Original Article

Is self-harm among orthodontic patients related to dislike of dentofacial

features and oral health-related quality of life?
Zaid B. Al-Bitara; Ahmad M. Hamdana; Iyad K. Al-Omaria; Farhad B. Nainib; Daljit S. Gillc;
Mahmoud K. Al-Omirid

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ABSTRACT
Objectives: To investigate the relationship between self-reported self-harm and dislike of
dentofacial features and oral health-related quality of life (OHRQoL).
Materials and Methods: Anonymous, self-reporting questionnaires were completed by 699 school
children (aged 13–14 years), representing over 1% of the age group in Amman, Jordan.
Participants were invited from 23 randomly selected schools in 10 educational directorates.
OHRQoL was assessed using the Child Perception Questionnaire (CPQ 11–14). Self-harm was
assessed using a constructed self-reporting questionnaire. The relationship between OHRQoL and
self-harm was assessed and significant findings were identified at probability of a ¼ 0.05.
Results: Over one-quarter of schoolchildren (26.9%, n ¼ 88) admitted self-harming behavior. Self-
harm was reported to be due to dislike of dentofacial appearance among 12.9% of participants (n ¼
90). Higher CPQ 11–14 total scores and individual dimension scores were associated with the
presence of self-harm (P , .001). High self-harm incidence was reported among participants who
had dentofacial features that affected appearance (P , .001). Among subjects admitting self-harm,
the frequency of self-harming behavior ranged from once to over 10 times per year.
Conclusions: Significant relationships were found between self-harm and dislike of dentofacial
features and OHRQoL. (Angle Orthod. 2022;92:240–246.)
KEY WORDS: Self-harm; Oral health-related quality of life

INTRODUCTION regarding the effects of bullying, particularly related to

dentofacial features, and self-harm in 13- to 14-year-
Self-harm may be defined as any act of self-
old school children.2 A relatively high experience of this
poisoning or self-injury carried out by an individual
phenomenon has been reported by adolescent school
irrespective of motivation.1 Relatively little is known
children, with many reporting self-harm as a result of
about the etiology and characteristics of children and
their dentofacial appearance and bullying due to
adolescents, particularly under the age of 15 years,
dentofacial features.3
engaging in such behavior. Even less is known
Researchers have found that attractive dental
a
Professor of Orthodontics, Department of Orthodontics and appearance is of great importance to adolescents4
Pediatric Dentistry, School of Dentistry, The University of Jordan, and that dentofacial esthetics represents an important
Amman, Jordan. factor in self-esteem.5 Several investigations have
b
Consultant, Kingston Hospital and St George’s Hospital and
Medical School, London, United Kingdom.
found an association between negative body attitudes,
c
Consultant, Great Ormond Street Hospital, London, United body image and dissatisfaction, and self-harm.6–8
Kingdom. Researchers have also found that adolescents who
d
Professor, Department of Prosthodontics, School of Dentist- show disregard for their body may be more prone to
ry, The University of Jordan, Amman, Jordan.
Corresponding author: Dr Ahmad M. Hamdan, Department of engaging in self-harm when faced with ‘‘aversive,
Orthodontics and Pediatric Dentistry, The University of Jordan, overwhelming emotional states.’’9
Amman 11942, Jordan. Oral health-related quality of life (OHRQoL) is
(e-mail: hamdan-a@ju.edu.jo)
defined as the absence of negative effects of oral
Accepted: October 2021. Submitted: June 2021.
Published Online: December 8, 2021
conditions on social life and a positive sense of
Ó 2022 by The EH Angle Education and Research Foundation, dentofacial self-confidence.10 Systematic reviews have
Inc. shown that malocclusion has a negative impact on

