Agreement between mothers and children with malocclusion in rating children's oral health-related...

ORIGINAL ARTICLE

Agreement between mothers and children withmalocclusion in rating children’s oral health-related quality of life

Philip Benson,a Catherine O’Brien,b and Zoe Marshmanc

Sheffield and Chesterfield, United Kingdom

Introduction: The aim of this study was to compare the assessment of oral health-related quality of life (OH-QoL) between children with malocclusion and their mothers, by using responses to the child perceptionsquestionnaire and the parental-caregivers perceptions questionnaire. Methods: The study was conductedin 90 children, aged 11 to 14 years, with a malocclusion grade of 4 or 5 according to the index of orthodontictreatement need dental health component. The children and their mothers completed the questionnaires in-dependently. Results: The mean ratings were similar for total scores (children, 20.4; mothers, 20.1), oralsymptoms (children, 5.2; mothers, 4.7), and social well-being (children, 4.3; mothers, 4.8). However, themothers group had a lower mean score for functional limitations (children, 5.3; mothers, 3.6) and a highermean score for emotional well-being (children, 5.6; mothers, 7.1). The correlations between children’s andmothers’ responses ranged from rs 5 0.545 for total score and emotional well-being to rs 5 0.357 forfunctional limitations. There were good correlations between their responses to global (rs 5 0.466) and lifeoverall (rs 5 0.427) questions, but poor correlations between the 2 questions, suggesting that theseconcepts were considered differently. Conclusions: Maternal opinions were similar to those of their childrenfor the overall impact on OH-QoL of malocclusion, but mothers were more dissatisfied with the appearance oftheir children’s teeth and overestimated the emotional impact of malocclusion. It would be useful to developa specific measure to assess OH-QoL in children with malocclusion. (Am J Orthod Dentofacial Orthop2010;137:631-8)

Quality-of-life measures are increasingly beingdeveloped and used in dentistry as the impor-tance of gaining the perspectives of patients

and the public is acknowledged. These measures arepatient-centered because they capture how oral condi-tions impact people’s lives, rather than a narrow focuson disease and mouth-centered approaches to the assess-ment of oral health. Potential uses include political ap-plications to influence policy makers, the developmentof theory by exploring models of health, and practicalpurposes to evaluate the effectiveness of interventions

aReader/honorary consultant, Department of Oral Health and Development,

School of Clinical Dentistry, University of Sheffield, Sheffield, United

Kingdom.bSpecialist registrar in orthodontics, Charles Clifford Dental Hospital and Ches-

terfield Royal Hospital NHS Foundation Trust, Chesterfield, United Kingdom.cSenior lecturer/consultant in dental public health, Department of Oral Health

and Development, School of Clinical Dentistry, University of Sheffield,

Sheffield, United Kingdom.

The authors report no commercial, proprietary, or financial interest in the

products or companies described in this article.

Reprint requests to: Philip Benson, Department of Oral Health and Develop-

ment, School of Clinical Dentistry, University of Sheffield, Sheffield, United

Kingdom S10 2TA; e-mail, [email protected].

Submitted, February 2008; revised and accepted, June 2008.

0889-5406/$36.00

Copyright � 2010 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2008.06.033

or to aid discussion of problems with patients.1,2

Recently, oral health-related quality of life (OH-QoL)has been defined as ‘‘the impact of oral disorders on as-pects of everyday life that are important to patients andpersons, with those impacts being of sufficient magni-tude, whether in terms of severity, frequency or duration,to affect an individual’s perception of the life overall.’’3

Several measures have been designed to assessOH-QoL,4-8 although the relationship between theiroutcomes and OH-QoL has recently been questioned.3

Many of the measures were developed for adults andmight not address issues relevant to children.9

A further problem with the assessment of quality oflife is that it is a dynamic rather than a static phenome-non.10 People alter the standards by which they ratetheir OH-QoL over time, because of changes in circum-stances or their physical and emotional development. Toovercome this limitation, it was suggested that a rangeof measures should be used to evaluate OH-QoL, oneof which could include information from parents orcaregivers when children’s OH-QoL is investigated.11

