Salehyar, Pawan Nyachhyon,
Sandra Palomino, Graziela De Luca Canto, Sheila Passos, Camila Pacheco, José
Roberto Pereira e Maurício Aquino.
À todos colegas de Mestrado e Doutorado da Faculdade de Odontologia da UFMG
pela convivência nestes quase três anos.
Às funcionárias do Colegiado de Pós-Graduação em Odontologia Laís, Priscila,
Letícia e Beth sempre muito dispostas e atenciosas.
Aos funcionários do Departamento de Odontopediatria e Ortodontia e às
funcionárias da disciplina de Ortodontia pela disponibilidade em ajudar. Poder fazer
minha coleta de dados dentro da Faculdade de Odontologia da UFMG foi um
enorme prazer.
À todos os adolescentes e seus pais ou responsáveis que aceitaram, gentilmente,
participar deste trabalho.
À Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) pela
concessão da bolsa de Doutorado no Brasil e pela concessão da bolsa do Programa
de Doutorado Sanduíche no Exterior.
Ao Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) e à
Fundação de Amparo a Pesquisa do Estado de Minas Gerais (FAPEMIG) pelo apoio
para o desenvolvimento do projeto.
Agradecimentos Afetivos
À Deus, por ter permitido este momento.
Aos meus pais, Modesto, pelo exemplo a ser seguido e Iris, pela dedicação
constante. A busca pelo conhecimento sempre foi um valor em nossa casa. Além da
motivação para o hábito da leitura e para o estudo da língua inglesa. Estes
estímulos, durante os anos, culminaram com minha ida, em certa época, para a
Inglaterra. Aquela foi minha primeira experiência no exterior. A passagem por aquele
país e a convivência com a cultura britânica tiveram um impacto enorme em minha
vida.
Aos meus irmãos Fabrício (In Memoriam) e Ana Martha pelo companheirismo.
Enfim, à todos meus familiares e amigos.
Uma manhã, acordei cego. O olho esquerdo recuperou a
visão no mesmo dia, mas o direito continuou inerte e
ofuscado. O oculista, que me examinou, disse que não
era nada de orgânico e diagnosticou a natureza do
distúrbio. Então me disse. Você olhou os quadros muito
de perto. Por que não os substitui por vastos horizontes?
Bruce Chatwin
Resumo
Impacto da má oclusão e do tratamento ortodôntico na qualidade de vida de
adolescentes
O objetivo do presente estudo foi avaliar o impacto da má oclusão e do tratamento
ortodôntico com aparelho fixo na qualidade de vida de adolescentes e seus
familiares. A apresentação deste estudo, no formato de tese, se dá em três seções.
A primeira, com as considerações iniciais, onde são descritos alguns conceitos de
qualidade de vida e qualidade de vida relacionada à saúde bucal. Dois artigos a
serem submetidos à periódicos científicos são apresentados na segunda seção. O
primeiro artigo objetivou avaliar a percepção de pais ou cuidadores com relação ao
impacto da má oclusão na qualidade de vida de adolescentes. Este estudo
transversal contou com uma amostra de 280 pais ou cuidadores de adolescentes
entre 11 e 12 anos que responderam o Parental-Caregiver Perceptions
Questionnaire (P-CPQ). A variável independente deste estudo foi a má oclusão dos
adolescentes avaliada através do Índice Estético Dental (IED). A idade e o gênero
dos adolescentes e a renda mensal das famílias foram consideradas variáveis de
confusão. A análise dos dados envolveu estatística descritiva, análise bivariada e
regressão de Poisson. A severidade da má oclusão dos adolescentes foi associada
significativamente com um impacto na percepção dos pais ou cuidadores com
relação à qualidade de vida destes adolescentes para a escala total (P
funcionais, bem estar emocional e bem estar social. A concordância foi determinada
através de análises de comparação e correlação. A primeira incluiu a comparação
das diferenças direcional e absoluta das médias obtidas referentes aos escores dos
instrumentos de qualidade de vida. A segunda se deu por meio da análise do
coeficiente de correlação intraclasse. Os resultados mostraram que a diferença
direcional entre as médias dos escores obtidos por adolescentes e seus pais ou
cuidadores foi significativa para o domínio de sintomas bucais (P=0,012). No
entanto, esta diferença não foi significativa para os domínios de limitações
funcionais, bem estar emocional e bem estar social e também para a escala total
(P>0,05). Os valores do índice de correlação intraclasse variaram de 0,52 a 0,59
para os quatro domínios de qualidade de vida indicando uma concordância
moderada. Para a escala total, o valor deste coeficiente foi 0,66, o que denota uma
concordância substancial. Portanto, existe uma boa concordância entre as
percepções de adolescentes e de seus pais ou cuidadores com relação ao impacto
do tratamento ortodôntico na qualidade de vida destes adolescentes. Por último, a
apresentação das considerações finais do trabalho. Nesta terceira seção, é feita
uma revisão abordando a associação entre desfechos ortodônticos e qualidade de
vida com várias referências bibliográficas, incluindo algumas publicadas, pelo nosso
grupo de pesquisa, em periódicos de ortodontia e odontopediatria.
Palavras-chave: qualidade de vida, má oclusão, ortodontia, adolescente, pais,
cuidadores, família
Abstract
Impact of malocclusion and orthodontic treatment on adolescents' quality of
life
The purpose of this study was to evaluate the impact of malocclusion and orthodontic
treatment with fixed appliances on the quality of life of adolescents and their families.
The study has been presented in three sections. Firstly, the preliminary
considerations, in which the definitions of quality of life and oral health related quality
of life have been described. Two articles to be submitted to scientific journals have
been presented in the second section. The first article aimed to assess
parents/caregivers perceptions of the impact of malocclusion on adolescents' quality
of life. This cross-sectional study comprised a sample of 280 parents/caregivers of 11
and 12-year-old adolescents who answered the Parental-Caregiver Perceptions
Questionnaire (P-CPQ). The main independent variable in this study was
adolescents' malocclusion which was diagnosed through the Dental Aesthetic Index
(DAI). Adolescents' age and gender, as well as family monthly income, were
considered to be confounding variables. Statistical analysis involved descriptive
statistics, bivariate analyses, and Poisson regression. The severity of adolescents'
malocclusion was significantly associated with the perceptions of parents/caregivers
of the adolescents' quality of life on the oral symptoms (P
of the mean directional and absolute differences. The latter was analyzed using the
intraclass correlation coefficient (ICC). The results showed that the mean directional
difference was significant for the oral symptoms subscale (P=0.012). However, it was
not significant for the functional limitations, emotional well-being, and social well-
being subscales as well as for the overall score (P>0.05). The ICC values ranged
from 0.52 to 0.59 for the four quality of life subscales, denoting moderate agreement.
For the overall scale, the ICC was 0.66 which is indicative of substantial agreement.
Thus, there was an agreement between adolescents and their parents/caregivers in
rating adolescents' quality of life during orthodontic treatment. The presentation of the
final considerations has been described in the third section. In this section, a review
of the association between orthodontic outcomes and quality of life has been
provided. The statements presented in this review have been supported by several
bibliographic references, including those published, by our research group, in
orthodontic and pediatric dentistry journals.
