A recent literature review on the oral health-related

benets of orthodontic treatment concluded that

there is little evidence to suggest that orthodontic
treatment can prevent or reduce the likelihood of
dental caries or of periodontal disease or dental
trauma and temporomandibular disorders (1).
Another systematic review, which assessed the
association between orthodontic treatment need
Community Dent Oral Epidemiol 2011; 39: 505514
All rights reserved
2011 John Wiley & Sons A/S
Quality of life and psychosocial
outcomes after xed orthodontic
treatment: a 17-year
observational cohort study
Arrow P, Brennan D, Spencer AJ. Quality of life and psychosocial outcomes
after xed orthodontic treatment: a 17-year observational cohort study.
Community Dent Oral Epidemiol 2011; 39: 505514. 2011 John Wiley & Sons
A S
Abstract Background: There is little evidence to suggest that orthodontic
treatment can prevent or reduce the likelihood of dental caries or of periodontal
disease or dental trauma and temporomandibular disorders, but there is a
modest association between the presence of malocclusion orthodontic
treatment need and quality of life. However, little is known of the long-term
outcomes of orthodontic treatment. This study reports on the longitudinal
follow-up of quality of life and psychosocial outcomes of orthodontic treatment
among a cohort of adults who were examined as adolescents in 1988 1989.
Materials and Methods: Children who were examined in 1988 1989 were invited
to a follow-up in 2005 2006. Respondents completed a questionnaire, which
collected information on quality of life, receipt of orthodontic treatment and
psychosocial factors, and were invited for a clinical examination. Oral health
conditions including occlusal status using the Dental Aesthetic Index were
recorded. Analysis of variance and multiple linear regression were used to
examine the relationship between the measured factors. Results: There was no
statistically signicant association between occlusal status at adolescence and
quality of life at adulthood. Those individuals who had orthodontic treatment
but did not need orthodontic treatment had higher self-esteem (23.1, SD 5.2) and
were more satised with life (18.5, SD 3.7) than other treatment groups (self-
esteem range, 20.022.7; life satisfaction range, 16.418.1), anova P < 0.01 and
P < 0.05, respectively. Occlusal status at adulthood was signicantly associated
with quality of life, P < 0.01. Multivariate analyses showed a statistically
signicant association between occlusal status at adolescence (Desirable
treatment b = 0.70, P = 0.04) and adulthood (Desirable treatment b = 1.66,
P < 0.01) with quality of life. Orthodontic treatment was negatively associated
with psychosocial factors (life satisfaction; xed orthodontic treatment (FOT)
b = )0.91, P = 0.02 and self-esteem; FOT b = )1.39, P < 0.01). Conclusions:
Occlusal status appears to have limited association with quality of life and
psychosocial factors. Receipt of xed orthodontic treatment does not appear to
be associated with oral health-related quality of life but appears to be negatively
associated with self-esteem and satisfaction with life.
Peter Arrow
1,2
, David Brennan
1
and
A. John Spencer
1
1
Australian Research Centre for Population
Oral Health, University of Adelaide,
Adelaide, Australia,
2
Dental Health Services,
Health Department of Western Australia,
Perth, Australia
Key words: OHIP; orthodontic treatment;
quality of life
Peter Arrow, Australian Research Centre for
Population Oral Health, The University of
Adelaide, 122, Frome Street, Adelaide, South
Australia 5000, Australia
Tel.: +61 8 8313 4171
Fax: +61 8 8313 3070
e-mail: peter.arrow@adelaide.edu.au
Submitted 4 November 2010;
accepted 1 April 2011
doi: 10.1111/j.1600-0528.2011.00618.x 505
and quality of life (QoL), concluded that there was
a modest association between the presence of
malocclusion orthodontic treatment need and
QoL; the majority of studies included in the review,
using various indices of orthodontic treatment
need and measures of quality of life among
children and adults found statistically signicant
associations (2).
Desire for orthodontic treatment appears to be
related more to the individuals perception of
aesthetics than normatively dened need, and
treatment is premised on the assumption that
improvements of oral function and aesthetics will
lead to improved psychological and social well-
being (3, 4). Among Brazilian adolescents, youths
who had recently completed orthodontic treatment
reported fewer oral health impacts than those not
treated or still undergoing orthodontic treatment;
statistically signicant odds ratios of experiencing
an oral health impact of 1.84 for those having
treatment and 1.43 for those untreated compared
with those treated, after controlling for need for
orthodontic treatment (5). Oral health impacts were
also expressed by youths judged also to have
objectively dened need for orthodontic treatment;
odds ratios 1.38 for those with moderate need and
2.65 for those with need compared with those not
needing treatment (5).
