Oral health is an imperative yet a frequently overlooked element that significantly alters the overall health and quality of life (QoL) [1
]. Traditionally, oral health has been defined as the absence of disease [2
]. However, this definition fails to consider the person’s values, understandings, and expectations [2
]. Furthermore, existing definitions of oral health mostly lack to address all the domains and elements that are integral factors of oral health [2
]. Therefore, the new definition acknowledges the versatile nature and attributes of oral health, which can be defined according to the World Dental Federation (FDI) as “Oral health is multifaceted, and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex” [3
]. Oral health-related quality of life (OHRQoL) reflects patients’ self-perception of their present oral health status in addition to its effect on their QoL [1
]. There has been an increasing interest in evaluating the effect of oral conditions on individuals’ QoL, which resulted in the emergence of several evaluation instruments [4
]. These instruments attempt to determine the extent that dental and oral disorders affect individuals’ daily lives [5
The most frequently used measures among children are the Child Perceptions Questionnaire (CPQ) [6
], the Child Oral Impacts on Daily Performances [8
], and the Child Oral Health Impact Profile [9
]. These measures differ in dimensions, age of targeted children, and methods of reporting OHRQoL (either by the children themselves or by a representative). These questionnaires comprise a variety of oral conditions like dental caries, malocclusion, and craniofacial anomalies [10
]. They were devised to measure the impact of oral health conditions on the daily lives of children and adolescents [10
The CPQ offers a comprehensive assessment in understanding OHRQoL. It also offers an extensive perspective on oral diseases and disorders in children. Consequently, the CPQ has the capability to help determine necessary treatments and selected therapies, progress monitoring, and evaluate the outcomes of therapies for affected children in several contexts like research purposes, clinical practices, and formulation of new policies [7
The CPQ for 8–10-year-old children (CPQ8–10
) was developed and validated in Canada [7
]. It showed good construct validity, excellent internal consistency, and acceptable test–retest reliability [7
]. It is one of the most commonly used scales to detect OHRQoL [10
]. It consists of 25 items distributed among 4 domains: oral symptoms, functional limitations, emotional well-being, and social well-being. It is self-reported by 8–10-year-old children using a 5-point Likert scale, and responses range from 0–4 for each item. Hence, total scores range from 0 to100, and higher scores indicate poorer OHRQoL [10
has been translated and validated in different languages such as Portuguese [4
], Danish [1
], Bosnian [11
], Spanish [12
], and Korean [13
]; all of which revealed the scale to be valid and reliable for use among 8–10-year-old children. However, it has not been translated into Arabic; therefore, the aim of this study was to develop an Arabic version of the CPQ8–10
by translating the English version into Arabic and assessing its psychometric properties.
The Arabic CPQ8–10 version was done by adjusting the translation of the following words: “ did you have “instead of “did you get” in questions 1, 2, 5, 7, 8, 9, 10, 13, 17 and 18 and by adjusting the words “felt” to replace “ did you have a feeling of …” in question 12. The most difficult concept that the children did not understand was the word “ulcer” Therefore, the phrase “sore spots” was added next to the word “ulcer” to clarify the meaning to the children.
shows participants’ demographic characteristics. There were no missing data in the questionnaires. Table 2
presents the descriptive statistics of participants’ CPQ8–10
Participants' demographic characteristics (n = 175)
Age, mean (SD)
Descriptive statistics of the overall and subscale scores of the CPQ8–10 (n = 175)
Participants’ overall CPQ8–10 scores and the domain scores were positively correlated with self-reported assessments of the influence of oral conditions on everyday life; i.e., the global rating items. The Spearman correlation coefficients were all significant (P < 0.001). Positive, moderate, and statistically significant correlations between oral health global rating, overall well-being global rating, and the total scale were observed (r = 0.5 and 0.6, respectively). A similar direction was seen with all the domains; the correlation ranged from 0.4 to 0.5 for oral health rating, and from 0.5 to 0.6 for overall well-being rating (Data not shown).
displays the descriptive statistics of participants’ CPQ8–10
scores with the dichotomized global ratings. The mean score for children reporting their oral health global rating as “fair/poor” was significantly higher than those reporting that their oral health rating was “very good/good.” Additionally, the mean score for children reporting that their overall well-being was affected “sometimes/a lot” by their oral or orofacial condition was significantly higher than those reporting that it was “not at all/a bit” affected. A similar direction was seen for the rest of the questionnaire domains.
Descriptive statistics for CPQ8–10 scores by global ratings (construct validity-convergent validity) (n = 175)
presents the overall and subscale CPQ8–10
scores according to the three groups. Of the three groups, group II had the highest scores. The differences among the scores were statistically significant. All the subscales showed the same direction of the differences between the three groups of children, except for the comparison between groups I and II in the oral symptoms domain, and the comparison between groups I and III in the social well-being domain.
Overall and subscale CPQ8–10 scores by clinical group (construct validity-discriminant validity) (n = 175)
scores according to the dental caries status. There was a significant difference in the total and subscale scores of the Arabic CPQ8–10
between children without dental caries and those with dental caries in one or more teeth. Children with untreated decayed teeth had higher overall CPQ8–10
scores than did caries-free children (P
< 0.001). The same direction of differences was observed in all the other subscale domains, with the mean scores being significantly higher in children with untreated decayed teeth compared to children without dental caries.
