Download knowledge and perception towards orthodontic treatment need in a

KNOWLEDGE
AND PERCEPTION
TOWARDS ORTHODONTIC
TREATMENT NEED IN A POPULATION ATTENDING THE
UNIVERSITY OF NAIROBI DENTAL TEACHING HOSPITAL.
A research proposal for a research project submitted in partial fulfilment of the degree of
Bachelor of Dental Science at the University of Nairobi.
INVESTIGATOR:
Macharia Maureen Wanjiru.
SUPERVISORS:
INTERNAL:
DR LOICE GATHECE BDS, MPH (NBI);
DEPARTMENT OF PERIODONTOLOGY,
COMMUNITY AND PREVENTIVE DENTISTRY,
FACULTY OF DENTAL SCIENCES,
UNIVERSITY OF NAIROBI.
EXTERNAL:
PROF NG'ANG'A P.M. BDS (NBI), MSD, PHD (Oslo);
DEPARTMENT OF PEDIATRIC DENTISTRY
AND ORTHODONTICS,
FACULTY OF DENTAL SCIENCES,
UNIVERSITY OF NAIROBI.
Duration of Study:
July - October 2005.
Cost of study:
Ksh 7000.00
Source of Funds:
Self & Family.
TABLE OF CONTENTS
TITLE PAGE
1
TABLE OF CONTENTS
2
LIST OF ABBREVIATIONS:
4
SUMMARy:
5
CHAPTER
1
,
6
INTRODUCTION
6
CHAPTER 2
7
LITERATURE
REVIEW:
7
PROBLEM STATEMENT
15
STUDY JUSTIFICATION
15
OBJECTIVES
15
General objective:
15
Specific objective:
15
HyPOTHESIS
15
VARIABLES
15
Independent
variables:
15
Dependence variables:
15
STUDY DESIGN
15
SAMPLING PROCEDURE
16
STUDY AREA
16
STUDY POPULATION
17
SAMPLING CRITERIA:
17
Inclusion criteria
17
Exclusion criteria
17
DATA COLLECTION
17
LOGISTICS
17
ETHICAL CONSIDERATIONS
17
DATA ANALYSIS AND PRESENTATION
PERCEIVED
BENEFITS
:
17
17
2
BUDGET
18
APPENDIX
19
QUESTIOINNAIRE;
19
REFERENCES:
22
3
SUMMARY:
Objective: To determine the knowledge on malocclusion and the orthodontic treatment need
among 9-12 year olds attending the U.O.N dental teaching hospital.
Design: A descriptive cross sectional study.
Sample and Methods: A population (n=58) aged 9-12 years will be studied over a period of
four months between July and October 2005. The patients will fill structured questionnaires
that will be pre-tested for reliability. The questionnaires will be composed of close ended
questions.
Data analysis: Data will be manually analysed.
Discussion:
From the results, recommendations
and policies will be made to address
respective treatment needs and to determine and if educational programmes on malocclusion
awareness need to be implemented.
5
CHAPTER!
INTRODUCTION
It is worth pointing out that there has been an awareness
of unsightly appearance
malaligned teeth since many centuries ago. The name of the speciality 'orthodontics'
of
comes
from two Greek words. That is 'orthos' meaning right or correct and 'dons' meaning tooth.
Malocclusion is the improper positioning of the teeth and jaws in variation of normal growth
and development. It affects the bite, ability to clean teeth properly, gum tissue health, jaw
growth, speech development and appearance.
Although most of the population has some form of malocclusion, it is considered a normal
variation in different communities and races. An example is the midline diastema which is
considered aesthetic in most African settings. Some cultural practices may also lead to
malocclusion. In Kenya, the Masaai community practiced traditional extraction of the lower
incisors to create space for feeding in case of tetanus or febrile illnesses
1.
This resulted in a
mesial teeth drift resulting to malocclusion.
Planned extractions can be done to correct malocclusion. In today's society where aesthetics
are regarded highly, the need for orthodontic treatment has increased tremendously. A study
done among school children in Nairobi showed that 5.6 % of extractions had been performed
as part of orthodontic treatment
2.
The main aim of the study is to determine knowledge and awareness of malocclusion and the
treatment need in a population aged 9-12 years attending the U.O.N dental teaching hospital.
This age group was chosen on basis of being in the late mixed dentition.
6
CHAPTER
2
LITERATURE REVIEW:
Not much study has been done to determine the prevalence of malocclusion in patients
attending the U.O.N dental teaching hospital.
A wide variation
in the prevalence
of
malocclusion has however been demonstrated. In Kenya, a study carried out by P. M
Ng'ang'a examined for specific intra- and inter-arch malocclusions
and tooth loss in two
hundred and fifty one African children aged 13-15 years. The children were from 6 schools
randomly selected from 154 primary schools in Nairobi. Overall, 47%of the children were
found to have malocclusion, the most frequently encountered anomaly was crowding
2·ln
a
study of children aged 3-6 years, 51%of the children had some form of malocclusion.