In Australia, Do and Spencer, in a cross-sectional
study, examined the association between the pres-
ence of unacceptable occlusion and oral health-
related quality of life (OHQoL) among children
and their parents in South Australia. There was an
association between the presence of unacceptable
occlusion and the emotional and social well-being
domains of the child oral health-related quality
of life scale (COHQoL) among 8- to 10-year-old
children and the children and their parents for the
total COHQoL score (6).
When orthodontic treatment and its effects on
quality of life among children were examined,
orthodontic treatment appears to have no impact
on the childs rating of their quality of life (7). There
was no association between objectively assessed
orthodontic treatment need (Index of Complexity,
Outcome and Need) and the childrens rating of
their quality of life (Childrens Oral Health Related
Quality of Life questionnaire) regardless of
whether they had orthodontic treatment or not.
Children who had orthodontic treatment rated
their overall global oral health as being better than
children who have not yet had orthodontic treat-
ment. The authors concluded that malocclusion
and orthodontic treatment do not appear to affect
general or oral health quality of life to any
measurable degree.
There are few longitudinal studies, which re-
ported on the long-term effects of malocclusion and
orthodontic treatment (8, 9). The studies were
based on a cohort of 11- to 12-year-old children
recruited in 1981 and observed over an interval of
20 years for the uptake of orthodontic treatment
and subsequent outcomes in terms of objectively
and subjectively measured oral health and psycho-
social factors. Orthodontic treatment resulted in the
improvements in objectively measured orthodontic
trait (a 31% reduction in occlusion score for those
who received orthodontic treatment and classied
as needing treatment, a 12.7% score reduction for
those needing treatment but were not treated, a
17.1% increase in occlusion score for those with no
need for orthodontic treatment and were not
treated, and an 11.4% increase in score for those
without need and were treated). Individuals who
had a dened need for orthodontic treatment as
children and obtained treatment had better tooth
alignment and higher satisfaction with physical
appearance.
Kenealy et al. (9) reported on the psychological
health gain from orthodontic treatment. Norma-
tively dened need for orthodontic treatment
predicted receipt of orthodontic treatment, and
there were some apparent psychosocial benets
from orthodontic treatment, but there were also
factors that were not affected. The authors focussed
on self-esteem, because of its importance in psy-
chological health, and reported that self-esteem
scores were better among those who had ortho-
dontic treatment. However, the effect of orthodon-
tic treatment on self-esteem was not signicant
when self-esteem at baseline was controlled in the
analysis. Self-esteem at childhood was more impor-
tant for self-esteem at adulthood irrespective of
orthodontic treatment status. The signicance of
other measured psychological variables also
became nonsignicant after baseline self-esteem
was controlled in the analysis. In a multivariate
analysis to test for factors contributing to self-
esteem at adulthood, baseline orthodontic treat-
ment score was a signicant factor, but the authors
concluded that dental status at age 11 was of minor
importance and other psychological and social
factors were of greater importance, and from their
study, there was little to support the assumption of
orthodontic treatment signicantly improving
long-term psychological well-being.
506
Arrow et al.
While the majority of orthodontic care is sought
for aesthetic reasons, little is known of the long-
term outcomes of orthodontic treatment (10). There
is evidence to suggest that individuals focus on
aesthetics and social aspects in their decision-
making on the seeking of orthodontic treatment.
For the majority of people, orthodontic treatment
does not appear to affect either objectively or
subjectively assessed oral health status (10). The
resource demands for orthodontic care, where
dened need is likely to exceed the capacity to
supply services means that an assessment of the
relative benets to accrue from orthodontic treat-
ment requires further investigation, in particular
the long-term benets of orthodontic treatment (3).
This study reports on the longitudinal follow-up
of quality of life and psychosocial outcomes of
orthodontic treatment among a cohort of adults
(approximately 30 years old) who were examined
as adolescents in 1988 1989 and who provided
information on the occlusal status and receipt of
xed orthodontic treatment (FOT) during the
subsequent 2 years. The ndings on the long-term
effects of orthodontic treatment on social accept-
ability of occlusal conditions will be reported in a
companion paper.
