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Oral Health-Related Quality of Life Principles and application Ziad D Baghdadi

Aims of the Lesson • Define HRQoL, giving historical relevant background • Explain the importance of HRQoL for • • • •

Health care Dental practice Research Community-based practice

• Describe how OHRQoL was used and is being used in research • Identify implications of OHRQoL research for health policy • Demonstrate the use of OHRQoL instruments in a study

Learning Objectives • Define HRQoL and OHRQoL and recognize the theoretical models underpinning the concepts • Assemble a timeline, which includes historical key developments of OHRQoL • Name 2 instruments used in measuring OHRQoL and identify 2 features of each instrument • Recognize that the relationships between SE and environmental factors and OHRQoL is not clear-cut • Support the inclusion of OHRQoL in dental practice, research, and community-based practice

What is Quality of Life? Aristotle • “…when it comes to saying in what happiness consists, opinions differ and the account given by the generality of mankind is not all like that of the wise. The former take it to be smoothing obvious and familiar, like pleasure or money or eminence and there are various other views, and often the same person actually changes his opinion. When he falls ill he says that it is health and when he is hard up he says it is money.” • George A Wells claimed that Pigou was the first to coin the term QoL in 1920 in a book on economics and welfare

A letter Jefferson wrote on July 6, 1787—eleven years before the Declaration of Independence—to his relative T.M. Randolph Jr.:

“With your talents and industry, with science and the steadfast honesty, which eternally pursues right regardless of consequences, you may promise yourself everything—but health, without which there is no happiness. An attention to health, then, should take place of every other object.” Thomas Jefferson 1787 American Founding Father, the principal author of the Declaration of Independence and the third President of the United States

Health World Health Organization

• Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

d on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

Oral Health Department of Health, England

• Oral Health is the standard of oral and related tissue health that enables individuals to eat, speak, and socialize without active disease, discomfort, or embarrassment, and that contributes to general wellbeing.

Department of Health. An Oral Health Strategy for England, London, DoH, 1994.

d on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

Quality of Life: Definition • QoL is the individual’s perceptions of his/her position in life in the context of culture and value systems in which he/she lives, and in relation to his/her goals, expectations, standards, and concerns (WHO 1995). • HRQoL is people’s subjective evaluation of the influences of their current health status, health care, and health promoting activities on their ability to achieve overall functioning that allows them to pursue valued life goals and that is reflected in their general wellbeing (Shumaker & Naughton 1995). • HRQoL is a dynamic construct affected by one’s ability to adapt to discrepancies between expected and experienced wellbeing (Padilla et al 1996)

Subjective Multidimensional Dynamic

Influences on QoL • Gender • Culture • Disease specific • Spiritual • Age

This paper examined the relationships of QoL to: 1. Socio-demographic characteristics (age, sex, income, education etc.) 2. Safety and security of place 3. Characteristics of people whose QoL excellent vs. poor 4. The changes between 2001 and 2004

History of HRQoL

35,000 yrs ago 14th -17th century

• 1940s – 1950s Studies on mortality and survival • 1960s – 1990s Shift of focus to health status, functional status, and other SINGLE dimension • 1990s Shift to patient-reported, multidimensional outcomes Patients’ perception adds an information that is not captured by physicians or ‘objective’ markers

Objective marker VS Patient-Reported Outcomes

Wiklund et al 1991

Exercise test Vs Physical functioning R = 0.40

“Objective” measure

© Pr Ingela Wiklund

“Subjective” measure

better HRQL

lower HRQL

Group health enrollees Cardiac arrest General population Moderate obesity Ulcerative colitis Myocardial inf arct

The condition impact on HRQoL is not always foreseeable and is not systematically correlated with the severity of the disease as perceived by the medical community

Angina Crohn's Hypothyroidism End-stage hemodialysis Rheumatoid arthritis Non-oxygen dependent COPD Physically disabled adults Back pain Chronic low back pain Oxygen dependent COPD Chronic pain non-responders Amyotrophic lateral sclerosis

0

5

10

15

20

25

Overall Sickness Impact Profile score

30

35

Single-item self-rating of oral health by patients compared with rating of clinicians

No.

