Barbosa et al.

Health and Quality of Life Outcomes 2011, 9:32

http://www.hqlo.com/content/9/1/32

RESEARCH Open Access

Evaluating oral health-related quality of life

measure for children and preadolescents with
temporomandibular disorder
Taís S Barbosa1, Marina S Leme1, Paula M Castelo2 and Maria Beatriz D Gavião1*

Abstract
Background: Oral health-related quality of life (OHRQoL) in children and adolescents with signs and symptoms of
temporomandibular disorder (TMD) has not yet been measured. This study aimed to evaluate the validity and
reliability of OHRQoL measure for use in children and preadolescents with signs and symptoms of TMD.
Methods: Five hundred and forty-seven students aged 8-14 years were recruited from public schools in Piracicaba,
Brazil. Self-perceptions of QoL were measured using the Brazilian Portuguese versions of Child Perceptions
Questionnaires (CPQ)8-10 (n = 247) and CPQ11-14 (n = 300). A single examiner, trained and calibrated for diagnosis
according to the Axis I of the Research Diagnostic Criteria for TMD (RDC/TMD), examined the participants. A self-
report questionnaire assessed subjective symptoms of TMD. Intraexaminer reliability was assessed for the RDC/TMD
clinical examinations using Cohen’s Kappa () and intraclass correlation coefficient (ICC). Criterion validity was
calculated using the Spearman’s correlation, construct validity using the Spearman’s correlation and the Mann-
Whitney test, and the magnitude of the difference between groups using effect size (ES). Reliability was
determined using Cronbach’s alpha, alpha if the item was deleted and corrected item-total correlation.
Results: Intraexaminer reliability values ranged from regular ( = 0.30) to excellent ( = 0.96) for the categorical
variables and from moderate (ICC = 0.49) to substantial (ICC = 0.74) for the continuous variables. Criterion validity
was supported by significant associations between both CPQ scores and pain-related questions for the TMD
groups. Mean CPQ8-10 scores were slightly higher for TMD children than control children (ES = 0.43).
Preadolescents with TMD had moderately higher scores than the control ones (ES = 0.62; p < 0.0001). Significant
correlation between the CPQ scores and global oral health, as well as overall well-being ratings (p < 0.001)
occurred, supporting the construct validity. The Cronbach’s alphas were 0.93 for CPQ8-10 and 0.94 for CPQ11-14. For
the overall CPQ8-10 and CPQ11-14 scales, the corrected item-total correlation coefficients ranged from 0.39-0.76 and
from 0.28-0.73, respectively. The alpha coefficients did not increase when any of the items were deleted in either
CPQ samples.
Conclusions: The questionnaires are valid and reliable for use in children and preadolescents with signs and
symptoms of temporomandibular disorder.