Jokovic et al7 developed the child oral health quality oflife questionnaire, which includes age-specific measuresfor children 6 to 14 years of age (child perceptions ques-tionnaire [CPQ]) and the parental-caregiver perceptions

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mailto:[email protected]

632 Benson, O’Brien, and Marshman American Journal of Orthodontics and Dentofacial Orthopedics

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questionnaire (P-CPQ).11 The CPQ for ages 11 to 14 yearsand the P-CPQ are comparable questionnaires with 31items in common organized into 4 domains: oral symp-toms, functional limitations, emotional well-being, andsocial well-being. In a study of 42 mothers and children,Jokovic et al12 found generally good agreement in thegroups. However, there were significant discrepanciesbetween pairs, particularly in the emotional and socialwell-being domains. This suggests that it is not appropri-ate to use mothers as proxies for their children at theindividual level.

Zhang et al13 examined agreement between P-CPQand CPQ in mothers, fathers, and children with ortho-dontic treatment need in Hong Kong. They found thatthe parents rated the OH-QoL poorer than did the chil-dren in all domains. They showed that, although therewas generally good agreement between mothers and fa-thers at the group level, agreement among mothers,fathers, and their children at the individual level waspoor. They concluded that not only did the childrenand parents have differing views about the impact ofmalocclusion, but also the 2 parents sometimes dis-agreed. This underlined the importance of consultingthe whole family when discussing orthodontic needand treatment.

The aim of this study was to examine the relation-ship between reports of OH-QoL from children withmalocclusion and their mothers in a sample in theUnited Kingdom. More specifically, we examined inwhich of the 4 domains of the child oral health qualityof life questionnaire the agreement or disagreementoccurred and to what extent it was apparent.

MATERIAL AND METHODS

Ethical approval was granted by the South SheffieldResearch Ethics Committee (reference number 03/262),and site-specific issues were reviewed by the Researchand Development Department at Chesterfield RoyalHospital.

The sample consisted of consecutive orthodonticpatients between the ages of 11 and 14 years whowere removed from a treatment waiting list, had pre-treatment records taken, and were considered ready tostart treatment at the Charles Clifford Dental Hospitalin Sheffield or the Chesterfield and North DerbyshireRoyal Hospital in Chesterfield. The subjects were re-cruited to a study examining the effect of malocclusionon OH-QoL.14 They were assessed to be in grades 4 or 5of the index of orthodontic treatment dental health com-ponent by a trained and calibrated examiner C.O.’B.,and all agreed to take part before treatment. Patientswith active dental disease, cleft lip or palate, complicat-

ing medical history, or severe dental mottling were ex-cluded. A sample size calculation suggested that 90patients should be recruited to detect a difference of30% in the total CPQ (a 5 0.05; b 5 0.90) between sub-jects with and without malocclusion.14

The child and the parent who was present at the con-sultation were asked to independently complete theCPQ for children aged 11-14 years and the P-CPQ, re-spectively. The child and the parent completed the ques-tionnaires separately in a quiet area of the orthodonticclinic with a researcher available to answer questions.Both the CPQ and P-CPQ have been evaluated for usein the United Kingdom and were found to have accept-able psychometric properties.15,16 These questionnairesalso include 2 global questions: (1) rating the health oftheir, or their child’s, teeth, lips, jaws, and mouth; and(2) how much their, or their child’s, teeth, lips, jaws,or mouth affect life overall. These global questionswere previously evaluated.17 They were worded,‘‘would you say that the health of your teeth, lips,jaws, and mouth is __?’’ with a 5-point response formatfrom excellent to poor; and ‘‘how much does the condi-tion of your teeth, lips, jaws, or mouth affect your lifeoverall?’’ with a response range from not at all to verymuch. A third question asked about satisfaction withtheir, or their child’s, teeth on a 5-point scale fromvery satisfied to very dissatisfied.

