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Questionnaire for Measuring Oral Health-related

Quality of Life in Eight- to Ten-year-old Children

Article in Pediatric dentistry · November 2003

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 Scientific Article

Questionnaire for Measuring Oral Health-related

Quality of Life in
Eight- to Ten-year-old Children
Aleksandra Jokovic, BDS, MHSc, PhD D. Locker, BDS, PhD B. Tompson, DDS G. Guyatt, MD, MSc
Dr. Jokovic is research associate; Dr. Locker is director, Community Dental Health Services Research Unit, and Dr. Tompson is head, Depart-
ment of Orthodontics, Faculty of Dentistry, University of Toronto, Toronto; Dr. Guyatt is professor, Department of Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, Ontario, Canada.
Correspond with Dr. Jokovic at [email protected]

Abstract
Purpose: This study measured oral health-related quality of life for children, which in-
volved the construction of child perceptions questionnaires (CPQs) for ages 6 to 7, 8 to
10, and 11 to 14. The purpose of this study was to present the development and evalu-
ation of the CPQ for 8- to 10-year-olds (CPQ8-10).
Methods: Questions (N=25) were selected from the CPQ for 11- to 14-year-olds based on
the child development literature and input from parents, child psychologist, and teacher of
grades 3 and 4 . Validity and reliability were evaluated on 68 and 33 children, respectively.
Results: There was a positive moderate correlation between the CPQ8-10 score and over-
all well-being rating (R=.45). The level of impact was slightly higher in the orofacial than
in the pediatric dentistry group (mean score=19.1 vs 18.4, respectively). Hypotheses
concerning the relationship between the CPQ8-10 score and number of decayed surfaces
were confirmed with R=.29, and the mean score higher in caries-afflicted than caries-
free children (21.1 vs 14.7). The Cronbach’s alpha and intraclass correlation coefficients
were 0.89 and 0.75, respectively.
Conclusions: Results suggest good construct validity, internal consistency, reliability and
test-retest reliability, but do not demonstrate discriminative validity. This is consistent,
however, with theoretical models of oral disease and its consequences. Further research
is required, as these are preliminary findings based on convenience sampling. (Pediatr
Dent. 2004;26:512-518)
KEYWORDS: CHILD, ORAL HEALTH, QUALITY OF LIFE, VALIDITY, RELIABILITY
Received February 6, 2004 Revision Accepted June 8, 2004

O
ral health-related quality of life (OHRQoL) mea- of oral and orofacial conditions on the functional, emo-
sures document the functional and psychosocial tional, and social well-being of children ages 6 to 14 years
outcomes of oral disorders. It is now generally and their families. It conforms to the World Health
accepted in the research community that they are as essen- Organization’s (WHO) definition of health and the con-
tial as clinical indicators when assessing the oral health of temporary conceptualization of child health as “…the
individuals and populations, making clinical decisions, and physical, emotional, and social functioning of the child and,
evaluating dental interventions, services, and programs. when indicated, his or her family…” (American Academy
Several OHRQoL measures for adults have been devel- of Pediatrics, 1984; American Cancer Society, 1995).
oped.1-5 They are being used with increasing frequency in The COHQoL was intended to incorporate both paren-
oral health surveys and clinical trials to complement clini- tal and child perceptions, and be sensitive to children’s
cal indicators in order to obtain a comprehensive account cognitive, emotional, and social development. Age-specific
of treatment needs and outcomes. self-report measures were required to accommodate differ-
The only OHRQoL measure currently available for ences in children’s self-concept, understanding of feelings,
children is the Child Oral Health Quality of Life Ques- and ability to interpret other people’s behavior across the 6-
tionnaire (COHQoL).6-8 This is a measure of the impact to 14-year age range.9,10 According to theory and research

