|Year : 2016 | Volume
| Issue : 1 | Page : 50-56
Dental esthetic perceptions and orthodontic treatment needs among school children aged 9–18 years of South Bengaluru: A cross-sectional study
S Athira1, HL Jayakumar2, Mahesh Chandra2, Taru Gupta3, PJ Swathy Anand4, C Dithi5
1 Department of Public Health Dentistry, Sri Sankara Dental College, Thiruvananthapuram, Kerala, India
2 Department of Public Health Dentistry, AECS Maaruti College of Dental Sciences and Research Centre, Bengaluru, Karnataka, India
3 Deparment of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA, USA
4 Department of Public Health Dentistry, Noorul Islam College of Dental Sciences, Thiruvananthapuram, Kerala, India
5 Department of Public Health Dentistry, Government Dental College, Thiruvananthapuram, Kerala, India
|Date of Web Publication||15-Mar-2016|
Department of Public Health Dentistry, Sri Sankara Dental College, Akathumuri, Vennicode P. O., Varkala, Thiruvananthapuram - 695 318, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Individual perception of malocclusion may vary from the clinician's point of view. Assessment of individual perception of malocclusion is important for treatment planning, priority setting, allocation of resources, as well as for patient education and motivation. Aim: To assess the perceptions of orthodontic treatment needs of school children and to find out the correlation, if any, between the subjective treatment need perceived by children and the objective need. Materials and Methods: The study was conducted among school children of South Bengaluru aged 9–18 years. The study was cross-sectional in design, and a convenience sampling method was adopted. The clinical examination was conducted using the Index of Orthodontic Treatment Need (IOTN) modified for use in epidemiological surveys (Modified IOTN). Chi-square/Fisher's exact test has been used to find the significance of study variables at 5% level of significance. Results: Among the participated children, 21% needed orthodontic treatment and among 79% of children there was no need for treatment according to the Dental Health Component (DHC) of the IOTN. There was a significant correlation between the subjective need for treatment and the IOTN-DHC. Conclusions: There exists a significant correlation between the subjective need for orthodontic treatment assessed using the index and the objective need perceived by the patient. Hence, it is necessary to evaluate the perceptions of subjects before beginning of any treatment planning to meet the expectations of patients in general as it is the patient who gains satisfaction from treatment.
Keywords: Esthetics, Index of Orthodontic Treatment Need, malocclusion, quality of life
|How to cite this article:|
Athira S, Jayakumar H L, Chandra M, Gupta T, Swathy Anand P J, Dithi C. Dental esthetic perceptions and orthodontic treatment needs among school children aged 9–18 years of South Bengaluru: A cross-sectional study. J Indian Assoc Public Health Dent 2016;14:50-6
|How to cite this URL:|
Athira S, Jayakumar H L, Chandra M, Gupta T, Swathy Anand P J, Dithi C. Dental esthetic perceptions and orthodontic treatment needs among school children aged 9–18 years of South Bengaluru: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2020 Dec 4];14:50-6. Available from: https://www.jiaphd.org/text.asp?2016/14/1/50/178724
| Introduction|| |
The concept and perception of malocclusion are more qualitative than quantitative when individuals are concerned. An individual's self-esteem can depend largely on appropriate facial features, beautiful smile, and well-aligned teeth. Orthodontic treatment needs are mainly assessed based on the clinician's point of view (normative need) neglecting the individual's subjective perceptions. A person's social needs cannot be neglected as the majority of the people seek orthodontic treatment to gain satisfaction from improved esthetics.,,
Overestimation of orthodontic treatment needs is the problem of major concern when need assessment is entirely based on clinician's point of view. What seems to be acceptable to the orthodontist may not be what the patients expect as the outcome of the treatment. Hence, it is better to incorporate patients' perceptions at the point of treatment need assessment itself.
Several indices have been used previously to measure orthodontic treatment need normatively and such data can be effectively utilized for health services planning. The Dental Aesthetic Index (DAI) has been developed to assess treatment need based on a person's subjective assessment. The Index of Orthodontic Treatment Need (IOTN) was described by Brook and Shaw (1989) and Shaw et al. (1991). The index comprises two parts: Dental Health Component (DHC) and the Aesthetic Component (AC). The incorporation of the AC which is entirely based on the assessment of subjective need makes the index fit for the situation.
The validity and reliability of the IOTN has been established by several researchers. As per the previous studies, the reproducibility of IOTN was examined and substantial agreement was obtained.,, Evaluation of malocclusion must consider not only morphological and functional factors but also esthetic and psychological ones., Even though the dentist can find out dental irregularities even at a minor level, very few patients seek orthodontic treatment.