No. of patient ratings identical to clinician rating

No. of higher clinician ratings

No. of lower clinician ratings

Excellent

142 (18%)

84

0

58

V. Good

228 (29%)

62

118

48

Good

244 (31%)

45

150

49

Fair

130 (17%)

33

90

7

Poor

32 (4%)

7

25

0

Total

776

231 (30%)

383 (49%)

162 (21%)

Patient Rating

Scientists, just like the rest of humanity, carry out their day to day affairs within a framework of pre-suppositions, called a paradigm, about what constitutes a problem, a solution and a method. At any given time a particular scientific community will have a prevailing paradigm that shapes and directs work in the field. People become very attached to their paradigms and scientific revolutions always involve intellectual bloodshed. Thomas Kuhn, The Structure of Scientific Revolutions, 1962

References to quality of life 1966-74 40 references 1986 – 99 more than 10,000 references NOW in PubMed more than 215,000 OHRQoL 1739

2013

More aggregated measures

Health-adjusted life years (HRQoL combined with life expectancy) summarizing overall health

HRQoL Indexes

Generic health status profiles

Disease specific scales Do not cover all health domains More disaggregate measures

Multitude of health indicators

National Research Council 2011

HALE is meant to measure not just how long people live, but the quality of their health through their lives (Health Canada 2013) QALY (Quality-Adjusted LifeYear) = quality of life + quantity of life lived

Domains addressed by 2 HRQoL indexes

• • • • • •

SF-6D (stands for short form 6D) Physical function Role limitation Social function Pain Mental health Vitality SF-6D describes 18,000 health states in all

HUI3 (Health Utilities Index Mark 3) • • • • • • • •

Vision Hearing Speech Dexterity Emotion Cognition Self-care Pain HUI2 and HUI3 describe 1,000,000 health states

Horsman et al 2003

Generic

Importance of content validity Generic SF-36

36 items 8 domains

Functional Digestive Disorders Quality of Life (FDDQoL)

Irritable Bowel Syndrome

• 1. Physical functioning

• 3. Sleep

• 4. General health

• 7. Emotional role functioning • 8. Mental health

8 domains • 2. Anxiety

• 3. Bodily pain

• 6. Social role functioning

43 items • 1. Daily activity

• 2. Physical role functioning

• 5. Vitality

Specific

Sleep and diet disturbances (83%)

• 4. Diet • 5. Abdominal discomfort

• 6. Coping with disease • 7. Control of disease • 8. Stress

OHRQoL: Definition, theoretical model, and dimension • In 1976 Cohen and Jago advocated the development of sociodental indicators to measure OHRQoL (Cohan & Jago 1976) • It includes how oral health affects • • • • •

Aspects of social life Self-esteem Social interaction School performance Job performance

• OHRQoL reflects people’s comfort when eating, sleeping, and engaging in social interaction; their self-esteem; and their satisfaction with respect to oral health (U.S. Department of Health and Human Services 2000) • It is the result of interaction between and among oral health conditions, social factors, contextual factors, and the rest of the body (Locker et al 2005)

Traditional model of disease development (Bio-Medical Model) Disease (Pathology)

Pathogen

Modifiers Lifestyles Individual susceptibility

Biopsychosocial model of illness

Pathogen

Psychosocial factors Attitudes Behavior Quality of Life

Illness (well-being)

Wilson and Cleary Model for Health-Related Quality Life. Symptom amplification Personality/Motivation Values Preferences

Psychological support Social support Economic support

Wilson, I.B., & Cleary, P.D (1995). Linking Clinical Variables with Health-Related Quality of Life: A Conceptual Model of Patient Outcomes. JAMA. 273, 59–65.

Audience!

List dimensions of quality of life that mentioned in the video. https://www.youtube.com/watch?v=O0qhuu4Ipj0

Common Risk Factors Approach Cohen 2012

COMMON RISK FACTORS

GENERAL DISEASES

TOBACCO

CVD ALCOHOL

ORAL DISEASES PERIODONTAL DISEASES

CANCER DIABETES RESPIRATORY

POOR DIET

ORAL CANCER

DENTAL CARIES



Characteristics of the individuals Demographics; Psych (depression, resilience); Medical history

Biological/Genetics (Type/extent of defect)

OHRQoL

Symptoms Functional wellbeing Oral health

Environment • Access/utilization—payer source, Income • Caregiver characteristics (children QoL) • Education, Family structure

General QoL

Sischo & Broder 2011

• • •

Theoretical Model for OHRQoL

The relationships between biological variables and HRQoL outcomes are not direct, BUT moderated by a variety of personal, social, and environmental variables.

