|Year : 2014 | Volume
| Issue : 3 | Page : 179-184
Factors influencing the perceived orthodontic treatment need and its relationship with awareness of malocclusion among college adolescents
Sudha P Patil1, RH Harsha2, Abhay B Mane3, Jitendra H Sharma4, Prabhakar R Patil5
1 Department of Anatomy, Navodaya Dental College, Raichur, Karnataka, India
2 Department of Prosthodontics, Navodaya Dental College, Raichur, Karnataka, India
3 Department of Community Medicine, Smt. Kashibai Navale Medical College, Pune, Maharashtra, India
4 Department of Internee, Navodaya Medical College, Raichur, Karnataka, India
5 Department of Pharmacology, Navodaya Medical College, Raichur, Karnataka, India
|Date of Web Publication||15-Nov-2014|
Abhay B Mane
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: The orthodontic need assessment is of interest for dental public health programs. The major factors determining a patient's perceived need for orthodontic treatment may be aesthetic, functional, financial, or social. Adolescents seeking orthodontic treatment have been found to have poorer aesthetics than their peers, but whether poor aesthetics alone generates greater treatment demand has not been determined in the Indian context. Objective: The aim was to study the factors determining perceived orthodontic treatment need among college adolescents. Materials and Methods: A total of 448 adolescents between 17 and 19 years of age were selected randomly from the colleges. Data were collected on pretested and standardized questionnaire. Perceived need for orthodontic treatment was assessed by asking question to the participants. Dental Esthetic Index (DAI) was used to assess the severity of malocclusion. Results: The prevalence of malocclusion was 21.6% as per DAI. The perceived need for orthodontic treatment was 11.2%, though the level of dissatisfaction with dental appearance was 19.2%. No agreement was seen between the treatment need assessed objectively by DAI and that perceived by the patient. The determinants for perceived and normative orthodontic treatment need were socioeconomic status (SES), awareness of malocclusion, dissatisfaction with dental appearance and avoided smile due to dental appearance. The positive correlation between perceived and normative need was statistically significant. Conclusion: The uptake of orthodontic care may be influenced by SES, awareness of malocclusion; dissatisfaction with dental appearance, perceived need and DAI score.
Keywords: Adolescent, dental aesthetic index, orthodontic treatment need, perceived need
|How to cite this article:|
Patil SP, Harsha R H, Mane AB, Sharma JH, Patil PR. Factors influencing the perceived orthodontic treatment need and its relationship with awareness of malocclusion among college adolescents. J Indian Assoc Public Health Dent 2014;12:179-84
|How to cite this URL:|
Patil SP, Harsha R H, Mane AB, Sharma JH, Patil PR. Factors influencing the perceived orthodontic treatment need and its relationship with awareness of malocclusion among college adolescents. J Indian Assoc Public Health Dent [serial online] 2014 [cited 2020 Jul 6];12:179-84. Available from: http://www.jiaphd.org/text.asp?2014/12/3/179/144789
| Introduction|| |
Societal forces define the norms for an acceptable, normal, and attractive physical appearance. Increased concern over dental appearance has been observed during childhood and adolescence to early adulthood. Social interactions that have a negative effect on self-image, career advancement, and peer-group acceptance have been associated with an unacceptable dental appearance.  The orthodontic treatment need and demand assessment is of interest for dental public health programs, clinical treatment and screening for treatment priority. The major factors determining a patient's perceived need for orthodontic treatment may be broadly described as aesthetic, functional, financial, or social.  Esthetics was of greater concern to children seeking orthodontic treatment than to other children. In young adults, even a minor deviation can be of perceived importance and the impact of malocclusion on the quality-of-life might be profound. Cultural or geographic origin can also influence demand for treatment. High correlations have been reported between dental aesthetics, need for treatment, and severity of malocclusion in clinical assessments. The desire for treatment by individuals who are dissatisfied with their appearance underlies most orthodontic treatments. For this reason, the orthodontist's objective is to improve the function and appearance and to ensure patient satisfaction at the end of treatment. Patients' awareness of their appearance and their satisfaction are, therefore, important to orthodontists.
The Dental Aesthetic Index (DAI) as an international index identifies occlusal traits and mathematically derives a single score. DAI scores have also been found to be significantly associated with the perception of treatment need by students and parents. 
Adolescents seeking orthodontic treatment have been found to have poorer aesthetics than their peers, but whether poor aesthetics alone generates greater treatment demand has not been determined in the Indian context. Understanding the factors involved in the demand for orthodontic treatment in a particular population enables a better planning of resources as well as a better assessment of treatment needs and priorities.
