The main objective of this study was to compare the variations in patients’ perception of OHRQoL, using the Moroccan version of PIDAQ, before and after orthodontic treatment among subjects with the same initial PAR Index score, age and gender.
The averages of the 4 PIDAQ domains (AC, PI, SI and DSC) were different between the 2 pre- and post-treatment groups. Indeed, the low averages of group A refer us to the low (Table 5) psychosocial impact of dental aesthetics after orthodontic treatment, contrary to the high averages of group B which reflected the measurable impact of dental malocclusion on the QoL of patients. These results, thus, confirm the benefits of orthodontic treatment and its contribution to improved QoL.
Recently, significant progress has been made in assessing quality of life measurement for health care, with over 1000 new articles each year, indexed under MeSH "quality of life". In addition to studies on patients’ satisfaction after orthodontic treatment, various studies have been conducted to assess the impact of malocclusion on patients’ QoL (9).
Today, there is a growing awareness of the multidimensional potential of oral health and the inadequacy of existing normative measures that have prompted the development of QoL tools, being now used to capture variables related to an individual's feelings, functioning, and coping strategies.
Although the clinical outcomes of orthodontic treatment are well established, relatively little is known about its psychological effects. It has been found in the orthodontic literature that improved smile aesthetics and subsequent improvement in psychosocial well-being are the most common reasons for undergoing orthodontic treatment. In particular, patients seek treatment with a view to gain psychosocial benefits. The PIDAQ is used for its specificity and selectivity to the orthodontic aspects of measuring and evaluating OHRQoL (10).
Several studies that have evaluated the relationship between malocclusion and OHRQoL, the impact of treatment and patient characteristics, were able to identify differences between treated and untreated patients’ cohort (11). A study carried out in Iran (12), on a sample of 71 patients, was able to highlight the improvement of OHRQoL after orthodontic intervention using a questionnaire evaluating 4 areas related to oral symptoms, functional limitations, emotional well-being and social well-being. Previous studies reported that patients' motivations for seeking orthodontic treatment were primarily related to appearance and self-image rather than to functional motives (13).
In the present study, patients’ demand for orthodontic treatment appears to be largely related to the desire to improve facial appearance. Thus, 64.3% of the patients surveyed reported that their reason for consulting was purely aesthetic.
In terms of the gender ratio, the need for orthodontic treatment was higher among females (67.2%) than males (32.8%). Several authors reported a similar distribution. Indeed, in a longitudinal study carried out in the UK included a sample of 337 subjects, the need for orthodontic treatment was higher among females (57%) (14). Studies conducted in Brazil (15) and Iran (16) included samples with 75.50% and 65.54% female predominance, respectively. This predominance can be explained by the fact that female patients perceive a malocclusion as aesthetically unpleasing and, therefore, are more motivated to seek treatment.
For the present study, the averages of the four PIDAQ domains (AC, PI, SI and DSC) were significantly different between group A and group B before and after treatment. Specifically, the low averages of group A refer us to the low psychosocial impact of dental aesthetics after orthodontic intervention, contrary to the high averages of group B which reflect the measurable impact of dental malocclusion on the quality of life of patients. These results help us to gain insights into the benefits of orthodontic treatment and its contribution to improved QoL.
A study carried out in Iksan, South Korea (17) was designed to evaluate the effect of malocclusion on the QoL of patients. This study was conducted on 860 people who needed clinical need for corrective treatment. The sample was divided into four groups: "normal occlusion," "malocclusion," "orthodontic treatment," and a final group "retention," which included patients who completed their orthodontic treatment. Patients in the "malocclusion" group had the highest PIDAQ scores compared to patients in the "normal occlusion" and "retention" groups. Female patients had higher scores than male patients.
A similar study undertaken in Seoul, South Korea (18) showed that patients requiring orthodontic treatment were 2.7 times more likely to have a poor OHRoL compared to the control group who did not need treatment. Malocclusion is significantly associated with functional limitations, social disability and physical pain in young adults.
