Assessing consistency in oral health-related quality of life (OHRQoL) across gender and stability of OHRQoL over time for adolescents using Structural Equation Modeling

Pathway analysis between dental caries and oral health-related quality of life in the transition from childhood to adolescence: a 10-year cohort study

PURPOSE

To evaluate the direct and indirect pathways between cavitated carious lesions and oral health-related quality of life (OHRQoL) during the transition from childhood to adolescence.

METHODS

A prospective cohort study followed an initial sample of 639 children (one to five years old), in southern Brazil for ten years. In addition to the baseline (T1), two subsequent reassessments were conducted after seven (T2) and ten years (T3). OHRQoL was measured through the Early Childhood Oral Health Impact Scale (ECOHIS) and Child Perceptions Questionnaire (CPQ8-10 and CPQ11-14), according to the age group. Dental caries was evaluated using the International Caries Detection and Assessment System (ICDAS) in the three waves. Socioeconomic variables and other factors related to oral health (frequency of toothbrushing and toothache) were also collected. Structural equation modeling was used to estimate the direct and indirect effects among the variables over ten years.

RESULTS

A total of 449 and 429 children were reevaluated at T2 and T3 (positive response rates of 70.3% and 67.1%, respectively). Dental caries in T1 and T2 directly predicted the occurrence of a worse OHRQoL in the respective follow-up periods. Dental caries at T3 indirectly predicted a worse OHRQoL (T3), via toothache. Dental caries at T1 and T2 directly predicted the occurrence of dental caries at T3, while a worse OHRQoL at T2 directly predicted a worse OHRQoL at T3.

CONCLUSION

Dental caries negatively impacts, directly and indirectly, the OHRQoL from early childhood to adolescence.

Impact of the onset of fixed appliance therapy on adolescents' quality of life using a specific condition questionnaire: A cross-sectional comparison between male and female individuals

OBJECTIVE

To evaluate the impact of the first six months of orthodontic treatment with fixed appliances on the oral health-related quality of life (OHRQoL) of adolescents, comparing boys and girls, using a specific condition questionnaire.

DESIGN

Cross-sectional.

SETTING

School of Dentistry of the Federal University of Minas Gerais, Belo Horizonte, Brazil.

PARTICIPANTS

Adolescents aged 10-17 years.

METHODS

Forty-six adolescents participated in this study. Adolescents' OHRQoL was evaluated using the Brazilian version of the questionnaire Impact of Fixed Appliances Measure. This questionnaire comprises 43 questions distributed across nine domains: aesthetics; functional limitation; dietary impact; oral hygiene impact; maintenance impact; physical impact; social impact; time constraints; and travel/cost/inconvenience implications. The answer options follow the Likert scale, in the range of 1-5. A higher score indicates a more negative impact on the OHRQoL. Adolescents' malocclusion was assessed using the Dental Aesthetic Index. Information on family income, adolescents' age and tooth extraction was also collected. A directed acyclic graph was used to identify potential confounders. Statistical analysis involved the chi-square test, the Student's t test and the analysis of covariance. The minimal clinically important difference was also calculated.

RESULTS

Of the 46 participants, 25 were girls and 21 were boys. The female adolescents presented a more negative impact from the orthodontic treatment on the quality of life when compared to the male adolescents (P < 0.001), regardless of the influence of the confounding variables. The most negative repercussions were identified in the domains of oral hygiene (P = 0.002), physical impact (P < 0.001) and social impact (P < 0.001).

CONCLUSION

The impact of the first six months of orthodontic treatment on OHRQoL is more negative in female individuals than in male individuals. The results of this study may be useful for the oral healthcare provider during the counselling of adolescents undergoing fixed appliance therapy.

Modification and psychometric evaluation of the child perceptions questionnaire (CPQ11-14) in assessing oral health related quality of life among Lithuanian children

Background

Oral health related quality of life (OHRQoL) research among children and adolescents in Lithuania is just starting and no measures have been validated to date. Therefore, this study aimed to validate a Lithuanian version of the full (37 items) Child Perceptions Questionnaire (CPQ_11–14) within a random sample of children aged 11 to 14.

Methods

A cross-sectional survey among a randomly selected sample of schoolchildren (N = 307) aged 11 to14 was conducted. An anonymous questionnaire included the full CPQ_11–14 and items on global life satisfaction, oral health and oral life quality self-rating. The questionnaire was translated into Lithuanian using translation guidelines. In addition, an item on the oral pain was modified identifying the pain location. Standard tests (Cronbach’s α, construct validity and discriminant validity), supplemented with both exploratory and confirmatory factor analyses, were employed for psychometric evaluation of the instrument. The questionnaire was also tested by comparison students’ and their parents’ (N = 255) responses about oral symptoms and functional limitations.

