|Year : 2021 | Volume
| Issue : 1 | Page : 42-47
Assessment of self-perception and need for orthodontic treatment using the index of orthodontic treatment need in visually impaired students of Northern Karnataka, India
Sanjeev B Singh, Roopa Jatti, Sumedh R Deshpande
Department of Orthodonics, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India
|Date of Submission||21-Jun-2019|
|Date of Acceptance||19-Jan-2021|
|Date of Web Publication||31-Mar-2021|
BC 132, Logde Road, Opp Benyon Smith School, Camp, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Background: In recent years, the perception of an individual with a disability like visual impairment has been slowly evolving from the “forgotten” person to one who is recognized as needing treatment. Aim: The aim is to assess the self-perception and orthodontic treatment need in visually impaired (VI) students and to compare these with the control group (CG), and also to create awareness about malocclusion and orthodontic treatment in both groups. Materials and Methods: The present cross-sectional study was conducted in the special schools for the VI in the North Karnataka region. The CG was from the local schools in the same region. A total of 125 VI, 162 control students aged 11–19 years were included in the study. Determination of Esthetic Component (AC) and dental health component (DHC) in VI and control students were done. Chi-square test and Kappa statistics were used to compare between the study and the CG and to find out the agreement between the subjects and the orthodontist respectively. A P value of <0.05 was considered to be statistically significant. Results: About 24% of VI and 6.1% of the control perceived to be in need of orthodontic treatment according to the AC. However, 24% of VI and 20.9% of control showed “definite need” of treatment based upon the DHC. The AC when compared between study and CG by Chi-square test, was found to be highly significant statistically with a P < 0.001. Conclusions: High percentage of VI students perceived a “definite need” as compared to control students based on AC. The data of the present study suggest that the VI students are more concerned about their malocclusion and perceive that they need orthodontic treatment.
Keywords: Aesthetic component, dental health component, index of orthodontic treatment need, self-perception, visually impaired persons
|How to cite this article:|
Singh SB, Jatti R, Deshpande SR. Assessment of self-perception and need for orthodontic treatment using the index of orthodontic treatment need in visually impaired students of Northern Karnataka, India. J Indian Assoc Public Health Dent 2021;19:42-7
|How to cite this URL:|
Singh SB, Jatti R, Deshpande SR. Assessment of self-perception and need for orthodontic treatment using the index of orthodontic treatment need in visually impaired students of Northern Karnataka, India. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Apr 17];19:42-7. Available from: https://www.jiaphd.org/text.asp?2021/19/1/42/312648
| Introduction|| |
Any deviation from what is generally considered as an ideal occlusion or normal relation of teeth in the same or opposing arches is often known as a malocclusion. It is estimated that at least one-third of the population has a clear need for orthodontic treatment. The possession of an obvious malocclusion is by no means the only factor which determines whether or not an individual will receive treatment. Since malocclusion is not an acute condition but a deviation from normal, the orthodontist's and patient's perception of treatment need is distorted by many different variables. This has resulted in a marked lack of uniformity for both assessments of treatment need and treatment uptake.
The use of occlusal indices in the assessment of orthodontics provides the opportunity to reduce subjective bias, and also to standardize the criteria which judgments are made throughout the profession. The objective assessment of malocclusion is important when documenting the prevalence and severity of malocclusion in the population. Harmony of life lies in the coordinated action of physical and mental facilities coupled with an ideal environment. Few individuals suffering from handicaps of varying nature can be seen in almost any community.
The rejection and stigma associated with people with disabilities is a common problem. Total visual impairment is one disorder that may result in frequent hospitalizations, separation from family, and slow social development. Trauma to the anterior teeth has been reported to occur with greater than average frequency. Consideration must be given to every developmental aspect of a child with blindness. In recent years, the perception of an individual with a disability like visual impairment has been slowly evolving from the “forgotten” person to one who is recognized as needing treatment. One area that occupies this reorganization is dentistry and specifically orthodontic care.