Keywords: quality of life, malocclusion, orthodontics, adolescent, parents,
caregivers, family
Listas de Abreviaturas
COEP – Comitê de Ética em Pesquisa
CPOD – Dentes cariados, perdidos e obturados
CPGO – Colegiado de Pós-Graduação em Odontologia
CPQ – Child Perceptions Questionnaire
DAI – Dental Aesthetic Index
EW – Emotional Well-Being
FIS – Family Impact Scale
FL – Functional Limitations
IADR – International Association for Dental Research
IED – Índice Estético Dental
IPC – Índice Periodontal Comunitário
OL – Overall
OMS – Organização Mundial de Saúde
OHRQoL – Oral Health Related-Quality of Life
OS – Oral Symptoms
P-CPQ – Parental-Caregiver Perceptions Questionnaire
PSDE – Programa de Doutorado Sanduíche no Exterior
SAS – Secretaria de Atenção à Saúde
SBPqO – Sociedade Brasileira de Pesquisa Odontológica
SPSS – Statistical Package for the Social Sciences
SUS – Sistema Único de Saúde
SW – Social Well-Being
TCLE – Termo de Consentimento Livre e Esclarecido
UFMG – Universidade Federal de Minas Gerais
Lista de Tabelas
Artigo 1
Tabela1: Socio-demographic characteristics of the sample and
adolescents' orthodontic need 46
Tabela 2: Mean (SD) overall and subscale P-CPQ scores according to
independent variables 47
Tabela 3: Multivariate Poisson regression model for the association
between overall and subscale P-CPQ scores and adolescents'
malocclusion 48
Artigo 2
Tabela I: Socio-demographic characteristics of sample 62
Tabela II: Mean subscale and overall scores for adolescents and
parents/caregivers 63
Tabela III: Mean directional and absolute differences for subscale and
overall scores 64
Tabela IV: Correlations between adolescents and parents/caregivers for
subscale and overall scores 65
Anexo D: Índice Estético Dental (IED)
Tabela 1: Severidade da má oclusão, valor do Índice Éstético Dental (IED) e indicação de tratamento ortodôntico 102
Lista de Figuras
Anexo D: Índice Estético Dental (IED)
Figura 1: Metodologia para medição de características oclusais 101
Sumário
1- Considerações Iniciais 19
2- Justificativa 23
3- Objetivos 25
4- Metodologia Expandida 27
5- Artigo 1
Summary 34
Introduction 35
Methods 36
Results 40
Discussion 41
Bullet Points 42
References 43
Tables 46
6- Artigo 2
Abstract 51
Introduction 52
Methods 53
Results 55
Discussion 56
Conclusions 58
References 58
Tables 62
7- Considerações Finais 67
8- Referências Gerais 71
9- Apêndices
Apêndice A: Termo de Consentimento Livre e Esclarecido (TCLE) 77
Apêndice B: Ficha Clínica 78
10-Anexos
Anexo A: Parecer do Comitê de Ética em Pesquisa da UFMG 80
Anexo B: Versão brasileira da forma curta do Child Perceptions
Questionnaire (CPQ11-14) 81
Anexo C: Versão brasileira do Parental-Caregiver Perceptions
Questionnaire (P-CPQ) 87
Anexo D: Versão brasileira do Family Impact Scale (FIS) 94
Anexo E: Índice Estético Dental (IED) 98
Anexo F: Normas para publicação no periódico International
Journal of Paediatric Dentistry 103
Anexo G: Normas para publicação no periódico American
Journal of Orthodontics and Dentofacial Orthopedics 113
11-Produção Científica no Doutorado 137
Considerações Iniciais
19
Considerações Iniciais
O termo qualidade de vida foi primeiramente usado, nos tempos modernos,
pelo Presidente dos Estados Unidos Lyndon Johnson, em um discurso à nação
americana em 1964. Para o Presidente Johnson, o progresso de um país não pode
ser mensurado pelo seu balanço bancário ou pelo equilíbrio de seu sistema
financeiro, mas sim, pela qualidade de vida que os seus cidadãos usufruem. Apesar
de ter ocorrido nos Estados Unidos, aquele discurso parece não ter sido dirigido
apenas aos norte-americanos. Pelo contrário, as palavras de Lyndon Johnson
ecoaram pelo mundo, e desde 1964, como um legado deixado por este estadista, o
termo qualidade de vida tem sido usado como um indicador confiável do progresso
das sociedades (Rapley, 2003). Sua contribuição como referência para a
organização dos serviços de saúde é sem paralelo.
Qualidade de vida foi definida pela Organização Mundial da Saúde (OMS), em
1993, como a percepção do indivíduo de sua posição na vida no contexto da cultura
e sistema de valores nos quais ele vive e em relação aos seus objetivos,
expectativas, padrões e preocupações (Organização Mundial da Saúde, 1993).
Trata-se de um construto ou um fenômeno dinâmico que engloba basicamente
quatro domínios: bem estar físico, bem estar funcional, bem estar emocional e bem
estar social (Cella, 1994). Diante destes domínios e considerando a natureza
dinâmica do fenômeno qualidade de vida, dois indivíduos, com o mesmo estado de
saúde, podem apresentar qualidade de vida totalmente diferentes dependendo de
suas experiências, expectativas e percepções (Allison et al., 1997).
O estudo da qualidade de vida relacionada à saúde bucal (Oral Health-
Related Quality of Life – OHRQoL) é a avaliação de como as condições da cavidade
bucal e de suas estruturas anexas impactam a vida de um indivíduo, decorrentes de
vários fatores que afetam a vida social, a alimentação, o exercício de atividades
diárias e o bem estar deste indivíduo (Locker et al., 2002). Antes restrito à pacientes
adultos (Locker & Jokovic, 1996), o estudo deste tema em crianças e adolescentes
tem despertado o interesse da comunidade científica nos últimos anos (Kumar et al.,
2014). Vários estudos relatam que condições bucais, tais como hipodontia (Kotecha
et al., 2013), cárie (Krisdapong et al., 2012), fluorose (Tellez et al., 2012) e
traumatismos dentários (Bendo et al., 2014a) têm um impacto negativo na qualidade
20
de vida de indivíduos jovens. Nos casos de crianças e adolescentes, torna-se
importante também avaliar a percepção de seus pais ou cuidadores (Barbosa &
Gavião, 2012), além do impacto destas condições bucais nas vidas das famílias
destes indivíduos (Abanto et al., 2012). Famílias de adolescentes com traumatismos
dentários mais severos relatam um maior impacto negativo na qualidade de vida,
com repercussões no bem estar emocional e na rotina das pessoas que convivem
com estes adolescentes, o que pode resultar em estresse e conflitos familiares
(Bendo et al., 2014b).
A má oclusão também afeta negativamente a qualidade de vida de
adolescentes. Indivíduos com anomalias oclusais mais severas apresentam um
impacto mais adverso destas condições na qualidade de vida quando comparados
com seus pares sem alterações ou com alterações menos severas (Ukra et al.,
2013). No entanto, a percepção de pais ou cuidadores sobre os efeitos da má
oclusão na qualidade de vida dos adolescentes e o impacto desta condição nas
famílias destes indivíduos ainda são insuficientemente documentados (Barbosa e
Gavião, 2009).
Existe interesse da comunidade científica em avaliar o impacto do tratamento
das diversas alterações bucais na qualidade de vida dos indivíduos jovens e de seus
pais e familiares (Ramos-Jorge et al., 2007; Malden et al., 2008). Por exemplo, o
tratamento de lesões de cárie severas em crianças está associado a uma melhora
significativa na qualidade de vida destes indivíduos e de membros de suas famílias
(Thomson & Malden, 2011). Estudos com indivíduos chineses mostram, também,
que algumas alterações na qualidade de vida de adolescentes ocorreram durante
terapia com aparelho ortodôntico fixo (Zhang et al., 2008; Chen et al., 2010). Nas
fases iniciais do tratamento, nota-se um grande impacto negativo na qualidade de
vida dos adolescentes devido, principalmente, a um comprometimento dos domínios
de sintomas bucais e limitações funcionais. No entanto, após o término do
tratamento e remoção do aparelho fixo, o impacto da terapia ortodôntica na
qualidade de vida destes adolescentes é substancialmente positivo devido ao
arrefecimento dos sintomas acarretados pelo uso de um dispositivo ortodôntico e a
uma melhora nos domínios de bem estar emocional e bem estar social (Chen et al.,
2010).
21
No Brasil, até o presente momento, alguns estudos avaliaram o impacto do
tratamento ortodôntico na qualidade de vida de adolescentes (Bernabé et al., 2008;
Feu et al., 2013). No entanto, devido à enorme abrangência do tema, o interesse por
este assunto ainda persiste. Além do mais, ainda são escassos, em nosso país,
trabalhos que objetivem avaliar a percepção de pais ou cuidadores com relação ao
impacto da terapia ortodôntica com aparelho fixo na qualidade de vida de
adolescentes e a repercussão desta modalidade de tratamento nas famílias destes
indivíduos.
