Reliability of a multidimensional questionnaire for adults with treated complete cleft lip and palate

Oral health-related quality of life in patients aged 8 to 19 years with cleft lip and palate: a systematic review and meta-analysis

BACKGROUND

Cleft lip and palate (CLP) is the most common facial birth defect worldwide and causes morphological, aesthetic, and functional problems with psychosocial implications for an individual's life and well-being. The present systematic review and meta-analysis assessed whether the treatment of CLP impacts the oral health-related quality of life (OHRQoL) in children and adolescents in comparison to healthy controls.

METHODS

We searched MEDLINE/PubMed, EMBASE, and PsycINFO databases using terms related to CLP, and included articles until August 2023. Observational comparison studies that assessed OHRQoL in non-syndromic CLP patients aged 8-19 years with validated scales designed to such aim or scales capable to identify aspects related to oral health compared to healthy controls were included. We used the ROBINS-I tool for risk of bias assessment. A meta-analysis of continuous variables was performed using inverse variance for pooling estimates, Standardized Mean Difference (SMD) as a summary measure, with random effects model. Heterogeneity was estimated by the I2 statistics. Sensitivity analyses included subgrouping based on the scale, risk of bias and scale domains. Meta-regression was performed under a mixed-effects model considering the variables type of scale, scale domains and risk of bias.

RESULTS

Fourteen studies were included comprising 1,185 patients with CLP and 1,558 healthy controls. The direction of the effect of OHRQoL favoured the healthy group (-0.92; 95% CI:-1,55;-0,10) and I2 = 95%. After removing three studies, I2 dropped to 80%. Meta-regression showed no influence on risk of bias (p = 0.2240) but influence of scale type (p = 0.0375) and scale domains (p < 0.001). The subgroup analysis indicated that the CPQ and COHIP scales presented very discrepant SMD values, despite pointing to the same effect direction. In contrast, the OHIP scale showed a non-significant difference between cases and controls, with estimates much lower than the other two scales. Results also suggest that OHRQoL associated with oral functionality and social well-being is more influential on outcomes than emotional well-being.

CONCLUSION

The global OHRQoL is slightly worst in the CLP patients than control group. The difference between OHRQoL was mainly detected through OHIP. The most affected domains are functional, emotional and social.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022336956.

Self-Reports of Psychosocial Functioning among Children and Young Adults with Cleft Lip and Palate

Objective:

A cross-sectional study was employed to determine the psychosocial effects of cleft lip and/or palate among children and young adults, compared with a control group of children and young adults without cleft lip and palate.

Participants:

The study comprised 160 children and young adults with cleft lip and/or palate and 113 children and young adults without cleft lip and/or palate. All participants were between 8 and 21 years of age.

Outcome measures:

Psychological functioning (anxiety, self-esteem, depression, and behavioral problems) was assessed using validated psychological questionnaires. Happiness with facial appearance was rated using a visual analog scale. Social functioning, including experience of teasing/bullying and satisfaction with speech, was assessed using a semistructured interview.

Results:

Participants with cleft lip and/or palate reported greater behavioral problems (p < .001) and more symptoms of depression (p < .01); they were teased more often (p < .001) and were less happy with their facial appearance (p < .01) and speech (p < .001), compared with controls. There were no significant difference between subjects with cleft lip and/or palate and subjects without cleft lip and/or palate in terms of anxiety (p > .05) or self-esteem (p > .05). Having been teased was a significant predictor of poor psychological functioning, more so than having a cleft lip and/or palate per se (p < .001).

Conclusions:

Teasing was greater among participants who had cleft lip and/ or palate and it was a significant predictor of poorer psychosocial functioning. Children and young adults with cleft lip and/or palate require psychological assessment, specifically focusing on their experience of teasing, as part of their routine cleft care.

Use of the Derriford Appearance Scale 59 to assess patient-reported outcomes in secondary cleft surgery

BACKGROUND

Secondary rhinoplasty, one of the final procedures in addressing the stigma of the cleft lip and palate (CLP), has both functional and aesthetic objectives. The way in which physicians evaluate outcomes in surgery concerning aesthetics is changing. Well-designed patient-reported outcome measures to assess health-related quality of life improvements attributable to surgery are increasingly being used. The Derriford Appearance Scale 59 (DAS-59) is currently the only available validated patient-reported outcome measure that assesses concern about physical appearance.

METHODS

Twenty patients with CLP presenting between May 2009 and May 2013 for secondary rhinoplasty to Sunnybrook Health Sciences Centre (Toronto, Ontario) were recruited. DAS-59 measures were administered both preoperatively and at least six months after surgery. Pre- and postoperative measures were scored and compared. Item-by-item analysis of the measure was also performed.