There always exists a difference between a child who has been visually impaired (VI) since birth and a child who had normal sight which was lost with time. A child who is congenitally blind has no scaffold/template to imagine what teeth look like or what is considered aesthetic. In the latter, the children already have an idea about what he might have looked like, so it's easier for him to imagine what might be unaesthetic. In a child who is congenitally blind, everything the child knows or believes is what he hears and imagines and not an accurate interpretation of the reality and thus would require more explanation to help them perceive the dental environment. Though the need for orthodontic treatment is well documented in the literature using the index of orthodontic treatment need (IOTN), very little information is available regarding the self-perception and orthodontic treatment need in VI students.
The IOTN which was developed recently is a grade index scale wherein occlusal traits are assessed and graded. It has been shown to be satisfactory in validity and reproducibility. IOTN index incorporates the dental health component (DHC) and the esthetic component (AC). The DHC is based on the recommendations of the Swedish Medical Board and the AC comprises a scale of 10 anterior intra-oral photographs showing different levels of dental attractiveness with grade 1 representing the most attractive and grade 10 the least attractive dentition. For VI students, the AC is assessed using 5 modified tactile models. These five modified tactile models represented photographs 1, 5, 8, and 10 and 10a.
The aim of the present study was to assess the self-perception and need for orthodontic treatment using IOTN in VI students of Northern Karnataka, and also to compare the results with the normal control group (CG) and to create awareness about malocclusion and orthodontic treatment need in both the groups.
| Materials and Methods|| |
This cross-sectional study was conducted in the special school for the VI of Northern Karnataka. The CG was taken from the local schools. Ethical clearance was obtained from the Institutional Ethical Committee before commencing the study. Informed consent in the form of oral expressed consent from the subjects as well as a written expressed consent from their care takers were obtained.
A total of 287 subjects were included in this study. The study group consisted of 125 congenitally VI students and the CG of 162 students who were not VI. The CG samples were collected from schools in Northern Karnataka, by random selection. Inclusion criteria required that students who are congenitally visual impaired (blind) and were between the age group of 11–19 years were included in the study. Exclusion criteria were that the students who at one time had sight, students who were already undergoing orthodontic treatment, and students having handicapping conditions other than congenital blindness were excluded from the study.
Material and equipment used were modified tactile models representing photographs 1, 5, 8, 10, and 10a of the AC for the VI [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5] and a set of 11 photographs showing a range of dental attractiveness of the AC for CG.
The IOTN is a visual-based index and has been widely used. However, there was a need to develop tactile models for VI students. Based on the tactile graphic version of IOTN for VI students, five tactile models were developed which represented photographs 1, 5, 8, 10, and 10a of the AC. To produce these models, first, the temporary denture record bases and occlusal rims of wax were made on ideal edentulous casts which were mounted on a three-point articulator. Teeth setting was done according to the photographs, except for the 10th photograph model, which was made as an open bite to better differentiate between the models. After teeth setting, all the models were acrylized with heat cure acrylic and polished. The upper and lower parts were joined by metal rings.
The subjects were examined under standardized lighting conditions using daylight. Each subject was examined for orthodontic treatment needs and the obtained details were recorded in data collection Performa.
In this study, an additional photograph, 10a, featuring class III malocclusion was added to the set of 10 standard photographs of AC. This was done to reduce confusion for subjects with class III malocclusion.
Self-perception of malocclusion was evaluated in CG by asking each subject a question– “Here is a set of photographs showing a range of dental attractiveness. Where would you put your teeth on this scale?”
For the VI group, five modified tactile models were used which represented photographs 1, 5, 8, 10, and 10a. Each individual was first asked to touch and feel (tactile sense) his or her own teeth, and later the five models. The individuals were then asked to tell to which model he/she would co-relate his/her teeth. The AC was determined accordingly.
The DHC was assessed for each subject using the standard five grades and the specially designed DHC ruler. The ruler contains all the information necessary to record the DHC (albeit in brief form). The ruler was developed for the clinical setting in which information is collected regarding the competence of the lips, displacement on closure, and masticatory/speech problems. Only the worst occlusal feature was recorded. When recording overjet, the ruler was held parallel to the occlusal plane and radial to the line of the arch. The most prominent aspect of the upper incisors was recorded. There are two ways of recording DHC. The first is to record the grade only; in the second, the initiating feature would be recorded, for example, an overjet greater than 9 mm would be 5a (the grade being 5 and the overjet signified by the letter). The second method provides more information regarding the prevalence of specific occlusal traits. The AC and DHC were determined separately and were used to allocate each child to: no need, moderate/borderline need, and definite need.
