Download Orthodontic treatment need in the Italian child population

Orthodontic treatment need
in the Italian child population
C. GRIPPAUDO, E.G. PAOLANTONIO, R. DELI, G. LA TORRE*
ABSTRACT. Aim To assess orthodontic treatment need in the Italian child population using the R.O.M.A. (Risk Of
Malocclusion Assessment) Index. Study Design Observational study (cross-sectional). Materials, Methods and
Results The ROMA Index was used in examining a sample of 420 children (214 males and 206 females; mean age:
9.3 years), none of whom had previously undergone orthodontic treatment. This basic sample was large enough
to become the object of an epidemiological study and to be analysed through inferential statistics. After
calculating the prevalence of malocclusion on the basis of the degrees of orthodontic risk determined by the Index,
we evaluated the distribution of the most frequent characteristics, signs and symptoms within each risk grade. The
percentage of children in each risk category was then worked out, together with its 95% confidence interval, in
order to verify whether our results could be generalised to the reference population. Significantly, 50% of the
examined children were classified as ‘at moderate risk’, as defined by grade 3 of the Index (non-severe alterations
in dental and/or skeletal relationships, but tending to persist and often worsen with growth). Equally remarkably,
a further 36% fell within grade 4 of the Index (‘great risk’), presenting major craniofacial skeletal malformations
and alterations of the occlusion, often in association with systemic or growth disorders likely to worsen the
prognosis. Thus, since patients at moderate or great risk amounted to 86% of the basic sample, it appears that
our estimate can be generalised to the reference population of Italian pre-adolescent children. Conclusion The
study showed a high percentage of children at moderate or great risk (86%), and that this estimate can be
generalised to the reference population of Italian pre-adolescent children. These findings should be taken into
great account in devising strategies to improve patient service quality, whether in public or private settings, and
also in planning preventive measures and interventions.
KEYWORDS: Orthodontic treatment need index, Risk of malocclusion, Growing child.
Introduction
Many studies have reported the prevalence of
malocclusions in children and adolescents of various
ethnic groups. Review of the literature has shown that
there are widely variable estimates of the prevalence,
ranging from 45% [Kerosuo et al., 1988] to 93% [Lew
et al., 1993]. This wide range may be due to differences
between specific ethnic groups, as well as to
discordances in recording methods and criteria used to
establish treatment need. However, the estimates still
represent the large number of individuals requiring
orthodontic treatment. Several indices have been
developed [Draker, 1960; Salonen et al., 1966; Cons
and Jenny, 1966; Grainger, 1967; Salzmann, 1968;
Summers 1971; Brook and Shaw, 1989; Danish
Department of Orthodontics, Catholic University of the Sacred Heart, Rome, Italy
*Epidemiology and Biostatistics Unit, Institute of Hygiene
Catholic University of the Sacred Heart, Rome, Italy
e-mail: [email protected]
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • VOL. 9/2-2008
National Board of Health, 1990; Espeland, 1992;
Russo et al., 1998; Daniels and Richmond, 2000] to
identify the individuals in special need of orthodontic
treatment (Table 1), on the grounds of the potential
damage a detected malocclusion might cause [Taylor,
1993]. They are widely used in those countries where
orthodontic treatment costs are partially or fully
covered by the national health system and by most
insurance companies. These indices are usually
limited to estimating the incidence of the different
problems detected, assigning each a score based on
immediate treatment need. They have been criticised
as not being easy to use, insofar as requiring a long
time, complicated calculations and qualified staff for
data collection [Tang and Wei, 1993]. Moreover,
lacking components to grade skeletal problems, they
seem really appropriate for use just in permanent
dentition and in examining patients whose growth is
already complete, rather than across all age ranges.
However, in young patients orthodontic problems are
not restricted to dental disorders, being often
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C. GRIPPAUDO ET AL.