• Pain • Bleeding gums • Spaces between teeth

• Anxious • Attractive • Unhappy

• School • Job

Social/ Emotional

Environment

Dimensions of OHRQoL

Oral Health

OHRQoL

Function

Treatment expectations

• Chewing • Talking

• Satisfaction

UNDP Administrator Helen Clark (the 37th Prime Minister of New Zealand) • “Oral diseases are obstacles to development. Something as preventable as tooth decay can impair people’s ability to eat, interact with others, attend school, or work. These consequences all detract from human wellbeing, economic potential, and development progress.”

Side event on Global Oral Health, NN High Level Meeting on Non-Communicable Diseases, 2012

Secretary of the U.S. Dept of Health, Donna E Shalala • “Oral health problems can lead to needless pain and suffering, causing devastating complications to an individual’s wellbeing, with financial and social costs that significantly diminish quality of life and burden American society.”

In her forward to the Surgeon General’s report on oral health, “Healthy People 2010”

OHRQoL = f [P + S + (P × S)] OHRQoL is a function of  the person (P),  the situation (S), and the  interaction between the person and the situation (P × S)

Inglehart & Bagramian 2002

OHIP-Oral Health Impact Profile GOHAI-General Oral Health Assessment Index CPQ-Child Perception Questionnaire DIDL-Dental Impact on Daily Living Strauss et al 1993 Dental Impact Profile Cushing et al 1986 Social impacts of dental disease

1980

Cohen & Jago 1976

Reisine 1984

Atchison et al 1990 GOHAI

1990

McGrath & Bedi 2000 OH-QoL UK

Leao & Sheiham 1996 DIDL Slade & Spencer 1994 OHIP

Broder et al 2004 COHIP

2000

Slade 1997 OHIP-14

2010 Jokovic & Locker 2002 COHQOL (CPQ)

Criteria for Development of QoL Measurements

Comprehensive (content validity)

Credibility (face validity)

Includes appropriate components of health

Appears sensible and interpretable

Accuracy (criterion validity) Consistently reflects true clinical status of patients

Criteria for Development of QoL Measurements

Sensitivity to change (discriminant validity) Detects smallest clinical important differences

Biological sense (construct validity) Matches hypothesized expectations when compared with other indirect measures

2

OHRQoL: Importance & scope • OHRQoL research includes

• Patients with oral cancer (ship 2002) • Toddlers with ECC (Filstrup et al 2003) • Children with craniofacial anomalies (Border 2007)

• Appropriate treatment care has been re-defined to focus on a person’s social and emotional experience and physical functioning • It gives patients more active role as members of the treatment team • It gives evidence to health practices • It is a valuable health outcome in case of chronic non-curable diseases • It can be useful in measuring the impact of oral health disparities on overall health and QoL • It has health policy implications

OHRQoL: Considerations for use

Generic

Diseasespecific

Generic • General • Less sensitivity to disease symptoms and impacts • Higher floor effects (i.e. no impact) • Less responsive to intervention

Disease-specific • Specific conditions • More sensitivity to disease symptoms and impacts • Lower floor effects (i.e. no impact) • Have effective evaluative properties (to detect response to intervention)

OHRQoL: Considerations for use • Parent(s) • Teacher • Caregiver

Proxy

Direct

Children

Adults

Michigan Oral Health-Related QoL Scale Version PG (parent/guardian)

• My child has difficulty chewing •

Strongly disagree………….strongly agree

• My child has difficulty biting hard • My child’s teeth are sensitive to hot or cold • My child’s teeth are sensitive to sweet food • My child is happy with teeth

Version C (child)

• Do your teeth hurt now? •

Yes

No

• Do your teeth hurt when you eat something sweet? • Do you like your teeth? • Are you happy with your teeth and smile? • Do kids make fun of your teeth?