The aim of the present study was to investigate the association between self-perceived orthodontic treatment need and malocclusion in adolescents. The objectives were to study the factors determining perceived orthodontic treatment need among college adolescents and to explore the relationship between awareness of malocclusion and its severity using the DAI.
| Materials and Methods|| |
The present study was a cross-sectional and descriptive that enrolled adolescents between 17 and 19 years of age studying in various colleges in Raichur, Karnataka. A pilot study was conducted on 30 adolescents to calculate the sample size using Epi Info 7 (CDC, Atlanta, USA) for a cross-sectional study with 95% confidence interval and design effect as 1. The estimated sample was 428.
A list of colleges was prepared, and 10 colleges were selected randomly by ballot for the study. The remaining 5 colleges did not give permission for the study due to administrative problems such as exams, sports and cultural activities in the college. The required sample was selected by simple random sampling method from each of the selected colleges by probability proportion to the size. Permission was obtained from the principal of the respective college. The study was approved by the Institutional Ethics Committee. Prior to the examination, the subjects signed an informed consent form after explaining the purpose of the study. The study was conducted from 1 st July to 31 st August 2012 as per the schedule. In the end, 448 adolescents participated in the study after meeting the inclusion criteria.
The inclusion criteria for the study were adolescents between 17 and 19 years who had not undergone any orthodontic treatment and willing to participate in the study. The two chosen examiners were dental interns who were trained and calibrated before the study commenced, assessing the agreement between their diagnoses of orthodontic treatment need using DAI. The kappa values for inter-examiner and intra-examiner agreement for DAI scores for the examiners were 0.80 and 0.87 respectively indicating good agreement. The subjects were examined by following the standard guidelines and procedures as suggested by American Dental Association. Inspection was done in good daylight illumination using mirror and probe. A community periodontal index probe was used for measurements in millimeters. The DAI as described by the World Health Organization (WHO) oral health survey, 1997 was used to assess the severity of malocclusion. All the 10 components were measured. Oral health education was given to the students and those who needed orthodontic treatment were referred to the Dental College and Hospital.
Master chart was prepared in excel after coding and further processed using SPSS Version 17.0 (SPSS Inc, Chicago, USA). Mean and standard deviation (SD) was calculated for continuous variables. Proportions were computed for qualitative variables. The tests of significance used were unpaired t-test and Chi-square test with a P ≤ 0.05 considered to be significant. Spearman rank-order correlation coefficients were computed to determine correlation between various factors and DAI scores.
| Results|| |
A total of 448 subjects were examined in the present study comprising 187 (41.7%) males and 261 (58.3%) females. The main sociodemographic characteristics of the study population are shown in [Table 1]. The mean age (SD) of the sample was 18.2 ± 0.6 years. Majority of participants were of 18 years of age [Figure 1].
Only 11.4% of subjects felt that their teeth looked much worse or worse than peers. About 25% of them avoided smile due to their teeth often or sometimes. Majority of subjects (95.1%) said they felt that their general appearance was same or better than peers while only few (4.9%) said worse. Among the total aware of malocclusion (41.7%), only 19.2% were dissatisfied with their dental appearance [Table 2].
The perceived need for orthodontic treatment was 11.2% while another 15% were uncertain. The prevalence of malocclusion by DAI score was 21.6% in the present study. The mean DAI score of the sample was 21.0 ± 4.6. There were no statistically significant (t = 0.37, P > 0.05) gender differences between the mean DAI scores in males (21.1 ± 4.3) and females (20.9 ± 4.7) [Figure 2].
|Figure 2: Mean Dental Aesthetic Index scores between male and female participants|
Click here to view
Different factors were assessed if they influenced the perceived need for treatment as shown in [Table 3]. Higher numbers of females (13.0%) than males (8.6%) were found to have perceived a need that was statistically not significant (P > 0.05). The younger age group of 17-year-old expressed a higher need for dental brace (20.8%) than the older group (10.0%), which was statistically significant (P < 0.05). Socioeconomic status (SES) also showed a significant association (P < 0.05) in determining the perceived need. When compared between upper high and high level together, (9.6%) against the middle and lower category (18.9%) together showed a significant difference in perceived need among them. The year of study of participants did not show a significant association for perceived need for treatment (P > 0.05). Awareness of malocclusion among 33 (17.6%) adolescents significantly (P < 0.01) influenced the perceived need compared to 17 (6.5%) who were unaware. Those who were dissatisfied (22.1%) with their dental appearance showed significantly higher (P < 0.01) perceived need than satisfied group. The participants with DAI score >25 showed a statistically significant higher perceived need of 20.6% as compared to 8.5% in subjects with score <25 (χ2 = 11.16, P < 0.01). Participants who avoided smile due to dental appearance showed a higher prevalence of 24.1% than who never avoided smile that was 6.8%. This difference in prevalence of perceived need among them was statistically significant (χ2 = 25.24, P < 0.01).
