This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: DR. BIRGITTA HÄGGMAN-HENRIKSON (Orcid ID : 0000-0001-6088-3739)
Article type : Review
The Impact of Orofacial Appearance on Oral Health Related Quality of Life: A Systematic Review
Pernilla Larsson1,2,3, Lars Bondemark4, Birgitta Häggman-Henrikson1,3
1 Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Sweden
2 Centre for Oral Rehabilitation, Folktandvården Östergötland, Linköping, Sweden 3Scandinavian Center for Orofacial Neurosciences (http://www.sconresearch.eu/) 4Department of Orthodontics, Faculty of Odontology, Malmö, Sweden
Running title: Impact of orofacial appearance on QoL Corresponding Author:
Dr B Häggman-Henrikson, Department of Orofacial Pain and Jaw Function, Malmö University, 205 06 Malmö, Sweden. E-mail: birgitta.haggman.henrikson@mau.se
Acknowledgement
The authors report no conflict of interest. No source of funding was received for this study. The authors gratefully acknowledge Stella Sekulic, Mike John and Nicole Theis-Mahon for assistance with the electronic literature search, screening of abstracts and allocation of included articles to the respective domains.
Author contributions
PL and BHH contributed to concept, study design, full text assessment and risk of bias assessment. LB contributed to the study design and interpretation of results. All authors critically revised the manuscript and provided final approval before submission.
Abstract
Esthetics in the orofacial region is important for perceived oral health and a common reason for treatment of discoloured, missing or crowded teeth. As one of the fundamental bricks of a patient’s oral health, changes in the domain of orofacial esthetics resides within the Oral Health Related Quality of Life (OHRQoL) of an individual. Four main dimensions, Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact, are suggested to cover the concept of OHRQoL. The aim of this systematic review was to map the impact from oral conditions with principal impact on the Orofacial Appearance dimension of OHRQoL (PROSPERO: CRD42017064033). Publications were included if they reported Oral Health Impact Profile (OHIP) mean or median domain scores for patients with esthetic treatment need relating to tooth wear, orthodontics, orthognathic surgery, frontal tooth loss or tooth whitening. A search in PubMed (Medline), EMBASE, Cochrane, CINAHL, and PsycINFO June 8, 2017 and updated January 14, 2019, identified 2,104 abstracts. After screening of abstracts, 1,607 articles were reviewed in full text and 33 articles included. These 33 articles reported OHIP-data for 9,409 patients grouped in 63 patient populations. Median orofacial appearance impact scores on a standardized 0 to 8 scale, for populations with treatment need relating to tooth wear, orthodontics, orthognathic surgery, frontal tooth loss and tooth whitening, ranged from 0.13 for tooth wear to 3.04 for tooth whitening populations. In conclusion, a moderate impact for the Orofacial Appearance dimension of OHRQoL was found in patients with different conditions with esthetically related treatment need.
Keywords: Dental esthetics, oral health, patient reported outcomes,
physical appearance, quality of life.
Background
The field of dentistry is constantly changing and developing. Traditional dentist-oriented focus was originally mainly on the biology and function aspects. Although this has not been abandoned, modern dentistry is more patient-oriented and today esthetic concerns are considered an important and integral part of an individual´s oral health.1
Consequently, esthetic concerns have been embraced in the dimension Orofacial
Appearance, which together with Oral Function, Orofacial Pain, and Psychosocial Impact, constitute the four dimensions of oral health-related quality of life (OHRQoL).2 The
orofacial appearance dimension is thus considered an integral component of the patient’s oral health experience, on par with pain, functional and psychosocial issues.
