14 Orthodontics January 2021

Enhanced CPD DO C

Sophy Barber Andrew Shelton

Patient Questionnaires
in Orthodontics
Abstract: Questionnaires are versatile tools that allow data to be collected from different respondent groups for a range of purposes.
This article outlines the use of questionnaires in orthodontics for research, quality improvement and clinical purposes. We highlight the
importance of questionnaire design, particularly choosing the type of response to generate useful data and approaches to psychometric
testing to measure validity and reliability. Orthodontic-specific questionnaires that have been developed and tested are summarized.
CPD/Clinical Relevance: Questionnaires are a useful tool for collecting information about patient concerns, experience and outcomes;
this information is essential to improve the quality of care. It is crucial that valid and reliable tools are used to optimize the usefulness of
information.
Ortho Update 2021; 14: 14–20

Questionnaires are instruments for
gathering data to answer a specific
question. Questionnaires enable
information about behaviour, attitudes,
preferences, opinion and intention to
be collected from a range of different
respondent groups, including patients,
families and carers, the public, health
professionals and service providers, such as
commissioners.1
Purpose of questionnaires
Questionnaires can be used in research,
quality improvement or to gather clinical
data. They are tools for collecting data,
rather than a specific methodology, so
can be used in a diverse range of research
study designs, including randomized
controlled trials, observational studies and
surveys, as well as for audit and service
evaluation. A single questionnaire provides
cross-sectional data for a group of people
at a specific point in time, while repeat
questionnaires allow data to be collected
longitudinally.2,3
Questionnaires can be used in
healthcare research to assess:4
 Epidemiology and risk factors
through population surveys;
 Outcomes from a particular
intervention or courses
of treatment;
 Experience of part, or all, of
a process.
Patient-reported outcome measures
(PROMs) and patient-reported experience
measures (PREMs) are increasingly
important for measuring the quality of care.5
Advantages and limitations of
questionnaires
Questionnaires have gained widespread
use, as they are relatively quick, easy
and inexpensive to administer, and data
can be collected from a large number of
people across a large geographical area.
Respondents can complete questions
in their own time and preferred setting,
with the reassurance of anonymity and
confidentiality. Instruments can be used
across different time points to measure
change over time, for example, to monitor
experience or identify change in behaviour
or opinion.2,3
Questionnaires are useful for gaining
information about opinion or behaviour
but are less able to explain why a
phenomenon has occurred. As with all
data collection tools, questionnaires
require careful design, sampling and data
collection methods to gain meaningful
results. Poorly worded questions,
inappropriate response formats, errors
in selecting the respondent group and
distributing the questionnaire can lead to
poor quality data.2,3
Types of data generated
by questionnaires
Different types of data can be collected,
depending on the intended purpose
of the information gathered. Closed
questions provide quantitative
data, while open questions offer the
opportunity to collect more detailed
qualitative data. Quantitative data are
often judged to be easier to manage;
however, there can be complexities in
correctly analysing and interpreting
numerical data. It is important that the
intended use of the data is clear when

Sophy Barber, BDS, MJDF(RCS Eng), MSc, MOrth(RCS Ed), Post-CCST Registrar in Orthodontics, Leeds Dental Institute, Leeds, UK.
Andrew Shelton, BDS, MFDS, RCS(Eng), MDentSci, MOrth, FDS RCSOrtho, Consultant Orthodontist, Orthodontic Department, Montagu
Hospital Adwick Road, Mexborough, UK. email: sophy.barber@googlemail.com
January 2021 Orthodontics 15

Excellent Very good Good Fair Poor and treating them as continuous. Without a
validated scoring system with appropriate
Figure 1. Likert scale to measure experience of service. item weighting, creating summative scores
is likely to lead to statistical analysis that is
Potential challenges to validity or reliability difficult to interpret in a meaningful way.6

