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Orthodontics in public health system. German experience and perspectives in Brazil
Orthodontics in public health system. German experience and perspectives in Brazil
Orthodontic treatment is closely linked to oral health-related quality of life (OHRQoL), and some of the main reasons for seeking orthodontic treatment are related to the benefits of aesthetics, oral-facial functionality and psycho-social well-being. These benefits are relevant in patients with malocclusion problems or facial disharmony. Therefore, studying these aspects is also essential for understanding patients’ perceptions of the treatment in evidence-based orthodontics and could be related to identified treatment needs. Therefore, this thesis aimed to evaluate OHRQoL of patients undergoing orthodontic treatment in three different patient cohorts, independently from each other: 1. general orthodontic patients; 2. patients with cleft-lip/palate; 3. patients in combined orthodontic-orthognathic therapy. The first patient cohort – patients currently undergoing orthodontic treatment with fixed or removable appliances – was evaluated in a multicenter study at four different universities’ orthodontic departments at the Ludwig-Maximilians-University Medical Center (LMU) in Munich, the Johannes-Gutenberg-University in Mainz (JGU), the Medicine University of Hannover (MHH) and the Heinrich Heine University in Dusseldorf (HHU). 898 orthodontic patients (40.9% males and 50.6% females) participated anonymously. They anonymously answered the validated German version of the Oral Health Impact Profile questionnaire (OHIP-G14) online and additional questions related to demography (i.e. age, gender, insurance and immigration status), and general questions about the orthodontic treatment such as the reason for treatment, the type of appliance used and the duration of orthodontic treatment. Descriptive and explorative statistics (Mann-Whitney U-test, Pearson chi-squared test, multiple linear regression modeling) were applied to the complete patient cohort. To conform with the German insurance system (governmental vs. private), the patient cohort was additionally analyzed according to age (6…17 years vs. ≥18 years). The main findings can be summarized as follows: 1. The mean OHIP-G14 score for the total sample was 9.92  8.22. There was a statistically highly significant difference in this score between the 6 to 17-years old patients and the ≥18-years-old adults (p < 0.001). 2. The OHIP-G14 subscales “physical pain” (2.68 ± 1.92), “psychological discomfort” (1.70 ± 1.75), and “psychological disability” (1.53 ± 1.58) showed the highest scores. 3. Adult patients showed significant higher mean scores for the OHIP subscales “physical pain” (young: 2.49  1.85; adult: 3.11  2.02; p < 0.001), “psychological discomfort” (young: 1.47  1.59; adult: 2.24  1.96; p < 0.001), “psychological disability” (young: 1.33  1.39; adult: 1.99  1.88; p < 0.001) and the overall OHIP-G14 score (young: 8.78  7.27; adult: 12.56  9.59; p <0.001) than the patients 6-17 years old. 4. Using the OHIP score as a continuous outcome variable, multiple linear regression analysis was performed, adjusting for age group, gender, reason for orthodontic treatment, type of appliance, duration of treatment, insurance and the nationality/immigration status of the patient. a. Remarkable findings from multiple linear regression were: adults and females have worst quality of life during the treatment. b. The co-variate “reason for treatment” was the most influential one: aesthetic in combination with pain and others, aesthetic in combination with function, pain and others and the combination of function, pain and others without aesthetics were highly significant factors increasing the OHIP-G14 score in both age groups. c. In the younger patient group aesthetics in combination with function, pain, and others significantly increased the OHIP score. d. In adults, function and pain were negatively affecting OHRQoL. e. In comparison to removable appliances, fixed appliances also increased the patient’s OHIP score. f. German, adult patients with a private insurance showed a lower OHIP score and therefore had a better OHRQoL. To evaluate the second patient cohort 50 CLP patients (54.0 % males and 46.0 % females) were anonymously invited to participate in an online survey applying the validated German version of Children Perception Questionnaire (CPQ-G11-14). Like in the first project, demographic items and information on their orthodontic treatment were acquired. Descriptive and explorative statistics (Mann-Whitney U test, Kruskal-Wallis test) were applied. The main findings can be summarized as follows: 1. The CLP patients’ mean age was 13.4  5.1. 2. Regarding the CLP classification, 42.0 % of the participants had unilateral CLP and 26.0 % had bilateral CLP. The remaining patients had cleft lip or palate imperfection only. 3. Patient satisfaction with orthodontic treatment was very high (“very satisfied”, 54.0 %; “satisfied”, 40.0 %). 