Materials and methods
Population cohort
The full details of the sampling and study partic-
ipants from baseline have been previously reported
(11, 12). Figure 1 shows the cohort sample over the
observation period. Children, approximate age of
13, who were enrolled with the School Dental
Service in South Australia and were due for a recall
examination in 1988 1989 were invited to partici-
pate. Of the 7637 students due for a recall exam-
ination, 4476 parents gave informed consent to
participate in the study and 3925 children were
clinically examined and had baseline data, includ-
ing their occlusal status, recorded. The children
were monitored for receipt of xed orthodontic
treatment during the following 2 years, and infor-
mation from 3262 students on receipt of ortho-
dontic treatment was collected. In 2005 2006,
participants from the original cohort who provided
the 2-year follow-up information were contacted
for a follow-up (1859), of which 632 adults
responded to a mailed questionnaire and 448
respondents of the cohort participated in a clinical
examination.
Concurrently in 2005 2006, a random sample of
adults of the same age as in the study cohort was
drawn from Adelaides electoral register to enable
comparison of the cohort with the general popula-
tion living in Adelaide. Ethical approval for the
study was given by the University of Adelaides
Human Research Ethics Committee, and all partic-
ipants who had a dental examination signed an
informed consent form.
The mailed self-completed questionnaire in
2005 2006 sought responses to questions on the
use of dental services, dental knowledge and
dental behaviours, history of uoride exposure,
attitudes towards oral health, oral health-related
quality of life (13), life satisfaction (14), self-esteem
(15) and sociodemographic factors (sex, education
level and income).
Oral health-related quality of life was collected
using the Oral Health Impact Prole (OHIP)-14,
which uses 14 items to capture the seven concep-
tual dimensions of oral health; functional limita-
tion, physical pain, psychological discomfort,
physical disability, psychological disability, social
disability and handicap (13). For each of the 14
OHIP questions, subjects were asked how fre-
quently they had experienced the impact in the
preceding 12 months using a Likert-like scale
coded 4 = very often, 3 = fairly often, 2 = occasion-
ally, 1 = hardly ever and 0 = never.
OHIP-14 scores are used in a variety of ways to
illustrate oral health impacts (prevalence, extent
and severity scores), and a range of OHIP-14
measures are in use (16). In this paper, OHIP was
coded by using cut-points of never hardly ever
(score 0) and occasionally fairly often very often
(score 1) to produce counts of extent score, range
014. Higher OHIP scores indicate poorer oral
health-related quality of life.
Well-being was measured using the Satisfaction
With Life Scale (SWLS), comprising ve items
measured on a 5-point Likert scale where 1 =
strongly disagree, 2 = disagree, 3 = neutral, 4 =
agree and 5 = strongly agree, with the scale score
created by summing the responses to the items;
higher SWLS scores indicate a higher level of well-
being (14).
Self-esteem was measured using the Rosenberg
Self Esteem Scale comprising ten items on a four-
point scale coded as 0 = strongly disagree, 1 = dis-
agree, 2 = agree and 3 = strongly agree (15). Half of
the items were negatively worded (items 3, 5, 8, 9,
10), and these were reverse coded for analysis. The
scale was computed by summing the 10 items to
507
Quality of life and psychosocial outcomes after xed orthodontic treatment
produce a scale with scores ranging from 0 to 30,
where 30 indicates the highest level of self-esteem.
The occlusal status of participants at baseline and
follow-up was assessed using the Dental Aesthetic
Index (DAI) (17). The index is a composite
weighted sum of ten traits derived from a regres-
sion equation related to the appearance of an
individual. The DAI score is an estimate of the
individuals dental aesthetics relative to others of
the target population. The resulting scores were
graded on the need for orthodontic treatment; DAI
scores were categorized into levels of need: DAI
score 25, no or slight treatment; DAI score 2630,
elective orthodontic treatment; DAI score 3135,
highly desirable orthodontic treatment; and DAI
score 36, mandatory orthodontic treatment.