Introduction an appreciation that a combination of physical, psycholo-

Over the years, different theories of etiology and different gical and social factors may contribute to the overall pre-
emphases on the causative factors for the various signs sentation of this disorder. Hence, today there is a
and symptoms of temporomandibular disorder (TMD) preference for a biopsychosocial integrated approach [2].
have been proposed in the literature [1]. The current per- Accordingly, TMD patients are a target population for
spective regarding TMD is now multidimensional, with quality of life (QoL) assessments because of the consider-
able psychosocial impact of orofacial pain [3]. TMD have
* Correspondence: [email protected]
1
generally been presumed to be conditions affecting only
Department of Pediatric Dentistry, Piracicaba Dental School, State University
of Campinas, Piracicaba/SP, Brazil
adults; however, epidemiological studies have reported
Full list of author information is available at the end of the article signs and symptoms in children and adolescents to be as
© 2011 Barbosa et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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frequent as in adults [4] and the prevalence varies widely orofacial conditions, based on contemporary concepts of
in the literature from 16% to 90%, due to the methodolo- pediatric health and which can accommodate develop-
gies focusing largely on samples of patients seeking treat- mental differences among children across age ranges
ment or because they were conducted on convenience [17,18]. It consists of two age specific instruments for
non-representative samples of the population. Brazilian children aged 8-10 years (CPQ8-10) [18] and 11-14 years
studies have shown that in primary dentition 34% of the (CPQ11-14) [17]. A preliminary study has confirmed the
99 children presented at least one sign and/or one symp- validity and reliability of these measures for use in Bra-
tom of TMD [5]. In the age of 12 years, 2.19% of the boys zilian children and adolescents [22]. Although these
and 8.18% of the girls met the Research Diagnostic Cri- questionnaires are standardized and widely used for
teria for TMD (RDC/TMD) when examined [6]. From 15 other oral conditions, they have not yet been tested in
to 20 years-old 35.4% presented at least one symptom of TMD samples.
TMD [7]. Signs and symptoms in childhood and adoles- Assessing the impact of TMD on children’s QoL is
cence have been indicating mild disorders, but these find- important in many fronts. It provides an insight into the
ings do not detract from the importance of early potential consequences of TMD to the day-to-day lives
diagnosis to provide proper growth and development of of children and thereby facilitates understanding of its
the stomatognathic system [8]. Additionally the known importance in the provision of oral health care [23].
fluctuation in signs and symptoms of musculoskeletal Moreover, identifying factors associated with the impact
disorders in a time-dependent context might have been of TMD on children’s QoL can influence management
better addressed by carrying out repeated clinical record- of such cases and inform best practice guidelines [24].
ings [4]. In addition, Dahlström and Carlsson [9], in a In this way, the present study aimed to test the validity
recent systematic review, observed a substantial negative and reliability of CPQ used in a population of Brazilian
impact on oral health-related quality of life (OHRQoL) in public school students aged 8-14 years to determine
patients diagnosed with TMDs, being greater than other whether these measures are sensitive to clinical signs
orofacial diseases/illnesses or conditions. and subjective symptoms of TMD. An additional aim
In this way, measuring health-related quality of life was to verify whether the presence and severity of signs
(HRQoL) in TMD patients with generic or condition-spe- and symptoms of TMD are sufficient to influence OHR-
cific HRQoL instruments can complement efficacy mea- QoL of this age-specific population.
sures, offering a complete picture of the impact of disease
and treatment on overall well-being, as observed in adoles- Material and methods
cents with type 1 diabetes [10]. Jedel et al. [11] compared This study was approved by the Research Ethics Com-
the HRQoL between children with TMD pain and a con- mittee of the Dental School of Piracicaba, State Univer-
trol group, using the Child health questionnaire-child sity of Campinas (protocol n°021/2006).
form 87 (CHQ-CF87), a generic multidimensional instru- A cross-sectional study with students of public schools
ment designed to assess physical and psychosocial impacts of Piracicaba, Brazil, was developed. Piracicaba city has
on children and adolescents aged 10-18 years. Although 368.843 scholars, with 50.187 enrolled in the elementary
the results supported the use of generic instrument to school system http://www.ibge.gov.br. The sample size
measure health and to evaluate the efficacy of treatment in was calculated by Epi info version 6.0.1 software. A
pediatric patients with TMD pain [11], other authors standard error of 2%, a 95% confidence interval level
recommend the use of condition-specific instruments, and a 5.73% prevalence of TMD [25] were used for the
which are more sensitive for detecting slight changes in calculation. The minimum sample size to satisfy the
specific conditions [12] and might allow a more detailed requirements was estimated at 513 subjects. A total of
evaluation of the disability caused by TMD [13]. Accord- 547 students (235 boys and 312 girls), with no systemic
ingly, studies were conducted to evaluate the impact of diseases or communication and/or neuromuscular pro-
TMD and associated pain on QoL in adult [3,12,14,15] blems, participated in the study. The subjects ranged
and elderly [16] populations, using a condition-specific from 8 to 14 years of age, and were from nine public
instruments, i.e., an OHRQoL measure (e.g., Oral Health schools, which were randomly selected. All students
Impact Profile and Geriatric Oral Health Assessment obtained parental consent.
Index). The concepts in OHRQoL provide an opportunity The exclusion criteria were conditions/children with