Furthermore, overall oral health is improving3 and with that the expectations of what is esthetically acceptable. Due to a lower prevalence, as well as improved management, of caries, periodontal disease and oral infections, fewer individuals have lost their teeth and the esthetic issues have become increasingly important for both dentists and patients.4 Thus, orofacial esthetics is a common reason for rehabilitation of discolored, worn, missing or crowded teeth. It is now acknowledged that esthetic concerns can have great psychosocial impact on the patient and from the dentist´s perspective, the increasing esthetic demands are apparent in all areas of dentistry, including not only orthodontics and prosthetics but also general dentistry.2
In a large study in UK, 15% of the respondents were dissatisfied with their dental appearance.5 Impaired orofacial esthetics was even more frequently reported by participants in a Swedish national population-based survey. In this study, only 10 % of the subjects were satisfied with all aspects of orofacial esthetics.6 In order to assess orofacial esthetics in a standardized way, two general approaches are available. One is to use specific dental patient-reported outcomes measures (dPROMs)7 such as the Orofacial Esthetic Scale (OES),8, 9 or instruments used by the dentist, such as the Prosthetic Esthetic Index (PEI.)10 Alternatively, Orofacial Appearance can be measured
within the umbrella construct OHRQoL as one of its four dimensions.11, 12 One advantage of specific dPROMs, such as the OES, is that they utilize only the necessary indicators, i.e., questionnaire items, to capture a construct. On the other hand, assessing an
attribute within OHRQoL also has advantages. Information on Orofacial Appearance can be collected and analyzed together with information on Oral Function, Orofacial Pain, and Psychosocial Impact. This allows Orofacial Appearance to be measured within other components of the patient’s global oral health suffering. Furthermore, it allows
comparison including all dimensions of oral health burden from different oral diseases. Such a comprehensive approach is essential to implement evidence-based dentistry across dental disciplines and to move forward to value-based oral health care, relating outcome to costs.
Therefore, the aim of this systematic review was to scientifically describe orofacial appearance as OHRQoL impact, using patient populations with treatment need relating to tooth wear, orthodontics, orthognathic surgery, frontal tooth loss, and tooth whitening as characteristic models for the esthetic concerns.
Methods
This systematic review followed a protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement13 registered in PROSPERO (CRD42017064033).
Inclusion criteria
● Human adult population or patients (> 18 years of age) with patients with treatment need relating to related to Tooth wear, Orthodontics, Orthognathic Surgery, Frontal tooth loss or Tooth whitening. The conditions could be self-reported or clinically diagnosed.
● Reporting OHRQoL with OHIP mean or median domain scores (49, OHIP-20, OHIP-19, and OHIP-14).14-16
● English language.
Exclusion criteria:
● Not full text publications (abstracts, editorials, etc.).
● No primary data available or data not in original 0 to 4 OHIP item response format.17
● Grey literature.
Literature search
As this review was part of a larger project on the 4 dimension-model of the OHIP a pool search was carried out that provided data for all four domains complemented by a manual search for the specific domains. The electronic literature search was conducted by a trained librarian (NTM, see acknowledgement) using the search terms “Oral Health
Impact Profile” OR “OHIP” to identify articles that measure OHRQoL by OHIP for any
oral health condition. An electronic search in PubMed (Medline), EMBASE, Cochrane, CINAHL, and PsycINFO from the inception of respective database to June 8, 2017, updated January 14, 2019, and supplemented with hand searches. Authors were not contacted for additional information.
Two reviewers (SS, NTM, see acknowledgement) independently screened all titles and abstracts for inclusion. At the full text assessment stage, articles were allocated into one of four groups according to which OHRQoL dimension was affected the most by the patients’ treatment need. Thus, the initial assignment of full text articles to the orofacial appearance dimension was carried out by two reviewers (SS, MJ, see
acknowledgement), and was checked by a third reviewer (PL). The assignment of an article was changed to one of the other dimensions (Orofacial pain, Esthetic or
Psychosocial impact) if agreed by all reviewers. These four groups were considered mutually exclusive. Even though a particular article could contain a population
representing more than one of the four dimensions, each article was assigned to one group only. If an article contained two or more different patient populations, the
assignment was guided by the largest number of patients. All potentially eligible articles were then reviewed independently in full text against the inclusion and exclusion criteria by two reviewers (SS, PL). Uncertainties were resolved by discussions with another fourth reviewer (MJ).17
Assessment of risk of bias in included studies
Two authors (PL, BHH) independently assessed the risk of bias for the eligible articles using a modified version of quality assessment for prevalence studies tool developed by Munn et al.18 Four of the ten items (number 2, 8, 9 and 10) in the appraisal tool were removed as they were not considered relevant for the present review.17 Each of the remaining six questions could be answered with “yes”, representing a low risk of bias, “unclear” representing medium risk or “no”, representing a high risk of bias. In cases of inter-examiner disagreement, each article was re-read and discussed until consensus was reached.