After the examination of both the components, students in both the groups were asked about their thoughts/viewpoint about undergoing orthodontic treatment for the correction of their malocclusions. Statistical Package for Social Sciences (SPSS) for Windows, Version 16.0., Released 2007 Chicago, SPSS Inc., was used to perform statistical analysis. Statistical methods used were the Chi-square test to compare between the study and CG, the gender difference was assessed again by the Chi-square test, and kappa statistics was calculated to find out the agreement between the subjects and the orthodontist. Descriptive and inferential statistical analysis has been carried out in the present study. Results on categorical measurements are presented in number (%). Significance was assessed at 5% level of significance. Chi-square test was used to find the significance of study parameters on a categorical scale between the groups. Kappa statistics were calculated to find out the agreement between the subjects and the orthodontist.
| Results|| |
Dental health component
When the VI subjects were examined, 55.2% showed “no treatment need,” 20.8% showed “borderline need” and 24% showed “definite need” [Table 1]. In the CG, 55.5% showed “no treatment need,” 23.4% showed “borderline need” and 20.9% showed “definite need.” The DHC when compared between the study and the CG by the Chi-square test was statistically insignificant (P = 0.512).
|Table 1: The dental health component of index of orthodontic treatment need between study and control group|
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Over 48.8% of the VI and 82.75% of the CG showed “no treatment need,” and 27.2% of the VI, and 11.1% of CG showed 'moderate need' and 24% of VI and 6.1% of CG showed “definite need” [Table 2]. When the AC was compared between the VI and the CG by the Chi-square test the result was suggested to be highly statistically significant (P < 0.001).
|Table 2: The aesthetic component of index of orthodontic treatment need between study and control group|
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Males and females were compared for the gender difference. The DHC and AC were compared separately, for both the study group and the CG. The P values obtained indicated that all the comparisons were not statistically significant for gender difference.
To measure the agreement between the AC (subject) and DHC (Operator/Doctor), Kappa statistics were calculated. There was fair agreement between AC and DHC of the study group with Kappa = 0.3122 [Table 3]. The CG also showed fair agreement with Kappa = 0.2745 [Table 4].
|Table 3: Evaluation of agreement between aesthetic component and dental health component of study group|
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|Table 4: Evaluation of agreement between aesthetic component and dental health component of control group|
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| Discussion|| |
The VI people present a special challenge to the orthodontic care team. Students aged 11–19 years were selected to form the study group, as they were considered old enough to possess perceptual awareness regarding orthodontic treatment need.
Results of the present study indicated that 30%–34% (study group) of 11–19 years old had an objective need for orthodontic treatment based on DHC. Several studies based on British populations found the need for treatment to be around 30%,,, while in a Finnish population, 20% of the samples were in need of treatment based on DHC. The large variation in results is further exampled by 14–15-year-old children from schools of Manchester, UK, where it was found that 52% needed treatment.
The subjects' perception of their dental appearance is of considerable importance in determining both treatment demand and the subsequent level of cooperation during the treatment. It is suggested that subjects of 11–19 years age group are capable of making objective esthetic evaluations of their teeth, but there is a broad range of what is considered acceptable to the subjects. There is also a possibility that the subjects in the current study distorted their answers to make a more favorable impression on the examiner, giving what they believed to be the most socially acceptable response.
In the current study, there seems to be a discrepancy in the proportion of children needing orthodontic treatment on esthetic and dental health grounds. Many more children had malocclusions where the orthodontic need was considered definite on esthetic grounds as compared with DHC. This is probably due to the presence of occlusal traits, which have implications on facial attractiveness but do not cause any oral health effect (for example, a diastema). Furthermore, the DHC score is based on a grade assigned to the single most severe occlusal trait which makes it an easy and reliable index to use, but ignores the cumulative effect if a number of less severe occlusal deviations. As a result, it may underestimate the severity of malocclusion in some individuals.
Assessment of an aesthetic need for orthodontic treatment is complex, and that is clearly seen by the difference in opinion between a professional person and the subject. Some children in the CG found the concept behind the AC difficult to grasp. Children constantly attempted to match their dentition to the photographs, looking for specific morphological traits. This was especially true for children with fractured incisors, bilateral congenitally absent or peg-shaped lateral incisors, all of whom found difficulty in the selection of a photograph which best represented their degree of dental attractiveness.