Response options do not reflect true opinion, forcing invalid response

Questionnaire properties
Misunderstanding of questions and/or answer options due to issues with It is essential that the chosen instrument is
Validity language or framing able to collect valid, reliable and unbiased
Desire to provide ‘correct’ answer or answer that is judged to be information to answer the question.8 Validity
socially desirable is defined as the ability of the questionnaire
to measure the variable of interest; this
Ambiguity in questions or answers leading to inconsistent responses or
is essentially to decide whether the
challenges during data analysis
questionnaire results reflect ‘the truth’. For
Reliability Lack of interest or engagement with questions leading to example, does the respondent interpret the
inconsistent responses questions and response options in the way
Inappropriate scale − missing or overlapping intervals intended and is the respondent able to give
an answer that reflects their true opinion or
Potential sources of bias
experience? Reliability is the ability of the
Identification of sample questionnaire to produce consistent data.
Access to the questionnaire, eg online access, literacy requirements Most commonly this is judged by whether
repeat questions from an individual provide
Sample Self-selection bias in respondents (responses may be skewed or represent
the same answer, or whether questionnaires
extreme or polarized views)
that have been administered or analysed by
Unacceptability of questionnaire to certain groups leading to refusal different people find the same result. Issues
to participate with validity can impact on reliability, as
Bias in questions, eg leading questions, suggestive introduction respondents are more likely to answer in an
to questionnaire erratic way if they are not able or willing to
Data give a true answer.
Respondent bias – answers given based on what the respondent thinks the
collection Bias is the term given to an erroneous
researchers wants or is most acceptable (desirability bias)
result arising from systematic errors in the
Use of scale that encourages central tendency bias collection of data. A number of factors
Recall bias may reduce the validity and reliability or
increase the risk of bias of questionnaires
Response Respondent learning/hypothesis guessing
(Table 1). Issues with validity can impact on
Failure to answer certain questions leading to missing data reliability because respondents are more
Table 1. Potential limitations in questionnaires that may reduce validity or reliability or increase the
likely to answer in an erratic way if they are
risk of bias. not able or willing to give a true answer.
Other important concepts in questionnaire
design are sensitivity, which is the ability
deciding what type of data are collected proportions, for example 21 people, or 5% of a questionnaire to measure change, and
and the most appropriate response format, scored the service as ‘Fair’. responsiveness, which is the ability of the
and that the appropriate analysis is then Discrete data are data that can only take questionnaire to measure change that is
used for the type of data collected. For certain values; there are a finite number of clinically significant and relevant.
detailed information about appropriate values possible. Discrete data are usually Increasingly, including the target
statistical analysis, further reading counts, for example, the number of people respondent group throughout the design
is recommended.6 with a Class II malocclusion or the number and development of data collection tools
Categorical data include nominal and of female respondents in a survey. Values is advocated to optimize relevance and
ordinal data. Nominal means labelled cannot be subdivided meaningfully, for acceptability.9 Ideally, any questionnaire
categories with no inherent order, for example, it does not make sense to describe should undergo a formal testing process
example, gender and ethnicity. Ordinal 2.7 people with Class II malocclusion. with an adequate sample from the target
data are categorical data with an order, Continuous data are numerical data population prior to use to allow the
for example, age categories or a Likert where any value is possible within a different properties of the questionnaire to
be assessed.10
scale. Ordinal data cannot be assumed range, depending on the sensitivity of the
to have interval properties, meaning that measurement tool. Examples include age,
the relationship between the categories height, overjet. Continuous data have interval Selecting a questionnaire
may vary across the scale. For example, properties, meaning the difference anywhere When selecting or devising a questionnaire,
on a 5-point Likert scale for measuring on the scale is the same, for example, the it is important to define the question and
the experience of treatment (Figure 1), it difference between 2−4 mm is the same as perspective of interest, for example, patient,
cannot be assumed that a change from 4−6 mm. parent or clinician, and to identify the
‘Excellent’ to ‘Very good’ is the same as a Questionnaires can be misused if data target population, the outcome of interest
change from ‘Fair’ to ‘Poor’.7 Categorical are used erroneously, for example converting and the type of data required explicitly,
data produce counts, frequencies and categorical responses into numerical data based on how they will be used. It is
16 Orthodontics January 2021

