Quality of Life Research

, Volume 24, Issue 2, pp 379–390 | Cite as

Psychosocial impact of dental aesthetics in adolescence: validity and reliability of a questionnaire across age-groups

  • Ulrich Klages
  • Christina Erbe
  • Sandra Dinca Sandru
  • Dan Brüllman
  • Heinrich Wehrbein



Dental malocclusion is a highly prevalent health condition in adolescence. Patients seek treatment primarily for aesthetic reasons. Therapy benefits are regarded, in the first place, to be psychosocial in nature. Therefore, it is mandatory to consider the perspective of the patient in treatment planning and control using a dental-aesthetics-related quality of life measure. The objective of this study was to investigate whether the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) developed in adult samples including the subscales Dental Self-Confidence, Social Impact, Psychological Impact and Aesthetic Concern is also applicable in adolescents aged 11 years and above. The psychometric properties were examined across three age-groups (11–12, 13–14, 15–17 year olds) with respect to factorial invariance, internal consistency, temporal stability, discriminant validity and gender- or age-associated scale mean differences and item response bias.


Participants were 1,112 adolescents recruited from 4 institutions: orthodontic and dental practices, schools, and youth clubs. They answered the 23 partially reformulated items of the PIDAQ. Subjective and dentist evaluations of dental occlusion were assessed using the Perception of Occlusion Scale and the Aesthetic Component of the Index of Orthodontic Treatment Need. Both indices were aggregated to one Malocclusion Index (MI-S and MI-D).


The fit indices using confirmatory factor analyses suggested that the factor structure and factor loadings underlying the PIDAQ items were invariant across ages (comparative fit index = 0.91, root-mean-square error of approximation = 0.04). Internal consistency and temporal stability were adequate within the age-groupings (Alpha = 0.71–0.88; intra-class correlations = 0.82–0.96). Adolescents with severe compared to slight malocclusion according to both self-evaluation and dentist evaluation were found to differ in all PIDAQ subscales at a level of p < 0.001 for all ages. PIDAQ scale scores were not related to age and gender. On the item level, no evidence for gender or age bias has been found.


The PIDAQ demonstrates to have good psychometric properties in adolescents, independent of their age. The instrument can be applied in making clinical decisions and in the assessment of psychosocial outcomes of orthodontic therapy.


Quality of life Adolescent Dental health Orthodontics Malocclusion 


Conflict of Interests

The authors declare that they have no competing interests.