Statistical analysis

The response option codes used for both the CPQand P-CPQ were 0, never; 1, once or twice; 2, some-times; 3, often; and 4, every day or almost every day.The P-CPQ questions also had a ‘‘don’t know’’ responseoption that was given a score of 0 in the analysis.18 The‘‘don’t know’’ response was included in the parents’questionnaire to acknowledge the limitations of the par-ent’s knowledge of the child’s oral health or everydayactivities. Total and domain scores were obtained bysumming the response option codes for each question.The response format for the global, life overall, and sat-isfaction with teeth questions was also a 5-point Likertscale.

The relationship between the CPQ and the P-CPQwas assessed in a number of ways. Comparisons weremade by examining the mean scores and the differencesbetween the scores. Mean directional differences weretested by using a paired t test. The magnitude of any sys-tematic differences was examined by dividing the meanby the standard deviation to obtain a standardized differ-ence.12 A standardized difference of 0.2 was consideredsmall, 0.5 was moderate, and 0.8 was great.11 An abso-lute mean difference was calculated by ignoring the

Table I. Descriptive characteristics for the children inthe study

n %

Subjects Boys 34 37.8

Girls 56 62.2

Age (y) 11 14 15.6

12 23 25.6

13 22 24.4

14 31 34.4

Mean age (SD) 13.3 (1.1)

American Journal of Orthodontics and Dentofacial Orthopedics Benson, O’Brien, and Marshman 633Volume 137, Number 5

positive and negative sign of the individual differences.This was then expressed as a percentage of the maxi-mum score to assess the size of the absolute differences.

Discrepancies between parent and child were alsoassessed by subtracting the child’s score from the par-ent’s score and using the standard deviation of the dif-ferences between the 2 scores to rate concordance.The scores were rated similar when the difference be-tween the scores was within .5 SD above or below a dif-ference of zero.19 If scores had a difference greater than.5 SD below an overall difference of zero, the child wasrated as giving a higher score than the parent. If thescores had a difference greater than .5 SD above anoverall difference of zero, the parent was rated as givinga higher score than the child.

The internal consistency of the measure used in thissample was assessed with Cronbach’s alpha. The asso-ciation between the parents’ and children’s responsesto the global question, the life overall, the satisfactionwith teeth, and the CPQ and P-CPQ total and domainscores were examined by using the Spearman correla-tion. Agreement was assessed with intraclass correla-tion coefficients.

RESULTS

A total of 116 pairs of children and parents or care-givers completed both questionnaires. The parents andcaregivers included 90 mothers, 20 fathers, and 6 others.Because there were few fathers and others, only the re-sponses between the children and the mothers werecompared. The sex and age of these children are shownin Table I.

The number of ‘‘don’t know’’ responses per motherranged from 0 to 12. Almost half (47.8%) of the mothersresponded ‘‘don’t know’’ at least once, 28.9% had 3 ormore ‘‘don’t know’’ responses, and 15.6% had 6 ormore.

The Cronbach’s alpha values were 0.91 for the totalCPQ score and 0.90 for the total P-CPQ score. TheCronbach’s alpha values for the respective CPQ andP-CPQ domain scores were 0.70 and 0.58 for oral symp-toms, 0.58 and 0.67 for functional limitations, 0.89 and0.90 emotional well-being, and 0.74 and 0.77 for socialwell-being. These figures are slightly lower than thoseobtained by Jokovic et al11 but still represent good inter-nal consistency.

Comparisons between the mean total and 4 domainscores from the CPQ and P-CPQ responses are shownin Table II. The mean ratings were similar for the totalscore (children, 20.4; mothers, 20.1), oral symptoms(children, 5.2; mothers, 4.7), and social well-being (chil-dren, 4.3; mothers, 4.8) domains. Differences in the

mean scores suggest that mothers underestimated func-tional impacts (children, 5.3; mothers, 3.6) and overesti-mated emotional impacts (children, 5.6; mothers, 7.1)compared with the children’s scores.