512 Jokovic et al. Questionnaire for measuring oral health-related quality of life Pediatric Dentistry – 26:6, 2004
 Table 1. Characteristics of Children who were fluent in English. Convenience samples were re-
cruited from patient populations attending public health
Test-retest dental clinics in the York Region, Ontario, Canada and the
Validity study reliability study orthodontic clinic of the craniofacial unit at The Hospital
N % N % for Sick Children, Toronto, Ontario. They are referred to
Clinical group in this study as the pediatric dentistry group and orofacial
Pediatric dentistry 42 62 18 55 group, respectively.
Orofacial 26 38 15 46 The first group targeted children with dental caries, and
Gender of child
the second group targeted children with clefts of the lip and
palate. They were chosen because they are the most preva-
Boy 39 57 19 58
lent oral conditions in 8- to 10-year-olds. In addition, they
Girl 29 43 14 42 have distinct clinical characteristics that are expected to
Age of child have a different effect on children’s quality of life.
8 yrs 18 27 8 24 The study was approved by the Human Subjects Certi-
9 yrs 23 34 12 36 fication Committee, University of Toronto and the
10 yrs 27 40 13 39 Research Ethics Board, The Hospital for Sick Children,
Toronto. A parental written consent was obtained prior to
Mean (±SD) 9.1±0.8 9.2±0.8
seeking a child’s verbal assent. A child’s dissent superseded
the parental consent.
Development process
in child psychology, the age groups 8 to 10 years and 11 to Questions for the CPQ8-10 were selected from the CPQ11-14
14 years are homogenous in terms of children’s cognitive, The child development literature and judgments of a child
emotional, social, and language development.9,10 psychologist, grades 3 and 4 teacher, and group of parents
Accordingly, the authors planned to construct 5 mea- provided the basis for this selection. Questions were reworded
sures for the COHQoL: for 8-year-olds by consulting writers of children’s manuals15
1. parental perceptions questionnaire (PPQ) that as- and a teacher of grades 3 and 4. The teacher also helped choose
sessed impact from the parent perspective; the recall period and response options, write instructions, and
2. family impact scale (FIS) that assessed impact on the format a self-completed questionnaire. Grammar and language
family; difficulty were further assessed with 2 readability statistics16:
3. child perceptions questionnaires (CPQ) for children 1. Flesch reading ease score (rates text on a 100-point
6 to 7 years of age (CPQ6-7), 8 to 10 years of age percentage scale, with a higher score indicating easier
(CPQ8-10), and 11 to 14 years of age (CPQ11-14) that reading);
assessed impact from the child’s perspective. 2. Flesch-Kincaid grade level score (rates text on a US
To date, the PPQ, FIS, and CPQ11-14 have been developed grade-school level 0-12), available in Microsoft Word
and evaluated for validity and reliability. The results indicated 2000 software (Microsoft Corp, Redmond, Va). They
that they have excellent psychometric properties.6-8 were 93% and 2.2, respectively, indicating that the
These questionnaires were constructed using a systematic questionnaire was appropriate for the population stud-
multistage process based on the theory of measurement and scale ied. Figure 1 summarizes the development process.
development.11,12 The procedures for the development and
evaluation of HRQoL measures described by Guyatt et al13 and
Juniper et al14 were followed.
The objective of this study Table 2. Descriptive Statistics for the CPQ8-10 Overall and Subscale Scores
was to describe the develop-
ment of the CPQ for children Mean±SD Range Floor effect* Ceiling effect†
ages 8 to 10 years (CPQ8-10) and Total scale (0-100)‡ 18.6±12.6 1-55 0.0 0.0
to present study results to evalu- Subscales
ate its validity and reliability.
Oral symptoms (0-20) 5.6±3.2 1-17 8.8 0.0
Methods Functional limitations (0-20) 4.1±3.5 0-15 16.2 0.0
Emotional well-being (0-20) 3.7±3.5 0-13 17.6 0.0
Participants Social well-being (0-40) 5.2±4.7 0-19 8.8 0.0
Study participants were children
ages 8 to 10 years who did not
have systemic and/or mental *Proportion with 0 score.
†Proportion with maximum score.
developmental disorders and ‡( )=range of possible values.

