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RESEARCH REPORT |
1 Department of Oral Sciences, School of Dentistry, University of Otago, PO Box 647, Dunedin, New Zealand; and
2 Community Dental Health Services Research Unit, Faculty of Dentistry, University of Toronto, 124 King Edward Street, Toronto, ON, Canada M5G 1G6;
* corresponding author, mthomson{at}gandalf.otago.ac.nz
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: child • oral health • quality of life • validity • malocclusion • dental caries
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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To date, the validity and reliability of the CPQ11-14 have been examined in a clinical convenience sample of 123 children recruited from among pediatric dentistry, orthodontic, and craniofacial patients in Toronto. These groups were chosen since they had distinct clinical characteristics that were expected to have differential effects on the children’s quality of life, thus maximizing variation for validity testing. The discriminative properties (i.e., cross-sectional validity and test-retest reliability) of the CPQ11-14 were found to be acceptable.
However, there have been no reports from other populations or settings, and questions remain about the performance of the CPQ11-14 in child populations which exhibit the full distribution of clinical presentations. It is important that the discriminative properties of such measures be acceptable in these populations. Their ability to distinguish between individuals (or groups) with poor OHRQoL and those with better OHRQoL is a key characteristic which would enable such instruments to contribute to improvements in oral health, through identifying those clinical or public health interventions which produce the greatest improvement in OHRQoL.
The aim of this study was to examine the construct validity of the CPQ11-14 in a probability-based population sample of 12- and 13-year-old New Zealanders. It was hypothesized that children with more severe malocclusions would have higher overall (and domain) CPQ11-14 scores, and that this would also apply to those with greater dental caries experience.
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MATERIALS & METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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Parents/caregivers of the sampled children were mailed consent documentation and a questionnaire which sought information on whether the child had received any orthodontic advice and/or treatment, and which included the Parental-Caregiver Perceptions Questionnaire that had been developed, along with the CPQ11-14 (www.cdhsru-uoft.ca/cohqol; Jokovic et al., 2002). We obtained consent from both parent and child before proceeding. Each child completed the CPQ11-14 in the dental clinic waiting room just prior to the dental examination; questions asked about the frequency of events during the previous three months. Response options and scores were: ‘Never’ (scoring 0); ‘Once or twice’ (1); ‘Sometimes’ (2); ‘Often’ (3); and ‘Every day or almost every day’ (4). An overall CPQ11-14 score was computed by addition of all of the item scores, and scores for each of the four domains were also computed. The test-retest reliability of the CPQ11-14 was not examined.
The clinical examinations (by LFP) took place in dental clinics at the children’s schools. A standardized sequence was used, with a standard dental caries examination (World Health Organization, 1997) preceding an assessment for malocclusion. Teeth were not cleaned and were examined wet. The orthodontic assessment was carried out based on the Dental Aesthetic Index (Cons et al., 1986), which assesses the relative social acceptability of dental appearance by collecting and weighting data on 10 intra-oral measurements. This enables each individual to be placed on a dental appearance continuum ranging from 13 (the most socially acceptable) to 100 (the least acceptable), and orthodontic treatment need can be prioritized based on the pre-defined categories of ‘minor/none’ (scores 13 to 25), ‘definite’ (26 to 31), ‘severe’ (32 to 35), or ‘handicapping’ (36 or more; Estioko et al., 1994). Where a child presented with a mixed dentition, he/she was asked directly about the reason for any missing teeth, since these are allocated the highest DAI weight. Prior to data capture, the dental examiner underwent a calibration session with an experienced dental epidemiologist (WMT), resulting in inter-examiner intraclass correlation coefficients (ICC) of 0.98 for the DAI score, and 0.93 for DMFS. We investigated intra-examiner reliability by conducting replicate examinations on 19 individuals; an ICC of 0.94 was obtained for the DAI score, and 0.94 for DMFS.
Clinical data were entered into a laptop computer by a research assistant. The resulting data were analyzed with the use of SPSS version 10.1 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were followed by bivariate analyses, which used (where appropriate) Chi-square tests for comparison of proportions, and Mann-Whitney or Kruskal-Wallis tests (as appropriate) for comparison of the means of continuous variables. The alpha value was set at P < 0.05.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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Males slightly outnumbered females, and one in five participants was Mäori (Table 1
). Almost three-quarters of the sample had had caries experience, and just over one-quarter had 4+ DMFS. Mean DAI scores were higher among females than males, but there were no significant sex differences by treatment category membership.