4. The registered frequencies of the CPQ-G11-14’s answers revealed “breathing through the mouth”, “unclear speech” and “reduced eating speed” as the most frequent problems. 5. The mean rate of the CPQ-G11-14 was higher in boys (28.4  16.26) than in girls (23.8  14.0). A similar pattern was found in almost every subscale, except for the subscale “oral symptoms” (boys 5.9  2.9; girls 6.2  3.4). 6. Explorative statistics showed, that syndrome-associated CLP patients showed the highest CPQ-G11-14 scores due to functional restrictions (subscale 2; p = 0.014). The third patient cohort consisted of 50 ortho-surgical patients (46.0 % males and 54.0 % females). They answered anonymously the German version of the Orthognathic Quality of Life Questionnaire (OQLQ-G). Additionally, demographic items and information on their orthodontic treatment were acquired. Descriptive and explorative statistics (Mann-Whitney U test, Kruskal-Wallis test) were applied. The main findings can be summarized as follows: 1. The ortho-surgical patients’ mean age was 28.0  8.7. 2. Seventy-eight percent of the study subjects reported problems in both jaws. Appearance and health were the main (58.0 %) reasons for treatment and/or surgery. 3. Their malocclusion classification/type was described as being class III by 32.0 % of the patients, with 6.0 % being associated with crossbite, whereas 30.0 % were class II (8.0 % associated with crossbite). 4. Most of the patients were “satisfied” (48.0 %) or “very satisfied” (44.0 %) with the orthodontic treatment. 5. The mean OQLQ-G score was statistically significant (p < 0.001) higher for females (50.2  14.3) than for males (31.1  16.0). These gender differences were also found in all four subscales, but only statistically significant in subscales 2-4. 6. Significant higher scores for the OQLQ-G overall score (p = 0.013) and its subscale scores “aesthetic” (p = 0.045) and “social aspects” (p = 0.016) were found in patients “being engaged/married” than those “being single”. 7. Patients reporting an improvement in self-esteem showed significantly increased OQLQ-G scores in the subscales “aesthetics” (p = 0.010), “social aspects” (p = 0.005) and the overall OQLQ-G score (p = 0.006).
Oral health-related quality of life, orthodontic treatment, oral health impact profile
Silva, Susie Paes da
2019
English
Universitätsbibliothek der Ludwig-Maximilians-Universität München
Silva, Susie Paes da (2019): Orthodontics in public health system: German experience and perspectives in Brazil. Dissertation, LMU München: Faculty of Medicine
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Abstract

Orthodontic treatment is closely linked to oral health-related quality of life (OHRQoL), and some of the main reasons for seeking orthodontic treatment are related to the benefits of aesthetics, oral-facial functionality and psycho-social well-being. These benefits are relevant in patients with malocclusion problems or facial disharmony. Therefore, studying these aspects is also essential for understanding patients’ perceptions of the treatment in evidence-based orthodontics and could be related to identified treatment needs. Therefore, this thesis aimed to evaluate OHRQoL of patients undergoing orthodontic treatment in three different patient cohorts, independently from each other: 1. general orthodontic patients; 2. patients with cleft-lip/palate; 3. patients in combined orthodontic-orthognathic therapy. The first patient cohort – patients currently undergoing orthodontic treatment with fixed or removable appliances – was evaluated in a multicenter study at four different universities’ orthodontic departments at the Ludwig-Maximilians-University Medical Center (LMU) in Munich, the Johannes-Gutenberg-University in Mainz (JGU), the Medicine University of Hannover (MHH) and the Heinrich Heine University in Dusseldorf (HHU). 898 orthodontic patients (40.9% males and 50.6% females) participated anonymously. They anonymously answered the validated German version of the Oral Health Impact Profile questionnaire (OHIP-G14) online and additional questions related to demography (i.e. age, gender, insurance and immigration status), and general questions about the orthodontic treatment such as the reason for treatment, the type of appliance used and the duration of orthodontic treatment. Descriptive and explorative statistics (Mann-Whitney U-test, Pearson chi-squared test, multiple linear regression modeling) were applied to the complete patient cohort. To conform with the German insurance system (governmental vs. private), the patient cohort was additionally analyzed according to age (6…17 years vs. ≥18 years). The main findings can be summarized as follows: 1. The mean OHIP-G14 score for the total sample was 9.92  8.22. There was a statistically highly significant difference in this score between the 6 to 17-years old patients and the ≥18-years-old adults (p < 0.001). 