Data analysis
The ndings are presented as descriptive statistics
on the basis of receipt of orthodontic treatment and
DAI treatment need. Bivariate analyses were con-
ducted on the oral health impact, satisfaction with
life, and self-esteem at follow-up with baseline
DAI, DAI at follow-up, and receipt of orthodontic
treatment. Analysis of variance and multivariate
analyses using linear regression was undertaken to
determine the effects of various factors on the
psychosocial outcomes of orthodontic treatment.
Income was grouped into tertiles; low-, medium-
and high-income groups (baseline; low < $351
weekly income, medium = $351$500 weekly
income, high > $501 weekly income; follow-up:
low < $40 001 annual household income, medium
$40 001$70 000, high > $70 000) and used as a
control variable. Separate regression models were
tested for each of the psychosocial factors OHIP,
satisfaction with life and self-esteem. To account
for changes in occlusal conditions over time and
the effects of orthodontic treatment, change in DAI
scores and receipt of xed orthodontic treatment
(coded no = 0, yes = 1) were entered as indepen-
dent variable in the regression analyses.
Results
Figure 1 shows the sampled cohort over the follow-
up period. Twenty-ve adults who were clinically
examined were excluded from analysis because of
invalid ID numbers or were inadvertently exam-
ined because of administrative errors. There are
fewer cases with complete data on DMFT, DAI at
baseline, DAI at follow-up and complete DAI at
both baseline and follow-up, and periodontal data
because of missing information. Table 1 shows the
comparison of mean psychosocial factors among
the study group and the community comparison
group.
Table 2 shows the mean values of OHIP, satis-
faction with life and self-esteem at follow-up with
baseline DAI stratied by receipt of FOT. There
were statistically signicant differences in mean
Baseline (Phase 1: 1988/89) N = 7673
(Phase 2: 1990/91)
Follow-up (Phase 3: 2005/06) Comparison
sample
Questionnaire
data
4476 Parental consent
3925 Students examined
3262 Dental treatment data
1859 Traced as living in Adelaide 547
632 Questionnaire data 145
473 Adults examined 112 Adults
examined
448 Number of teeth
447 DMFT
441 DAI (13 years)
427 DAI (30 years)
421 DAI (13 years and 30 years)
423 Periodontal data
Questionnaire data on household and
parental characteristics
Clinical data: oral health status and
occlusal condition (DAI)
Clinical records on orthodontic
treatment
Psychological factors, oral health
impact, health behaviours, socio-
demographics
Clinical data: oral health status 25 excluded, invalid age/ID
(13-year-old students SDS)
Fig. 1. Sampled cohort over the
observation period.
508
Arrow et al.
score of satisfaction with life and self-esteem
among the group who had FOT and were classied
as desirable need category and no need category,
and elective need and no need category, respec-
tively. Income at baseline had a statistically signif-
icant association with OHIP, satisfaction with life
and self-esteem among those without FOT and
statistically signicant association with OHIP
among those with FOT.
Table 3 shows the mean values of psychosocial
factors by occlusal condition at follow-up. The
stratication by receipt of orthodontic treatment
Table 3. Mean values of OHIP extent, satisfaction with life and self-esteem scores among individuals at follow-up
classied by DAI and income level at follow-up; mean (SD)
OHIP SWLS Self-esteem
DAI 25; No Need (n = 359) 1.5 (2.2)** 18.5 (4.0) 23.0 (4.7)
DAI 2630; Elective (n = 38) 1.8 (2.8) 19.0 (3.3) 23.4 (4.9)
DAI 3135; Desirable (n = 20) 3.1 (3.2)** 18.0 (4.7) 22.3 (5.3)
DAI 36; Mandatory (n = 10) 1.3 (1.6) 16.8 (5.6) 23.4 (6.0)
Income
Low (n = 118) 2.6 (3.3)** 16.3 (4.3)** 21.6 (5.5)*,**
Medium (n = 171) 1.3 (1.8)** 18.9 (3.5)** 23.1 (4.5)*
High (n = 147) 1.2 (1.8)** 19.6 (3.6)** 23.8 (4.3)**
DAI, dental aesthetic index; OHIP, oral health impact prole; SWLS, satisfaction with life scale.
SWLS, satisfaction with life scale.
*P < 0.05; **P < 0.01.