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), and were positively skewed, as were the domain scores (requiring the use of non-parametric tests of statistical significance).
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), it did not quite reach statistical significance (P = 0.06); however, the mean emotional well-being domain score for females was higher than that for males. Children in the top quartile of the DMFS distribution had higher CPQ11-14 scores overall, as well as higher scores for each of the four domains. There was a distinct gradient in mean CPQ11-14 scores across the categories of malocclusion severity, whereby those in the ‘Handicapping’ category had the highest and those in the ‘Minor/none’ category had the lowest CPQ11-14 score, on average. Such a gradient was also observed with respect to the emotional well-being and social well-being domain scores, but not with the other two domains.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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This study set out to examine the construct validity of the CPQ11-14. It was hypothesized that children with more severe malocclusion would have higher scores. This was certainly the case with the overall CPQ11-14 scores, with a clear ascending gradient demonstrated across ascending categories of orthodontic treatment need. However, the domain scores showed some noteworthy differences, with no clear, statistically significant gradient observed for oral symptoms or functional limitations; the emotional and social well-being domain scores did show clear gradients, though. Concerning dental caries experience, there were distinct differences in both the overall and the domain scores between those who were in the highest quartile for DMFS and the remainder. These findings are not counter-intuitive: Other factors being equal, children in the most severe disease quartile are likely (for example) to have experienced more oral pain, had difficulties in chewing, to have worried or been upset about their mouths, or to have missed school due to their cumulative disease experience. However, malocclusion is as much a social phenomenon as an anatomical one, and the DAI was designed specifically to assess the relative social acceptability of dental appearance based upon public perceptions of dental aesthetics. Thus, it is not surprising that clear gradients were observed (across the ascending DAI treatment-need categories) for two of the domains, since ‘being teased’ or ‘avoiding smiling or laughing’ (social well-being) and ‘being upset’ or ‘worrying about being different’ (emotional well-being) are known to be associated with malocclusion, and are important motivating factors in the uptake of orthodontic treatment (Plunkett, 1997). That no clear gradients were observed with the oral symptoms or functional limitations domains is also unsurprising, perhaps, since only the most severe malocclusion might be expected to produce effects in those domains.
Validation of measures such as the CPQ11-14 at the population level is important, since clinical samples may give a misleading picture of their utility, because of the biased nature of the sample (Locker, 2000). Further research should (a) examine the validity of the CPQ11-14 in other populations and settings, and (b) investigate its evaluative properties to determine its usefulness as a clinical outcome measure in dental health services research.
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ACKNOWLEDGMENTS |
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Received September 13, 2004; Last revision March 15, 2005; Accepted April 22, 2005
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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Cons NC, Jenny J, Kohout FJ (1986). DAI: the Dental Aesthetic Index. Iowa City, IA: College of Dentistry, The University of Iowa.
Cushing AM, Sheiham A, Maizels J (1986). Developing socio-dental indicators—the social impact of dental disease. Community Dent Health 3:3–17.
Estioko LJ, Wright FA, Morgan MV (1994). Orthodontic treatment need of secondary school children in Heidelberg, Victoria: an epidemiologic study using the Dental Aesthetic Index. Community Dent Health 11:147–151.[Medline]
Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G (2002). Validity and reliability of a questionnaire for measuring child oral-health-related quality of life. J Dent Res 81:459–463.
Leão A, Sheiham A (1996). The development of a socio-dental measure of dental impacts on daily living. Community Dent Health 13:22–26.[Medline]
Locker D (2000). Response and nonresponse bias in oral health surveys. J Public Health Dent 60:72–81.[Medline]
Locker D, Miller AM (1994). Subjectively reported oral health status in an adult population. Community Dent Oral Epidemiol 22:425–430.[ISI][Medline]
Plunkett DJ (1997). The provision of orthodontic treatment: some ethical considerations. NZ Dent J 93:17–20.
Slade GD, Spencer AJ (1994). Development and evaluation of the Oral Health Impact Profile. Community Dent Health 11:3–11.[Medline]
World Health Organization (1997). Oral health surveys. Basic methods. 4th ed. Geneva: World Health Organization.
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