Pediatric Dentistry – 26:6, 2004 Questionnaire for measuring oral health-related quality of life Jokovic et al. 513
 Table 3. Construct Validity—Rank Correlations Between qualitative interview was conducted concerning each child’s
CPQ8-10 Scores and Global Ratings of Oral Health and understanding of instructions, wording of items, recall period,
Overall Well-being (N=68)
and response options. The “think-aloud”17 and observational
monitoring18 pretesting techniques were also applied.
Oral health Overall well-being
R* P† R* P† Evaluation
Overall scale 0.17 NS 0.45 <.001 The performance of the CPQ8-10 was assessed in a validity
Subscales and reliability study. A new sample of children completed
Oral symptoms 0.31 0.010 0.45 <.001 the questionnaire. This provided data for validity and in-
Functional limitations 0.03 NS 0.48 <.001 ternal consistency reliability testing. A subgroup of these
children was invited to complete the questionnaire again
Emotional well-being 0.29 0.017 0.32 .008
after a period of 2 weeks for the purpose of test-retest reli-
Social well-being 0.08 NS 0.25 .038
ability assessment. In the follow-up questionnaire, global
ratings were replaced with global transition ratings (ie, ques-
*Spearman’s correlation coefficient. tions that ask if the child’s oral health and/or overall
†P value. well-being has changed since recruitment). This informa-
NS-Not significant tion is required to calculate the test-retest reliability
coefficient as the proportion of the score variance attrib-
The CPQ8-10 consists of 25 questions organized into 4 utable to true differences between patients whose health
health domains: status is stable over time.11 Baseline and follow-up ques-
1. oral symptoms (N=5); tionnaires were self-administered. Dental charts provided
2. functional limitations (N=5); clinical data for the study participants.
3. emotional well-being (N=5);
4. social well-being (N=10).
The questions ask about the fre-
quency of events in the previous 4
weeks in relation to the child’s
oral/orofacial condition. The re-
sponse options are: “never”=0;
“once/twice”=1; “sometimes”=2;
“often”=3; and “everyday/almost
everyday”=4. The instrument also
contains global ratings of the
child’s oral health and extent to
which the oral/orofacial condition
affected his/her overall well-being.
They are worded as follows:
“When you think about your teeth
or mouth, would you say that they
are…” and “How much do your
teeth or mouth bother you in your
everyday life?” A 4-point response
format, ranging from “very
good”=0 to “poor”=3 and from
“not at all”=0 to “a lot”=3, respec-
tively, is offered for these ratings.
Pretesting
The questionnaire was assessed for
readability, comprehension, and
ease of administration in a study that
involved a convenience sample from
patient populations attending pub-
lic health dental clinics in the York
Region, Ontario. Following self-ad-
ministration of the questionnaire, a Figure 1. Development of the CPQ8-10 questions.

514 Jokovic et al. Questionnaire for measuring oral health-related quality of life Pediatric Dentistry – 26:6, 2004
 Overall and subscale scores Table 4. Construct Validity—Overall and Subscale CPQ8-10 Scores by
for the CPQ8-10 were calculated Global Ratings of Overall Well-being
by adding up the response
codes. To test construct valid- Overall well-being affected*
ity, the associations between the Not at all (N=24) Some/a little bit (N=43) P†
scores and global ratings were Median Mean±SD Median Mean±SD
determined. This involved cor- Total scale 11.5 11.3±6.7 17.0 22.4±13.4 <.001
relation and comparison Subscales
analyses. In the latter, the differ-
Oral symptoms 3.0 4.0±2.3 6.0 6.5±3.3 .001
ences in scores were assessed
according to the global ratings Functional limitations 1.5 2.0±1.9 4.0 5.2±3.7 <.001
categories. The variation in Emotional well-being 1.0 1.9±2.1 3.0 4.6±3.7 .002
scores according to the severity Social well-being 3.0 3.5±3.2 4.0 6.1±5.2 .031
of the child’s condition was also
examined, as this was feasible
given the clinical data that were *Category A lot not included as N=1.
†P values obtained from Mann-Whitney test.
collected. In the pediatric den-
tistry group, the correlation
between the overall score and Table 5. Construct Validity—Overall and Subscale CPQ8-10
the number of decayed tooth Scores by Clinical Group
surfaces (DS) and difference in
overall scores between children Clinical group
with and without caries were Pediatric dentistry (N=42) Orofacial (N=43) P*
examined. Testing of construct Median Mean±SD Median Mean±SD
validity for the orofacial group Total scale 15.0 18.4±11.5 14.0 19.1±14.4 NS
could not be undertaken because Subscales
of the small numbers in the di-
Oral symptoms 6.0 6.1±3.2 5.0 5.0±3.1 NS
agnostic categories. Since score
distributions were asymmetrical, Functional limitations 4.0 3.5±2.7 4.0 5.0±4.5 NS
the rank correlation and the Emotional well-being 3.0 4.0±3.5 2.0 3.1±3.5 NS
Mann-Whitney test were used in Social well-being 3.5 4.7±4.6 4.0 6.1±4.8 NS
analyses performed.
Internal consistency reliabil-
ity was tested by means of *P values obtained from Mann-Whitney test.
Cronbach’s alphas, and test-re-
test reliability was tested via
Table 6. CPQ8-10 Reliability Statistics
intraclass correlation coefficients
calculated using a one-way
Intraclass
analysis of variance random ef- Cronbach’s alpha correlation
fects parallel model.19,20 No. of items (N=68) coefficient* (N=33)
Overall scale 25 0.89 0.75
Results Subscales
Participants’ characteristics Oral symptoms 5 0.63 0.89
Thirty-seven children partici- Functional limitations 5 0.68 0.80
pated in the study to pretest the Emotional well-being 5 0.78 0.69
CPQ8-10. The validity and inter- Social well-being 10 0.76 0.16
nal consistency reliability
testing involved 68 children, of
whom 33 completed the ques- *One-way random effect parallel model.
tionnaire twice and provided
data for the test-retest reliabil- Pretesting results
ity assessment. Table 1 presents the characteristics of the While all 9- and 10-year-olds were able to follow the in-
validity and reliability study participants in terms of clini- structions, 10 of 13, 8-year-old children did not relate to
cal group, gender, and age. the introductory/transition statement: “In the past 4 weeks,
because of your teeth or mouth …”, when responding to