Angle Orthodontist, Vol 92, No 2, 2022 240 DOI: 10.2319/060421-448.1

ORAL HEALTH-RELATED QUALITY OF LIFE AND SELF-HARM 241

OHRQoL, which usually increases with the severity of School principals were contacted to obtain approval
the malocclusion.11–13 for their school to participate in the study. Consent
A positive association between self-harm and letters were sent to all parents who had children in the
bullying victimization was reported in adolescents.14 eighth grade. The consent form explained the nature
Among self-harmed children in the UK, 66% were and goals of the study. All eighth-grade school children
victims of bullying.15 In Jordan, previous work has who agreed to participate were included in the study.
shown that 47% of 11- to 12-year-old children reported The questionnaire was distributed in the classroom in
being bullied, with the most common targeted feature the presence of teachers, but the children completed
being the teeth.16 the questionnaires with no assistance. One of the
The aim of this investigation was to investigate the researchers was available to clarify any items in the

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potential relationship between self-reported self-harm questionnaire that were not clear to participants. Any
due to dentofacial features and OHRQoL. questionnaire that was not completed correctly was
excluded from further analysis.
MATERIALS AND METHODS
Statistical Analysis
Ethical approval for the study was obtained from the
Research and Ethics Committee at the University of Statistical Package for Social Sciences computer
Jordan. The Ministry of Education in Jordan gave software (IBM SPSS Statistics v19; IBM Corp, Armonk,
approval to carry out the study in schools in the capital. NY, USA) was used for statistical analyses. A
This was a cross-sectional, observational study Kolmogorov-Smirnov test showed that the data were
involving a representative sample of 8th grade school- not normally distributed. Chi square test was used to
children (13 to 14 years old) in Amman. A total of 851 identify associations between different self-harm and
school children were invited to participate in the study. OHRQoL variables. The Mann-Whitney U test was
Twenty-three schools randomly selected from a list of used to identify differences between groups according
all schools in the 10 educational directorates in Amman to gender, presence of self-harm, and presence of
were asked to participate. dentofacial features that affected appearance. Alpha
The Child and Adolescent Self-harm in Europe (a)  0.05 was regarded as significant.
(CASE) questionnaire17 was used in the present study. Hierarchical logistic regression analysis was used to
The questionnaire was anonymous and self-harm was assess the odds of the presence of self-harm in
recorded if school children answered ‘‘yes’’ to the relation to OHRQoL and CPQ scores. Confounding
following question:17 ‘‘Have you ever hurt yourself on effects of gender, school directorate, being from private
purpose in any way?’’ The frequency of self-harm or public school, and having dentofacial features that
during the last year was assessed by asking the affected appearance were evaluated in the regression
participants to identify how many times they harmed models.
themselves during the last year. According to Hanania et al.,20 the self-harm preva-
Questions to assess the link between self-harm and lence was 22.6% among a population of 11- to 19-
dentofacial features that affect appearance were year-old adolescents in Amman, Jordan. Therefore,
modified from the questionnaire used by Al-Bitar et this was used as the proportion of the population (effect
al.3 It included questions about possible contribution of size) during the sample size estimation for this study.
various dentofacial features that affect the appearance The sample size for this study was then calculated
to self-reported self-harm.16 The dentofacial features using computer software (G*Power, version 3.1.9.7;
were proclined upper anterior teeth, proclined lower Heinrich-Heine University, Düsseldorf, Germany). A
anterior teeth, forward chin position, crooked teeth, priori power analysis using logistic regression test
tooth shape or color, presence of a gap between the showed that a total sample size of 662 participants was
teeth or having missing teeth, anterior open bite, required to obtain an effect size of 22.6%, a two-tailed
gummy smile, incompetent lips, wearing fixed ortho- significance level (a) of .05, a Z score of 1.96 for 95%
confidence intervals, an odds ratio of 1.3, and a study
dontic appliances, and wearing removable orthodontic
power (1 – b) of 80%. Extra participants were invited
appliances.
and recruited to compensate for possible dropouts or
The short version of the Arabic Child Perception
incomplete answers
Questionnaire (CPQ) was used for assessing oral
health-related quality of life in 11- to 14-year-olds (CPQ
RESULTS
11–14).15–18 The original questionnaire was developed
by Jocovic et al19 and is divided into four health Of the 851 students approached to participate in the
domains: oral symptoms, functional limitations, emo- study, the parents of 85 (9.9%) children declined their
tional well-being, and social well-being. participation in the study and 67 questionnaires were