RESULTS

Total scores for this CLP group indicated greater concern about appearance than the general population. Across all subscales of the measure, there was a reduction in scores after secondary rhinoplasty suggesting less patient concern with appearance and a positive effect of surgery on patient quality of life. Item-by-item analysis suggested relatively few items in the measure were driving overall change in total scores.

CONCLUSION

Comparison of pre- and postoperative scores with the DAS-59 in secondary cleft rhinoplasty suggests there is less concern with appearance after surgery. However, a small number of items within this generic scale contributing to this difference may suggest the need for a more patient specific measure for assessment of surgical outcomes in the cleft population.

Use of the Derriford Appearance Scale 59 to assess patient-reported outcomes in secondary cleft surgery

Background

Secondary rhinoplasty, one of the final procedures in addressing the stigma of the cleft lip and palate (CLP), has both functional and aesthetic objectives. The way in which physicians evaluate outcomes in surgery concerning aesthetics is changing. Well-designed patient-reported outcome measures to assess health-related quality of life improvements attributable to surgery are increasingly being used. The Derriford Appearance Scale 59 (DAS-59) is currently the only available validated patient-reported outcome measure that assesses concern about physical appearance.

Methods

Twenty patients with CLP presenting between May 2009 and May 2013 for secondary rhinoplasty to Sunnybrook Health Sciences Centre (Toronto, Ontario) were recruited. DAS-59 measures were administered both preoperatively and at least six months after surgery. Pre- and postoperative measures were scored and compared. Item-by-item analysis of the measure was also performed.

Results

Total scores for this CLP group indicated greater concern about appearance than the general population. Across all subscales of the measure, there was a reduction in scores after secondary rhinoplasty suggesting less patient concern with appearance and a positive effect of surgery on patient quality of life. Item-by-item analysis suggested relatively few items in the measure were driving overall change in total scores.

Conclusion

Comparison of pre- and postoperative scores with the DAS-59 in secondary cleft rhinoplasty suggests there is less concern with appearance after surgery. However, a small number of items within this generic scale contributing to this difference may suggest the need for a more patient specific measure for assessment of surgical outcomes in the cleft population.

Measurement of Health-Related and Oral Health–Related Quality of Life among Individuals with Nonsyndromic Orofacial Clefts: A Systematic Review and Meta-Analysis

Objective

To compare health-related quality of life and oral health–related quality of life between nonsyndromic individuals with and without cleft lip and/or cleft palate and to identify the most affected quality of life dimensions in individuals with cleft lip and/or palate.

Design

Systematic review and meta-analysis were conducted. Of the 314 identified citations, 23 articles were submitted to quality assessment. Data from nine studies on health-related quality of life and six on oral health–related quality of life were extracted for meta-analysis.

Main Outcome Measures

Pooled mean differences of health-related quality of life between adults with and without cleft lip and/or palate, pooled means of health-related quality of life dimensions of children and adults with cleft lip and/or palate and oral health–related quality of life dimensions of children and adolescents with cleft lip and/or palate with a 95% confidence interval were calculated.

Results

Quality assessment revealed methodological differences between studies. Lack of subgroup stratification and absence of control for confounders were the main limitations. Heterogeneity was detected on the comparison of oral health–related quality of life and health-related quality of life between children with and without cleft lip and/or palate, and oral health–related quality of life between adolescents with and without cleft lip and/or palate. A random-effect model showed a significant difference on health-related quality of life between adults with and without cleft lip and/or palate (mean difference = 0.10; 95% confidence interval, 0.16 to 0.05). Psychological health (mean, 78.9; 95% confidence interval, 70.1 to 87.7) and vitality (mean, 68.1; 95% confidence interval, 48.0 to 88.1) were the most affected health-related quality of life dimensions in children and adults with cleft lip and/or palate, respectively. Means of health-related quality of life dimensions in children and adults with cleft lip and/or palate and oral health–related quality of life in children and adolescents with cleft lip and/or palate varied yet did not differ in indirect comparisons.

Conclusion

The presence of cleft lip and/or palate negatively affected the health-related quality of life of adults, mainly on psychosocial dimensions.

A qualitative analysis of identity and goals in patients with deformities: preparation for an evidence-based advocacy for a vulnerable population

INTRODUCTION

Economically and socially vulnerable patients with deformities are likely to live a marginalized life, reducing their quality of life and societal participation. An evidence-based approach is needed for these patients who may not be able to advocate for themselves. The objective of this study is to identify important aspects of the perceived identity of adult patients with deformities.