The difference between the answers of the childrenand their mothers in the functional impacts domainwas mainly due to 2 questions. The biggest discrepancyin responses was to the question ‘‘in the past 3 months,because of your or your child’s teeth, mouth, lips, andjaws, how often have you, or has your child, breathedthrough the mouth?’ The proportion of children re-sponding ‘‘never’’ to this question was 26%; the propor-tion of mothers responding ‘‘never’’ was 43%, and 20%responded ‘‘don’t know.’’ The second question causingthe discrepancy in the functional domain was: ‘‘in thepast 3 months, because of your or your child’s teeth,mouth, lips, and jaws how often have you, or has yourchild, taken longer than others to eat a meal?’’ The pro-portion of children responding ‘‘never’’ to this questionwas 50%; the proportion of mothers responding ‘‘never’’was 75%, with no mothers responding ‘‘don’t know.’’

The difference in the answers between children andmothers in the emotional well-being domain was alsomainly due to the responses to 2 questions. The ques-tion, ‘‘in the past 3 months, because of your or yourchild’s teeth, mouth, lips, and jaws, how often haveyou, or has your your child, been upset?’ produceda ‘‘never’’ response in 64% of children compared with44% of mothers, with just 3 mothers choosing ‘‘don’tknow.’’ The question, ‘‘in the past 3 months, becauseof your or your child’s teeth, mouth, lips, and jaws,how often have you, or has your child, been nervous,anxious, or fearful?’ produced a ‘‘never’’ response in72% of children compared with 50% of mothers, with7 mothers choosing ‘‘don’t know.’’

Table III shows the mean directional differences andconfirms that the responses for the functional limitations(P \0.001) and emotional domains (P 5 0.026) weresignificantly different. The standardized differencesare shown in Table IV. They were generally small, rang-ing from –0.02 for the total score to –0.46 for the

Table II. Comparisons of the mean totals and the 4 domain scores from the CPQ and P-CPQ responses

Items (n)

Children Mothers

Mean SD Minimum Maximum Mean SD Minimum Maximum

Total score (0-124) 31 20.4 12.7 0 50 20.1 14.8 1 73

Domains

Oral symptoms (0-24) 6 5.2 3.4 0 13 4.7 3.2 0 13

Functional limitations (0-28) 7 5.3 3.6 0 19 3.6 3.9 0 18

Emotional well-being (0-32) 8 5.6 5.4 0 21 7.1 6.6 0 25

Social well-being (0-40) 10 4.3 4.1 0 20 4.8 4.8 0 20

Table III. Mean directional differences between the totaland 4 domain scores from the paired CPQ and P-CPQdata

Meandifference SD

95% CI of difference

PCPQ–P-CPQ Lower Upper

Total score 0.3 12.4 �2.3 2.9 0.826

Domains

Oral symptoms 0.5 3.6 �0.2 1.2 0.185

Functional limitations 1.7 3.7 0.9 2.5 \0.001

Emotional well-being �1.4 6.0 �2.7 �0.2 0.026

Social well-being �0.5 3.9 �1.3 0.3 0.224

Table IV. Standardized and absolute differences betweenthe total and 4 domain scores from the paired CPQ andP-CPQ data

Standardizeddifferences

(mean [SD])

Absolute differences

Mean SD% of maximum

score

Total score �0.02 9.6 7.8 8

Domains

Oral symptoms �0.14 2.8 2.2 12

Functional limitations �0.46 3.2 2.5 12

Emotional well-being 0.24 4.7 4.0 15

Social well-being 0.13 2.7 2.8 7


May 2010

functional limitations domain, which approaches mod-erate disagreement. The absolute differences for the to-tal and domain scores are also shown in Table IV. Theyranged from 0 to 31, with 59% of the child-mother pairsshowing a difference of 10 or less. The mean absolutedifferences ranged from 7% of the maximum score forsocial well-being to 15% of the maximum score foremotional well-being.

