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An exploration of predictor variables for changes in self-esteem and self-concept as a result of orthodontic treatment

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An exploration of predictor variables for changes in self-esteem and self-concept as a result of orthodontic treatment

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Content AN EXPLORATION OF PREDICTOR VARIABLES FOR CHANGES IN SELF-
ESTEEM AND SELF-CONCEPT AS A RESULT OF
ORTHODONTIC TREATMENT

by

Ariana Shweish

____________________________________________________________________

A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CRANIOFACIAL BIOLOGY)

May 2008

Copyright 2008 Ariana Shweish
ii

DEDICATION
To my Family:
Mahmoud Shweish
Selma Shweish
Alan Shweish
Ava Shweish
Omar Shweish

iii
ACKNOWLEDGEMENTS
A special thank you to:

Dr. Robert Keim

Dr. Richard Clark

Dr. Jane Forrest

Dr. Mahvash Navazesh

Ursula Czoik

USC Graduate Orthodontic faculty and staff

iv
TABLE OF CONTENTS

Dedication ii
Acknowledgements iii
List of Tables v
List of Figures vi
Abstract viii
Chapter 1: Introduction 1
Chapter 2: Review of Literature 3
Chapter 3: Hypotheses 19
Chapter 4: Subjects and Methods 20
Chapter 5: Results 31
Chapter 6: Discussion and Conclusions 71
Bibliography 76

v
LIST OF TABLES
Table 1: TSCS: 2 Scores 23
Table 2: Phase of Treatment 31
Table 3: Patient's Gender 32

Table 4: Patient's Ethnicity 33
Table 5: Income Category 34
Table 6: Father's Level of Education 35

Table 7: Mother's Level of Education 36

Table 8: Descriptive Statistics 37

vi
LIST OF FIGURES
Figure 1: Phase of Treatment 31
Figure 2: Patient’s Gender 32
Figure 3: Patient’s Ethnicity 33
Figure 4: Income Category 34
Figure 5: Father’s Level of Education 35
Figure 6: Mother’s Level of Education 36
Figure 7: Inconsistent Responding 38
Figure 8: Self Criticism 39
Figure 9: Faking Good 40
Figure 10: Respond Distribution 41
Figure 11: Total Self-Concept 42
Figure 12: Conflict 43
Figure 13: Physical Scale 44
Figure 14: Moral Scale 45
Figure 15: Personal Scale 46
Figure 16: Family Scale 47
Figure 17: Social Scale 48
Figure 18: Academic Scale 49
Figure 19: Identity 50
Figure 20: Satisfaction 51
Figure 21: Behavior 52
Figure 22: Total Self-Concept changes, Phase of Treatment, Patient Ethnicity 55
vii
Figure 23: Physical Scale changes, Phase of Treatment, Patient’s Ethnicity 56
Phase 24: Identity changes, Phase of Treatment, Patient’s Ethnicity 57
Figure 25: Conflict changes, Phase of Treatment, Patient’s Ethnicity 58
Figure 26: Inconsistent Responding, Phase of Treatment, Patient’s Ethnicity 59
Figure 27: Total Self-Concept, Phase of Treatment, Income Category 60
Figure 28: Physical Scale, Phase of Treatment, Income Category 61
Figure 29: Identity, Phase of Treatment, Income Category 62
Figure 30: Conflict, Phase of Treatment, Income Category 63
Figure 31: Inconsistent Responding, Phase of Treatment, Income Category 64
Figure 32: Total Self-Concept, Patient’s Ethnicity, Income Category 65
Figure 33: Conflict, Patient’s Ethnicity, Income Category 66
Figure 34: Physical Scale, Patient’s Ethnicity, Income Category 67
Figure 35: Identity, Patient’s Ethnicity, Income Category 68

viii
ABSTRACT
Introduction: The benefits of orthodontic treatment often go beyond improving
patients’ dental appearance and leads to an improvement in their self-esteem and self-
concept. However, the beneficial psychological effects may vary from patient to patient
due to certain predisposing factors. Purpose: To evaluate whether certain independent
variables allow for prediction of the psychological outcome of conventional orthodontic
treatment. Methods: A sample of 140 adolescent patients grouped by stage of
orthodontic treatment (pre-, mid-, and post- orthodontic treatment). Self-esteem and self-
concept were measured by the Tennessee Self-Concept Scale II. Results: The
Multivariate Analysis of Variance indicated that the only combination of predictor
variables that demonstrated significant interactions was the combination of Treatment
Phase, Ethnicity, and Income class (F=2.560, p<.044). Conclusions: Changes in Self-
Esteem and Self-Concept are different for different socioeconomic backgrounds and
different races. Lower income groups and Blacks benefit the most, then Hispanics, then
Whites; Asians did not benefit.

1
Chapter 1: Introduction
Reported benefits of orthodontic treatment include a more physiologic occlusion,
enhanced masticatory efficiency, and a dental arrangement that more readily lends itself
to hygienic conditions. In spite of the many physiologic benefits of orthodontic
treatment, the majority of patients seek orthodontic care for the purposes of improving
their facial and dental appearance.

The physiologic benefits of orthodontic treatment have been well-documented in the
scientific literature but few studies have been conducted that address the psychological
benefits. A large body of literature in social psychology validates the proposition that
improved facial appearance bestows a myriad of psychological benefits on patients. A
thesis by Dr. Firoozeh Rahbar, conducted in 2000-2001, at the University Of Southern
California School Of Dentistry Graduate Orthodontic Clinic examined 330 subjects for
improvements in self-esteem and self-identity utilizing a standardized psychological
instrument, the Tennessee Self-Concept Scale II. Results of this preliminary study
indicated that: 1. The patient’s view of their own physical appearance was within normal
limits initially and improved with orthodontic treatment (p <.05) 2. The patients’ self-
identity scores were within normal limits for all groups initially and improved upon
beginning orthodontic treatment (p<.01). These results “underscore the beneficial nature
of orthodontic treatment in the psychological well being of adolescents”.

The benefits of orthodontic treatment often go beyond improving patients’ dental
appearance and dental health. Patients usually feel that they look better after orthodontic
2
treatment, which can lead to an improvement in their self-esteem and self-concept.
However, the beneficial psychological effects that result from orthodontic treatment may
well vary from patient to patient due to a number of different predisposing
factors.variations in treatment seeking exist across ethnic groups. This suggests that
ethnic and cultural factors influence people’s concern with their appearance. (Reichmuth,
Greene et al. 2005). Socioeconomic status also affects the development of self esteem in
children and adolescents.

Muijs (1997) found a positive correlation between self esteem and parental
socioeconomic status in school children. This study demonstrated that the lower a child’s
socioeconomic status, the lower his or her self-esteem (Muijs 1997). The study proposed
for this thesis will investigate the validity of various predictor variables in estimating the
impact of orthodontic treatment on self-esteem and self-identity. Such variables may
include subject age, gender, ethnicity, geographic locale, and socio-economic status.

Purpose of the Study
The purpose of this study is to evaluate whether certain independent variables allow for
prediction of the psychological outcome of conventional orthodontic treatment. It will
specifically address the areas of self-esteem and self-identity as measured by the
Tennessee Self-Concept Scale II, a standard, commercially available psychological
instrument and will assess the validity of a variety of hypothesized predictor variables to
include, but not limited to, subject age, gender, ethnicity, geographic locale, and socio-
economic status.
3
Chapter 2: Review of Literature
Self-Esteem and Self-Concept, Definitions:
Dann et al. (1995) defined self-concept as a “relatively stable set of attitudes that reflects
a description and evaluation of one’s own behavior and attributes.” Moreover, the
authors stated that self-concept defines an individual’s organization of self-attitudes,
including perceptions and beliefs with respect to body structure and appearance, referred
to as “body image” (Dann, Phillips et al. 1995). Self-concept or self-identity is the
mental and conceptual understanding and persistent regard that sentient beings hold for
their own existence. In other words, it is the sum total of a being's knowledge and
understanding of his or her self. The self-concept is different from self-consciousness,
which is an awareness or preoccupation with one's self.