tempting to use the opportunity afforded

Title Clear, unambiguous and reflects content
by a questionnaire to collect as much data
Introduction Explains purpose of questionnaire in a non-biased way as possible, but only data relevant and
Provides information about time required for completion necessary to answer the question should
Explicitly addresses confidentiality, anonymity and right to be collected.
refuse/withdraw Where possible, it is preferable to use
Information about point of contact for questionnaire an existing questionnaire that has been
Layout Clear font validated with the target population
Appropriate use of graphics and has been shown to be reliable. It
Instructions Information about how to answer questions may be necessary to alter questions
Information about returning the questionnaire or format to suit the desired use. The
validity and reliability of a questionnaire
Demographic questions Necessary information sought following alteration, or if used with a new
Justification for information requested, particularly respondent group, should be considered
personal information
during analysis and interpretation.11
Avoidance of unnecessary sensitive or potentially
Where no suitable questionnaire exists,
offensive questions
it may be necessary to develop an
Measures Valid and reliable questions instrument. Best practice guidance for
Appropriate response options questionnaire design can support the
Appropriate length with avoidance of repetition or development process.12,13 Some of the
unnecessary questions key components of questionnaires are
summarized in Table 2.
Closure Clear identification of the end of the questionnaire
The questionnaire purpose and
Acknowledgement and thanks for completion
planned mode of administration will
Sources of further information and support (if appropriate)
influence the approach to sampling,
Table 2. Summary of key components of a questionnaire. for example, whether a representative

Name of questionnaire Brief description Method of development Psychometric testing

Orthodontic-specific quality of life measures
Malocclusion Impact
Questionnaire (MIQ)30,31
Psychosocial Impact of Dental
Aesthetics Questionnaire
(PIDAQ)32
Child Oral Health Impact Profile-
ortho (COHIP-ortho)33
Hypodontia-specific OHQoL
measure15,16
17 items relating to how teeth
look, impact of teeth on life
and eating and health of teeth
3-point rating scale
23 items in four domains:
 Dental self-confidence
 Social impact
 Psychological impact
 Aesthetic concern
5-point rating scale
 11 items relating to oral
health impacts
 One question about
perceived need for orthodontic
treatment
 Six questions about general
health perception
5-point rating scale
Four domains:
 Treatment
 Activities
 Appearance
 Reaction of other people
5-point rating scale
Interviews with patients aged
10−16 years prior to orthodontic
treatment to generate items
Development and interview
piloting of tool with revisions
Interviews from previous studies
generated items
Expert group selected and
reformulated items from
other scales
Piloted with 12
orthodontic patients
Item selection from existing
validated COHIP by experts
Focus groups with 22 people
aged 11−18 years with
hypodontia to generate items
Questionnaire design with
readability testing and
preliminary piloting with 10
patients
Evaluated with 10−16 year-olds
pre-orthodontic treatment for:
 Criterion validity
 Construct validity
 Internal reliability
 Test–retest
Questionnaire tested by 194
people aged 18−30 years
 Principal component analysis
 Cross-validation
 Reliability
243 parents with their child
from one orthodontic practice
to test:
 Reliability
 Criterion validity
 Construct validity
 Convergent validity
Evaluated with 46 11−18 year-
olds with varying severity of
hypodontia at different stages
of treatment
 Criterion validity
 Construct validity
 Internal consistency
 Test–retest (10 people)