Nearly half of the mother and child total scores(46%) were within .5 SD above and below a differenceof zero, although this was true for only 25% of the func-tional limitations domain, with 52% of the childrenscoring higher than their mothers. Conversely, 41% ofthe mothers scored higher than their children in theemotional well-being domain. The concordance be-tween mother and child was similar for both oral symp-toms and social well-being.

Table V shows the mean scores from the global, lifeoverall, and satisfaction with teeth questions, and TableVI shows the correlations between the mother and childresponses to the global question, the life overall, the sat-isfaction with teeth, and the CPQ and P-CPQ total anddomain scores. The Spearman correlations (rs) rangedfrom 0.545 for total CPQ and emotional well-being to0.097 for satisfaction with teeth. The correlationswere all significant, except for satisfaction with teeth.The intraclass correlation coefficients ranged from sub-

stantial for social well-being (0.62) to moderate for oralsymptoms 0.42.20 The association between the globaland life overall responses were weak for both children(rs 5 0.390) and mothers (rs 5 0.265).

The Figure shows the concordance between thechild and mother for the global, life overall, and satis-faction with teeth questions. The concordance betweenpairs for the global and life overall questions was good.Mothers and children gave the same score for the globalrating in 39% of pairs, and 92% were within 1 point oneither side of the score. The results for the life overallquestion were also very similar, with 38% equal, and87% within 1 point on either side. The concordancefor the satisfaction with teeth question was poor, withonly 19% of child-mother pairs recording the samescore; in 46% of the pairs, the mother scored higherthan the child— ie, nearly half of the mothers weremore dissatisfied with their children’s teeth than werethe children.

DISCUSSION

We found generally good agreement betweenchildren with malocclusion and their mothers at thegroup level regarding their perceptions of the impactof occlusal deviations. Means and standardized and ab-solute differences were small for the total CPQ and the

Table V. Comparison of the mean scores from the global, life overall, and satisfaction with teeth questions

Children Mothers

Mean SD Mean SD

Would you say the health of your (child’s) teeth, lips, jaws, and mouth is: (0 5 excellent to 5 5 poor) 2.0 0.8 2.1 1.0

How much does the condition of your (child’s) teeth, lips, jaws, or mouth affect your (child’s) life overall?

(0 5 not at all to 5 5 very much)

1.4 1.0 1.5 1.0

How satisfied are you with the appearance of your (child’s) teeth? (0 5 very satisfied to 5 5 very dissatisfied) 2.2 0.9 2.9 1.3

Table VI. Spearman and intraclass correlation coeffi-cients (ICC) for mothers’ and children’s responses tothe global question, life overall, satisfaction with teeth,and the CPQ and P-CPQ total and domain scores

Spearman (rs) P ICC

Global 0.466 \0.001 -

Life overall 0.427 \0.001 -

Satisfaction with teeth 0.097 0.365 -

Total CPQ/P-CPQ 0.545 \0.001 0.60

Domains

Oral symptoms 0.403 \0.001 0.42

Functional limitations 0.357 0.001 0.45

Emotional well-being 0.545 \0.001 0.49

Social well-being 0.535 \0.001 0.62


P-CPQ scores, and for the oral symptoms and socialwell-being domains.

The numbers of children and mothers involved wereclose to similar studies published in this area.12,13

Although the sample size was based on the differencein the total CPQ scores between groups with andwithout malocclusion, a power calculation with thedata obtained showed that a sample size of 90provided a power of 0.87 to detect a 40% differencein the total CPQ scores between children and mothers(the standard deviation of the differences was 12.4).

These results differ from those of Jokovic et al,12

who found that Canadian children had higher overallCPQ scores compared with their mothers’ P-CPQscores; however, they also found good agreementbetween mothers and children at the group level. Theirsample included children with various dental prob-lems, including orthodontic and orofacial conditions,which might have been more severe than those in ourstudy.