Este projeto foi desenvolvido junto ao Programa de Pós-Graduação da
Faculdade de Odontologia da Universidade Federal de Minas Gerais (UFMG) com o
intuito de avaliar o impacto da má oclusão e do tratamento ortodôntico com aparelho
fixo na qualidade de vida de adolescentes e de seus familiares. Portanto, esta tese
inclui a justificativa, os objetivos e a metodologia expandida de todo o projeto e dois
artigos a serem submetidos a periódicos científicos. O primeiro avaliou a percepção
de pais ou cuidadores com relação ao impacto da má oclusão na qualidade de vida
de adolescentes e o segundo mediu o nível de concordância entre o relato de
adolescentes e o relato de seus pais ou cuidadores com relação ao impacto do
tratamento ortodôntico na qualidade de vida destes adolescentes. Por fim, foram
feitas algumas considerações finais sobre este assunto e uma relação de toda
produção científica originada deste trabalho até a presente data.
Justificativa
23
Justificativa
Podemos elencar as seguintes justificativas para o presente trabalho.
Considerar a má oclusão como um problema de saúde pública devido à sua
alta prevalência (de Almeida & Leite, 2013).
Considerar a importância da atenção odontológica e mais especificamente do
tratamento ortodôntico para a organização dos serviços de saúde oferecidos às
populações, principalmente quando estes serviços são custeados com recursos
públicos (Petersen et al., 2005).
Considerar que o impacto do tratamento ortodôntico na qualidade de vida de
adolescentes ainda é, prospectivamente, muito pouco explorado, principalmente no
mundo ocidental. Mais escassas ainda, são avaliações da percepção dos pais ou
cuidadores e o impacto da terapia com aparelho fixo nas famílias dos adolescentes.
Objetivos
25
Objetivos
Objetivos Gerais
Avaliar o impacto da má oclusão e do tratamento ortodôntico com aparelho
fixo na qualidade de vida de adolescentes.
Avaliar a percepção de pais e cuidadores com relação ao impacto da má
oclusão e do tratamento ortodôntico com aparelho fixo na qualidade de vida de
adolescentes.
Avaliar o impacto da má oclusão e do tratamento ortodôntico com aparelho
fixo nas famílias dos adolescentes.
Objetivos específicos
Avaliar propriedades técnicas, tais como responsividade e mínima diferença
clinicamente importante (MCDI) de questionários de qualidade de vida no cenário
ortodôntico.
Avaliar o nível de concordância entre as percepções dos adolescentes e de
seus pais e cuidadores com relação ao impacto da má oclusão na qualidade de vida
de adolescentes
Avaliar o nível de concordância entre as percepções dos adolescentes e de
seus pais e cuidadores com relação ao impacto do tratamento ortodôntico com
aparelho fixo na qualidade de vida de adolescentes.
Metodologia Expandida
27
Metodologia Expandida
1- Desenho de estudo
Estudo Longitudinal Prospectivo
2- Amostra
A amostra foi composta por adolescentes, entre 11 e 12 anos, submetidos a
tratamento ortodôntico no Curso de Especialização em Ortodontia da Faculdade de
Odontologia da Universidade Federal de Minas Gerais (UFMG). Os pais ou
cuidadores destes adolescentes também foram convidados a participar do presente
estudo.
2.1- Critérios de elegibilidade
Para a participação dos adolescentes e seus pais ou cuidadores foram
considerados os seguintes critérios de inclusão e exclusão.
2.2- Critérios de inclusão
Adolescentes entre 11 e 12 anos e seus pais e cuidadores
Voluntários que junto com seus pais ou responsáveis entregarem o Termo de
Consentimento Livre e Esclarecido – TCLE (Apêndice A) devidamente assinado.
2.3- Critérios de exclusão
Adolescentes e pais ou cuidadores sem um bom entendimento da língua
portuguesa.
Adolescentes com anomalias craniofaciais.
Adolescentes com cárie dentária. O diagnóstico de cárie dentária foi realizado
segundo o índice de dentes cariados, perdidos e obturados (CPOD) (OMS, 1997).
Adolescentes com traumatismo dentário. Para avaliar traumatismo dentário,
utilizou-se a classificação de Andreasen (Andreasen et al., 2007).
Adolescentes com doença periodontal. Para avaliação da condição gengival
dos adolescentes foi utilizado o índice de Löe (Löe, 1967).
Adolescentes que foram submetidos a tratamento odontológico nos últimos 3
meses antes do início da pesquisa.
3- Princípios éticos
O projeto de pesquisa foi submetido à análise e foi aprovado pelo Comitê de
Ética em Pesquisa (COEP) com seres humanos da Universidade Federal de Minas
Gerais (UFMG) (Anexo A). O TCLE foi apresentado aos adolescentes e aos seus
28
responsáveis para que fosse garantida a livre escolha quanto a participação na
presente pesquisa.
4- Levantamento de dados
Os dados foram coletados em uma das clínicas da Faculdade de Odontologia
da UFMG. Foram utilizados espelhos clínicos e sondas periodontais adotadas pelo
Índice Periodontal Comunitário (IPC) (Croxson, 1984). Estes instrumentos foram
empacotados e esterelizados. O profissional que coletou os dados trajava roupa
branca e no momento do exame clínico usava gorro, máscara, óculos de proteção,
avental branco e luvas descartáveis, dentro das normas de controle de infecção na
prática odontológica (Secretaria de Políticas de Saúde do Ministério da Saúde,
2000). Os dados obtidos no exame clínico foram anotados por um auxiliar que
também trajava roupa branca.
4.1- Ficha clínica
A ficha clínica reunia informações pessoais e demográficas e as
características da má oclusão apresentadas pelos adolescentes (Apêndice B). Para
a avaliação da má oclusão e a necessidade do tratamento ortodôntico, foi utilizado o
Índice Estético Dental – IED / Dental Aesthetic Index –DAI (Jenny & Cons, 1996).
4.2- Avaliação do nível socioeconômico dos adolescentes e seus familiares
Foram coletadas informações sobre a renda mensal das famílias dos
adolescentes, através da soma do número de salários mínimos ganho por cada
membro economicamente ativo daquelas famílias.
4.3- Avaliação do impacto do tratamento ortodôntico na qualidade de vida de
adolescentes
Os adolescentes participantes da pesquisa responderam a forma curta do
questionário sobre qualidade de vida Child Perceptions Questionnaire – CPQ11-14
(Anexo B), que foi desenvolvido no Canada (Jokovic et al., 2006) e validado e
adaptado transculturalmente para uso no Brasil (Torres et al., 2009).
4.4- Percepção de pais e cuidadores sobre o impacto do tratamento
ortodôntico na qualidade de vida de adolescentes
Os pais ou cuidadores responderam o Parental-Caregiver Perceptions
Questionnaire (P-CPQ) (Anexo C), que foi idealizado no Canadá (Jokovic et al.,
2003) e adaptado transculturalmente e validado para uso na população brasileira
(Goursand et al., 2009a).
29
4.5- Avaliação do impacto do tratamento ortodôntico na família dos
adolescentes
Os pais ou cuidadores responderam também o Family Impact Scale – FIS
(Anexo D), que também foi desenvolvido no Canadá (Locker et al., 2002) e validado
e adaptado transculturalmente para uso no Brasil (Goursand et al., 2009b).
4.6- Entrevistas com os participantes
Adolescentes responderam a forma curta do CPQ11-14 em seis momentos:
antes da colocação de bandas ortodônticas e colagem do aparelho fixo e 1 mês, 4
meses, 6 meses, 8 meses e 12 meses após a colagem do mesmo.
Pais e cuidadores responderam o P-CPQ e o FIS também em seis momentos:
antes da colocação de bandas ortodônticas e colagem do aparelho fixo nos
adolescentes e 1 mês, 4 meses, 6 meses, 8 meses e 12 meses após a colagem do
mesmo. As informações sobre renda mensal das famílias foram fornecidas pelos
pais e cuidadores junto com a primeira avaliação de qualidade de vida antes da
montagem do aparelho fixo.