INDICES
AUTHORS
YEAR
Handicapping Labiolingual Deviation Index (HLDI)
Draker HL
1960
Grade Index Scale For Assessment of Treatment Need (GISATN)
Salonen L, Mohlin B, Gotzlinger B
1966
Dental Aestetic Index (DAI)
Cons NC, Jenny J
1966
Treatment Priority Index (TPI)
Grainger RM
1967
Handicapping Malocclusion Assessment Record (HMAR)
Salzmann JA
1968
Occlusal index (OI)
Summers CJ
1971
Index of Orthodontic Treatment Need (IOTN)
Brook PH, Shaw WC
1989
Memorandum of Orthodontic Screening and
Indications for Orthodontic Treatment
Danish National Board of Health
1990
Need for Orthodontic Treatment Index (NOTI)
Espeland LV, Ivarson K, Stenvik A
1992
Risk Of Malocclusion Assessment (ROMA) Index
Russo E, Grippaudo C, Marchionni P, Deli R 1998
Index of Complexity, Outcome and Need (ICON)
Daniels C, Richmond S
2000
TABLE 1 - Indices of orthodontic treatment need.
accompanied by altered underlying bone relationships
and closely related to cranio-facial growth and
development. That is why the age and stage of
development of the patient entail different degrees of
risk of malocclusion, accompanied by negative effects
on the masticatory function. The R.O.M.A. Index
(Risk Of Malocclusion Assessment Index) [Russo et
al., 1998] is a tool to assess treatment need in young
patients. Taking into account the negative effects of
malocclusion on both the dento-skeletal apparatus and
on psycho-social wellbeing, the index, previously
validated [Grippaudo et al., 2007], identifies five
grades (Table 2), ranked in increasing order of
malocclusion severity, or rather, according to whether
there is a higher or lower risk of dysfunction. Unlike
other indices, the R.O.M.A. Index was specifically
devised for use in examining young patients, in an
attempt to grade, beside malocclusions, also skeletal
and functional aspects, which, in children, are
determinants of oro-facial development. The index is
also intended as a tool to prevent the patient’s
condition from worsening, to estimate the length of
treatment, and to help choosing treatment timing. As a
guide to clinical signs of malocclusion (which, once
detected, entail a greater or lesser need for orthodontic
intervention) it identifies five risk grades, ranked in
increasing order of severity. The score is assigned
based on the most severe feature noted during
examination.
The aim of this study is to assess the prevalence of
malocclusion and the related orthodontic treatment
need in a sample of Italian pre-adolescents using the
R.O.M.A. Index.
72
Materials and methods
The R.O.M.A. Index was used in examining 420
children: 214 males and 206 females with a mean age
of 9.3 years (range 4.4 to 12.7). In detail, 257 were
patients of the “Agostino Gemelli” General Hospital in
Rome: 214 of the Orthodontic Service located in the
Department of Dentistry; 43 of the Paediatric
Outpatient Department. The remaining 163 were
primary school students (67 from Rome and 96 from
Calabria). None of them had previously undergone
orthodontic treatment.
The patient sample was large enough to become the
object of an epidemiological study and to be analysed
through inferential statistics. To this purpose, this
basic sample was divided into two sub-samples: the
214 children examined in the Department of Dentistry
(sub-sample A), and the 206 examined in the
Paediatric Outpatient Department or the two primary
schools (sub-sample B).
After calculating the prevalence of malocclusion on
the basis of the degrees of orthodontic risk determined
by the Index, we evaluated the distribution of the most
frequent characteristics, signs and symptoms both
within each risk grade and in the basic sample.
The percentage of children in each risk category was
then worked out, together with its confidence interval,
in order to verify whether our results could be
generalised to the reference population.
Results
Analysis of the data (Table 3) showed that the
percentage of grade 4 children was higher in subEUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • VOL. 9/2-2008
MALOCCLUSION RISK ASSESSMENT
GRADE 5
Systemic Problems
Malformation syndromes
Congenital malformations
5a
5b
GRADE 4
Systemic Problems
Postural/orthopaedic problems
Medical/auxological problems
Familial tendency for malocclusion
Craniofacial Problems
Facial or mandibular asymmetries
Articular dysfunctions
Sequelae of traumas or surgery of the cranio-facial district
Maxillary hypodevelopment or mandibular
hyperdevelopment (OVJ <0 mm)
Maxillary hyperdevelopment or mandibular
hypodevelopment (OVJ >6 mm)
Mandibular hypo- or hyperdivergence
Dental Problems
Scissor bite
Anterior or posterior cross-bite >2mm
Displacement >4 mm
Open-bite >4 mm
Hypodontia of permanent dentition
4c
4d
4e
4f
4g
4j
4k
4h
4i
4m
4n
4o
4p
4q
GRADE 3
Craniofacial Problems
Maxillary hypodevelopment or mandibular
hyperdevelopment (OVJ >0 mm)
Maxillary hyper- or mandibular hypodevelopment
(3 mm<OVJ<6 mm)
Dental Problems
Caries and early loss of deciduous dentition
Anterior or posterior cross-bite >1 mm
Displacement >2 mm
Open-bite >2 mm
OVB >5mm
3k
3h
3l
3n
3o
3p
3r
GRADE 2
Craniofacial Problems
Maxillary hyper- or mandibular hypodevelopment
(0 mm<OVJ<3 mm)
Dental Problems
Anterior or posterior cross-bite <1 mm
Displacement >1 mm
Open-bite >1 mm
Permutation anomalies
Poor oral hygiene
Normal mesial or distal occlusion (up to a cuspid)
Functional Problems
Functional asymmetries
Bad habits
Mouth breathing
2h
2n
2o
2p
2s
2t
2u
TABLE 2 - R.O.M.A. Index.