The significant determinants (P < 0.05) for normative need in the present study were SES, year of study, awareness of malocclusion, dissatisfaction with dental appearance, perceived need and avoid smile due to dental appearance. These findings are depicted in [Table 4].
|Table 4: Determinants of normative need for orthodontic treatment assessed by DAI |
Click here to view
The spearman rank-order correlation was not statistically significant (P > 0.05). But the subjects awareness of malocclusion showed a positive correlation (r = 0.174) at 0.01 level with perceived need. The subjects dissatisfaction with their dental appearance and perceived need showed a significant positive correlation at 0.01 level (r = 0.263). Similarly, a significant positive correlation (r = 0.179) was found between dissatisfaction with dental appearance and normative need. Hence, the participants' awareness of malocclusion did not agree with their objectively determined normative need but agreed with perceived need. The participant's dissatisfaction with dental appearance did agree with the perceived need as well as normative need.
| Discussion|| |
The primary goal of the present study was to detect the prevalence of malocclusion in adolescents between 17 and 19 years. It also investigated the factors influencing both the perceived need and the normative need. The prevalence of malocclusion was found to be 21.6% by DAI. The present study reveals the perceived need for orthodontic treatment to be only 11.2% though the level of dissatisfaction with dental appearance was higher (19.2%). There was no agreement between the treatment need assessed objectively by DAI and that perceived by the patient. The relationship between the orthodontic treatment need determined by the indices employed and the patient's own perception of malocclusion found no clear relationship between objective and perceived need. This observation is in agreement with other studies. ,,, In a similar study  the majority of the children (79.9%) required no or little treatment and 20.1% had definite malocclusion requiring definite orthodontic treatment. Higher prevalence of 42% was reported by another Indian study using DAI. 
The prevalence of malocclusion among adolescents can be greatly reduced by early intervention. Hence identifying the factors influencing the perceived need among the adolescent population in this region of Karnataka is important. The mean DAI scores did not differ statistically between the genders. The current evidence regarding the influence of gender and SES on both normative and perceived need for orthodontic treatment is not consistent. A higher need for females than for males has been suggested.  In the present study, female adolescents had a greater need for treatment than males which is similar to a study,  but inconsistent with other study.  No statistical gender differences in perceived need and normative need for treatment was found similar to other studies. , This finding is in contrast to studies , that concluded that males were more likely to seek orthodontic treatment. This means that awareness of malocclusion and seeking treatment cannot be explained by an individual's gender from the present study.
Most of the determinants of perceived and normative orthodontic treatment need were similar in the present study. The determinants common for both were SES, awareness of malocclusion, dissatisfaction with dental appearance and avoid smile due to dental appearance. We found that the only additional determinant for perceived need was age and for normative need was year of study. The correlation between perceived need and normative need was found to be statistically significant (P < 0.01). The awareness of malocclusion and dissatisfaction with dental appearance among participants agreed with their objectively determined and perceived orthodontic need. This finding is in agreement with other studies , but in contrast to the study.  Hence, the desire for treatment who are dissatisfied with their appearance underlies most orthodontic treatments. Patient's awareness of their appearance and their satisfaction are, therefore, important to orthodontists for patient satisfaction. The greater the severity of the malocclusion the higher the degree of treatment need. The complexity of cases in a particular region is extremely important because it is found that the pretreatment DAI score to be a good indicator of treatment difficulty. Cases with higher pretreatment scores took longer time to treat. , There was also a large group who were uncertain about their need for treatment (15%) showing less awareness among them. Similar findings have been documented in both epidemiological studies and orthodontic patient populations in previous studies. ,
Limitation of the study would be that it is a college based study. Hence, adolescents as college dropouts are not included that may not give the clear picture of the community.
Malocclusion can be considered a public health problem due to its high prevalence and prevention/treatment possibilities. A number of studies have been demonstrated its impact on quality of life , and it has been considered the third highest oral health priority by the WHO. 
| Conclusion|| |
The overall prevalence of malocclusion among adolescents aged 17-19 years was 21.6%. The corresponding need for orthodontic treatment was expressed by only half of them (11.2%). The uptake of orthodontic care may be influenced by SES, awareness of malocclusion; dissatisfaction with dental appearance, perceived need as well as by the dentist's rating by DAI for treatment need. There is a definitive need for orthodontic treatment among adolescents, which is not matched with a similar level of perceptive need by the same population.
Hence, we recommend that the awareness of malocclusion should be improved among the adolescents that will create a higher perceived need for an early orthodontic treatment. Further studies are required to improve our understanding of normative and perceived need for orthodontic treatment, especially in developing countries like India.
| Acknowledgment|| |
This research paper is from the project selected by the Indian Council of Medical Research (ICMR) as STS-2012 project. All the authors are thankful to ICMR and duly acknowledge their support.
| References|| |
Adams GR. Physical attractiveness research: Toward a developmental psychology of beauty. Hum Dev 1997;20:217-39.