4.7- Calibração para aplicação do Índice Estético Dental
A calibração para aplicação do Índice Estético Dental (Anexo E) envolveu
duas etapas. A primeira etapa, de caráter teórico, consistiu de uma discussão dos
critérios de diagnóstico deste índice e análise de modelos de estudo. Um professor
universitário, especialista em ortodontia, com 20 anos de experiência coordenou
esta fase. A segunda etapa, prática, também coordenada pelo padrão ouro,
envolveu o exame de 15 adolescentes. A concordância inter-examinador (0,85) e a
concordância intra-examinador (0.86) foram verificadas através do teste Kappa de
Cohen. Para a concordância intra-examinador, o intervalo entre a primeira e a
segunda avaliação foi de 10 dias.
5- Análise estatística
A análise estatística foi conduzida através do programa SPSS – Statistical
Package for the Social Sciences (versão 17.0 SPSS Inc., Chicago, IL, EUA).
Para a confirmação da distribuição normal ou não da amostra, foi utilizado o
teste Kolmogorov-Smirnov.
Para avaliação da qualidade de vida dos adolescentes durante o tratamento
ortodôntico, a percepção dos pais e cuidadores e o impacto da terapia ortodôntica
nas famílias dos adolescentes, foi utilizado testes estatísticos para a escala total dos
30
questionários com valores de P < 0.05 indicativos de significância estatística. Para
os domínios dos questionários foi adotada a correção de Bonferroni com valores de
P < 0.013 considerados estatísticamente significativos.
Os cálculos da responsividade dos questionários CPQ11-14, P-CPQ e FIS
foram feitos através do effect size em artigos que avaliaram a qualidade de vida dos
participantes em um momento antes do início do tratamento ortodôntico dos
adolescentes (T1) e em um momento após a bandagem e colagem do aparelho fixo
nestes indivíduos (T2). O effect size foi dados pela diferença entre as médias dos
escores em T1 e T2 dividida pelo desvio padrão da média em T1. De acordo com o
valor do effect size, a responsividade era considerada pequena, moderada ou
grande. A MCDI foi calculada multiplicando-se o desvio padrão da média em T2 por
0,5.
Nesta tese também foi avaliado o impacto da má oclusão na qualidade de
vida de adolescentes além da percepção de pais e cuidadores e o impacto desta
desordem bucal nas famílias destes indivíduos.
O nível de concordância entre os relatos de adolescentes e os relatos de seus
pais e cuidadores com relação ao impacto da má oclusão e do tratamento
ortodôntico na qualidade de vida destes adolescentes foi avaliado através dos
cálculos da diferença direcional, da diferença absoluta e do coeficiente de correlação
intra-classe (ICC).
Artigos
32
Artigo 1
Parents/caregivers perceptions of the impact of malocclusion on
adolescents' quality of life
Lucas G. Abreu1; Camilo A. Melgaço1; Mauro H. N. G. Abreu2; Elizabeth M. B.
Lages1; Saul M. Paiva1
1 Department of Paediatric Dentistry and Orthodontics, School of Dentistry,
Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha,
Belo Horizonte, Minas Gerais, Brazil, 31270-901.
2 Department of Community and Preventive Dentistry, School of Dentistry,
Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha,
Belo Horizonte, Minas Gerais, Brazil, 31270-901.
Word count: 3697
Corresponding Author
Lucas Guimarães Abreu
Rua Maranhao, 1447 / 1101, Funcionarios
30150-331, Belo Horizonte, MG, Brazil
55 31 3283 9653
mailto:[email protected]
33
Artigo a ser submetido para publicação no periódico International Journal
of Paediatric Dentistry (Anexo F)
Dados bibliométricos do periódico
Fator de impacto (2014): 1,541
Ranking SCImago (cites per doc): 0,860
Qualis CAPES (Odontologia): A1
34
Summary
Background: Though well-documented from the adolescents' perspective, the
impact of malocclusion on those individuals' oral health-related quality of life
(OHRQoL) using the views of their parents/caregivers has been poorly
investigated thus far.
Aim: To assess parents/caregivers perceptions of the impact of malocclusion
on adolescents' OHRQoL.
Materials and Methods: This cross-sectional study consisted of a sample of
280 parents/caregivers of 11 and 12-year-old adolescents who answered the
Parental-Caregiver Perceptions Questionnaire (P-CPQ). The main independent
variable, in this study, was adolescents' malocclusion which was diagnosed
through the Dental Aesthetic Index (DAI). Adolescents' age and gender, as well
as family monthly income, were considered to be confounding variables.
Statistical analysis involved descriptive statistics, bivariate analyses, and
Poisson regression with robust variance.
Results: Of the 280 parents/caregivers initially accepted in this study, 18
refused to answer the P-CPQ. Therefore, 262 individuals participated in this
study providing a response rate of 93.5%. The severity of adolescents'
malocclusion was significantly associated with a higher negative impact on
parents'/caregivers' perceptions on the oral symptoms (P
35
Introduction
Oral health related quality of life (OHRQoL) has been defined as the
extent to which oral outcomes affect individuals' oral functioning, psychological
well-being, and social well-being1. In recent decades, patient-centered tools
focusing on individuals' own perceptions have been used to assess the impact
of oral conditions on their quality of life2,3. Traditional methods to evaluate oral
health based on clinical standards are undeniably important. However, they
have proven to be limited, since they do not consider the psychosocial aspects
of health and should, therefore, be supplemented by subjective measures4.
More recently, efforts have been made to develop measures of OHRQoL that
would be suitable for use on children and adolescents5,6. The introduction of
OHRQoL has unveiled a new perspective by suggesting how oral outcomes
impact the lives of young patients and their families in general6.
The results of a systematic review showed that malocclusion negatively
impacts adolescents' OHRQoL7. In general, an increased severity of the
condition is associated with a higher impact on one's quality of life8. The primary
effect of malocclusion on adolescents' OHRQoL has most commonly been
recognized in the domains of emotional and social well-being7. Adolescents
clearly attribute high importance to an attractive dental appearance, and
irregularities in the position of one's teeth may reduce social acceptance9 and
induce low self-esteem10 which can ultimately deteriorate one's quality of life
through psychosocial pathways. Moreover, evidence shows that malocclusion
can compromise adolescents' chewing and speech capabilities11.
Though well-documented from the adolescents' perspective, the impact
of malocclusion on those individuals' OHRQoL using the views of their
parents/caregivers has received little scientific attention to date12. Factors
influencing parental attitudes and behaviors related to adolescents' orthodontic
outcomes warrant a broader and more in-depth investigation13. For many
reasons, clinicians should consider the guardians' beliefs and values regarding
symptoms, oral function, and well-being when presenting treatment options for
adolescents with malocclusion. First, the information provided by
parents/caregivers can serve to complement existing reports provided by
adolescents12. Second, parents/caregivers may be aware of some key
36
orthodontic variables regarding their sons/daughters and these attributes may
have an impact on both their informed consent and their satisfaction with the
future orthodontic treatment provided14. Finally, data collected from
parents/caregivers are also relevant because these individuals are often the
main decision-makers regarding adolescents' health, and their perceptions exert
a major influence on treatment choices15.
Therefore, the aim of this study was to evaluate parents'/caregivers'
views of the impact of malocclusion on the OHRQoL of Brazilian adolescents
using the Parental-Caregiver Perceptions Questionnaire (P-CPQ)16. It was
hypothesized that malocclusion is not associated with an impairment of
adolescents' OHRQoL when the perceptions of parents/caregivers are
assessed.
Methods
Subjects, setting, period of recruitment and eligibility criteria
A consecutive sample of parents/caregivers of 11 and 12-year-old
adolescents was selected. Participants, in this study, were identified through the
dental screening program of the Department of Orthodontics at the Federal
University of Minas Gerais in September 2013. This program consists of the
oral examination of adolescents who were referred to the School of Dentistry to
discover whether or not they needed orthodontic treatment. Adolescents, along
with their parents/caregivers, were invited to participate. For inclusion in the
sample, parents/caregivers needed to be literate and fluent in Portuguese. The
exclusion criteria consisted of parents/caregivers of adolescents with dental
caries, history of dental trauma, poor gingival health, craniofacial anomalies,
and cognitive disorders, as well as those who had undergone any dental
treatment within the past three months. Calibration for dental caries was
performed according to World Health Organization (WHO) criteria17. The
Andreasen classification18 was used for traumatic dental injury, whereas the
criteria developed by Loe19 were used to analyse gingival diseases.