Components of the self-concept include physical, psychological, and social attributes,
which can be influenced by the individual's attitudes, habits, beliefs and ideas. These
components and attributes can be condensed to the general concepts of self-image and the
self-esteem. Nathaniel Branden in 1969 briefly defined self-esteem as "…the experience
of being competent to cope with the basic challenges of life and being worthy of
happiness". This two-factor approach, as some have also called it, provides a balanced
definition that seems to be capable of dealing with limits of defining self-esteem
primarily in terms of competence or worth alone.

Branden (1969). For the purposes of
empirical research, psychologists typically assess self-esteem by a self-report
4
questionnaire yielding a quantitative result. They establish the validity and reliability of
the questionnaire prior to its use.

Psychological impacts of malocclusion
Orthodontists are becoming aware of the importance of patient’s own perceived need for
orthodontic treatment, and evaluate the improvement that orthodontic treatment might
bring to patients’ daily lives.

Malocclusion has often been the cause of bullying among schoolchildren. DiBiase (2001)
found that the persistently bullied child represents a certain psychological type. These
children have poorly developed social skills and they have a submissive nature. Some of
the factors that cause bullying are facial form and physical appearance. Teasing because
of dental appearance seamed to be most hurtful. There is little evidence of a significant
improvement of self esteem following orthodontic treatment in children. There is more
evidence of a marked increase of body concept in adults following orthodontic treatment.
(DiBiase and Sandler 2001). O’Brian et al. also found that malocclusion has a negative
impact on the oral health related quality of life of adolescents. . (O'Brien, Benson et al.
2007)

Onyeaso et al. did a series of studies in Nigeria in 2005 evaluating the psychological
effects of malocclusion on Nigerian children. One of the studies analyzed the
psychosocial implications of malocclusion in Nigeria. Their sample consisted of 614
secondary school children aged 12-18 years. They used a questionnaire that had questions
5
about body image and self-esteem in relation to dental appearance. Subjects rated only
the teeth significantly least satisfactory among other twelve items of body image.
Subjects with crowding of the maxillary and mandibular incisors had the lowest ratings.
Subjects with minor malocclusion showed significantly higher scores. Their results also
showed that schoolmates' teasing occurred more often in children with malocclusion.
Subjects with malocclusions that were more obvious in the anterior region also expressed
a negative perception of their facial form. These malocclusions included irregularities of
up to 1 mm and more, spacing of both maxillary and mandibular incisor segments,
midline diastema, crowding (especially of the mandibular incisor segment) and anterior
open bite. Their conclusions were that those particular malocclusions may adversely
affect body image and self-concept of Nigerian adolescents.(Onyeaso and Sanu 2005)

Social psychology and facial form
Professional assessment of the need for orthodontic treatment requires knowing whether
the malocclusion has adverse effects on the oral health and the social and psychological
well being of the patients. The motivation to seek orthodontic treatment appears to be
strongly affected by their will to improve their facial appearance. (Keim, Bishara
2001)There is a body of opinion that patients’ level of satisfaction with their facial
appearance may significantly affect for their self esteem.

It has also been found that minor variation in tooth positions could determine the overall
aesthetic impression of a face. The teeth also seem to be an important target for bullying
among school children. It has been noticed that children themselves see peers who are
6
physically attractive as more socially attractive and unattractive children are more likely
to be the victims of teasing. Onyeaso states that “In deed unacceptable dental appearance
including deviant dental characteristics are a phenomena that may affect many facets of
social interaction including career advancement, peer group acceptance, and negative
effect on self concept.”

This author also studied a group of Nigerian orthodontic patients and looked into the
psychological effects of malocclusion. In this study (Onyeaso, Utomi et al. 2005) the
authors noticed that 27% of the patients were depressed when they first noticed their
malocclusions. They also found that about 50% of these subjects felt that their
malocclusion negatively affected their facial appearance. This in turn affected their social
lives in different ways; not laughing in public, not forming close relationships and not
meeting people in public. They concluded that due to the considerable psychological
effects of malocclusion on these patients, professional counseling is needed to improve
theses patients’ self – esteem and social interactions.

A study done by Rutzen (1973) assessed patients 5 years after finishing orthodontic
treatment. The compared those 250 subjects with 65 control subjects who were diagnosed
with malocclusion but did not undergo orthodontic treatment. They found that those who
were treated showed a noticeably more positive assessment of their appearance. Those
subjects also mentioned oral features more frequently as their most attractive
characteristics. The treated patients also achieved higher levels of occupational status,
even though the groups did not differ in social class or educational levels. (Rutzen 1973)
7
Self-perception of malocclusion and socioeconomic status
Studies have suggested gender, age and socio-economic background as factors affecting
the self-perception of dental appearance. High social class individuals and females are
usually more critical of their facial appearance in general and especially of their dental
appearance than younger children. (Horowitz, Cohen et al. 1971; Jenkins, Feldman et al.
1984).

Another study looked into the effects of self-perception of malocclusion and its relation
to age, gender and areas of living (Abu Alhaija, Al-Nimri et al. 2005) This study assessed
the factors affecting self-perception and the demand for orthodontic treatment among
north Jordanian school children. The results showed a great effect of gender and age on
the self-perception of malocclusion and provided information regarding the effect of
rural/urban areas of living and gender on the uptake of orthodontic treatment.

Reichmuth et al. (2004) looked into the impact of ethnicity and socioeconomic status on
children’s occlusal perception. The authors researched whether demand for orthodontic
treatment was uniform for different ethnic and socioeconomic groups. Their study
consisted from 3 groups that were different in location, payment source and ethnicity.
The first group consisted of 150 subjects from the Bronx, NY with a 69% ethnic
minority. The second group had 100 subjects from Seattle, Wash with a 92% ethnic
minority. The third group had 88 patients from Seattle, Anchorage (Alaska) and Chicago
with 22% ethnic minority. The first 2 groups had started or waiting to start orthodontic
treatment in publicly funded clinics, the third group subjects were patients at private
8
orthodontic offices. The third group subjects were also about 2 years younger than the
first two groups. Their results stated that “Desire for treatment was higher among
children in the publicly funded clinics and among black children than whites or Asian
Americans. Children in publicly funded clinics rated themselves as having worse
occlusions as determined by anterior crowding, overbite, overjet, diastema, and open bite.
Children in the Bronx clinic accepted a wider range of occlusion as attractive. Stage of
treatment affected judgments of attractiveness. Vicarious experience with orthodontics
through parents or siblings made children more tolerant of dentofacial disharmony, with
more favorable ratings of malocclusion in this group than among children who had no
family experience with orthodontics. Hispanic and mixed-ethnicity children rated
themselves more negatively on all dimensions.” The authors concluded that clinicians
must understand the important role of social, ethnic and familial factors of patients’ lives
in their desire to seek orthodontic treatment, and also the effect of these factors on
patients’ motivation and their expectations throughout orthodontic treatment.
(Reichmuth, Greene et al. 2005)

Another study was done in the UK be Burden et al in 1995. Their subjects were
adolescents (15 and 16 years old) and they were divided into three groups: ‘no aesthetic
need’ for orthodontic treatment, ‘border line aesthetic need’ and ‘definite aesthetic need’
for treatment. Their results showed that children who have similar dental aesthetics have
similar perceptions of their malocclusion. The different social backgrounds or different
genders did not show a difference in those results. (Burden and Pine 1995)

9
Emira et al in 2004 looked into Tanzanian children’s perception of their dental
attractiveness. Their subjects were 9 to18 year-old public school children, which
represents a wide range of social backgrounds. Their results indicated that 38% of the
sample said they needed orthodontic treatment. Around 30% of the children were not
happy with the arrangement of their teeth, and 85% were aware that well aligned teeth
play an important role in the overall facial appearance. The authors suggested that more
studies should be done regarding different areas of the country, especially rural areas,
which represents different socioeconomic status. (Mugonzibwa, Kuijpers-Jagtman et al.
2004)

Psychological Aspects of Facial Form
The facial region plays a major role in determining physical attractiveness. Senna et al.
assessed the capability of successfully managing interpersonal relationships in young
adults and how that might be related to the facial characteristics. This study looked into
the relationship between facial skeletal class and expert-rated interpersonal skill in young
Italian adults. This study found in conclusion that improvements on the facial region by
orthodontic treatment might have a significant beneficial impact on the capacity of
managing successfully interpersonal relationships in young adults, especially with
females since because they are more sensitive to this issue. Moreover, this study
contributed to understand the structural determinants of the perceived beauty, which
might be helpful when planning specific surgical and/or orthodontic intervention.(Senna,
Abbenante et al. 2006)
10
Shaw et al. had similar results and they stated that “Physical appearance, including the
dentition, is an important aspect of human activity, as one aims to be liked, respected or
accepted by those around him/her. The uptake of orthodontic treatment is influenced by
the desire to look attractive, the self-perception of dental appearance, self-esteem, gender,
age and peer group norms” (Shaw, O'Brien et al. 1991)

Graber (2000) stated that “Orthodontics now is viewed more clearly as a health service
dedicated to establishing emotional and physical wellness. Dental and facial distortions
create a disability that can influence physical and mental health. Appropriate treatment
can be important for the patient’s well-being.”