Even those with extreme malocclusions may not go for the treatment as some of them do not recognize that they have problems and others believe that they cannot afford orthodontic treatment. Another reason for not availing treatment is that the actual motivation for orthodontic treatment from the patient's viewpoint is an improvement in appearance or esthetics. Hence, if they think they are normal or good in appearance, they would not bother about the normatively assessed malocclusion or dental irregularity.
Hence, the aim of the study was to assess the opinions of school children of South Bengaluru on dental attractiveness and their perceptions of orthodontic treatment need as measured by the IOTN modified for use in epidemiological surveys and to find out the correlation, if any, between the subjective orthodontic treatment need perceived by children and the objective need.
| Materials and Methods|| |
Ethical clearance and official permissions
A cross-sectional study was conducted among school children aged 9–18 years of South Bengaluru. Ethical clearance for the study has been obtained from the Ethical Committee of the Institution. The required official permissions were obtained from the authorities of the respective schools. A written and oral informed consent was obtained from the participating children in the study. For children below 12 years of age, assent was obtained.
Sample size and sampling method
The sample size was determined at 95% confidence interval, considering the prevalence of malocclusion as 60% and 95% precision, and 10% margin of error and was finally decided to be 310. A convenience sampling method has been adopted to get the desired sample size. All children who were available at the time of investigation were included in the study.
School children between the age of 9 and 18 (both males and females) of South Bengaluru who were able to read and answer the questions and who were ready to give consent for participating in the study were included.
Students who are under or had undergone orthodontic treatment.
Training and graded calibration
For the purpose of understanding and application of the oral examination criteria, the investigator was trained and calibrated in the Department of Public Health Dentistry of the institution under the guidance of the research guide in order to limit the diagnostic variability. A selected group of 20 subjects in the age group of 9–18 years without the history of orthodontic treatment was chosen. These subjects were examined under the direct supervision of the research guide using the set of examination criteria standardized for the study. The calibration sessions were held for a period of 1 week. Each case was meticulously examined and the findings were compared to know the diagnostic variability and agreement. The calibration exercise and the kappa value (0.89) showed good agreement for these observations and measurements in terms of intraexaminer variability.
A pilot study on 20 subjects for a period of 1-week was undertaken by the investigator in the school premises. Pilot study assessments were utilized for planning and execution of the main study and also to finalize the proforma, questionnaire, and research protocol to be used for the collection of data.
Schedule of the study
The survey was systematically scheduled to spread over a period of 5 weeks in June 2012 and July 2012. A detailed schedule was prepared well in advance by informing and obtaining consent from authorities of respective schools. On an average, sixty participants were examined every week.
All participants were examined by the investigator at the school premises, during the school hours of 9 am to 3.30 pm. The examination area was kept clean, uncongested, free from noise, and well-ventilated, with adequate lighting, facilitating ease of examination. The school children were examined either in the classroom or in the corridor of school premises. The children were made to sit comfortably on an ordinary chair where sufficient natural daylight was available. When required a battery operated torch (artificial illumination) was used.
Method of obtaining the data
A specially designed proforma was used to collect information on demographic characteristics, particularly age, sex, parents' education, and employment status. The second section of the proforma dealt with the awareness of the children's own occlusions, including questions on their subjective need for treatment, satisfaction with the arrangement and appearance of their teeth, and the importance of well-aligned teeth. The questions were prevalidated and were scaled and scored with 3 or 5 points.
The proforma also included the criteria for recording the IOTN, which consisted of both the DHC and the AC. The DHC was registered based on five criteria (Missing teeth, Overjet, Crossbite, Displacement of contact points, and Overbite) and the AC was recorded based on ten intraoral frontal photographs. The subjects were asked to close on their back teeth, and the lips were retracted. The dental attractiveness of the anterior teeth was graded and the grade awarded is for overall dental attractiveness rather than specific morphological similarity to the photographs.
Descriptive and inferential statistical analysis has been carried out in the present study. Results on continuous measurements are presented on mean ± standard deviation (Min-Max) and results on categorical measurements are presented in number (%). Significance was assessed at 5% level of significance. Chi-square/Fisher's exact test has been used to find the significance of study parameters on a categorical scale between two or more groups.
| Results|| |
Maximum proportions of subjects (34.9%) were found to be in the age group of 13–14 years with a mean age of 13.57 ± 2.17 years. Out of the 310 participants, 49.4% were males and 50.6% were females. Among the 310 participants, 44.2% of the fathers and 45.2% of the mothers had primary education and below. Maximum number of fathers (50.3%) and mothers (62.6%) came under the peasant and home job category, respectively.