Zhang et al13 found that children with malocclusionhad significantly lower CPQ scores (ie, rated their OH-QoL better) than did their parents across all domains, al-though the functional limitations and social well-beingdomains were not statistically significant. Their sampleconsisted of children with malocclusion accepted for or-thodontic treatment, but it is not clear where the study

was undertaken and whether cultural differences mightexplain this difference in outcome.21 The intraclass cor-relation coefficients for the total and domain scores inthis study were lower than those found by Jokovicet al12 but higher than those of Zhang et al13; this mightreflect the differences in the samples.

Wilson-Genderson et al19 found low to moderateagreement between the child and the caregiver withthe child oral health impact profile. Their sample in-cluded children with pediatric, orthodontic, and cranio-facial conditions from 3 sites in North America. Thelowest correlations were found in the craniofacialgroup, and the authors concluded that children in the pe-diatric and orthodontic groups were more likely to agreewith caregivers or to rate their OH-QoL more negativelythan those in the craniofacial group.

There was a statistically significant systematic dif-ference between the children’s and mothers’ scores inthe functional and emotional domains in this study. Ex-amination of the mean differences gives an indication ofthe discrepancies in the groups, but the more importantcomparisons for these data are the differences withinmother-child pairs. This was determined by using stan-dardized and absolute differences as well as concor-dance levels. There was a higher standardizeddifference for the functional and emotional domains,and a higher absolute difference for the emotional do-main. Closer examination of the responses to individualquestions clearly showed that the differences betweenchild and mother were due to 2 of the 7 questions inthe functional domain and 2 of the 8 questions in theemotional well-being domain.

In the functional domain, mothers underestimatedthe frequency of mouth-breathing and the length oftime it took for their children to eat a meal than did theirchildren. Jokovic et al12 also found poor agreement be-tween children and mothers for this question in the func-tional domain; however, this question also produced themost ‘‘don’t know’’ responses from mothers; this agreeswith a previous study.18 A high prevalence of ‘‘don’tknow’’ responses by a mother does not represent a differ-ence in views between the mother and the child buta lack of knowledge about whether the child is afflicted

Fig. Graph showing the concordance between mothers and children for the global, life overall, andsatisfaction with teeth questions.


May 2010

with this particular condition. This finding thereforeshould be interpreted with caution.

The mouth-breathing item produced one of the high-est prevalence of impacts from the children’s responses;74% of the children scored this as occurring once ortwice or more frequently in the past 3 months, witha mean item score of 2.0. The frequency with which chil-dren report mouth-breathing might suggest that theyconsider this normal, rather than an impact on their lifebecause of an oral condition. Therefore, this might notbe a useful question to include in a questionnaire de-signed to assess OH-QoL, and it was excluded fromthe short form of the questionnaire.22 This finding alsosupports the need for qualitative work with children onthe measure and its meaning for them, because somequestions, particularly in the oral symptom and func-tional limitation domains of the CPQ, might not seemrelevant to patients with malocclusion. Hence, it mightbe appropriate to develop a condition-specific measureto assess OH-QoL in children with malocclusion.23

The relevant content of a malocclusion-specific measurewould make it more sensitive, acceptable to participants,and responsive to change.24 Such a measure could beused to evaluate the relative effectiveness of various or-thodontic treatments or to monitor patient care or patientpreference.

In the emotional domain, the mothers overestimatedhow frequently the teeth, lips, mouth, or jaws causedtheir children to be upset, or nervous, afraid, anxious,or fearful compared with the children’s responses. Jo-

kovic et al12 also found poor agreement between childand mother for the first question. The second questionhas different wording between the CPQ and the P-CPQ. The CPQ asks children how often they have‘‘felt nervous or afraid,’’ whereas the P-CPQ asks theparent how often their child has been ‘‘anxious or fear-ful.’’ This difference in wording between the 2 question-naires might explain the difference in responses;however, unlike this study, Jokovic et al12 found goodagreement between child and mother for this question.