Similar discussions were reported by Murphy (1976) who reported that people who seek
orthodontic treatment have a more negative feeling about their teeth than people who do
not seek treatment. Graber also suggested that this negative effect of the dentofacial
disfigurement on the psychological well-being of children is accepted by most
professional and even lay people. In spite all that, arguments can still present as to
whether or not facial esthetic impairment is sufficient cause for seeking orthodontic
treatment. Here is how Graber explained both points of view. The rationale behind
treatment recommendation for dentofacial impairment is that the result of malocclusion
on esthetic appearance negatively affects other people’s reaction. This could lead to low
self-esteem and poor social adjustments. Graber explains the opposing rationale, saying
that psychologically healthy people can adjust to their appearance, and that only people
with low self esteem can be negatively affected by their malocclusions. Graber also
11
discussed the “Modern society” and how it does not want to deny treatment to a child if
there are potential social and psychological benefits. He stated that even with the high
cost of orthodontic treatment, and the little coverage by insurance companies, parents
may still “choose to provide orthodontic treatment to their children to enhance
dentofacial esthetics, alleviate psychological problems, improve function, or prevent
future dental disease.”

Treatment and Physical Appearance
An increased concern for dental appearance during adolescence has been observed. The
decision to start orthodontic treatment nowadays is primarily affected by the physical
appearance and the psychological well being. An unacceptable dental appearance has
been linked to various negative social interactions such as difficulties in peer-group
acceptance, self-concept and career advancement. This is because of the awareness of the
relationship between malocclusion and satisfaction with personal appearance. A study
done in Nigeria (Onyeaso and Sanu 2005) looked into the relationship between the
adolescents’ awareness of their malocclusion, their satisfaction with their dental
appearance and the severity of their malocclusion. They found a significant negative
correlation between awareness of malocclusion and satisfaction with dental appearance.
Severity of malocclusion was not significantly related.

Ando et al. (1961) found that uncooperative patients often have poor relationships with
parents and tangentially to personality, age, or sex. They found that orthodontic
treatment creates a stress situation of variable intensities. Their conclusions were: “the
12
stress did not correspond to the pain and discomfort actually involved in the orthodontic
treatment. It appeared to be related to the emotional state of the child, who tended to
project his own problems and anxieties on treatment.” (Ando 1961) Klima et al. (1979)
divided his subjects into 4 groups: orthodontic retention patients, prospective orthodontic
patients, a population sample, and mothers of prospective patients. They found that there
was a significant difference between prospective orthodontic patients' self-concept
importance and their mother's perception of self-concept importance. There teen-agers
placed more emphasis on their self-concept than did their mothers. The authors suggest
that this tends to improve the young patient’s attitude toward treatment, and that people
attribute personal worth to others on basis of facial attractiveness. (Klima, Wittemann et
al. 1979)

Studies in the area of patients’ own perceptions of improved self-esteem show that most
individuals feel that their self-confidence has improved along with heir improved
appearance, (Oullette, 1979). In order to emphasize the importance of evaluating patient’s
emotional status, Kiyak et al (1985) evaluated the emotional shift among patients who
need orthognathic surgery but did not chose to do it and patients who underwent
orthognathic surgery. They study found that patients who chose conventional
orthodontics only were particularly vulnerable to emotional problems because their
treatment was longer and more complex. The authors realized the “importance of
continued psychological support for both orthodontic and surgical patients throughout
their course of treatment.” (Kiyak, McNeill et al. 1985).
13
Nicodemo et al studied self-esteem changes in class III patients before and after
orthognathic surgery. Their sample consisted of 29 patients ages between 17 and 46 years
old. All of these patients had Angel class III malocclusions and they needed orthognathic
surgical treatment. They compared their findings in 2 different stages during surgery:
preoperative (orthodontic preparation) and postoperative (6 months after the surgery).
Their found that more female patients presented with an improved self-esteem than males
after the surgery. They also presented with less depression than preoperatively. These
results confirm the idea that the benefits gained from the changes in appearance reflect
the patients’ desire to recover self-esteem. The authors stated that “From infancy
onwards, interpersonal relationships perform a fundamental role in the formation of a
positive or negative concept of self, influencing aperson’s emotional state, including
depression. A growing number of studies regarding quality of life in the area of health
demonstrate that the perception of an individual regarding self, of their physical and
emotional state, is an important indicator in treatment management”(Nicodemo, Pereira
et al. 2008)

Several other studies have concluded that the psychological benefits from orthognathic
surgery include an improvement in self-esteem and self-confidence, positive changes in
patient’s personality and improved interpersonal relationships. These studies also found
that the general health-related quality of life and the psychological functions were
significantly improved after orthognathic surgery was performed.(Motegi, Hatch et al.
2003)

14
Dennington (1975) has reported that the mere placement of orthodontic appliances results
in improved self-esteem. This improvement may be the patient’s reaction to his or her
expectations of an improved appearance.

In contrast, Graber (1980) suggested that treatment regimens that improve facial
appearance appear to have concomitant improvements in esthetic self-satisfaction and
body image. Graber states that “more precise research is required in this area to define
those changes which contribute most to improved self-esteem”.

Psychological and social effects of orthodontic treatment
One of the assumed benefits of early orthodontic treatment is the positive psychological
outcome. Obrian et al evaluated evaluate whether early orthodontic treatment with the
Twin-block appliance for the developing Class II Division 1 malocclusion resulted in any
psychosocial benefits. Their subjects were between the age of 8 and 10 years with Class
II Division 1 malocclusions randomly selected and treated with Twin-block appliances.
They found that that early treatment with Twin-block appliances resulted in an increase
in self-concept and a reduction of negative social experiences. Other treatment benefits
that could be related to improved self-esteem were found in these patients.(O'Brien,
Wright et al. 2003)

Similar results were found in a study done by Tung et al in 1998 where the authors
looked into the psychological issues that should be considered when making a decision
about the timing of orthodontic treatment, and whether it should be done in one or 2
15
phases. The authors found that “younger children are good candidates for Phase I
orthodontics, have high self-esteem and body-image, and expect orthodontics to improve
their lives. White children who have been referred for Phase I orthodontics appear to
have a narrower range of aesthetic acceptability than minority children.”(Tung and Kiyak
1998)

A number of studies have confirmed what is intuitively obvious, that severe malocclusion
could be a social handicap. A very common caricature of a person who is not too bright
often includes extremely protruded teeth. A pleasing smile, which indicates well-aligned
teeth, carry positive status at all social levels. On the other hand, irregular or protruding
teeth are a reason for teasing and they carry negative social status. (Shaw 1981; Shaw,
Rees et al. 1985)

Tests of the psychological reactions of subjects to different dental conditions show that
cultural differences smaller than usually anticipated. Farrow (1993) found that a dental
appearance pleasing to Americans was also pleasing to Australia and Germany, and a
dental appearance that was carried out with a social handicap drew the same response in
these other countries. Protruding incisors are judged unattractive within populations
where most individuals have prominent teeth, just as they are in less protrusive groups.
(Farrow, Zarrinnia et al. 1993)