Results

The modified Lithuanian version of CPQ_11–14 revealed good internal consistency reliability (Cronbach’s alpha for the total scale was 0.88). The measure showed significant associations with perceived oral health status and oral well-being, as well as with global life satisfaction (p < 0.01). Discriminant validity of the instrument was approved by comparison of children’s groups defined by self-reported caries experience and malocclusion. Factor analysis revealed a complex structure with two or three factors in each of four domains of the CPQ_11–14. Excellent or acceptable levels of indices of model fitting with the given data were obtained for oral symptoms, functional limitations and emotional well-being domains, but not for the social well-being domain. A significant association between child and parental responses was found (intraclass correlation coefficient was 0.56 and 0.43, correspondingly in domains of oral symptoms and functional limitations).

Conclusion

The Lithuanian version of the CPQ_11–14 (with a modified item that identifies location of oral pain) appears to be a valid instrument to be used in further studies for measuring OHRQoL among 11 to 14 year old children in Lithuania.

Electronic supplementary material

The online version of this article (10.1186/s12903-018-0701-5) contains supplementary material, which is available to authorized users.

Longitudinal measurement invariance and explanatory IRT models for adolescents' oral health-related quality of life

BACKGROUND

Longitudinal invariance is a perquisite for a valid comparison of oral health-related quality of life (OHRQoL) scores over time. Item response theory (IRT) models can assess measurement invariance and allow better estimation of the associations between predictors and latent construct. By extending IRT models, this study aimed to investigate the longitudinal invariance of the two 8-item short forms of the Child Perception Questionnaire (CPQ_11-14) regression short form (RSF:8) and item-impact short form (ISF:8) and identify factors associated with adolescents' OHRQoL and its change.

METHODS

All students from S1 and S2 (equivalent to US grades 6 and 7) who were born in April 1997 and May 1997 (at age 12) from 45 randomly selected secondary schools were invited to participate in this study and followed up after 3 years. Data on the CPQ_11-14 RSF:8 and CPQ_11-14 ISF:8, demographics, oral health behavior and status were collected. Explanatory graded response models were fitted to both short forms of the CPQ_11-14 data for assessing longitudinal invariance and factors associated with OHRQoL. The Bayesian estimation method - Monte Carlo Markov Chain (MCMC) with Gibbs sampling was adopted for parameter estimation and the credible intervals were used for inference.

RESULTS

Data from 649 children at age 12 at baseline and 415 children at age 15 at follow up were analyzed. For the 12 years old children, healthier oral health behavior, better gum status, families with both parents employed and parents' education level were found to be associated with better OHRQoL. Four items among the 2 short forms lacked longitudinal invariance. With statistical adjustment of longitudinal invariance, OHRQoL were found improved in general over the 3 years but no predictor was associated with OHRQoL in follow-up. For those with decreased family income, their OHRQoL had worsened over 3 years.

CONCLUSIONS

IRT explanatory analysis enables a more valid identification of the factors associated with OHRQoL and its changes over time. It provides important information to oral healthcare researchers and policymakers.

Evaluation of psychometric properties and differential item functioning of 8-item Child Perceptions Questionnaires using item response theory

Background

Four-factor structure of the two 8-item short forms of Child Perceptions Questionnaire CPQ_11–14 (RSF:8 and ISF:8) has been confirmed. However, the sum scores are typically reported in practice as a proxy of Oral health-related Quality of Life (OHRQoL), which implied a unidimensional structure. This study first assessed the unidimensionality of 8-item short forms of CPQ_11–14. Item response theory (IRT) was employed to offer an alternative and complementary approach of validation and to overcome the limitations of classical test theory assumptions.

Methods

A random sample of 649 12-year-old school children in Hong Kong was analyzed. Unidimensionality of the scale was tested by confirmatory factor analysis (CFA), principle component analysis (PCA) and local dependency (LD) statistic. Graded response model was fitted to the data. Contribution of each item to the scale was assessed by item information function (IIF). Reliability of the scale was assessed by test information function (TIF). Differential item functioning (DIF) across gender was identified by Wald test and expected score functions.

Results

Both CPQ_11–14 RSF:8 and ISF:8 did not deviate much from the unidimensionality assumption. Results from CFA indicated acceptable fit of the one-factor model. PCA indicated that the first principle component explained >30 % of the total variation with high factor loadings for both RSF:8 and ISF:8. Almost all LD statistic <10 indicated the absence of local dependency. Flat and low IIFs were observed in the oral symptoms items suggesting little contribution of information to the scale and item removal caused little practical impact. Comparing the TIFs, RSF:8 showed slightly better information than ISF:8. In addition to oral symptoms items, the item “Concerned with what other people think” demonstrated a uniform DIF (p < 0.001). The expected score functions were not much different between boys and girls.