The responses to the global and life overall ques-tions were similar to those of Jokovic et al,25 who foundthat 77% of children in their sample rated the health oftheir teeth, lips, jaws, and mouth as excellent to good. Inour study, 76% of the children rated their oral health ex-cellent to good, compared with 68% of their mothers.Therefore, neither group viewed the child’s malocclu-sion as detrimental to oral health. Just under half ofthe children (43%) said that the condition of their teeth,lips, jaws, and mouth affected their life some, a lot, orvery much, compared with just over half of the mothers(52%). This is a higher proportion than Jokovic et al25

found, when 30% of the children said that the conditionof their teeth, lips, jaws, and mouth affected their lifesome, a lot, or very much.

Similar proportions of children (44%) and mothers(48%) who stated that their or their child’s oral healthwas excellent to good also responded that their or theirchild’s teeth affected their life some, a lot, or very much.A higher proportion of children (59%) compared with


mothers (38%) who stated that their (or their child’s)oral health was fair or poor also claimed that their (ortheir child’s) teeth affected their life little or not at all.These data support the view of Jokovic et al25 that chil-dren and, to a lesser extent, their parents view the con-cepts of health and well-being differently. This seemsparticularly to apply in our sample of children with mal-occlusion, which can be viewed not as a disease, but asa condition that varies from what is considered normalby society.

We found that mothers expressed more dissatisfac-tion with their children’s teeth than did the children.This is a common finding. Evans and Shaw26 showedthat parents were more critical of their children’s teeththan the children when developing a scale to rate dentalattractiveness. Chew and Aw27 found that more parentswere dissatisfied with their children’s dental appearanceand had a greater desire for their children to have ortho-dontic treatment than did their children. Although it isimportant to involve parents in the decision of whethera child should undergo orthodontic treatment, cliniciansshould be cautious about overemphasizing a parent’sopinion, because they might exaggerate the impact ofdental appearance on the child. In this study, mothersoverestimated the emotional impacts of a malocclusioncompared with the children’s opinions. Hunt et al28

found that parents of children with cleft lip and palateconsidered their children to be less happy with their fa-cial appearance than the children actually were. Patel etal,29 using a video-based assessment of children smil-ing, found poor correlation between the child’s self-assessment of the smile and the parent’s proxy assess-ment based on the responses to the questions ‘‘my childlikes his or her smile’’ and ‘‘my child is happy with hisor her teeth.’’

In addition, the parental desire for orthodontic treat-ment for the child might not be rationalized in terms ofthe perceived psychosocial benefits. Birkeland et al30

examined the relationship between dental appearanceand satisfaction longitudinally in orthodonticallytreated and untreated subjects. They found that, al-though 92% of the treated children’s parents were surethat they would allow their child have the same treat-ment again, only 34% were sure that the treatment resulthad a positive impact on their child’s social skills; 23%said that it was likely to have a positive influence on thefuture choice of a mate, and 19% stated that it wouldhave significance for their child’s future working career.Using an OH-QoL measure at the start of treatment forboth the child and the parent would help to identify theirconcerns and enable the appropriate help and guidancewhen making decisions about whether the child shouldundergo treatment.

CONCLUSIONS

The CPQ scores of a child with malocclusion andthe P-CPQ scores of the mother were similar, suggestinggood agreement between them on the effect of occlusaldeviations on the child’s OH-QoL. We therefore recom-mend obtaining parental opinions to supplement theinformation from the child, but not to replace thatinformation.

Mothers of children with malocclusion were moredissatisfied with the appearance of their children’s teeththan were the children; however, they overestimated theemotional impact of the malocclusion on the child. Thisshows the need to provide appropriate advice and guid-ance to parents, along with their children, when discus-sing orthodontic services.

Most children and mothers did not believe that mal-occlusion affected the child’s oral health, but half be-lieved that it affected their life overall. Therefore, the2 concepts were considered different.

It would be useful to develop a specific measure toassess OH-QoL in children with malocclusion.

We thank the children and their parents who freelygave their time to complete the questionnaires.

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