Proffit (2000) stated that “there is no doubt that social responses conditioned by the
appearance of the teeth can severely affect in individual’s whole adaptation to life.”
16
Proffit used the term ”handicapping malocclusion” describing individuals who are
affected constantly by their teeth. The degree of the psychological handicap is not
directly proportional to the anatomic severity of the problem. (Proffit, W. R. 2000)

Kenealy (1989) also found that the impact of a physical defect on patients is strongly
influenced by their self-esteem. The same degree of anatomic disfigurement can be
merely a condition with no consequences on one individual, greatly affect someone else.
(Kenealy, Frude et al. 1989)

Dann et al evaluated early treatment for children with Class II malocclusion and the
impact of the treatment in improving social acceptance and hence self-concept. Their
subjects consisted of 208 class II patients with increased overjet ages between 7 and 15
years. These patients listed their reasons for seeking orthodontic treatment as: 1.
Appearance of teeth, 84%, 2. Advice of dentist, 52%, 3. Appearance of face, 41%. The
authors found that those patients had a low self-esteem to begin with, but no change in
mean self-concept scores of these children during early treatment. Their finding suggest,
in contrast to previous studies, that “ children with Class II malocclusion do not generally
present for treatment with low self-concept and, on average, self-concept does not
improve during the brief period of early orthodontic treatment.” (Dann, Phillips et al.
1995)

Tung et al. (1998) studied the psychological influences that should be considered to
determine the timing of orthodontic treatment. They stated that “psychologic
17
development during the preadolescent and adolescent stages may influence the child's
motive for, understanding of, and adherence to treatment regimens” their results suggest
that it is better to start at younger ages because younger children have high self-esteem
and expect the orthodontic treatment to improve their lives.(Tung and Kiyak 1998)

Similar results were found in a study done by Albino et al. in1994. This study analyzed
93 children with mild to moderate malocclusions. The subjects were divided into groups
according to the timing if the start of orthodontic treatment. They studies subjects’
responses to psychological and social measures at different times: before treatment,
during treatment, and three times after completion of treatment, the last occurring one
year after termination. The authors found that “parent-, peer-, and self- evaluations of
dental-facial attractiveness significantly improved after treatment, but treatment did not
affect parent- and self-reported social competency or social goals, nor subjects’ self-
esteem.”(Albino, Lawrence et al. 1994)

Varela et al (1995) did a longitudinal prospective study of 40 adult patients who had been
treated with conventional orthodontic treatment for their moderate to severe
malocclusions. The authors stated that “considerable controversies exist about the
psychological repercussions of malocclusions on affected persons and the positive effect
of treatment on patients’ body image and self-concept.” These patients completed a series
of psychological questionnaires at three different measurement intervals: 1) before the
start of treatment, 2) 6 months afterwards, and 3) from 1 to 4 weeks after the end of
active treatment. The results showed that the group that consisted of patients at 6
18
months after orthodontic treatment resulted in a more noticeable overall body image
improvement. Facial body image did not change. They suggested that “longer follow-up
is needed to evaluate the persistence of results and the eventual occurrence of any late
changes in self-esteem.” (Varela and Garcia-Camba 1995)

Because of the great controversy regarding the impact of orthodontics on self-esteem and
self-confidence, a number of other variables were studied. Giddon (1995) defined
esthetics as relating to feeling, and perception as the organization of environmental
stimuli. The authors evaluated several physical, psychological, and social factors that
affect perceptual judgments and described the development and maintenance of self-
image and /or concept. They discussed perceptions of dentofacial attractiveness on
motivation for seeking orthodontic care.(Giddon 1995) Another research done by al
Yami et al. (1998) evaluated the relation between the Index of Orthodontic Treatment
Need and the Aesthetic Component of the Index. They stated that “There was a highly
significant influence of orthodontic treatment on facial and dental aesthetic scores in the
group which was not treated orthodontically at the first observation.” (al Yami, Kuijpers-
Jagtman et al. 1998)

The conclusion, supported by a large body of evidence, and the continuing demand for
orthodontic treatment to improve facial and dental appearance, is that orthodontics does
indeed improve the quality of life for patients. It can be particularly valuable to children
who are suffering from harassment or discrimination because of their appearance.

19
Chapter 3: Hypotheses
With respect to the research questions, the following null and alternative hypotheses were
tested.
1. H
o
: There is no significant difference in mean self-concept scores between
groups as defined by socioeconomic status.
H
a
: Self-esteem and self-concept scores differ significantly between the
different socioeconomic groups.
2. H
o
: None of the independent variables identified in the study significantly
predict changes in self-esteem scores.
H
a
: At least one of the independent variables identified in the study is a
significant predictor of changes in self-esteem as a result of orthodontic
treatment.

20
Chapter 4: Materials and Methods
Human Subjects/ Patients
A sample of 140 participants was selected arbitrarily from the active patient pool of the
Graduate Orthodontic Clinic at the University of Southern California and from the Oral
Health Center at the University of Southern California. The sample was divided into
three groups: Group I consisting of pre-orthodontic patients, Group II mid-treatment, and
Group III post-treatment/retention.

All participants received the child form or the adult form of the Tennessee Self-Concept
Scale-2
nd
edition (TSCS: 2) according to their age. Prior to distributing the questionnaire,
the examiner discussed the study with each participant and their parent(s). An informed
consent for the human subjects was also explained and signed by the patient and/or the
legal guardian. Dr. Shweish, administered the questionnaire, and the subjects were given
15-20 minutes to complete it.

Questionnaire
The Tennessee Self-Concept Scale-2
nd
edition, revised in 1996 assesses an individual’s
self-concept along a number of dimensions: Physical, Moral, Personal, Family, Social
and Academic/Work. The TSCS:2 also provides a Total Self Concept score as a measure
of global self-concept, in addition scale assessing how the individual describes his or her
identity (Identity), how the person feels about his or her perceived self-image
(Satisfaction) and the individual’s perception of his or her own behavior (Behavior).
21
Individuals are asked rate each item on a 5-point scale from ‘always false’ to ‘always
true’ and T-scores are generated for the Total score and the sub-scores. The following
was used by Dr. Rahbar in her thesis, and is taken from information presented in the
Second Edition Manual developed for the Tennessee Self-Concept Scale (TSCS) (Fitts
and Warren).

The Tennessee Self-Concept Scale (TSCS) was originally developed to fill the need for a
scale that would be simple for the respondent, broadly applicable, and multidimensional
in its description of self-concept. The TSCS has allowed for the accumulation of
knowledge about the relationship between self-concept and human behavior to be tied
together with a common instrument. The success of the TSCS in meeting the needs of
clinicians and researcher in this area is reflected in the large number of published
references to the TSCS since its development in the 1960’ (Fitt, Warren). By 1988, the
scale averaged more than 200 references annually in a wide variety of publications in the
fields of education, psychology, and the social and health sciences.

The TSCS: 2 have been restandardized on a nationwide sample of over 3,000 individuals
ranging in age from 7 to 90 years old. There are two forms of the TSCS: 2- the Adult
Form and the Child Form. The Adult Form has 82 items and the Child Form has 76
items. Both forms consist of self descriptive statements that allow the individual to
portray his or her own self-picture using five response categories- “Always False”,
“Mostly False”, “ Partly False and Partly True”, “ Mostly True”, and “ Always True”.
The Forms can be administered individually and completed in 10 to 20 minutes. The
22
Adult Form can be completed by individuals who can read at approximately a third grade
level or higher, and it is standardized on 1,944 individual aged 13-90. The Child Form
can be completed by children who can read at a second-grade level or higher, and it is
standardized on 1,784 children aged 7-14.