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242 AL-BITAR, HAMDAN, AL-OMARI, NAINI, GILL, AL-OMIRI

Table 1. Descriptive Statistics of Oral Health Related Quality of Life and Frequency of Self-Harm Among the Study Samplea
Participants With Participants With
All Participants Self-Harm no Self-Harm
(n ¼ 699) (n ¼ 188) (n ¼ 511)
Median IQR Range Median IQR Range Median IQR Range
Total CPQ Score 14 16 0–59 19 18 0–59 12 15 0–59
Oral Symptoms score 5 5 0–16 6.5 5 0–14 5 4 0–16
Functional Limitations score 3 5 0–16 5 6 0–16 2 6 0–16
Emotional Wellbeing score 4 7 0–16 5 7 0–16 3 5 0–16
Social Wellbeing score 1 3 0–16 2 6 0–16 0 3 0–16
Global rating of child’s oral health score 2 2 0–4 2 2 0–4 2 1 0–4

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Effects of oral condition on overall wellbeing score 1 1 0–4 2 2 0–4 1 1 0–4
a
CPQ indicates Child Perception Questionnaire; IQR, interquartile range.

incomplete and thereby excluded. The final sample oral symptom CPQ scores (P ¼ .001) and higher social
comprised 699 students (339 girls and 360 boys), well-being scores (P ¼ .039) than females. Among
representing 82% of the invited students and 1.26% of participants who did not report self-harm, the total CPQ
all eighth grade students in Amman. scores ranged from 0 to 59 (mean score 6 SD: 14.53
Self-harm was reported by 26.9% (99 males and 89 6 10.62, median ¼ 12) (Table 1). Statistical analyses
females) of participants (P , .001). Dentofacial using Mann-Whitney U-test showed no significant
features that affected appearance were identified by gender differences (P . .05) except that females
12.9% (46 males and 44 females) of participants as reported higher effects of oral condition on overall well-
being the main reason for self-harming behavior (P , being (P ¼ .038) than males.
.001). Frequency of reported self-harm in the previous The participants who reported self-harm scored
year was as follows: 80 participants (42.6%) harmed higher total CPQ scores, CPQ individual dimension
themselves once, 57 (30.3%) harmed themselves 2–5 scores, global oral health ratings, and effects of oral
times, 23 (12.2%) harmed themselves 6–10 times, and condition on overall well-being (ie, signifying a worse
28 (14.9%) harmed themselves more than 10 times. impact on OHRQoL) than the participants who reported
Table 1 illustrates descriptive statistics of oral health- no self-harm (P , .001, Table 2). The frequency of self-
related quality of life and frequency of self-harm among harm was not related to the total CPQ scores, CPQ
the study sample. The total CPQ scores ranged from 0 individual dimension scores, global oral health ratings,
to 59 (mean score 6 SD: 16.19 6 11.54, median ¼ 14) or the effects of oral condition on overall well-being (P
(Table 1). Statistical analyses using Mann-Whitney U- . .05, Table 3).
test showed no significant gender differences for all
High self-harm incidence was reported among
measured variables (P . .05). Among the participants
participants who had dentofacial features that affected
who reported self-harm, the total CPQ scores ranged
their appearance (P , .001). The presence of
from zero to 59 (mean score 6 SD: 20.71 6 12.70,
dentofacial features that affected appearance was
median ¼ 19) (Table 1). Statistical analyses using
associated with higher total CPQ scores, CPQ
Mann-Whitney U-test showed no significant gender
individual dimension scores, global oral health ratings,
differences (P . .05) except that males reported higher
Table 3. Relationship Between Oral Health Related Quality of Life
Table 2. Differences in Oral Health Related Quality of Life Between
and Frequency of Self-Harm Among Study Sample who Reported
Participants who Reported Self-Harm (n ¼ 188) and Participants who
Self-Harm (n ¼ 188)a
did not Report Self-Harm (n ¼ 511) in the Study Sample (nTotal ¼ 699)a
Frequency of Self-Harm
Variables M-W U Z P
Variables X2 df P
Total CPQ Score 33724.500 -6.048 ,.001
Oral Symptoms score 37550.000 -4.446 ,.001 Total CPQ Score 195.897 192 .408
Functional Limitations score 35840.500 -5.198 ,.001 Oral Symptoms score 64.817 56 .196
Emotional Wellbeing score 36152.500 -5.051 ,.001 Functional Limitations score 53.168 64 .831
Social Wellbeing score 37516.500 -4.728 ,.001 Emotional Wellbeing score 57.143 64 .716
Global rating of child’s oral 36704.500 -4.953 ,.001 Social Wellbeing score 52.267 64 .853
health score Global rating of child’s oral 20.208 16 .207
Effects of oral condition on 39254.000 -3.815 ,.001 health score
overall wellbeing score Effects of oral condition on 13.254 16 .654
overall wellbeing score
a
CPQ indicates Child Perception Questionnaire; M-W U, Mann-
Whitney U-test coefficient; Z, Z statistics using Mann-Whitney U-test; a
CPQ indicates Child Perception Questionnaire; X2, Chi square
P, 2-tailed probability value. test coefficient; df, degree of freedom; P, 2-tailed probability value.