Josefsson E, Bjerklin K, Halling A. Self-perceived orthodontic treatment need and culturally related differences among adolescents in Sweden. Eur J Orthod 2005;27:140-7.
Spencer AJ, Allister JH, Brennan DS. Utility of the Dental Aesthetic Index as an Orthodontic Screening Tool in Australia. Adelaide, Australia: University of Adelaide; 1992.
Hamdan AM. The relationship between patient, parent and clinician perceived need and normative orthodontic treatment need. Eur J Orthod 2004;26:265-71.
Bernabé E, Flores-Mir C. Normative and self-perceived orthodontic treatment need of a Peruvian university population. Head Face Med 2006;2:22.
Tuominen ML, Nyström M, Tuominen RJ. Subjective and objective orthodontic treatment need among orthodontically treated and untreated Finnish adolescents. Community Dent Oral Epidemiol 1995;23:286-90.
Kerosuo H, Kerosuo E, Niemi M, Simola H. The need for treatment and satisfaction with dental appearance among young Finnish adults with and without a history of orthodontic treatment. J Orofac Orthop 2000;61:330-40.
Shivakumar K, Chandu G, Shafiulla M. Severity of malocclusion and orthodontic treatment needs among 12- to 15-year-old school children of Davangere district, Karnataka, India. Eur J Dent 2010;4:298-307.
Poonacha KS, Deshpande SD, Shigli AL. Dental aesthetic index: Applicability in Indian population: A retrospective study. J Indian Soc Pedod Prev Dent 2010;28:13-7.
Holmes A. The subjective need and demand for orthodontic treatment. Br J Orthod 1992;19:287-97.
Onyeaso CO, Sanu OO. Perception of personal dental appearance in Nigerian adolescents. Am J Orthod Dentofacial Orthop 2005;127:700-6.
Burden DJ, Mitropoulos CM, Shaw WC. Residual orthodontic treatment need in a sample of 15- and 16-year-olds. Br Dent J 1994;176:220-4.
Roberts EE, Beales JG, Dixon L, Willcocks AJ, Willmot DR. The orthodontic condition and treatment status of a sample of 14-year-old children in North Derbyshire. Community Dent Health 1989;6:249-56.
Brown DF, Spencer AJ, Tolliday PD. Social and psychological factors associated with adolescents' self-acceptance of occlusal condition. Community Dent Oral Epidemiol 1987;15:70-3.
Otuyemi OD, Ugboko VI, Adekoya-Sofowora CA, Ndukwe KC. Unmet orthodontic treatment need in rural Nigerian adolescents. Community Dent Oral Epidemiol 1997;25:363-6.
Onyeaso CO. An assessment of relationship between self-esteem, orthodontic concern, and dental aesthetic index (DAI) scores among secondary school students in Ibadan, Nigeria. Int Dent J 2003;53:79-84.
Shue-Te Yeh M, Koochek AR, Vlaskalic V, Boyd R, Richmond S. The relationship of 2 professional occlusal indexes with patients' perceptions of aesthetics, function, speech, and orthodontic treatment need. Am J Orthod Dentofacial Orthop 2000;118:421-8.
Richmond S, O'Brien KD, Roberts CT, Andrews M. Dentists variation in the determination of orthodontic treatment need. Br J Orthod 1994;21:65-8.
Cassinelli AG, Firestone AR, Beck FM, Vig KW. Factors associated with orthodontists' assessment of difficulty. Am J Orthod Dentofacial Orthop 2003;123:497-502.
Onyeaso CO. Relationship between index of complexity, outcome and need and dental aesthetic index in the assessment of orthodontic treatment complexity and need of Nigerian adolescents. Pesqui Bras Odontopediatria Clin Integr 2008;8:141-5.
Onyeaso CO, Begole EA. Relationship between index of complexity, outcome and need, dental aesthetic index, peer assessment rating index, and American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop 2007;131:248-52.
Marques LS, Ramos-Jorge ML, Paiva SM, Pordeus IA. Malocclusion: Esthetic impact and quality of life among Brazilian schoolchildren. Am J Orthod Dentofacial Orthop 2006;129:424-7.
Bernabé E, Flores-Mir C, Sheiham A. Prevalence, intensity and extent of oral impacts on daily performances associated with self-perceived malocclusion in 11-12-year-old children. BMC Oral Health 2007;7:6.
World Health Organization. Health through Oral Health: Guidelines for Planning and Monitoring for Oral Health Care. London: World Health Organization (WHO) and Fédération Dentarie Internationale, Quintessence; 1989.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]