Quality of Life in an Adolescent Orthodontic Population: Invisalign® versus Fixed Appliances

By

Richa Sharma

A Thesis Submitted to The Faculty of Graduate Studies of The University of Manitoba in partial fulfilment of the requirements of the degree of MASTER OF SCIENCE

Department of Preventive Dental Science Dr. Gerald Niznick College of Dentistry Rady Faculty of Health Sciences University of Manitoba Winnipeg, Manitoba, Canada

Copyright© 2020 Richa Sharma

1 Acknowledgments

This study was supported by the Dr. Gerald Niznick College of Dentistry Endowment Fund.

A sincere thank you to:

My supervisor, Dr. Robert Drummond, for being an approachable, supportive, and dedicated mentor throughout my studies.

My committee members, Dr. Robert Schroth, and Professor Mary Bertone for their guidance and support.

Dr. Milos Lekic for his assistance with the study design and data collection, as well as for his mentorship.

Dr. Robert Tate for not only the statistical analysis, but also for his time, encouragement, and dedication to my thesis.

2 Table of Contents

Abstract: ...... 6 Chapter 1: Introduction and Review of the Literature ...... 7 Background on Fixed Appliances and Invisalign® ...... 7 Adolescents ...... 8 Malocclusion ...... 9 Concept of Oral Health-Related Quality of Life ...... 10 Quality of Life Measures ...... 11 Indices of Treatment Need ...... 12 Perceived Need ...... 13 Expectations ...... 14 Satisfaction ...... 15 Motivation for Treatment ...... 17 Impact of Malocclusion on Emotional and Psychosocial Well-Being ...... 21 Bullying ...... 23 Oral Health and Functional Impact of Malocclusion ...... 24 Impact of Orthodontic Treatment on OHRQOL ...... 26 Impact of Orthodontic Treatment in Fixed Appliances or Invisalign® ...... 26 Psychosocial Impact of Fixed Appliances ...... 27 Functional Impact of Fixed Appliances ...... 28 Oral Health Impact of Fixed Appliances ...... 34 Impact of Invisalign® on OHRQOL ...... 35 Studies Comparing Fixed Appliances and Invisalign® ...... 37 Purpose ...... 42 General Objective ...... 43 Null Hypotheses ...... 43 Chapter 2: Materials and Methods: ...... 44 Study Sample ...... 44 Inclusion Criteria ...... 44 Exclusion Criteria ...... 44 Case Selection and Recruitment ...... 45 Study Questionnaire ...... 46 Satisfaction Measurement ...... 48 Statistical Analysis ...... 48 Test Groups ...... 49 Chapter 3: Results: ...... 50 Demographic Data ...... 50 Findings ...... 54

Chapter 4: Discussion ...... 61 Clinical Significance ...... 75 Considerations and Limitations ...... 75 Future Recommendations ...... 77

3

Chapter 5: Conclusion ...... 78 Revisiting the Null Hypotheses: ...... 78 References ...... 80 Appendices ...... 92 Appendix 1 ...... 93 Appendix 2 ...... 94 Appendix 3 ...... 95 Appendix 4 ...... 96 Appendix 5 ...... 97 Appendix 6 ...... 99 Appendix 7 ...... 100 Appendix 8 ...... 105 Appendix 9 ...... 122

List of Tables Table 1: Demographic Data ...... 50 Table 2: Summary of responses: All participants ...... 51 Table 3: Summary of significant results from each test group ...... 53 Table 4: Detailed summary of significant results from each test group ...... 53 Table 5: Summary of COHIP-19 Scores: Fixed Appliances Vs. Invisalign (All participants) ... 58 Table 6: Summary of quality of life, satisfaction and domain scores among all test groups ...... 59 Table 7: Summary of significant correlations (Fixed Appliances, All participants) ...... 60 Table 8: Summary of significant correlations (Invisalign®, All participants) ...... 60

List of Figures Figure 1: Comparison of satisfaction scores (All participants) ...... 56 Figure 2: Comparison of COHIP-19 mean domain scores (All participants) ...... 57 Figure 3: Responses to item 1 ...... 122 Figure 4: Responses to item 2 ...... 122 Figure 5: Responses to item 3 ...... 123 Figure 6: Responses to item 4 ...... 123 Figure 7: Responses to item 5 ...... 124 Figure 8: Responses to item 6 ...... 124 Figure 9: Responses to item 7 ...... 125 Figure 10: Responses to item 8 ...... 125 Figure 11: Responses to item 9 ...... 126 Figure 12: Responses to item 10 ...... 126 Figure 13: Responses to item 11 ...... 127 Figure 14: Responses to item 12 ...... 127 Figure 15: Responses to item 13 ...... 128 Figure 16: Responses to item 14 ...... 128 Figure 17: Responses to item 15 ...... 129 Figure 18: Responses to item 16 ...... 129 Figure 19: Responses to item 17 ...... 130 Figure 20: Responses to item 18 ...... 130

4 Figure 21: Responses to item 19 ...... 131 Figure 22: Responses to item 20 ...... 131 Figure 23: Responses to item 21 ...... 132 Figure 24: Responses to item 22 ...... 133 Figure 25: Responses to item 23 ...... 133 Figure 26: Responses to item 24 ...... 134 Figure 27: Responses to item 25 ...... 135 Figure 28: Responses to item 26 ...... 135 Figure 29: Responses to item 27 ...... 136 Figure 30: Responses to item 28 ...... 136 Figure 31: Responses to items 29 & 30- Fixed appliances group ...... 137 Figure 32: Responses to items 29 & 30- Invisalign® group ...... 137 Figure 33: Responses to item 31 ...... 138 Figure 34: Responses to item 32 ...... 138 Figure 35: Responses to item 33 ...... 139 Figure 36: Responses to item 34 ...... 139 Figure 37: Responses to item 35 ...... 140 Figure 38: Responses to item 36 ...... 140 Figure 39: Responses to item 37 ...... 141 Figure 40: Responses to item 38 ...... 141 Figure 41: Responses to item 39 ...... 142

5 Abstract

Objective: To investigate adolescent orthodontic patient experiences with fixed appliances compared to Invisalign® by means of a quality of life questionnaire.

Materials and Methods: Ethical approval was obtained by the University of Manitoba’s Health

Research Ethics Board. Adolescent patients between the ages of 11-18 from the University of

Manitoba Graduate Orthodontic Clinic and from four private practices in Winnipeg currently undergoing orthodontic treatment with either Invisalign® or fixed appliances were provided a questionnaire. Pearson's chi-squared test was used to evaluate whether the participants in the fixed appliances group answered each item differently than those in the Invisalign® group (p < 0.05), and unpaired t-tests (p < 0.05), were used to test for differences in mean satisfaction, quality of life, and domain scores.

Results: Overall, 74 patients (37 in each group) participated. No significant difference was noted in the mean quality of life, domain, or satisfaction score between the two groups. A significant difference was noted in the time taken to adjust to appliances with the Invisalign® group demonstrating faster adaption. Additionally, the fixed appliances group was 3.8 times more likely to report missing school because of their appliance (95% CI: 1.2, 12.5, p= 0.02) and 2.7 times more likely to report having difficulty eating certain foods compared to the Invisalign® group (95% CI: 1.1, 7.1, p= 0.04).

When the subgroup of females between the ages of 14-18 was analyzed, a higher proportion of the

Invisalign® group reported feeling attractive compared to the fixed appliances group.

Conclusion: The overall oral health- related quality of life of adolescent patients undergoing treatment in fixed appliances and Invisalign® for a minimum of six months is similar. Both groups expressed high satisfaction with treatment, and the majority would choose their current modality again.

6 Chapter 1: Introduction and Review of the Literature

Background on Fixed Appliances and Invisalign®

Today’s orthodontic patients have the option of two different treatment modalities: fixed orthodontic appliances and clear aligners. Fixed orthodontic appliances, also known as braces, have been the conventional modality for over a century (Ke, Zhu, and Zhu 2019).

Metal or tooth-colored ceramic brackets that possess specific features to control the three- dimensional position of the teeth are bonded to each tooth and wires are placed in the bracket slots to elicit movement. The wire is secured with a colored elastic or metal ligature, or with sliding doors in self-ligating brackets. While fixed appliances may be the most common treatment modality in adolescents (Azaripour et al. 2015), Invisalign® has become a popular treatment alternative due to the increasing esthetic demands of patients (Rosvall et al. 2009).

In 1945, Dr. H. D. Kesling described moving teeth without the use of bands, brackets and wires by using a flexible tooth positioning appliance and plaster models (Kesling 1945,

(Wong, Scholz, and Turpin 2002). However, this process was laborious and time-consuming.

In 1997, Align Technology introduced the Invisalign® appliance, which utilized computer technology combined with laboratory techniques, making Kesling’s proposal more practical

(Wong, Scholz, and Turpin 2002; Phan and Ling 2007). Invisalign® therapy corrects tooth malposition by a series of customized, removable clear polyurethane trays that fit over the entire surface of the teeth (Nedwed and Miethke 2005). Each aligner is designed to move the teeth about 0.25 to 0.3 mm and is worn over a period of 1-2 weeks (Phan and Ling 2007).

Excellent compliance is mandatory as the appliance must be worn for a minimum of 20-22 hours a day, and should only be removed to eat, drink and perform oral hygiene (Phan & Ling

2007, Invisalign®.com 2019). The choice of one treatment modality over the other may impact

7 the quality of life during treatment.

Adolescents

The World Health Organization defines an adolescent as a person between 10-19 years of age (World Health Organization 2019). Adolescents comprise the majority of orthodontic patients (Geoghegan et al. 2019; Javidi, Vettore, and Benson 2017). During this stage, individuals experience extensive physical, emotional, and psychological changes (Sharma et al. 2017), and they begin to acquire a unique personal identity (Proffit et al. 2019). This sense of identity includes the feeling of belonging to a larger peer group, along with the realization of being able to exist outside of the family (Proffit et al. 2019). Peers become important role models, and the opinions of parents and other authority figures are often rejected (Proffit et al.

2019). Adolescents are often concerned with improving their appearance and social attractiveness, and are aware of their dental image (Sharma et al. 2017). They are able to recognize crowding, spacing, and general irregularities in alignment (Samsonyanová and

Broukal 2014), and children as young as eight years old have similar criteria to adults when assessing their own physical attraction (Tung and Kiyak 1998).

An adolescent’s perception of their physical appearance is associated with their self- esteem (Veiga da Silva Siqueira et al. 2019). During this transition from childhood to adulthood, they may face pressures from peers or social media, and orthodontic treatment can directly affect their confidence (Twigge et al. 2016). The media’s unrealistic portrayal of celebrities can affect an adolescent’s self-perception and heavily influence their ideals of beauty and attractiveness (Al-Kharboush et al. 2017), especially with the large presence of social media in their lives today. As a result, these popular images can lead to self-criticism and dissatisfaction during their formative years (Kiyak 2008).

8 Bayat et al. (2013) interviewed a group of adolescents to investigate how their dental appearance affected their lives. Most of the participants were aware of the impact of media on society. They described that when someone famous corrects their irregular teeth, it sends a message that having straight teeth is important. The group felt that straight teeth and a beautiful smile would be a solution to many of their social problems. Based on the ideals to which they had been exposed, the adolescents reported evaluating other people’s teeth and comparing themselves. They considered a smile and teeth to be an essential component of facial esthetics and for assessing people. They also felt that they were being judged based on the appearance of their teeth, and would avoid smiling in social situations, or in photographs.

Undergoing orthodontic treatment was regarded as a way to feel more confident during their interactions with others, and this desire was stronger if their peers were undergoing treatment.

Adolescents believe that others are as concerned with their image as much as they are, and constantly feel as though they are being observed and criticized by those around them

(Proffit et al. 2019). Consequently, treatment with fixed appliances or Invisalign® may directly affect their self-esteem.

Malocclusion

Deviation from an ideal occlusion, or from an accepted societal norm is known as malocclusion. Many of these deviations are within the range of normal biologic variation

(Bayat et al. 2017). Dental malocclusions are very prevalent among children and adolescents worldwide (Ferrando-Magraner et al. 2019). The World Health Organization ranks malocclusion as third in prevalence among dental health problems, following dental caries, and periodontal disease, thus ranking third among dental public health priorities (Ferrando-

Magraner et al. 2019). Malocclusion can lead to physical and functional consequences such as

9 trauma, or difficulty chewing. It can also negatively affect a child’s emotional well-being by impacting self-esteem, confidence, and overall quality of life (Bayat et al. 2017).

Concept of Oral Health-Related Quality of Life

Over the years, there has been a paradigm shift in the definition of health from a medical model to a biopsychosocial model (Baiju et al. 2017). In 1948, the World Health

Organization Quality of Life Group (WHOQoLG) expanded the definition of health to describe not only the absence of disease, but also the state of complete physical, mental, and social well-being (Broder, McGrath, and Cisneros 2007). This definition can also be applied to oral health to include eating, talking, smiling, and general well-being (Baiju et al. 2017).

Locker (1988) described oral health as “a standard of the oral tissues which contributes to overall physical, psychological and social well-being by enabling individuals to eat, communicate and socialize without discomfort, embarrassment or distress and which enables them to participate in their chosen social roles fully.” Quality of life is considered to be a multidimensional concept that is influenced by many different factors. The WHOQoLG defines it as an individual’s perception of their position in life in the context of culture and value systems in which they live and in relation to their personal goals, expectations, standards and concerns (Broder, McGrath, and Cisneros 2007). It can also be described as a "sense of well-being derived from satisfaction or dissatisfaction with areas of life considered important for an individual" (Feu, Quintão, and Miguel 2010). The impact of oral health on one’s quality of life is referred to as oral health-related quality of life (OHRQoL). This can be further described as the functional impacts, psychosocial impacts and symptoms that occur as a result of diseases and disorders (Locker, Matear, and Jokovic 2002). Measuring OHRQoL is becoming an increasingly valuable evaluation in dentistry due to the contemporary

10 understanding that it is the patient as a whole who is being treated, and not just their dental condition alone (Baiju et al. 2017). Malocclusion is associated with OHRQOL, and it is generally accepted that orthodontic treatment can improve the quality of life by inducing positive physical, social, and psychological changes (Zhang, McGrath, and Hägg 2006).

A patient’s psychosocial well-being is an essential component of oral health, and it must be considered during treatment. In an effort to help improve one’s quality of life and to achieve shared decision-making, an orthodontist must understand and respect the patient’s values and perceptions. Patient-centred research helps reduce the knowledge and perception gaps between the patient and the orthodontist and provides evidence that is suitable for patients to understand (Hua 2019). Additionally, it can also be used to identify which treatment modality will benefit an individual patient based on their needs and expectations.

Quality of Life Measures

Two major instruments have been developed to measure OHRQoL in school-aged children: the Child Perceptions Questionnaire (CPQ) and the Child Oral Health Impact Profile

(COHIP). Reliability and validity have been established for both questionnaires (Jocovic et al.

2004; Broder and Wilson-Genderson 2012). However, the CPQ’s sensitivity and specificity in children requiring orthodontic treatment is questionable (Jocovic et al. 2004; Broder and

Wilson-Genderson 2012)

The most recently developed OHRQoL instrument and a refinement of the CPQ is the

COHIP. The COHIP is a 38-item questionnaire designed to measure OHRQoL reported by children and adolescents and is well known in dental research (Kragt et al. 2016). The COHIP has been used in many studies and is designed for use in a variety of different groups, including pediatric, orthodontic, and community-based samples (Broder and Wilson-

11 Genderson 2012; Kragt et al. 2016). Unlike the CPQ, this questionnaire contains both positively and negatively worded items to capture the positive impacts of treatment and the positive influence that oral health and the appearance of the face and teeth have on overall health and well-being (Broder and Wilson-Genderson 2007). This assessment of positive outcomes complies with the World Health Organization’s concept of health being more than just the absence of disease.

Indices of Treatment Need

Orthodontic treatment need can be defined as the degree to which a person requires orthodontic treatment owing to certain characteristics of their malocclusion, and due to the negative functional, oral health, psychosocial or esthetic impacts the malocclusion imparts on the individual (Bellot-Arcís, Montiel-Company and Almerich-Silla 2012). In order to estimate the treatment need for population groups, and to reduce the subjectivity associated with the evaluation of malocclusion (Borzabadi-Farahani 2011), occlusal indices measuring the severity of malocclusion are utilized (Proffit et al. 2019). There are a variety of indices including the Index of Orthodontic Treatment Need (IOTN), the Dental Aesthetic Index

(DAI), the Peer Assessment Rating (PAR), and the Index of Complexity Outcome and Need

(ICON) (Baram et al. 2019). However, because psychosocial and facial considerations play an essential role in defining orthodontic treatment need, it can be difficult to determine treatment need based on dental casts and radiographs alone (Proffit et al. 2019).

The most commonly used index accepted as the standard for measuring need is the

IOTN (Khandakji and Ghafari 2019). The IOTN’s reliability and validity has been demonstrated, and it has been shown to correlate reasonably well with clinicians’ judgments of treatment need (Proffit et al. 2019). This index classifies treatment need by identifying various

12 traits of malocclusion and grading them according to severity against a standard scale (Cure

2019). The IOTN has two parts: The Dental Health Component (DHC) and the Aesthetic

Component (AC). The DHC has five levels ranging from Grade 1 (no need) to Grade 5, (very great need). A grade is designated based on the severity of the worst single occlusal feature

(Khandakji and Ghafari 2019). The AC consists of a series of ten intraoral photos illustrating ten malocclusions ranging from the most attractive dental appearance to least attractive, reflecting the patient’s psychosocial need for orthodontic treatment (Khandakji and Ghafari

2019; Baram et al. 2019). Baram et al. (2019) reported that only the IOTN-AC showed evidence of the psychosocial impact of malocclusion out of the four most commonly used indices. Khandakji and Ghafari (2019) showed that the IOTN-DHC demonstrated a stronger correlation with treatment need than the IOTN-AC, the ICON, and the PAR. In this study, the

IOTN-DHC was used to assess the eligibility requirements of the participants.

Perceived Need

Both the perceived need and demand vary with social, geographic, and cultural conditions (Proffit et al. 2019). Patients and dental professionals differ in their evaluation of the severity of malocclusion and treatment need (Hunt et al. 2002). That is, perceived treatment need does not always reflect normative treatment need (Ghijselings et al. 2014).

Traditional indices do not reflect patient perceptions of treatment need (de Oliveira and

Sheiham 2003) and do not provide any insight on how malocclusion impacts the quality of life with regard to function and psychosocial well-being (Kok et al. 2004).

Interestingly, the psychological distress caused by one’s dental or facial appearance is not always directly proportional to the anatomic severity of the problem and is strongly influenced by a person’s self-esteem (Proffit et al. 2019). Some children have strong levels of

13 concern with minor malocclusions, yet others are tolerant of severe occlusal problems (Agou et al. 2008). In fact, it has been reported that more adolescents with good occlusion feel dissatisfied with the appearance of their teeth (Ghijselings et al. 2014). Often, patients with high treatment demands have a low normative need and vice versa (Baram et al. 2019).

In a study by de Oliveira and Sheiham (2003), the authors found that 26.8% of children with no treatment need or low need as assessed by the IOTN still reported oral health impacts.

An individual with high self-esteem will have a higher level of self-perceived attractiveness of their face and more positive feelings towards the dentofacial region (Ghijselings et al. 2014).

Therefore, it is fair to speculate that the relationship between reported self-perceived treatment need and malocclusion is most likely influenced by other psychological factors (Ghijselings et al. 2014).

Expectations

Expectation is an important psychological factor that often influences a patient’s evaluation of the quality of their treatment and their overall satisfaction with treatment. This concept has an even greater influence in long-term treatments where esthetics are of key importance (Yao et al. 2016). Patients may assess treatment effectiveness through the comparison of their expectations with the actual experiences, and any difference between their expectations and reality may lead to dissatisfaction and poor compliance (Yao et al. 2016).