Scoring was done by hand and it yields the same score for both the Adult Form and the
Child Form. The basic scores are two Summary Scores, Total Self-Concept and Conflict,
and the Six Self-Concept Scales (Physical, Moral, Personal, Family, Social, and
Academic/Work). There are four Validity Scores for examining response bias:
Inconsistent Responding, Self-Criticism, Faking Good, and Respond Distribution. There
are also three Supplementary Scores, which involve combining items from some of the
basic scales in a way that reflect the original theoretical thrust of the test. The
supplementary scores are Identity, Satisfaction, and Behavior. The TSCS:2 Adult Form is
appropriate for adolescents in high school and for adults (ages 13 and older. The TSCS:
2 Child Form is appropriate for use with children in elementary and junior high school
(ages 7 through 14)

23
Table 1: TSCS: 2 Scores
Validity Scores Summary Scores Self-Concept
Scales

Supplementary
Score
Inconsistent
Responding (INC)
Total Self-Concept
(TOT)
Physical Self-
Concept (PHY)
Identity
(IDN)
Self-Criticism
(SC)
Conflict (CON) Moral Self-
Concept (MOR)
Satisfaction
(SAT)
Faking Good
(FG)
Personal Self-
Concept (PER)
Behavior
(BHV)
Response
Distribution (RD)
Family Self-
Concept (FAM)

Social Self-
Concept (SOC)

Academic/ Work
Self-Concept
(ACA)

24
Variables Studied:
1. Validity Scores- The validity scores are designed to identify defensive, guarded,
socially desirable, or other unusual or distorted response patterns
a. Inconsistent Responding (INC)- This score indicated whether there is an
unusually wide discrepancy in the individual’s responses to pairs of items
with similar content
b. Self-Criticism (SC) – these items are mildly derogatory statements, which
consist of common frailties that most people would admit to when responding
candidly. Scores between 40 and 70T indicate normal, healthy openness and
capacity for self- criticism
c. Faking Good (FG) - the scale is an indicator of the tendency to project a
falsely positive self- concept.
d. Response Distribution (RD) – this score is highly correlated with the pattern
of the individual’s responses as distributed across all five available response
options for the each TSCS: 2 items. It is interpreted as a measure of certainty
about the way one sees oneself.

Profile Patterns:
The TSCS: 2 scores for most individuals tend to fall between 40T and 60T. These
relatively “flat “ profiles indicate no disturbance or only mild disturbances in self-
concept. In the absence of unusual validity scores, high scores between 60T and 70 T
on the TSCS: 2 indicate areas of particular individual strength. Well-rounded
individuals who are consistently self- confidant and flexible obtain scores in this
25
range on all TSCS: 2 scales. Specific disturbances in self-concept are indicated by
low scores below 40T.

2. Summary Scores:
a. Total Self-Concept (TOT)-
Reflects the individual’s overall self-concept and associated level of self-
esteem. Individuals with high TOT scores (> 60 T) tend to define themselves as
generally competent and to like themselves. They feel that they are people of
value and worth; they have self-confidence and thy act accordingly. People with
high TOT scores generally view themselves as having many positive aspects that
can be called upon to compensate for threats or injury to specific aspects of their
self-image. Individuals with low TOT scores (< 40) are doubtful about their own
worth. They may see themselves as undesirable but they are cautious and
conservative in their self- descriptions. . They often feel anxious, depressed and
unhappy, and exhibit little self-confidence.

b. Conflict (CON)-
This score compares the extent to which an individual differentiated his or her
self-concept by assertion through agreement with positive items. When the CON
score is above average or high, the individual is focusing more on assertion than
on negation, this may indicate a balance self-view or is may signal the presence or
emergence of conflict. Individuals with low scores are focusing more on who
they are not than on who they are. These individuals are likely to be defensive.
26

3. Self –Concept Scales
a. Physical Self-Concept (PHY)-
This score presents the individual’s view of his or her body, state of health,
physical appearance, skills and sexuality. Because it is always on display for
evaluation, physical appearance is highly associated with global self-esteem
across the life span. High PHY scores are obtained by people with a positive
view of how they look and of their health status. Low PHY scores indicate
dissatisfaction with the body, which may reflect actual liabilities or may be a
result of distorted body image and unrealistic expectations about how one’s body
should look and function. Individuals, especially females, with low scores are at
increased risk for depression, eating disorders, and similar syndromes.

b. Moral Self-Concept (MOR)-
This score describes the self from a moral- ethical perspective: examining moral
worth, feelings of being a “ good” or “bad” person, and, for adults, satisfaction
with one’s religion or lack of it. Individuals with high MOR scores are generally
satisfied with their conduct and do not experience any great amount of dissonance
between their ideal and actual personal ethics. Having internalized a consistent
code of conduct, they are nonetheless flexible and forgiving of both themselves
and others, and can make allowances for special circumstances. People who
obtain low scores perceive in themselves an impulsivity that overrides moral
considerations. This may indicate actual difficulty exercising an adequate level of
27
impulse control, or it may reflect moral standards held by the individual or
significant others that are unrealistically high.

c. Personal Self-Concept (PER)-
This score reflects the individual’s sense of personal worth, feeling of adequacy
as a person, and self-evaluation of the personality apart from the body of
relationships to others. This score is a good reflection of overall personality
integration, and particularly well-adjusted individuals will obtain a high score on
this scale. Low scores may indicate that the individual experiences a somewhat
variable self-concept.

d. Family Self-concept (FAM)-
This score reflect the individual’s feelings of adequacy, worth, and value as a
family member. It refers to the individual’s perception of self in relation to his or
her immediate circle of associates. For children, the family self-concept strongly
influences how they perceive their relationships with their teachers. Individuals
with high FAM scores have expressed a sense of satisfaction with their family
relationships. They have indicated that they derive a sense of support and
nurturance in the context of their families. Low FAM score is likely to be
accompanied by a low MOR score for individuals with conduct- related
difficulties or associated clinical “externalizing” syndromes.

28
e. Social Self-Concept (SOC )-
This score is a measure of how the self is perceived in relation to others. It
reflects the individual’s sense of adequacy and worth in social interaction with
other people. The social self-concept tends to be associated with the physical
self- concept for people of all ages. Individuals who obtain high scores are
usually viewed by both themselves and others as being friendly, easy to be with,
and extroverted. Low SOC scores are sign of social awkwardness related to a
perceived lack of social skill. They often feel isolated, but are hesitant to take
the social risks involved in relieving their isolation.

f. Academic/Work self-concept (ACA)-
This score is a measure of how people perceive themselves in school and work
settings, and of how they believe that are seen by others in those settings. It is the
most strongly related of all the TSCS: 2 scores to actual academic performances.
People with high ACA scores feel confident and competent in learning and work
situations. They are comfortable when approaching new tasks. People with low
ACA scores have expressed difficulty performing in work or school settings.
This difficulty may be related to actual performance levels or this may indicate
the presence of unrealistic expectations about how they should perform.

29
4. Supplementary Scores
a. Identity (IDN) - If the IDN score is above 50T and is much higher than the
Satisfaction score, it is an indication of a desire to change alone with a self-view
that can probably tolerate the challenges involved in transition. If the IDN score
is above 70T, it may indicate an inflexibility of self-concept that could impede the
process of change and personal growth. When the IDN score is below 40T, it is
an indication of an actively negative self-view. It may also indicate a self-view
that is particularly vulnerable to situational factors and to the reactions and
opinions of others.
b. Satisfaction (SAT) - this score describes how satisfied the individual feels with
his or her perceived self-mage. In general, this score reflects the level of self-
acceptance. If the score is high the individual may not be motivated to seek
change in areas of disturbed self- concept.
c. Behavior (BHV) - this score measured the individual’s perception of his or her
own behavior or the way he or she functions.

Statistical Analyses
Data were initially recorded on an Excel spreadsheet and then imported into SPSS
version 15.0 for all data analyses. The independent variables were: “Phase of
Treatment”, “Age in Months”, “Gender”, “Ethnicity”, “Grade in School”, “Median
Family Income” (generated from US Census Department data based on zip code of
patient’s residence), “Income Class” (assigned based on lower third of Median Family
Income, middle third, or upper third) “Father’s Level of Education”, and “Mother’s Level
30
of Education”. The dependent variables were the individual scores recorded for the sub-
scales of the Tennessee Self-Concept Scale II.