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • VOL. 9/2-2008
0,14
0,12
0,1
0,08
0,06
2v
2w
2x
GRADE 1
None of the problems listed above
sample A than in sub-sample B (43% vs 29%). Indeed,
sub-sample A included more individuals classified in
higher risk categories (grade 3 = 43%; grade 4 = 43%;
grade 5 = 4%), being comprised of patients of the
Department of Dentistry, most of whom had
deliberately come to the Clinic to undergo orthodontic
treatment.
In sub-sample B, 59% of the children were at
moderate risk and 29% at great risk, and none at
extreme risk. The cumulative percentage frequency of
grades 1 and 2 was 12%, close to that in sub-sample A
(11%).
The 95% confidence intervals relating to the largest
groups are narrow enough to suggest that the
percentage estimates can be generalised to the
reference population of each sub-sample (Table 3).
In the basic sample, the main disorders
were maxillary hyperdevelopment/mandibular
hypodevelopment (4h, 3h, 2h) and increased overbite
(3r) (Fig. 1). There was a considerable frequency of
problems relating to oral hygiene and bad habits in the
lower grades of the index (Fig. 2), but these do not
necessarily imply dento-skeletal disharmony. And,
indeed, it was the higher risk grades that included
more skeletal and dental problems (Fig. 3, 4). In this
regard, it is quite remarkable that 50% of the
examined children were classified as ‘at moderate
risk’, as defined by grade 3 of the Index (non-severe
alterations in dental and/or skeletal relationships, but
tending to persist and often worsen with growth).
Significantly, a further 36% fell within grade 4 of the
Index (‘great risk’), presenting major cranio-facial
skeletal malformations and alterations of the
occlusion, often in association with systemic or
growth disorders likely to worsen the prognosis (Fig.
5).
Thus, since patients at moderate or great risk
0,04
0,02
0
2h
2t
2u
3h
3l
3n
3r
4h
N
FIG. 1 - Characteristics of the most frequent malocclusions
in the basic sample.
73
C. GRIPPAUDO ET AL.
GRADE
PATIENTS
PERCENTAGE
< 95% CI LIMIT
> 95% CI LIMIT
SAMPLE
A
SAMPLE
B
SAMPLE
A
SAMPLE
B
SAMPLE
A
SAMPLE
B
SAMPLE
A
SAMPLE
B
1
1
3
0%
1%
0%
0%
1%
2%
2
23
22
10%
11%
6%
6%
14%
15%
3
91
121
43%
59%
36%
52%
50%
66%
4
91
60
43%
29%
36%
23%
50%
35%
5
9
0
4%
0%
2%
0%
6%
0%
TOTAL
214
206
TABLE 3 - Inference in sub-samples A and B.
GR AD E 4
GRADE 2
25%
30%
28%
30%
21%
20%
20%
20%
15%
15%
10%
10%
6%
5%
3%
6%
5%
26%
25%
4%
5%
5%
22%
13%
11%
7%
6% 6%
3%
2%
1%
1%
1%
0%
0%
0%
2h
2n
2o
2p
2s
2t
2u
2v
2w
2x
FIG. 2 - Distribution of the characteristics of risk grade 2
in the basic sample.
4c
4d
4e
4f
4g
4j
4k
4h
4m 4n
4o
4p
FIG. 4 - Distribution of the characteristics of risk grade 4
in the basic sample.
GRADE 3
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
42%
21%
12%
11%
9%
3%
2%
3k
3h
3l
3n
3o
3p
3r
FIG. 3 - Distribution of the characteristics of risk grade 3
in the basic sample.