Data extraction
The following data were extracted from the included articles: first author, year of publication, journal name, study population, characteristics of the individual patient samples, age and gender information, OHIP version used, OHIP Psychologic Discomfort domain score (mean or median), OHIP Psychologic Discomfort domain score distribution values (confidence intervals, standard errors, standard deviations, interquartile ranges).
Accepted Article
Data extraction of the included articles was carried out by one reviewer (SS), and then checked by a second reviewer (PL). For studies that evaluated treatment, the pre-treatment baseline data was used.
Data analysis
The study included mean values derived from four versions of the OHIP questionnaire (14-, 19-, 20-, and 49-item). The data from OHIP-19, OHIP-20 and OHIP-49 were converted to OHIP-14 means together with 95% confidence interval values restricted to fit on a 0 to 8 scale.17 The mean and 95% confidence interval values were derived either directly from the articles when provided, or converted from other values. When mean values were absent, median values were used instead. If confidence interval values were missing, they were calculated from data provided as standard deviation, standard error, interquartile range, or 25% and 75% quartile range.
Results
The literature search identified 2,104 abstracts and after screening of the abstracts, 1,607 articles were reviewed in full text. Following application of the inclusion and
exclusion criteria 33 articles were included for the Orofacial Appearance domain (Fig.1).
In total, the 33 articles included 63 patient populations. With regard to the main areas of esthetic treatment need, 1 publication concerned tooth wear, 13 articles orthodontics, 13 articles orthognathic surgery, 3 articles frontal tooth loss and 3 articles concerned tooth whitening. Of these primary studies, 15 articles included one patient sample and the remaining 18 articles contained 2-5 patient samples.
The risk of bias assessment was carried out with a modified tool for prevalence studies and for the domain “recruitment” a substantial proportion of articles, including a total of 34 patient populations were deemed to have an unclear risk of bias with a further 10 patient populations deemed to have a high risk of recruitment bias (Fig. 2). All included articles were retained for further analyses.
The 33 studies reported OHIP-data represented by 9,409 patients grouped in 63 patient populations (Table 1).
A typical orofacial appearance impact for a majority of populations was between 2 and 3 on a 0 to 8 converted scale. The esthetic impact scores ranged from 0.09 to 6.25. The individual appearance condition with the highest reported impact was for treatment need relating to orthognathic surgery with an average score of 2.8. The patients with the other four esthetic conditions reported average impact for the patient populations from 0.1 to 2.6 (Fig. 3).
Discussion
In this systematic review we report as a main finding, that patients with oral health conditions deemed representative for the Orofacial Appearance domain report a high
degree of esthetic concerns. We identified a total of 33 publications investigating QoL impact related to Orofacial Appearance in a total of 63 patient populations. Together with orofacial pain, oral function and psychosocial impact, orofacial appearance is an obvious key for OHRQoL and oral health. The review provides standardized information from patient populations with five types of esthetic conditions as a model for the orofacial appearance dimension of quality of life.
Appearance or esthetics is basically a fundamentally subjective perception that varies between individuals and also varies with regard to importance.19 This is challenging when measuring and evaluating interventions in dental treatment that can alter or aim to
improve the orofacial esthetics. Therefore, it is not sufficient to make assessments using exclusively professional or normative measures alone. Thus, patients´ self-reported perceptions are very important when dental treatment together with esthetic concerns are evaluated.20
As mentioned before there are basically two measurement approaches for esthetics, with dPROMs especially designed to measure the dimension Orofacial Appearance only, or this dimension together with other dimensions. The OHIP measure was developed back in the 1990’s in an elderly population where esthetic concerns had a relatively low priority for both patients and dentists.16 In the present review we have been able to present a remarkable amount of information based on OHIP-data for 9,409 patients in 63 patient populations published in 33 publications regarding orofacial appearance
concerns.
This large amount of data may reflect that the demands and interest in facial esthetics have increased. Most of the available information was found in populations with
orthodontic and orthognathic surgery treatment need. Furthermore, the original 49 item OHIP scale only includes 4 esthetic items which in the previous 7-domain model was distributed in 3 different domains. Therefore, one advantage with the new 4-dimensional model for OHRQoL might be the inclusion of Orofacial Appearance as one out of four dimensions.11, 12 These dimensions have been showed to underlie widely used OHRQoL
instruments in particular,21 and all generic multi-item dPROMs in general.22
As OHIP is a global and generic oral health measure, and useable in all adult populations, the esthetic items have to be few and broad. The first item “Have you noticed a tooth that does not look right?” is a direct or primary esthetic question without involving any other domain while the other two items “Have you felt uncomfortable about the appearance or teeth, mouth or dentures?” and “have you avoided smiling because of problems with your teeth, mouth or dentures?” are closely related to psychosocial
impact. In population studies and larger surveys these measures are sufficient, but for more specific intervention studies of evaluating different types of treatments that affect patients´ opinion of their own orofacial appearance, more specific measures are needed. Such specific measures can in those situations be utilized to complement the broad esthetic measure in OHIP.23 There are instruments targeting orofacial esthetics
specifically where the OES reports patients opinion8, 9 and the PEI the professionals´.10 While aesthetic concerns constitute one of four dimensions in OQRQoL, other additional measurements are needed. This is also concluded in a review article by Frese et al, proposing that there is a large interest and need for adequate measurements of dentofacial esthtetic.24
One approach to handle the extensive psychometric instrument of 49 items provided by the OHIP has been suggested. A short form of OHIP was developed, especially
addressed for dental esthetic studies, OHIP-esthetic, that more accurately can capture the esthetic effectiveness on tooth whitening.20, 25 On the other hand, the Dental
Appearance Questionnaire was correlated with a well-being test (Beltz Test) and OHIP-49 with the interpretation that the OHIP-OHIP-49 alone did not evaluate dental appearance sufficiently.26 Another approach to sharpen the esthetic measure in a specific population or in an intervention study is to combine the generic OHIP measure with a more direct and specific measure.8, 9 This is also suggested in another study evaluating OHRQoL and Orofacial esthetics in patients with tooth wear.27 Moreover, a newly developed Spanish version of the Orofacial Esthetic Scale (OES) recommend a similar approach of
measuring self-reported orofacial appearance, i.e. to combine OHIP and a specific direct esthetic measure.28 In line with this, we suggest, while there is no systematic review of
the OES, this should be performed and subsequently the metric should be adjusted in direction to compatibility with OHIP. This would allow providing an even more complete picture how patients perceive their Orofacial Appearance and are impacted esthetically. An esthetic dPROM is needed, and in a future the OHRQoL psychometrics, all
dimensions of the concept should ideally be included in one psychometric instrument. Esthetics is in our view a substantial part of OQRQoL.
Our systematic review is one part of a larger comprehensive project on OHRQoL and patient populations were assigned to one of the four dimensions, and these four groups were considered mutually exclusive. Studies targeting general dentistry were evaluated in the psychosocial domain systematic review, even though these patients often have an esthethic concern. This is a limitation that we are aware of.
Nevertheless, orofacial appearance is measurable with the same psychometric measure as the three other components of OHRQoL (Orofacial Pain, Oral Function and
Psychosocial Impact), and conceptually appearance is not different from pain and
function. They are subjective in their nature. Most often these four dimensions (Orofacial Appearance, Orofacial Pain, Oral Function and Psychosocial Impact) act together to give an individual his or her perspective of oral health and OHRQoL. Consequently, in the present review we evaluated data from 33 studies and 63 populations exclusively regarding orofacial appearance but there was a considerable amount of four-dimension OHRQoL information that could not be used in this setting since focus was put on each of the four domains. The authors of this article, accompanied by their colleagues from the other articles in this Special Issue, recommended to use standardized assessment of OHRQoL to have a complete four-dimensional assessment across all settings.
In conclusion, this systematic review concerning orofacial appearance presented standardized information from different conditions with treatment need relating to esthetics, and the results indicate a varied but moderate impact of OHRQoL, when assessed by OHIP, in patients with orofacial appearance concerns.
Table 1. OHIP scores for Included articles reporting OHIP scores for patient populations with different conditions with treatment need relating to esthetics (n=33)
First author Year Population Population N (% women) Mean age (yrs) (SD) Range Instrument Mean score (SD) Standardized mean score (95% CI) † Treatment need related to tooth wear
Daly 201129
I: Moderate erosion into dentin
II: No/mild erosion into dentin
III: Severe erosion into dentin 117 326 392 OHIP-49 0.23 (0.68) OHIP-49 0.34 (0.84) OHIP-49 0.4 (0.9) 0.09 (0.04 0.14) 0.14 (0.10 0.17) 0.16 (0.12 0.20) Treatment need related to orthodontic treatment
Antoun 201530 I: Cleft lip/palate II: Malocclusion III: Orthognathic patients 24 (41.7%) 30 (43.3%) 29 (48.3%) 12.6 (2.8) 14.5 (1.9) 19.0 (4.3) OHIP-14 2.54 (2.32) OHIP-14 3.00 (2.52) OHIP-14 4.83 (2.41) 2.54 (1.56 3.52) 3.00 (2.06 3.94) 4.83 (3.91 5.75) Ashari 201631
I: Orthodontic patients 150 OHIP-14
3.71 (2) 3.71 (3.39 4.03) Choi
201532
I: Dental patients, private orthodontics
II: Ortho need, extensive 244 (59.5%) 136 22.4 OHIP-14 1.08 (1.08) OHIP-14 2 (1.5) 1.08 (0.94 1.22) 2.00 (1.75 2.25)
Accepted Article
III: Ortho need, moderate 108 22.4 OHIP-14 1.7 (1.6) 1.70 (1.39 2.01) Choi 201733
I: Orthodontic patients 66 (54.5%) 24.2 (5.2) OHIP-14
1.8 (2.0) 1.80 (1.31 2.29) Clijman
201534
I: Orthodontic patients 189 OHIP-14
3 (2.1) 3.00 (2.70 3.30) Javed
201635
I: Class I
II: Class II
III: Class III