OHRQoL: Considerations for use • OHRQoL surveys can be used to examine trends in oral health and population-based needs assessment • Example • Locker (2007) found that children from low-income families in Canada have poor OHRQoL than children from high-income families (indicating socioeconomic disparity) • Makhiji et al (2006) found that OHRQoL is strongly associated with sociodemographic factors (race, education, transportation difficulties) for elderly patients in Alabama

• The relationship between sociodemographic factors and OHRQoL is NOT clear-cut (Sischo & Broder 2011)

• Extent/type of medical conditions are associated with low OHRQoL and, therefore, included in the theoretical model • Example • Mulligan et al (2008) found that women with HIV have lower OHRQoL • Mehrsted et al (2008) found individuas with dental anxiety/fear have lower OHRQoL • The greater the DMFS, the lower the OHRQoL (Kim et al 2009)

• This assessment may inform health practitioners of specific areas of focus from the patients’ perspectives

• Characteristics of the individual (self-concept, psychological well-being) are considered as mediating factors in OHRQoL and, therefore, included in the theoretical model • Example • Barbosa and Gaviao (2008) found that the relationship between clinical variables and OHRQoL is mediated by various personal, social, and environmental factors

• By identifying groups who are vulnerable for low OHRQoL, investigators can use data from survey research to create programs to improve oral health and elevate OHRQoL

OHRQoL: Considerations for use • OHRQoL is being recently used to measure efficaciousness of treatment to improve care • Example • Broder is currently examining changes in OHRQoL following surgical interventions among school-aged children with cleft conditions in 6-center NIDCR-supported project (Sischo & Broder 2011) • Hyde et al (2006) found that rehabilitative dental treatment improved welfare reciepients’ OHRQoL and employment outcome

• The use of OHRQoL as an evaluative measure outcome is • Congruent with patient-centered care • Providing evidence that costs associated with treatment protocols are worth the expense • Assisting patients (and families) in treatment decision-making

• The multidimensional nature of OHRQoL is useful in identifying atrisk populations and developing interventions that care for the WHOLE person • Example • Turner et al (2006) found that cognitive-behavioral therapy (CBT) for patients with chronic TMJ disorder pain reduces pain and depression at one year CBT includes instruction and practice in progressive relaxation and abdominal/diaphragmatic breathing, as well as discussions of fear avoidance, identification and challenging of negative thoughts in response to pain, relapse prevention, and dealing with setbacks

• OHRQoL can help assess clinically meaningful change • It helps identify whether a statistically significant difference between experimental and comparison groups has clinical meaningfulness • It helps identify whether a statistically significant difference at the group level has relevance for clinically meaningful change at the individual level

There is a dearth of published studies assessing meaningful change in the oral health arena (Wyrwich et al 2005, Sischo & Broder 2011)

• Sloan et al (2002) emphasized the importance of incorporation of QOL assessment (and assessing clinical significance) in the treatment of patients with neoplastic diseases

OHRQoL: Implications • Using the association between oral health conditions and QoL can be an effective mechanism to communicate with policymakers to reveal the importance of oral health and equal access to care (Al Shamrany 2006) • Measuring the impact of health services (such as treatment of dental caries through community health centers) before and after treatment may improve evidence-based decision-making related to treatment needs, effectiveness, and policy perspectives

• Decayed, missing, and filled teeth (DMFT) scores are used as a common measurement of dental health • Politicians may get a better sense of the need for providing oral health care to underserved populations if they realize that these scores translate into impaired QoL for a child A child with high DMFT score may be malnourished because of inability to eat or unable to sleep through the night or concentrate in school due to associated pain

• NIH and NIDCR are supporting Centers for Research to Reduce Oral Health Disparities • CRROHD is studying the effect of ECC on young children’s OHRQoL (Cunnion et al 2010)

• NIH has incorporated HRQoL into its roadmap • There are 3 NIDCR-funded projects examining OHRQoL acroos lifespan from childhood to old age, across geographic regions (urban, rural, international), and for chronic conditions • NIDCR supports research that examines correlates of OHRQoL (e.g. body image, health beliefs) and research that seeks to uncover social determinants of oral health

• By measuring OHRQoL, oral health professionals can enhance evidence-based care • Practitioners Engaged in Applied Research and Learning Network is completing longitudinal protocols to compare objective (clinical ratings) and subjective assessments (patient OHRQoL ratings) to measure treatment outcomes • PEARL’s aim is to elucidate the interrelationships among oral healthcare and QoL factors, and to exemplify how patients are an invaluable source of information regarding treatment protocols, outcomes, and how oral health is related to QoL

OHRQoL to Assess Treatment Needs • QoL can give the patient a voice to assess his/her needs assessment • Health needs assessment is a systematic approach attempting to ensure that the health service uses its resources to improve the health of the population in the most efficient way (Tsakos 2008)

Normative VS Needs Assessment Normative Need • Identifies diseases and impairments (based on clinical indices) without considering the subjective perceptions of the subject

Needs Assessment • Focus on effectiveness of interventions that will bring about health again

Shortcomings of Normative Measures • Lack of objectivity and reliability • Neglect psychosocial aspect • No consideration for health behaviors • Unrealistic as it ignores limited resources • Serious conceptual limitations • “Clinical measures tell us nothing about the functioning of the oral cavity or the person as a whole” (Locker 1989) • “---essential for measuring disease…but not for health and treatment need” (Sheiham et al 1982)

Some people with oral impacts are denied treatment and some of those without oral impacts are treated.