The most important contribution of our results is the matching between subjects with the same PAR Index score, in the same age group and of the same gender.
According to a study conducted in India that evaluated the effect of malocclusion in patients before treatment and treatment after a year , using a Hindi version of the PIDAQ (10), the mean PIDAQ score obtained in pre-treatment patients was 59.59, indicating that malocclusion had a very strong PI in all patients who participated in the study. All subjects showed significantly reduced DSC with a score of 19.19. The high scores of the SI factor (score of 17.01) seemed to indicate that malocclusion greatly affected the psychological well-being of patients in social interactions. Subjects also showed great aesthetic concern for their dental appearance (score of 8.10). A very significant reduction in the PIDAQ score was observed with fixed orthodontic treatment during the one-year study period (p<0.001). In this study, since each patient was in control of his or her own case, significant differences in the mean values of the scores of the four factors before and during treatment were extremely reliable. The decrease in PI as assessed by the Hindi version of PIDAQ can be attributed to the correction of their malocclusion. The results support the assertion that orthodontic treatment not only results in improved dental aesthetics, but also impacts significantly the psychological aspects of patients.
In Jerusalem, a study (19) was conducted to evaluate the short-term psychosocial impact of improving dental aesthetics in adult subjects using PIDAQ. A statistically significant improvement P<0.001 was found for all four factors: DSC, SI, PI and AC.
The previous results are in agreement with the results of the present study. Indeed, the DSC domain was determinant with the highest score, 90.69, followed by the determinant of the AC with a score of 69.44 and then the PI and the SI with scores of 54.16 and 46.66, respectively. There were notable reductions in scores in all areas of PIDAQ. The scores of the determinant DSC dropped by 77.36 points. The AC decreased by 67.22 points, as did the scores for PI and SI, which decreased by 47.63 and 36.87 points. The differences in scores that we were able to identify in our study were certainly greater than the differences in PIDAQ scores identified in the Indian study. One explanation for this is that we interviewed patients before and after treatment and that the divergence of responses was notable, unlike the Indian patients who completed the questionnaires with an interval of 6 months and therefore still had a minimal impact of malocclusion. In the same vein, the results of our study asserted that orthodontic treatment, in addition to improving dental aesthetics, contributed significantly to improving the psychosocial aspects of the patients’ life.
Using the different tests of associations between the variables, Chi2 and Levene and Mann Whitney, it was possible to demonstrate that aesthetics was the most common reason for consultation, regardless of the patient's gender. 68% of the male patients and 57.8 % the female patients consulted for aesthetic reasons. These results were not compatible with studies carried out in China (20) and Spain (21), which demonstrated females’ sensitivity patients to aesthetics compared to males’ patients. This difference can be explained by cultural, traditional or social differences.
Furthermore, our study showed no significant association between gender and orthodontic need for treatment. Nevertheless, with a significant difference (p) = 0.013 < 0.05, female patients were more motivated by improved self-confidence than male patients. This sensitivity of females to self-confidence could be accounted for by the fact that female patients make their appearance a central pillar and the main factor contributing to increased self-esteem. However, there was no significant association between gender and the need to improve social interactions or increase work opportunities.
Comparison of the results of the different studies with ours is limited due to differences in methodology. Thus, to allow direct comparison, case-control studies with a matching process by age, gender, and degree of malocclusion should be conducted to allow for more relevant results. On the other hand, the significance of these results remains controversial due to the subjectivity of patients’ responses and individual and personal perception of malocclusion, and the inability to take into account imperceptible variables such as personality traits and treatment circumstances.
Indeed, the association between the severity of the malocclusion and its psychosocial impact is generally modest. For example, some patients show a remarkable level of concern for minor abnormalities, paradoxically, others tolerate severe occlusal problems. Not to mention the fact that the improvement in QoL after treatment does not depend exclusively on orthodontic intervention, but also on the psychological well-being of the patient (22).