Conclusions

Items related to oral symptoms were not informative to OHRQoL and deletion of these items is suggested. The impact of DIF across gender on the overall score was minimal. CPQ_11–14 RSF:8 performed slightly better than ISF:8 in measurement precision. The 6-item short forms suggested by IRT validation should be further investigated to ensure their robustness, responsiveness and discriminative performance.

Assessment of the quality of measures of child oral health-related quality of life

Background

Several measures of oral health-related quality of life have been developed for children. The most frequently used are the Child Perceptions Questionnaire (CPQ), the Child Oral Impacts on Daily Performances (C-OIDP) and the Child Oral Health Impact Profile (COHIP). The aim of this study was to assess the methodological quality of the development and testing of these three measures.

Methods

A systematic search strategy was used to identify eligible studies published up to December 2012, using both MEDLINE and Web of Science. Titles and abstracts were read independently by two investigators and full papers retrieved where the inclusion criteria were met. Data were extracted by two teams of two investigators using a piloted protocol. The data were used to describe the development of the measures and their use against existing criteria. The methodological quality and measurement properties of the measures were assessed using standards proposed by the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) group.

Results

The search strategy yielded 653 papers, of which 417 were duplicates. Following analysis of the abstracts, 119 papers met the inclusion criteria. The majority of papers reported cross-sectional studies (n = 117) with three of longitudinal design. Fifteen studies which had used the original version of the measures in their original language were included in the COSMIN analysis. The most frequently used measure was the CPQ. Reliability and construct validity appear to be adequate for all three measures. Children were not fully involved in item generation which may compromise their content validity. Internal consistency was measured using classic test theory with no evidence of modern psychometric techniques being used to test unidimensionality of the measures included in the COSMIN analysis.

Conclusion

The three measures evaluated appear to be able to discriminate between groups. CPQ has been most widely tested and several versions are available. COHIP employed a rigorous development strategy but has been tested in fewer populations. C-OIDP is shorter and has been used successfully in epidemiological studies. Further testing using modern psychometric techniques such as item response theory is recommended. Future developments should also focus on the development of measures which can evaluate longitudinal change.

Factors influencing adolescents' oral health-related quality of life (OHRQoL)

BACKGROUND

OHRQoL comprises an apparently complex array of biological and psychological aspects of oral health.

AIM

To determine the relative contribution of sociodemographic, psychosocial, or clinical characteristics to OHRQoL in adolescents.

DESIGN

A cross-sectional study of Dunedin adolescents was carried out. Each participant completed a self-administered questionnaire and underwent a clinical examination. Information collected included sociodemographic characteristics (sex, ethnicity, and household deprivation), psychosocial characteristics (self-esteem, psychological well-being, somatisation, and self-perception scores for body image), and clinical measures (DMFS and Dental Aesthetic Index). OHRQoL was measured using the 16-item impact short-form CPQ₁₁₋₁₄ questionnaire. Linear regression analyses used the CPQ₁₁₋₁₄ as the dependent variable, with independent variables entered in related groups.

RESULTS

Three hundred and fifty-three children (48.4% females) took part, representing a 58.8% response rate. Linear regression modelling of the CPQ₁₁₋₁₄ score showed that sociodemographic characteristics were predictors, but the model's overall explanatory power was low (R(2) = 0.05). This increased slightly with inclusion of the clinical variables. When the psychosocial variables were added, however, the R(2) increased to 0.50; all psychosocial variables (except self-esteem) were strongly associated with the CPQ₁₁₋₁₄ score. Psychological well-being was the strongest predictor.

CONCLUSION

Psychosocial characteristics are important contributors to OHRQoL in adolescents and appear to be more important than sociodemographic or clinical characteristics.

Clinical status in adolescents: is its impact on oral health-related quality of life influenced by psychological characteristics?

The objective of this study was to examine, using structural equation modelling, the relationships among clinical characteristics (such as caries experience and malocclusion), oral health-related quality of life (OHRQoL), and psychological characteristics (mental health, self-esteem, somatisation, and social perception of body image) in adolescents in New Zealand. Adolescents were examined for malocclusion using the Dental Aesthetic Index (DAI) and for dental caries. Among the 353 (58.8%) 12- and 13-yr-old adolescents who took part in this cross-sectional study, the overall mean ± SD decayed, missing, or filled surfaces (DMFS) value was 1.6 ± 3.0, with slightly more than 50% of being caries-free; the mean ± SD DAI was 31.5 ± 7.6, with one-quarter of subjects having a 'handicapping' malocclusion. The structural equation modelling analysis showed that the structural model was a good fit to the data. As hypothesized, the DAI score significantly predicted OHRQoL. There was no direct relationship between caries experience (DMFS) and OHRQoL, but there was an indirect effect of DMFS on OHRQoL mediated through psychological characteristics. The amount of OHRQoL variance accounted for in the model was substantial, at 62%. It appears that investigating OHRQoL in adolescents is not straightforward; while malocclusion directly affects OHRQoL, the influence of dental caries experience is less direct.