FIG. 5 - Distribution of risk grades in the basic sample.
amounted to 86% of the basic sample, it appears that
our estimate can be generalised to the reference
population of Italian pre-adolescent children.
of orthodontic treatment need, the ROMA Index
specifically targets the problems of patients in the age
of development. Being intended not only to measure
the severity of the malocclusion, but also to provide
information regarding the best time for intervention, it
is a useful tool for making concise clinical diagnosis,
planning therapy and choosing treatment timing. For
Discussion
Unlike other European and North American indices
74
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • VOL. 9/2-2008
MALOCCLUSION RISK ASSESSMENT
this study, we tested it on a sample of 420 Italian
children, in order to assess orthodontic treatment need
in the Italian child population.
The management and planning of orthodontic
treatment within public health settings require precise
information on the treatment needs of the population.
The results of this study show that 86% of the
examined children were at moderate or great risk, and
that this estimate can be generalised to the reference
population of Italian pre-adolescent children. These
findings should be taken into great account in devising
strategies to improve patient service quality, whether
in public or private settings, and also in planning
preventive measures.
The observation of a large number of child patients
with major orthodontic problems confirms that
intervention is often needed before the pubertal peak
and the end of occlusal development. In such cases,
early therapy is also intended as a preventive measure,
to avoid more complex treatment in the future and
worsening case prognoses.
Conclusion
R.O.M.A. index is a new tool, created to evaluate the
priorities of orthodontic treatment in childhood. Its
goal is to answer the questions: why and when is the
time to start an orthodontic treatment?
It takes into account the importance of the signs of
malocclusion at the present and in a future perspective.
The authors are testing it to evaluate its efficiency and
find out how it can be improved in the future.
References
Brook PH, Shaw WC. The development of an index of
orthodontic treatment priority. European Journal of
Orthodontics 1989; 11: 309-20.
Cons NC, Jenny J. Establishing malocclusion severity levels on
the Dental Aesthetic Index (DAI) scale. Australian Dent J
1966; 41: 43-6.
Daniels C, Richmond S. The development of the Index of
Complexity, Outcome and Need (ICON). Journals of
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • VOL. 9/2-2008
Orthodontics 2000; 27:149-62.
Danish National Board of Health. Memorandum of orthodontic
screening and indications for orthodontic treatment. P.O. Box
2020, DK-1012 Copenhagen K, 1990.
Draker HL. Handicapping labiolingual deviations: a proposed
index for public health purposes. Am J Orthod 1960; 46: 295305.
Espeland LV, Ivarson K, Stenvik A. A new Norwegian index of
orthodontic treatment need related to orthodontic concern
among 11-years old and their parents. Comm Dent Oral Epid
1992; 20: 274-9.
Grainger RM. Orthodontic treatment priority index. PHS
publication no 1000, Series 2, No 25. US Government
Printing Office, Washington, 1967.
Grippaudo C, Paolantonio EG, Deli R, La Torre G. Validation of
the Risk Of Malocclusion Assessment (ROMA) Index.
European Journal Of Paediatric Dentistry 2007; n.3 (8): 13642.
Kerosuo H, Laine T, Kerosuo E, Nagassapa D, Honkala E.
Occlusion among a group of Tanzanian and Finnish urban
schoolchildren. Community Dentistry and Oral Epidemiology
1988; 16 :306-309.
Lew KK, Foong WC, Loh E. Malocclusion prevalence in an
ethnic Chinese population. Australian Dental Journal 1993;
38: 442-449.
Russo E, Grippaudo C, Marchionni P, Deli R. Il ROMA index
come metronomo della terapia ortodontica nel paziente in
crescita. Procedings National Congress of SIDO, Firenze, 2831 oct. 1998.
Salonen L, Mohlin B, Gotzlinger B, Hellden L. Need and
demand for orthodontic treatment in adult Swedish
population. European Journal of Orthodontics 1992; 14 : 35968.
Saltzmann J A 1968 Handicapping malocclusion assessment to
establish treatment priority. American Journal of Orthodontics
and Dentofacial Orthopedics 54: 749-65.
Summers CJ. A system for identifying and scoring occlusal
disorders. Am J Orthod 1971; 59: 552-67.
Taylor N G. Orthodontic in the Netherlands. British Dental
Journal 1993; 23: 333-35.
Tang ELK, Wei SHY. Recording and measuring malocclusion: a
review of the literature. American Journal of Orthodontics and
Dentofacial Orthopedics 1993; 103: 344-50.
75