Does Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) reflect the impact of malocclusion on facial aesthetics?

ABSTRACT Introduction: Malocclusion is presumed to have adverse effects on dental and facial attractiveness, leading to deleterious psychosocial impact and Quality of life(QoL) of the individual. The Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ) has proved to be effective for assessment of psychosocial impact of malocclusion on dental aesthetics, but it’s effectiveness for assessing facial aesthetics is unknown. Objective: The aim of the present study was to assess the effectiveness of PIDAQ on its ability to reflect the psychosocial impact of malocclusion on facial attractiveness, using the Facial Aesthetic index (FAI) after its translation and validation in the regional language. Methods: The 23-item PIDAQ, after translation process, cross-cultural adaptation and pilot testing, was administered to 330 subjects (62.5 % females and 37.5 % males; age range 18-30 years) with varying degrees of severity of malocclusion, assessed by the two components of the Index of Orthodontic Treatment Need (Dental Health Component, IOTN-DHC, for normative need; and self-administered Aesthetic Component, IOTN-AC, for subjective need) and FAI. Results: The internal consistency and test-retest reliability were good (Cronbach’s alpha = 0.859 - 0.958; Intraclass correlation coefficient =0.984). FAI, IOTN-DHC and IOTN-AC scores showed highly significant correlation with PIDAQ scores, depicting strong convergent validity (p< 0.001). One-way analysis of variance (ANOVA) and Bonferroni post-hoc test showed highly significant correlations (p-value < 0.001) for all comparisons. There were no significant differences between responses of males and females. The regional version of PIDAQ had excellent reliability. Conclusions: PIDAQ showed good psychometric properties and was able to effectively reflect the psychosocial impact of malocclusion on altered facial aesthetics.


INTRODUCTION
Physical characteristics are very important in the development of self-esteem and self-image. 1 People with good facial aesthetics are invariably more confident and have higher self esteem. 1 Malocclusion alters dentofacial aesthetics and influences a person's body image, self confidence and even social integration. 2With facial aesthetics being such an important concern in today's society, aesthetic improvement is often the most frequent subjective reason for seeking orthodontic treatment. 3aditional methods of orthodontic assessment are invariably based on an objective evaluation of the face and occlusion, both clinically and cephalometrically. 4Patient's self-perception of the malocclusion and how it affects his/her quality of life are usually not taken into consideration.The clinician's assessment of the problem may not necessarily coincide with the patient's reason for seeking orthodontic treatment, which in turn may lead to dissatisfaction from the patient's viewpoint. 4kewise, facial aesthetics may not be judged correctly by simply analyzing the occlusion.Sometimes facial profiles may be unacceptable, even in the absence of a malocclusion.Due to this, there is a paradigm shift in orthodontic diagnosis and treatment planning towards improvement of the soft tissues of the face.
Goal-oriented approach specifies identification and preservation of positive attributes along with elimination of the negative ones.The need for an independent appraisal of the face has been previously recognized, and the Facial Aesthetic Index (FAI) was developed for this purpose in 2016. 68][9] However, the psychosocial impact of altered facial aesthetics has never been investigated so far.
Therefore it can be seen that malocclusion impacts both dental and facial aesthetics.To improve the overall quality of life, it is absolutely necessary to understand the psychosocial impact of malocclusion on both facial and dental aesthetics if the patient's needs are to be considered adequately. 10ere are many instruments assessing the oral health related quality of life (OHRQoL) primarily aimed at the adult population regarding caries, tooth loss, periodontal disease etc. 11,12 Instruments measuring OHRQoL in children and adolescents like the Child Perception Questionnaire (CPQ [11][12][13][14] ), Child-Oral Impact on Daily Performance (OIDP) etc., are not directly applicable to orthodontic treatment in young adults. 13,14One instrument that did address this issue was the Orthognathic Quality of Life Questionnaire, which was developed for use in patients requiring Orthognathic surgery. 15This is what lead to the development of the promising instrument specific to orthodontic aspects of OHRQoL, the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) for young adults in the age range of 18-30 years, using a self-rated questionnaire. 16is questionnaire was initially developed in English as it was meant for the English speaking countries.Later on, it has been translated into many other languages after making appropriate adaptations, depending upon the social and cultural variations of the region. 178][19][20][21][22][23][24][25] Obviously, PIDAQ effectively reflects patient perception of altered dental aesthetics.Malocclusion alters both dental and facial aesthetics.Whether PIDAQ would also be able to reflect the psychosocial impact of malocclusion-induced altered facial aesthetics has not yet been evaluated.From the clinician point of view, this would be a great advantage, as he/she would need to use only one instrument for assessing both issues.Hence it was decided to investigate this important aspect, for which PIDAQ needs to be translated and validated in the regional language.Thus, after translation and cross-cultural adaptation to the regional language, the aim of this study was to: » Assess the psychosocial effects of malocclusion-induced altered facial aesthetics, using PIDAQ.
Dental Press J Orthod.2023;28(4):e232211 » Assess the psychosocial effect of malocclusion, based on its severity and treatment need.
» Assess the effect of gender on the perceived Quality of Life (QoL) as affected by the malocclusion.