  1. 1.
    Ashley, F. P., Usiskin, L. A., Wilson, R. F., & Wagaiyu, E. (1998). The relationship between irregularity of the incisor teeth, plaque, and gingivitis: a study in a group of school children aged 11–14 years. European Journal of Orthodontics, 20, 65–72.PubMedCrossRefGoogle Scholar
  2. 2.
    Glans, R., Larsson, E., & Ogaard, B. (2003). Longitudinal changes in gingival condition in crowded and noncrowded Dentitions subjected to fixed orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics, 124, 679–682.PubMedCrossRefGoogle Scholar
  3. 3.
    Pietilä, T., & Pietilä, I. (1995). Dental appearance and orthodontic services assessed by 15-16-year old adolescents in Eastern Finland. Community Dental Health, 13, 139–144.Google Scholar
  4. 4.
    Baubiniené, D., Sidlauskas, A., & Miseviciené, I. (2009). The need for orthodontic treatment among 10–11- and 14–15-year-old Lithuanian schoolchildren. Medicina, 45, 814–821.PubMedGoogle Scholar
  5. 5.
    Nobile, C. G. A., Pavia, M., Fortunato, L., & Angelillo, I. F. (2007). Prevalence and factors related to malocclusion and orthodontic treatment need in children and adolescents in Italy. European Journal Public Health, 17, 637–641.CrossRefGoogle Scholar
  6. 6.
    Joseffson, E., Bjerklin, K., & Lindsten, R. (2007). Malocclusion frequency in Swedish and immigrant adolescents: influence of origin on orthodontic treatment need. European Journal of Orthodontics, 29, 79–87.CrossRefGoogle Scholar
  7. 7.
    Birkeland, K., Katle, A., Lovgreen, S., Boe, O. E., & Wisth, P. J. (1999). Factors influencing the decision about orthodontic treatment: a longitudinal study among 11- and 15-year olds and their parents. Journal of Orofacial Orthopedics, 60, 292–307.PubMedCrossRefGoogle Scholar
  8. 8.
    Sergl, H. G., Klages, U., & Pempera, J. (1992). On the prediction of dentist evaluated patient compliance. European Journal of Orthodontics, 14, 463–468.PubMedCrossRefGoogle Scholar
  9. 9.
    Bos, A., Hoogstraten, J., & Prahl-Andersen, B. (2005). Towards a comprehensive model for the study of compliance in orthodontics. The European Journal of Orthodontics, 27, 296–301.CrossRefGoogle Scholar
  10. 10.
    Bos, A., Hoogstraten, J., & Prahl-Andersen, B. (2003). Expectations of treatment and satisfaction with dentofacial appearance in orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics, 123, 127–132.PubMedCrossRefGoogle Scholar
  11. 11.
    Hunt, O., Hepper, P., Johnston, C., Stevenson, C., & Burden, D. (2001). Professional perceptions of the benefit of orthodontic treatment. European Journal of Orthodontics, 23, 315–323.PubMedCrossRefGoogle Scholar
  12. 12.
    Klages, U., & Zentner, A. (2007). Dentofacial aesthetics and quality of life. Seminars in orthodontics, 13, 104–115.CrossRefGoogle Scholar
  13. 13.
    Birkeland, K., Boe, O. E., & Wisth, P. J. (1997). Subjective evaluation of dental and psychological results after orthodontic treatment. Journal of Orofacial Orthopedics, 58, 44–61.PubMedGoogle Scholar
  14. 14.
    Klages, U., Claus, N., Wehrbein, H., & Zentner, A. (2006). Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults. European Journal of Orthodontics, 28(2), 103–111.PubMedCrossRefGoogle Scholar
  15. 15.
    Gazit-Rappaport, T., Haisraeli-Shalish, M., & Gazit, E. (2010). Psychosocial reward of orthodontic treatment in adult patients. European Journal of Orthodontics, 32(4), 441–446.PubMedCrossRefGoogle Scholar
  16. 16.
    Khan, M., & Fida, M. (2008). Assessment of psychosocial impact of dental aesthetics. Journal of the College of Physicians and Surgeons Pakistan, 18, 559–564.PubMedGoogle Scholar
  17. 17.
    Afroz, S., Rathi, S., Raiput, G., & Rahman, S. A. (2013). Dental esthetics and its impact on psycho-social well-being and dental self-confidence: a campus survey of north Indian university students. The Journal of Indian Prosthodontic Society, 13(4), 455–460.Google Scholar
  18. 18.
    Dahong, X., Xiangrong, C., Ying, L., Yusong, L., Ying, G., & Yan, S. (2013). Effect of incisor position on the self-perceived psychosocial impacts of malocclusion among Chinese young adults. Angle Orthodontist, 83(4), 617–622.PubMedCrossRefGoogle Scholar
  19. 19.
    Lin, H., Quan, C., Guo, C., Zhou, C., Wang, Y., & Bao, B. (2011). Translation and validation of the Chinese version of the psychosocial impact of dental aesthetics questionnaire. European Journal of Orthodontics, 35(3), 354–360.PubMedCrossRefGoogle Scholar
  20. 20.
    Chen, P., Yu, S., & Zhu, G. (2012). The psychosocial impacts of implantation on the dental aesthetics of missing anterior teeth patients. British Dental Journal, 213(11), E20.PubMedCrossRefGoogle Scholar
  21. 21.
    Kolawole, K. A., Ayeni, O. O., & Osiatuma, V. I. (2012). Psychosocial impact of dental aesthetics among university undergraduates. International Orthodontics, 10(1), 96–109.PubMedGoogle Scholar
  22. 22.
    Ngom, P. I., Attebi, P., Diouf, J. S., Diop, B. K., Badiane, A., & Diagne, F. (2013). Translation and cultural adaptation of a French version of the psychosocial impacts of dental aesthetics questionnaire: pIDAQ. Orthodontie Francaise, 84(4), 319–331.PubMedCrossRefGoogle Scholar
  23. 23.
    Sardenberg, F., Oliveira, A. C., Paiva, S. M., Auad, S. M., & Vale, M. P. (2011). Validity and reliability of the Brazilian version of the psychosocial impact of dental aesthetics questionnaire. European Journal of Orthodontics, 33(3), 270–275.PubMedCrossRefGoogle Scholar
  24. 24.
    Klages, U., Rost, F., Wehrbein, H., & Zentner, A. (2007). Perception of occlusion, psychological impact of dental esthetics, history of orthodontic treatment and their relation to oral health in naval recruits. Angle Orthodontist, 77(4), 675–680.PubMedCrossRefGoogle Scholar
  25. 25.
    Spalj, S., Vlatka, L., & Ivankovich, L. (2013). Qual Life Res,. doi: 10.1007/s11136-013-0547-x.Google Scholar
  26. 26.
    de Paula, D. F., Santos, N. C. M., da Silva, E. T., de Fatima Nunes, M., & Leles, C. R. (2009). Psychosocial impact of dental esthetics on quality of life in adolescents. Angle Orthodontist, 79, 1188–1193.CrossRefGoogle Scholar
  27. 27.
    Paula, D. F, Jr, Silva, É. T., Campos, A. C., Nuñez, M. O., & Leles, C. R. (2011). Effect of anterior teeth display during smiling on the self-perceived impacts of malocclusion in adolescents. Angle Orthodontist, 81(3), 540–545.PubMedCrossRefGoogle Scholar
  28. 28.
    Bellot-Arcis, C., Montiel-Company, J. M., & Almerich-Silla, J. M. (2013). Psychosocial impact of malocclusion in Spanish adolescents. The Korean Journal of Orthodontics, 43(4), 193–200.CrossRefGoogle Scholar
  29. 29.
    Montiel-Company, J. M., Bellot-Arcis, C., & Almerich-Silla, J. M. (2013). Validation of the psychosocial impact of dental aesthetics questionnaire (Pidaq) in Spanish adolescents. Medicina Oral, Patologia Oral y cirugia Bucal, 18(1), e168–e173.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Food and Drug Administration. (2009). Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims. Silver Spring: Food and Drug Administration.Google Scholar
  31. 31.
    Meade, A. W., & Bauer, D. J. (2007). Power and precision in confirmatory factor analytic tests of measurement invariance. Structural Equation Modeling, 14(4), 611–635.CrossRefGoogle Scholar
  32. 32.
    Westland, J. C. (2010). Lower bounds of sample size in structural equation modeling. Electronic Commerce Research and Applications, 9(6), 476–487.CrossRefGoogle Scholar
  33. 33.
    Scott, N. W., Fayers, P. M., Aronson, N. K., et al. (2010). Differential item functioning (DIF) analyses of health-related quality of life instruments using logistic regression. Health Qual Life Outcomes,. doi: 10.1186/1477-7525-8-81.PubMedCentralPubMedGoogle Scholar
  34. 34.
    Bonett, D. G. (2002). Sample size requirements for estimating intraclass correlations with desired precision. Statistics in Medicine, 21, 1331–1335.PubMedCrossRefGoogle Scholar
  35. 35.
    Grzywacz, I. (2003). The value of the aesthetic component of the index of orthodontic treatment need in the assessment of subjective orthodontic treatment need. European Journal of Orthodontics, 25, 57–63.PubMedCrossRefGoogle Scholar
  36. 36.
    Paunonen, S. V., & Gardner, R. C. (1991). Biases resulting from the use of aggregated variables in psychology. Psychological Bulletin, 109, 520–523.CrossRefGoogle Scholar
  37. 37.
    Gregorich, S. E. (2006). Do self-report instruments allow meaningful comparisons across diverse population groups? Testing measurement invariance using the confirmatory factor analysis framework. Medical Care, 44(3), 78–94.CrossRefGoogle Scholar
  38. 38.
    Chen, F. F. (2007). Sensitivity of goodness of fit indexes to lack of measurement invariance. Structural Equation Modeling, 14(3), 464–504.CrossRefGoogle Scholar
  39. 39.
    DeVet, H. C. W., Terwee, C. B., Knol, D. L., & Bouter, L. M. (2006). When to use agreement versus reliability measures. Journal of Clinical Epidemiology, 59, 1033–1039.Google Scholar
  40. 40.
    Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6(4), 284–290.CrossRefGoogle Scholar
  41. 41.
    Cohen, J. (1969). Statistical power analysis for the behavioral sciences. New York: Academic Press.Google Scholar
  42. 42.
    Nourisis, M. J. (1985). SPSS advanced statistics guide. New York: McFraw-Hill.Google Scholar
  43. 43.
    Long, J. S. (1997). Regression models for categorical and limited dependent variables. Thousand Oaks: Sage.Google Scholar
  44. 44.
    Thornton, B., & Ryckman, R. M. (1991). Relationship between physical attractiveness, physical effectiveness, and self-esteem: a cross-sectional analysis among adolescents. Journal of Adolescence, 14, 85–98.PubMedCrossRefGoogle Scholar
  45. 45.
    Davison, T. E., & McCabe, M. (2006). Adolescent body image and psychosocial functioning. Journal of Social Psychology, 146, 15–30.PubMedCrossRefGoogle Scholar
  46. 46.
    Jovanovic, J., Lerner, R. M., & Lerner, J. A. (1989). Objective and subjective attractiveness and early adolescent adjustment. Journal of Adolescence, 12, 225–229.CrossRefGoogle Scholar
  47. 47.
    Varni, J. W., Burwinkle, T. M., & Lane, M. M. (2005). Health related quality of life measurement in pediatric clinical trials: an appraisal and precept for future research and application. Health Qual Life Outcomes, 3, 1–9.CrossRefGoogle Scholar
  48. 48.
    Sergl, H. G., Klages, U., & Zentner, A. (1998). Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. American Journal of Orthodontics and Dentofacial Orthopedics, 114(6), 684–691.PubMedCrossRefGoogle Scholar
  49. 49.
    Sergl, H. G., Klages, U., & Zentner, A. (2000). Functional and social discomfort during orthodontic treatment: effects on compliance and prediction of patients’ adaptation by personality variables. European Journal of Orthodontics, 22, 307–315.PubMedCrossRefGoogle Scholar
  50. 50.
    Doll, G. M., Zentner, A., Klages, U., & Sergl, H. G. (2000). Relationship between patient discomfort, appliance acceptance and compliance in orthodontics. Journal of Orofacial Orthopedics, 61(6), 398–413.PubMedCrossRefGoogle Scholar
  51. 51.
    Klages, U., Bruckner, A., Guld, Y., & Zentner, A. (2005). Dental esthetics, orthodontic treatment, and oral-health attitudes in young adults. American Journal of Orthodontics and Dentofacial Orthopedics, 128, 442–449.PubMedCrossRefGoogle Scholar
  52. 52.
    Klages, U., Sergl, H. F., & Burucker, I. (1992). Relations between verbal behavior of the orthodontist and communicative cooperation of the patient in regular orthodontic visits. American Journal of Orthodontics and Dentofacial Orthopedics, 102(4), 265–269.PubMedCrossRefGoogle Scholar
  53. 53.
    Cash, T. F., & Strachan, M. D. (2002). Cognitive-behavioral approaches to changing body image. In T. F. Cash & T. Pruzinsky (Eds.), Body image: a handbook of theory, research, and clinical practice (pp. 478–486). New York: Guilford.Google Scholar

Copyright information

© © European Union 2014

Authors and Affiliations

  • Ulrich Klages
    • 1
  • Christina Erbe
    • 1
  • Sandra Dinca Sandru
    • 1
  • Dan Brüllman
    • 2
  • Heinrich Wehrbein
    • 1
  1. 1.Department of OrthodonticsUniversity Medical Center of the Johannes Gutenberg-University MainzMainzGermany
  2. 2.Department of Oral SurgeryUniversity Medical Center of the Johannes Gutenberg-University MainzMainzGermany

Personalised recommendations