Sample size calculation
Based on a pilot study, the sample size was calculated to establish a
power of 80% and a confidence interval of 95%. The following parameters were
also considered: a standard deviation of the mean overall P-CPQ score in the
37
unexposed group (parents/caregivers of adolescents with no orthodontic
treatment needs) of 11.7 and a standard deviation of the mean overall P-CPQ
score in the exposed group (parents/caregivers of adolescents with orthodontic
treatment needs) of 16.7. The difference to be detected was set at 4.3. The
minimum sample size to satisfy the requirements was estimated to be 237
individuals. Taking into consideration non-response attrition, the final sample
size was 280 parents/caregivers of adolescents
Ethical clearance
All aspects of this study, including methods to obtain informed consent
and agreement from participants (parents/caregivers and adolescents), were
independently reviewed and deemed to be ethical by the Research Ethics
Board of the Federal University of Minas Gerais. This study was conducted in
accordance with the principles for medical research involving human subjects
set forth in the Helsinki Declaration. Collected data remained anonymous and
confidential.
Measures
The outcome variable was defined as the parents'/caregivers'
perceptions of the impact of malocclusion on adolescents' quality of life.
Adolescents' malocclusion was the main independent variable. Family monthly
income, as well as adolescents' age and gender, were used as confounding
variables.
OHRQoL tool
Quality of life data were collected through the Parental-Caregiver
Perceptions Questionnaire (P-CPQ)16 which was developed in Canada,
translated, and verified for use in the Portuguese language20. It consists of 31
questions distributed into four subscales: oral symptoms (OS), functional
limitations (FL), emotional well-being (EW), and social well-being (SW). Each
question has five response options: “never” = 0; “once or twice” = 1;
“sometimes” = 2; “often” = 3; and “every day or almost every day” = 4.16 A “don't
know” option is also allowed. The overall score is computed by adding up all the
questions' scores. Scores for each of the four subscales can also be computed
separately. A higher score denotes a greater negative perception on the part of
parents/caregivers as regards their adolescents' OHRQoL16,20. The P-CPQ
38
shows reliability and validity. The former reflects the degree to which a test
score is free from measurement errors. The latter refers to the appropriateness,
significance, and usefulness of specific inferences drawn from test scores,
which is, therefore, considered a process of accumulating evidence based on
such inferences21. Parents/caregivers answered the questionnaire separately in
order to ensure that adolescents did not influence their answers in any way. The
information was provided in a quiet area of the university clinic with a
researcher available to clarify any question. The questions address the
frequency of events regarding problems with adolescents' teeth, lips, jaws, or
mouth, considering a self-reported recall of the previous three months. For this
reason, the administration of the questionnaires was limited to
parents/caregivers of adolescents with no dental disease other than
malocclusion and no dental treatment in a period of time shorter than this
interval, thereby avoiding any bias that could have occurred if the three-month
timeframe had not been considered.
Malocclusion assessment
Adolescents were clinically examined to assess malocclusion and to
determine their orthodontic treatment needs using the Dental Aesthetic Index
(DAI). This cross-cultural index consists of 10 occlusal characteristics related to
dentofacial anomalies according to three components: dentition (number of
missing incisors, canines, and premolars); crowding and/or spacing (crowding in
the incisal segments, spacing in the incisal segments, midline diastema, largest
anterior irregularity on the maxilla, and largest anterior irregularity on the
mandibula); and occlusion (maxillary overjet, madibular overjet, anterior open
bite and anterior posterior molar relationship). The scores for each occlusal
characteristic are multiplied by their specific weight and a constant value of 13
is added to obtain the final DAI score for each participant. Based on DAI cut-off
points, adolescents were classified into four grades of malocclusion with distinct
orthodontic treatment recommendations assigned to each grade: normal or
minor malocclusion/no need or slight treatment needed (DAI≤25), definite
malocclusion/elective treatment (26≤DAI≤30), severe malocclusion/highly
desirable treatment (31≤DAI≤35), and very severe malocclusion/mandatory
treatment (DAI≥36)22.
39
The calibration exercise was carried out before beginning the study to
ensure reliable data collection. Two dentists received adequate training for the
use of DAI. This calibration process consisted of both theoretical and clinical
steps. The theoretical step involved a discussion on the criteria used to
diagnose malocclusion. The clinical step involved the examination of 15
adolescents who were not included in the main study. Examinations were
performed by each of the two dentists separately to calculate the inter-examiner
agreement. Ten days later, adolescents were re-assessed to calculate the intra-
examiner agreement. Kappa values ranged from 0.84 to 0.90 for both inter and
intra-examiner agreement. As the Kappa coefficients were very good, the
examiners were considered apt to conduct this epidemiological study.
Family monthly income
Household income was categorized in terms of the Brazilian Monthly
Minimum Wage (BMMW), which corresponded to US$ 325.00 at the time of the
study, and was established as the monthly income of all economically active
members of the family. For statistical analysis, household income was
categorized as follows: parents/caregivers of adolescents whose families have
a monthly income of equal to or lower than 1 BMMW, > 1 to ≤ 3 BMMWs, > 3 to
≤ 5 BMMWs or higher than 5 BMMWs.
Pilot study
Following the calibration process, a pilot study, conducted with
adolescents and their parents/caregivers who did not participate in the main
study, was carried out in order to calculate the sample size as well as to test the
administration of the questionnaires and the dental examination of adolescents.
The results of the pilot study showed that changes in the proposed data
collection protocol were unnecessary.
Statistical analysis
All statistical analyses were performed using the Statistical Package for
the Social Sciences (SPSS for Windows, Version 22.0, SPSS Inc., Chicago, IL,
USA). Descriptive statistics were calculated, followed by the application of a
nonparametric bivariate analysis. The Mann-Whitney and Kruskal-Wallis tests
were used to compare the overall and subscale P-CPQ scores for malocclusion,
family monthly income, and adolescents' age and gender. Poisson regression
40
with robust variance was used to perform a multivariate analysis. Overall and
subscale P-CPQ scores were compared in terms of the robust rate ratio and the
respective 95% confidence intervals for the malocclusion categories.
Malocclusion was incorporated into the model and adjusted for confounding
variables (family monthly income as well as adolescents' age and gender). The
confounding variables were incorporated into the model based on statistical
significance (P
41
Discussion
The present study assessed parents/caregivers perceptions of the impact
of malocclusion among adolescents on their OHRQoL. Parents/caregivers
reported a negative impact of malocclusion on the overall quality of life of their
adolescents. The results were also statistically significant in the OS, FL, EW,
and SW subscales. To the best of our knowledge, this is the first study that
involved parents/caregivers of 11 and 12-year-old adolescents and that used a
validated quality of life tool to reach this specific outcome. Similar results were
found in previous reports; however, the primary aim of those reports was to
validate the P-CPQ in different languages and cultures, using convenience
samples and assessing other types of oral conditions, such as dental caries,
fluorosis, and gingivitis16,23. Therefore, the present study represents a significant
contribution to the scientific knowledge by unveiling such evidence in a sample
of Brazilian adolescents and their respective guardians.
Results from the present study run in direct contrast with those from prior
reports that assessed the impact of malocclusion on the quality of life of
preschoolers24,25. In those reports, parents'/caregivers' views did not indicate
any significant impact on children's OHRQoL. This lack of impact is most likely
due to the fact that, at this age, children do not prioritize aesthetics, which is a
major concern for adolescent groups, especially as regards the impact on the
EW and SW subscales26. In addition, more severe cases of malocclusion, such
as increased overjet and diastema, which can exert a negative impact on the FL
subscale, are more prevalent in mixed and permanent dentitions11.