to summarize a variety of possible psychosocial impacts in facial traumatism, neurological or psychiatric disorders,
relation to specific oral diseases [14]. use of dental prostheses, current use of medications (e.
Measures have been developed specifically for asses- g., antidepressive, muscle relaxant, narcotic or non-ster-
sing OHRQoL of children and adolescents [17-21]. The oidal anti-inflammatory), previous or present orthodon-
Child Perceptions Questionnaire (CPQ) is a measure tic treatment and other orofacial pain conditions, which
applicable to children with a wide variety of oral and could interfere with TMD diagnoses.
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Data collection that it won’t open all the way?; (3) Was this limitation
Oral health-related quality of life evaluation in jaw opening severe enough to interfere with your abil-
Data were collected using the Portuguese versions of the ity to eat? The other questions of Axis II were not
CPQ for individuals aged 8-10 years (CPQ8-10) and 11- included due to difficulty to understand or inappropriate
14 years (CPQ11-14) [22]. These formed the components for children.
of the Child Oral Health Quality of Life Questionnaire Clinical signs evaluation The clinical signs of TMD
that had been designed to assess the impact of oral con- were assessed using the RDC/TMD criteria (Axis I)
ditions on the QoL of children and adolescents [17,18]. described as follows [28,29]:
They were both self-completed. Items of the CPQ used Pain Site. To determine whether the present pain was
Likert-type scales with response options of “Never” = 0; ipsilateral to the pain provoked by the clinical examina-
“Once or twice” = 1; “Sometimes” = 2; “Often” = 3; and tion of the masticatory muscles and during jaw function.
“Very often” = 4. For the CPQ11-14, the recall period was Mandibular Range of Motion (mm) and Associated
three months, while for that of the CPQ8-10, it was four Pain. Jaw-opening patterns. Corrected and uncorrected
weeks. Items were grouped into four domains: oral deviations in jaw excursions during vertical jaw opening.
symptoms, functional limitations, emotional well-being Vertical range of motion of the mandible. Extent of
and social well-being. unassisted opening without pain, maximum unassisted
Children and adolescents were also asked to give over- opening and maximum assisted opening. Mandibular
all or global assessments of their oral health and the excursive movements. Extent of lateral and protrusive
extent to which the oral or oro-facial condition affected jaw excursions.
their overall well-being. These questions preceded the Temporomandibular Joint Sounds. Palpation of the
multi-item scales in the questionnaires. A four-point TMJ for clicking, grating, and crepitus sounds during
response format, ranging from “Very good” = 0 to vertical, lateral and protrusive jaw excursions.
“Poor” and from “Not at all” = 0 to “A lot” = 3, was Muscle and Joint Palpation for Tenderness. Bilateral
offered for these ratings in CPQ8-10. In CPQ11-14, these palpation of extraoral and intraoral masticatory and
global ratings had a five-point response format ranging related muscles (n = 20 sites) and bilateral palpation of
from “Excellent” = 0 to “Poor” = 5 for oral health and the TMJ (n = 4 joint sites).
from “Not at all” = 0 to “Very much” = 5 for well-being. The clinical evaluation selected individuals with at least
Evaluation of signs and symptoms of TMD one sign and one symptom of TMD [30], who were
Intraexaminer reliability Prior to the clinical examina- referred to as the TMD group in this present study. Sub-
tions, the dental examiner (TSB) participated in the cali- jects meeting the criteria for myofascial pain with or
bration process, which was divided into theoretical without limited opening (Axis I, Group 1a or 1b disor-
discussions on codes and criteria for the study, as well ders) and/or for disc displacement with reduction, with-
as practical activities. Intra-examiner reliability was out reduction with limited opening or without reduction
investigated by conducting replicated examinations on without limited opening (Axis I, Group 2a, 2b or 2c) or
20 individuals one week later to minimize recall bias as for arthralgia or arthritis (Axis I, Group 3a or 3b) were
a result of the first test. considered to have an RDC/TMD diagnosis (RDC/TMD
RDC/TMD The RDC/TMD is a classification system diagnosis group) [28]. The control group consisted of
composed by a dual-axis approach: Axis I (physical find- individuals with no current signs or symptoms of TMD
ings) and Axis II (pain-related disability and psychoso- (supercontrols) or those without signs or symptoms of
cial status). TMD (control group) [14,28]. This recruitment strategy
Subjective symptom interview A self-report question- was based on the principle that subjects belonging to dif-
naire was used to assess subjective symptoms according ferent groups will almost certainly respond differently to
to Riolo et al. [26], regarding pain in the jaws when the questionnaire [31]. If the questionnaire is valid, it
functioning (e.g., chewing), unusually frequent head- must be sensitive to such differences.
aches (i.e., more than once a week and of unknown
etiology), stiffness/tiredness in the jaws, difficulty open- Data analysis
ing one’s mouth, grinding of the teeth and sounds from Statistical analyses were performed using SPSS 9.0
the TMJ. Each question could be answered with a “yes” (SPSS, Chicago, IL, USA) with a 5% significance level
or a “no.” and normality was assessed using the Kolmogorov-Smir-
Moreover, three specific questions (yes/no) of the nov test. Since score distributions were asymmetrical,
RDC/TMD Axis II were considered for further TMD non-parametrical tests were used in the performed
diagnosis [27,28]: (1) Have you had pain in the face, analyses.
jaw, temple, in front of the ear or in the ear in the past Overall scores for each participant were calculated by
month?; (2) Have you ever had your jaw lock or catch so summing the item codes, whereas the subscale scores
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were obtained by summing the codes for questions Internal reliability