MATERIAL AND METHODS
The PIDAQ is a psychometric instrument composed of 23 items.

TRANSLATION
The PIDAQ was first translated into the regional language, Malayalam (State of Kerala, India) by three orthodontic postgraduate students, who were proficient in both languages.
They were familiar with QoL terminologies and instruments.
Thus, version I of the questionnaire was formed.

BACK TRANSLATION
The first draft of this version was translated back to English by a committee comprising of an English teacher and two dental postgraduate students.All three were proficient in both languages, but were unaware of the purpose of the study and had no knowledge of the original scale.

ASSESSMENT OF TRANSLATIONAL QUALITY
The original and back translated versions of the questionnaire were compared by a committee comprising of two orthodontists and a general dentist, fluent in both languages, with good knowledge regarding QoL.The committee made recommendations, so that the back translated version would come as close to the original as possible.

CULTURAL ADAPTATION
This was achieved with the help of another committee comprising of three orthodontists working in nearby hospitals and a community group in the district.They evaluated the questionnaire to see if the various concepts would be relevant to the cultural context of this society.Conceptual and semantic equivalence were assessed, and proposed modifications were made to improve accuracy and clarity.Thus an adapted Version II of the questionnaire was formed.FAI was assessed based on facial profile photographs depicting underlying malocclusions, which were coded from A to H (Table 1).In this investigation, FAI scoring A,B were grouped as "no need/ slight need"; C,D,E were grouped as "moderate need"; and F,G,H were grouped as "definite need".The image depicting different facial aesthetic types is presented in Figure 2.
Representative photographs of patients included in the study with moderate and more definite treatment needs, based on the Facial Aesthetic Index, are presented in Figures 3 and 4     After a period of four weeks, 90 subjects who reported again from among those contacted, were subjected to a retest to assess the reliability.A flowchart depicting the sequence of events is given in Figure 5.

RESULTS
There was a total of 330 subjects, of which 37.5% were males.
Within each domain and overall Qol, there were no statistically significant differences between males and females.
Table 2 shows the means and standard deviations and independent sample t-test of the responses obtained for all the different domains and overall QoL with respect to sex.Results showed that there were no significant differences between males and females with respect to all domains -DSC, SI, PI and AC.
Table 3 shows the results of one-way analysis of variance (ANOVA) test comparing PIDAQ scores with different grades of malocclusion as categorized by IOTN-DHC, IOTN-AC & FAI rated by the subjects' mean, standard deviations (SDs), F-statistics, and level of significance.