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ORAL HEALTH-RELATED QUALITY OF LIFE AND SELF-HARM 243

Table 4. Differences in Oral Health Related Quality of Life Between more open and honest responses, mainly because
Participants who had Dentofacial Features That Affected self-harm is considered a secretive behavior.
Appearance (n ¼ 90) and Participants who did not Have Such
Facial Features (n ¼ 609) in the Study Sample (nTotal ¼ 699)a
Gender variations in reported self-harm among
different populations have been contradictory. Some
Variables M-W U Z P
researchers identified a higher tendency for self-harm
Total CPQ Score 15137.000 -6.865 ,.001 among females,25–28 whereas others found no gender
Oral symptoms score 19918.500 -4.203 ,.001
differences.29 In this study, no significant gender
Functional limitations score 17322.500 -5.690 ,.001
Emotional wellbeing score 16316.500 -6.241 ,.001 differences were found for any investigated parame-
Social wellbeing score 17688.500 -5.783 ,.001 ters.
Global rating of child’s oral 19333.000 -4.672 ,.001 Significant relationships were found between self-
health score

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harm and OHRQoL. Worse impacts on OHRQoL were
Effects of oral condition on 19723.000 -4.419 ,.001
associated with presence of self-harm, higher frequen-
overall wellbeing score
cy of self-harm during the previous year, and presence
a
CPQ indicates Child Perception Questionnaire; M-W U, Mann-
Whitney U-test coefficient; Z, Z statistics using Mann-Whitney U-test;
of self-harm due to dentofacial features. Facial features
P, 2-tailed probability value. may have negatively impacted OHRQoL, leading to
distress that might have caused individuals to inflict
and effects of oral condition on overall well-being (ie, self-harm. This might have also been influenced by the
signifying a worse impact on OHRQoL) (P , .001, psychological impact of poor OHRQoL and dentofacial
Table 4). The presence of dentofacial features that features.
affected appearance was not related to the frequency Reported self-harm prevalence in the current study
of self-harm (P ¼ .093). was 26.9%. This was slightly higher than that
previously reported among 11–19 years old adoles-
Hierarchical logistic regression showed that global
cents (22.6%) in Jordan.20 This difference could have
ratings of child’s oral health, CPQ total scores, and
been due to differences in age and underlying
CPQ dimensional scores of oral symptoms, functional
socioeconomic conditions of tested populations. In
limitations, and emotional wellbeing were able to
addition, the level of self-harm among the population of
predict and contributed toward the presence of self-
this investigation was higher than those reported in
harm (P , .05, Table 5). Participants who scored Scotland (13.8%), 27 Ireland (9.2%),30 and Japan
higher on these oral health related quality of life (9.9%).31 This variation might be attributed to variations
parameters would have higher odds of reporting self- in cultural and ethnic backgrounds, age, socioeconom-
harm (Table 5). The covariance and confounding ic status, tested populations, and psychological attri-