Taylor et al. (2009) investigated the association between treatment expectations and experiences, and quality of life. The authors were unable to find an association between the degree of improved occlusion after treatment as judged by an orthodontist, and patients’ perceived improvements in their oral function, appearance, social lives, or general health.

Post-orthodontic patients reported as much improvement as they had expected independent of

14 the professionally assessed occlusal improvement. This may imply that greater improvement in occlusion may not necessarily influence a patient’s personal perception of the improvement achieved from orthodontic treatment (Taylor et al. 2009).

Yao et al. (2016) conducted a systematic review to assess the role of patient expectations on their treatment outcome, satisfaction, cooperation and compliance. The authors noted that both parents and children appeared to possess basic knowledge and practical expectations about orthodontic treatment, but parents seemed to have more realistic expectations with regard to the impact of treatment. Adolescents may be more easily influenced by the notions of beauty represented in the media, causing them to have potentially unrealistic treatment expectations, coupled with underestimating the complexity of procedures

(Yao et al. 2016). The authors also investigated whether females had higher expectations than males, but this hypothesis could not be confirmed. However, background factors such as ethnicity, education level and different health systems were postulated to be potential factors influencing patients’ expectations. Overall, the authors concluded that the role of expectations on orthodontic treatment, and in relation to satisfaction has not been investigated at present and that future studies are recommended. In this study, the authors investigated and compared expectations between the two treatment groups.

Satisfaction

While many questionnaires use the term satisfaction to evaluate the outcome of orthodontic treatment, this concept is considered ambiguous, and not much is known regarding its validity. The major aim of orthodontic treatment is to have a satisfied patient at the end of treatment (Bos Vosselman, Hoogstraten et al. 2005). Greater patient satisfaction reflects better quality of care, resulting in improved OHRQoL. Research has shown that after treatment, only

15 34% of orthodontic patients were totally satisfied, 62% were relatively satisfied, and 4% were dissatisfied (Al- Omiri and Alhaija 2006).

The patient’s perspective and expectations must be considered when investigating satisfaction with treatment. Factors associated with treatment satisfaction may be related to the overall experience such as being seen on time, difficulty finding parking, gentleness of the operator, friendliness of the office environment, and other aspects of the treatment process

(Vig et al. 2007). It has also been reported that the more excited patients are about their outcome before treatment, the more satisfied they are after treatment (Anderson, Arruda, and

Inglehart 2009). Pain and discomfort during orthodontic treatment have also been shown to impact a patient’s overall satisfaction (Krukemeyer, Arruda, and Inglehart 2009). The doctor- patient relationship has also been found to be an important contributing factor (Bos et al. 2005;

Pacheco-Pereira, Brandelli, and Flores-Mir 2018).

Yassir, McIntyre, and Bearn (2019) performed an overview of systematic reviews to investigate the impact of fixed appliances on patient perceptions before, during, and after treatment. The majority of the studies were based on an adolescent patient population. Based on the available literature, the authors concluded that neither age, gender or ethnicity could be related to treatment satisfaction.

A person’s individual personality also plays a role in their satisfaction and compliance with treatment. Al-Omiri and Alhaija (2006) found that patients who scored average or high on the trait of neuroticism tended to be more dissatisfied with their treatment. Furthermore, patients seeking orthodontic treatment for relatively minor malocclusions may express more dissatisfaction with their treatment outcome. Barker, Thomson, and Poulton (2005) reported that those who scored high in the impulsivity, stress-reaction, or social isolation domains of

16 their multidimensional personality questionnaire were more likely to be dissatisfied with their orthodontic outcome. Therefore, it is essential for the orthodontist to understand certain aspects of a patient’s personality before commencing treatment and to fully understand the treatment goals in order to reduce potential dissatisfaction after treatment.

Measuring patient satisfaction can be challenging as it is difficult to define the complex concept of satisfaction and because of the various potential confounding factors that can lead to measurement error (Voutilainen et al. 2016). The visual analogue scale (VAS) is a simple and frequently used method that has shown good reliability and validity (Brokelman et al.

2012). Unlike a Likert scale, a VAS does not offer any predefined options when asking to evaluate satisfaction. Instead, the respondent is asked to mark a position on a line between the upper and lower endpoints, which best represents their opinion (Voutilainen et al. 2016). In comparison to a Likert scale, a VAS has been shown to be less vulnerable to bias from confounding factors, and it also requires less time to complete (Voutilainen et al. 2016).

In this study, a VAS was used to evaluate the respondent’s overall satisfaction with their treatment modality.

Motivation for Treatment

Motivation can be defined as a concept that describes the conscious or unconscious stimulus for action toward a desired goal and can be either external or internal. External motivation results from influence from others such as family, friends, or schoolmates, whereas internal motivation comes from a person’s own desire for treatment (Pabari, Moles, and

Cunningham 2011). Motivation for treatment is derived from a variety of sources. The desire to improve one's quality of life, the influence of media, or a referral from a dental professional all play a role. The self-perception of one’s dental appearance and the decision to have

17 orthodontic treatment is influenced by a wide array of social, cultural, psychological and personal factors (Leandro S. Marques, Pordeus, et al. 2009). Determining and understanding this motivation and maintaining it throughout treatment is essential for a successful result.

When this motivation is lost, a patient’s compliance will deteriorate, which can lead to early termination of treatment or a compromised outcome (Pabari, Moles, and Cunningham 2011).

In today’s world of social media and increased image consciousness, esthetic concerns are high, and an individual’s teeth and smile are considered essential components of facial attractiveness (Kiyak 2008). Researchers have consistently found that facial attractiveness affects success in school and employment settings. Attractive children and adults generally receive better academic and performance reviews than unattractive individuals, which results in a higher level of confidence for those who are deemed to be attractive (Kiyak 2008). The message that beauty is a positive attribute is apparent in the media and society in general.

Models and celebrities often display perfectly aligned teeth that are bleached and have ideal proportions. Television heroes tend to have attractive teeth, while the villains possess crooked and discolored teeth (Kiyak 2008). Adolescents struggling to find their identities may find it challenging to resist the influence of media, professionals, and reference groups in their decision to undergo orthodontic treatment (Trulsson et al. 2002).

The oral-facial region is considered an area of significant concern because it is the primary source of vocal, physical, and emotional communication. This area also draws the most attention from others during interpersonal interactions. Thus, not surprisingly, esthetic improvement tends to be a major factor in seeking orthodontic treatment (Kiyak 2008; Daniels,

Seacat, and Inglehart 2009; Marques, Filogônio, et al. 2009; Abdullah, Yassin, and Zamzam

2001; Wȩdrychowska- Szulc and Syryńska 2010; Yassir, McIntyre, and Bearn 2019; de

18 Oliveira and Sheiham 2003; Geoghegan et al. 2019). Even for children as young as 8 years old, the esthetic and social aspects of OHRQoL are the main desire to seek orthodontic treatment (Kiyak 2008). Kiyak (2008) found that in patients seeking orthodontic treatment, the main area of concern with regard to body image was teeth. While other parts of the body were consistently rated moderate to high, the face was rated lower, particularly for the appearance of the teeth and mouth. Thus, straight teeth and an attractive smile may be more important to laypersons than improved oral function (Kiyak 2008).

Compromised esthetics because of a malocclusion has been shown to have a significant impact on the quality of life of children (Marques et al. 2006). Children and their parents believe that cosmetic improvement through orthodontic treatment will improve their social acceptance and self-esteem (Johal, Cheung et al. 2007). De Oliveira and Sheiham (2003) reported that functional issues were less often a reason adolescents sought treatment compared to the desire to improve their appearance. An American study of 227 patients and their parents concluded that esthetic concerns accounted for 93.4% of the children's motivation for seeking treatment. Furthermore, the authors also found that patients with greater motivation before treatment had better compliance during treatment (Daniels, Seacat, and Inglehart 2009).

In a survey of 403 adolescents by Marques, Pordeus et al. (2009), it was reported that

78% of children expressed the desire to receive orthodontic treatment, and 72% believed that it could improve their quality of life. Other motivational factors included: their parents’ experience with orthodontics (3%), the belief that that orthodontic treatment would make it easier to get a job in the future (41%), to find a romantic partner (27%), for their style or a status symbol (22%), and due to the teasing they endured from classmates due to the appearance of their teeth (12%).

19 Wȩdrychowska-Szulc and Syryńska (2010) also found that the main motivation for treatment in 674 children between the ages of 7-18 was to improve esthetics. They also reported that more patients expressed dissatisfaction with the appearance of their teeth as they got older, and that females tended to be more concerned with their appearance than males.

Parental influence plays a strong role in the motivation for orthodontic treatment. In fact, a mother’s perception has been shown to be the primary reason families seek orthodontic care (Miner et al. 2007). In a study conducted by Benson, O’Brien, and Marshman (2010), 90 adolescents between the ages of 11-14 and their mothers independently completed a questionnaire. The authors reported that the mothers expressed more dissatisfaction with the appearance of their children’s teeth than their children themselves. The mothers also overestimated the emotional impact of the appearance of their child’s teeth. Wȩdrychowska-

Szulc and Syryńska (2010) reported that 77% of parents sought treatment for their children due to irregular positioning of teeth, wanting their children to look pretty (54%), and 64% feared being accused of neglecting their parental duties from their children in the future if they did not seek treatment. In a 1993 study by Kilpeläinen, Phillips, and Tulloch, 85% of parents reported that they sought treatment due to the appearance of their child’s teeth, 73% because of a dentist’s advice, 46% because of their facial appearance, 16% because of their speech, and

44% because of their child being teased due to their teeth. Pratelli, Gelbier, and Gibbon (1998) reported that parents who had a history of orthodontic treatment, currently desired treatment themselves, or who regretted not having treatment earlier, expressed a desire for their children to have treatment.

The general dentist also plays an essential role in motivating patients to seek orthodontic treatment (Geoghegan et al. 2019). Daniels, Seacat, and Inglehart (2009) reported

20 that the majority of patients and parents stated that their general dentist motivated them to have treatment. The authors also found that the children who reported being the main motivating factor for seeking treatment were also more motivated for treatment than those who did not report themselves as being the main motivating factor. This may show an association between an adolescent’s interest in seeking treatment and their motivation during treatment (Daniels,

Seacat, and Inglehart 2009).

Overall, the literature supports that the main motivation to undergo orthodontic treatment in adolescent patients appears to be the desire to improve their appearance and fulfil social norms regarding dental esthetics, which reflects the importance of image in today’s society. These motivations are not just cosmetic; they can have a major impact on the quality of life (Proffit et al. 2019). Patients also seek treatment to improve their psychosocial health, in addition to their oral health and function. In this study, the authors investigated and compared the motivations for treatment in the fixed appliances and Invisalign® group.

Impact of Malocclusion on Emotional and Psychosocial Well-Being

When a person avoids smiling, laughing, or talking because of the appearance of his or her teeth, the psychosocial impact of malocclusion can be appreciated (Laniado, Oliva, and

Matthews 2017). Patel, Tootla and Inglehart (2007) suggested that a child’s perception of their smile relates to the psychological aspect of their oral health-related quality of life.

Additionally, the way a child smiles may also reflect the social aspect of their OHRQoL, especially in relation to how comfortable they feel during social interactions at school or during activities with other children.

In a study of 1134 adolescents, da Rosa et al. (2016) showed that malocclusion had a negative effect on the emotional and social well-being aspects of OHRQoL. Furthermore,

21 children with a definite malocclusion reported lower levels of happiness than children with no malocclusion or a mild form.

A systematic review conducted in 2015 included six studies involving child and adolescent populations. Two studies reported that increased orthodontic treatment need was related to poor OHRQoL. Furthermore, two of the studies concluded that the main aspects of

OHRQoL that were primarily affected by malocclusion were emotional and social well-being

(Dimberg, Arnrup, and Bondemark 2015). A systematic review and meta-analysis by Kragt et al. (2016) included 40 cross-sectional studies assessing the association of malocclusion with

OHRQOL in children. The authors found that children with malocclusion were 1.74 times more likely to have an impact on OHRQOL compared to children without malocclusion. The authors also demonstrated the influence of the patients’ cultural environment. Kragt et al.

(2016) reported that children with malocclusion were more likely to report decreased

OHRQOL than children without malocclusions among almost all of the countries reviewed.

Certain characteristics of malocclusion may have a greater impact on the quality of life than others. Tessarollo, Feldens, and Closs (2012) reported that a maxillary anterior malalignment ≥ 3mm and a mandibular anterior malalignment ≥ 2mm were among the greatest reasons for dissatisfaction with one’s dental appearance. A study by Johal et al. (2007) of 90 adolescents between the ages of 13-15 and their parents in the United Kingdom revealed that spaced dentition and increased overjet negatively affected the quality of life of both the children and their parents. In a Brazilian study of 270 children between the ages of 8-10, it was found that malocclusion in the anterior region can negatively impact a child’s psychosocial well-being (Dutra et al. 2018). In the study by Anthony, Zimba, and Subramanian (2018) of

384 Zambian adolescents between the ages of 12-14, spacing, a central diastema, and

22 crowding were most prevalent malocclusions that resulted in an inverse association with

OHRQoL. In the systematic review by Dimberg, Arnrup, and Bondemark (2015), four studies revealed that severe malocclusions (mainly anterior crowding, generalized spacing, or a large overjet) negatively impacted OHRQoL. One of the studies revealed a negative effect of malocclusion because of anterior spacing or increased overjet, even in children as young as 8-

10 years old. Children with unesthetic occlusal traits can become targets for harassment and teasing by their peers (Johal et al. 2007), further impacting their psychosocial health.

Bullying

Bullying in adolescence is a global phenomenon with a reported prevalence ranging from 5% to 58% worldwide (Al-Omari et al. 2014). Bullying can be described as a power imbalance between the victim and the aggressor where the victim is repeatedly and intentionally mistreated by one or more people (Seehra et al. 2011). The victim is subjected to direct or indirect forms of aggression. Direct actions include physical and verbal abuse, such as being hit, insulted or threatened. Indirect forms involve social exclusion and gossiping (Seehra et al. 2011).

Al-Omari et al. (2014) surveyed 920 children between the ages of 11-12. The first part of this study reported that the prevalence of bullying was 47% and that teeth were the physical feature most frequently targeted for bullying. The second part of the study found that children who were bullied due to their dental features had a poorer OHRQOL. Seehra et al. (2011) surveyed 336 children between the ages of 10-14. Forty-three participants (12.8%) revealed that they had been bullied at least two times in the past two months. Bullied children with malocclusion also reported significantly lower levels of social and athletic competence, and lower self-esteem compared to non-bullied children. This group also reported more oral

23 symptoms, functional issues, and an overall poorer OHRQoL compared to both non-bullied participants and to a sample of children with normal occlusion. When their malocclusion was assessed using the IOTN, bullied children had a higher need for treatment.

Given that negative comments about one’s dental appearance have been reported to be more hurtful compared to comments about other physical features, one can appreciate how a child who is bullied due to malocclusion is affected emotionally and socially (Seehra et al.

2011). In fact, when children were assessing their appearance, their teeth were a feature they mentioned they would change first (Johal et al. 2007). Wearing orthodontic appliances may result in a child being bullied, and there may be a difference in the psychosocial impact on adolescents in fixed appliances compared to those in Invisalign®.

Oral Health and Functional Impact of Malocclusion

Adolescents with malocclusion may express the desire to improve their oral health and function when seeking treatment. The affects on long term dental health and function are often speculated disadvantages of malocclusion (Benson, Javidi, and Dibiase 2015). There is some evidence to support that a crowded dentition may make it more difficult to maintain good oral hygiene, and a link between increased overjet and greater plaque scores has been reported.

While there is no direct link between malocclusion and an increase in caries or periodontal disease, certain traits such as a traumatic overbite, or an anterior crossbite with a mandibular shift can lead to periodontal damage (Benson, Javidi, and Dibiase 2015). Malocclusion has also been associated with a risk of dental injury. A recent meta-analysis of observational studies concluded that an increased overjet might double or even triple the risk of dentoalveolar trauma (Petti 2015).

Some patients express having difficulty eating due to their malocclusion. It has been

24 shown that a normal occlusion improves chewing efficiency and overall function. However, depending on the severity, its effect on everyday life is debatable (Benson, Javidi, and Dibiase

2015). In a literature review by Zhang, McGrath, and Hägg (2006), the authors found that without orthognathic surgery, conventional orthodontics alone generally does not improve masticatory capability.

Since certain sounds are made by placing the tongue against the upper incisors, it seems logical that certain types of malocclusions could be the cause of some speech disorders.

However, there is no strong evidence to support that orthodontic treatment will lead to resolution without combining treatment with speech therapy (Benson, Javidi, and Dibiase

2015).

Although some studies have shown associations between signs and symptoms of temporomandibular disorders and occlusal traits such as anterior openbite, crossbites and increased overjet, the correlations are weak and do not prove causation (Benson, Javidi, and

Dibiase 2015). Temporomandibular disorders are a complex group of conditions with a multifactorial etiology, and orthodontic treatment has not been shown to cause dysfunction or improvement (Benson, Javidi, and Dibiase 2015).

Overall, there is little evidence that malocclusion leads to any long term health issues

(Benson, Javidi, and Dibiase 2015). Many traditional beliefs regarding the oral health implications of malocclusion are now considered inconclusive and are unsupported by the literature (Javidi, Vettore, and Benson 2017). While recent systematic reviews have reported that malocclusion has a negative impact on OHRQoL (Liu, McGrath, and Hägg 2011,

Dimberg, Arnrup, and Bondemark 2015), when the individual domains are explored, the functional limitations and oral symptoms domains do not improve greatly with treatment

25 (Javidi, Vettore, and Benson 2017).

Impact of Orthodontic Treatment on OHRQOL

In a recent systematic review by Ferrando-Magraner et al. (2019), ten studies were assessed to evaluate changes in the quality of life of adolescent patients after orthodontic treatment. One study showed that adolescents who had previous orthodontic treatment reported less oral health impacts on daily life activities such as eating, talking and smiling compared to those who never had treatment (de Oliveira and Sheiham 2003). Most of the studies reported a significant improvement in OHRQoL once treatment was completed. The exception was the study by Benson, Da’as et al. (2014) that reported that although there was a slightly greater improvement in the overall quality of life after treatment, the difference was not statistically significant.

A recent systematic review and meta-analysis by Javidi, Vettore, and Benson (2017) assessed the impact of orthodontic treatment on the OHRQoL of adolescents under the age of

17 years. The authors concluded that OHRQoL improves moderately after treatment and that the emotional and social well-being dimensions are impacted in particular. Since malocclusion has been shown to significantly impact these two dimensions, it is reassuring to see that orthodontic treatment leads to their improvement (Javidi, Vettore, and Benson 2017).

Impact of Orthodontic Treatment in Fixed Appliances or Invisalign®

It is generally accepted that in order to obtain an improvement in the quality of life at the end of orthodontic care, patients must endure some treatment-related side effects (Liu,

McGrath, and Hägg 2011) such as pain and discomfort, appliances breaking, ulcers, gingivitis, problems eating and speaking, difficulty with oral hygiene, as well as some psychosocial

26 effects. Different impacts may be experienced depending on whether treatment is rendered with fixed appliances or Invisalign®.

Psychosocial Impact of Fixed Appliances

Due to the visibility of fixed appliances and potential effects on speech, an individual’s self-confidence may be impacted, especially during social interactions when attention is focused on the face and mouth (Sergl, Klages, and Zentner 2000). Some patients express embarrassment or feel that they are being teased by their peers because of the appearance of their orthodontic appliances (Brown and Moerenhout 1991). This can lead to shyness and a lack of confidence when smiling (Sergl, Klages, and Zentner 2000; Costa et al. 2011). Chen,

Wang, and Wu (2010) reported that patients expressed feeling self-conscious and embarrassed during treatment. However, treatment still led to an increase in self-concept and a decrease in negative social experiences overall.