Pediatric Dentistry – 26:6, 2004 Questionnaire for measuring oral health-related quality of life Jokovic et al. 515
the questions. This indicated that 8-year-olds require ei- high internal consistency reliability, as the coefficients ranged
ther a simpler format or an interviewer supervised/ from 0.63 for oral symptoms to 0.78 for emotional well-
administered questionnaire. Because the authors intended being.11 The overall scale Cronbach’s alphas were 0.88 in the
to develop a self-completing questionnaire, the layout was pediatric dentistry group and 0.92 in the orofacial group.
simplified by making the aforementioned statement part Although 39 children participated in the test-retest reli-
of each question. ability study, the intraclass correlation coefficient (ICC) was
based on data from 33 children. The remaining 6 children
Evaluation results were excluded because they reported that their oral health
CPQ8-10 descriptive statistics—There were no missing data. and/or overall well-being had changed between the 2 admin-
The overall scores ranged from 1 to 55, with a mean of 18.6 istrations of the questionnaire. The ICC for the overall scale
and a standard deviation of 12.6 (Table 2). There were no was 0.75, indicating substantial agreement.21 The oral symp-
children with either floor effect (ie, score=0) or ceiling ef- toms, functional limitations, and emotional well-being
fect (ie, maximum score). The subscale scores also showed subscales showed substantial to almost perfect test-retest re-
substantial variability, with moderate floor and no ceiling liability, as their ICCs were 0.89, 0.80, and 0.69, respectively.
effects (Table 2). When the responses “often” or “everyday/ The ICC for the social well-being subscale was low at 0.16
almost everyday” are counted for each child, the proportion (Table 6). For the pediatric dentistry and orofacial groups,
of those reporting 1 or more symptoms, functional limita- the ICCs were 0.75 and 0.78, respectively.
tions, emotional experiences, and impacts on social
well-being was 34%, 24%, 16%, and 25%, respectively. Discussion
CPQ8-10 construct validity—Almost all hypotheses con- This paper presents the results of a study to develop and
cerning relationships between the CPQ8-10 scores and global evaluate a questionnaire measuring the impact of various
ratings were confirmed. In other words, there were posi- oral and orofacial diseases and disorders affecting children
tive correlations between the overall scores and the ratings ages 8 to 10 years. The CPQ8-10 consists of 25 items orga-
for oral health and overall well-being. Also, as expected, the nized into 4 health domains: (1) oral symptoms; (2)
rank correlation coefficient was higher for the overall well- functional limitations; (3) emotional; and (4) social well-
being rating (r=0.45; P<.001) than the oral health rating being. Therefore, it conforms to the contemporary concepts
(r=0.12; not significant, Table 3). Positive correlations were of child health.
also observed between all subscale scores and both global The CPQ8-10 development process ensured that it as-
ratings, except between the functional limitations and so- sesses not only experiences related to disease/disorder, but
cial well-being scores and oral health rating (Table 3). also the extent to which these experiences compromise the
Furthermore, the mean score for children reporting that individual’s quality of life.22,23 Questions selected from the
their well-being was “not at all” affected by their oral or initial item pool concern problems that children reported
orofacial condition was 2 times smaller than the mean score as the most frequent as well as the most bothersome. Thus,
for those reporting that it was affected “some/a little bit” they combine information about oral health status and the
(11.5 vs 22.4; P<.001, Table 4). All subscales showed the value attached to that status. As such, the CPQ8-10 reflects
same direction of the differences between these 2 groups the intent of the WHO definition of health by capturing
of children (Table 4). both health status and well-being.24
The impact level was, on average, higher in the orofacial The questionnaire and its components demonstrated re-
than in the pediatric dentistry group, as expected. The dif- markable feasibility in that there were no missing data.
ference in scores, however, was only 0.7 (19.1 vs 18.6; not Furthermore, the range of overall and subscale scores showed
significant). While children in the pediatric dentistry group that the CPQ8-10 detected substantial variability in children’s
reported more oral symptoms, children in the orofacial perceptions of their OHRQoL indicating its substantial
group were more likely to experience functional limitations measurement sensitivity. The study results suggest that the
and effects on social well-being (Table 5). CPQ8-10 has good construct validity. It did not, however,
As predicted, within the pediatric dentistry group there was demonstrate discriminative validity. The small difference in
a positive correlation between overall scores and the number the impact on quality of life reported by pediatric dentistry
of decayed tooth surfaces (r=0.29; P=.05). Moreover, children and orofacial patients can be attributed to the high quality
with decayed teeth had, on average, a higher overall score than of clinical and psychosocial care provided to the latter by The
caries-free children (21.1 vs 14.7; P=.037). The same direc- Hospital for Sick Children treatment teams continuously
tion of differences was observed in all domains, with the mean from their birth throughout childhood. The lack of a marked
emotional and social well-being score being 2 times higher in difference is also consistent with the contemporary models
the former than in the latter patient group: 5.2 vs 2.5 (P=.028) of disease/disorder and its consequences. The model by
and 5.7 vs 3.4 (P=.018), respectively. Cleary et al25 indicates that health outcomes experienced by
CPQ11-14 reliability—Cronbach’s alpha for the overall an individual are not determined only by the nature and se-
scale was 0.89, indicating very high internal consistency re- verity of the disease/disorder, but also by the personal and
liability (Table 6). The subscales demonstrated moderate to environmental characteristics.