Table 1. Oral health-related quality of life and psychosocial factors among study participants and community
comparison group
Study cohort Community group P value (t-test)
OHIP (N): mean: SE (448) 1.63; 0.11 (111) 1.82; 0.24 0.47
Satisfaction with Life (N): mean: SE (447) 18.36; 0.19 (111) 18.53; 0.39 0.69
Self-esteem (N): mean: SE (442) 22.94; 0.23 (111) 22.54; 0.49 0.44
OHIP, oral health impact prole.
Table 2. Mean values of OHIP extent, satisfaction with life and self-esteem scores among individuals at follow-up
classied by DAI and income level at baseline and receipt of FOT; mean (SD)
FOT OHIP SWLS Self-esteem
No FOT (N = 286)
DAI 25; No Need (n = 144) 1.6 (2.3) 18.8 (4.1) 23.3 (4.4)
DAI 2630; Elective (n = 81) 1.3 (1.9) 18.9 (3.8) 24.1 (4.1)
DAI 3135; Desirable (n = 35) 2.1 (3.0) 17.9 (4.7) 22.8 (5.0)
DAI 36; Mandatory (n = 26) 2.1 (2.9) 18.3 (3.1) 22.8 (5.0)
Income
Low (n = 76) 2.3 (2.8)** 17.7 (3.7)** 22.6 (4.7)*
Medium (n = 76) 1.8 (2.5) 18.8 (4.0) 23.2 (4.9)
High (n = 126) 1.1 (1.7)** 19.3 (3.8)** 24.1 (4.0)*
Yes FOT (N = 155)
DAI 25; No Need (n = 53) 1.5 (2.0) 18.5 (3.7)* 23.1 (5.2)**
DAI 2630; Elective (n = 32) 1.3 (2.6) 18.1 (4.4) 20.0 (5.3)**
DAI 3135; Desirable (n = 27) 2.4 (3.6) 16.4 (4.7)* 21.5 (5.5)
DAI 36; Mandatory (n = 43) 1.7 (2.2) 17.8 (4.0) 22.7 (4.9)
Income
Low (n = 22) 2.7 (3.2)* 17.1 (3.4) 21.5 (6.8)
Medium (n = 36) 2.0 (2.9) 16.6 (4.8) 20.7 (5.9)
High (n = 88) 1.3 (2.1)* 18.3 (3.9) 22.6 (4.4)
DAI, dental aesthetic index; FOT, xed orthodontic treatment; OHIP, oral health impact prole; SWLS, satisfaction with
life scale.
*P < 0.05; **P < 0.01.
509
Quality of life and psychosocial outcomes after xed orthodontic treatment
was not undertaken because of small cell sizes for
some strata. Occlusal conditions at follow-up were
statistically signicantly associated with OHIP
scores, while income levels at follow-up were
statistically signicantly associated with OHIP
scores, life satisfaction and self-esteem.
Table 4 shows the multivariate analysis of occlu-
sal conditions at baseline and income on the
psychosocial factors. Two groups of regression
were run: Group 1 (Table 4) used occlusal condi-
tion (classied into need) and income at baseline
(classied into tertiles) and Group 2 (Table 5) used
occlusal condition and income at follow-up, classi-
ed as in Group 1. Group 1 regression models
indicate that baseline occlusal conditions after
controlling for income was a statistically signicant
factor for OHIP, those in the desirable group
experienced more impacts, and while those in the
mandatory group also had more impacts, it was
not statistically signicant. The effect of occlusal
conditions at baseline on life satisfaction and self-
esteem was in the expected direction, those with
poorer occlusal condition reported lower scores on
Table 5. Regression models of occlusal conditions, in-
come at follow-up and FOT on OHIP, life satisfaction and
self-esteem
Group 2
Regression
coefcient
Standard
error
P
value
OHIP (R
2
= 0.08)
DAI (follow-up)
No need
(reference group)
Elective 0.39 0.38 0.30
Desirable 1.66 0.52 <0.01
Mandatory 0.08 0.74 0.91
Income
Low
(reference group)
Medium )1.23 0.27 <0.01
High )1.25 0.28 <0.01
FOT
No (reference)
Yes 0.09 0.23 0.70
Life satisfaction (R
2
= 0.12)
DAI (follow-up)
No need
(reference group)
Elective 0.42 0.65 0.52
Desirable )0.30 0.89 0.74
Mandatory )1.51 1.27 0.24
Income
Low
(reference group)
Medium 2.72 0.47 <0.01
High 3.47 0.48 <0.01
FOT
No (reference)
Yes )0.97 0.39 0.01
Self-esteem (R
2
= 0.03)
DAI (follow-up)
No need
(reference group)
Elective 0.51 0.82 0.54
Desirable )0.31 1.11 0.78
Mandatory 0.79 1.57 0.61
Income
Low
(reference group)
Medium 1.28 0.59 0.03
High 2.10 0.60 <0.01
FOT
No (reference)
Yes )1.37 0.48 <0.01
DAI, dental aesthetic index; FOT, xed orthodontic
treatment; OHIP, oral health impact prole.