Usually, subjects tend to rate their dental appearance lower in the aesthetic scales compared with the orthodontist's rating. This was true in the CG. However, the study group had similar self-perception as that of orthodontist's assessment. An explanation of this could be the increased awareness about their malocclusion created by orthodontist and criticism of their perception of dental attractiveness. Although explanation is accomplished through touching and hearing, reinforcement takes place through smelling and tasting. The modalities of listening, touching, tasting and smelling are extremely important for these children in helping to learn coping behavior. Reports indicate that, once speech is developed, the other senses assume heightened importance and other development can occur that is comparable to that in children with sight.
In terms of treatment needs, there was no gender difference in both study and CG. This finding is contradictory to the earlier studies by Brown et al. and Otuyem's et al. who concluded that males were more likely to seek orthodontic treatment. However, in another study by Roberts et al. and Holmes, concluded that females had a higher level of subjective treatment need and demand than males.
The assessment of the parents attitudes about their child's need for orthodontic treatment is important and the possible influence of the socio-economic background on the rating and self-perception of malocclusion needs to be considered.
The observations of the study suggest that the subjects of the study group, even being VI, are more concerned about their malocclusion and perceive that they need orthodontic treatment. The visually blind children hence should not be considered any different from the normal children and deserve the same level of orthodontic care we would provide for normal individuals. This information on the perception of malocclusion can be used to influence decision making on the orthodontic services to be provided, human resource training needs, the design of treatment facilities, continuing education for oral health personnel, public health programs, screening for treatment priority, and resource planning, and also for patient education and information.
| Conclusions|| |
The high percentage of VI (24%) students perceived a “Definite need” of orthodontic treatment as compared with only 6.1% of control students based on AC. Based on DHC, both the VI and the control students had similar orthodontic treatment needs (24% and 20.9%, respectively). In terms of treatment need, there was neither gender difference in neither study nor CG. There was “Fair” agreement between the subjects and the orthodontist of both the study and CG.
The data of the present study suggest that the subjects of the study group, even being VI, are more concerned about their malocclusion and perceive that they need orthodontic treatment.
I would like to thank the teachers and students of the blind school for their co-operation and patience throughout the study process. I would also like to thank my parents for their constant support throughout this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al-Sarheed M, Bedi R, Hunt NP. The views and attitudes of parents of children with a sensory impairment towards orthodontic care. Eur J Orthod 2004;26:87-91.
McDonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent. 8th
ed. Mosby; 2004.
Al-Sarheed M, Bedi R, Hunt NP. Orthodontic treatment need and self-perception of 11-16-year-old Saudi Arabian children with a sensory impairment attending special schools. J Orthod 2003;30:39-44.
Tang EL, Wei SH. Recording and measuring malocclusions: A review of the literature. Am J Orthod Dentofac Orthop 1993;103:344-51.
Al-Sarheed M, Bedi R, Hunt NP. The development of a tactile graphic version of IOTN for visually impaired patients. Clin Orthod Res 2000;3:94-100.
Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989;11:309-20.
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.
Holmes A. The subjective need and demand for orthodontic treatment. Br J Orthod 1992;19:287-97.
Pietilä T, Pietilä I. Dental appearance and orthodontic services assessed by 15-16-year-old adolescents in eastern Finland. Community Dent Health 1996;13:139-44.
Mandall NA, McCord JF, Blinkhorn AS, Worthigton HV, O'Brien KD. Perceived aesthetic impact of malocclusion and oral self-perception in 14-15-year-old Asian and Caucasian children in greater Manchester. Eur J Orthod 2000;22:175-83.
O'Brien K, McComb JL, Fox N, Wright J. Factors influencing the uptake of orthodontic treatment. Br J Orthod 1996;23:331-4.
Holmes A. The prevalence of orthodontic treatment need. Br J Orthod 1992;19:177-82.
Burden DJ, Pine CM. Self-perception of malocclusion among adolescents. Community Dent Health 1995;12:89-92.
Brown DF, Spencer AJ, Tolliday PD. Social and psychological factors associated with adolescent's self-acceptance of occlusion condition. Common Dent Oral Epidemiol 1987;15:70-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]