effects of gender, being from private or governmental butes. Nevertheless, the reported levels of self-harm in
school, the school district, and having dentofacial this study agreed with a previous cross-national study
features that affected appearance were considered in Germany and the USA, which reported comparable
and were not found to have significant effects (P . levels of self-harm (26% and 23%, respectively).26 In
.05). addition, the levels of self-harm among this study
population were comparable to those reported by
DISCUSSION Giletta et al. in Italy (24%), the Netherlands (26%),
and the USA (22%).28
Previous investigators reported associations be-
Over a quarter (26.9%) of 13- to 14-year-old children
tween dentofacial esthetics and OHRQoL, bullying,
investigated admitted self-harming behavior, with
self-esteem, body image, and well-being.16,21–23 How-
almost half of this group (12.9%) admitting that the
ever, none investigated the relationship between self-
reason was related to their facial appearance. As the
harm, dislike with dentofacial features, and OHRQoL. study sample was just over 1% of 13- to 14-year-old
A total of 188 of 699 school children admitted self- school children in Amman, extrapolation of the data to
harming behavior from once to 10 times in a 1-year the population of the city in this age group would
period, and 90 claimed this to be due to dislike of their suggest approximately 14,000 children involved in self-
dentofacial appearance. These findings highlight the harming behavior, 7000 due to concerns with their
potential role that dentofacial features might play in facial appearance. Even as an approximation, these
self-harm among adolescents. are distressingly large numbers and warrant applica-
Earlier investigations showed that the age of onset of tion of measures to confront the issue.
self-harm was 12–14 years.20,24 Consequently, children This investigation presented baseline data to im-
in the eighth grade (aged 13–14 years) were selected prove understanding and cast light on the associations
for this study. A self-reported questionnaire rather than between deliberate self-harm, self-perceived dentofa-
an interview was used in the present study to obtain cial appearance, and oral health-related quality of life.

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244 AL-BITAR, HAMDAN, AL-OMARI, NAINI, GILL, AL-OMIRI

Table 5. Prediction of Self-Harm Presence Utilizing the Scores of Different Oral Health Related Quality of Life Variables and Other Covariates
Among the Study Population Using the Hierarchical Logistic Regression Analysis (n ¼ 699)a
Exp (B) 95% CI
Models to Predict Self-harm Using OHRQoL Variables* B SE df Sig. Exp (B) Lower Upper
Self-harm presence and Global rating of child’s oral health (Block 2 Nagelkerke R ¼ .510, Block 2 Hosmer and Lemeshow test
2

probability value [P] ¼ .750)

Gender .007 .233 1 .978 1.007 .638 1.589
School directorate 9 .036
Being from private or public school .919 .529 1 .082 2.507 .889 7.069
Dentofacial appearance 23.030 5598.599 1 .997 1.004E10 .000 .
Global rating of child’s oral health .308 .106 1 .004 1.361 1.105 1.675