Table 4. Regression model of baseline occlusal condi-
tions and income on OHIP, life satisfaction and self-
esteem
Group 1
Regression
coefcient
Standard
error
P
value
OHIP (R
2
= 0.06)
DAI (baseline)
No need
(reference group)
Elective )0.30 0.28 0.30
Desirable 0.70 0.35 0.04
Mandatory 0.03 0.34 0.92
Income
Low
(reference group)
Medium )0.60 0.33 0.07
High )1.30 0.29 <0.01
Life satisfaction (R
2
= 0.04)
DAI (baseline)
No need
(reference group)
Elective )0.08 0.48 0.86
Desirable )1.70 0.59 <0.01
Mandatory )0.84 0.58 0.15
Income
Low
(reference group)
Medium 0.47 0.55 0.40
High 1.29 0.49 <0.01
Self-esteem (R
2
= 0.02)
DAI (baseline)
No need
(reference group)
Elective )0.24 0.58 0.68
Desirable )1.26 0.73 0.09
Mandatory )0.42 0.71 0.55
Income
Low
(reference group)
Medium )0.03 0.68 0.96
High 1.04 0.60 0.08
DAI, dental aesthetic index; OHIP, oral health impact
prole.
510
Arrow et al.
life satisfaction and self-esteem, but only the
orthodontic treatment desirable had a statistically
signicant association with life satisfaction.
Group 2 regression models showed that after
controlling for income, those in desirable category
occlusal conditions at follow-up had statistically
signicant association with the extent of oral health
impacts, while higher income levels had amelio-
rated the extent of oral health impacts and positive
association with life satisfaction and self-esteem.
The association between occlusal conditions at
follow-up and life satisfaction and self-esteem
was not statistically signicant. Interestingly,
receipt of orthodontic treatment was negatively
associated with life satisfaction and self-esteem;
those who had FOT reported less satisfaction with
life and had lower self-esteem.
Further analyses to determine the contribution of
individual DAI traits to OHIP showed that missing
teeth in the anterior segment and the molar antero-
posterior relationship were statistically signicant
factors; more missing teeth had greater impacts,
P < 0.01, and greater antero-posterior relationship
discrepancy had more impacts, P < 0.05. Analyses
to determine which OHIP domain was affected by
DAI scores showed that the domain of psycholog-
ical discomfort was signicantly associated with
desirable orthodontic need category.
Table 6 shows the results of the regression on
OHIP, life satisfaction and self-esteem by change in
DAI scores, income at follow-up and FOT. When
income was controlled, the association between
DAI change and, quality of life, satisfaction with
life and self-esteem was not statistically signicant.
Receipt of xed orthodontic treatment was nega-
tively associated with life satisfaction and self-
esteem (negative coefcients; lower satisfaction
with life and self-esteem scores).
Because of the nding of statistically signicant
association of baseline and follow-up DAI with oral
health-related quality of life, the OHIP score was
entered as an independent variable, along with
DAI change, income levels and FOT in a regression
analysis of satisfaction with life and self-esteem to
test the association between oral health-related
quality of life and psychosocial factors (Table 7).
For both psychosocial factors of satisfaction with
life and self-esteem, income levels, FOT and OHIP
scores were statistically signicant, while change
score in DAI was not. The coefcient for OHIP was
negative, indicating that higher OHIP score (poorer
quality of life) was associated with lower life
satisfaction and self-esteem scores.
Discussion
Of concern in any longitudinal study is the likeli-
hood of bias resulting from the loss of participants.