Table 3. A summary of some orthodontic-specific questionnaires that report the development and psychometric testing process. (Continued on pages 17 and 18)
January 2021
Name of questionnaire
Orthodontic-specific quality of life measures
Orthognathic-specific
OHRQoL measure17,18
Orthognathic-specific measure
of psychological aspects of
facial deformity19
Demand and expectations for orthodontic
Demand for
Orthodontic Treatment
Questionnaire (DOTQ)34
Expectations prior to
orthodontic treatment35
Measures of orthodontic experience and outcome
Orthodontic Patient Treatment
Impact Questionnaire (OPTIQ)36
Orthodontic treatment37
Expectations and experiences of
orthodontic treatment38
Brief description
22 items in four domains:
 Social aspects of facial
deformity
 Facial aesthetics
 Oral function
 Awareness of facial deformity
4-point rating scale
Pre-operative questions
relating to:
 Wellbeing
 Expectations
Post-operative questions
relating to:
 Wellbeing
 Expectations
115 items across three domains:
 Psychological and social
 Malocclusion-related
 Treatment demand
5-point rating scale
Expectations about treatment
 At initial appointment
 Type of orthodontic
treatment
 Impact of treatment
 Outcome from treatment
100-mm visual analogue scale
12 questions across four
domains:
 Patient-reported treatment
need
 Patient expectations
 Treatment experience
 Patient-reported
treatment outcome
25 items in three domains:
 Satisfaction with
treatment process
 Satisfaction with psychosocial
effects of treatment
 Satisfaction with overall
treatment outcome
5-point rating scale
46 items in five domains:
 Treatment motivation
 Treatment expectation
 Pain and discomfort
 Functional jaw impairment
 Questionnaire validity
Measured with visual analogue
scale or 4-point rating scale
Method of development
Interviews with dental
professional and patients aged
>16 years both pre-treatment
and pre-surgery to generate
items
Item reduction with 46 patients
(pre-treatment and pre-surgery)
Item generation and selection
through literature review, expert
consultation and interviews
with pre- and post-surgical
patients (n = 30).
Pilot with pre-surgical (n =
39) and post-surgical (n = 36)
patients
 Readability (Flesch-Kincaid)
 Test-retest (n = 30)
Questionnaire revision before
final testing
Items generated from previous
qualitative and piloting studies.
New items added
Re-evaluation of all items to
select final items
Interviews with patients and
parents to generate items
Piloting with five pre-treatment
patients and parents
Focus groups with pre- (n = 12)
and post-orthodontic (n = 12)
patients to generate item pool
Item reduction by expert panel
Piloting tool with 12 patients of
all ages
Interviews with patients, parents
and orthodontists with review
of existing questionnaires to
generate items
Factor analysis to reduce items
Focus groups with adolescents
who had recently completed
orthodontic treatment and
parents, plus review of existing
measures to generate items
Orthodontics 17
Psychometric testing
Evaluated with patients at
different stages of treatment
 Internal reliability
 Test–retest
 Validity testing
 Responsiveness
Testing pre-operative
questionnaire (n = 110) and
post-operative questionnaire (n
= 72) patients
 Internal consistency
 Validity and responsiveness
(Rasch analysis)
 Test–retest (n = 23)
Tested with 150 13-year-olds for:
 Dimensionality
 Reliability
 Predictive validity
Testing with 39 pre-treatment
patients aged 12−14 years and
39 parents
 Internal consistency
 Test–retest (22 participants)
Psychometric testing with 142
patients of all ages
 Criterion validity
 Convergent validity
 Discriminant validity
 Test–retest reliability
 Internal reliability
Testing with 299 parents of
children who had completed
orthodontic treatment to
preliminarily test validity and
reliability
Tested with 30 adolescents pre-
orthodontic treatment and 30
adolescents in active treatment
to test:
 Internal consistency
 Test–retest reliability
 Face validity
18 Orthodontics January 2021

Name of questionnaire Brief description Method of development Psychometric testing

Orthodontic-specific quality of life measures
Experience of orthodontic
treatment process39,40
Experience of orthognathic
treatment41
Table 3. A summary of some orthodontic-specific questionnaires that report the development and psychometric testing process (continued).
Multi-section questionnaire
including:
 Reason for treatment
 Visiting the orthodontist
 Having treatment
 Information before treatment
 Problems
61 items across nine domains:
 Reason for treatment
 Experience before treatment
 Experience of braces
 Nature of surgery
 Experience of surgery
 Post-operative care
 Appointments and travelling
 Benefits of treatment
 Information given
Qualitative methods with
people aged 12−18 years
undergoing orthodontic
treatment used to generate
items (five focus groups with
26 participants and three
telephone interviews)
Questionnaire development
then tested for readability and
ease of completion
Focus groups with 46
patients who had undergone
orthognathic treatment to
generate items
Questionnaire development
and piloted on 15 patients then
modified and re-tested on a
further 10 patients. Readability
testing was performed
Testing with patients
undergoing orthodontic
treatment:
 Test–retest (31 participants)
 Criterion validity via
telephone interviews with
17 participants
 Construct validity
Testing with 66 patients at least
3 months post-surgery:
 Face and content validity
 Criterion validity
 Construct validity
 Test–retest