DISCUSSION
[18] The Chinese version, on the other hand, differs from the original in that it has only three domains, due to merging of Psychological Impact and Aesthetic Concern domains, to form one single domain called Aesthetic Attitude. 19Nepalese version has five domains, due to the addition of another domain termed Dental self-Consciousness.As severity of malocclusion increased, indicated by increase in scores of IOTN-DHC, there was definite increase in scores of DSC, SI, PI, AC and overall scores.This highly significant increase reflects the increasing concern of the subjects with respect to their occlusion and dental health.The statistically significant increase in the scores of the different domains, as the orthodontic treatment need progressed from slight need to moderate need and then to definite need, shows the ability of PIDAQ to discriminate between different levels of malocclusion.
Patient's perception of malocclusion and subjective need of treatment is of profound importance.Professional evaluation of malocclusion may not always coincide with patient's perception.The effect of self-reported degree of malocclusion on the QoL may be assessed with IOTN-AC.The present findings show that DSC, SI, PI and AC were highly affected by the IOTN-AC similar to the English, Italian and Chinese versions. 16,19,21Impact of increasing severity was reflected in the increasing DSC, SI, PI, AC and overall scores.
Patients seek treatment primarily for improvement of facial aesthetics.Evaluation of facial aesthetics is an important factor in overcoming psychosocial difficulties related to dental and facial appearance.Isolated correction of malocclusion should not be considered successful if facial aesthetics is not satisfactory at treatment completion. 27However, thus far, no It has one positive and three negative domains.The four subscales are: Aesthetic Concern (AC), having 3 items; Psychosocial impact (PI), having 6 items; Social Impact (SI), having 8 items; and Dental self confidence (DSC), having 6 items.The possible responses for each item are marked using a 5-point Likert scale, as follows: zero = not at all; one = a little; two = somewhat; three = strongly; and four = very strongly.Later, occlusal irregularities and normative treatment need was assessed using the Dental Health Component (IOTN-DHC) and subjective need using the Aesthetic Component (IOTN-AC) of the Index of Orthodontic Treatment Need (IOTN).26

Faraj M ,
Shobha S, Latheef V, Nivedita P -Does Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) reflect the impact of malocclusion on facial aesthetics?Dental Press J Orthod.2023;28(4):e232211 PRETEST This was followed by a pilot study conducted on a sample of 30 patients between the ages of 18-30 years comprising of 15 females and 15 males.The pilot test was performed by a single investigator (FM), through direct interview, to assess possible difficulties in understanding the questionnaire.At the end of this phase, appropriate adjustments were made and Version III of questionnaire was obtained (Fig 1).

Figure 1 :
Figure 1: The adapted version of PIDAQ questionnaire.

Faraj M ,
Shobha S, Latheef V, Nivedita P -Does Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) reflect the impact of malocclusion on facial aesthetics? 10 Dental Press J Orthod.2023;28(4):e232211 The validity and reliability of the translated version of PIDAQ was carried out among the patients and students reporting for treatment at Government Dental College, Calicut, Kerala, India.Inclusion criteria were as follows: Only subjects who were willing to participate in the study, having full set of teeth, with no history of previous orthodontic treatment, no craniofacial anomalies, no carious / missing / fractured / fluorosed / discoloured teeth.Exclusion criteria were as follows: Students with physical disabilities preventing assessment of the questionnaire and mental / behavioural disorders that reduced their ability for self-determination.Sample size was determined to provide an 80% statistical power in identifying a significant difference in psychosocial impact, and was found to be 320.Later, 330 individuals in the age range of 18 to 30 years (mean 23 ± 0.6 years) were included in the study.Approval for the study was obtained from the Institutional Research Committee and Institutional Ethics Committee of Government Dental College (IEC No: 112/2107/DCC).Informed consents from all the patients/students participating in the study were also obtained during the course of the research The subjects were asked to fill up the PIDAQ questionnaire and were then examined by the trained orthodontist, without knowledge of their responses.Each patient took about 10-15 minutes to fill up the questionnaire.Dental Press J Orthod.2023;28(4):e232211 They were then examined for malocclusion using the Index of Orthodontic Treatment Need, based on Dental Health Component for normative need and Aesthetic Component for subjective assessment (IOTN, DHC & AC).Facial aesthetic assessment was based on FAI.IOTN-AC -The patients were presented with ten photographs of the front teeth, displaying varying degrees of malocclusion, and were asked to indicate which grade of photograph (1-10) they think most closely resembled their own dentition.The ten IOTN-AC grades were combined into three groups: Grades 1-4 (slight), Grades 5-7 (moderate), and Grades 8-10 (definite).The IOTN-DHC was assessed by the examiner and the various grades were combined into three groups: Grades 1-2 (no/slight malocclusion), Grade 3 (moderate) and Grades 4-5 (definite malocclusion). .