Overall and subscale CPQ8–10 scores by dental caries (construct validity-discriminant validity) (n = 175)
Regarding the CPQ8–10 scores according to the DAI, there was an association between the overall CPQ8–10 scores and severity of malocclusion. Children with highly desirable/mandatory orthodontic treatment needs had, on average, higher overall scores than did children with no/slight/elective orthodontic treatment needs (29.5 ± 15 vs. 18.1 ± 20.2, respectively). Additionally, the same direction of differences was observed in the subscale domains (P < 0.001). However, the oral symptoms subscale did not show significant differences between the children with highly desirable/mandatory orthodontic treatment needs and the children with no/slight/elective orthodontic treatment needs (6.3 vs. 5.7, respectively) (Data not shown).
The Arabic CPQ8–10, showed acceptable to excellent internal consistency. Cronbach’s alpha was 0.95 for the entire scale; and 0.78, 0.82, 0.86, and 0.92 for the oral symptoms, functional limitations, emotional well-being and social well-being domains, respectively. With regards to test–retest reliability, the ICC value was highest for the overall scale, 0.97 (95% CI 0.95–0.98). While for oral symptoms, it was 0.91 (95% CI 0.86–0.95), and 0.93 (95% CI 0.90–0.95) for the functional limitation. The ICC for emotional well-being and social well-being was 0.93 (95% CI 0.90–0.96), and 0.90 (95% CI 0.81–0.96), respectively (Data not shown).
This study examined the validity and reliability of the Arabic version of the CPQ8–10
. The instrument had appropriate construct validity (convergent and discriminant), internal consistency, and test–retest reliability among Arabic-speaking children aged 8–10 years. Every time an instrument is used in a new context or with a different group of individuals, it is necessary to re-establish its psychometric properties [4
]. This study showed that the psychometric properties of the Arabic version of the CPQ8–10
were suitable among this target group.
The study showed that overall CPQ8–10
scores were positively correlated with the global assessment of the influence of dental health on children’s everyday life. Furthermore, all the subscales showed the same direction of results in the three groups of children, confirming the relationships between the Arabic CPQ8–10
scores and global ratings. Specifically, the analysis confirmed that higher CPQ8–10
scores and subscale scores for each of the four domains were associated with poorer self-perceived oral and general health, which was similar to the findings associated with the original CPQ8–10
except for the correlation between the functional limitations and social well-being scores with the oral health rating in the original version [7
]. The correlation rank coefficient is considered moderate to high according to a study [25
]. Also, the findings of our study were higher than similar studies that were conducted [1
In this study the three groups were analyzed together in order to assess the correlation of the CPQ8–10
scores with the ratings for oral health and overall well-being. However, we don’t believe that the results were affected because usually children with different oral conditions would be able to rate their oral health and the extent of which their oral/orofacial condition would impact their overall well-being in a similar manner regardless of the oral health condition. Analyzing different groups together was also observed in the original version [7
However, our results contrasted those associated with the Danish version [1
], which showed that the relationship between the global ratings of oral health and CPQ8–10
scores was low concerning oral symptoms. This can be possibly explained by 8–10-year-old children’s familiarity with oral symptoms like loose primary teeth, which might have less of an impact on their daily lives. In addition, our results were not in agreement with the Brazilian version of the CPQ8–10
], which revealed non-significant associations between global ratings of oral health and the social well-being and functional limitations subscales. This might be explained by the differences in children's understanding of oral health and well-being that may be affected by age-related experiences related to oral health in 8–10 year old children. As they reported many problems related to natural processes such as primary teeth exfoliation and spaces prior to permanent teeth eruption which might simultaneously affect their QoL.
This study also demonstrated the critical impact of child’s oral and orofacial condition on their functional, emotional, and social well-being, and that children can give psychometrically acceptable accounts of that impact; thus, it performs well as a valid measure. Similarly, the original English version [7
], demonstrated a higher impact in children with orofacial conditions than among other children. However, the Danish version [1
] showed that children with orofacial conditions reported CPQ8–10
scores similar to those reported by healthy children. This can be explained by the chronicity of the cleft lip and palate condition, which may have allowed time for the affected children to adapt to their situation. It would be hypothesized that the scores of the three groups would be different, as a result of the different clinical conditions and severity. Children with cleft lip and palate would have the worst OHRQoL as a result of the functional limitations and psychological implications associated with the condition, while it’s hypothesized that children with caries would have a better OHRQoL, as the degree of distress due to caries would be somewhat less than that of cleft lip and palate. Moreover, the group with the best OHRQoL would be hypothesized to be the orthodontic treatment group, as they usually have good oral health, no caries and their level of distress would be the least of the three groups.