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Self-harm presence and Effects of oral condition on overall wellbeing (Block 2 Nagelkerke R2 ¼ .503, Block 2 Hosmer and Lemeshow
test probability value [P] ¼ .372)
Gender -.048 .231 1 .835 .953 .605 1.500
School directorate 9 .048
Being from private or public school .947 .529 1 .073 2.579 .914 7.276
Dentofacial appearance 23.045 5632.291 1 .997 1.019E10 .000 .
Effects of oral condition on overall wellbeing .177 .096 1 .066 1.194 .989 1.442
Self-harm presence and Total CPQ scores (Block 2 Nagelkerke R2 ¼ .507, Block 2 Hosmer and Lemeshow test probability value [P] ¼
.223)
Gender -.004 .232 1 .985 .996 .632 1.568
School directorate 9 .041
Being from private or public school .867 .525 1 .099 2.379 .850 6.656
Dentofacial appearance 22.948 5614.534 1 .997 9.251E9 .000 .
Total CPQ scores .027 .010 1 .008 1.028 1.007 1.048
Self-harm presence and CPQ oral symptoms scores (Block 2 Nagelkerke R2¼ .505, Block 2 Hosmer and Lemeshow test probability value
[P] ¼ .847)
Gender .000 .232 1 1.000 1.000 .635 1.575
School directorate 9 .066
Being from private or public school .768 .525 1 .143 2.156 .771 6.033
Dentofacial appearance 23.031 5615.833 1 .997 1.005E10 .000 .
CPQ oral symptoms scores .082 .035 1 .020 1.085 1.013 1.162
Self-harm presence and CPQ functional limitations scores (Block 2 Nagelkerke R2 ¼ .505, Block 2 Hosmer and Lemeshow test
probability value [P]¼ .715)
Gender -.048 .232 1 .837 .953 .606 1.501
School directorate 9 .048
Being from private or public school .881 .525 1 .093 2.414 .862 6.761
Dentofacial appearance 22.977 5624.890 1 .997 9.526E9 .000 .
CPQ functional limitations scores .075 .032 1 .018 1.078 1.013 1.147
Self-harm presence and CPQ emotional wellbeing scores (Block 2 Nagelkerke R2 ¼ .504, Block 2 Hosmer and Lemeshow test probability
value [P] ¼ .657)
Gender -.019 .231 1 .936 .982 .624 1.544
School directorate 9 .047
Being from private or public school .840 .524 1 .109 2.317 .829 6.474
Dentofacial appearance 22.937 5637.953 1 .997 9.146E9 .000 .
CPQ emotional wellbeing scores .061 .029 1 .036 1.063 1.004 1.126
Self-harm presence and CPQ social wellbeing scores (Block 2 Nagelkerke R2 ¼ .501, Block 2 Hosmer and Lemeshow test probability
value [P] ¼ .505)
Gender -.002 .231 1 .994 .998 .634 1.571
School directorate 9 .070
Being from private or public school .908 .527 1 .085 2.479 .883 6.961
Dentofacial appearance 22.979 5651.177 1 .997 9.544E9 .000 .
CPQ social wellbeing scores .051 .033 1 .118 1.052 .987 1.122
a
B indicates the B coefficient of the model; CI, confidence intervals; df, degree of freedom; Exp (B), exponentiated B coefficients (odds ratio);
OHRQoL, oral health-related quality of life; SE, standard error; Sig., significance of 2-tailed probability value (P).
* For the hierarchical logistic regression analysis, variables entered in Block 1: Gender, being from private or public school, school directorate,
and having dentofacial features. Variables entered in Block 2: Oral health related quality of life variables. For each model, the predicted overall
percentage for Block 0 (Beginning Block), Block 1, and Block 2 equals 73.1, 86.0, and 86.0 respectively. Nagelkerke R2 for Block 1 in every model
¼ .498. Hosmer and Lemeshow test probability value (P) for Block 1 in every model ¼ .882.

There were some limitations to this investigation. The incomplete responses, and this might have been
cross-sectional design precluded longitudinal evalua- caused by sociocultural attributes and sensitivity of
tion of the tested parameters. Also, 152 invited this issue. This could have potentially affected the
students either did not agree to participate or provided results. However, the response rate was high in this

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ORAL HEALTH-RELATED QUALITY OF LIFE AND SELF-HARM 245

study and the number of included participants was far psychopathology, relationship variables, and styles of
more than the estimated sample size required for this emotional regulation? Cogn Behav Ther. 2008;37:26–37.
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non-suicidal self-injury in adolescents. J Adolesc. 2012;35:
of a large metropolitan city, the size of classrooms,
1–9.
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impact of malocclusions on oral health-related quality of life
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