within the four health domains. Descriptive statistics Reliability can be defined as a measure of the internal
were followed by bivariate analyses, which used (where consistency or homogeneity of the items. Two measures
appropriate) Chi-squared and Fisher’s exact tests for a were used for the analysis of internal reliability; the cor-
comparison of proportions and Mann-Whitney test for rected item total correlation and the Cronbach’s alpha
a comparison of the means of the continuous variables. coefficient [37]. Values above 0.2 for the former and 0.7
Intraexaminer reliability for the latter can be acceptable [38]. Alphas were also
Intraexaminer reliability calculations were performed on calculated with each item deleted.
20 individuals who participated in the Axis I assessment
and the Axis II diagnosis interview. Only three questions Results
(3, 14a, 14b) from the latter were used as required Descriptive statistics
determinants for the Axis I diagnoses. A sample distribution of the evaluated characteristics (e.
The two most commonly accepted methods for asses- g., age, gender, TMD groups and CPQ scores) is shown
sing the intraexaminer reliability were used [32]. When in Additional file 1. Female children and preadolescents
the clinical examination variable could be measured on were more prevalent in TMD groups. Muscle tenderness
a continuous scale, reliability was assessed by computing and headaches were the most frequent signs and symp-
the intraclass correlation coefficient (ICC), using the toms of TMD found in children and preadolescents,
one-way analysis of variance random effect parallel being observed more significantly in girls than in boys
model [33]. The strength of the intra-examiner agree- (Chi-squared test).
ment was based on the following standards for ICC: <
0.2, poor; 0.21-0.40, fair; 0.41-0.60, moderate; 0.61-0.80, Intraexaminer reliability
substantial and 0.81-1.0, excellent to perfect [34]. The Among the 20 subjects for the reliability study, there
Kappa statistic (Cohen’s Kappa, ) was computed to were 14 girls and 6 boys with an average age of 10.30 ±
assess the reliability when variables were measured with 1.78 years. Fourteen of the subjects complained of
a categorical rating scale (e.g., yes/no). Kappa values symptoms suggestive of TMD, while six were asympto-
above 0.8 were considered excellent, from 0.61 to 0.8 matic. In almost all subjects (n = 19), at least one sign
good, 0.41 to 0.6 acceptable, 0.21 to 0.40 regular and of TMD was observed. The frequency of individuals
below 0.20 fair [35]. with RDC/TMD diagnosis was 10% for muscle tender-
Validity ness and 5% for disc displacements, respectively.
The validity of a questionnaire represents the degree to Table 1 shows the intraexaminer reliability for the
which it measures what it is meant to measure. Criterion clinical examinations and diagnostic questions of RDC/
validity was calculated by comparing the correlations TMD. The ICC and Kappa values for the former ranged
between CPQ scores and pain scores (obtained from from 0.49 to 0.74, indicating a moderate to substantial
Question 3 of the RDC/TMD Axis II), using the Spear- agreement and from 0.30 to 0.96, indicating a regular to
man’s correlation coefficient. As pain was considered a excellent agreement, respectively. High levels of reliabil-
variable only in the TMD patients, the relevant correlation ity were found for all three questions of the Axis II,
coefficients were calculated only for the TMD groups. with kappa values ranging from 0.70 to 0.81.
Discriminant construct validity was evaluated by com-
paring the mean scale scores between TMD and control Criterion validity
groups using the Mann-Whitney test. The magnitude of Table 2 shows the correlations between the scores of the
the difference between groups was assessed using the different subscales and variable pain, which was the sum
effect size (ES). This was derived from the mean difference of the positive responses to question number 3 of the
in scores between the groups divided by the pooled SD of RDC/TMD Axis II, “Have you had pain in the face, jaw,
scores: a value of 0.2 was taken to be small, 0.5 to be mod- temple, in front of the ear or in the ear in the past
erate and 0.8 to be large [36]. Discriminant construct month?” There were positive correlations between the
validity was also assessed by verifying the difference CPQ 11-14 total scores and variable pain (r = 0.32, p <
between RDC/TMD diagnosis (individuals in Group I, II 0.0001). Positive correlations were also observed
or III diagnosis) and “supercontrol” groups (individuals between all of the domains of CPQ11-14 and pain scores.
with no current sign and symptom of TMD). Correlational There were no significant correlations observed between
construct validity was assessed by comparing the mean the scale and subscale CPQ8-10 scores and variable pain,
scores and global ratings of oral health and overall well- with the exception of the functional limitation subscale
being using Spearman’s correlation coefficient. (r = 0.18, p < 0.05).
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Table 1 Intraexaminer reliability of diagnostic questions and clinical examinations of the RDC/TMD criteria (n = 20)
Reliability
RDC/TMD criteria Statistical tests Interpretation
Sign of TMD - Axis I
Muscle tenderness
Extraoral myofascial sites (4-category variable)† 0.74 Substantial agreement
Intraoral myofascial sites (4-category variable)† 0.53 Moderate agreement
Jaw movements* 0.46 Acceptable agreement
Joint pain
Palpation (4-category variable)† 0.67 Substantial agreement
Jaw movements* 0.96 Excellent agreement
Range of motion
Vertical dimension (mm)† 0.68 Substantial agreement
Jaw excursions (mm)† 0.49 Moderate agreement
Jaw-opening pattern* 0.30 Regular agreement
Joint sounds
Sound on jaw movement* 0.84 Excellent agreement
(Question) Symptom of TMD - Axis II*
(3) Pain in facial area, the jaws or the jaw joint 0.81 Excellent agreement
(14a) Limitation in jaw opening 0.70 Good agreement
(14b) Diet restriction due to limitation in jaw opening 0.80 Good agreement
RDC/TMD, research diagnostic criteria for temporomandibular disorder
* Cohen’s Kappa
† Intraclass correlation coefficient

Discriminant construct validity also higher than in all subscales. When expressed as
Children with signs and symptoms of TMD reported, on effect size, the magnitude of the mean differences was
average, worse OHRQoL than the control group, as small to moderate. The mean score in the RDC/TMD
indicated by the mean overall scores of 20.6 versus 13.5, diagnosis group (25.6 ± 22.3) was moderately higher
respectively (Table 3). The effect size of 0.43 indicated than in the “supercontrol” group (7.5 ± 7.8) (Table 4).
that the difference between the groups was moderate (p There were also significant differences between the
< 0.0001). The CPQ8-10 scores for the TMD group were groups for all the domains, with effect sizes ranging
from moderate for functional (ES = 0.58), emotional (ES
= 0.50) and social (ES = 0.54) domains to large for the
Table 2 Criterion validity: correlations between the CPQ oral symptom subscale (ES = 0.87).
scores and variable pain (Question 3, RDC/TMD Axis II) Preadolescents in the TMD group had, on average,
for TMD groups
higher overall scores than in the control group (27.6 vs.
TMD groups Pain variable 16.3; p < 0.0001) (Table 3). The same difference was
a
r P observed in all domains, with the mean functional and
CPQ8-10 Total scale 0.14 0.089 social well-being score being two times higher in the for-
n = 141 Subscales mer than in the latter patient group: 6.5 vs. 3.6 (p <
Oral symptoms 0.13 0.106 0.0001) and 5.9 vs. 2.9 (p < 0.0001). The magnitude of the
Functional limitations 0.18 0.024 differences between the clinical groups was moderate, ran-
Emotional well-being 0.06 0.476 ging from 0.46 in the oral symptoms domain to 0.62 in
Social well-being 0.09 0.278 the functional limitations domain. When the scores for
CPQ11-14 Total scale 0.32 < 0.0001 the RDC/TMD diagnosis groups were examined, preado-
n = 176 Subscales lescents diagnosed with TMD had significantly higher
Oral symptoms 0.33 < 0.0001 scores than the “supercontrol” group for all total and sub-
Functional limitations 0.26 0.000 scale CPQ11-14 scores (Mann-Whitney U test) (Table 4).
Emotional well-being 0.24 0.001
Social well-being 0.27 0.000 Correlational construct validity
TMD, temporomandibular disorder; CPQ, child perceptions questionnaire As an index of construct validity, Spearman’s correlation
a
Spearman’s correlation coefficient was highly significant at the 0.0001 level in both global
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Table 3 Discriminant construct validity: a comparison between the CPQ mean scores of the TMD and control groups
TMD group (n = 141) Control group (n = 106)
Mean (SD) Mean (SD) P* ES†
CPQ8-10 Overall scale [0-100] 20.6 (17.7) 13.5 (15.4) < 0.0001 0.43
Subscales
Oral symptoms [0-20] 7.2 (4.0) 5.2 (3.9) < 0.0001 0.55
Functional limitations [0-20] 3.8 (4.2) 2.6 (3.8) 0.001 0.36
Emotional well-being [0-20] 4.6 (4.7) 2.6 (4.1) < 0.0001 0.52
Social well-being [0-40] 5.5 (7.4) 3.1 (5.9) 0.009 0.39
TMD group (n = 176) Control group (n = 124)
Mean (SD) Mean (SD) P* ES†
CPQ11-14 Overall scale [0-148] 27.6 (20.7) 16.3 (14.8) < 0.0001 0.62
Subscales
Oral symptoms [0-24] 7.0 (4.7) 5.2 (3.5) < 0.0001 0.46
Functional limitations [0-26] 6.5 (5.6) 3.6 (4.2) < 0.0001 0.62
Emotional well-being [0-36] 7.9 (7.6) 4.5 (5.6) < 0.0001 0.53
Social well-being [0-52] 5.9 (6.7) 2.9 (4.0) < 0.0001 0.56
TMD, temporomandibular disorder; CPQ, child perceptions questionnaire
Values in square brackets indicate range of possible scores
* P-values obtained from Mann-Whitney test
† ES = Effect sizes, difference in group means/pooled SD

ratings for CPQ 8-10 total scales in the TMD group scores for all CPQ11-14 subscale scores and both global
(Table 5). Positive correlations were also observed ratings (Table 5).
between all the CPQ8-10 subscale scores and global oral
health ratings, as well as overall well-being. Reliability
The TMD group showed significant correlations Internal consistency reliability was assessed for the
between overall CPQ11-14 scores and global oral health TMD samples using Cronbach’s alpha (Table 6). This
ratings (p < 0.0001) and overall well-being (p < 0.0001). was 0.93 for the total CPQ8-10 and ranged from 0.68 to
Significant correlations were also observed between the 0.90 for the subscales, indicating an acceptable to good

Table 4 Discriminant construct validity: CPQ overall and domain scores by the RDC/TMD diagnosis and “supercontrol”
groups
RDC/TMD Diagnosis Group (n = 32) Supercontrol Group (n = 28)
Mean (SD) Mean (SD) P* ES†
CPQ8-10 Overall scale [0-100] 25.6 (22.3) 7.5 (7.8) < 0.0001 0.61
Subscales
Oral symptoms [0-20] 8.7 (4.6) 3.5 (3.4) < 0.0001 0.87
Functional limitations [0-20] 4.8 (4.7) 1.3 (1.9) < 0.0001 0.58
Emotional well-being [0-20] 4.7 (5.2) 1.1 (1.7) 0.000 0.50
Social well-being [0-40] 7.4 (9.6) 1.7 (3.1) 0.006 0.54
RDC/TMD Diagnosis Group (n = 69) Supercontrol Group (n = 29)
Mean (SD) Mean (SD) P* ES†
CPQ11-14 Overall scale [0-148] 35.0 (24.1) 11.7 (9.6) < 0.0001 0.88
Subscales
Oral symptoms [0-24] 8.7 (5.8) 4.2 (2.1) < 0.0001 0.74
Functional limitations [0-26] 8.8 (7.0) 2.2 (2.9) < 0.0001 0.89
Emotional well-being [0-36] 10.0 (8.9) 3.1 (4.1) < 0.0001 0.73
Social well-being [0-52] 7.5 (6.8) 2.1 (3.4) < 0.0001 0.82
TMD, temporomandibular disorder; CPQ, child perceptions questionnaire
Values in square brackets indicate range of possible scores
* P-values obtained from Mann-Whitney test
† ES = Effect sizes, difference in group means/pooled SD
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Table 5 Correlational construct validity: correlations between CPQ scores and global ratings of oral health and overall
well-being (TMD groups)
TMD groups CPQ8-10 (n = 141) CPQ11-14 (n = 176)
Oral Health Overall Well-being Oral Health Overall Well-being
Ra Pb Ra Pb Ra Pb Ra Pb
Total scale 0.36 < 0.0001 0.41 < 0.0001 0.37 < 0.0001 0.62 < 0.0001
Subscales
Oral symptoms 0.37 < 0.0001 0.39 < 0.0001 0.36 < 0.0001 0.42 < 0.0001
Functional limitations 0.25 0.002 0.41 < 0.0001 0.28 0.000 0.48 < 0.0001
Emotional well-being 0.44 < 0.0001 0.38 < 0.0001 0.34 < 0.0001 0.57 < 0.0001
Social well-being 0.28 0.000 0.36 < 0.0001 0.26 0.000 0.53 < 0.0001
TMD, temporomandibular disorder; CPQ, child perceptions questionnaire

level of internal consistency. For the overall CPQ 8-10 Discussion

scale, the corrected item-total correlation coefficients This study was undertaken to provide evidence of the
were from 0.39 to 0.76 and for the domains the same reliability and validity of the CPQ8-10 and CPQ11-14 in
coefficients ranged from 0.37 to 0.77. The alpha coeffi- children and preadolescents with signs and symptoms of
cients did not increase when any of the items were TMD. Our previous study had indicated that these mea-
deleted. sures were able to discriminate between children and
A total of 176 TMD individuals were used to test the preadolescents with different levels of severity of dental
internal reliability of the CPQ11-14 (Table 6). Cronbach’s caries, malocclusion, fluorosis and gingivitis [22].
alpha for CPQ11-14, as a whole, was excellent (0.94). For According to Locker et al. [39], the process of evaluat-
the domains of the CPQ 11-14 , the coefficients ranged ing HRQoL measures consists of two stages; the first
from 0.69 for oral symptoms to 0.90 for emotional well- involves an assessment of the reliability and validity and
being, indicating an acceptable to good levels of internal the second consists of on-going evaluations of the per-
consistency reliability. The corrected item-total correla- formance in different populations and the various con-
tions for the total CPQ11-14 scale ranged from 0.28 to texts for which it was intended. Furthermore, the
0.73. For the CPQ 11-14 subscales, the corrected item- linguistic and cultural context in which a measure is
total correlation coefficients ranged from 0.28, which used can have a bearing on the validity, as can the
represented the lower coefficient for the social well- intended purpose of the measure; thus prior validity and
being domain, to 0.76 for emotional well-being. The reliability tests, the instruments must be translated,
alpha was not higher when any item was deleted. back-translated, and cross culturally adapted in order to