This study's findings demonstrated that OHRQoL progressively
deteriorated as the severity of adolescents' malocclusion increased. The
presence of an ascending gradient in the P-CPQ overall and subscale scores
referent to the severity of adolescents' malocclusion severity could be explained
by the following reasons. First is the sample size26. The number of participants
based on a sample size calculation may impact the distribution of adolescents
in each DAI category, thereby influencing the association between the severity
of adolescents' malocclusion and P-CPQ scores. The second explanation may
be the questionnaire itself. Despite being a generic OHRQoL measure, the P-
CPQ is a validated tool with reliable psychometric properties tested mainly in
42
pediatric and orthodontic groups16,20. A final explanation that could be argued is
the fact that cultural and ethnic characteristics, treatment expectations, and
access to orthodontic services impacts the quality of life of young individuals
and may also have an impact on the responses provided by their
parents/caregivers27,28.
In interpreting the outcome of this study, it is important to bear in mind its
limitations. Firstly, the study was conducted with a sample of individuals who
were parents/caregivers of adolescents seeking orthodontic treatment at a
university clinic. Those individuals were more likely to have higher P-CPQ
scores than those who were parents/caregivers of adolescents not seeking
treatment, possibly leading to an overestimation of the final results. Secondly,
this study presented a cross-sectional design and; therefore, the temporal
relationship between the outcome and the main predictor could not be defined.
However, adolescents' malocclusion possibly preceded the outcome avoiding
the occurrence of reverse-causality bias8.
The results of the present study can serve as a source of information for
health planners and governmental authorities in organizing public policies and
oral health services29. This information is also relevant for clinicians to inform
parent/caregivers about the repercussions of malocclusion on adolescents'
quality of life. However, future studies considering different populations with
different ethnic and cultural characteristics should be conducted to confirm the
findings presented herein. There is also a need for longitudinal studies to
furnish more consistent information and assess the long-term effects of
adolescents' malocclusion and orthodontic treatment on the views of their
parents/caregivers.
Why this paper is important to paediatric dentists
The parents/caregivers surveyed in this study reported a negative impact
of malocclusion on adolescents' quality of life. An increased severity of
malocclusion is associated with a higher adverse impact on OHRQoL.
Measures of quality of life play a relevant role in clinical practice as an
efficient tool through which paediatric dentists can obtain additional
information provided by parents/caregivers about the psychosocial
impact of oral disorders, such as malocclusion on adolescents' OHRQoL.
43
Awareness of this information should aid paediatric dentists when
referring adolescent patients with the diagnosis of malocclusion to
orthodontic treatment.
Acknowledgements
This study was supported by the National Council for Scientific
Development (CNPq), the Coordination for the Improvement of Higher Level
Education Personnel (CAPES), and the State of Minas Gerais Research
Foundation (FAPEMIG), Brazil.
Conflict of interest
The authors declare no conflict of interest.
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adolescents among Chinese, Malay and Indians in Singapore. Qual Life
Res. 2005; 14: 1755-1768.
28-Kiyak HA. Does orthodontic treatment affect patients' quality of life? J
Dent Educ. 2008; 72: 886-894.
29-Martins-Júnior PA, Marques LS, Ramos-Jorge ML. Malocclusion: social,
functional and emotional influence on children. J Clin Pediatr Dent. 2012;
37: 103-108.
46
Table 1: Socio-demographic characteristics of the sample and adolescents' orthodontic need
Number (%)
Adolescents' gender Male 120 (45.8) Female 142 (54.2) Adolescents' age (years) 11 96 (36.6) 12 166 (63.4) Family monthly income (BMMW) ≤ 1BMW 20 (7.6) > 1 to ≤ 3 BMWs 129 (49.3) > 3 to ≤ 5 BMWs 93 (35.5) > 5 BMWs 20 (7.6) Adolescents' malocclusion (DAI) ≤ 25 98 (37.4) 26 to 30 98 (37.4) 31 to 35 47 (17.9) ≥ 36 19 (7.3)
BMMW, Brazilian Monthly Minimum Wage DAI, Dental Aesthetic Index
47
Table 2: Mean (SD) overall and subscale P-CPQ scores according to independent variables
OS Mean (SD) FL Mean (SD) EW Mean (SD) SW Mean (SD) OL Mean (SD)
Adolescents' gender Male Female P-value
*
5.03 (2.72) 4.58 (2.55) 0.125
5.09 (3.51) 4.65 (3.69) 0.200
5.10 (4.25) 5.24 (3.57) 0.319
5.10 (5.41) 5.68 (5.51) 0.520
20.33 (12.42) 20.08 (12.25) 0.807
Adolescents' age (years) 11 12 P-value
*
4.66 (2.80) 4.86 (2.54) 0.375
5.20 (3.72) 4.66 (3.54) 0.200
5.78 (4.68) 4.83 (3.32) 0.272
6.52 (6.68) 4.77 (4.51) 0.133
22.16 (14.87) 19.05 (10.42) 0.292
Family Income (BMMW) ≤ 1 BMMW > 1 to ≤ 3 BMMWs > 3 to ≤ 5 BMMWs > 5 BMMWs P- value
**
4.80 (3.45) 4.78 (2.39) 4.95 (2.74) 4.10 (2.82) 0.538
6.20 (5.37) 5.29 (3.87) 4.24 (2.76) 3.55 (2.37) 0.144
7.10 (5.34) 5.38 (4.14) 4.71 (3.20) 4.10 (2.86) 0.262
8.10 (7.26) 5.60 (5.55) 4.90 (4.87) 3.90 (4.83) 0.153
26.20 (18.47) 21.05 (12.43) 18.69 (10.31) 15.65 (10.33) 0.076
Adolescents' malocclusion (DAI) ≤ 25 26 to 30 31 to 35 ≥ 36 P-value
**
4.72 (2.54) 4.69 (2.75) 5.68 (2.39) 3.37 (2.45) 0.003
4.30 (3.08) 4.47 (3.32) 6.40 (4.76) 5.89 (3.23) 0.021
4.41 (3.09) 4.87 (3.71) 6.55 (4.79) 7.32 (4.66) 0.007
4.43 (4.40) 4.76 (4.92) 7.43 (6.99) 8.89 (6.48) 0.002
17.76 (9.25) 18.79 (12.17) 26.06 (15.59) 25.47 (12.31) 0.003
OS, oral symptoms; FL, functional limitations; EW, emotional well-being; SW, social well-being; OL,overall score SD, standard deviation BMMW, Brazilian Monthly Minimum Wage DAI, Dental Aesthetic Index *Mann-Whitney test
**Kruskal-Wallis test
48
Table 3: Multivariate Poisson regression model for the association between overall and subscale P-CPQ scores and adolescents' malocclusion
OS Robust RR (95% CI) FL Robust RR (95% CI) EW Robust RR (95% CI) SW Robust RR (95% CI) OL Robust RR (95% CI)
Malocclusion (DAI) ≤ 25 26 to 30 31 to 35 ≥ 36
1.00 0.98 (0.86 – 1.11) 1.18 (1.01 – 1.37)
*
0.72 (0.55 – 0.94)*
1.00 1.04 (0.91 – 1.19) 1.45 (1.25 – 1.68)
**
1.31 (1.06 – 1.63)*
1.00 1.12 (0.98 – 1.28)
1.48 (1.28 – 1.72)**
1.60 (1.31 – 1.95)**
1.00 1.10 (0.97 – 1.26)
1.70 (1.47 – 1.95)**
1.81 (1.50 – 2.17)**
1.00 1.07 (1.00 – 1.14)
*
1.45 (1.35 – 1.57)**
1.37 (1.24 – 1.52)**
OS, oral symptoms; FL, functional limitations; EW, emotional well-being; SW, social well-being; OL, overall score RR, rate ratio CI, confidence interval DAI, Dental Aesthetic Index *P < 0.05,
**P < 0.001
Model adjusted for control variables (gender, age, and family income)
49
Artigo 2
Agreement between adolescents and parents/caregivers in rating adolescents'
quality of life during orthodontic treatment
Lucas Guimarães Abreua; Camilo Aquino Melgaçob; Mauro Henrique Nogueira
Guimarães Abreuc; Elizabeth Maria Bastos Lagesd; Saul Martins Paivae
a PhD student, Department of Pediatric Dentistry and Orthodontics, School of
Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627,
Pampulha, Belo Horizonte, MG, Brazil, 31270-901. [email protected]
b Post doctoral fellow, Department of Pediatric Dentistry and Orthodontics, School of
Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627,
Pampulha, Belo Horizonte, MG, Brazil, 31270-901. [email protected]
c Associate professor, Department of Community and Preventive Dentistry, School of
Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627,
Pampulha, Belo Horizonte, MG, Brazil, 31270-901. [email protected]
d Associate professor, Department of Pediatric Dentistry and Orthodontics, School of
Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627,
Pampulha, Belo Horizonte, MG, Brazil, 31270-901. [email protected]
e Full professor, Department of Pediatric Dentistry and Orthodontics, School of
Dentistry, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627,
Pampulha, Belo Horizonte, MG, Brazil, 31270-901. [email protected]
Corresponding Author
Lucas Guimarães Abreu
Rua Maranhao, 1447 / 1101, Funcionarios
30150-331, Belo Horizonte, MG, Brazil
55 31 3283 9653 / 55 31 9966 5008 / [email protected]
mailto:[email protected]
50
Artigo a ser submetido para publicação no periódico American Journal of
Orthodontics and Dentofacial Orthopedics (Anexo G)
Dados bibliométricos do periódico
Fator de impacto (2014): 1,997
Ranking SCImago (cites per doc): 1,567
Qualis CAPES (Odontologia): A1
51
Abstract
Introduction: To assess the agreement between Brazilian adolescents and their
parents/caregivers regarding adolescents' oral health-related quality of life (OHRQoL)
during orthodontic treatment.
