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Assessment of Self-Esteem and Quality of Life in Patients with Complete Unilateral Cleft Lip and Palate Undergoing Orthodontic Treatment
A Kaja Mohaideen1, Satinder Pal Singh1, Adarsh Kohli2, Sanjeev Verma1, Vinay Kumar1, Raj Kumar Verma1
1 Department is Unit of Orthodontics, OHSC, PGIMER, Chandigarh, India
2 Department of Psychiatry, PGIMER, Chandigarh, India
|Date of Submission||04-Jun-2021|
|Date of Decision||12-Oct-2021|
|Date of Acceptance||09-Feb-2022|
|Date of Web Publication||03-Nov-2022|
Satinder Pal Singh,
Room Number 208, Unit of Orthodontics and Dentofacial Orthopaedics, OHSC, PGIMER, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To assess the self-esteem and quality of life (QOL) in patients with complete unilateral cleft lip and palate (UCLP) who were undergoing orthodontic treatment. Materials and Methods: This cross-sectional study was conducted on a total sample of 300 individuals consisted of 150 patients with UCLP (Group I) and 150 normal controls (Group II) with an age range of 10–25 years, who were undergoing comprehensive orthodontic treatment from December 2016 to December 2018. The Self Esteem and QOL were assessed using the Rosenberg Self Esteem scale (RSE) and Modified Paediatric QOL Inventory Scale (M-PQOL), respectively, in Group I and II. Results: The comparison of overall mean scores of responses to RSE questionnaires showed nonsignificant differences for all the responses and was significant only for RSE 6 and RSE 8 in the age group of 10–15 years and 21–25 years, respectively, and nonsignificant for all other questions in all the age groups. The comparison of overall mean scores of M-PQOL for the total sample showed nonsignificant differences in Group I and II for physical functioning, emotional functioning, and school functioning domain, and were highly significant differences (P ≤ 0.001) in the social functioning domain and M-PQOL 12 and M-PQOL 21. Conclusions: This study demands a definite need of a psychologist/psychiatrist among the cleft care team to counsel the patients with cleft during orthodontic treatment for motivating them to gain self-respect and acceptance in the society as certain aspects, particularly social functioning domain made them feel different from normal children because of the functional and aesthetic problems.
Keywords: Cleft lip and palate patients, modified pediatric quality of life inventory, Rosenberg self-esteem
|How to cite this URL:|
Mohaideen A K, Singh SP, Kohli A, Verma S, Kumar V, Verma RK. Assessment of Self-Esteem and Quality of Life in Patients with Complete Unilateral Cleft Lip and Palate Undergoing Orthodontic Treatment. Contemp Clin Dent [Epub ahead of print] [cited 2023 Feb 2]. Available from: https://www.contempclindent.org/preprintarticle.asp?id=360371
| Introduction|| |
Cleft lip and/or palate is the most common developmental craniofacial anomaly with an incidence of 1 in 700 live births worldwide and 0.93–1.3 in India. This anomaly is associated with general oral health complications such as oro-facial deformities, disturbances in the number of teeth such as agenesis, supernumerary teeth, misaligned teeth, and speech problems such as hypernasality and psychological repercussions that affect the social relationship, adaptation to society and both the quality of life (QOL) and self-esteem of the patients and their family.,
QOL may be defined as “the individual's perception of their position in life in the context of the culture and value systems in which they live and concerning their goals.” QOL involves several dimensional concepts that generally consisted of subjective estimations of both positive and negative features of life. self-esteem is the overall affective evaluation of one's own worth, value, or importance.
This anomaly affecting the orofacial structures leading to obvious visible and aesthetic differences and speech difficulty from the general population of a similar age group is anticipated to have a paramount effect on social communications and QOL of the patients with cleft. QOL in nonsyndromic cleft lip and palate patients had been assessed in different descriptive, observational, cross-sectional, and longitudinal studies in different parts of the world.,,,, The results mostly show the lower QOL in emotional, social, and school functioning. A few studies also showed the QOL comparable to normal control., A cross-sectional study in Polish adolescents and young adults with unilateral complete cleft lip and palate and found higher self-esteem for body functioning and defensive self-enhancement and no differences in social relationship domains, coping styles, and health-related QOL.
Since there is paucity in the literature to assess the Self-Esteem and QOL of patients with unilateral cleft lip and/or palate (UCLP) among the Indian population, hence the objective of this study is to assess the self-esteem and QOL of patients with complete UCLP.
| Materials and Methods|| |
This cross-sectional study was conducted on a total sample of 300 individuals who were undergoing comprehensive orthodontic treatment in the Unit of Orthodontics and Dentofacial Orthopaedics of the institution from December 2016 to December 2018. The sample size was calculated according to a study by Berk et al. which examined the social anxiety in Chinese adults with orofacial clefts. The power of the study was kept at 98% and a significance level of α = 0.001. The calculated sample size was n = 109. But to reduce the attrition bias, the sample size was chosen to be n = 150. Hence, the final sample consisted of 150 patients with UCLP (Group I) and 150 normal control subjects (Group II) with an age range of 10–25 years. The study was approved by the Institute ethical committee, Postgraduate Institute of Medical Education and Research (NK/3754/MDS/24 dated October 10, 2017). Research has been conducted in full accordance with ethical principles and guidelines, including the World Medical Association Declaration of Helsinki (version 2013). An informed and written consent was obtained from the participants. Inclusion criteria: (a) Group I consisted of patients with complete UCLP, classified as Group 3 (R or L) of Balakrishnan classification involving the lip, alveolus, and palate, and had a history of cleft lip and palate repair, (b) Group II consisted of normals with pleasing profile and no history of orthodontic treatment. The patients of the two groups were evaluated in three different groups according to their age range of 10–15 years, 16–20 years, and 21–25 years. No attempt was made on the differentiation according to gender. The exclusion criteria included patients with a) cleft lip only, cleft palate only, and bilateral cleft lip and palate and/or, b) syndromic patients, c) requiring surgical intervention (orthognathic/distraction osteogenesis) for skeletal discrepancies and c) associated with any systemic diseases or mental retardation.
The patients were informed about the study and the questionnaires were explained to them and were advised to fill up the Performa of Self-Esteem and QOL questionnaire in a quiet area of the respective department. Sociodemographic variables and clinical detail assessment were also recorded. As the evaluation of self-esteem and health-related QOL was done using questionnaires,, every effort was made to enable maximum people to understand it. The questionnaires were translated into Hindi and back-translated into English to access the validity of the questionnaires.
Rosenberg self esteem scale
This scale included ten items of 5 positive and 5 negative statements. Four respondent choices were given for each item. They were strongly agree, agree, disagree, and strongly disagree. Low self-esteem responses were “disagree” or “strongly disagree” on items 1, 3, 4, 7, 10, and “strongly agree” or “agree” on items 2, 5, 6, 8, 9. The total mean score of the Rosenberg Self-Esteem Scale would range from 1 to 4. The mean value >2 was considered as the higher Self-Esteem and lesser than that was considered as the lower Self-Esteem.
Modified pediatric quality of life inventory scale
The PedsQL Generic Core Scales have 23-item and were considered to quantify the dimensions of health as defined by the World Health Organization. In addition to these, 12 new items were constructed to examine the need and deficiency of previous questionnaires [Supplementary File 1]. The 35-item modified form of PedsQL 4.0 Generic Core Scales encompass 1) Physical Functioning (8 items), 2) Emotional Functioning (10 items), 3) School Functioning (5 items), and 4) Social Functioning (12 items). Twelve questions added were specifically related to UCLP patients, regarding speech, social participation, appearance, and eating ability to evaluate QOL as they cover all the aspects of health and well-being.
The test-retest was used to evaluate the reliability of questionnaires of Rosenberg Self Esteem scale (RSE) and Modified Paediatric QOL Inventory Scale (M-PQOL) scale in 15 (10%) patients with UCLP by Intraclass correlation coefficient (ICC). The ICC value for RSE and M-PQOL Inventory was 0.809 and 0.76, respectively, and were satisfactory.
The Statistical Analysis was conducted using IBM SPSS Statistics for Windows, Version 22.0. (Armonk, NY: IBM Corp). The descriptive and inferential statistics were carried out. The quantitative data were presented as mean ± standard deviation and qualitative as frequency (percentage). The normality of data was assessed using Kolmogorov–Smirnov tests. Since the data of the present study followed a normal distribution, so the parametric test was applied. The independent t-test was used to check the statistically significant difference between the groups, while analysis of variance was used to check the statistical difference between three or more groups. The statistical tests were two-sided and were performed at a significance level of α = 0.001.
| Results|| |
The age- and gender-wise distribution of the 300 patients into two groups is shown in [Table 1]. Among 150 cleft patients, 59 patients each were in the age range of 10–15 years and 16–20 years and 32 patients in the age range of 21–25 years and among 150 controls, 65, 60 and 25 patients were in the age range of 10–15 years, 16–20 years, and 21–25 years, respectively. [Table 2] shows the mean scores of responses to RSE 1–10 questions for the cleft patients and the control group. The comparison of overall mean scores of responses to RSE questionnaires for the total sample showed nonsignificant differences of means for cleft patients and the control group for all the responses. The comparison of differences of means was significant for RSE 6 in the age group of 10–15 years and RSE 8 in the age group 21–25 years and nonsignificant for all other questions in all the age groups.
|Table 1: Distribution of total sample according to age and gender (n=300)|
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|Table 2: Comparison of self-esteem between Group I and Group II among various age ranges|
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[Table 3] shows the comparison of overall mean scores of responses to M-PQOL for the total sample in which the physical functioning domain (M-PQOL 1–8) showed nonsignificant differences for cleft patients and the control group. In the emotional functioning domain (M-PQOL 9–18), only M-PQOL 12 showed highly significant differences. The school functioning domain (M-PQOL 19–23) showed nonsignificant differences for all the responses except M-PQOL 21. The responses to all the items in the social functioning (12 items) domain (M-PQOL 24–35) showed highly significant mean differences.
|Table 3: Quality of Life between Group I and Group II for the total sample using Modified Paediatric Quality of Life Inventory Scale#|
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In the age group, 10–15 years responses to M-PQOL 8, 9, 12 were statistically significant and in the social functioning domain, all the responses are highly significant except M-PQOL 28 and 29 as shown in [Table 4]. [Table 5] shows that the mean differences of responses to all the items in the age group of 16–20 years in the social functioning (12 items) domain (M-PQOL 24–35) were highly significant. In the age group, 21–25 years responses to M-PQOL 1, 4, 6, 9, 10, 12, 19, 27, 31, 33, and 35 showed highly significant mean differences as shown in [Table 6].
|Table 4: Comparison of quality of life between Group I and Group II among 10-15 years of age using Modified Pediatric Quality of Life Inventory Scale#|
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|Table 5: Comparison of quality of life between Group I and Group II among 16-20 years of age using Modified Pediatric Quality of Life Inventory Scale#|
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|Table 6: Comparison of quality of life between Group I and Group II among 21-25 years of age using Modified Paediatric Quality of Life Inventory Scale#|
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| Discussion|| |
In the present study, the comparison of the overall Self-Esteem of UCLP and the normal individuals was nonsignificant. However, among three different age groups responses to two questions were highly significant. The scores of responses RSE 6, i.e., “I certainly feel useless at times” in the age range of 10–15 years may be significant due to the reason that many a time the UCLP patients may have a feeling of worthlessness. In the age range of 21–25 years, the score of RSE 8, i.e., “I wish I could have more respect for myself” was higher and highly significant as the real feeling in patients with UCLP that they craved for more respect showing higher self-esteem. Kramer et al. reported that the self-esteem was lower in nonsyndromic patients with an orofacial cleft in a German population independent of the gender and cleft type. Sagheri et al. found higher scores in Self-Esteem for children with nonsyndromic cleft lip and palate in the German population when compared to the normal population. Pisula et al. evaluated the self-esteem in patients with UCLP in a Polish population of age range 16–23 years and concluded that there were insignificant differences of self-esteem between patients with UCLP and controls, similar to the present study. Conceptually, by the time the child with UCLP becomes an adult, he evolves as an individual, socially, psychologically, and emotionally and compensates for his/her self-esteem or finds a way to enhance it.
The QOL was similar for both the cleft and the control group concerning the Physical and emotional functioning domain in the present study. However in the age range of 10–15 years, the patients did not have trouble sleeping than their normal counterparts and showed lower energy and fear which were improved in the patients of age range 21–25 years as compared to the controls. This shows, by the time they were adults they devised ways to deal with their impairment and became confident.
The QOL concerning the social functioning domain showed the patients had high absenteeism from the school, because of their frequent visits to the hospital for their treatment. Though, they did not show any difficulty in keeping their school work or paying attention in class, than the normal controls.
The QOL was lower in the social functioning domain as the patients with UCLP have speech impairment due to velopharyngeal incompetence as well as insufficiency hence they find it awkward in attending the social gathering. The palatal defect in patients with UCLP leads to nasal regurgitation and these anatomic and functional changes make them feel different from other normal children in society.
Thus, the QOL of patients with UCLP was lower than the control subjects, among the age range from 10 to 20 years in agreement to a cross-sectional study by Kortelainen et al. The QOL was higher than the controls in the age range of 21–25 years in relation to the physical functioning domain, in agreement with a cross-sectional study conducted by Foo et al. in which they determined the general health-related QOL and oral health impact of patients with UCLP of 18–65 years with normal population norms in Australia and they also concluded that the patients with UCLP scored 1.1 times higher values on physical role function of QOL and lowered on the vitality and mental health.
In the present study, the questionnaires were individually perceived by the patients, under the supervision in the respective department, without any influence from parents or any other family members. Thus, the self-report by the patients tends to be effective in measuring Self-Esteem and QOL.
Limitation and future prospective
One of the limitations of the study was that though the questionnaires used in the study were not condition-specific and were modified from the generic QOL questionnaires for patients with UCLP. Hence, condition-specific questionnaires should be formed and used for evaluation. There was no Lie Scale to assess if the questions were manipulated.
The effect of dentofacial orthopedics, fixed orthodontic, and orthosurgical treatment on the self-esteem and QOL of patients with cleft lip and palate should be evaluated prospectively.
| Conclusions|| |
To conclude, the self-esteem of patients with UCLP and control subjects was similar among all three age groups. The cleft patients in the age range of 10–15 years had a feeling of being useless at times and this feeling cannot be ignored completely and in the age range of 21–25 years, expressed a need to be more respected and accepted. The overall QOL among the total sample of cleft patients in relation to the physical, emotional, school functioning domain was similar to the control group. Although the patients in all the domains had trouble at an early age (10–15 years) due to lower energy, fear, high absenteeism from school as compared to their normal counterparts but in later life, they devised ways to deal with their impairment and became confident. The cleft patients showed lower QOL in the social functioning domain as speech impairment and esthetics make them awkward in attending the social gathering. Hence, orthodontists must formulate a treatment plan and future follow-up appointments to minimize the high absenteeism from school and an effort be made to keep the appointment of such patients together for interaction to improve confidence and reduce fear. Thus, the results of this study demand a definite need for a psychologist/psychiatrist among the cleft care team to counsel these patients during orthodontic treatment for motivating them to gain self-respect and acceptance in society.
Take home message
The take-home message from the present study is that psychological factors such as lowered self-esteem and difficulties during social interactions should be identified during the management of patients with cleft lip and palate and thus necessitates the role of psychologists in the cleft team.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sousa AD, Devare S, Ghanshani J. Psychological issues in cleft lip and cleft palate. J Indian Assoc Pediatr Surg 2009;14:55-8.
] [Full text]
Turner SR, Rumsey N, Sandy JR. Psychological aspects of cleft lip and palate. Eur J Orthod 1998;20:407-15.
The World Health Organization Quality of Life assessment (WHOQOL): Position paper from the World Health Organization. Soc Sci Med 1982 1995;41:1403-9.
Robinson JP, Shaver PR, Wrightsman LS, Andrews FM, editors. Measures of Personality and Social Psychological Attitudes. San Diego: Academic Press; 1991. p. 753.
Stock NM, Stoneman K, Cunniffe C, Rumsey N. The psychosocial impact of cleft lip and/or palate on unaffected siblings. Cleft Palate Craniofac J 2016;53:670-82.
Kortelainen T, Tolvanen M, Luoto A, Ylikontiola LP, Sándor GK, Lahti S. Comparison of oral health-related quality of life among schoolchildren with and without cleft lip and/or palate. Cleft Palate Craniofac J 2016;53:e172-6.
Aravena PC, Gonzalez T, Oyarzún T, Coronado C. Oral health-related quality of life in children in chile treated for cleft lip and palate: A case-control approach. Cleft Palate Craniofac J 2017;54:e15-20.
Mariano NC, Sano MN, Curvêllo VP, de Almeida AL, Neppelenbroek KH, Oliveira TM, et al.
Impact of orofacial dysfunction on the quality of life of adult patients with cleft lip and palate. Cleft Palate Craniofac J 2018;55:1138-44.
Leonard BJ, Brust JD, Abrahams G, Sielaff B. Self-concept of children and adolescents with cleft lip and/or palate. Cleft Palate Craniofac J 1991;28:347-53.
Abebe ME, Deressa W, Oladugba V, et al. Oral Health–Related Quality of Life of Children Born With Orofacial Clefts in Ethiopia and Their Parents. The Cleft Palate-Craniofacial Journal 2018;55:1153-7.
Sagheri D, Ravens-Sieberer U, Braumann B, von Mackensen S. An evaluation of Health-Related Quality of Life (HRQoL) in a group of 4-7 year-old children with cleft lip and palate. J Orofac Orthop 2009;70:274-84.
Pisula E, Lukowska E, Fudalej PS. Self-esteem, coping styles, and quality of life in polish adolescents and young adults with unilateral cleft lip and palate. Cleft Palate Craniofac J 2014;51:290-9.
Berk NW, Cooper ME, Liu YE, Marazita ML. Social anxiety in Chinese adults with oral-facial clefts. Cleft Palate Craniofac J 2001;38:126-33.
World Medical Association General Assembly. Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects. Fortaleza, Brazil: World Medical Association General Assembly; 2013.
Agrawal K. Classification of cleft lip and palate: An Indian perspective. J Cleft Lip Palate Craniofac Anom 2014;1:78.
Varni JW, Seid M, Kurtin PS. PedsQLTM 4.0: Reliability and validity of the pediatric quality of life InventoryTM Version 4.0 generic core scales in healthy and patient populations. Med Care 2001;39:800-12.
Kramer FJ, Gruber R, Fialka F, Sinikovic B, Schliephake H. Quality of life and family functioning in children with nonsyndromic orofacial clefts at preschool ages. J Craniofac Surg 2008;19:580-7.
Foo P, Sampson W, Roberts R, Jamieson L, David D. General health-related quality of life and oral health impact among Australians with cleft compared with population norms; age and gender differences. Cleft Palate Craniofac J 2012;49:406-13.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]