Table 6 Internal consistency reliability: Cronbach’s alpha, Alpha if item deleted and Corrected item-total correlation
(TMD groups)
TMD Number of Cronbach’s Range of a’s if items Range of corrected item total
groups items alpha deleted correlations
CPQ8-10 Total scale 25 0.93 (0.93-0.93) (0.39-0.76)
n = 141 Subscales
Oral symptoms 5 0.68 (0.61-0.66) (0.37-0.48)
Functional 5 0.78 (0.70-0.75) (0.51-0.67)
limitations
Emotional well- 5 0.85 (0.81-0.83) (0.60-0.71)
being
Social well-being 10 0.90 (0.88-0.90) (0.52-0.77)
CPQ11-14 Total scale 37 0.94 (0.93-0.94) (0.28-0.73)
n = 176 Subscales
Oral symptoms 6 0.69 (0.62-0.68) (0.33-0.51)
Functional 9 0.79 (0.76-0.78) (0.40-0.57)
limitations
Emotional well- 9 0.90 (0.88-0.89) (0.59-0.76)
being
Social well-being 13 0.87 (0.85-0.87) (0.28-0.67)
TMD, temporomandibular disorder; CPQ, child perceptions questionnaire
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ensure their conceptual and functional equivalences these results must be carefully considered given the low
[22,27,31]. specificity of muscle palpation [50,51]. The prevalence
The RDC/TMD had been the best and most used of joint pain was substantial, being the second most fre-
classification system to date for epidemiological studies quent sign observed in 48.9% of the children and 44.9%
that sought to understand TMD etiology and mechan- of the preadolescents, higher than values observed in
isms [40]. Together, Axis I and Axis II assessments con- adolescents by Bonjardim et al. [41] (7.83%-10.6%). The
stitute a comprehensive evaluation consistent with the less prevalent sign of TMD were TMJ sounds, found in
biopsychosocial health model [2]. In this study, only just 5% of the children and 8% of the preadolescents
three specific items for the latter were included, since and even lower than those observed in previous studies
they were more appropriate for the age sample. Accord- [41,56,57]. The difference in findings may reflect varia-
ingly, a questionnaire containing items regarding self- tions in the tools being used. The high sensitivity of
reported pain and associated symptoms of TMD [26] RDC/TMD classification for TMJ sounds, which is
was used to replace the pain-related disability approach based on reproducible clicks on two of three trials, con-
of RDC/TMD Axis II [41]. tributes to the elimination of indistinct or temporary
Reliability and validity are the basic underpinnings of clicking sounds [32], decreasing the probability of false
any scientific measure. The reliability of a diagnostic positive results.
instrument sets the upper limit for its validity [42]. Sev- In TMD groups, the presence of headaches was higher
eral studies evaluating the reliability of clinical findings in children than in preadolescents, as previously
have shown that the experiences and calibration of the observed [41,56,58]. There was no gender difference in
examiners are crucial for accuracy of the results the symptomatic children, but among preadolescents,
[32,43,44], as done in the present study. Individuals with the prevalence of headaches associated with TMD was
most common TMD conditions as well as asymptomatic higher in girls than in boys. In line with these findings,
controls were included in the reliability assessment (n = previous studies found an increasing of this association
20) to ensure that a broad spectrum, ranging from none with age among adolescents, especially in females
to severe findings, was present [32,45]. It provided a [59,60]. Similarly, the higher prevalence of the clinical
more realistically simulated actual clinical and research signs of TMD, mainly painful signs among females, was
conditions, wherein patients and subjects who were consistent with some previous findings [57,58,61],
both symptomatic and asymptomatic for TMD might whereas others found no gender-linked relationships
actually appear to undergo RDC/TMD diagnostic exami- [41,62]. The difference between genders could probably
nations [46]. Other influencing factors included the fea- be explained by the fact that girls may be more sensitive
sibility of conducting such examinations in an to tenderness and pain on palpation of the TMJ and
acceptable time frame [46-48]. adjacent muscles [63] mainly in older age due to hormo-
Considering the minimum acceptable level for agree- nal changes [56,61].
ment at 0.40 (kappa) for categorical measures and at Ideally, criterion validity would be measured relative
0.70 (ICC) for continuous variables [49], inconsistency to a “gold standard.” As no such standard exists for oral
was found in some RDC/TMD measurements, mainly in health status measures, criterion validity was evaluated
the pain scores and in the ranges of motion. However, by correlating the CPQ scores with a score correspond-
the overall reliability results were still good. The poor ing to the sum of the answers to the item investigating
intraoral muscle reliability found in the present study pain (Question 3, RDC/TMD Axis II). This approach is
and by others [43,47] could be explained by the low spe- consistent with literature reports that suggest the use of
cificity of muscle palpation [50,51]. Moreover, a low external criteria to test criterion validity [31]. Subjects
reproducibility for the pain scores is not unusual with pain-associated conditions presented higher
because pain intensities do vary over even short periods impacts on daily function in this study and in others
of time [52] partly due to poor memory recall for pain performed in adult [3,12] and elderly [10] populations.
[53]. Only a moderate level of reproducibility was found Accordingly, the patients’ well-being decreased as a
for jaw excursions, compared with other studies where function of pain duration and increased in pain inten-
more agreement was observed [43,47]. In addition, dif- sity, frequency and number of pain sites [12,31]. In the
ferences in reliability findings may reflect variations in only study to address this issue in youth patients, Jedel
the methodology, such as differences in subject samples, et al. [11] found that children and adolescents with
numbers of examiners, study designs, statistical analyses, TMD pain more than once a week were associated with
as well as prevalence and sampling variability [43,46,54]. higher impacts on physical functioning, emotional roles
Muscle tenderness was the most frequent clinical sign, and behavioral roles, resulting in limitations on physical
found in 77.3% of children and 67% of preadolescents, activities, school work and activities with friends. Simi-
agreeing with Tuerlings and Limme [55]. However, larly, positive correlations were observed between all the
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domains of CPQ11-14 and pain scores for preadolescents. the higher impact found in adults diagnosed with TMD
Although a substantial prevalence of pain symptoms when compared with control groups in the study by