The steps in the data analysis were: 1. generation of initial frequency tables, histograms
(for the scalar variable), bar charts (for the nominal variables) and descriptive statistics,
including mean, median, mode, standard deviation, skewness, and kurtosis for each
variable. 2. Tests of the assumptions for Analysis of Variance including a Kolmogorov-
Smirnov One-Sample Test to test the assumption of normal distribution of the data and a
Levene’s test for equality of variance. 3. A series of Analyses of Variance to test the null
hypothesis that there was no difference between the means of each of the dependent
variables on the any of the independent variables (Phase of Treatment, Ethnicity, , with
Scheffe and Dunnett T3 post-hoc tests to identify specific differences and an a priori
contrast on pre-treatment versus during- and post-treatment groups. 4. A Kruskal-Wallis
non-parametric K-samples test to test the same null hypothesis for any variables that were
not normally distributed. 5. A Multivariate Analysis of Variance using a General Linear
Model procedure to test for interactions between the independent predictor variables. 6. A
Multiple Linear Regression, with dummy coding for the categorical variables, to rank
order the significant predictor variables found in the previous analyses, those being the
Total Self-Concept, Physical, Identity, Inconsistent Responding, Conflict, and Academic
scales respectively.
Chapter 5: Results
There were 140 subjects in the study sample. The frequencies distributions and bar
charts for each of the independent variables are presented in the tables below.

Table 2: Phase of Treatment

Frequency Percent Valid Percent
Cumulative
Percent
Before Treatment
41 29.3 29.3 29.3
During Treatment
76 54.3 54.3 83.6
After Treatment
23 16.4 16.4 100.0
Valid
Total
140 100.0 100.0

Figure 1: Phase of Treatment

Phase of Treatment
After Treatment During Treatment Before Treatment
Frequency
80
60
40
20
0
ase o eat e t

31
Table 3: Patient's Gender

Frequency Percent Valid Percent
Cumulative
Percent
Male
67 47.9 47.9 47.9
Female
73 52.1 52.1 100.0
Valid
Total
140 100.0 100.0

Figure 2: Patient’s Gender
Patient's Gender
Female Male
Frequency
80
60
40
20
0
Patient's Gender
32
Table 4: Patient's Ethnicity

Frequency Percent Valid Percent
Cumulative
Percent
Asian
8 5.7 5.7 5.7
Black
14 10.0 10.0 15.7
Hispanic
86 61.4 61.4 77.1
White
32 22.9 22.9 100.0
Valid
Total
140 100.0 100.0

Figure 3: Patient’s Ethnicity
Patient's Ethnicity
White Hispanic Black Asian
Frequency
100
80
60
40
20
0
Patient's Ethnicity

33
Table 5: Income Category

Frequency Percent Valid Percent
Cumulative
Percent
lower
85 60.7 60.7 60.7
middle
34 24.3 24.3 85.0
upper
21 15.0 15.0 100.0
Valid
Total
140 100.0 100.0

Figure 4: Income Category
Income Category
upper middle lower
Frequency
100
80
60
40
20
0
Income Category

34
Table 6: Father's Level of Education

Frequency Percent Valid Percent
Cumulative
Percent
1.00
40 28.6 28.6 28.6
2.00
46 32.9 32.9 61.4
3.00
54 38.6 38.6 100.0
Valid
Total
140 100.0 100.0

Figure 5: Father’s Level of Education
Father's Level of Education
3.00 2.00 1.00
Frequency
60
50
40
30
20
10
0
Father's Level of Education

35
Table 7: Mother's Level of Education

Frequency Percent Valid Percent
Cumulative
Percent
1.00
43 30.7 30.7 30.7
2.00
49 35.0 35.0 65.7
3.00
48 34.3 34.3 100.0
Valid
Total
140 100.0 100.0

Figure 6: Mother’s Level of Education
Mother's Level of Education
3.00 2.00 1.00
Frequency
50
40
30
20
10
0
Mother's Level of Education

The One-Sample Kolmogorov-Smirnov test for normal distribution demonstrated that all
dependent variables except for Identity (K-S Z = 3.760, p<.001) were normally
distributed in the current sample. Any subsequent analyses of the Identity sub-scale
were non-parametric. The Levene’s Test for Equality of Variance demonstrated that all
36
37
dependent variables except for Family (Levene’s Statistic = 4.226, p<.05). Any
subsequent analyses involving Family utilized an alpha level adjusted for inequality of
variance. Descriptive statistics for each of the dependent variables were generated and
are presented in the table 8.

Histograms for each of the dependent variables with a normal curve superimposed over
their individual distributions are presented.

Table 8: Descriptive Statistics

N Minimum Maximum Mean Std. Deviation
Inconsistent Responding
140 20.00 80.00 51.1643 9.64821
Self Criticism
140 23.00 511.00 46.2214 40.73181
Faking Good
140 30.00 75.00 53.6500 9.60435
Respond Distribution
140 29.00 72.00 52.3643 8.66417
Total Self-Concept
140 26.00 81.00 59.9143 9.81739
Conflict
140 20.00 80.00 50.7857 11.55082
Physical Scale
140 26.00 86.00 57.5714 9.93225
Moral Scale
140 25.00 71.00 53.8071 8.69292
Personal Scale
140 26.00 77.00 54.8071 10.15555
Family Scale
140 29.00 74.00 53.7643 9.62133
Social Scale
140 27.00 78.00 56.3143 8.86030
Academic Scale
140 25.00 77.00 52.7643 9.44321
Identity
140 14.00 485.00 62.3143 37.56435
Satisfaction
140 27.00 72.00 54.6714 8.26577
Behavior
140 20.00 78.00 53.6357 10.36195
Valid N (listwise)
140

Figure 7: Inconsistent Responding
Inconsistent Responding
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
40
30
20
10
0
Inconsistent Responding
Mean =51.16
Std. Dev. =9.648
N =140

38
Figure 8: Self Criticism
Self Criticism
600.00 500.00 400.00 300.00 200.00 100.00 0.00
Frequency
120
100
80
60
40
20
0
Self Criticism
Mean =46.22
Std. Dev. =40.732
N =140

39
Figure 9: Faking Good
Faking Good
80.00 70.00 60.00 50.00 40.00 30.00
Frequency
30
20
10
0
Faking Good
Mean =53.65
Std. Dev. =9.604
N =140

40
Figure 10: Respond Distribution
Respond Distribution
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
25
20
15
10
5
0
Respond Distribution
Mean =52.36
Std. Dev. =8.664
N =140

41
Figure 11: Total Self-Concept
Total Self-Concept
80.00 60.00 40.00 20.00
Frequency
30
20
10
0
Total Self-Concept
Mean =59.91
Std. Dev. =9.817
N =140

42
Figure 12: Conflict
Conflict
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
20
15
10
5
0
Conflict
Mean =50.79
Std. Dev. =11.551
N =140

43
Figure 13: Physical Scale
Physical Scale
80.00 60.00 40.00 20.00
Frequency
40
30
20
10
0
Physical Scale
Mean =57.57
Std. Dev. =9.932
N =140

44
Figure 14: Moral Scale
Moral Scale
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
30
20
10
0
Moral Scale
Mean =53.81
Std. Dev. =8.693
N =140

45
Figure 15: Personal Scale
Personal Scale
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
25
20
15
10
5
0
Personal Scale
Mean =54.81
Std. Dev. =10.156
N =140

46
Figure 16: Family Scale
Family Scale
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
25
20
15
10
5
0
Family Scale
Mean =53.76
Std. Dev. =9.621
N =140

47
Figure 17: Social Scale
Social Scale
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
30
20
10
0
Social Scale
Mean =56.31
Std. Dev. =8.86
N =140

48
Figure 18: Academic Scale
Academic Scale
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
25
20
15
10
5
0
Academic Scale
Mean =52.76
Std. Dev. =9.443
N =140

49
Figure 19: Identity
Identity
500.00 400.00 300.00 200.00 100.00 0.00
Frequency
120
100
80
60
40
20
0
Identity
Mean =62.31
Std. Dev. =37.564
N =140

50
Figure 20: Satisfaction
Satisfaction
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
40
30
20
10
0
Satisfaction
Mean =54.67
Std. Dev. =8.266
N =140

51
Figure 21: Behavior
Behavior
80.00 70.00 60.00 50.00 40.00 30.00 20.00
Frequency
25
20
15
10
5
0
Behavior
Mean =53.64
Std. Dev. =10.362
N =140

Analyses of Variance
A series of preliminary one-way analyses of variance were conducted taking each of the
subscales of the TCS-II as dependent variables on each of the independent variables:
Treatment Phase, Gender, Ethnicity, Income Category, Father’s Education, and Mother’s
Education respectively.