516 Jokovic et al. Questionnaire for measuring oral health-related quality of life Pediatric Dentistry – 26:6, 2004
 The CPQ8-10 scale and subscales showed substantial in- Acknowledgements
ternal consistency reliability. Test-retest reliability was also The research on which this paper is based was supported
acceptable, except for the social well-being subscale. Al- by The Hospital for Sick Children Foundation, Grant No.
though a 2-week interval was intended for a post-test XG99-085 and by a post-doctoral fellowship from the
administration, it ranged between 13 and 38 days, with al- Canadian Institutes of Health Research (CIHR) Institute
most 50% of children completing the questionnaire at or of Population and Public Health.
after 20 days. As the questionnaire recall time is 4 weeks,
this meant that these children were referring to a different References
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ABSTRACT OF THE SCIENTIFIC LITERATURE

ASSESSING THE IMPACT OF ORAL HEALTH ON THE LIFE QUALITY OF CHILDREN
Dental caries remains one of the most prevalent diseases of childhood, despite efforts to improve preven-
tion and treatment. While the measurement of oral disease and conditions as they exist in children is clinically
important, this paper suggests that these parameters should not be used to indicate the overall oral health of
children. Oral health has been described as the standard of health of the oral and related tissues that contribute
to the general well-being of an individual. Equating treatment needs with oral health may be an oversimplifi-
cation of the concept. Currently, there are very few techniques designed to comprehensively assess the physical,
social, and psychological effects of oral health and oral health-related quality-of-life issues. This paper outlines
the value of and need for assessing child oral health-related quality of life (COHQoL) with various instru-
ments. This may be important, since quality-of-life assessments can reflect children’s feelings about their oral
health and can be used to improve communication between patients, parents, and dental care providers. These
assessments can also be used to plan oral health policy and care prioritization. Finally, COHQoL assessments
can be used to develop guidelines for evidence-based practice. The development of useful assessment tools will
be complicated and challenging, but a number of international studies have begun developing such measures.
As the field of COHQoL expands, several measures will be available for use. It will be important, however, to
evaluate the instruments and make sure they are appropriate to serve their purposes.
Comment: This paper proposes interesting insight into oral health assessments. It may be advantageous
to consider the “whole child” when developing policies and evidence-based care programs. BB
Address correspondence to Colman McGrath, Periodontology and Dental Public Health, Prince Philip Dental
Hospital, University of Hong Kong, 34 Hospital Road, Hong Kong SAR, China. [email protected]
McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality
of children: Implications for research and practice. Community Dent Oral Epidemiol. 2004;32:81-85.
56 references

518 Jokovic et al. Questionnaire for measuring oral health-related quality of life Pediatric Dentistry – 26:6, 2004

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