There was substantial loss to follow-up of the
cohort after 17 years, and 53% was unable to be
traced as living within the survey area and of those
traced and in-scope, 29% of the target group
provided useable clinical data; a similar longitudi-
nal study of orthodontic treatment achieved 33%
follow-up (8). A comparison of the study cohort
with a representative community sample suggests
that the cohort is a reasonable representation of the
wider community, and the oral health-related
quality of life, satisfaction with life and self-esteem
scores between the groups were not statistically
signicantly different, which suggests minimal
likelihood of bias from the loss (Table 1).
This study is an observational study of an
individuals receipt of xed orthodontic treatment
and does not include other types of orthodontic
Table 6. Regression models of DAI change, income and
FOT on OHIP, life satisfaction and self-esteem
Regression
coefcient
Standard
error
P
value
OHIP (R
2
= 0.06)
DAI change )0.01 0.01 0.53
Income
Low
(reference group)
Medium )1.19 0.28 <0.01
High )1.33 0.29 <0.01
FOT
No (reference)
Yes 0.16 0.24 0.51
Life satisfaction (R
2
= 0.12)
DAI change 0.003 0.02 0.88
Income
Low
(reference group)
Medium 2.29 0.47 <0.01
High 3.40 0.48 <0.01
FOT
No (reference)
Yes )0.96 0.40 0.02
Self-esteem (R
2
= 0.05)
DAI change )0.01 0.03 0.78
Income
Low
(reference group)
Medium 1.33 0.59 0.02
High 2.11 0.61 <0.01
FOT
No (reference)
Yes )1.45 0.50 <0.01
DAI, dental aesthetic index; FOT, xed orthodontic
treatment; OHIP, oral health impact prole.
511
Quality of life and psychosocial outcomes after xed orthodontic treatment
therapy. In Australia, xed orthodontic treatment
is usually provided by specialist orthodontists and
can be taken to mean treatment of more complex
orthodontic conditions. Study participants were
not randomly assigned to undergo xed orthodon-
tic treatment; the decision is a result of a negotiated
outcome between the adolescent (usually) and
his her parents carers and the orthodontist. There-
fore, it is possible that there are factors, which
remains unmeasured, which inuenced an indi-
viduals uptake of orthodontic treatment at child-
hood and which are related to the psychosocial
factors examined in this study, and these and other
psycho-social factors may be of equal or more
importance (18).
The proportion of variance explained by the
regression models in this study ranged from two
per cent for self-esteem with baseline DAI and
income to 12% for life satisfaction using with DAI
and income at follow-up. Baseline DAI and income
did not have any signicant effect on self-esteem at
follow-up. Kenealy et al. (9) reported that occlusal
conditions at adulthood and perceptions of general
oral health explained eight per cent of the variation
in self-esteem among their study participants. The
explanatory power of their regression model
increased to 65% when other psychosocial vari-
ables were used in the regression model, suggest-
ing that factors other than occlusal conditions had
more inuence on self-esteem.
The results of our study suggest that occlusal
conditions as measured through the DAI had
minimal effect on satisfaction with life and self-
esteem. Only baseline DAI was signicantly asso-
ciated with satisfaction with life at follow-up; DAI
at follow-up had no effect on satisfaction with life
and self-esteem. Oral health-related quality of life
at follow-up was associated with occlusal condi-
tions at baseline and follow-up, the desirable need
category was signicantly associated with higher
OHIP score. The OHIP domain most frequently
affected was psychological discomfort, and the
DAI trait of the most inuence was missing teeth
in the anterior segment. This is consistent with
ndings elsewhere that the majority of orthodontic
treatment is sought for aesthetic reasons (4, 10).
When the change in occlusal conditions, income
at follow-up and receipt of orthodontic treatment
were entered into a regression model, the change in
occlusal condition had no signicant association
with quality of life and psychosocial measures.
This nding supports the ndings of Taylor et al.
(7) that changes in occlusal condition as a result of
orthodontic treatment had little effect on reported
changes in oral health, appearance, social lives or
their general health. They found no correlation
between change scores in total ICON score and the
aesthetic component of the ICON score with
changes in oral function, social relationships, per-
ceived appearance and general health among their
study participants who had undergone orthodontic
treatment.