Figure 2 :Figure 4 :
Figure 2: Representation of Facial Aesthetic Index chart, showing various profile variations.

Figure 3 :
Figure 3: Representative photos of patients with moderate treatment need, based on Facial Aesthetic Index ( FAI ).
Convergent validity between PIDAQ score and IOTN-DHC, IOTN-AC and FAI was evaluated by ANOVA and Bonferroni post-hoc test.Construct validity of the tool was evaluated by Cronbach's alpha.

Faraj M , Figure 5 : 15 Dental
Figure 5: Flowchart depicting sequence of events in methodology.

Faraj M , 19 Dental
Shobha S, Latheef V, Nivedita P -Does Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) reflect the impact of malocclusion on facial aesthetics?Press J Orthod.2023;28(4):e232211 attempts have been made to assess the psychosocial impact of malocclusion induced impaired facial aesthetics on the QoL of orthodontic patients.This is the first study making an attempt to assess this very important aspect.The QoL score of individuals was shown to deteriorate as the facial profile became worse, as assessed by FAI with respect to individual domains and overall QoL.An increasing trend in the scores was observed from no need /slight need, to moderate need, and to definite need treatment groups for DSC, SI ,PI, AC and overall QoL of the PIDAQ (p < 0.05).As the impact of facial profile aesthetics on OHRQoL has not been investigated so far, it was not possible to compare the present findings with previous research.This shows the ability of the current version of PIDAQ to differentiate the normal acceptable profile from other profile variations concomitant with different types and grades of malocclusion.The present findings show that PIDAQ was able to reflect the impact of malocclusion effectively on both facial and dental aesthetics.Correlations representing convergent validity testing were strong between the PIDAQ domains and the self-assessed dental aesthetics, treatment need and facial profile aesthetics, as evaluated by ANOVA and Bonferroni post-hoc test, between PIDAQ score and IOTN-DHC, IOTN-AC and FAI.Construct validity was found to be good, as evidenced by Cronbach's alpha.

Table 1 :
The Facial Aesthetic Index description of various profiles and their codes.
Posteriorly divergent profile and a markedly reduced profile angle <165º, with inability to approximate the lips, due to normal maxilla with severely retrognathic mandible / severely prognathic maxilla with normal mandible, or combinationsSevere Class II profile GAnteriorly divergent profile and a markedly increased profile angle >175º, with inability to approximate the lips, due to normal maxilla and severely prognathic mandible / severely retrognathic maxilla and normal mandible, or combinationsSevere Class III profile H

Table 4
increasing PIDAQ scores reflect the impact of altered dental and facial aesthetics and the results were highly significant.Dental Press J Orthod.2023;28(4):e232211

Table 2 :
Means and SD, with independent t-test of the responses obtained for all the different domains and overall Quality of Life (QoL), with respect to sex.

Table 3 :
Results of one-way analysis of variance (ANOVA) comparing psychosocial impact of dental aesthetics questionnaire scores (Individual domains and Overall Sum) in respondents with different grades of malocclusion, as categorized by IOTN-DHC, IOTN-AC and FAI.