Among the 310 children, 36.8% answered that they need orthodontic treatment, 47.1% said no and 13.5% do not know whether they need treatment or not. According to the DHC of the IOTN, 21.0% of the children needed orthodontic treatment and for 79.0% children there was no need for treatment. A significant association has been found between the IOTN-DHC and subjective need for orthodontic treatment. Among those children who gave the response as no to the question on the subjective need for treatment, 48.9% were in the category of no need for treatment according to the DHC [Table 1].
|Table 1: Association of responses need for correction or treatment for the arrangement and alignment of teeth with Index of Orthodontic Treatment Need-Dental Health Component|
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Most of the children were either very happy (35.5%) or happy (37.7%) with the arrangement of their front teeth. Only 10.3% were unhappy and 0.3% were very unhappy with the arrangement of their front teeth. A significant association has been found between the IOTN-DHC and the satisfaction with the arrangement and appearance of the teeth [Table 2].
|Table 2: Association of responses to happiness with the arrangement of front teeth with Index of Orthodontic Treatment Need-Dental Health Component|
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Similar to the previous question, most of the children were either very happy (28.1%) or happy (43.9%) with the appearance of their own teeth compared to the teeth of their friends. Only 11.0% of them were unhappy and 0.6% of them were very unhappy with the arrangement of their own teeth. Moreover, majority of the children who were very happy (38.7%) and happy (37.1%) with the arrangement and appearance of their teeth and those who were very happy (29.7%) and happy with the arrangement of their front teeth compared to the teeth of their friends (44.8%) were in the category of no need for treatment according to the DHC [Table 3].
|Table 3: Association of responses to happiness with the appearance of teeth compared to the teeth of friends with Index of Orthodontic Treatment Need-Dental Health Component|
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Maximum number of children (51.9%) considered well-aligned teeth as very important for overall facial appearance and 31.6% of them answered important. For some 2.3%, it is not important and for 1.6% of them it is not important at all [Table 4].
|Table 4: Association of responses to importance of well-aligned teeth important for overall facial appearance with Index of Orthodontic Treatment Need-Dental Health Component|
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There was no significant association between the subjective need for treatment and the IOTN-AC [Table 5].
|Table 5: Association of responses need for correction or treatment for the arrangement and alignment of teeth with Index of Orthodontic Treatment Need-Esthetic Component|
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Most of the children who were very happy (36.0%) and happy (38.7%) with the arrangement and appearance of their teeth were in the category of no need for treatment according to the AC. Only few children who were very happy (25.0%) and happy (18.7%) with the arrangement and appearance of their teeth were in the category of need for treatment according to the AC. A significant association was found between the satisfaction with the arrangement and appearance of the teeth and the IOTN-AC (P = 0.010) [Table 6].
|Table 6: Association of responses to happiness with the arrangement of front teeth with Index of Orthodontic Treatment Need-Esthetic Component|
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Most of the children were either very happy or happy with the appearance of their teeth compared to the teeth of friends, and there were no significant associations of the responses with IOTN-AC [Table 7].
|Table 7: Association of responses to happiness with the appearance of teeth compared to the teeth of friends with Index of Orthodontic Treatment Need-Esthetic Component|
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Majority of the participants were aware of the importance of well-aligned teeth for overall facial appearance and the association with the IOTN-AC was not found to be significant [Table 8].
|Table 8: Association of responses to importance of well-aligned teeth important for overall facial appearance with Index of Orthodontic Treatment Need-Esthetic Component|
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A highly significant association was found between the subjective need for treatment and age (P = 0.002) and gender (P = 0.006) [Table 9].
|Table 9: Association of age and gender with responses to the question on the subjective need for orthodontic treatment|
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As per [Table 10], significant associations were found with age (P = 0.052) and gender (P = 0.014) to the responses to the question on the importance of well-aligned teeth for overall facial appearance.
|Table 10: Association of age and gender with responses to the question on the importance of well-aligned teeth important for overall facial appearance|
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| Discussion|| |
Physical appearance can have an impact on the self-esteem of every human being. Properly aligned teeth can have a positive impact, and irregular or protruded teeth can have a negative impact. The main motivation for the demand for orthodontic care is the desire to improve esthetics, and dental esthetics is found to have a profound influence on oral health-related quality of life. Although oral health-related quality of life is given importance in all age groups, it is highly relevant among children and adolescents as concern about beauty and appearance starts developing in this age group.