According to the more recent study by Seehra, Newton, and Dibiase (2013), orthodontic appliances have become more socially acceptable within the adolescent age group.

At one time, there was a certain stigma associated with being the only one in a peer group wearing fixed appliances. Now that orthodontic treatment has become so common, individuals who are not in braces may feel a loss of status, and unnecessary treatment may be requested in order to socially integrate (Proffit et al. 2019).

Patel et al. (2010) also reported that teenagers viewed fixed orthodontic appliances as being part of a normal dental appearance, and no social judgments were made solely because of the appliances. However, 67% of respondents still proposed a nickname for images shown of children in fixed appliances including: metal mouth, tinsel teeth and tin grin (Patel et al.

2010). Due to the widespread use of fixed appliances today, adolescents undergoing

27 orthodontic treatment may be considered normal by bulliers, and the favorable treatment effects and the appliances themselves may distract from the underlying malocclusion and dental appearance. Furthermore, the process of undergoing treatment and addressing a malocclusion may instill confidence and empower an individual, making them stronger against further bullying (Seehra, Newton, and Dibiase 2013). This concept is supported by Zhang,

McGrath, and Hägg (2008) and by Abreu et al. (2014) who reported an improvement in emotional well-being during orthodontic treatment with fixed appliances.

Functional Impact of Fixed Appliances

Orthodontic treatment can understandably be an uncomfortable experience.

Orthodontic appliances are foreign objects placed in a sensitive area of the body, leading to physical and psychological discomfort (Marques et al. 2014). Children and parents anticipate pain, discomfort, embarrassment, and difficulties related to eating, speaking and cleaning teeth when being treated with fixed appliances (Sayers and Newton 2007). Pain is a crucial aspect of orthodontic treatment that can affect diet, oral hygiene, sleep and general well-being (Marques et al. 2014). It is also a leading factor of noncompliance and for missing appointments, which can compromise the treatment outcome (Krukemeyer, Arruda, and Inglehart 2009). According to the literature, 90% of orthodontic patients state that their treatment was painful, and 30% considered discontinuing treatment early due to pain (Rakhshan and Rakhshan 2015). Over

90% of patients report pain during the first 24 hours after placement of fixed appliances, and analgesic consumption to alleviate orthodontic pain is common. In a study by Fleming et al.

(2009), up to 60% of adolescent patients reported requiring analgesics for the first week following the placement of fixed appliances with symptoms subsiding within seven days.

Krukemeyer, Arruda, and Inglehart (2009) investigated the pain experiences of 116

28 adolescent patients in fixed appliances and found that 18% reported experiencing pain during appointments, and 12.6% stated that the pain from their appliances affected their daily lives.

Over half of the participants (58.5%) reported that they had pain for a few days after an appointment, and 21.9% stated that the pain led them to change their diet. Patients also reported being unable to brush and floss effectively. Additionally, the authors found that orthodontists underestimated the amount of pain experienced by their patients, and there was a generalized lack of pain control utilized by patients despite significant reports of discomfort.

Johal, Fleming, and Al Jawad (2014) described an increase in pain experience during mastication following the placement of fixed appliances over a period of up to three months.

The authors also found a significant difference between the treated group and the control in the oral symptoms and functional limitation domains of the CPQ at both the four to six-week follow-up, and at the three-month follow-up, likely due to pain, and oral health issues such as gingivitis, ulceration and speech problems. Although the overall OHRQoL in the treatment group deteriorated during the initial weeks of treatment, they recovered back to baseline levels after three months, reflecting potential adaptation to treatment.

Marques et al. (2014) analyzed the impact of fixed appliances on the daily lives of 272 adolescents between the ages of 9-18 who were in treatment for a minimum of six months.

Discomfort associated with fixed appliances was significantly associated with tooth mobility, halitosis, impaired taste, bleeding gingiva and with difficulties associated with eating, oral hygiene and speech. The prevalence of discomfort due to fixed appliances was 16%, and

15.9% reported a negative impact on daily activities. Interestingly, the participants did not cite pain as having a negative influence on their quality of life. This may be due to adaptation as treatment progresses, and because pain may stop being the focus of their attention over time

29 (Marques et al. 2014).

Feu et al. (2013) assessed 284 subjects between the ages of 12-15 and concluded that patients’ OHRQoL deteriorated during treatment due to functional limitations and physical pain at the one-year follow-up. However, their overall ORHQoL improved significantly following treatment. Similarly, de Oliveira and Sheiham (2003) reported that adolescent patients who were currently in treatment for at least six months were more likely to report one or more negative dental impacts on their daily lives compared to those who had already completed treatment.

Zhou et al. (2014) reported that the overall OHRQOL was negatively impacted until approximately one month after the placement of fixed appliances. After one week, the impact on physical pain, psychological discomfort, and physical limitations was the most severe.

Overall, the patients’ OHRQoL was worse before and during treatment, compared to when orthodontic treatment was completed. Costa et al. (2011) also reported that children between the ages of 11–14 in fixed appliances were 1.66 times more likely to have a worse OHRQoL than controls. The authors also found that female adolescent patients in fixed appliances were

1.8 times more likely to report a negative impact on their on OHRQoL compared to male adolescents. Similar findings were found by Corradi-Dias et al. (2019) during the first six months of treatment.

Mandall et al. (2006) investigated the impact of fixed appliances on the quality of life of adolescents between the ages of 10-18 who had been in treatment for at least six months.

The authors reported that the patients expressed fairly low impacts on esthetics, functional limitations, pain, diet, and oral hygiene at their first visit. There was no significant improvement noted in these factors over time. The authors also found that the younger patients

30 in their sample reported less impacts of the fixed appliances on their daily life and that they they may be more adaptable.

In the 2007 study by Bernabé, Sheiham, and De Oliveira (2008), the authors reported that approximately 25% of adolescents between the ages of 15-16 in fixed appliances reported negative impacts on their OHRQoL, with the most affected functions being eating and speaking. These findings are also supported by Mandall et al. (2006) and Chen, Wang, and Wu

(2010) who reported that pain and chewing impairment were the most challenging issues during the first month after bonding. Sergl, Klages, and Zentner (2000) reported that the short- and long-term functional impacts of wearing appliances were on the feeling of oral constraint and on speech and swallowing. These findings were also corroborated by Khattab et al. (2013).

Zhang, McGrath, and Hägg (2008) assessed 217 Chinese children undergoing treatment with fixed appliances during the first six months of treatment. The authors reported more impacts on the oral symptoms and functional limitations domains of the CPQ compared to pre-treatment findings including: bad breath, pain, mouth sores, food packing in between teeth, difficulties chewing and speaking, and taking longer to eat a meal. Overall, patients experienced poorer OHRQOL compared to pre-treatment scores due to pain and psychological discomfort, suggesting that treatment with fixed appliances had a negative affect on overall quality of life (Zhang, McGrath, and Hägg 2008). Chen, Wang, and Wu (2010) also reported that patients undergoing orthodontic treatment with fixed appliances exhibited a poorer

OHRQoL compared to pre-treatment OHRQOL, especially during the first week with pain and discomfort being at the highest level. Reports reflecting a negative impact on function included: ‘‘had a painful aching in the mouth’’ (42.79%), ‘‘found it uncomfortable to eat any food’’ (51.35%), and ‘‘had an unsatisfactory diet’’ (33.78%). However, the authors did not

31 note a difference between the pre-treatment OHRQoL and the OHRQoL measured at the one- month follow-up, despite continued compromises with physical, social and psychological discomfort. This indicates that there may be a decrease in discomfort, or an adaptation to treatment (Chen, Wang, and Wu 2010).

Costa et al. (2016) assessed the OHRQOL in 327 adolescents between the ages of 11-

14 undergoing treatment with fixed appliances. The main finding was that adolescents in fixed appliances were 4.88 times more likely to report a negative impact on OHRQoL than controls.

All four domains of the CPQ (oral symptoms, functional limitations, emotional well-being and social well-being) were significantly worse. The authors concluded that the main functional effects of fixed appliances include pain, discomfort, and difficulty eating and speaking.

The majority of patients report pain while eating food which can impact their diet

(Krukemeyer, Arruda, and Inglehart 2009). Carter et al. (2015) reported that orthodontic patients in fixed appliances between the ages of 11-14 expressed difficulty chewing, being messy with food, taking longer to finish a meal, and having restricted food choices.

Johal et al. (2013) investigated whether pain, analgesic consumption, or dietary advice provided by the clinician would be a predictor of changes in fat percentage or dietary behaviour in adolescents during the first three months of treatment with fixed appliances.

During their first checkpoint at six weeks, they found that 66% of patients reported difficulty eating due to pain, 54.7% reported eating less snacks, and 49.1% said they had to cut their food into pieces or cook it in an alternative manner. These numbers dropped to 54.7%, 39.6% and 41.5% respectively at the three-month follow-up. While 35.8% agreed that having braces resulted in them eating less healthy at the six-week follow-up, this number increased to 43.4% by three-months. In both follow-up periods, the majority of patients reported eating less sticky

32 and hard foods. Overall, the authors found that pain or analgesic consumption did not significantly affect dietary intake, body mass index, or body fat percentage in patients treated with fixed appliances.

Al-Jawad et al. (2011) also investigated the dietary intake and behaviour of 10 adolescent patients four to six weeks after the initial placement of fixed appliances. With regard to pain, all patients reported pain and discomfort after being bonded, ranging from one day to two weeks. In addition, pain levels ranging from mild to severe were reported. The site of the pain was variable, but was mainly localized to the teeth. With regard to eating, the majority of patients reported difficulty chewing, and all of the patients reported a change in diet as a result of their fixed appliances. Patients also reported eating less, choosing softer foods, and altering their method of food preparation. Many also opted for different foods due to certain types of getting stuck in the appliance, resulting in difficulty maintaining good oral hygiene. Another common reason for a dietary change was based on the instructions provided by the orthodontist, such as avoiding hard foods and those with high sugar content.

Some patients also complain of speech problems due to their braces (Paley et al. 2016).

Paley et al. (2016) investigated the impact of fixed appliances on speech and found that 44% of patients did not express difficulty, 39% were temporarily affected and were able to adapt within two months, and 17% displayed persistent speech errors at two months. Sibilant sounds were affected most often, particularly /s/. The authors concluded that potential speech issues depend on the severity of the malocclusion to a certain extent.

Overall, it can be concluded that adolescents undergoing orthodontic treatment with fixed appliances are likely to report a variety of negative impacts affecting their overall quality of life.

33 Oral Health Impact of Fixed Appliances

Patients undergoing orthodontic treatment endure many oral health-related impacts.

Ulcerations and mucosal damage is a common finding in patients with fixed appliances.

Although mucosal lesions are painful and uncomfortable, they tend to heal quickly due to the quick turnover of oral mucosa in young and healthy orthodontic patients (Baricevic et al.

2011). Baricevic et al. (2011) compared 60 patients in fixed appliances to 51 controls and found that mucosal lesions were present more often in the treatment group. The most common findings were gingival inflammation, erosion, ulceration, and contusion. Interestingly, the subjects in the treatment group had better oral hygiene, even though it is more challenging to maintain good oral hygiene due to trapped food and oral debris.

Many patients in fixed appliances complain of having bad breath. When fixed orthodontic appliances are bonded, plaque accumulation and proteins from gingival crevicular fluid and saliva increase, which raises the nutrients available for microorganisms that generate volatile sulphur compounds that can cause halitosis (Abdulraheem et al. 2019). Based on a recent systematic review of three randomized controlled trials, the authors found contradicting evidence regarding whether there was an increase in the amount of volatile sulphur compounds during treatment with fixed appliances. In the two studies that showed an increase, the levels were not high enough to cause halitosis. The authors also compared conventional brackets and self-ligating brackets and found no difference in the increase of volatile sulphur compounds or in the development of halitosis.

Orthodontic brackets interfere with the effective removal of plaque, thereby increasing the risk of gingivitis and making brushing and flossing more difficult (Elkordy et al. 2019). In a recent systematic review of systematic reviews investigating the effects of fixed appliances

34 on the periodontium, the authors found that they cause a minor temporary worsening of the periodontal status when compared to controls, which tends to revert after the appliances are removed. With regard to the development of gingival recessions, the authors concluded that this topic is highly debatable, and further research is required. The authors also compared self- ligating brackets to conventional brackets and found that there was no difference in periodontal outcomes.

Overall, the hardships associated with treatment are generally well-tolerated by patients who are motivated by positive treatment outcomes, such as improved appearance and confidence. Most patients are able to manage problems, and the side effects are rarely a barrier to treatment acceptance (Perry et al. 2018), although they do impact the quality of life during treatment.

Impact of Invisalign® on OHRQOL

Invisalign® therapy has its own potential group of side effects. A recent study analyzed the content of Invisalign® patient testimonials on YouTube. The authors found that pain and oral symptoms were the most frequently reported complaints by video bloggers, and were also regarded as a disadvantage by the viewers in the video comments (Livas, Delli, and Pandis

2018). Several video bloggers also complained about the need to brush their teeth after snacking and before reinserting their trays. Tooth sensitivity was another common complaint that made them adjust the frequency of their meals or the types of food they were eating.

Another functional limitation frequently mentioned was speech difficulties. However, positive comments related to treatment experience were much more prevalent than negative comments, although one must keep the potential bias of video sponsorship in mind as paid patient

35 testimonials are common.

Pacheco-Pereira, Brandelli, and Flores-Mir (2018) assessed 81 patients between the ages of 26-35 immediately after completing Invisalign® treatment. The greatest improvements were seen in the appearance and eating categories, with more than 70% of the questions answered positively. The greatest sources of dissatisfaction during treatment were food getting stuck between the teeth (24%) and pain (16%). Overall, the experience was very positive, with the doctor-patient relationship correlating highly with multiple aspects of patient satisfaction.

Nedwed and Miethke (2005) surveyed 54 patients between the ages of 15-58 who were between three to six months into their Invisalign® treatment. The majority of patients (83%) adapted to their aligners within one week, and the remaining 17% required a maximum of two weeks. With regard to pain experience, 35% reported no pain at all, 54% reported mild pain, and 11% described the pain as strong. Patients reported an average pain duration of two to three days, with a range of a few hours to the entire two weeks the aligner was worn. When comparing genders, the authors found that 50% of the men experienced no pain compared to

31% of the women. There was no difference between the genders for those who reported severe pain. There was also no clear association between pain perception and age. With regard to speech, 52% reported slight impairment, and only one patient reported strong impairment.

Only 7% of patients reported inhibitions while speaking. Lingual irritations from the aligner were reported as mild in 24% and strong in 6%. Most patients (76%) did not report feeling any constriction or narrowing of the lingual space due to the aligner. With regard to eating, 44% reported pressure sensitivity while chewing, food getting stuck between temporary spacing during alignment, and an altered occlusion. Those who reported temporomandibular joint

(TMJ) problems such as clicking during treatment (9%) already had symptoms prior to

36 commencing treatment. One patient reported feeling bilateral TMJ tension after inserting the aligners, but none of the patients reported TMJ pain. In terms of motivation and satisfaction,

89% were satisfied with their treatment progress, and 96% were still highly motivated to continue.

Schaefer and Braumann (2010) assessed 36 patients between the ages of 20-66 during the first eight months of Invisalign® treatment and reported only minimal impairment of overall oral health and associated quality of life. There was no evidence of dry mouth, halitosis, or of an increase in inflammation and plaque indices. While the pronunciation of certain words was slightly affected, this was resolved during the course of treatment.

Tuncay et al. (2013) assessed the plaque, gingival bleeding, and decalcification scores of 62 teenage patients undergoing clear aligner therapy at the first appointment, and at three- month intervals until the end of treatment or up to two years. The authors found no adverse oral health impacts and found significantly better oral conditions than those reported by patients in fixed appliances. Additionally, questions regarding physical and social comfort were asked every three months to assess patient satisfaction. The large majority of patients reported either never or seldom limiting the foods they ate, feeling self-conscious, or avoiding contact or communication with others because of their aligners. At the first three-month follow-up, about 70% reported seldom or never feeling discomfort, and 80% had never or seldom used analgesics to manage pain. As the treatment progressed, even less concerns were expressed.

Studies Comparing Fixed Appliances and Invisalign®

Align Technology advertises Invisalign® treatment as offering a superior patient experience over traditional fixed appliances by emphasizing comfort, esthetics, easier hygiene,

37 and better overall lifestyle (Invisalign.com 2019). Orthodontic treatment with clear aligners is a fast-growing sector in orthodontics (Wheeler 2017). Patients who choose to be treated with

Invisalign® are often seeking appliances that are less obtrusive in their daily lives, and they are willing to incur greater treatment costs with the hopes of acquiring less negative impacts on their quality of life (Miller et al. 2007). Many patients also choose Invisalign® due to the improved esthetics (Rosvall et al. 2009). Only a few studies exist in the literature that compares the treatment effects and patient experiences in Invisalign® and fixed appliances, and none have been conducted on an adolescent population.

While adolescents may not be as concerned about looking different since orthodontic treatment has become so common, they are still influenced by their peers with regard to how the appliances should look (Proffit et al. 2019). This has led to opting for tooth-colored plastic or ceramic brackets that appear less visible, or requesting brightly colored elastics, imitating their peer group (Proffit et al. 2019).

Walton et al. (2010) surveyed the preferences and acceptability of various orthodontic appliances in children and adolescents. The survey presented 12 different orthodontic appliances variations to 139 children in 3 age groups: 9-11 (n= 45), 12-14 (n= 49), and 15-17

(n= 45). The variations included standard stainless steel twin brackets with clear and colored ties, stainless steel self-ligating brackets, hybrid brackets, ceramic self-ligating brackets, ceramic brackets with clear and discolored ties, and clear aligners. For the 9-11 and 12-14 year old age group, the highest-rated appliances were the stainless steel twin brackets with colored ties (92% and 89% respectively), the shaped brackets with colored ties, followed by clear aligners. Clear aligners were found to be statistically more attractive than any of the ceramic brackets. For the 15-17 year old age group, clear aligners were rated significantly more

38 attractive than all other appliances (91%), which is similar to the study by Feu et al. (2013) that reported that adolescents between the ages of 15 and 17 often consider braces to be unesthetic. The authors concluded that children and adults differ in their preferences. While adults prefer to reduce the visibility of metal, it does not appear to be a major esthetic factor among children (Walton et al. 2010).

Shalish et al. (2012) compared the adaptation to fixed appliances and Invisalign® in adult patients. The authors found that the Invisalign® patients reported more severe pain than the fixed appliance group during the first week of treatment. The authors theorized that a greater force might have been applied in the Invisalign® group early into treatment, compared to the fixed appliance group, where the wire’s flexibility may produce a more gradual and lighter force. While the Invisalign® group reported lower oral symptoms, similar levels of general activity disturbances and oral dysfunction were reported for both groups. With regard to eating difficulties, the fixed appliance group reported significantly higher concerns.

Miller et al. (2007) investigated treatment impacts between 60 adult patients treated with Invisalign® and fixed appliances during the first week of treatment. The impact and pain progression of Invisalign® was shown to be similar to fixed appliances, with the only difference being that the first three days were reported to be more painful in the fixed appliances group. In terms of analgesic consumption, the fixed appliances group consumed more pain medication during the first three days of treatment, but there was no difference from the fourth through the seventh day. Overall, patients in both groups reported the highest amount of pain and negative impacts on day one and returned to baseline levels by day seven.

Quality of life was also investigated between the two groups. From day one to day seven, the fixed appliance group reported more negative impacts on the functional, psychosocial and

39 pain-related dimensions. The two groups also differed in their motivations for treatment. More patients in the Invisalign® group reported seeking treatment to improve their appearance, whereas more patients in the fixed appliances group stated they sought treatment because their dentist referred them. The mean psychosocial scores were higher than the baseline level for all treatment days in the Invisalign® group, while the fixed appliance group only obtained a higher than baseline score by day seven.

Fujiyama et al. (2014) investigated whether Invisalign® or fixed appliances caused more pain in 145 adult patients undergoing treatment. A significant difference was noted for the intensity of pain, its duration, and the overall level of discomfort between the two groups.

The results showed that the Invisalign® group not only reported less pain during the initial stages, but also less overall pain during the course of treatment compared to the fixed appliances group at the end of treatment. The major cause of pain or discomfort in the

Invisalign® group was tray deformation.

Noll et al. (2017) analyzed 419,363 tweets discussing orthodontics to assess if there was a difference in the sentiments of those in fixed appliances and Invisalign®. More than half of the tweets were positive (61%). The authors found no significant difference in the distribution of positive and negative tweets between fixed appliances and Invisalign® patients.

Negative sentiments for Invisalign® users included complaints about speech issues, while those in fixed appliances expressed frustration about the appearance of the appliances.

As previously mentioned, the presence of orthodontic brackets, wires and bands can make proper plaque removal more challenging, which can lead to enamel demineralization and gingival inflammation. Aligners have the advantage of being removable allowing for more straightforward brushing and flossing (Azaripour et al. 2015). Two recent systematic reviews

40 with meta-analysis reported that aligners allowed for better periodontal health compared to fixed appliances (Lu et al. 2018; Jiang et al. 2018).

However, aligners can still still pose a significant oral health risk. Tuncay et al. (2013) showed that patients in aligners may experience increased plaque accumulation and mild gingival bleeding. Türköz et al. (2012) found that regardless of proper oral hygiene techniques, a significant amount of plaque remained on the surface of aligners. The general assumption is that aligners are hygienic by design. However, since aligners cover the teeth, salivary flow is reduced, self-cleansing processes are interrupted, and plaque entrapment can result, leading to an increased risk of developing new white spot lesions. Furthermore, some patients do not follow recommendations and drink acidic beverages without removing the aligners, creating a cariogenic environment.

Azeem and Hamid (2017) assessed 25 patients between the ages of 14-18 undergoing orthodontic treatment with aligners. The overall incidence of new white spot lesions was low at 2.85%, compared to reports of as high as 60.9% in patients treated with fixed appliances

(Enaia, Bock, and Ruf 2011). The authors concluded that clear aligner therapy should be recommended for patients with a high risk of developing white spot lesions.

Azaripour et al. (2015) compared 50 patients in Invisalign® and 50 patients in fixed appliances and evaluated their periodontal health and overall satisfaction. The patients in the fixed appliances group were an average age of 16.3 ± 6.9 with a range of 11–61 and the patients in the Invisalign® group were an average age of 31.9 ± 13.6 with a range of 12–61.

The authors designed their own questionnaire and investigated oral hygiene habits, food choices, and overall well-being. The findings revealed significantly better gingival health conditions in the Invisalign® group and less plaque, although the difference in plaque scores

41 was not significant. The Invisalign® group also expressed greater satisfaction and less negative impacts compared to the fixed appliances group.

Miethke and Vogt (2005) also compared the periodontal health in 60 adult patients treated with fixed appliances or Invisalign®. In contrast with Azaripour et al. (2015), this study reported that the Plaque Index was significantly lower in patients treated with Invisalign®, but the Gingival Index, Papillary Bleeding Index, and sulcus probing depths in both groups were similar.

In 2018, Flores-Mir, Brandelli, and Pacheco-Pereira (2018) assessed patient satisfaction and quality of life among 145 adults treated with fixed appliances or Invisalign® immediately after completion of treatment. The authors found that there were statistically similar satisfaction outcomes for almost all of the dimensions investigated in both groups.

However, there was a significant difference with regard to eating and chewing, with almost half of the Invisalign® group reporting 100% satisfaction, compared to only 24% in the fixed appliances group.

Purpose

In order for the patient and the orthodontist to make more informed decisions regarding treatment modality, more studies are required to evaluate the impacts of Invisalign® and fixed appliances on patients’ quality of life (Miller et al. 2007). There are currently no studies in the literature comparing adolescents’ quality of life in fixed appliances and Invisalign® either during or after treatment.

The purpose of this study was to address a gap in the literature regarding adolescent patient experiences in fixed appliances an Invisalign®, and to aid in shaping the informed consent process by providing patients with realistic expectations of what they may experience

42 during treatment, which will assist families and patients in choosing which treatment modality will suit their individual needs best. The findings from this study may also be used to educate and encourage patients during treatment, which may lead to better compliance and thus, an improved treatment outcome and overall quality of life.

General Objective

To compare the quality of life, experiences, and satisfaction of adolescents in fixed appliances versus Invisalign® between two different age groups: 11-18 and 14-18, and between males and females in the two different age groups by means of a questionnaire.

Null Hypotheses

For each group mentioned above, the null hypotheses are:

1. There is no difference in the quality of life scores between the fixed appliances group and

the Invisalign® group.

2. There is no difference in the overall satisfaction scores between the fixed appliances

group and the Invisalign® group.

3. There is no difference in the domain scores between the fixed appliances group and the

Invisalign® group.

43 Chapter 2: Materials and Methods

Ethical approval was obtained from the University of Manitoba’s Health Research

Ethics Board, Bannatyne Campus (Appendix 1). Data collection occurred over an eight-month period.

Study Sample

Adolescent patients between the ages of 10-19 were recruited to participate. This study aimed to assess a sample of at least 60 patients total in two groups: fixed appliances and

Invisalign®. Similar sample sizes were utilized in previous quality of life studies by Jokovic et al. (2004) and Locker, Jokovic, and Tompson (2005).

Inclusion Criteria

Patients between the ages of 10-19 who were:

• Active patients in treatment for a minimum of six months

• Grade 2 or Grade 3 in the Index of Treatment Need (Appendix 4)

• Undergoing their first course of orthodontic treatment

Exclusion Criteria

• Patient of the principal investigator

• Learning difficulties (which would preclude participants from understanding and

completing questionnaire)

• Physical disability

• Chronic medical conditions

44 • Symptoms of pain or discomfort from any other body part

• Active dental decay, poor periodontal health

• Syndromes and craniofacial anomalies

• No history or current use of any auxiliary appliances: Rapid palatal expander,

headgear, Nance holding arch, transpalatal arch, mandibular advancement device, fixed

class II correctors

• Extraction cases

• Poor compliance

® • Patients who have experienced both fixed appliances and Invisalign

Case Selection and Recruitment

Records of current patients in active treatment at the University of Manitoba Graduate

Orthodontic Clinic were screened using the electronic patient database. Any patients who fit the inclusion criteria were placed on a list with the date of their next appointment. The administration team was asked to distribute the survey package. If they were unable to administer, the principal investigator approached the participant (and their parent if present) and explained the purpose of the survey. Participants were provided with written informed consent.

It was made clear that participation was voluntary and that their treating resident or orthodontist would never be able to access their responses.

The survey package contained the informed consent disclosure (Appendix 5), information on the purpose of the study, the participant’s role, information on how to contact the principal investigator if required, risks and benefits, privacy and confidentiality measures, and explained the option to decline participation if desired. Completing the survey implied

45 consent. The participant was asked to return the survey to the administration team, or to the principal investigator once completed. The front page of the survey included two draw cards to win either a $100 Visa gift card, or an electric toothbrush as an incentive (Appendix 6). The participant was informed that the draw card, which would have identifying information, would be linked to their survey by a unique coding number, but that the card would be torn off when the completed survey was received. Once all prizes were claimed, the draw cards were destroyed.

In an effort to increase the representation of patients and orthodontists, four private practice offices were also included in the study whose offices were in different areas of the city.

The principal investigator explained the purpose of the study, the consent process, and the inclusion and exclusion criteria to the orthodontists and to their office managers, who then distributed the surveys. In order to verify the eligibility of the participants from the private practices, the principal investigator reviewed each participant’s chart and records.

Study Questionnaire

The survey instrument used in this study was the Child Oral Health Impact Profile Short

Form-19 (COHIP-SF 19) with approval from Dr. Hillary Broder. The original questionnaire was the COHIP-38, which was validated with a diverse sample of children between the ages of

8-17 with a variety of oral and health conditions from different ethnicities (Broder and Wilson-

Genderson 2012). However, it has been recommended to use short forms of quality of life measures as long instruments can be burdensome (Broder and Wilson-Genderson 2012). Both reliability and validity testing confirmed that the COHIP-SF 19 was consistent with the original

COHIP-38, rendering it to be a more efficient instrument appropriate for clinical research and epidemiological studies. The questionnaire was developed for children between the ages of 8-15

46 with a readability score of 3.5, making it suitable for children in third grade or higher (Broder and Wilson-Genderson 2012). However, it has been proven to be suitable for a wider age range, as reliability and validity has been assessed for ages 7–18 in the short version (Broder and

Wilson-Genderson 2012). In the present study, the questionnaire was used for subjects up to age 18.

The COHIP-SF 19 assesses three domains: Oral Health Well-Being, Functional Well-

Being, and Social-Emotional Well-Being. It also evaluates a Global Health score, which is a measure of the child’s self-rated oral health (item 20). The Global Health score is not included in the final overall COHIP score. The Oral Health domain is comprised of items asking about oral symptoms such as pain, and bleeding gums (items 1-5). Items in the Functional Well-Being domain pertain to the individual’s ability to carry out everyday tasks and activities such as eating and sleeping (items 9, 13, 17, 18). Social-Emotional Well-Being involves peer interactions, positive feelings about oneself, issues related to school, and mood states (items 6,

7, 8, 10, 11, 12, 14, 15, 16, 19). All participants were instructed to choose the answer that best describes their experience in the past three months regarding their teeth, mouth or face. They were also asked to consider their braces or Invisalign® when responding. Five possible responses include: never, almost never, sometimes, fairly often, and almost all of the time, recorded on a Likert scale of 0–4. Scoring of the negatively worded items was reversed, and a higher COHIP score reflected more positive OHRQOL (Broder and Wilson-Genderson, et al.

2012). Using items 1-19, the domain score was produced by summing the mean scores of each item that comprise the domain. The total COHIP score, referred to as the quality of life score, was generated by summing the mean scores of each domain. It was ensured that all participants who answered school-related questions were indeed students. In addition to this validated

47 questionnaire, supplementary questions were added to the survey to investigate jaw pain, brushing habits, expectations, and satisfaction (Appendix 7).

Satisfaction Measurement

A 10 cm visual analog scale was used to measure each respondent’s overall satisfaction with their treatment modality on a typical day, with a higher measurement indicating greater satisfaction. Responses were evaluated using a ruler and measuring to the point where the respondents’ line intersected with the scale.

Statistical Analysis

Descriptive analysis of the data was performed to analyze the frequency of events and the extent of the impact of fixed appliances compared to Invisalign® on the oral health-related quality of life of adolescents. Additionally, inferential analysis of the data was performed using Pearson's chi-squared test to evaluate whether the participants in the fixed appliances group answered each item differently than those in the Invisalign® group (p < 0.05). Unpaired t-tests (p < 0.05), were used to test for differences in mean satisfaction, quality of life, and domain scores.

For items 1–23, an odds ratio was calculated (95% confidence interval, p < 0.05). In order to construct a 2x2 table to calculate the odds ratio, the responses sometimes, fairly often and almost all of the time were combined together, and the responses almost never and never were combined separately in order to create a binary response.

Each domain score was correlated to the overall quality of life score and to the overall satisfaction score. An analysis of variance (ANOVA) test was performed to investigate the relationship between expectations and satisfaction, and to compare satisfaction scores between

48 genders.

Test Groups

All participants: Full sample between the ages of 11-18 years (n= 74)

Fixed Appliances: n= 37, Invisalign®: n= 37

In order to investigate the impact of age and gender, the sample was subdivided into the following groups:

Participants age 14-18 years: n= 56

Fixed Appliances: n= 32, Invisalign®: n= 24

All males: n= 30 Fixed Appliances: n= 16, Invisalign®: n= 14

Males age 14-18 years: n= 24

Fixed Appliances: n= 13, Invisalign®: n= 11

All females: n= 44

Fixed Appliances: n= 21, Invisalign®: n= 23

Females age 14-18 years: n= 32

Fixed Appliances: n= 19, Invisalign®: n= 13

The group with all participants (n= 74) was the main test group analyzed in this study.

Only significant results and general comparisons were reported for the remainder of the

groups.

49 Chapter 3: Results

Demographic Data

A total of 127 potential participants were invited to participate in this study. No participants declined to participate. However, only 74 adolescents met the inclusion criteria.

The mean age of the participants was 14.9 ± 1.9 years. The fixed appliances group consisted of

37 participants with a mean age of 15.3 ± 2.3 years. Of the 37 participants, 16 were males, and

21 were females. The Invisalign® group also consisted of 37 participants with a mean age of

14.1 ± 1.8 years, of which 14 were males, and 23 were females (Table 1). There was no significant difference in the distribution of genders in both groups (p= 0.81). Figure 1 below depicts the distribution of ages in each group.

Table 1: Demographic Data ® Fixed Appliances Invisalign (n= 37) (n= 37) Males 16 14 Females 21 23

Age (years) 11 1 1 12 1 3 13 3 9 14 9 7 15 6 6 16 6 6 17 5 2 18 6 3 Mean Age 15.3 ± 2.3 14.1 ± 1.8

The group with all participants (n= 74) was the main focus of this study, and detailed figures were constructed in order to compare the responses of each treatment group for each item of the questionnaire (Appendix 9). Table 2 provides a detailed summary of the responses .

50

Table 2: Summary of responses: All participants

B = Braces B I B I B I B I B I I = Invisalign Never Almost Never Sometimes Fairly Often All the Time Items n (%) n (%) n (%) n (%) n (%) 1) Pain in teeth/ 7 8 10 8 19 19 1 2 0 0 toothache (18.9%) (21.6%) (27%) (21.6%) (51.4%) (51.3%) (2.7%) (5.4%) 2) Crooked teeth/ 10 10 7 10 12 11 3 1 5 5 spaces (27%) (27%) (18.9%) (27%) (32.4%) (29.7%) (8.1%) (2.7%) (13.5%) (13.5%) 3) Discolored teeth 18 20 10 11 7 3 2 2 1 0 (48.7%) (54.1%) (27%) (29.7%) (18.9%) (8.1%) (5.4%) (5.4%) (2.7%) 4) Bad breath 9 10 15 10 9 14 3 3 1 0 (24.3%) (27%) (40.5%) (27%) (24.3%) (37.8%) (8.1%) (8.1%) (2.7%) 5) Bleeding gums 16 18 9 7 8 8 2 3 1 0 (44.4%) (50%) (25%) (19.4%) (22.2%) (22.2%) (5.6%) (8.3%) (2.8%) 6) Unhappy or sad 19 23 6 8 8 4 3 1 1 1 (51.4%) (62.2%) (16.2%) (21.6%) (21.6%) (10.8%) (8.1%) (2.7%) (2.7%) (2.7%) 7) Missed school 16 22 6 8 10 4 2 1 2 0 (44.4%) (62.9%) (16.7%) (22.9%) (27.8%) (11.4%) (5.6%) (2.9%) (5.6%) 8) Been confident 2 2 3 2 13 11 13 10 6 12 (5.4%) (5.4%) (8.1%) (5.4%) (35.1%) (29.7%) (35.1%) (27%) (16.2%) (32.4%) 9) Difficulty eating 8 13 5 9 12 12 9 3 3 0 (21.6%) (35.1%) (13.5%) (24.3%) (32.4%) (32.4%) (24.3%) (8.1%) (8.1%) 10) Felt worried or 19 25 11 6 5 5 2 1 1 0 anxious (75%) (65.7%) (11.1%) (14.3%) (5.6%) (17.1%) (5.6%) (2.9%) (2.8%) 11) Not wanted to 27 23 4 5 2 6 2 1 1 0 speak/read out loud (75%) (65.7%) (11.1%) (14.3%) (5.6%) (17.1%) (5.6%) (2.9%) (2.8%) 12) Avoiding 27 27 5 5 4 1 0 3 1 1 smiling/laughing (73%) (73%) (13.5%) (3.5%) (10.8%) (2.7%) (8.1%) (2.7%) (2.7%) 13) Trouble sleeping 23 17 8 18 5 2 1 0 0 0 (62.2%) (46%) (21.6%) (48.7%) (13.5%) (5.4%) (2.7%) 14) Been teased or 33 35 3 2 1 0 0 0 0 0 bullied (89.2%) (94.6%) (8.1%) (5.4%) (2.7%) 15) Felt attractive 4 5 11 6 12 12 3 10 7 4 (10.8%) (13.5%) (29.7%) (16.2%) (32.4%) (32.4%) (8.1%) (27%) (18.9%) (10.8%) 16) Felt that you look 11 12 7 7 10 5 7 7 2 6 different (29.7%) (32.4%) (18.9%) (18.9%) (27%) (13.5%) (18.9%) (18.9%) (5.4%) (16.2%) 17) Difficulty saying 20 15 8 12 7 6 1 4 1 0 certain words (54.1%) (40.5%) (21.6%) (32.4%) (18.9%) (16.2%) (2.7%) (10.8%) (2.7%) 18) Difficulty keeping 10 16 11 13 11 6 4 0 1 2 teeth clean (27%) (43.2%) (29.7%) (35.1%) (29.7%) (16.2%) (10.8%) (5.4%) (2.7%) (5.4%) 19) Worried about 25 25 5 5 2 3 2 3 3 1 what others think (67.6%) (67.6%) (13.5%) (13.5%) (5.4%) (8.1%) (5.4%) (8.1%) (8.1%) (2.7%) 21) Felt shy or 25 27 8 5 3 2 0 3 0 0 embarrassed (69.4%) (73%) (22.2%) (13.5%) (8.3%) (5.5%) (8.1%) 22) Sore spots 11 10 6 13 15 10 4 4 1 0 (29.7%) (27%) (16.2%) (35.1%) (40.5%) (27%) (10.8%) (10.8%) (2.7%) 23) Felt annoyed or 9 10 11 12 14 11 3 3 0 1 frustrated (24.3%) (27%) (29.7%) (3.4%) (37.8%) (29.7%) (8.1%) (8.1%) (2.7%) 20) Rate your oral health Poor Fair Average Good Excellent 1 1 7 4 21 22 8 10 0 0 (2.7%) (2.7%) (18.9%) (10.8%) (56.8%) (59.5%) (21.6%) (27%) 24) Reasons for feeling annoyed/frustrated Food Gets Stuck Wire Pokes Insertion/Removal Eating Pain/sores/Sensitivity 6 0 7 6 2 1 4 3 0 0 (16.2%) (18.9%) (16.2%) (5.4%) (2.7%) (10.8%) (8.1%)

Oral Hygiene Other N/A 1 1 2 4 15 22 (2.7%) (2.7%) (5.1%) (10.8%) (40.5%) (59.4%)

51

Yes No 25) Trouble focusing 5 2 31 33 in classroom (13.9%) (5.7%) (86.1%) (94.3%) 26) Avoided 1 1 35 34 sports/music/field trips (2.8%) (2.9%) (97.2%) (97.1%) 27) Did you have jaw 5 3 32 35 pain before (13.5%) (8.1%) (86.5%) (91.1%) 28) Jaw pain More pain now Less pain now Same as before No jaw pain compared to before 10 3 3 2 2 21 31 0 (27.8%) (8.3%) (8.3%) (5.6%) (5.6%) (58.3%) (86.1%) 29) How often did you 7 days 5-6 days 3-4 days 1-2 days Never floss per week before 6 3 1 2 6 12 16 14 7 6 (16.7%) (8.1%) (2.8%) (5.4%) (16.8%) (32.4%) (44.4%) (37.8%) (19.4%) (16.2%) 30) How often do you 7 days 5-6 days 3-4 days 1-2 days Never floss per week now 5 8 3 11 12 6 13 9 4 3 (13.5%) (21.6%) (8.1%) (29.7%) (32.4%) (16.2%) (35.1%) (24.3%) (10.8%) (8.1%) 31) Time taken to get Immediately 1 day 1-2 weeks 1 month 3 months used to appliance 2 4 8 15 21 7 7 9 1 0 (5.4%) (10.8%) (21.6%) (40.5%) (56.8%) (18.9%) (18.9%) (24.3%) (2.7%) 32) Why did you get Parents made me I wanted treatment Both parents and I Dentist told me braces/Invisalign 1 1 6 7 25 19 14 18 Choose all that apply (2.7%) (2.7%) (16.7%) (18.9%) (67.6%) (51.4%) (37.8%) (48.7%) 33) Compared to Better than Worse than Just as I expected expectations, how are expected expected your results now 22 24 1 1 14 12 (59.5%) (64.9%) (2.7%) (2.7%) (37.8%) (32.4%) 34/35) Top 3 Increase expectations while in Braces: Healthier Confidence Smile More treatment: mouth (25.7%) (25.7%) (31.4%) Be more attractive Increase Invisalign: Smile (23.5%) Confidence More (31.4%) Healthier mouth (23.5%) (23.5%) 36) Results so far for Better Worse than than first expectation expected Just as I expected expected 21 19 13 16 0 0 (61.8%) (54.3%) (38.2%) (45.7%) Better 37) Results so far for Worse than than second expectation expected Just as I expected expected 12 15 22 19 0 0 (35.3%) (44.1%) (64.3%) (55.9%) 38) Results so far for Better Worse than than third expectation expected Just as I expected expected 17 9 1 17 25 0 (48.6%) (26.7%) (2.9%) (48.6%) (73.5%) 39) Current Invisalign / Braces / Braces Braces / Invisalign Invisalign / Braces modality/What Invisalign modality would you choose if you had to 28 9 32 5 have treatment again (75.7%) (24.3%) (86.5%) (13.5%) Satisfaction score B I B I B I B I B I B I B I (1-10) 4 4 5 5 6 6 7 7 8 8 9 9 10 10 n 1 0 0 2 5 3 8 5 7 12 14 13 2 2 2.7 0 0 5.4 13.5 8.1 21.6 13.5 18.9 32.4 37.8 35.1 5.4 5.4 % % % % % % % % % % % % % % %

52 Table 3: Summary of significant results from each test group Item Test Group Significance OR: 3.8 7) Missed school for any reason because of your teeth, mouth, or All participants (95% CI 1.2, 12.5, face p= 0.02)

Participants age 8) Been confident because of your teeth, mouth, or face p= 0.007 14-18 years OR: 2.7 9) Had difficulty eating foods you would like to because of your All participants (95% CI 1.1, 7.1, teeth, mouth, or face p= 0.04)

All females p= 0.006 13) Had trouble sleeping because of your teeth, mouth, or face. Females 14-18 p= 0.03 years

15) Felt that you were attractive (good looking) because of your All females p= 0.04 teeth, mouth, or face

Participants age 30) How often do you floss now that you have braces or p= 0.003 14-18 years Invisalign? p= 0.03 Males 14-18 years 31) How long did it take for you to get used to your braces or All participants p= 0.03 Invisalign? All females p= 0.014

Table 4: Detailed summary of significant results from each test group

B = Braces B I B I B I B I B I I = Invisalign Never Almost Never Sometimes Fairly Often All the Time Items n (%) n (%) n (%) n (%) n (%) 7) Missed school 16 22 6 8 10 4 2 1 2 0 All participants (44.4%)(44.4%) (62.9%)(62.9%) (16.7%) (22.9%)(22.9%) (27.8%) (11.4%) (5.6%)(5.6%) (2.9%)(2.9%) (5.6%)(5.6%) 8) Been Confident: 1 2 3 1 12 7 13 3 3 11 Participants 14-18 years (3.1%) (8.3%) (9.4%) (4.2%) (37.5%) (29.2%) (40.6%) (12.5%) (9.4%) (45.8%) 8 13 5 9 12 12 9 3 3 9) Difficulty eating: 0 All participants (21.6%) (35.1%) (13.5%) (24.3%) (32.4%) (32.4%) (24.3%) (8.1%) (8.1%) 13 7 3 14 4 2 1 13) Had trouble 0 0 0 sleeping: All females (61.9%) (30.4%) (14.3%) (60.9%) (19.1%) (8.7%) (4.8%) Females 14-18 13 5 2 7 4 1 0 0 0 0 years (68.4%) (38.5%) (10.5%) (53.6%) (21.1%) (7.7%) 15) Felt that you were attractive (good 3 1 7 4 7 8 1 9 3 1 looking): All females (14.3%) (4.4%) (33.3%) (17.4%) (33.3%) (34.8%) (4.8%) (39.1%) (14.3%) (4.4%) 30) How often do 7 days 5-6 days 3-4 days 1-2 days Never you floss per week 2 2 6 7 3 7 3 2 now? All males (12.5%) (14.3%) 0 (42.3%) (43.8%) (21.4%) (43.8%) (21.4%) 0 (14.3%)

1 2 4 5 1 7 3 1 Males Subgroup 14-18 years 2 0 0 (7.7%) (18.2%) (36.4%) (38.5%) (9.1%) (53.9%) (27.3%) (9.1%) 31) Time taken to Immediately 1 day 1-2 weeks 1 month 3 months get used to 2 4 8 15 21 7 7 9 1 appliance: 0 (5.4%) (10.8%) (21.6%) (40.5%) (56.8%) (18.9%) (18.9%) (24.3%) (2.7%) All participants

2 3 3 6 14 4 6 6 0 0 (9.5%) (14.9%) (13.0%) (28.6%) (60.9%) (19.1%) (26.1%) (28.6%) All females

53 Findings

Item 7- All participants: Odds ratio: 3.8 (95% CI: 1.2, 12.5, p= 0.02)

The fixed appliances group was 3.8 times more likely to miss school compared to the Invisalign® group. Three participants who were not students were excluded from the analysis of this item.

The majority of the fixed appliances group (22.9%) reported missing school sometimes because of the appliance, whereas the majority of the Invisalign® group (62.9%) reported never missing school.

Item 8- Participants age 14-18 years: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group for item 8 (p= 0.007) . The majority of the Invisalign® group between the ages of 14-18 (48.5%) reported feeling confident all of the time, compared to only 9.4% of the fixed appliances group.

Item 9- All participants: Odds ratio: 2.7 (95% CI: 1.1, 7.1, p= 0.04)

The fixed appliances group was 2.7 times more likely to report difficulty eating compared to the

Invisalign® group. The majority of the fixed appliances group reported sometimes having difficulty eating food they would like, whereas the majority of the Invisalign® group reported never having difficulty. Further, 8.1% of the fixed appliances group reported having trouble eating all of the time, compared to no one in the Invisalign® group.

Item 13- All females: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group in the all-female sample (p= 0.006). The majority of the fixed appliances group (61.9%) reported never having trouble sleeping because

54 of their appliance, compared to 30.4% in the Invisalign® group.

Females age 14-18 years: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group of the all-female sample between the ages of 14 and 18 (p= 0.03). The majority of the fixed appliances group (68.4%) reported never having trouble sleeping because of their appliance, compared to 38.5% in the Invisalign® group.

Item 15- All females: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group of the all-female sample (p= 0.04). The majority of the Invisalign® group (39.1%) reported feeling attractive fairly often due to their appliance, compared to only 4.8% of the females in the fixed appliances group.

Item 30- All males: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group in the all-male sample. The patients in the Invisalign group reported flossing more often than the fixed appliances group.

Item 30- Males age 14-18 years: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group in the all-male sample between the ages of 14-18. The patients in the Invisalign® group reported flossing more often than the fixed appliances group.

Item 31- All participants: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Neither group took longer than three months to adapt to treatment. The majority of respondents took between one and two weeks to adapt to treatment. However, 24.3% of the fixed appliances sample took three months to get

55 used to their appliance (n= 9), whereas only 2.7% of the Invisalign® group took this long (n=1).

All females: There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group (p= 0.014). The majority of the all-female Invisalign® sample took between one to two weeks to adapt to treatment, compared to the majority of the fixed appliances group who took from between one to two weeks to up to two months.

Figures 1-2 illustrate the satisfaction, domain, and quality of life scores for each treatment group

(n= 74).

Figure 1: Comparison of satisfaction scores (All participants)

There was no significant difference in satisfaction scores between the fixed appliances and Invisalign® group. The majority of both groups reported high overall satisfaction with their fixed appliances or Invisalign® on a typical day (p= 0.68). The mean satisfaction score of the fixed appliances group was 8.34 ± 1.39 out of 10 with a range of 4.45 to 10.00. The mean satisfaction score of the Invisalign® group was 8.47 ± 1.33 out of 10 with a range of 5.20 to 10.00. Additionally, there was no significant difference in satisfaction scores between males and females (males: p= 0.51, females p= 1.0). ANOVA testing revealed that those who felt that their expectations were exceeded had significantly higher satisfaction scores (fixed appliances group: p= 0.0078, Invisalign® group: p= 0.0065)

56

Figure 2: Comparison of COHIP-19 mean domain scores (All participants)

Figure 2 was generated by plotting the mean domain and mean overall quality of life score of each treatment group. The minimum and maximum values for each domain are illustrated by the vertical lines extending from the mean. Out of a maximum of 74, the mean quality of life score for the fixed appliances group was 55.49 ± 9.11. The mean quality of life summary score for the Invisalign® group was 57.81 ± 9.06. Overall, the average domain scores between the two groups were also similar.

57 Table 5: Summary of COHIP-19 Scores: Fixed Appliances Vs. Invisalign (All participants) Fixed Appliances Invisalign® Domain & Items Mean (SD) Range Mean (SD) Range Oral Health Well-Being 1. Had pain in your teeth/toothache 2.62 ± 0.83 1 – 4 2.59 ± 0.90 1 – 4 2. Had discolored teeth or spots on your teeth 2.38 ± 1.34 0 – 4 2.51 ± 1.30 0 – 4 3. Had crooked teeth or spaces between your teeth 3.19 ± 0.94 1 – 4 3.27 ± 1.02 0 – 4 4. Had bad breath 2.76 ± 1.01 0 – 4 2.73 ± 0.96 1 – 4 5. Had bleeding gums 3.03 ± 1.08 0 – 4 3.11 ± 1.04 1 – 4 Oral Health Domain score (0- 20) 13.98 ± 3.03 6 – 20 14.21 ± 3.31 5 – 20 Functional Well-Being 9. Had difficulty eating foods you would like 2.16 ± 1.26 0 – 4 2.86 ± 1.00 1 – 4 13. Had trouble sleeping 3.43 ± 0.83 1 – 4 3.41 ± 0.60 2 – 4 17. Had difficulty saying certain words 3.22 ± 1.03 0 – 4 3.03 ± 1.01 1– 4 18. Had difficulty keeping your teeth clean 2.68 ± 1.08 0 – 4 3.11 ± 1.05 0 – 4

Functional well-being domain score (0- 16) 11.49 ± 2.77 4 – 16 12.41 ± 2.36 6 – 16 Social-Emotional Well-Being (Questions finish with “because of your teeth, mouth, or face”) 3.05 ± 1.15 0 – 4 3.38 ± 0.98 0 – 4 6. Been unhappy or sad 2.89 ± 1.21 0 – 4 3.46 ± 0.82 1 – 4 7. Missed school for any reason 2.49 ± 1.04 0 – 4 2.76 ± 1.14 0 – 4 8. Been confident 3.27 ± 0.90 1 – 4 3.49 ± 0.84 1 – 4 10. Felt worried or anxious 3.50 ± 1.03 0 – 4 3.43 ± 0.88 1 – 4 11. Not wanted to speak/read out loud in class 3.54 ± 0.90 0 – 4 3.46 ± 1.07 0 – 4 12. Avoiding smiling or laughing with other children 3.84 ± 0.55 1 – 4 3.95 ± 0.23 14. Been teased, bullied, or called names by other 1.95 ± 1.27 1 – 4 2.05 ± 1.20 3 – 4 children 2.49 ± 1.26 2.32 ± 1.51 15. Felt that you were attractive (good looking) 0 – 4 0 – 4 16. Felt that you look different 3.27 ± 1.28 0 – 4 3.35 ± 1.11 0 – 4 19. Been worried about what other people think about 0 – 4 0 – 4 your teeth, mouth, or face

30.29 ± 5.50 15 – 40 31.65 ± 5.80 15 – 40 Social-Emotional score (0- 40) COHIP-19 Summary Score (0- 74) 55.49 ± 9.11 33 - 73 57.81 ± 9.06 34 – 70

Table 5 depicts the detailed mean responses of all participants for items 1-19. Table 6 illustrates that there were no significant differences in the mean quality of life, satisfaction, or domain scores between the two treatment groups among all the test groups analyzed. Thus, regardless of treatment modality, both groups responded to the questionnaire similarly.

58 Table 6: Summary of quality of life, satisfaction and domain scores among all test groups

Fixed Appliances Invisalign® Domain & Test Groups Mean (SD) Range Mean (SD) Range T- Test p-value Oral Health Well-Being (0-20) All participants (n= 74) 13.89 ± 3.03 6 – 20 14.14 ± 3.31 5 – 20 -0.33 0.74 Participants age 14-18 (n= 56) 14.00 ± 2.83 6 – 20 13.50 ± 3.09 5 – 19 0.63 0.53 All males (n= 30) 14.25 ± 2.46 10 – 18 13.93 ± 2.43 9 – 17 0.36 0.72 Males age 14-18 (n= 24) 14.00 ± 1.91 12 – 17 13.55 ± 2.54 9 – 17 0.50 0.62 All females (n= 44) 13.62 ± 3.43 6 – 20 14.26 ± 3.79 5 – 20 -0.59 0.56 Females age 14-18 (n= 32) 14.00 ± 3.37 6 – 20 13.46 ± 3.60 5 – 19 0.43 0.67

Functional Well-Being (0- 16) All participants (n= 74) 11.49 ± 2.77 4 – 16 12.41± 2.36 6 – 16 -1.54 0.13 Participants age 14-18 (n= 56) 11.56 ± 2.31 6 – 16 12.67 ± 2.34 8 – 16 -1.74 0.09 All males (n= 30) 12.25 ± 2.86 8 – 16 13.64 ± 1.91 10– 16 -1.54 0.13 Males age 14-18 (n= 24) 12.00 ± 2.52 8 – 16 13.73 ± 1.95 10 – 16 -1.85 0.08 All females (n= 44) 10.90 ± 2.61 4 – 15 11.65 ± 2.33 6 – 15 -1.00 0.32 Females age 14-18 (n= 32) 11.26 ± 2.18 6– 15 11.77 ± 2.42 8 – 15 -0.62 0.54 Social-Emotional Well-Being (0-40) All participants (n= 74) 30.11 ± 5.50 15 – 40 31.27 ± 5.80 15 – 40 -1.54 0.38 Participants age 14-18 (n= 56) 29.69 ± 5.52 15 – 40 30.00 ± 6.59 15 – 40 -0.19 0.85 All males (n= 30) 30.13 ± 6.04 15 – 39 32.50 ± 3.46 26– 40 -1.29 0.21 Males age 14-18 (n= 24) 28.77 ± 5.79 15 – 35 32.55 ± 3.93 26 – 40 -1.83 0.08 All females (n= 44) 30.01 ± 5.20 20 – 40 30.52 ± 6.81 15 – 38 -0.23 0.82 Females age 14-18 (n= 32) 30.32 ± 5.40 20 – 40 27.85 ± 7.70 15 – 38 1.07 0.29

COHIP-19 Summary Score (0-74) All participants (n= 74) 55.49 ± 9.11 33 - 73 57.81 ± 9.06 34 – 70 -1.10 0.27 Participants age 14-18 (n= 56) 55.25 ± 8.53 33 - 69 56.17 ± 9.88 34 – 70 -0.37 0.71 All males (n= 30) 56.63 ± 8.61 43 - 73 60.07 ± 5.62 49– 70 -1.28 0.21 Males age 14-18 (n= 24) 54.78 ± 7.55 43 - 64 59.82 ± 6.37 49 – 70 -1.75 0.09 All females (n= 44) 54.62 ± 9.58 33 - 69 56.43 ± 10.51 34 – 69 -0.60 0.55 Females age 14-18 (n= 32) 55.58 ± 9.34 33 - 69 53.08 ± 11.43 34 – 68 0.68 0.50

Satisfaction (0- 10) All participants (n= 74) 8.34 ± 1.39 4.45 – 10.00 8.47 ± 1.33 5.20 – 10.00 -0.41 0.68 Participants age 14-18 (n= 56) 8.19 ± 1.42 4.45 – 10.00 8.45 ± 1.32 5.20 – 10.00 -0.71 0.48 All males (n= 30) 8.26 ± 1.52 4.45 – 10.00 8.59 ± 1.13 6.60 – 10.00 -0.66 0.51 Males age 14-18 (n= 24) 8.07 ± 1.60 4.45 – 10.00 8.66 ± 1.17 6.60 – 10.00 -1.02 0.32 All females (n= 44) 8.40 ± 1.32 6.00 – 10.00 8.40 ± 1.45 5.20– 10.00 -0.00 1.00 Females age 14-18 (n= 32) 8.27 ± 1.32 6.00 – 9.95 8.27 ± 1.45 5.20– 10.00 -0.01 1.00

Table 7 reports the significant correlations between the domains and the satisfaction and quality

of life scores.

59

Table 7: Summary of significant correlations (Fixed Appliances, All participants)

Correlation p-value Satisfaction & Social-Emotional Well-Being: 0.58 0.0002 Satisfaction & Overall Quality of Life: 0.52 0.001 Overall Quality of Life & Oral Health: 0.83 <0.001 Overall Quality of Life & Functional Well-Being: 0.68 <0.001 Overall Quality of Life & Social-Emotional Well-Being: 0.86 <0.001

A low impact on Social-Emotional Well-Being domain was significantly correlated with

overall satisfaction in the fixed appliances group. Significant correlations were also noted for

each domain and the overall quality of life score. The domain with the greatest correlation

with the overall quality of life score was Social-Emotional Well-Being (0.86, p= <0.001).

Thus, the lower the impact of the items that comprise this domain, the higher the overall

quality of life. Further, as the overall quality of life increased, so did the satisfaction scores.

Table 8: Summary of significant correlations (Invisalign®, All participants)

Correlation p-value Overall Quality of Life & Oral Health: 0.77 <0.001 Overall Quality of Life & Functional Well-Being: 0.56 0.0003 Overall Quality of Life & Social-Emotional Well-Being: 0.90 <0.001

For the Invisalign® group, each domain was also significantly correlated with the overall quality of life score. The domain with the greatest impact on quality of life was Social-

Emotional Well-Being (0.90, p= <0.01). Unlike the fixed appliances group, there was no significant correlation between the satisfaction score and any domain, or with the overall quality of life score.

60 Chapter 4: Discussion

This study sought to compare the quality of life, treatment experiences, and overall satisfaction of adolescents undergoing treatment with fixed appliances and Invisalign®. There was no significant difference in the mean quality of life, domain, or satisfaction scores between the two treatment groups among all the test groups analyzed, indicating that their overall treatment experience was similar. Each treatment group reported experiencing similar oral health, functional, and social-emotional impacts. Both groups reported fairly high, and similar quality of life scores, indicating a relatively low negative impact of their respective appliances.

(Table 5). However, while there were no significant differences in the overall domain scores between the two groups, there were significantly different responses for individual items that comprise the domains among the six test groups investigated (Table 3).

Tables 7 and 8 illustrate the correlations between the various domains and the overall quality of life and satisfaction scores of the two treatment groups. In both groups, each mean domain score was significantly correlated with the overall quality of life score. Accordingly, the less of a negative impact each of the domains had on daily life, the higher the quality of life score, and vice versa. For both groups, the domain with the highest impact on overall quality of life was Social-Emotional Well-Being. These findings are supported by the systematic review by Javidi, Vettore, and Benson (2017) who reported that social and emotional dimensions are impacted most with orthodontic treatment, and by Bayat et al. (2017) who stated that the benefits of orthodontic treatment are mainly psychosocial.

The mean satisfaction score of the fixed appliances group was almost identical to the

Invisalign® group, and there was no significant difference noted between males and females in the two groups or between the two age groups (11-18 and 14-18). This finding is consistent

61 with the overview of systematic reviews performed by Yassir, McIntyre, and Bearn (2019) and

Al-Omiri and Alhaija (2006) in which age or gender was not found to be related to treatment satisfaction. It is important to note that factors related to treatment satisfaction may not be exclusively related to their experience with their treatment modality alone, but also to their overall experience such as being seen on time, difficulty finding parking, the gentleness of the operator, friendliness of the office environment, and other aspects of the treatment process

(Vig et al. 2007). In the study by Pacheco-Pereira, Brandelli, and Flores-Mir (2018), the doctor-patient relationship was shown to be the most important factor relating to satisfaction.

Thus, a good doctor-patient relationship may be even more important to the patient than just a technical successful treatment outcome (Keles and Bos 2013).

In the fixed appliances group, only the Social-Emotional Well-Being domain was significantly correlated with satisfaction. Thus, the fewer negative impacts this domain had on their psychosocial health, the higher the satisfaction score, and vice versa. These findings are in contrast to the study by Al-Omiri and Alhaija (2006) in which physical impacts such as comfort, function, and ease of eating contributed most to satisfaction. In the Invisalign® group, there was no significant correlation between any of the domains and satisfaction scores.

A significant correlation was also noted between the overall quality of life and satisfaction scores in the fixed appliances group. Therefore, the less obtrusive the fixed appliances were on the daily lives of the sample, the higher their satisfaction scores. There was no significant correlation noted between the overall quality of life and satisfaction scores in the

Invisalign® group.

The fixed appliances group expressed frustrations with the wire poking (18.9%), and the Invisalign® group indicated frustrations with insertion and removal of their appliance.

62 Aside from these unique challenges that are specific to each treatment modality, the distribution of the other responses were more similar. Both groups expressed similar frustrations with being unable to eat certain foods, having generalized pain, sores in the mouth, sensitive teeth, and challenges with brushing and flossing. The majority of both groups either answered “N/A” or left the question blank, which was interpreted as the individual not finding their appliance particularly frustrating or annoying. Overall, the hardships and frustrations associated with treatment are well-tolerated and accepted by patients in order to gain the perceived positive outcomes (Perry et al. 2018).

Similar findings have been corroborated by other authors. In the 2014 study by

Marques et al., adolescent patients in fixed appliances for a minimum of six months reported impaired taste, tooth mobility, halitosis, bleeding gingiva and difficulties with eating, oral hygiene and speech as their main concerns, while Zhang, McGrath, and Hägg (2008) cited bad breath, pain, mouth sores, and food packing in between teeth as additional issues of adolescent patients in treatment for the same duration.

With regard to Invisalign®, the 2018 analysis of YouTube patient testimonials revealed that complaints included speech difficulties, sensitivity, and having to brush before reinserting their aligners after snacking. Pacheco-Pereira, Brandelli, and Flores-Mir (2018), and Nedwed and Miethke (2005) reported food packing between teeth as another common complaint.

However, in this study, only the fixed appliances group reported food getting stuck as a frustration. Furthermore, both groups reported never, or almost never having difficulty saying certain words, although speech complaints were common in studies investigating treatment with either modality (Bernabé, Sheiham, and De Oliveira 2008; Noll et al. 2017; Pacheco-

Pereira, Brandelli, and Flores-Mir 2018; Livas, Delli, and Pandis 2018). However, it is

63 important to note that while the study by Bernabé, Sheiham, and de Oliveira (2008) investigated patients undergoing treatment for a minimum of six months, the study by Noll et al. (2017) and Pacheco-Pereira, Brandelli, and Flores-Mir (2018) did not indicate treatment duration. Therefore, the experiences reported in their studies may have been during their first stages of treatment, when side effects of pain and functional limitations are at their highest.

When asked about problems associated with eating (item 9, Table 2), there was no significant difference in the distribution of responses between the fixed appliances and

Invisalign® group. However, based on the odds ratio, the fixed appliances group was 2.7 times more likely to report difficulties compared to the Invisalign® group (95% CI: 1.1, 7.1, p= 0.04).

The majority of the fixed appliances group reported sometimes having difficulty eating food they would like, whereas the majority of the Invisalign® group reported never having difficulty. Furthermore, 8.1% of the fixed appliances group reported having trouble eating all of the time, compared to no one in the Invisalign® group.

Eating difficulties have been reported in the literature for both treatment modalities.

Carter et al. (2015) found that adolescent patients in fixed appliances report difficulty chewing, being messy while eating, taking longer to finish a meal, and having restricted food choices, while patients treated with Invisalign® desctibe having to follow the “Invisalign®-diet” by decreasing the frequency of their meals, or the changing the types of food they were eating due to tooth sensitivity (Livas, Delli, and Pandis 2018). Although Align Technology promotes

Invisalign® as having an advantage over conventional braces as the removability of the appliance makes it possible to enjoy all the same foods as before having treatment

(Invisalign.com 2019), 32.4% of the Invisalign® group still reported sometimes having difficulty eating the foods they would like. This may be due to the fact that although

64 Invisalign® patients do not necessarily have to restrict their food choices as do those in fixed appliances, aligners must still be removed, and teeth should be brushed before reinserting the aligners, which was a frequently reported complaint noted for item 24 for the Invisalign® group.

In the recent study by Flores-Mir, Brandelli, and Pacheco-Pereira (2018) comparing the quality of life of adult patients in fixed appliances and Invisalign®, findings regarding eating and chewing were significantly different between the two treatment modalities with 47% of

Invisalign® patients reporting 100% satisfaction, compared to only 24% of the fixed appliances group. In this study, the general trend appears to be similar with patients in the fixed appliances group being more likely to report having difficulty eating.

There was no significant difference in the distribution of responses between the two treatment groups with respect to jaw pain. However, 27.8% of the fixed appliances group reported currently having more pain than before starting treatment, compared to 8.3% in the

Invisalign® group. A small proportion of the fixed appliances group (8.3%) reported an improvement in jaw pain, while some patients in both groups with no history of jaw pain reported experiencing new symptoms. This is in contrast to the Invisalign® study by Nedwed and Miethke (2005) in which patients who reported TMJ problems such as clicking (9%) already had symptoms prior to commencing treatment, and no new symptoms were reported. It is important to note that the etiology of temporomandibular disorder (TMD) is considered multifactorial, and there is no association between orthodontic treatment during adolescence and the development or prevention of TMD later in life (Michelotti and Iodice 2010).

Furthermore, because signs and symptoms of TMD increase with age, particularly during adolescence, TMD that arises during orthodontic treatment may not be correlated (Michelotti

65 and Iodice 2010).

There was a significant difference in the distribution of responses between the respondents in fixed appliances and Invisalign® with regard to the time taken to adapt to treatment (item 31, Table 4). While the majority of patients in both treatment groups took between one and two weeks to adapt to treatment, 24.3% of the fixed appliances group took three months compared to only 2.7% of the Invisalign® group who took as long. The absence of brackets and wires, not having to adjust oral hygiene techniques or diet, and the decreased visibility of the Invisalign® appliance may be factors that aid in faster adaptation. Chen, Wang, and Wu (2010) reported that adolescent patients undergoing orthodontic treatment with fixed appliances reported pain and discomfort being at the worst level during the first week after bonding. However, by one month, OHRQoL was similar to baseline levels, compared to approximately one-fourth of the fixed appliances sample in this study that required three months. Nedwed and Miethke (2005) reported that the majority of the patients took one week

(but never exceeding two weeks) to adapt to Invisalign® treatment, which is consistent with the sample in this study.

While patients in fixed appliances commonly experience ulcerations and mucosal damage (Baricevic et al. 2011), there was no significant difference noted in the distribution of responses between the two treatment groups with regard to the frequency of sore spots due to fixed appliances or Invisalign® (item 22, Table 2). The similarity of responses between both groups is surprising, considering the lack of wires and brackets in the Invisalign® group.

Patients in the Invisalign® group may have reported a similar frequency of sore spots as those in the fixed appliances group due to potential irritation from their attachments during function, pinching of soft tissue during insertion, and a possible rough finish of the aligner edges.

66 Research in healthcare has shown that satisfaction is influenced by expectations and that expectations are the best predictors of patient satisfaction (Hsieh and Kagle 1991).

Patients possess certain positive expectations of the treatment that they will receive, and when their experience meets these expectations, they are likely to be satisfied (Hsieh and Kagle

1991). Williams (1994) found that patients with a higher number of met expectations had significantly higher satisfaction scores compared to those with a lower number of fulfilled expectations. Alternatively, patients may also have certain negative expectations about treatment, and when their experience is better than they expected, they may express higher satisfaction. These findings were supported by the results of this study. Participants who felt that their expectations were exceeded had significantly higher satisfaction scores in both treatment groups.

Item 34 asked participants to provide their top three expectations of treatment. In general, each treatment group expressed similar expectations. Interestingly, the main expectations reported were in contrast to what is cited in the literature. The top three expectations of treatment in the fixed appliances group were: 1) They will help me to have a healthier mouth, 2) They will make me more confident, and 3) They will help me to smile more. The top three expectations of treatment in the Invisalign® group were: 1) They will help me to smile more, 2) They will make me more confident and 3) Tie between: 3a) They will make me more attractive and 3b) They will help me to have a healthier mouth (item 34, Table

2). While it is important to note that these expectations were chosen from a provided list of options in the questionnaire, the respondents were also given the option to list their own motivations.

The most common motivation for orthodontic improvement reported by various

67 authors is an esthetic improvement (Kiyak 2008; Daniels, Seacat et al. 2009; Marques, Pordeus et al. 2009; Abdullah, Yassin et al. 2001; Wedrychowska-Szulc and Syryńska 2010; Yassir,

McIntyre et al. 2019; de Oliveira & Sheiham 2003; Geoghegan, Birjandi et al. 2019). Kiyak’s study (2008) revealed that regardless of ethnicity, gender, and age differences, improved appearance is a greater motive for young patients than improvements in oral function. It has been estimated that 80% of patients seek treatment for esthetic concerns, instead of for health or function (de Oliveira and Sheiham 2003). However, the results of this study show that having a healthier mouth was the top expectation for the fixed appliances group, and the third most important (tied with esthetic improvement) in the Invisalign® group. Given the high focus on esthetics in today’s generation of adolescents, it was surprising to see that only the

Invisalign® group chose improving esthetics as a top-rated expectation of treatment, and only ranked third in importance. This finding is similar to the study by Miller et al. (2007) of adult patients in which more patients in the Invisalign® group reported wanting to improve their appearances when compared to the fixed appliances group. Given this sample’s IOTN of 2 or

3, perhaps esthetics concerns were not as paramount in this sample. However, it is also important to note that the anatomical severity of one’s malocclusion is not always proportional to their individual perceived need (Agou et al. 2008). Another consideration is the Hawthorne effect (Abreu et al. 2018). Since patients knew they were being evaluated, they may not have wanted to admit their desire to improve their appearance and instead chose more modest choices such as improving oral health.

When asked why they chose to have treatment (item 32, Table 2), the respondents were asked to choose as many predefined options that were applicable. The majority of both groups responded that it was a shared decision between themselves and their parents, and that their

68 general dentist also played a role. This is consistent with findings from other studies in which the patients’ general dentist’s recommendation was a key reason for seeking treatment

(Geoghegan et al. 2019, Daniels, Seacat, and Inglehart 2009). Almost one-fifth of each treatment group stated that they got treatment because they wanted to, as opposed to choosing the option that included their parents in the decision (item 32, Table 2). Similar findings were also reported by Trulsson et al. (2002) and in Daniels, Seacat, and Inglehart (2009), in which adolescent patients also reported that they felt they had made the independent decision to have treatment, possibly representing their effort to exert autonomy.

For participants between the ages of 14 and 18, a significant difference in the distribution of responses was noted for item 8 (p= 0.007). Almost half of the Invisalign® group

(48.5%) reported feeling confident almost all of the time compared to only 9.4% of the fixed appliances group (item 8, Table 4). However, the majority of the fixed appliances group

(40.6%) reported feeling confident fairly often, which is still a relatively regular occurrence, and the difference between reporting almost all of the time versus fairly often may not be clinically significant. Given that attention is usually focused on the face and mouth during social interactions (Sergl, Klages, and Zentner 2000), perhaps the majority of the Invisalign® group reported feeling confident almost all of the time more often than the fixed appliances group due to the decreased visibility of the appliance, and because of its ability to be removed for social events. However, in general, both groups reported high levels of confidence.

There was no statistical difference in the distribution of responses between the fixed appliances and Invisalign® group with regard to items 11, 12, 19 and 21. The large majority of both groups did not feel like their appliances inhibited them from wanting to speak or read out loud in class, did not avoid smiling or laughing because of their appliance, did not worry about

69 what others thought about their appliances, and did not feel shy or embarrassed around their friends because of their appliance. These findings imply that their appliances did not adversely affect their confidence.

Chen, Wang, and Wu (2010) reported that even though patients expressed feeling self- conscious and embarrassed during treatment, undergoing treatment still led to an increase in self-concept and a decrease in negative social experiences overall. Thus, the overall positive socio-emotional findings in both groups in this study could be related to the concept of gaining confidence and empowerment by undergoing treatment and addressing a malocclusion

(Seehra, Newton, and Dibiase 2013). Furthermore, since orthodontic treatment is popular in the adolescent population, peers are accustomed to seeing orthodontic appliances, which may also play a role in making patients’ psychological adaptation easier (Zhang, McGrath, and

Hägg 2008).

Since orthodontic appliances are viewed as a part of a normal dental appearance in teenagers (Patel et al. 2010), it may explain why such a high proportion of the fixed appliances and Invisalign® group reported never being teased, bullied or called names by other children in the past three months due to their appliance (item 14, Table 2). However, patients still reported feeling that they looked different because of their appliance (item 16, Table 2), despite the popularity of orthodontic treatment in the adolescent age group. This may be due to the fact that adolescents tend to be self-conscious and are concerned with their image (Proffit et al.

2019).

In the all male sample (n=30) and in the males aged 14-18 years sample (n= 24), a significant difference in the distribution of responses regarding flossing frequency was noted

(item 30, Table 4). In both subgroups, the Invisalign® group reported flossing more frequently

70 compared to the fixed appliances group. This is likely due to the lack of wires and brackets which makes flossing an easier process.

Item 18 asked whether each group had difficulty keeping their teeth clean in the past three months. Given that it is more challenging to brush and floss in fixed appliances due to trapped food and oral debris around brackets and wires, it was surprising to see that there was no significant difference in the distribution of responses between the fixed appliances and

Invisalign® group among any of the test groups analyzed. The majority of the Invisalign® group (78.3%) reported never or almost never having difficulty keeping their teeth clean. This can be attributed to the ability to remove the aligners, which facilitates easier oral hygiene procedures. In the fixed appliances group, only 56.7% had the same response.

Tuncay, Bowman et al. (2013) reported significantly better oral conditions in adolescent patients treated with Invisalign® compared to patients wearing fixed appliances.

These findings were also corroborated by two recent systematic reviews with meta-analysis which concluded that clear aligners allowed for better periodontal health compared to fixed appliances (Lu et al. 2018, Jiang et al. 2018). Nonetheless, it must be kept in mind that aligners still pose a significant risk to one’s oral health due to the decreased salivary flow, interruption to self-cleansing processes, and plaque entrapment as a result of the full-coverage design of aligners (Azeem and Hamid 2017). When asked to rate their own oral health, there was no significant difference in the distribution of responses between the two groups. The majority of both groups stated that their oral health was either good, or excellent (item 20, Table 2). While patients had to possess good oral health in order to be eligible to participate in this study, the oral health between the groups was not compared clinically.

Item 3 asked respondents whether they had any discolored spots on their teeth, and no

71 significant difference was found in the distribution of responses between the two groups.

However, this finding must be evaluated with caution for many reasons. First, these spots cannot be interpreted as meaning white spot lesions, especially since they were not evaluated by a dental professional. Second, patients may have had spots on their teeth prior to commencing treatment.

With respect to item 4, there was no significant difference in the distribution of responses between the two groups with regard to whether they felt they had bad breath, although this is a frequent complaint during orthodontic treatment with fixed appliances

(Abdulraheem et al. 2019; Man Zhang, McGrath, and Hägg 2008).

In the all female sample 4 (n= 44), and in the females aged 14-18 years sample (n= 32), there was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group with regard to having trouble sleeping in the past three months due to their appliances (item 13, Table 4). While approximately two-thirds (61.9%) of the fixed appliances group reported never having trouble sleeping because of their appliance, only approximately one-third of the Invisalign® group (30.4%) had the same response. However, the majority of the Invisalign® group (60.9%) reported almost never having trouble sleeping because of their appliance, which is also a positive response. Therefore, the difference between never and almost never may not be clinically significant. Overall, both groups reported never or almost never having trouble sleeping in the past three months because of their appliances.

This is consistent with the findings of Bernabé, Sheiham, and de Oliveira (2008) and Marques et al. (2014) who reported that sleep was rarely affected during fixed appliance therapy, and

Noll et al. (2017) who found that both the fixed appliances and Invisalign® group reported similar levels of sleep.

72 In the all female sample, there was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group (p= 0.04) with regard to feeling attractive because of their appliances (item 15, Table 4). The majority of the Invisalign® group

(39.1%) reported feeling attractive fairly often due to their appliance, compared to only 4.8% of the females in the fixed appliances group. There was no significant difference found in the male group of the same age. These findings are consistent with the emphasis placed on female beauty and appearance in western society, resulting in adolescent females being concerned with their image (Helfert and Warschburger 2013). The decreased visibility of the Invisalign® appliance, and the ability to remove the appliance for social events may explain why more females in Invisalign® report feeling attractive more often compared to those in fixed appliances.

With regard to item 1, there was no significant difference noted in the distribution of responses between the fixed appliances and Invisalign® group (Table 2). The majority of both groups reported that they sometimes have pain in their teeth, and the majority of the remainder reported never, or almost never having pain. These findings are consistent with the study by

Mandall et al. (2006) of patients undergoing fixed appliance therapy in which pain after the first six months of treatment was fairly low. For those who reported never or almost never experiencing pain in the Invisalign® group, the reason may be due to the fact that tooth movement per aligner is minimal and precisely controlled. Additionally, after active movement of a tooth, it is immobilized in a splint-like effect with subsequent aligners

(Nedwed and Miethke 2005). The overall low to moderate frequency of pain reported by both groups may be due to the fact that because post-adjustment pain or pain after changing aligners is relatively short- lived, the overall impact on daily life between appointments may not be as

73 marked, especially since most patients tend to adapt to treatment by the third month (Johal,

Fleming, and Al Jawad 2014). Another consideration is that because patients may be expecting some amount of pain during treatment, they may be able to cope better (Mandall et al. 2006).

Although there was no significant difference noted in the distribution of responses between the two treatment groups regarding missing school for any reason because of their appliance (item 7, Table 2), when an odds ratio was calculated, it revealed that the fixed appliances group was 3.8 times more likely to report having to miss school compared to the

Invisalign® group (95% CI: 1.2, 12.5, p= 0.04). The majority of the Invisalign® group reported never having to miss school (62.9%) compared to 44.4% of the fixed appliances group. This may be due to the fact that treatment with Invisalign® often involves greater intervals between appointments. However, this finding must be interpreted with caution as some patients may be booking appointments strategically in order to avoid missing school.

The large majority of both treatment groups in this study stated that they would choose their current treatment modality if they had to have treatment again (item 39, Table 2).

However, 24.3% of the fixed appliances group (n= 9) would switch to Invisalign®, and 13.5% of the Invisalign® group (n= 5) would switch to fixed appliances. No significant difference was noted in each treatment group with regard to which group was more likely to stay, or switch from their currently treatment modality if they had to have treatment again. Overall, the high satisfaction reported by both groups is consistent with previous research that demonstrates that the benefits of orthodontic treatment are highly valued (Perry et al. 2018).

The results of this study suggest that both groups are generally very satisfied with their treatment modality. This is in contrast to the study by Azaripour, Weusmann et al. (2015) in which the Invisalign® group expressed greater satisfaction and less negative impacts compared

74 to the fixed appliances group. However, it is important to note that the age of their sample ranged from 11-62 years old. The high satisfaction measured in this study is analogous to the quality of life study by Flores-Mir, Brandelli et al. (2018) of adult patients in which the authors found that there was statistically similar satisfaction outcomes for almost all of the aspects investigated in both groups. Thus, despite the various advantages promoted by Align

Technology over fixed appliances such as improved esthetics, comfort and hygiene

(Invisalign®.com 2019), patient satisfaction and quality of life were comparable between the

Invisalign® group and those in fixed appliances.

Clinical Significance

It is essential to understand the physical and psychosocial effects of wearing orthodontic appliances on one’s daily life in order to provide advice and encouragement during treatment and to enhance the odds of achieving a successful outcome. By providing evidence- based information regarding patient perceptions and experiences, realistic expectations can be provided during the informed consent process. This can aid the clinician, the patient and their parents in choosing the most appropriate treatment modality. Making more informed decisions may also help improve patient compliance and treatment outcome, all of which will contribute to enhanced patient satisfaction and an improvement in the quality of life.

Considerations and Limitations

The present study has several limitations and considerations that must be taken into account when evaluating the validity and reliability of the findings.

First, the study of OHRQoL in adolescents is complicated by the fact that one’s concept of quality of life can change with age. Thus it can be difficult to separate changes due

75 to normal development from those due to orthodontic intervention (Cunningham and O’Brien

2007). Another factor to consider is cognitive development. Children must not only understand the questions, but they must also have an understanding of how to grade their responses relative to a specific scale (Cunningham and O’Brien 2007). The relevance and interpretation of questions can differ between children of similar ages, or may not be as applicable to children even a few years apart in age. Furthermore, although the survey asked the patient to complete it on their own without the aid of their parent/guardian, there may have been parental involvement, which may have influenced responses.

It is also essential to emphasize that the concept of satisfaction is considered ambiguous and more research is required to better understand its validity. Although many approaches have been tested, satisfaction studies have consistently shown that most patients are generally satisfied with their care, despite health care providers being unable to provide perfect care, all of the time (Staniszewska and Ahmed 1999). Furthermore, patients may not naturally rate their health care experience in terms of a satisfaction ranking, making satisfaction a challenging concept to measure.

Another limitation of this study is the fact that only the first half of this questionnaire was validated (items 1-20) while the remainder was constructed by the authors of this study.

Another consideration is that while participants in this study had to be in treatment for a minimum of six months in order to become adapted to their appliance, there was no further attempt to standardize the duration of treatment time when they responded to the survey. Thus, some respondents may have been in treatment for less than twelve months, or some may have been in treatment for over two years. This range in treatment duration at the time of survey delivery may have led to variability in their responses. Additionally, the cross-sectional nature

76 of this study also poses a limitation as it only allows for a snapshot of their current situation and may not be representative of their overall experience.

Finally, the Hawthorne effect may have played a role in the choice of responses as patients may have altered their behaviour due to their awareness of being evaluated (Abreu, dos Santos et al. 2018). It could also be argued that the findings were simply a result of the natural fluctuations in OHRQoL that occur in the adolescent population (Javidi, Vettore, and

Benson 2017) .

Future Recommendations

The second half of the questionnaire used in this study should be validated. In order to enhance the study’s power and generalizability, a prospective randomized control trial should be conducted to ensure even allocation of patient numbers, gender, and age. A longitudinal design would capture the dynamic concept of OHRQoL by observing patients at various controlled time points.

77 Chapter 5: Conclusion

The overall oral health-related quality of life of adolescent patients undergoing treatment by fixed appliances and Invisalign® for a minimum of six months is similar.

However, there was a difference in the time taken to adjust to appliances with the Invisalign® group demonstrating faster adaption. Additionally, the fixed appliances group was 3.8 times more likely to report missing school because of their appliance and 2.7 times more likely to report having difficulty eating certain foods compared to the Invisalign® group. When females between the ages of 14-18 was analyzed, a higher proportion of the Invisalign® group reported feeling attractive compared to the fixed appliances groups. Overall, both groups experienced similar challenges, and the process of treatment, regardless of modality, imparted a relatively low impact on their oral health, and on their emotional and functional well-being (Figure 2).

Both groups expressed high satisfaction with treatment, and the majority would choose their current modality again.

Revisiting the Null Hypotheses:

1. There is no difference in the quality of life scores between the fixed appliances group and

the Invisalign® group.

• There was no significant difference noted. Therefore, the first null hypothesis is accepted.

2. There is no difference in the overall satisfaction scores between the fixed appliances

group and the Invisalign® group.

• There was no significant difference noted. Therefore, the second null hypothesis is accepted

3. There is no difference in the domain scores between the fixed appliances group and the

78 Invisalign® group.

• There was no significant difference noted. Therefore, the third null hypothesis accepted.

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Appendices

92 Appendix 1

93

Appendix 2

94 Appendix 3

95 Appendix 4

Box 1-2 from Proffit, William R., Henry W. Jr. Fields, Brent E. Larson, and David M. Sarver. 2019. Contemporary Orthodontics. Edited by William R Proffit. 6th ed. St. Louis, Mo: Elsevier/Mosby.

96 Appendix 5

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99 Appendix 7

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Appendix 8

Journal Article

Title: Quality of Life in an Adolescent Orthodontic Population: Invisalign® versus Fixed Appliances

Authors: Richa Sharma a; Robert Drummond b; Robert Schroth c; Mary Bertone d; Milos Lekic e Robert Tate f

a Graduate Orthodontic Resident, Department of Preventive Dental Science, Division of Orthodontics, College of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada. b Assistant Professor, Graduate Orthodontic Clinic Director, Department of Preventive Dental Science, Division of Orthodontics, College of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada. c Professor, Department of Preventive Dental Science, College of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada. d Director and Associate Professor, School of Dental Hygiene, College of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada. e Assistant Professor, Department of Preventive Dental Science, Division of Orthodontics, College of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada. f Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.

Corresponding author: Dr. Richa Sharma, c/o Robert Drummond, Department of Preventive Dental Science, Division of Orthodontics, School of Dentistry, University of Manitoba, 790 Bannatyne Avenue, Winnipeg, Manitoba, R3E 0W2, Canada.

105 Abstract

Objective: To investigate adolescent orthodontic patient experiences with fixed appliances

compared to Invisalign® by means of a quality of life questionnaire.

Materials and Methods: The study was reviewed and approved by the University of Manitoba’s

Health Research Ethics Board. Adolescent patients between the ages of 11-18 from the

University of Manitoba Graduate Orthodontic Clinic and from four private practices in Winnipeg

currently undergoing orthodontic treatment with either Invisalign® or a fixed appliance were

provided a questionnaire. Pearson's chi-squared test was used to evaluate whether the participants

in the fixed appliances group answered each item differently than those in the Invisalign® group

(p < 0.05), and unpaired t-tests (p < 0.05), were used to test for differences in mean satisfaction,

quality of life, and domain scores.

Results: Overall, 74 patients (37 in each group) participated. No significant difference was noted

in the mean quality of life, domain, or satisfaction score between the two groups. A significant

difference was noted in the time taken to adjust to appliances with the Invisalign® group

demonstrating faster adaption. Additionally, the fixed appliances group was 3.8 times more likely

to report missing school because of their appliance (95% CI: 1.2, 12.5) and 2.7 times more likely

to report having difficulty eating certain foods compared to the Invisalign® group (95% CI: 1.1,

7.1). When the subgroup of females between the ages of 14-18 was analyzed, a higher proportion

of the Invisalign® group reported feeling attractive compared to the fixed appliances groups.

Conclusion: Both groups expressed high satisfaction with treatment and reported similar

treatment experiences. The overall oral health-related quality of life of adolescent patients

undergoing treatment in fixed appliances and Invisalign® for a minimum of six months is similar.

106 Introduction

Background

Today’s orthodontic patients have the option of two different treatment

modalities: fixed orthodontic appliances and clear aligners. Fixed orthodontic

appliances, also known as braces, have been the conventional modality for over a

century (Ke, Zhu, and Zhu 2019). However, since Invisalign® was introduced in

1997, treatment with clear aligners have become a fast-growing sector in

orthodontics (Wheeler 2017). The choice of one treatment modality over the other

may impact quality of life during treatment.

Align Technology advertises Invisalign® treatment as offering a superior patient

experience over traditional fixed appliances by emphasizing comfort, esthetics, easier

hygiene, and a better overall lifestyle (Invisalign.com 2019). Patients who choose to

be treated with Invisalign® are often seeking appliances that are less obtrusive in their

daily lives and they are willing to incur greater treatment costs with the hopes of

acquiring less negative impacts on their quality of life (Miller et al. 2007).

Concept of Oral Health-Related Quality of Life

Quality of life is considered to be a multidimensional concept that is

influenced by many different factors. The World Health Organization Quality of Life

Group defines it as an individual’s perception of their position in life in the context of

culture and value systems in which they live and in relation to their personal goals,

expectations, standards and concerns (Broder, McGrath, and Cisneros 2007). It can

also be described as a "sense of well-being derived from satisfaction or

dissatisfaction with areas of life considered important for an individual" (Feu,

107 Quintão, and Miguel 2010).

The impact of oral health on one’s quality of life is referred to as oral health-

related quality of life (OHRQoL). This can be further described as the functional

impacts, psychosocial impacts and symptoms that occur as a result of diseases and

disorders (Locker, Matear, and Jokovic 2002). Measuring OHRQoL is becoming an

increasingly valuable evaluation in dentistry as patient-centered research helps to

reduce the knowledge and perception gaps between the patient and the orthodontist

and provides evidence that is suitable for patients to understand (Hua 2019).

Quality of Life Measures

The survey instrument used in this study was the Child Oral Health Impact

Profile (COHIP) Short Form-19, with additional supplementary questions added by

the authors. The COHIP is a validated instrument reported by children and

adolescents and is well known in dental research (Kragt et al. 2016).

Purpose

The purpose of this study was to address a gap in the literature regarding

adolescent patient experiences in fixed appliances an Invisalign®, and to aid in

shaping the informed consent process by providing patients with realistic

expectations of what they may experience during treatment, which will assist families

and patients in choosing which treatment modality will suit their individual needs

best. The objective was to compare the treatment impacts, quality of life and

satisfaction of adolescents in fixed appliances versus Invisalign®.

108 Materials and Methods

Ethical approval was obtained from the University of Manitoba Health

Research Ethics Board.

Patients between the ages of 11-18 from the University of Manitoba Graduate

Orthodontic Clinic and from four private practices in Winnipeg currently undergoing

orthodontic treatment with either Invisalign® or fixed appliances were enrolled into

this study. Informed consent was obtained from the participants prior to

administering the questionnaire. Entry to win either a $100 Visa gift card, or an

electric toothbrush was used as incentive to increase participation.

Inclusion Criteria

Patients between the ages of 11-18 who were:

• Active patients in treatment for a minimum of six months

• Grade 2 or Grade 3 in the Index of Treatment Need

• Undergoing their first course of orthodontic treatment

Exclusion Criteria

• Patient of principal investigator

• Learning difficulties

• Physical disability

• Chronic medical conditions

• Symptoms of pain or discomfort from any other body part

• Active dental decay

• Poor periodontal health

• Syndromes and craniofacial anomalies 109 • No history or current use of other auxiliary appliances

• Extraction cases

® • Patients who have experienced both fixed appliances and Invisalign

Questionnaire

The COHIP-19 assesses three domains: Oral Health Well-Being, Functional Well-

Being, and Social-Emotional Well-Being. All participants were instructed to choose

the answer that best describes their experience in the past three months regarding

their teeth, mouth or face. They were also asked to consider their fixed appliances or

Invisalign® when responding. Five possible responses to the 19 items include: never,

almost never, sometimes, fairly often, and almost all of the time, recorded on a Likert

scale of 0 - 4. The domain score was produced by summing the mean scores of each

item that comprise that domain. The total COHIP score, referred to as the quality of

life score, was generated by summing the mean scores of each domain. Scoring of the

negatively worded items was reversed, and a higher COHIP score reflects a more

positive OHRQOL (Broder and Wilson-Genderson, et al. 2012). In addition to this

validated questionnaire, supplementary questions of interest were added to the

survey.

Satisfaction Measurement

A 10 cm visual analog scale was used to measure each respondent’s overall

satisfaction with their treatment modality on a typical day, with a higher

measurement indicating greater satisfaction.

110 Statistical Analysis

Descriptive analysis of the data was performed to analyze the frequency of events

and the extent of the impact of fixed appliances compared to Invisalign® on the oral

health-related quality of life of adolescents. Using a 95% confidence interval, odds

ratios were calculated for Group 1 for each item of the survey where applicable (p <

0.05). In order to construct a 2x2 table to determine the odds ratio, the responses

sometimes, fairly often and almost all of the time were combined together, and the

responses almost never, and never were combined separately in order to create a

binary response. Additionally, inferential analysis of the data was performed using

Pearson's chi-squared test to evaluate whether the participants in the fixed appliances

group answered each item differently than those in the Invisalign® group (p < 0.05),

and unpaired t-tests (p < 0.05) were used to test for differences in mean satisfaction,

quality of life, and domain scores.

Test Groups

All participants: Full sample between the ages of 11-18 (n=74)

Fixed Appliances: n= 37, Invisalign®: n= 37

In order to investigate potential gender and age differences, the participants

were divided into the following groups:

Participants age 14-18 years: All participants between the ages of 14-18 (n=56)

Fixed Appliances: n= 32, Invisalign®: n= 24

All males: All male participants (n=30)

111 Fixed Appliances: n= 16, Invisalign®: n= 14

Males age 14-18 years: All male participants between the ages of 14-18 (n=24)

Fixed Appliances: n= 13, Invisalign®: n= 11

All females: All female participants (n=44)

Fixed Appliances: n= 21, Invisalign®: n= 23

Females age 14-18 years: All female participants between the ages of 14-18 (n=32)

Fixed Appliances: n= 19, Invisalign®: n= 13

Results:

A total of 74 adolescents participated in this study. The mean age of the participants

was 14.9 ± 1.9 years. There was no significant difference in the distribution of

genders in both groups (p= 0.81). Table 1 below depicts the distribution of ages in

each treatment group.

Table 2 depicts the detailed mean responses of all participants for items 1-19.

Table 3 illustrates that there were no significant differences in the mean quality of

life, satisfaction, or domain scores between the two treatment groups among all the

test groups analyzed. Thus, regardless of treatment modality, both groups responded

to the questionnaire similarly.

No significant differences were noted between the treatment groups with

respect to experiencing pain, bad breath, sore spots, speech issues, difficulty keeping

teeth clean, trouble focusing in the classroom, feeling worried or anxious, feeling shy

or embarrassed around friends, feeling annoyed or frustrated, avoiding smiling or

112 laughing, being teased or bullied, or feeling that they looked different because of

their fixed appliances or Invisalign®.

Discussion:

This study sought to compare the quality of life, treatment experiences, and

overall satisfaction of adolescents undergoing treatment with fixed appliances and

Invisalign®. There was no significant difference in the mean quality of life, domain,

or satisfaction scores between the two groups among all the test groups analyzed,

indicating that their quality of life and overall treatment experience was similar. Both

treatment groups reported fairly high, and similar quality of life scores indicating a

low negative impact of their respective appliances (Table 3).

With regard to experiencing difficulty eating, the fixed appliances group was 2.7

times more likely to report difficulties compared to the Invisalign® group. The

majority of the fixed appliances group reported sometimes having difficulty eating

food they would like, whereas the majority of the Invisalign® group reported never

having difficulty. Furthermore, 8.1% of the fixed appliances group reported having

trouble eating all of the time, compared to 0% in the Invisalign® group.

A similar trend was noted in the recent study by Flores-Mir, Brandelli, and

Pacheco-Pereira (2018) comparing the quality of life of adult patients in fixed

appliances and Invisalign®, in which findings regarding eating and chewing were

significantly different between the two treatment modalities with 47% of Invisalign®

patients reporting 100% satisfaction, compared to only 24% of the fixed appliances

group.

Eating difficulties have been reported in the literature for both treatment

113 modalities. Carter et al. (2015) found that adolescent patients in fixed appliances

reported difficulty chewing foods, being messy while eating, taking longer to finish a

meal, and having restricted food choices, while in the Invisalign® group, tooth

sensitivity often caused patients to follow the “Invisalign®-diet” by decreasing the

frequency of their meals, or the type of foods they were eating (Livas, Delli, and

Pandis 2018).

Although Align Technology promotes Invisalign® as having an advantage

over conventional fixed appliances as the removability of the appliance makes it

possible to enjoy all the same foods as before having treatment (Invisalign.com

2019), 32.4% of the Invisalign® group still reported sometimes having difficulty

eating the foods they would like. This may be due to the fact that although

Invisalign® patients do not necessarily have to restrict their food choices as do those

in fixed appliances, aligners must still be removed, and teeth should be brushed

before reinserting the aligners

There was a significant difference in the distribution of responses between the

fixed appliances and Invisalign® group with regard to the time taken to adapt to

treatment in the all participants group, and the all female group. While the majority

of patient in both treatment groups took between one and two weeks to adapt to

treatment, 24.3% of the fixed appliances group took three months to adapt to their

appliances, compared to only 2.7% of the Invisalign® group. The absence of brackets

and wires, not having to adjust oral hygiene techniques, and the decreased visibility

of the Invisalign® appliance may be factors that aid in faster adaptation.

When asked about feeling confident, a significant difference in the

distribution of answers was noted in Subgroup 1 (p= 0.007). Almost half of the

114 Invisalign® group (48.5%) reported feeling confident all of the time compared to only

9.4% of the fixed appliances group. However, the majority of the fixed appliances

group (40.6%) reported feeling confident fairly often, which is still a relatively

regular occurrence, and the difference between reporting all the time versus fairly

often may not be clinically significant. In the all female sample, there was a

significant difference in the distribution of responses between the fixed appliances

and Invisalign® group (p=0.04) with regard to feeling attractive because of their

appliances. The majority of the Invisalign® group (39.1%) reported feeling attractive

fairly often due to their appliance, compared to only 4.8% of the females in the fixed

appliances group. Given that attention is usually focused on the face and mouth

during social interactions (Sergl, Klages, and Zentner 2000), perhaps the Invisalign®

group reported feeling confident and attractive more often than the fixed appliances

group due to the decreased visibility of the appliance, and due to the fact that it can

be removed for social events.

Given that it is more challenging to perform oral hygiene techniques in fixed

appliances due to trapped food and oral debris around brackets and wires, it was

surprising to see that there was no significant difference between the treatment

groups in any of the groups analyzed. The majority of the Invisalign® group (78.3%)

reported never, or almost never having difficulty keeping their teeth clean. This can

be attributed to the ability to remove the aligners which facilitates easier oral hygiene

procedures. In the fixed appliances group, only 56.7% had the same response.