Key Factors of Socio-Dental Approach to Needs Assessment • • • •

Clinical dental measures Subjective perceptions (OHRQoL) Behavioral propensity Evidence-based interventions • (Gherunpong et al 2006)

An OHRQoL measure for Needs Assessment

The Child Oral Impacts on Daily Performance (ChildOIDP)

Eating food Speaking clearly Cleaning mouth Sleeping Smiling, laughing, showing teeth without embarrassment • Maintain usual emotional state without being irritable • Carrying out school work • Enjoying contact with other people • • • • •

Gherunpong et al 2004

Impairments

no No intervention

Sheiham & Tsakos 2007

yes

no Perceived impacts

Normative Treatment Need

yes

Perceived impacts on QoL

Investigation Counseling

yes

no Dental Health Edu & Prom

Impact related need Propensity for treatment

Model for Needs Assessment

Propensity related need

Low

Initially planned treatment + DHE/OHP

Medium

High

Most appropriate (evidencebased) treatment

Normative Need

100 children

Impact-Related Need

30.2

PropensityRelated Need

Low

Med-low

Med-high

High

1.5

8.9

18.9

0.9

PRN:  Oral hygiene  dental attendance  Patient cooperation

Total number examined 1126

Gherunpong et al 2006

Orthodontic Treatment Needs

Prosthodontic Treatment Needs

Normative Need

324

Impact Related Need

80

Propensity Related Need

Total number of patients examined 1029

Good

Poor

64

16 Ryu et al 2008

This will decrease the number of dental clinicians needed per 100,000 adults from 115 (NN) to 30 (IRN) to 25 (PRN)

Conclusion • OHRQoL has a multitude of substantive applications for the field of dentistry, healthcare, and dental research • Patient-oriented outcomes like OHRQoL will enhance understanding of the relationship between oral health and general health • OHRQoL research can be used to inform public policy and help eradicate oral health disparities

Oral-Health Related Quality of Life in Children Effects of Dental Treatment Case Study

Oral-Health-Related Quality of Life OHRQoL is that part of a person’s quality of life that is affected by this person’s oral health.  Person functioning (biting, chewing, speaking)  Sensations of pain/discomfort  Psychological  Appearance and self-esteem  Social well-being

Inglehart 2006

OHRQoL measures provide  Information of the impact of oral conditions on people’s lives  Ways of determining whether clinical interventions are efficacious Usual developmental sequence:

Conceptual development

Item pool, reduction, psychometric testing

Theory, models

Development

Range of settings and populations Field testing, validation

Short-form versions

Routine clinical and HSR usage

Desired endpoint

Optional but desirable

Thomson 2011

OHRQoL Parental-Caregivers Pereception Questionnaires (P-CPQ) Family Impact Scale (FIS) PCPQ subscales (domains)

FIS subscales (domains)

• Oral symptoms (e.g. pain)

• Family/parental activity

• Functional limitations (e.g. Difficulty eating)

• Parental emotions • Family/financial conflict

• Emotional well-being (e.g. Avoid smiling) • Social well-being (e.g. Being teased)

Jokovic et al 2003

Total number of items 33

OS 6 items FL Oral health status in general

Effects of oral health on general wellbeing

Full

P-CPQ

8 items

EWB 9 items

SWB 10 items Jokovic et al 2003

Total number of items 16

OS

4 items FL Oral health status in general

Effects of oral health on general wellbeing

Short

P-CPQ

4 items

EWB 2 items

SWB 6 items Thomson et al 2012

Total number of items 14

FA

5 items PE Oral health status in general

Effects of oral health on general wellbeing

Full

FIS

4 items

FC 4 items

FC 1 items Jokovic et al 2003

Total numbers of items 9

FA

4 items PE Oral health status in general

Effects of oral health on general wellbeing

Short

FIS

2 items

FC 2 items

FC 1 items Thomson et al 2012

Pre-Operative General Questions Global Transition Items •

How would you rate the health of your child’s teeth, lips, jaws and mouth?    