or purposive sample is preferable.
Convenience sampling is often the
most practical approach for audit and
usually this will provide a satisfactory
sample, but results may have limited
generalizability to other settings or
populations. For clinical questionnaires,
the need for clinical information will
determine when, how and to whom
the questionnaire is distributed. The
planned method of data collection may
also influence which questionnaire
is most appropriate. Remote data
collection, for example, by post or
online, provides limited opportunity to
explain questions or explore responses,
so simple, clear tools are essential.
Face-to-face data collection allows
clarification of questions and answers,
so questionnaires may be selected that
allow further exploration, for example
questionnaires with open questions, or
more complicated instruments.14
Patient questionnaires in
orthodontic research
In research, questionnaires have
been used to explore a number of
areas including oral health-related
quality of life and the impact of
malocclusion, experience of treatment
and treatment outcome. Quality of life
(QoL) questionnaires may be generic
or condition-specific, for example,
questionnaires that explicitly measure
the impact of hypodontia15,16 or facial
deformity.17–19 Condition-specific QoL
questionnaires have been shown to
be more discriminative than generic
measures owing to their ability to
measure more subtle aspects of
malocclusion20 and a study testing
the validity of a generic measure with
orthodontic patients highlighted the
need for child-centred, malocclusion-
specific questionnaires.21 Surprisingly,
to date, there are no condition-specific
QoL measures for measuring the impact
of cleft lip and palate,22–24 although
generic measures have been validated
for this group.25
Questionnaires can also be used
in research to measure treatment
experience or outcome for treatment
as a whole, or for a single treatment
modality. For example, satisfaction
questionnaires have been used to gain
patient feedback on different types
of appliances26,27 and in randomized
controlled trials to provide a patient-
centred outcome.28,29
A summary of some orthodontic-
specific questionnaires that have
been developed and tested is given in
Table 3. In addition, many non-validated
questionnaires have been used in
orthodontic research, particularly to
assess satisfaction with treatment
outcome. Usually a new tool was judged
to be necessary because the existing
tools were not suitable; however, the
development and testing process is
often poorly described. This can lead
to challenges when attempting to
assess the quality of the study and
translate the findings into clinical
practice.
Patient questionnaires
in quality improvement
in orthodontics
In the NHS, quality improvement
aims to improve patient outcomes
and the delivery of care through
seven areas of activity, collectively
called clinical governance.42 Data are
required to measure and evaluate
performance for clinical governance
purposes and questionnaires are one
method for obtaining these data,
often from a patient perspective. An
interesting paper from 2014 describes
an experience-based design approach
to measure feedback of patient
experience in orthodontics to target
service improvement.43
One of the most widely used
questionnaires is the Friends and
Family Test (FFT), launched in 2013
and now in use in most NHS-funded
services in England.44 The FFT aims to
provide patients with an opportunity
to give feedback on their experience
and identify areas for improvement.
The results of the FFT are published
regularly to promote transparency
January 2021
and allow comparison across services.
There are, however, some concerns
over the ability of the FFT to capture
patient experience and its success as
a performance measure45 and, as with
other generic measures, it may not
identify service-specific issues.
The other key quality
improvement area where patient
questionnaires are regularly used
is data collection for clinical audit.
The audit process aims to monitor
clinical practice against an agreed
standard of care and questionnaires
are commonly used to collect
information about patient satisfaction
with service delivery and treatment
outcome. Often audit questionnaires
are developed for one specific audit
and the lack of standardization can
make it difficult to compare findings
across audits. Few audits report how
the questionnaire was developed and
tested. While this does not necessarily
mean the information obtained is
not useful for quality improvement
purposes, if results do not reflect what
is observed clinically, the instrument
may require careful examination of
its validity.
Patient questionnaires for
clinical use
Patient questionnaires may be a
useful tool to collect information
prior to, during or after orthodontic
treatment to assist clinicians with
planning or delivering treatment.
Pre-treatment questionnaires can
be used to establish the impact of
malocclusion and the motivation for
treatment to determine the patient’s
expectations from treatment and to
focus the consultation and relevant
information provision. During
treatment, questionnaires may be
used to monitor treatment experience
and to identify any changes in goals
and expectations. Post-treatment
questionnaires tend to focus on
satisfaction with outcome and overall
experience of treatment.
As with audit questionnaires,
many clinical questionnaires
are developed locally and are
not standardized or validated
through a formal process. In these
cases, it is up to the clinician and
patients to determine whether
the questionnaire is able to gain
information that is accurate and
useful and often a pragmatic
approach is taken. The Malocclusion
Impact Questionnaire30,31 is the only
questionnaire identified by the authors
that explicitly states that it is for
both clinical and research purposes;
however, other research questionnaires
may be useful in routine clinical
application to gain patient input.
Conclusions
Questionnaires have a useful role in
research, quality improvement and
clinical services. It is important that
the purpose and perspective of the
questionnaire is defined and the
chosen instrument is relevant and able
to engage the target population to
gain meaningful results. The validity
and reliability of an instrument is
fundamental and measures should
be taken to reduce potential biases as
much as possible.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
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