52

53
The preliminary analysis of variance on the Treatment Phase indicated that the groups
differed on the Total Self-Concept (F=10.139, p<.001) and Physical Scale (F=10.663,
p<.001). An a priori contrast demonstrated that Total Self-Concept (t = -4.179, p<.001),
Physical Scale (t=-3.785, p<.001), and Identity (chi square=24.717, p<.001) all differed
with respect to treatment phase.

The preliminary analysis of variance on Gender indicated that the genders did not differ
on any of the dependent variables (p>.05).

The preliminary analysis of variance on Ethnicity indicated that the ethnic groups
differed only on the Conflict scale (F=4.278, p<.01). A post hoc Tukey’s test showed
that the specific differences were between the Hispanic group (mean=53.40, s=10.94)
differing significantly (p<.01) from the White group (mean=45.63, s=10.80). The ethnic
groups did not differ on any other dependent variables.

The preliminary analysis of variance on Income Class indicated that the groups differed
on Total Self-Concept (F=3.112, p<.05) with the Tukey post hoc test demonstrating that
the difference (p<.05) was between the Middle Income (mean=59.74, s=8.67) and Upper
Income groups (63.95, s=8.04).

The preliminary analysis of variance on Father’s Level of Education indicated that the
groups differed on the Inconsistent Responding Scale (F=4.840, p<.01) and the Conflict
Scale (F=9.656, p<.001). Tukey’s post hoc test on Inconsistent Responding demonstrated
54
that the differences (p<.01) were between the middle (high school with some college)
group (mean=51.18, s=8.34) and the upper (college graduate) group (mean=48.48,
s=10.22). Tukey’s post hoc test on Conflict demonstrated that all three groups differed
significantly differences (p<.001).

The preliminary analysis of variance on Mother’s Level of Education indicated that the
groups did not differ significantly (p>.05) on any of the dependent variables.

Following the preliminary one-way analyses of variance, a multivariate analysis of
variance was conducted to investigate potential interactions between Treatment Phase
(i.e. stage of orthodontic treatment) and any of the other independent variables. The
multivariate analysis of variance indicated that the combination of predictor variables:
Treatment Phase, Ethnicity, and Income class, demonstrated a significant interaction
effect (F=2.560, p<.044). No other combinations of independent variables demonstrated
significant interaction effects.

In order to illustrate the differences between the Treatment Phase groups on each of the
dependent variables that were found to be significant in the preliminary ANOVAs (Total
Self-Concept, Physical, Identity, Conflict, and Inconsistent Responding) by the
independent variables that were found to interact significantly in the MANOVA
(Treatment Phase, Ethnicity, and Income Class), clustered line charts were produced.
Clustered bar charts are used to illustrate the comparative means of the dependent
variable scales found to be significant by phase of treatment, ethnicity, and income
category. The clustered line charts and the clustered bar charts are presented below:

Figure 22: Total Self-Concept changes, Phase of Treatment, Patient Ethnicity
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Total Self-Concept
70.00
65.00
60.00
55.00
50.00
White
Hispanic
Black
Asian
Patient's Ethnicity

55
Figure 23: Physical Scale changes, Phase of Treatment, Patient’s Ethnicity
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Physical Scale
70.00
65.00
60.00
55.00
50.00
White
Hispanic
Black
Asian
Patient's Ethnicity

56
Phase 24: Identity changes, Phase of Treatment, Patient’s Ethnicity
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Identity
90.00
80.00
70.00
60.00
50.00
40.00
White
Hispanic
Black
Asian
Patient's Ethnicity

57

Figure 25: Conflict changes, Phase of Treatment, Patient’s Ethnicity
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Conflict
55.00
50.00
45.00
40.00
35.00
30.00
White
Hispanic
Black
Asian
Patient's Ethnicity

58
Figure 26: Inconsistent Responding, Phase of Treatment, Patient’s Ethnicity
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Inconsistent Responding
60.00
55.00
50.00
45.00
40.00
White
Hispanic
Black
Asian
Patient's Ethnicity

59
Figure 27: Total Self-Concept, Phase of Treatment, Income Category
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Total Self-Concept
75.00
70.00
65.00
60.00
55.00
50.00
upper
middle
lower
Income Category

60
Figure 28: Physical Scale, Phase of Treatment, Income Category
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Physical Scale
70.00
65.00
60.00
55.00
50.00
upper
middle
lower
Income Category

61
Figure 29: Identity, Phase of Treatment, Income Category
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Identity
90.00
80.00
70.00
60.00
50.00
upper
middle
lower
Income Category

62
Figure 30: Conflict, Phase of Treatment, Income Category
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Conflict
54.00
52.00
50.00
48.00
46.00
44.00
upper
middle
lower
Income Category

63
Figure 31: Inconsistent Responding, Phase of Treatment, Income Category
Phase of Treatment
After Treatment During Treatment Before Treatment
Mean Inconsistent Responding
55.00
52.50
50.00
47.50
45.00
upper
middle
lower
Income Category

64
Figure 32: Total Self-Concept, Patient’s Ethnicity, Income Category
Income
Category
upper
middle
lower
Mean Total Self-
Concept
80.00
60.00
40.00
20.00
0.00
Patient's
Ethnicity
White
Hispanic
Black
Asian
After Treatment
During Treatment
Before Treatment
Phase of
Treatment

65
Figure 33: Conflict, Patient’s Ethnicity, Income Category
Income
Category
upper
middle
lower
Mean Conflict
60.00
40.00
20.00
0.00
Patient's
Ethnicity
White
Hispanic
Black
Asian
After Treatment
During Treatment
Before Treatment
Phase of
Treatment

66
Figure 34: Physical Scale, Patient’s Ethnicity, Income Category
Income
Category
upper
middle
lower
Mean Physical Scale
80.00
60.00
40.00
20.00
0.00
Patient's
Ethnicity
White
Hispanic
Black
Asian
After Treatment
During Treatment
Before Treatment
Phase of
Treatment

67
Figure 35: Identity, Patient’s Ethnicity, Income Category
Income
Category
upper
middle
lower
Mean Identity
125.00
100.00
75.00
50.00
25.00
0.00
Patient's
Ethnicity
White
Hispanic
Black
Asian
After Treatment
During Treatment
Before Treatment
Phase of
Treatment

Multiple Regressions
Multiple Linear Regression indicated that the cluster of independent variables regressed
(Phase of Treatment, Income Class, Father’s Level of Education, Mother’s Level of
Education, Ethnicity, Age, Gender, and Grade in School) explained a small
(R
2
= .198) but significant amount (20%) of the variance in Total Self Concept (F =
2.389, p<.01). Of the predictor variables, only Phase of Treatment was a significant
predictor of Total Self-Concept (t = 4.052, p<.001; beta = .392).
68

69
Multiple Linear Regression indicated that the cluster of independent variables regressed
(Phase of Treatment, Income Class, Father’s Level of Education, Mother’s Level of
Education, Ethnicity, Age, Gender, and Grade in School) explained a small
(R
2
= .240) but significant amount (24%) of the variance in the Physical variable (F =
3.066, p<.001). Of the predictor variables, Phase of Treatment = During Treatment
(t=4.490, p<.001; beta=.422), and Ethnicity = Black (t=2.201, p<.05; beta = .186) were
significant predictors of the Physical scale.

Multiple Linear Regression indicated that the cluster of independent variables regressed
(Phase of Treatment, Income Class, Father’s Level of Education, Mother’s Level of
Education, Ethnicity, Age, Gender, and Grade in School) explained a small
(R
2
= .196) but significant amount (20%) of the variance in the Conflict scale (F = 2.365,
p<.01). Of the predictor variables, only Father’s Education = Some college was a
significant predictor of the Conflict scale (t = 2.416, p<.05; beta = .274).