existed in the CPQ8-10 sample (36.2%), only the func- Rener-Sitar et al. [15], which suggested that diagnoses
tional domain was associated with this variable. It is associated with pain (e.g., myofascial pain, arthralgia)
likely that reporting symptoms of minor severity or of have a higher impact than non-pain-related diagnoses
fleeting nature resulted in such a high prevalence. Less (e.g., disc displacement with reduction). Considering
severe pain and sensations may be responsible for less that muscle tenderness was the most frequent diagnosis
impaired OHRQoL in children reporting TMD. In fact, observed among the evaluated TMD sample, greater
patients with TMD initially display functional limita- impact on QoL was expected for these subjects.
tions. These are followed by psychological discomfort, The construct validity was further supported when the
social disability and handicap and finally chronic pain CPQ scores were assessed for the TMD groups against
[31]. This progression can also explain the different dis- the global questions, as high correlations between them
criminant construct validity results, which compared the suggest that they are measuring the same construct.
controls with both TMD groups and with the advanced Moreover, these associations showed that the reported
cases. issues and concerns of the TMD groups extend beyond
The discriminant construct validity of the question- oral health and are of sufficient magnitude to have some
naires was supported by their ability to detect differ- effect on their life as a whole. It means that the ques-
ences in the impact on QoL, evidenced by the highest tionnaires actually measured as originally intended [38].
scores being seen in children and preadolescents with Accepted minimal standards for internal reliability
signs and symptoms of TMD. However, although the coefficients are 0.70 for group comparisons and 0.90-
difference in scores supported the validity of the mea- 0.95 for individual comparisons [66]. Accordingly, the
sures, the magnitude of these differences was only low reliability coefficients for both CPQ total and subscales
to moderate. According to Reissmann et al. [14], the exceeded standards for group and individual level com-
magnitude of TMD impact depends on the definition of parisons [67], except for oral symptoms domains, which
the comparison group without TMD diagnoses. were slightly lower at 0.68 for CPQ8-10 and at 0.69 for
Although patients in the general population are the CPQ11-14. However, these values can be acceptable, as
most plausible choice for comparison (which was chosen they are far greater than 0.50, an indicative level for
in the present study), they may have some signs and non-homogeneous scales [68]. According to Gherun-
symptoms of TMD; these are insufficient to warrant an pong et al. [59], alpha is not a perfect indicator of relia-
RDC/TMD diagnosis but sufficient to influence QoL. bility, as it tends to underestimate the reliability of
This is consistent with the findings by Reissmann et al. multidimensional scales and because lower values can
[14], where subjects without diagnosis had a more than be expected from health-related measures. All item-total
50% higher OHRQoL impact levels compared to sub- correlations were above the minimum recommended
jects without any TMD sign or symptom. Other authors level of 0.20 [19] and alpha did not increase when an
suggest that differences in scores of QoL measures can item was deleted.
be properly interpreted only after minimally important The greatest strenght of this study is the use of the
differences have been recognized [64]. The minimum standardized OHRQoL questionnaires and also the stan-
important difference is defined as the smallest difference dardized assessment of the level of impairment of differ-
in scores that patients perceive as being important, ent anatomical structures that constitute a
which would suggest a change in the patient’s manage- stomatognathic system according to the RDC/TMD pro-
ment [65]. This score can be determined only following tocol [15]. Besides that, the recruitment strategy of sam-
longitudinal studies in which some individuals changed ple allowed for a spectrum of participants, which
and some did not, either as the result of therapy or nat- provided a valid estimation of the differences between
ural fluctuations in the disorder. This evaluation has yet individuals with variety levels of severity of the same
to be undertaken with respect to the measures used in clinical condition, so that a judgement could safely be
this study. made concerning the generalisation of the results to
Evidence that the higher scores of the TMD indivi- that population [31]. On the other hand, it is also
duals may be important was found in the responses of important to recognize the limitations of the work per-
the advanced cases when compared to the “supercon- formed in terms of the methodology and analytic strate-
trol” reports. Analyses of the scores derived from both gies used [69]. Given the cross-sectional nature of the
questionnaires indicated that the QoL of children and data study, the observed finding could address only the
preadolescents diagnosed with TMD was markedly descriptive and discriminative potential of OHRQoL
worse than that of individuals with no current signs or measures in relation to TMD condition. Further
symptoms of TMD. These results were consistent with research is required to determine whether or not these
Barbosa et al. Health and Quality of Life Outcomes 2011, 9:32 Page 10 of 12
http://www.hqlo.com/content/9/1/32

instruments discriminated between groups of children Authors’ contributions

TSB participated in conception and design of the study, data analysis and
and adolescents with different clinical conditions. Stu-
interpretation, acquisition of data and drafting the manuscript. MSL
dies should also include the measurement of factors that contributed to the data collection. PMC made critical comments on the
may account for the variation in OHRQoL observed in manuscript. MBDG participated in the conception and design of the study
and critical revision of manuscript. All authors read and approved the final
TMD patients, as well as, for other oral conditions.
manuscript.
Finally, longitudinal studies are required to demonstrate
OHRQoL responsiveness to change prior to using it in a Competing interests
The authors declare that they have no competing interests.
context where change is expected, desired or possible
[70]. Received: 15 February 2011 Accepted: 12 May 2011
Published: 12 May 2011
Conclusions
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doi:10.1186/1477-7525-9-32
Cite this article as: Barbosa et al.: Evaluating oral health-related quality
of life measure for children and preadolescents with
temporomandibular disorder. Health and Quality of Life Outcomes 2011
9:32.

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