When asked about missing school for any reason because of their appliance,

the fixed appliances group was 3.8 times more likely to report having to miss school

compared to the Invisalign® group. The majority of the Invisalign® group reported

115 never having to miss school (62.9%), compared to 44.4% of the fixed appliances

group who chose the same response. This may be due to the fact that treatment with

Invisalign® often involves greater intervals between appointments. However, this

finding must be interpreted with caution as some patients may be booking

appointments strategically in order to avoid missing school.

The results of this study suggest that both groups are generally very satisfied with

their treatment modality. This is in contrast to the study by Azaripour, Weusmann et

al (2015) in which the Invisalign® group expressed greater satisfaction and less

negative impacts compared to the fixed appliances group. However, it is important to

note that the age of their sample ranged from 11-62 years old.

The high satisfaction measured in this study reflect similar findings in the quality of

life study by Flores-Mir, Brandelli et al (2018) of adult patients in which the authors

found that there were statistically similar satisfaction outcomes for almost all of the

dimensions investigated in both groups. Thus, despite the various advantages

promoted by Align Technology over fixed appliances such as improved esthetics,

comfort and hygiene, patient satisfaction was comparable between the Invisalign®

group and those in fixed appliances.

This study should be interpreted within its limitations. OHRQoL in adolescents is

complicated by the fact that one’s concept of quality of life can change with age.

Thus it can be difficult to separate changes due to normal development from those

due to orthodontic intervention (Cunningham and O’Brien 2007). Another factor to

consider is that the cross-sectional nature of this study only allows for a snapshot of

their current situation may not be representative of their overall experience.

116 Conclusion:

• There was no significant difference in the mean domain, quality of life, or

satisfaction scores between the two treatment groups among all test groups analyzed.

• The Invisalign® group demonstrated faster adaption to treatment.

• The fixed appliances group was 3.8 times more likely to report having to miss school.

• The fixed appliances group was 2.7 times more likely to report having difficulty

eating.

• A higher proportion of the females between 14-18 in the Invisalign® group reported

feeling attractive.

• Overall, the findings from this study can be used to help clinicians, parents and

patients select a treatment modality that will suit the patients’ needs best.

References

Azaripour, A., J. Weusmann, B. Mahmoodi, D. Peppas, A. Gerhold-Ay, C. J.F. Van Noorden, and B. Willershausen. 2015. “Fixed appliances versus Invisalign®: Gingival Parameters and Patients’ Satisfaction during Treatment: A Cross-Sectional Study.” BMC Oral Health 15 (1): 1–5. https://doi.org/10.1186/s12903-015-0060-4. Broder, Hillary L., Colman McGrath, and George J. Cisneros. 2007. “Questionnaire Development: Face Validity and Item Impact Testing of the Child Oral Health Impact Profile.” Community Dentistry and Oral Epidemiology 35 (SUPPL. 1): 8–19. https://doi.org/10.1111/j.1600-0528.2007.00401.x. Broder, Hillary L., and Maureen Wilson-Genderson. 2012. “Reliability and Convergent and Discriminant Validity of the Child Oral Health Impact Profile (COHIP Child’s Version).” Community Dentistry and Oral Epidemiology 35 (SUPPL. 1): 20–31. https://doi.org/10.1111/j.1600-0528.2007.0002.x. Carter, Louise A., Mieke Geldenhuys, Paula J. Moynihan, Dina R. Slater, Catherine E. Exley, and Sarah L. Rolland. 2015. “The Impact of Orthodontic Appliances on Eating - Young People’s Views and Experiences.” Journal of Orthodontics 42 (2): 117 114–22. https://doi.org/10.1179/1465313314Y.0000000128. Cunningham, Susan J., and Catherine O’Brien. 2007. “Quality of Life and Orthodontics.” Seminars in Orthodontics 13 (2): 96–103. https://doi.org/10.1053/j.sodo.2007.03.005. Feu, Daniela, Cátia Cardoso Abdo Quintão, and José Augusto Mendes Miguel. 2010. “Quality of Life Instruments and Their Role in Orthodontics.” Dental Press Journal of Orthodontics 15 (6): 61–70. https://doi.org/10.1590/S2176-94512010000600008. Flores-Mir, Carlos, Jeremy Brandelli, and Camila Pacheco-Pereira. 2018. “Patient Satisfaction and Quality of Life Status after 2 Treatment Modalities: Invisalign and Conventional Fixed Appliances.” American Journal of Orthodontics and Dentofacial Orthopedics 154 (5): 639–44. https://doi.org/10.1016/j.ajodo.2018.01.013. Hua, Fang. 2019. “Increasing the Value of Orthodontic Research Through the Use of Dental Patient-Reported Outcomes.” Journal of Evidence-Based Dental Practice 19 (2): 99–105. https://doi.org/10.1016/j.jebdp.2019.04.005. Invisalign.com. "FAQ". Invisalign. Accessed 31 Mar. 2019 https://www.invisalign.com/frequently-asked-questions Ke, Yunyan, Yanfei Zhu, and Min Zhu. 2019. “A Comparison of Treatment Effectiveness between Clear Aligner and Fixed Appliance Therapies.” BMC Oral Health 19 (1): 1– 10. https://doi.org/10.1186/s12903-018-0695-z. Kragt, Lea, Henning Tiemeier, Eppo B. Wolvius, and Edwin M. Ongkosuwito. 2016. “Measuring Oral Health-Related Quality of Life in Orthodontic Patients with a Short Version of the Child Oral Health Impact Profile (COHIP).” Journal of Public Health Dentistry 76 (2): 105–12. https://doi.org/10.1111/jphd.12118. Livas, Christos, Konstantina Delli, and Nikolaos Pandis. 2018. “‘My Invisalign Experience’: Content, Metrics and Comment Sentiment Analysis of the Most Popular Patient Testimonials on YouTube.” Progress in Orthodontics 19 (1): 1–8. https://doi.org/10.1186/s40510-017-0201-1. Locker, David. 1988. Measuring oral health: A conceptual framework. Community Dent. Health 5(1), 3–18. Locker, D., Matear, D., Stephens, M. and Jokovic, A. 2002." Oral health-related quality of life of a population of medically compromised elderly people." Community Dental Health 19 (2): 90-97.

118 Miller, Kevin B., Susan P. McGorray, Randy Womack, Juan Carlos Quintero, Mark Perelmuter, Jerome Gibson, Teresa A. Dolan, and Timothy T. Wheeler. 2007. “A Comparison of Treatment Impacts between Invisalign Aligner and Fixed Appliance Therapy during the First Week of Treatment.” American Journal of Orthodontics and Dentofacial Orthopedics 131 (3): 302.e1-302.e9. https://doi.org/10.1016/j.ajodo.2006.05.031. Proffit, William R., Henry W. Jr. Fields, Brent E. Larson, and David M. Sarver. 2019. Contemporary Orthodontics. Edited by William R Proffit. 6th ed. St. Louis, Mo: Elsevier/Mosby. Sergl, Hans Georg, Ulrich Klages, and Andrej Zentner. 2000. “Functional and Social Discomfort during Orthodontic Treatment - Effects on Compliance and Prediction of Patients’ Adaptation by Personality Variables.” European Journal of Orthodontics 22 (3): 307–15. https://doi.org/10.1093/ejo/22.3.307. Wheeler, Timothy T. 2017. “Orthodontic Clear Aligner Treatment.” Seminars in Orthodontics 23 (1): 83–89. https://doi.org/10.1053/j.sodo.2016.10.009.

119 Tables

Table 1: Demographic Data

Fixed Appliances Invisalign® (n=37) (n=37) Males 16 14 Females 21 23 Age (years) 11 1 1 12 1 3 13 3 9 14 9 7 15 6 6 16 6 6 17 5 2 18 6 3 Mean Age 15.3 ± 2.3 14.1 ± 1.8

Table 2: Summary of COHIP-19 Scores: Fixed Appliances vs Invisalign® (Group 1)

Fixed Appliances Invisalign®

Domain & Items Mean (SD) Range Mean (SD) Range Oral Health Well-Being 1. Had pain in your teeth/toothache 2.62 ± 0.83 1 – 4 2.59 ± 0.90 1 – 4 2. Had discolored teeth or spots on your teeth 2.38 ± 1.34 0 – 4 2.51 ± 1.30 0 – 4 3. Had crooked teeth or spaces between your teeth 3.19 ± 0.94 1 – 4 3.27 ± 1.02 0 – 4 4. Had bad breath 2.76 ± 1.01 0 – 4 2.73 ± 0.96 1 – 4 5. Had bleeding gums 3.03 ± 1.08 0 – 4 3.11 ± 1.04 1 – 4 Oral Domain score (0- 20) 13.98 ± 3.03 6 – 20 14.21 ± 3.31 5 – 20 Functional Well-Being 9. Had difficulty eating foods you would like 2.16 ± 1.26 0 – 4 2.86 ± 1.00 1 – 4 13. Had trouble sleeping 3.43 ± 0.83 1 – 4 3.41 ± 0.60 2 – 4 17. Had difficulty saying certain words 3.22 ± 1.03 0 – 4 3.03 ± 1.01 1– 4 18. Had difficulty keeping your teeth clean 2.68 ± 1.08 0 – 4 3.11 ± 1.05 0 – 4

Functional well-being domain score (0- 16) 11.49 ± 2.77 4 – 16 12.41 ± 2.36 6 – 16 Social-Emotional Well-Being (Questions finish with “because of your teeth, mouth, or face”) 3.05 ± 1.15 0 – 4 3.38 ± 0.98 0 – 4 6. Been unhappy or sad 2.89 ± 1.21 0 – 4 3.46 ± 0.82 1 – 4 7. Missed school for any reason 2.49 ± 1.04 0 – 4 2.76 ± 1.14 0 – 4 8. Been confident 3.27 ± 0.90 1 – 4 3.49 ± 0.84 1 – 4 10. Felt worried or anxious 3.50 ± 1.03 0 – 4 3.43 ± 0.88 1 – 4 11. Not wanted to speak/read out loud in class 3.54 ± 0.90 0 – 4 3.46 ± 1.07 0 – 4 12. Avoiding smiling or laughing with other children 3.84 ± 0.55 1 – 4 3.95 ± 0.23 14. Been teased, bullied, or called names by other children 1.95 ± 1.27 1 – 4 2.05 ± 1.20 3 – 4 15. Felt that you were attractive (good looking) 2.49 ± 1.26 2.32 ± 1.51 16. Felt that you look different 0 – 4 0 – 4 19. Been worried about what other people think about your 3.27 ± 1.28 0 – 4 3.35 ± 1.11 0 – 4 teeth, mouth, or face 0 – 4 0 – 4

Social-Emotional score (0- 40) 30.29 ± 5.50 15 – 40 31.65 ± 5.80 15 – 40 COHIP-19 Summary Score (0- 74) 55.76 ± 9.11 33 - 73 58.27 ± 9.06 34 – 70 120

Table 3: Summary of quality of life, satisfaction and domain scores among all test groups

121 Appendix 9

Figure 3: Responses to item 1

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of each group answered sometimes.

Figure 4: Responses to item 2

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. While this question is somewhat redundant to an orthodontic

122 patient pool that is undergoing treatment, the question was still included in order to maintain the structure of the validated survey. The majority of each group answered sometimes.

Figure 5: Responses to item 3

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group for item 3. In both groups, the majority of respondents reported never experiencing discolored teeth or spots on their teeth.

Figure 6: Responses to item 4

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of the fixed appliances group (40.5%) reported 123 almost never experiencing bad breath, while the majority of the Invisalign® group (37.8%) reported having bad breath sometimes.

Figure 7: Responses to item 5

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of participants in both groups reported never having bleeding gums.

Figure 8: Responses to item 6

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported never being unhappy because of their orthodontic appliance.

124

Figure 9: Responses to item 7

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Three participants who were not students were excluded from the analysis of this item. The majority of the fixed appliances group (22.9%) reported missing school sometimes because of the appliance, whereas the majority of the Invisalign® group (62.9%) reported never missing school for the same reason. Odds ratio: 3.8 (95% CI: 1.2, 12.5, p= 0.02). The fixed appliances group was 3.8 times more likely to miss school compared to the Invisalign® group.

Figure 10: Responses to item 8

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of the fixed appliances group (35.1%) reported feeling confident because of their orthodontic appliance sometimes or fairly often, 125 whereas the majority of the Invisalign® group (32.4%) reported feeling confident all of the time for the same reason.

Figure 11: Responses to item 9

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of the fixed appliances group reported sometimes having difficulty eating food they would like, whereas the majority of the Invisalign® group reported never having difficulty. Further, 8.1% of the fixed appliances group reported having trouble eating all of the time, compared to no one in the Invisalign® group. Odds ratio: 2.7 (95% CI: 1.1, 7.1, p= 0.04). The fixed appliances group was 2.7 times more likely to report difficulty eating compared to the Invisalign® group.

Figure 12: Responses to item 10

126 There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported never feeling worried or anxious because of their fixed appliances or Invisalign®.

Figure 13: Responses to item 11

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Three participants who were not students were excluded from the analysis of this item. The majority of both groups reported that their fixed appliances or Invisalign® never made them feel like they did not want to read out loud in class.

Figure 14: Responses to item 12

127 There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported never avoiding smiling or laughing with others because of their fixed appliances or Invisalign®.

Figure 15: Responses to item 13

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of participants in either groups reported never or almost never having trouble sleeping because of their fixed appliances or Invisalign®.

Figure 16: Responses to item 14

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. A large majority of both groups reported never being 128 bullied because of their appliances. Only one person in the fixed appliances group reported being bullied fairly often.

Figure 17: Responses to item 15

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported that they sometimes felt attractive because of their appliance.

Figure 18: Responses to item 16

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. There was a wide range of responses for this item, with 129 the majority of both groups (approximately 30%) reporting never feeling that they looked different, but 18.9% of each group reporting feeling like they looked different fairly often.

Figure 19: Responses to item 17

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. While the majority of both groups reported never having difficulty saying certain words, 10.8% of the Invisalign® group reported having difficulty fairly often, compared to only 2.7% in the fixed appliances group.

Figure 20: Responses to item 18

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of the Invisalign® group (43.2%) reported

130 never having difficulty keeping their teeth clean, whereas the majority of the fixed appliances group (35.1%) reported almost never having difficulty.

Figure 21: Responses to item 19

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The same proportion of both groups (67.6%) reported never being worried about what other people thought of their teeth, mouth or face because of their appliances.

Figure 22: Responses to item 20

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Over half of both groups rated their oral health as being

131 good. This item was not used in the calculation of any domain score, or overall quality of life score.

Note: Items 1-20 represented the short-form of the Child Oral Health Impact Profile. The remainder of the questions were constructed by the authors of this study.

Figure 23: Responses to item 21

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported never feeling shy or embarrassed because of their appliance.

132

There was no

Figure 24: Responses to item 22 significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Both groups reported similar frequencies of sore spots because of their appliance.

Figure 25: Responses to item 23

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Both groups reported feeling annoyed or frustrated to a similar degree.

133

Figure 26: Responses to item 24

Item 24 asked, “If you do find your braces or Invisalign® annoying, please write a brief sentence explaining why. The majority of the participants in the braces group (40.5%) and in the Invisalign® group (59.4%) either did not respond to the question (interpreted as N/A), or wrote “ N/A” as a response. Common responses were grouped into categories. The fixed appliances group expressed frustrations with the wire poking (18.9%), and the Invisalign® group complained about having to insert and remove their appliance often (16.2%). Similar proportions of both groups reported experiencing pain, difficulty with oral hygiene, and problems related to eating. Reasons grouped together as “other” in the fixed appliances group included: “Frustrated that they’re on” and “Hard to play instruments while in the Invisalign® group “Not coming off when supposed to” and “Make my teeth look odd” were cited as “other” on the graph.

134

Figure 27: Responses to item 25

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of children do not have any trouble focusing in the classroom because of their orthodontic appliance. Three participants who were not students were excluded from the analysis of this item.

Figure 28: Responses to item 26

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Three participants who were not students were excluded from the analysis of this item. The large majority of both groups responded not having to avoid taking part in sports, music, or field trips because of their appliance.

135

Figure 29: Responses to item 27

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of respondents did not experience any jaw pain prior to treatment.

Figure 30: Responses to item 28

The majority of participants in both groups reported not having any jaw pain. However, 27.8% of the fixed appliances group (n= 10) reported that they have more pain now, compared to 8.3% of the Invisalign® group. A small proportion of each group (5.6%, n= 2) reported that their pain is the same as it was prior to treatment, and 8.3% of the fixed

appliances group (n= 3) reported improvement in jaw pain. 136

Figure 31: Responses to items 29 & 30- Fixed appliances group

Items 29 and 30 analyzed the flossing frequency of both groups prior to treatment, and during treatment. Cross-tabulated data was used to generate this graph. In the fixed appliances group, those who now floss 7 days a week are represented by the dark blue color. Of those who used to floss 7 days a week prior to treatment, 66.7% still floss 7 days a week, 6.7% now floss 3-4 days a week, and 16.7% no longer floss at all. Conversely, out of those who did not floss at all, 33.3% now report flossing 5-6 days a week, 30.8% now floss 1-2 days a week, and 50% still do not floss at all.

Figure 32: Responses to items 29 & 30- Invisalign® group

137 In the Invisalign® group, out of those who flossed 7 days a week, 100% still floss daily. Of those who reported never flossing at all before treatment, 16.7% now floss 3-4 days a week,

66.7% now floss 1-2 days a week, and 16.7% still do not floss at all.

Figure 33: Responses to item 31 There was a significant difference in the distribution of responses between the fixed appliances and Invisalign® group. Neither group took longer than three months to adapt to treatment. The majority of respondents took between one and two weeks to adapt to treatment. However, 24.3% of the fixed appliances sample took three months to get used to their fixed appliances

(n= 9), whereas only 2.7% of the Invisalign® group took this long (n= 1).

Figure 34: Responses to item 32 There was no significant difference in the distribution of responses between the fixed

138 appliances and Invisalign® group in all four of the possible responses. The majority of the respondents reported that both they and their parents were the main reasons they sought orthodontic treatment. The second most common reason was due to the suggestion of their dentist. Only one patient in each group reported that the only reason they sought treatment was that their parents made them.

Figure 35: Responses to item 33

There is no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of participants reported that their result with their treatment modality is better than they expected. Only 2.7% (n= 1) of the adolescents reported that their results so far are worse than they expected.

Figure 36: Responses to item 34

139 There was no significant difference in the distribution of responses between the fixed

appliances and Invisalign® group. Participants were given 8 options from a list and also given

an opportunity to write their own under “Other”. Responses written under “other” included:

“straight teeth” and “help me like me smile more”.

Figure 37: Responses to item 35

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The top three expectations of treatment in the fixed appliances group were: 1) They will help me to have a healthier mouth, 2) They will make me more confident, and 3) They will help me to smile more. The top three expectations of treatment in the Invisalign® group are: 1) They will help me to smile more, 2) They will make me more confident and 3) Tie between a) They will make me more attractive and b) They will help me to have a healthier mouth

Figure 38: Responses to item 36 140 There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported that their results so far are better than they expected for their main expectation.

Figure 39: Responses to item 37

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported that their results so far are just as they expected for their second most important expectation.

Figure 40: Responses to item 38

There was no significant difference in the distribution of responses between the fixed appliances and Invisalign® group. The majority of both groups reported that their results so

141 far are just as they expected for their third most important expectation.

Figure 41: Responses to item 39

The large majority of both groups would choose their same treatment modality if they had to have treatment again. However, 24.3% of the fixed appliances group (n= 9) would choose Invisalign®, and 13.5% of the Invisalign® group (n= 5) would choose fixed appliances. There was no significant difference in the proportion of participants who would stay or switch between the two treatment groups (p= 0.23)

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