With respect to the Academic Scale, the Multiple Linear Regression indicated that none
of independent variables regressed (Phase of Treatment, Income Class, Father’s Level of
Education, Mother’s Level of Education, Ethnicity, Age, Gender, and Grade in School)
were significant predictors of that criterion variable (F=1.297, p = .218).

With respect to the Identity Scale, the Multiple Linear Regression indicated that none of
independent variables regressed (Phase of Treatment, Income Class, Father’s Level of
70
Education, Mother’s Level of Education, Ethnicity, Age, Gender, and Grade in School)
were significant predictors of that criterion variable (F=.987, p=.471).

71
Chapter 6: Discussion and Conclusions
Discussion
Dentofacial esthetics is an important motivational factor to seek orthodontic treatment,
and patients usually expect an improvement in appearance. This underscores the
importance of having facial esthetics as an essential treatment goal. Personal esthetic
perceptions of the dentofacial complex and the associated psychosocial need are relevant
to the consumers of orthodontic care. Treatment is therefore often influenced more by
demand than by need.

The purpose of this cross-sectional study was to demonstrate psychological benefits of
undergoing orthodontic therapy in populations of “at risk” adolescents. After this can be
demonstrated, it is more likely that government funding agencies, such as DentiCal, may
provide increased funding for orthodontic treatment for adolescents who cannot afford
orthodontics

The improvement of self-esteem was based on ethnicity and SES. These changes were
different between the races with Blacks benefiting the most, then Hispanics, then Whites;
Asians did not benefit These results are similar to other studies that found gender, age
and socio-economic background as factors affecting the self-perception of dental
appearance. (Jenkins et al. 1984).

72
Our study found that the mere placement of orthodontic appliances leads to an
improvement in self-esteem, which reaffirmed Rahbar’s findings. In the past, orthodontic
treatment need was evaluated by the need to correct any functional problems, but several
studies have stated that self-perceived dental appearance is also important in the decision
to seek orthodontic treatment.

Many studies lead us to expect that individuals with previous orthodontic treatment
would have higher self-perception of their dental esthetic appearance than untreated
individuals. This is not always true, and Bernabe et al. (2006) tried to explain these
contradictory findings previously reported. Possible reasons include “the fact that
orthodontic treatment may have raised their expectations, the amount of orthodontic
treatment required was high and optimal results were never attained, relapse, young
adults have a more critical appraisal of orthodontic treatment need than other age groups,
or the subjective orthodontic need perception changes over time even without previous
treatment”.(Bernabe, Kresevic et al. 2006)

When looking into the changes in self-concept during adolescence, our study
demonstrated that age was not a significant predictor for the changes in self-esteem and
self-concept as a result of orthodontic treatment. Studies on the relationship between
orthodontic treatment and self-esteem show mixed results. It has also been known that
self-esteem improves naturally as we get older. That raises the question of whether the
improvement in self-esteem was going to occur regardless of undergoing orthodontic
treatment. Our results contradict with the results of Chiam (1987), who also used the
73
Tennessee Self-Concept Scale, second edition, on a group of Malaysian adolescents. He
studied the changes in various components of self-concept changes and with age. This
study shows that “the self-concept of adolescent boys changes with age in the direction
predicted. The trend is less obvious and less consistent for girls.” (Chiam 1987)

To address this issue further, Kenealy et al. (2007) did a 20 year follow-up study
compared the dental and psychosocial status of individuals who received, or did not
receive, orthodontics as teenagers.(Kenealy, Kingdon et al. 2007). These authors had
studied the effect of orthodontics on self-esteem in 1991, and they found that despite the
widespread belief that orthodontics improves psychological well-being and self-esteem,
there is little objective evidence to support this. (Kenealy, Hackett et al. 1991)

The results of their recent study showed that “participants with a prior need for
orthodontic treatment as children who obtained treatment demonstrated better tooth
alignment and satisfaction. However when self-esteem at baseline was controlled for,
orthodontics had little positive impact on psychological health and quality of life in
adulthood. Lack of orthodontic treatment where there was a prior need did not lead to
psychological difficulties in later life. Dental status alone was a weak predictor of self-
esteem at outcome explaining 8% of the variance. Self-esteem in adulthood was more
strongly predicted (65% of the variance) by psychological variables at outcome:
perception of quality of life, life satisfaction, self-efficacy, depression, social anxiety,
emotional health, and by self-perception of attractiveness.”(Kenealy, Kingdon et al.
2007)
74
When we compared the improvement in self-esteem and self-concept for different
socioeconomic areas, we found that this improvement is different for different
socioeconomic backgrounds, with lower income groups benefiting the most. Another
study shows similar results A multi- disciplinary research began in 1981 (Shaw 1981) as
a longitudinal study that investigated oral health, social and psychological effects of
malocclusion, and the effectiveness of orthodontic treatment. The study looked into the
relationship between attractiveness and teacher expectations, attractiveness and self-
esteem, and social class and the uptake of orthodontic treatment. Their initial results
provided little support for the widespread belief that children with visible malocclusion
were likely to be socially and psychologically disadvantaged.

Shaw et al. concluded in 2007 that despite the major hypothesis that orthodontic
treatment improves psychological well-being and self-esteem, there is little objective
evidence to support this. The purpose of their latest study was to compare the dental and
psychosocial status of patients who received orthodontic treatment as teenagers and a
control group.(Shaw, Richmond et al. 2007) Their results showed that “lack of
orthodontic treatment when there was need did not lead to psychological difficulties in
later life.”

When we evaluated Gender, however, it was not a significant predictor for the
improvement of self-esteem and self-concept, which is contradictory to previous studies.
Horowitz found that High social class individuals and females are usually more critical of
75
their facial appearance in general and especially of their dental appearance than younger
children. (Horowitz et al. 1971)

Assumptions
1. The patient pool at USC was representative of the general population of Southern
California
2. The TSCS-II is a valid and reliable psychological instrument.
3. Subjects were truthful in their response to the questionnaire
4. Calculations of TSCS-II scales were accurate and reproducible.

Limitations
The time period allocated for the proposed project only allowed for a cross-sectional
approach to stage of treatment categorization. A longitudinal approach would be better
but would require at least a three year time period.

Conclusions
1. Self-Esteem and Self-Concept improve as a result of orthodontic treatment
2. This improvement is different for different socioeconomic backgrounds, with
lower income groups benefiting the most
3. These changes are different between the races with Blacks benefiting the most,
then Hispanics, then Whites; Asians did not benefit.
4. Age and Gender differences did not affect changes in self-esteem and self-concept
76
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Abstract (if available)

Abstract Introduction: The benefits of orthodontic treatment often go beyond improving patients dental appearance and leads to an improvement in their self-esteem and self-concept. However, the beneficial psychological effects may vary from patient to patient due to certain predisposing factors. Purpose: To evaluate whether certain independent variables allow for prediction of the psychological outcome of conventional orthodontic treatment. Methods: A sample of 140 adolescent patients grouped by stage of orthodontic treatment (pre-, mid-, and post- orthodontic treatment). Self-esteem and self-concept were measured by the Tennessee Self-Concept Scale II. Results: The Multivariate Analysis of Variance indicated that the only combination of predictor variables that demonstrated significant interactions was the combination of Treatment Phase, Ethnicity, and Income class (F=2.560, p<.044). Conclusions: Changes in Self-Esteem and Self-Concept are different for different socioeconomic backgrounds and different races. Lower income groups and Blacks benefit the most, then Hispanics, then Whites

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Asset Metadata

Creator Shweish, Ariana (author)

Core Title An exploration of predictor variables for changes in self-esteem and self-concept as a result of orthodontic treatment

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Publication Date 04/09/2008

Defense Date 02/28/2008

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,orthodontic treatment,self-concept,self-esteem,socioeconomic status

Language English

Advisor Keim, Robert G. (committee chair), Clarck, Dick (committee member), Forrest, Jane (committee member)

Creator Email shweish@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m1088

Unique identifier UC1273267

Identifier etd-Shweish-20080409 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-51796 (legacy record id),usctheses-m1088 (legacy record id)

Legacy Identifier etd-Shweish-20080409.pdf

Dmrecord 51796

Document Type Thesis

Rights Shweish, Ariana

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu