INTRODUCTION

It is widely known that orthodontic treatment and appliances occasionally cause discomfort, pain, or functional limitations.12 However, while most previous studies have only assessed the experiences of pain and discomfort among orthodontic patients immediately after insertion of appliances or during the progression of treatment,2–8 few studies have assessed the sociodental impacts of wearing orthodontic appliances.25910

Due to its large psychosocial component, orthodontics is one of the dental treatments that requires the use of oral health related quality of life (OHRQoL) measures.1112 However, specific rather than generic OHRQoL measures should be used because the focus of specific measures makes them potentially more responsive to small, but clinically important changes in health.13–15 Therefore, a condition-specific OHRQoL measure to assess the impact on daily performances of wearing orthodontic appliances would identify the problems patients experience during the progression of orthodontic treatment.910

Because of the dearth of data in relation to the sociodental impacts of orthodontic treatment, the objective of this study was to assess, among Brazilian adolescents, the prevalence, intensity, and extent of the impacts on daily performances related to wearing different types of orthodontic appliances.

MATERIAL AND METHODS

A total of 1657 adolescents were randomly selected from a population of 2200 15- to 16-year-old students attending all 11 public and 10 private secondary schools in the city of Bauru, São Paulo, Brazil. Of the 1657, only those wearing orthodontic appliances at the time of the survey and agreeing to participate were selected for this study. Ethical approval was obtained from the Ethics Committee of the Dental School at the University of São Paulo.

Information about sociodemographic characteristics and the impact of their oral conditions on daily life in the last 6 months was collected through face-to-face structured interviews. The Oral Impact on Daily Performances (OIDP), which had been previously used among Brazilian adolescents,1112 was used to collect information on sociodental impacts.

The OIDP assesses the serious oral impacts on eight daily performances, namely, eating, speaking, cleaning the mouth, relaxing, smiling, studying, emotion, and social contact. If adolescents reported an impact on any performance, its frequency (scale from 1, for “1 to 7 days” or “once or twice a month” to 3 for “15 days or more” or “3 or more times a week”) and severity of its effect on their daily life (scale from 1, for “little effect” to 3 for “severe effect”) were scored. If no impact was reported, then a zero score was assigned. Additionally, adolescents were asked to identify oral problems that, in their opinion, caused the impact. Only those impacts related to wearing orthodontic appliances, hereafter referred as condition-specific impacts (CSI), were considered for the analysis.

The performance score was calculated by multiplying the corresponding frequency and severity scores. The overall OIDP score was the sum of the eight performance scores (ranging from 0 to 72) multiplied by 100 and divided by 72.1617 Then, the prevalence of CSI on daily performances was calculated as the percentage of adolescents with an OIDP score higher than zero. Among those adolescents reporting the CSI, each performance score was reclassified into five levels to obtain the intensity of the impacts per performance. Since only six numbers can be obtained by multiplying 3-point frequency and severity scales (1, 2, 3, 4, 6, and 9), the intensity of the impacts was classified into very little (1), little (2), moderate (3–4), severe (6), and very severe (9).17–19 The overall intensity of the CSI was then calculated as the most severe impact on any of the eight performances. Finally, the extent of the CSI was calculated as the number of performances affected, and ranged from one to eight performances.17–19

After assessing whether the child had an impact or not, adolescents were clinically examined to identify the type of orthodontic appliance they were wearing at the time of the survey. Orthodontic appliances were classified as only fixed, only removable, or a combination of both types.

In order to assess the effects of sociodemographic factors, the prevalence and intensity of the CSI were compared according to the gender, socioeconomic status (SES), and type of orthodontic appliance, using the chi-square test. The extent of the CSI was compared according to gender and SES using the Mann-Whitney U-test and by the type of orthodontic appliance, using the Kruskal-Wallis test.

RESULTS

Three hundred fifty-seven adolescents, 129 (36.1%) boys and 228 (63.9%) girls, undergoing orthodontic treatment participated in this study. One hundred four adolescents were from low SES and 253 from high SES (29.1% and 70.9%, respectively). Their mean age was 15.31 ± 0.46 years.

The prevalence of the CSI related to orthodontic appliances was 22.7%. Eating (9.5%) and speaking (8.1%) were the most commonly affected daily performances. On the other hand, studying and social contact were not impacted at all by wearing appliances (Table 1). There was no statistically significant difference in the prevalence of CSI by gender and SES (P = .099 and .344, respectively). However, the prevalence of CSI was significantly higher in adolescents wearing only fixed appliances compared to those wearing only removable or both types of appliances (P = .001) (Table 2).

Table 1.  Prevalence and Intensity of Impacts Attributed to Orthodontic Appliances in 15- to 16-Year-Old Brazilian Schoolchildren

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Table 2.  Prevalence of Impacts Attributed to Orthodontic Applianc es in 15- to 16-Year-Old Brazilian Schoolchildren, by Covariables^a

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Among the 81 adolescents with CSI, 35.8% reported impacts of severe or very severe intensity (Table 1). Although relaxing was the most severely impacted daily performance, only two adolescents reported impacts on relaxing. On the other hand, numerous adolescents with CSI related to wearing orthodontic appliances reported impacts of severe or very severe intensity for speaking (44.8%) and eating (35.3%). There was no statistically significant difference for the intensity of CSI by gender and type of orthodontic appliance (P = .117 and .247, respectively). However, the percentage of adolescents with severe or very severe intensity CSI was higher in adolescents from high SES than in those from low SES (P = .040) (Table 3).

Table 3.  Intensity of Impacts Attributed to Orthodontic Appliances in 15- to 16-Year-Old Brazilian Schoolchildren, by Sex, Socioeconomic Status, and Type of Orthodontic Appliance^a

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The mean number of performances affected was 1.10 ± 0.30 per adolescent; 90.1% of the children with impacts reported one affected performance and 9.9% reported two affected performances. There was no statistically significant difference in the extent of CSI by gender, SES, or type of orthodontic appliance (P = .824, .191, and .153, respectively) (Table 4).

Table 4.  Extent of Impacts Attributed to Orthodontic Appliances in 15- to 16-year-old Brazilian Schoolchildren, by Sex, Socioeconomic Status, and Type of Orthodontic Appliance

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DISCUSSION

This study investigated the sociodental impacts experienced by adolescents wearing different types of orthodontic appliances. The prevalence as well as the intensity and extent of condition-specific impacts caused by wearing orthodontic appliances were assessed in this study. This was done because information about intensity and extent of impacts represent an alternative method of describing or comparing the impacts in relation to the oral conditions causing them.1819 Moreover, using an OHRQoL measure to associate sociodental impacts to specific oral conditions is useful in planning and for prioritizing oral health care,20–22 including orthodontics.23 This study demonstrates that an OHRQoL measure, such as the OIDP, can be used to assess not only the outcomes of dental treatments, but also the side effects experienced during dental treatment.

In this study, almost one-quarter of adolescents wearing orthodontic appliances reported CSI on at least one daily performance during the last 6 months. Eating, speaking, and smiling were the daily performances most commonly affected (Table 1), supporting previous findings by Scheurer et al,5 Sergl et al,2 and Mandall et al.9 Scheurer et al5 found that biting and chewing were the most painful everyday activities affected in the week after insertion of appliances. Sergl et al2 reported that the main short- and long-term impacts of wearing appliances were on speech and swallowing as well as in reduced confidence when in public. And Mandall et al9 reported that undergoing orthodontic treatment caused impacts related to aesthetic as well as to functional limitations.

Among the Brazilian adolescents with condition-specific impact, slightly more than one-third reported severe or very severe intensity impacts and 90% reported impacts on only one daily performance. No adolescent reported CSI on three or more performances, indicating that activities such as maintaining emotional stability or relaxing (including sleeping) were not usually affected. Indeed, in our population activities such as studying and enjoying social contact were not affected at all by wearing orthodontic appliances.

There was no significant difference, by gender, in the prevalence, intensity, and extent of impacts caused by wearing orthodontic appliances. This finding agrees with some previous studies,9 but differs from others.524 It is likely that the different methodologies used among studies to assess condition-specific impacts may explain these differences. Since we used a psychometrically valid and reliable condition-specific OHRQoL measure,1112 our results are only comparable to those reported by Mandall et al9 who also found no influence of gender on impacts of fixed orthodontic appliances.

The intensity, but not prevalence and extent, of the condition-specific impact differed according to the SES of the participants. Adolescents from high SES reported more severe or very severe condition-specific impact than those from low SES (Table 3). However, it has been previously suggested that socioeconomic background generally did not influence the impact of fixed appliances on daily life among adolescents.9 Since there is little literature with which to compare our results, further studies are required to gain some insights into this area.

As expected, there was a different pattern of sociodental impacts by type of orthodontic appliance worn by adolescents. The differences were found only for the prevalence, but not for the intensity or extent of condition-specific impact. Adolescents wearing fixed appliances had a higher frequency of impacts than those wearing removable or both types of appliance simultaneously. Over the short- and long-term courses of treatment, fixed or functional appliances have been previously reported to produce a higher intensity of discomfort than removable appliances.25–7

The present findings provide useful information in relation to the likelihood of pain, discomfort, and side effects for patients undergoing orthodontic treatment. However, further studies are needed, especially longitudinal studies, to assess the change over time of the condition-specific impacts related to wearing orthodontic appliances. The potential side effects of orthodontic therapy, including the most common sociodental impacts on daily living, should be discussed with potential patients before they give informed consent to treatment.2526

CONCLUSIONS

• Almost one-quarter of the Brazilian adolescents reported impacts on their daily life related to wearing orthodontic appliances, which implies that most adolescents wearing appliances had no problems.

• Among those adolescents with CSI related to wearing orthodontic appliances, slightly more than one-third reported impacts of severe or very severe intensity and 90% reported impacts on only one daily performance, commonly on eating or speaking.

• The prevalence of CSI differed by type of orthodontic appliance, whereas the intensity of CSI differed by SES of the adolescents. However, the extent of CSI did not differ by covariables.