Materials and Methods: The sample consisted of 104 adolescent-parent/caregiver
pairs. Adolescents answered the short form of Child Perceptions Questionnaire
(CPQ11-14) and parents/caregivers answered the Parental-Caregiver Perceptions
Questionnaire (P-CPQ). The CPQ11-14 and the P-CPQ have 14 items in common
organized across four subscales: oral symptoms (OS), functional Limitations (FL),
emotional well-being (EW), and social well-being (SW). Agreement on the overall
score and the subscales was determined using comparison and correlation analysis.
The former was performed through comparison of the mean directional and absolute
differences. The latter was analyzed using the intraclass correlation coefficient (ICC).
Results: The mean directional difference was significant for the OS subscale with
parents' reports being lower than adolescents' reports (P=0.012). However, it was not
significant for the FL, EW, and SW subscales as well as for the overall score
(P>0.05). The mean absolute difference for the overall score was 5.15, representing
9.2% of the maximum possible score. The ICC was 0.66, indicating substantial
agreement.
Conclusion: There was an agreement between adolescents and their
parents/caregivers in rating adolescents' OHRQoL during orthodontic treatment.
52
Introduction
The concept of oral health-related quality of life (OHRQoL) was developed to
measure subjective perceptions regarding the impact of oral health and functional
status on quality of life.1 The assessment of OHRQoL has been increasingly
recognized as an important health outcome measure in dentistry, since oral
problems, such as malocclusion, can have a negative impact on the physical and
psychological well-being of young individuals.2
Orthodontic treatment can also have an impact on the OHRQoL of children
and adolescents. Quality of life is positively affected after the removal of the
orthodontic appliance as a result of improvements in emotional and social well-
being.3 However, OHRQoL is often reduced at the onset of treatment due to the
worsening of oral symptoms and the impairment of oral functions.4 Information on the
early first months of orthodontic therapy is of considerable importance to clinicians,
since the inconvenience of pain and functional limitations, in this period, can lead to
disappointment on the part of patients, which may ultimately result in treatment
dropouts.5
Research has been conducted to evaluate the agreement between pediatric
patients and their parents/caregivers with regard to rating children's and adolescents'
OHRQoL.6 The findings of a systematic review indicate that, while some studies
report a good level of agreement between parents/caregivers and
children/adolescents, other investigations have found a low level of agreement.7
However, this does not lessen the value of parents’/caregivers’ reports in pediatric
health outcome research.8 Parents/caregivers are the main decision makers
regarding the oral health of children/adolescents and their perceptions exert a major
influence on the choices involved in orthodontic treatment.9 Therefore, even in the
cases in which children/adolescents are able to self report, the proxy reports of
parents/caregivers regarding the quality of life of their sons and daughters should be
considered as an additional outcome measure.10 When the reports of both
parents/caregivers and adolescents are used, the former should be interpreted as a
complement and not a substitute for the latter.11 Information provided by
parents/caregivers is valuable in guiding orthodontists with regard to clinical decision
making.12 Such information could also be useful for general and pediatric dentists
before referring patients for orthodontic treatment.13
53
The impact of ongoing orthodontic treatment on the OHRQoL of adolescents
has been well documented.14 However, the agreement between parents/caregivers
and their sons/daughters in rating OHRQoL among adolescents undergoing
orthodontic therapy with a fixed appliance has been under-investigated and this
question is yet to be answered fully.12 Studies with different populations on this type
of agreement should be highly encouraged. Indeed, the validity of
parents'/caregivers' reports and, therefore, whether or not parents/caregivers can
serve as proxies for their sons/daughters, depends on the understanding of this issue
in its entirety.8 Moreover, ethnicity is a marker for oral health outcomes. It is important
to take into account that among different populations, there are differences in oral
health behaviors and beliefs.15 Thus, the aim of the present study was to evaluate the
level of agreement in the assessment of OHRQoL between Brazilian adolescents
undergoing orthodontic treatment with a fixed appliance and their parents/caregivers.
Methods
Participants and setting
The sample consisted of 104 adolescents undergoing orthodontic treatment
with a fixed appliance at the Department of Pediatric Dentistry and Orthodontics of
the Federal University of Minas Gerais and their parents/caregivers. For inclusion in
the study, adolescents along with their parents/caregivers needed to be literate and
fluent in Brazilian Portuguese. The exclusion criteria were adolescents with
craniofacial anomalies and cognitive disorders.
Sample size calculation
The sample size was determined using the intraclass correlation coefficient
(ICC). The null hypothesis for the ICC was set at 0.4 (moderate agreement). The ICC
regarded as indicating a significant agreement was set at 0.6 (substantial
agreement).16 Considering an α of 0.05 and β of 0.217, 87 was the minimum number
of pairs of adolescents and parents/caregivers required. This figure was increased by
20% to compensate for possible losses. Therefore, the sample comprised 104 pairs
of adolescents and parents/caregivers.
Ethical considerations
This study received approval from the Human Research Ethics Committee of
the Federal University of Minas Gerais (Brazil). All participants received clarifications
regarding the objectives of the study and signed a statement of informed consent.
54
Confidentiality was ensured, as only the researchers had access to the raw data. All
study personnel signed a confidentiality agreement that outlined their responsibilities
concerning the privacy of the participants. Hard copies were locked in a filing cabinet.
Digital information was kept in a computer protected by a password.
Data collection and measures
OHRQoL was measured using the Child Oral Health Quality of Life
Questionnaires (COHQoL©). Adolescents answered the short form of the Child
Perceptions Questionnaire (CPQ11-14)18 and parents/caregivers answered the
Parental-Caregiver Perceptions Questionnaire (P-CPQ).11 Both instruments are valid
and reliable and have been cross-culturally adapted for use on the Brazilian
population.19,20 Adolescents and parents/caregivers answered the questionnaire
separately in a quiet area of the orthodontic clinic with a researcher available to
clarify any questions. Assessments were performed eight months after the banding
and bonding of a fixed appliance.