METHODS

This retrospective qualitative analysis is of applicant responses to an intake questionnaire for Fresh Start Surgical Gifts, a charitable reconstructive surgery organization serving children and adults with deformities. Five open-ended questions were analyzed and grouped into 2 broad categories: Identity and Goals. Keywords were identified by an online survey website and subjective judgment of the investigators. Keywords were then combined into broader themes.

RESULTS

Seventy respondents with a mean age of 24.79 (median 23) between 1992 and 2011 were analyzed. Social and professional issues were the most frequently occurring themes among Identity and Goals questions.

CONCLUSION

The current identity of patients with deformities centers on social aspects of their lives, rather than a career or profession, yet they do hold both professional and social aspirations. This research will guide the development of an objective tool to measure patient-reported impact and outcomes of reconstructive plastic surgery.

General Health-Related Quality of Life and Oral Health Impact among Australians with Cleft Compared with Population Norms; Age and Gender Differences

Objective

To evaluate general health-related quality of life (HRQoL) and oral health impact among adults treated for cleft to determine age and gender differences, and to compare against population norms.

Design

Cross-sectional prospective study.

Participants/Setting

Nonsyndromic cleft patients treated by the Australian Craniofacial Unit from 1975 to 2009 were recruited (n = 112). Response rate was 79% (n = 88).

Main outcome measures

HRQoL was measured by the Short Form (SF)-36 questionnaire. Oral health impact was measured by the Oral Health Impact Profile (OHIP)-14 questionnaire. State-based and national norms were used for comparative purposes.

Results

There were no significant age or sex differences in the cleft sample's SF-36 and OHIP-14 scores. When compared against South Australian 2002 state-level norms, cleft participants scored higher on physical function and physical role function but lower on vitality and mental health. The prevalence of having experienced one or more of OHIP–14 items “fairly often” or “very often” was 2.7 times higher than national-level estimates, while extent was 2.8 times and severity 1.7 times higher.

Conclusions

The oral health impact among cleft patients included in our study was poor compared with population-level estimates. The HRQoL showed mixed results, with the vitality and mental health components being poorer in the cleft group compared with population-level estimates. These results indicate that treatment for orofacial clefting does not entirely remove the factors contributing to poor HRQoL and oral health.

Quality of Life Varies with Gender and Age among Adults Treated for Unilateral Cleft Lip and Palate

Objective

To evaluate health-related quality of life among adults treated for unilateral cleft lip and palate and to investigate whether patients were affected differently depending on gender and age.

Design

Cross-sectional population study with long-term follow-up.

Patients/Settings

All unilateral cleft lip and palate patients born 1960–1987 and treated at Uppsala University Hospital were invited (n = 109). Response rate was 79% (n = 86). Mean follow-up time was 35 years. Norm data matched for age and gender were used for comparison (n = 1385).

Main Outcome Measures

Health-related quality of life measured with the SF-36 questionnaire. High values indicate good level of health-related quality of life.

Results

The total patient group had lower values in the Mental Health subscale compared with norm data ( p = .005). Values in all other subscales did not differ from norm data. Women had a higher positive difference than men in the subscale emotional role function compared with the matched norm population (p < .001). The younger age group (20 to 32 years old) consistently had a larger negative difference to matched norm data compared with the older age group (33 to 47 years old) in the subscales social function ( p = .009), physical role function ( p < .001), and emotional role function ( p < .001).

Conclusions

Unilateral cleft lip and palate affected health-related quality of life differently depending on gender and age of the patient. Younger patients were affected more negatively than older patients on several subscales. However, except for the mental health subscale, health-related quality of life was similar among unilateral cleft lip and palate patients and norm data.

Satisfaction with facial appearance and its determinants in adults with severe congenital facial disfigurement: a case-referent study

BACKGROUND

Patients with severe congenital facial disfigurement have a long track record of operations and hospital visits by the time they are 18 years old. The fact that their facial deformity is congenital may have an impact on how satisfied these patients are with their appearance. This study evaluated the level of satisfaction with facial appearance of congenital and of acquired facially disfigured adults, and explored demographic, physical and psychological determinants of this satisfaction. Differences compared with non-disfigured adults were examined.

METHODS

Fifty-nine adults with a rare facial cleft, 59 adults with a facial deformity traumatically acquired in adulthood, and a reference group of 201 non-disfigured adults completed standardised demographic, physical and psychological questionnaires.

RESULTS

The congenital and acquired groups did not differ significantly in the level of satisfaction with facial appearance, but both were significantly less satisfied than the reference group. In facially disfigured adults, level of education, number of affected facial parts and facial function were determinants of the level of satisfaction. High fear of negative appearance evaluation by others (FNAE) and low self-esteem (SE) were strong psychological determinants. Although FNAE was higher in both patient groups, SE was similar in all three groups.