Our study showed good discriminant validity. Participants’ overall scores were associated with untreated dental caries status in all subscales, especially in the oral symptoms, functional limitations, and emotional well-being subscales, which is similar to the findings from the Korean study [13
]. The lesions in untreated dental caries could progress to become painful and distressing. Additionally, children’s experiences during the mixed-dentition period are related to physiological processes like dental eruption which can simultaneously affect their OHRQoL [4
]. According to other studies, children with more severe caries would experience a greater impact on their OHRQoL [5
]. However, in the Brazilian study, only primary dentition showed a significant correlation with overall CPQ8–10
]. Moreover, the English CPQ8–10
did not demonstrate discriminant validity between the groups studied i.e., a dental caries group and a cleft lip and palate group [7
]. The authors stated that this was likely because the children had previously received clinical and psychological treatment [7
The present study also showed that the overall scores were positively associated with the malocclusion status in all the subscales except for the oral symptoms subscale. Oral symptoms are likely associated with pain due to the presence of untreated dental caries or mechanical and frictional trauma from orthodontic appliances. Another possible explanation is that malocclusion severity due to a cleft lip and palate is a congenital disorder, which allows the children time to adapt to their situation. Further, affected children likely complain from food impaction and halitosis more so than physical pain. It is noteworthy to mention that social functioning and experiences might be more likely to show variability over time than the physical and emotional effects of oral and orofacial conditions, especially for young children owing to their rapidly evolving dental and facial features. In agreement with most previous studies, the CPQ8–10
allowed us to discriminate between groups with known differences in dental health [1
The internal consistency of a questionnaire shows whether all the items that make up the instrument are related to one another [17
]. The Cronbach’s alpha coefficient should be at least 0.7 to be considered satisfactory when comparing groups [24
]. For clinical applications, much higher values are required, with a minimum of 0.9 being desirable [24
]. The overall Cronbach’s alpha in the present study was 0.95, indicating a very high overall internal consistency. However, the Cronbach’s alpha for the oral symptoms domain was only satisfactory. This can be explained by how oral symptoms such as “sore spots” may show variability over time owing to the healing of the offending lesions.
Our study’s internal consistency was higher in comparison to that of the original questionnaire (0.89) [7
]. Moreover, the Cronbach’s alpha for the Arabic version of the CPQ11-14
was only satisfactory (0.81) [5
], as was the Cronbach’s alpha for the Lebanese cross-cultural adaptation of the Arabic version of the CPQ11-14
Concerning subscales, in comparison to other additional studies, the present study showed higher Cronbach’s alpha values (0.78–0.95) than did the Korean K-CPQ8–10
], the Canadian version (0.63–0.89) [7
], the Denmark version (0.57–0.82) [1
], the Australian version (0.65–0.88) [30
], and the Brazilian version (0.67–0.95) [4
The second questionnaire was administered after two weeks to prevent memory recall and to minimize clinical changes [10
]. The ICC is considered excellent when it is above 0.90, good when between 0.75 and 0.90, moderate when between 0.5 and 0.75, and poor when less than 0.5 [31
]. Our results showed excellent stability of the questionnaire for both the total scale and the subscales (0.90–0.97), which can be explained by the brief time between both administrations. The original instrument [7
] showed good reliability, except for the social well-being subscale, which showed variability in children’s social functioning and experiences over time.
In daily clinical situations, dental healthcare providers will most likely be concerned about oral symptoms when they assess patients’ oral health. As demonstrated in this study, subjective experiences should be given more weight and are as important as other clinical indicators when evaluating children’s OHRQoL. Our findings underline the value of considering broader aspects of children’s dental health rather than only the clinical indicators. Moreover, it is vital to gain insight into how oral conditions affect children’s daily functioning and future development.
This study had a few limitations. First, we used the DMFT guidelines to evaluate dental caries [18
], which might create problems with underestimating dental caries that may be present proximally and could not be viewed without the aid of radiographs. Moreover, although the number of participants was small in two of the groups, we do not believe that it could have affected the results. Seeing that orofacial clefts are relatively rare, also not many children between the ages of 8–10 are treated orthodontically. Therefore, the participants recruited were the maximum number that could be collected during the timeframe. Further, the length of time the questionnaire took to complete was quite long for young children, even with the help of an interviewer; therefore, a short form of the Arabic CPQ8–10
may be useful among large populations.
The strengths of the study lie in that the psychometric properties were evaluated using the same method as the original CPQ8–10
]. Moreover, our study included a larger sample size compared to the original (n
= 175 vs. n
= 68, respectively) to effectively evaluate measurement equivalence. In the present study, none of the children had received dental treatment, which is important in discriminating their QoL due to their oral condition rather than the dental treatment that the child was subjected to. Further, participants were consecutively recruited from clinical settings and they represented a wide range of Arabic nationalities. Moreover, the interview process for collecting the data prevented any external influence on children’s responses; thus, the study effectively reflected children’s own judgments and perceptions. Additionally, the data collected had no missing values.
In conclusion, the Arabic version of the CPQ8–10 was a valid and reliable instrument for measuring OHRQoL among 8–10-year-old Arabic-speaking children. The Arabic CPQ8–10 showed good convergent validity, discriminant validity, internal consistency, and test–retest reliability.
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