The perception of beauty is a highly subjective phenomenon. Perception is defined as the process by which patterns of environmental stimuli are organized and interpreted and can be influenced by a variety of physical, physiological, psychological, and social factors. Perception can vary among individuals, races, and sexes. Moreover, the perception of the clinician or orthodontist may not match with the perception of the patient.
The IOTN has been widely used in epidemiological studies of malocclusion for prioritizing treatment needs and to plan the resources in order to avoid wastage of expenditure. The index comprises of a DHC and AC. The DHC records occlusal impairments and AC is recorded by comparing the patient's appearance against standard photographs. The index is found to be valid and reliable.,
In this study, the subjective need for treatment was expressed by 36.8% of children which is similar to the Tanzanian study  (38%). In the study by Ali H Hassan among Saudi Arabian adults, only 16.1% of subjects said that they need orthodontic treatment which is different from the results of our study. Adults were examined in the Saudi Arabian study, and the adolescent age group was considered in our study. The prevalence and perception of malocclusion can vary among different age groups.
Good correlation has been found between the IOTN-DHC and the subjective need for orthodontic treatment and satisfaction with the arrangement and appearance of the teeth. As IOTN-DHC measures the objective need for treatment, this correlation shows that the children of this age group are capable of evaluating their teeth precisely.
Children who were unhappy with the arrangement and appearance of their teeth had higher scores of AC. This underlines the validity of the index and the usefulness of the index in correctly identifying those who are in need for treatment. The incorporation of the AC has made the index useful to reflect patient's point of view. Adequate exposure to orthodontics among children is still in question as 13.5% of our study subjects did not know whether they needed orthodontic treatment or not.
Our study showed a significant association between the subjective need for treatment and the AC of the index which is in contrast to the findings of previous study among Tanzanian children  and the study among patients seeking orthodontic treatment in Damman Central Hospital in Saudi Arabia. Hence, it can be concluded that there is a moderate correlation between the AC of the index and the demand for treatment.
According to this study, there is an association between age and the subjective need for treatment. Due to the unequal distribution of subjects in the different age groups, it is not possible to predict the correct age group which is in need for treatment from our results. Further studies are needed to correctly define the age group in which maximum number of children are in need for treatment so that targeted measures can be specifically oriented toward that age group.
In addition, there is an association between gender and the subjective need for treatment which is in line with the results of the study by Singh et al. in South Birmingham. Surprisingly, in this study males were more toward the subjective need for treatment than females. This may be due to the smaller sample size considered for the study or can be due to the inclusion of younger children of ages 9 and 10 on whom the perceptions of beauty are yet to develop.
Many occlusal traits or deviations which can have an effect on oral health need not affect esthetics. This can be the probable reason for the variation in the percentage of children who needed treatment according to the DHC and AC. Moreover, the DHC is graded according to the most severe occlusal trait, whereas the AC is graded according to the cumulative effect of malocclusion.
More than 80% of the children identified the importance of well-aligned teeth. Age and gender were significantly correlated with this variable.
Modern view in orthodontic practice is that the main motivation for orthodontic treatment is improvement in esthetics when considering the patient's point of view. Hence, the perception of patients should be given due value as it is these patients who gain satisfaction from improved appearance. But dentists also need normative measurements to provide a satisfactory and beautiful smile to the patient in need. In this scenario, the comparison of self-perceived and normative orthodontic treatment needs cannot be neglected.
The study has some limitations which may restrict the generalizability of the findings. First, the instrument used in the study was IOTN modified for use in epidemiological surveys (modified IOTN). Therefore, comparison with other studies done using standard instruments such as DAI and the peer assessment rating index is not possible.
Second, in the schools included in the study, most of the children were from the low socioeconomic background. Hence, the sample does not represent the children of the same age group in the area but a group of disadvantaged population who is lacking dental care. In addition, the children aged 9 and 10 years may not have understood the exact meaning of the questions related to orthodontic treatment. An individual discussion with these small children would have improved the response rate.
| Conclusions|| |
It is evident from the results of the study that the children in this age group are capable of subjectively evaluating their teeth as most of the children were aware of the importance of teeth for appearance and esthetics. Hence, it is necessary to evaluate the perceptions of subjects before beginning any treatment planning to meet the expectations of patients in general as it is the patient who gains satisfaction from treatment.
We wish to thank Dr. Suresh K. P (Statistician) for his timely and valuable help in completing this work. We would also like to express our sincere gratitude to the undergraduate students of the institution for their assistance throughout the study period.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]