Excellent Very good Good Fair

 Poor



How much is your child’s overall wellbeing affected by the condition of his/her teeth, lips, jaws and mouth?     

Not at all Very little Some A lot Very much

P-CPQ items Examples •

During the last 3 months, how often your child had: –

Pain in the teeth, lips, jaws or mouth      



Never Once or twice Sometimes Often Every day or almost every day Don’t know

During the last 3 months, because of his/her teeth, lips, mouth or jaws, how often has your child: –

Missed school (e.g., due to toothache or emergency dental appointment)      

Never Once or twice Sometimes Often Every day or almost every day Don’t know

FIS items Examples •

During the last 3 months, because of your child’s teeth, lips, mouth or jaws, how often have you or another family member –

Felt guilty      



Never Once or twice Sometimes Often Every day or almost every day Don’t know

During the last 3 months, because of your child’s teeth, lips, mouth or jaws, how often have you or another family member –

Caused financial difficulties for your family      

Never Once or twice Sometimes Often Every day or almost every day Don’t know

Post-Operative General Question •

Since the operation to fix his/her teeth, is your child’s overall quality of life    

Much improved A little improved The same A little worse

 Much worse

Methods

Study Design • Pre-treatment P-CPQ and FIS

• Dental treatment under GA 3-4 weeks

• Post-treatment P-CPQ and FIS

Analyses

Analyses

Cross-sectional construct validity

Examining the association between means of pretreatment scores and the rating of the pre-treatment global transition item (Kruskal-Wallis)

Cronbach’s alpha Internal consistency

More than 0.9 Excellent 0.7 – 0.9 Good 0.6 – 0.7 Acceptable 0.5 – 0.6 Poor Less than 0.5 Unacceptable

Interclass Correlation Coefficient (ICC) Test-retest reliability

0 no agreement 1 perfect agreement

Analyses

Resposnsiveness

Effect size

ES

Subtracting post-treatment scores from pretreatment scores (paired t-test)

Dividing the mean of change scores by the SD of the pre-treatment scores

 Less than 0.2 small change  0.2 – 0.7 moderate change  Above 0.7 large change

Results

How much is the child’s wellbeing affected by oral health?

Reponsiveness 25

20

Large Effect size descriptors

15

Large 10

Large Large Moderate

5

0 P-CPQ

FIS

OS

FL

Pretreatment

Posttreatment

EWB

SWB

Cronbach’s Alpha & ICC

Alpha

ICC

0.81

0.93

OS

0.61

0.91

FL

0.61

0.93

EWB

0.49

0.76

SWB

0.66

0.86

FIS

0.67

0.84

P-CPQ+FIS

0.84

0.94

P-CPQ

Conclusions



1



2



3

Test – retest reliability is strong



4

This instrument can be used for children with severe caries



5

Validity and responsiveness in other groups need to be explored

Dental treatment associated with positive effects on quality of life P-CPQ and FIS are valid and responsive

This is an example text. Go ahead and replace it This is an example text. Go ahead and replace it

THANK YOU!

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References

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Dawoodbhoy I, Delgado-Angulo E, Bernabe E. Impact of malocclusion on the quality of life of Saudi children. The Angle Orthodontist. 2013;83(6):1043–1048. [PubMed] Jokovic A, Locker D, Guyatt G. Short forms of the Child Perceptions Questionnaire for 1114-year-old children (CPQ11-14): development and initial evaluation. Health and Quality of Life Outcomes. 2006;4, article 4 [PMC free article] [PubMed] Thomson WM, Foster Page LA, Gaynor WN, Malden PE. Short-form versions of the parentalcaregivers perceptions questionnaire and the family impact scale. Community Dentistry and Oral Epidemiology. 2013;41(5):441–450. [PubMed] Gaynor WN, Thomson WM. Changes in young children’s OHRQoL after dental treatment under general anaesthesia. International Journal of Paediatric Dentistry. 2011;22(4):258– 264. [PubMed] Barbosa TD, Gavião MB. Validation of the parental-caregiver perceptions questionnaire: agreement between parental and child reports. Journal of Public Health Dentistry. 2013 [PubMed]

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