The CPQ11-14 is composed of 16 items distributed among four subscales: oral
symptoms (OS), functional limitations (FL), emotional well-being (EW) and social
well-being (SW). Each item has five response options: “never” = 0; “once or twice” =
1; “sometimes” = 2; “often” = 3; and “every day or almost every day” = 4.18 The P-
CPQ consists of 31 items distributed among the same four subscales with the same
five response options. For the P-CPQ, a “don't know” response is also allowed.11 The
two questionnaires have 14 items in common: four items on the OS subscale, four on
the FL subscale, three on the EW subscale and three on the SW subscale.21 The
items on both questionnaires address the frequency of events in the previous three
months regarding problems with adolescent's teeth, lips, jaws or mouth. The overall
score is computed by summing all the item scores. Scores for each of the four
subscales can also be computed. For the 14 items in common, the overall score on
both questionnaires ranges from 0 to 56. For the CPQ11-14, a higher score denotes a
greater impact on the adolescent’s OHRQoL.18 For the P-CPQ, a higher score is
indicative of a greater negative perception on the part of parents/caregivers with
regard to the OHRQoL of their adolescent sons/daughters.11
Household income
Parents/caregivers were also asked to answer a question on household
income, which was measured in terms of the Brazilian monthly minimum wage, which
55
is a standard for this type of assessment and corresponded to approximately US$
325.00 at the time of the data collection.
Statistical analysis
Statistical analysis was carried out using the Statistical Package for the Social
Sciences (SPSS for Windows, version 17.0, SPSS Inc., Chicago, IL, USA).
Descriptive statistics were performed. The directional differences were determined by
subtracting the CPQ11-14 score from the P-CPQ score. The overall and subscale
directional differences were then compared to zero (0) using paired t-tests to
evaluate statistical significance. To assess the magnitude of systematic bias, mean
directional differences were divided by their respective standard deviations. For
interpretation of the magnitude of the differences, a standardized difference of 0.2
was considered small, 0.5 was considered moderate and 0.8 was considered large.22
Mean absolute differences were calculated by ignoring the positive and the negative
signs of the directional differences, which provided an indicator of agreement. This
was then expressed as a percentage of the maximum score to assess the size of the
absolute differences. ICCs were also calculated for the overall and subscale scores
and the level of agreement was categorized as follows: poor (< 0.2), fair (0.2 to 0.4),
moderate (0.41 to 0.60), substantial (0.61 to 0.80) and excellent (0.81 to 1.0).16
Results
A total of 102 pairs of adolescents and parents/caregivers agreed to answer
the questionnaires (response rate: 98.1%). Mean age of adolescents was 11.37 ±
0.67 years. Among the 102 families that participated in the study, 74 earned less
than three times the Brazilian monthly minimum wage (Table I).
Adolescents had worse overall OHRQoL scores than their corresponding
parents/caregivers (Table II). However, the mean directional difference of 0.79 for the
overall score was non-significant (P = 0.248). The mean directional differences for
the subscales ranged from 0.08 to 0.64. The mean directional difference was
statistically significant for the OS subscale (P = 0.012), with adolescents' scores
higher than parents'/caregivers’ scores. When the mean directional differences were
standardized, the magnitude of the directional difference for the overall OHRQoL
score was 0.11. The mean absolute differences between the overall CPQ11-14 and P-
CPQ scores was 5.15 ± 4.52, representing 9.2% of the maximum possible score of
56 (Table III).
56
The ICC for the overall OHRQoL score was 0.66, demonstrating substantial
agreement between adolescents and parents/caregivers in rating adolescents'
OHRQoL during orthodontic therapy with a fixed appliance. Among the different
subscales, the ICC ranged from 0.52 to 0.59, demonstrating moderate agreement
(Table IV).
Discussion
When measuring the OHRQoL of children and adolescents, it may also be
necessary or desirable to obtain reports from their parents/caregivers. Parallel
reporting has been increasingly recommended in studies involving the assessment of
health outcomes in child and adolescent populations.8 The present study found a
good level of agreement between adolescents and their parents/caregivers regarding
their perceptions of the impact of orthodontic treatment on the OHRQoL of
adolescents submitted to orthodontic therapy with a fixed appliance. The mean
directional differences and the mean absolute differences were small and no
statistically significant differences were found between the reports of the adolescents
and the reports of their parents/caregivers for the FL, EW and SW subscales or the
overall score. However, a statistically significant difference was found regarding the
OS subscale. These results are in contrast with the findings of a systematic review,
which reports that the level of agreement appears to be dependent on the subscale,
with adequate agreement on the symptoms and function subscales and poor
agreement on subscales that reflect emotional and social aspects.23 However, a
Dutch study, which also evaluated agreement between adolescents and
parents/caregivers in rating the OHRQoL of adolescents during orthodontic treatment
with a fixed appliance found a good level of agreement between parents and their
sons/daughters, with a small but significant difference on the OS subscale.12
Therefore, only minor differences are found in the perceptions of orthodontic patients
and their parents/caregivers regarding OHRQoL.24
The standardized difference indicates systematic bias and is similar to an
effect size calculation for paired observations.22 The standardized difference between
parents/caregivers and adolescents, in the present study, could be interpreted as
small for all subscale and the overall scores. Similar results were reported in studies
evaluating the level of agreement between reports by children and adolescents and
their mothers regarding the impact of oral health on the quality of life of the young
57
individuals.21,25 In contrast, systematic bias was moderate for the OS, EW and SW
subscales as well as the overall score in a study addressing agreement regarding
perceptions of OHRQoL between children with malocclusion and their mothers.6
It is not easy to interpret the magnitude of absolute differences between the
scores of adolescents and their parents/caregivers, since there is no rule or statistical
method for these type of data.25 However, the interpretation of absolute differences
could be carried out using the maximum obtainable score.26 In the present study, the
mean absolute difference for the overall scores between adolescents and
parents/caregivers was 5.15, which corresponds to 9.2% of the maximum obtainable
score. Among the subscales, this percentage ranged from 12% to 13.8%. These
figures are slightly lower than the percentages reported in previous studies.25,26
The present study has limitations that should be recognized. The sample of
parents/caregivers is not representative of all parents/caregivers of orthodontic
patients, since the participants were limited to the clinic of a single university.
Therefore, further research on the level of agreement between parents/caregivers
and their adolescents should be conducted using larger samples recruited from
different locations to confirm the findings reported herein and determine the
characteristics of adolescents and parents/caregivers that influence agreement in
their reports.27 Moreover, the majority of the present sample consisted of families
with a low socioeconomic status. Although this finding shows that a considerable
portion of Brazilian population is economically underprivileged,28 this may affect oral
health outcomes and may confound proxy measures.29 Finally, future studies using a
longitudinal design should be conducted to investigate the impact of the proxy's
gender in combination with the gender of the adolescent, the stability of agreement
regarding perceptions of OHRQoL and the effect of changing health status.30 Quality
of life assessment is a dynamic rather than a static phenomenon. Individuals alter the
standards by which they rate their OHRQoL over time due to changes in their
circumstances or physical and emotional development.31
In summary, the mean directional differences, mean absolute differences and
standardized differences indicate considerable agreement on the group level
between the reports of adolescents and their parents/caregivers regarding the
ORHQoL of adolescents submitted to orthodontic therapy with a fixed appliance. On
an individual level, the ICC for the overall score was substantial and the ICCs for the
58
subscales were moderate, which also demonstrates adequate agreement between
the reports of adolescents and their parents/caregivers. This has implications in
clinical practice when the impact of orthodontic treatment on quality of life is being
considered.26 The findings suggest that parents/caregivers provide reliable
information in surveys on the impact of orthodontic treatment with a fixed appliance
on the OHRQoL of adolescents.12 The views of both adolescents and their
parents/caregivers should, therefore, be considered when assessing the well-being
and quality of life of adolescents with oral and orofacial disorders. Valuable
information may be lost by choosing one over the other, as these two sources are
best seen as complementary. For instance, if both sources are considered to be
indicators of treatment motivation and predictors of treatment compliance, they may
be used to guide the decision making process.27
Conclusions
Substantial agreement was found between adolescents and their
parents/caregivers in rating the quality of life of adolescents during orthodontic
treatment with a fixed appliance.
The view of both parties should be considered to obtain a more
comprehensive understanding of the impact of orthodontic therapy on adolescents'
quality of life.
Acknowledgments
This work was supported by the National Council for Scientific Development
(CNPq), the Coordination for the Improvement of Higher Level Education Personnel
(CAPES), and the State of Minas Gerais Research Foundation (FAPEMIG), Brazil.
The authors declare no potential conflicts of interest with respect to the authorship
and/or publication of this article.
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