139 42 41 OHIP-14 2.04 (2.04) OHIP-14 2.67 (1.73) OHIP-14 2.63 (2.21) 2.04 (1.70 2.38) 2.67 (2.13 3.21) 2.63 (1.93 3.33) Kang 201436 I: Malocclusion
II: Ortho patients
III: Ortho patients wearing retainer 202 (53.9%) 241 (60.2%) 209 (58.8%) 26.5 (5.6) 24.5 (4.9) 25.6 (5.3) OHIP-14 3.82 (1.58) OHIP-14 3.61 (1.66) OHIP-14 2.81 (1.62) 3.82 (3.60 4.04) 3.61 (3.40 3.82) 2.81 (2.59 3.03) Masood 201337
I: Ortho need, high
II: Ortho need, little
85 87 OHIP-14 4.9 (1.7) OHIP-14 3.8 (1.8) 4.90 (4.53 5.27) 3.80 (3.42 4.18)
Accepted Article
III: Ortho need, moderate 80 OHIP-14 4.5 (1.6) 4.50 (4.14 4.86) Masood 201438
I: Cross bite 71 OHIP-14
4.24 (1.69) 4.24 (3.84 4.64) Masood 201739 I: Cross-bite/scissor-bite absent II: Cross-bite/scissor-bite present III: Increased overbite/open bite absent IV: Increased overbite/open bite present V: Increased overjet absent
VI: Increased overjet present Total number population I-VI: 4,085 (53.3%) Range: 30-55 OHIP-14 0.7 (0.03*) OHIP-14 0.7 (0.05*) OHIP-14 0.7 (0.02*) OHIP-14 0.9 (0.1*) OHIP-14 0.6 (0.02*) OHIP-14 0.9 (0.09*) 0.70 (0.64 0.76) 0.70 (0.60 0.80) 0.70 (0.66 0.74) 0.90 (0.70 1.10) 0.60 (0.56 0.64) 0.90 (0.72 1.08) Zanatta 201240 I: Gingival enlargement during orthodontic treatment 330 OHIP-14 1.95 (0.93) 1.95 (1.84 2.05) Zheng 201541 I: Class I II: Class II 35 32 OHIP-14 3.94 (1.29) OHIP-14 3.93 (1.38) 3.94 (3.50 4.38) 3.93 (3.43 4.43)
Accepted Article
III: Class III 14 OHIP-14 0.53 (0.5) 0.53 (0.24 0.82) Zhou 201442 I: Conventional ortho brackets
II: Self-ligating ortho brackets 75 75 OHIP-14 3.25 (1.09) OHIP-14 3.12 (1.12) 3.25 (3.00 3.50) 3.12 (2.86 3.38) Treatment need related to orthognathic surgery
Antoun 201743 I: Hyperdivergent II: Normodivergent 80 (65%) 80 (65%) 17.1 (4.5) 17.3 (4.6) OHIP-14 1.8 (1.7) OHIP-14 1.6 (1.8) 1.8 (1.42 2.18) 1.6 (1.20 2.00) Baherimogh addam 201644 I: Class II
II: Class III
28 (57.1%) 30 (36.7%) 25.1 (3.4) 21.3 (2.7) OHIP-14 3.07 (2.09) OHIP-14 5.23 (1.07) 3.07 (2.26 3.88) 5.23 (4.83 5.63) Belucci 201445
I: Oral cleft palate deformity
50 OHIP-14
1.16 (1.19) 1.16 (0.82 1.50) Choi
201046
I: Orthognathic patients 32 (68.8%) 23.9 (6.6) OHIP-14
4.44 (2) 4.44 (3.72 5.16) Choi
201647
I: Ages 20-29 with malocclusion
II: Ages 30-39 with malocclusion
III: Over 40 with malocclusion 194 46 18 OHIP-14 1.12 (1.01) OHIP-14 1.1 (1.07) OHIP-14 1 (0.79) 1.12 (0.98 1.26) 1.1 (0.78 1.42) 1.0 (0.61 1.39)
Accepted Article
IV: Teens with malocclusion 214 OHIP-14 0.73 (0.87) 0.73 (0.61 0.85) Goelzer 201448 I: Class I II: Class II
III: Class III
5 11 58 OHIP-14 3.11 (0.56) OHIP-14 2.45 (1.07) OHIP-14 2.7 (1.16) 3.11 (2.41 3.81) 2.45 (1.73 3.17) 2.70 (2.39 3.01) Huang 201649 I: Malocclusion, ortho then surgery II: Malocclusion, surgery then ortho
25 25 OHIP-14 6.25 (2.09) OHIP-14 6.12 (2.12) 6.25 (5.39 7.11) 6.12 (5.24 7.00) Kilinc 201550
I: Class III (bimaxillary)
II: Class III (monomaxillary) 19 (36.8%) 11 (72.7%) 22.7 (4.5) 23.2 (2.7) OHIP-14 1.26 (1.59) OHIP-14 1.45 (1.03) 1.26 (0.49 2.03) 1.45 (0.76 2.14) Lee 200751 I: Dentalfacial deformity 76 21.5 OHIP-14 3.59 (2.02) 3.59 (3.13 4.05) Lee 200852 I: Presurgical, bimaxillary ortho surgery 36 (30.6%) 23.25 (6.6) OHIP-14 4.42 (1.98) 4.42 (3.75 5.09) Nichols 201853 I: Orthognathic patients (standard) II: Orthognathic patients (cleft) 16 (56.3%) 19 (36.8%) 15.1 (2.1) 12.7 (3.1) OHIP-14 3.4 (2.7) OHIP-14 2.6 (2.3) 3.4 (1.96 4.84) 2.6 (1.49 3.71)
Accepted Article
III: Orthognathic patients (surgery) 22 (40.9%) 19.3 (4.7) OHIP-14 4.7 (2.1) 4.7 (3.77 5.63) Silva 201654
I: Orthognathic patients 55 OHIP-14
1.78 (1.27) 1.78 (1.44 2.12) Sun 201855 I: Orthognathic patients (preoperative) 85 (63.5%) 24 (17-41) OHIP-14 1.59 (1.23) 1.59 (1.32 1.86) Treatment need related to frontal tooth loss
Armellini 200856
I: >18 years
II: SDA-intact anterior region
III: SDA-intact anterior region IV: SDA-interrupted anterior region V: SDA-interrupted anterior region 38 (47%) 25 (56%) 44 (50%) 32 (50%) 21 (38%) 32 (10) 69 (7) 57 (14) 62 (11) 57 (15) OHIP-49 0.7 (0.2) OHIP-49 1.7 (0.4) OHIP-49 1.4 (0.2) OHIP-49 1.7 (0.3) OHIP-49 1.7 (0.3) 0.28 (0.25 0.31) 0.68 (0.61 0.75) 0.56 (0.54 0.58) 0.68 (0.64 0.72) 0.68 (0.63 0.73) Goshima 200957
I: missing teeth. tooth agenesis up to 4 teeth 18 (50%) 32 (10) OHIP-49 10.4 (8.7) 4.16 (2.43 5.89) Hashem 201358 II: Amelogenesis imperfecta I: Hypodontia 27 41 OHIP-49 12.3 (5) OHIP-49 10 (6.2) 4.92 (4.13 5.71) 4.00 (3.22 4.78)
Accepted Article
Treatment need related to tooth whitening Martin
201559
I: Whitening treatment 30 OHIP-14
5.58 (1.5) 5.58 (5.02 6.14) McGrath
200560
I: Whitening treatment 157 OHIP-49
4.44 (2.82) 1.78 (1.60 1.95) Wong
200720
I: Whitening treatment 87 OHIP-49
4.44 (2.82) 1.78 (1.54 2.02) †: Mean scores and SD from OHIP-49 were converted into OHIP-14 mean and 95% CI values; SD: Standard deviation; 95% CI: 95% confidence interval. SDA: Shortened Dental Arch.
Figure legends
Fig. 1. PRISMA flowchart of included and excluded studies.
Fig. 2. Risk of bias assessment of the 33 included studies presented as proportions for the total number of patient populations (n=63) of the assessed domains, i.e. Representativeness,
Recruitment, Characterization, Coverage, Standard, and Reliability. Low (green), unclear (yellow) and high (red) risk of bias.
Fig. 3. The 33 studies reporting impact (0-8 OHIP-scale) for different conditions with treatment need relating to esthetics; 1 article concerned tooth wear, 13 articles orthodontics, 13 articles orthognathic surgery, 3 articles anterior tooth loss, and 3 articles concerned tooth whitening. The red line indicates the median OHIP score for each population.
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