Receipt of orthodontic treatment was negatively
associated with satisfaction with life and self-
esteem. In this observational study, it is likely that
unmeasured psychosocial factors may be inuenc-
ing orthodontic treatment uptake. The study by
Shaw et al. (8) suggested that the observed effects
of occlusal changes as a result of orthodontic
treatment on self-esteem at adulthood were ex-
plained by childhood self-esteem. The present
study measured the change in occlusal conditions
over the observation period and psychosocial
factors only at follow-up, and changes in psycho-
social factors over the observation period could not
be determined.
The observation in this study of the association
between occlusal conditions and psychosocial fac-
tors is in agreement with other longitudinal stud-
ies, which found little effect of occlusal conditions
Table 7. Regression models of DAI change, income, FOT
and OHIP on life satisfaction and self-esteem
Regression
coefcient
Standard
error
P
value
Life satisfaction (R
2
= 0.16)
DAI change 0.0006 0.02 0.98
Income
Low
(reference group)
Medium 2.28 0.47 <0.01
High 2.95 0.49 <0.01
FOT
No (reference)
Yes )0.91 0.40 0.02
OHIP )0.34 0.08 <0.01
Self-esteem (R
2
= 0.11)
DAI change )0.12 0.03 0.64
Income
Low
(reference group)
Medium 0.75 0.58 0.20
High 1.46 0.60 0.02
FOT
No (reference)
Yes )1.39 0.49 <0.01
OHIP )0.54 0.10 <0.01
DAI, dental aesthetic index; FOT, xed orthodontic
treatment; OHIP, oral health impact prole.
512
Arrow et al.
on psychosocial factors (8, 9). Kenealy et al.
reported that self-esteem was signicantly associ-
ated with the aesthetic component of the occlusion
index, the total occlusal index score at follow-up
and perceptions of general oral health. In an
exploratory analysis, when all other variables in
addition to the dental factors were entered into the
regression model for self-esteem, only the total
baseline occlusal index score remained signicant
in the model while the remaining variables com-
prise psychosocial factors (9). The authors con-
cluded that malocclusion assessed at childhood
contributing to self-esteem in adulthood, while of
interest, was of minor importance and that the data
did not support the assumption of orthodontics
improving long-term psychological well-being.
The nding in this study of small (inconsistent)
associations between occlusal conditions in child-
hood and adulthood on psychosocial factors sug-
gests that a closer examination of oral health
outcomes with orthodontic treatment for dened
occlusal conditions is required. The study suggests
that quality of life is associated with occlusal
conditions at adulthood, mainly in the domain of
psychological discomfort and that oral health-
related quality of life is strongly associated with
satisfaction with life and self-esteem (Table 7).
However, the ndings of the study suggest that
the association between orthodontic treatment and
quality of life is relatively weak and that ortho-
dontic treatment may have a negative association
with satisfaction with life and self-esteem. A
limitation of this observational study is that oral
health-related quality of life and psychosocial
factors likely to inuence uptake of orthodontic
treatment were not measured at baseline (in ado-
lescence), and hence, changes in these factors over
time were not able to be determined. However, the
comparison of the study cohort and a community
group sample suggests the study cohort is a
reasonable representation of the general commu-
nity and provides condence that bias is unlikely
with the observations and reects the situation
prevailing in the general community.
Conclusions
Occlusal status as determined through the DAI and
xed orthodontic treatment appears to have lim-
ited association with the quality of life and
psychosocial factors. Undergoing xed orthodontic
treatment may not inuence oral health-related
quality of life and appears to be negatively asso-
ciated with satisfaction with life and self-esteem.
While occlusal conditions are associated with oral
health-related quality of life, receipt of xed
orthodontic treatment was not. The reasons for
the uptake of orthodontic treatment may have
associations with perceived oral health-related
quality of life and psychosocial factors, which were
not examined in this paper. The nding suggests
that further critical examination of the association
of psychosocial factors and objectively dened
occlusal conditions and receipt of orthodontic
treatment is required. Furthermore, the ndings
suggest a critical examination of the benets of
orthodontic treatment for dened occlusal condi-
tions in improving the oral health-related quality of
life and psychosocial well-being.
Acknowledgements
This research was supported by the Commonwealth
Department of Community Services and Health, Re-
search and Development Grant; South Australian Dental
Services; and the South Australian Health Commission in
19881989, and the National Health and Medical Re-
search Council (project grant 299057) in 20052006.
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