CONCLUSION

Satisfaction with facial appearance of individuals with a congenital or acquired facial deformity is similar and will seldom reach the level of satisfaction of non-disfigured persons. A combination of surgical correction (with attention for facial profile and restoring facial functions) and psychological help (to increase SE and lower FNAE) may improve patient satisfaction.

Satisfaction with treatment outcome in bilateral cleft lip and palate patients

The aim of this case-controlled study was to assess satisfaction with facial appearance and function, and health-related quality of life (HRQL) in bilateral cleft lip and palate patients (BCLP). The study sample was composed of adult BCLP subjects and controls matched for age, gender and socioeconomic status. Outcome measures included a self-administered questionnaire evaluating satisfaction with facial appearance, function and HRQL. Bivariate statistics were computed to analyse the association between BCLP status and outcome measures. Forty-three treated adult BCLP patients (mean age 28.2 years, SD 7.8) were compared to 43 controls without clefts (mean age 28.5 years, SD 8.0). Quantitative and qualitative assessment revealed that BCLP patients were significantly less satisfied with the appearance of the upper lip, the nose and nasal breathing. Additionally, satisfaction with facial appearance correlated positively with HRQL. For speech, hearing and drinking, quantitative scores did not differ between BCLP and controls, while qualitative assessment revealed that BCLP patients had considerable problems and concerns with these functions. This study underlines the importance of qualitative assessment of patient satisfaction with treatment outcome to identify individual problems and concerns not revealed by quantitative measures alone.

Reliability of a Questionnaire Assessing Experiences of Adolescents in Orthodontic Treatment

OBJECTIVE

To evaluate the reliability of a questionnaire that assessed the expectations and experiences of adolescent patients about orthodontic treatment.

MATERIALS AND METHODS

The study included two groups of patients: 30 consecutive patients (19 girls and 11 boys, mean age 14.6 years, SD 2.3 years) naïve to orthodontic treatment, and 30 consecutive adolescent patients (17 girls and 13 boys, mean age 15.1 years, SD 2.0 years) in active orthodontic treatment with fixed appliances in both jaws. A questionnaire comprising 46 items was developed, based upon focus group interviews and previous established questionnaires. The questionnaire covered the following domains: Treatment motivation; treatment expectations; pain and discomfort from teeth, jaws, and face; functional jaw impairment; and questionnaire validity. Internal consistency as well as temporal stability with the test-retest method was investigated.

RESULTS

A majority of the questions exhibited acceptable test-retest reliability, and composite scores yielded excellent reliability for all domains. Internal consistency was acceptable and good face validity was found for all domains.

CONCLUSION

The questionnaire can be recommended for use in the assessment of expectations and experiences of orthodontic treatment.

Methods of assessment of cleft-related facial deformity: a review

OBJECTIVE

To review the stimulus media, measurements and scoring system, rater's characteristics, and facial region used in assessment of the appearance of cleft-related deformity.

METHODS

A review of the literature was conducted using MedLine from January 1966 to June 2003. Key orthodontic journals and The Cleft Palate-Craniofacial Journal were hand searched as well.

RESULTS

Most studies used a static two-dimensional means of assessment. Direct clinical assessment, three-dimensional media, or both have been used to a lesser extent. Only one study utilized all three assessment media. Three studies, however, attempted to compare the direct clinical assessment with that obtained using two-dimensional media. Most of the studies demonstrated that appearance of the cleft-related deformity could be measured by a variety of judges. The reliability and validity of the three different media as methods of assessment have received limited attention. The facial area assessed has varied from the full face, nasolabial area, or specific features of the lip or nose.

CONCLUSIONS

Wide variation exists in the study design related to assessment of cleft-related deformity. An internationally agreed objective method of assessment for this facial deformity is required. A three-dimensional, rather than a two-dimensional, means of assessment should be adopted.

Patient-based measures of outcome in plastic surgery: current approaches and future directions

OBJECTIVES

To evaluate current approaches to patient-based outcome measurement in plastic surgery and make recommendations for future research.

METHODS

Comprehensive review of the plastic surgery literature relevant to patient-based outcomes.

RESULTS

Two main types of patient-based outcome measure have been used in the plastic surgery literature: generic and disease-specific. The majority of studies using generic measures investigate aspects of psychological functioning with fewer studies focussing on wider aspects of health-related quality of life. Disease-specific measures are mainly used to assess symptoms. However, almost all of these are ad-hoc measures produced for a particular study, with no psychometric evaluation.

CONCLUSIONS

There is a lack of psychometrically sound measures, and there is scope for improvement in methodology used in plastic surgery research. The development and psychometric testing of new plastic surgery specific measures is encouraged.