2. The OHIP-G14 subscales “physical pain” (2.68 ± 1.92), “psychological discomfort” (1.70 ± 1.75), and “psychological disability” (1.53 ± 1.58) showed the highest scores. 3. Adult patients showed significant higher mean scores for the OHIP subscales “physical pain” (young: 2.49  1.85; adult: 3.11  2.02; p < 0.001), “psychological discomfort” (young: 1.47  1.59; adult: 2.24  1.96; p < 0.001), “psychological disability” (young: 1.33  1.39; adult: 1.99  1.88; p < 0.001) and the overall OHIP-G14 score (young: 8.78  7.27; adult: 12.56  9.59; p <0.001) than the patients 6-17 years old. 4. Using the OHIP score as a continuous outcome variable, multiple linear regression analysis was performed, adjusting for age group, gender, reason for orthodontic treatment, type of appliance, duration of treatment, insurance and the nationality/immigration status of the patient. a. Remarkable findings from multiple linear regression were: adults and females have worst quality of life during the treatment. b. The co-variate “reason for treatment” was the most influential one: aesthetic in combination with pain and others, aesthetic in combination with function, pain and others and the combination of function, pain and others without aesthetics were highly significant factors increasing the OHIP-G14 score in both age groups. c. In the younger patient group aesthetics in combination with function, pain, and others significantly increased the OHIP score. d. In adults, function and pain were negatively affecting OHRQoL. e. In comparison to removable appliances, fixed appliances also increased the patient’s OHIP score. f. German, adult patients with a private insurance showed a lower OHIP score and therefore had a better OHRQoL. To evaluate the second patient cohort 50 CLP patients (54.0 % males and 46.0 % females) were anonymously invited to participate in an online survey applying the validated German version of Children Perception Questionnaire (CPQ-G11-14). Like in the first project, demographic items and information on their orthodontic treatment were acquired. Descriptive and explorative statistics (Mann-Whitney U test, Kruskal-Wallis test) were applied. The main findings can be summarized as follows: 1. The CLP patients’ mean age was 13.4  5.1. 2. Regarding the CLP classification, 42.0 % of the participants had unilateral CLP and 26.0 % had bilateral CLP. The remaining patients had cleft lip or palate imperfection only. 3. Patient satisfaction with orthodontic treatment was very high (“very satisfied”, 54.0 %; “satisfied”, 40.0 %). 4. The registered frequencies of the CPQ-G11-14’s answers revealed “breathing through the mouth”, “unclear speech” and “reduced eating speed” as the most frequent problems. 5. The mean rate of the CPQ-G11-14 was higher in boys (28.4  16.26) than in girls (23.8  14.0). A similar pattern was found in almost every subscale, except for the subscale “oral symptoms” (boys 5.9  2.9; girls 6.2  3.4). 6. Explorative statistics showed, that syndrome-associated CLP patients showed the highest CPQ-G11-14 scores due to functional restrictions (subscale 2; p = 0.014). The third patient cohort consisted of 50 ortho-surgical patients (46.0 % males and 54.0 % females). They answered anonymously the German version of the Orthognathic Quality of Life Questionnaire (OQLQ-G). Additionally, demographic items and information on their orthodontic treatment were acquired. Descriptive and explorative statistics (Mann-Whitney U test, Kruskal-Wallis test) were applied. The main findings can be summarized as follows: 1. The ortho-surgical patients’ mean age was 28.0  8.7. 2. Seventy-eight percent of the study subjects reported problems in both jaws. Appearance and health were the main (58.0 %) reasons for treatment and/or surgery. 3. Their malocclusion classification/type was described as being class III by 32.0 % of the patients, with 6.0 % being associated with crossbite, whereas 30.0 % were class II (8.0 % associated with crossbite). 4. Most of the patients were “satisfied” (48.0 %) or “very satisfied” (44.0 %) with the orthodontic treatment. 5. The mean OQLQ-G score was statistically significant (p < 0.001) higher for females (50.2  14.3) than for males (31.1  16.0). These gender differences were also found in all four subscales, but only statistically significant in subscales 2-4. 6. Significant higher scores for the OQLQ-G overall score (p = 0.013) and its subscale scores “aesthetic” (p = 0.045) and “social aspects” (p = 0.016) were found in patients “being engaged/married” than those “being single”. 7. Patients reporting an improvement in self-esteem showed significantly increased OQLQ-G scores in the subscales “aesthetics” (p = 0.010), “social aspects” (p = 0.005) and the overall OQLQ-G score (p = 0.006).