Maxillary over jet accounted for deep bite 13%, dental midline displacement 6%, frontal open
bite 12% and anterior cross bite 5%.Anthropoid spaces were observed in 85%of the children,
while over60 %had spacing in the incisor region. Straight terminal plane of the deciduous
second molars was diagnosed in 53% of the children, mesial step in 43% and distal step
occlusion in one percent of the children
3 .
In Uganda' a study to determine the prevalence of the common orthodontic anomalies was
done amongst 12-15 year old school children in Kampala and their attitudes towards
treatment. A total of 322 children consisting of 181males and 141females were engaged in the
cross sectional study and self administered
and guide questionnaires
as well as clinical
examination were used as data collecting tools. Orthodontic anomalies had prevalence of
75.5%of the entire subjects affected. Most of the patients were not concern about their
malocclusion problems and the few who did had not sought treatment because of its cost and
fear4.
In a study to determine the prevalence and the severity of malocclusion and treatment need
amongst randomly selected (n: 703) rural and urban Nigerian children aged 12-18
years (mean 14.0 +1' 1.84) using the dental aesthetic index (DAI), and to assess whether
malocclusion was affected by age, gender and socio-economic background. Data was
collected according to the method recommended by WHO. Most of the children (77.4 per
cent) had a dental appearance, which required no orthodontic treatment. Over 13per cent fell
7
into the group where treatment for malocclusion is considered to be 'elective'. However, a
substantial
proportion
(9.2 per cent) of the population
had severe to handicapping
malocclusion where treatment is' highly desirable'or'mandatory'.
differences
There were no significant
(P > O.OS) in DAI scores between age groups, gender and socioeconomic
background. This study also found that Nigerian-adolescents
had better dental appearance
and less orthodontic treatment need compared with the Caucasian and Oriental populations
5.
In Tanzania, a study was performed with the aim of assessing opinions of Tanzanian children
on dental attractiveness and their perceptions of orthodontic treatment need in relation to their
own dental attractiveness
orthodontic
treatment
as measured by the aesthetic component (AC) of the index of
need (IOTNl
A random
sample of 368 school children (48%
boys,S2% girls), aged 9 to 18 years was selected. The subjective need was assessed using a
pre structured questionnaire,
photographs.
and attractiveness
was scored by using 18 intraoral frontal
Orthodontic treatment need was measured with the IOTN, and I I %of the
children definitely needed orthodontic treatment (grades 8-10 of the AC with 4-S of the
dental health component
[DHC]). The AC indicated
that 11%of the children needed
orthodontic treatment, whereas the DHC indicated 22%. Although 38 %of the children said
they needed treatment, 33%and 3l%were unhappy with the arrangement
and the appearance
of their teeth, respectively.
Most children (8S%) recognized well-aligned teeth as important for overall facial appearance.
Photographs
showing severe deviation
including
crowding were regarded
as the most
unattractive,
with older children tending to dislike them the most (P <.OOOS).
It was
concluded that, from the children's point of view, grades 8-10 of the ACand 4-S of the DHC
could
be given the first priority when considering
an orthodontic
treatment policy in
Tanzania6
In Ibadan, Nigeria a study was performed
to investigate
the concerns for orthodontic
treatment by parents of adolescents for their children and to compare the observations with
objectively determined orthodontic treatment need using DAI. A total of 271 udents agedl218 years (mean 14.8 +1-1.1) drawn from five secondary schools in Ibadan were clinically
examined while their parents were asked about their opinions in a questionnaire. About6l3%
8
of the adolescents had normal or minor malocclusions needing no treatment. The restneeded
orthodontic treatments ranging from definite to mandatory treatment needs. No sex difference
was noted (P > 0.05). Their psychosocial treatment need indicated by parental orthodontic
concern revealed that 86% of them needed no orthodontic treatment. Most parents (87.1 %)
perceived dental aesthetics to be equally important for girls and boys and no sex difference
was observed in their orthodontic concern (p > 0.05). Parents' orthodontic concern had
significant weak correlation with DAI scores. The results suggest a need for more orthodontic
awareness in our community and confirm that there is a difference of opinion on orthodontic
treatment need between laypersons and orthodontists as would be
expected
In Kronoberg county, Sweden8 a study was carried out to compare the outcome of
orthodontic treatment and the desire for further treatment in 19-year-old young adults treated
by specialists in urban and rural areas and to study the influence of the level of education of
their parents. The individuals were clinically and retrospectively examined with reference to
malocclusions and orthodontic treatment received during childhood and adolescence. The
subjects included a sample of 302 young adults, all individuals who had received orthodontic
treatment by specialists (n = 60). The individuals were compared according to outcome of
treatment and place of residence. The pre-treatment need, the residual treatment need, the
treatment results, and the desire for further treatment were estimated as well as treatment
duration, number of visits, percentages
of discontinued
treatments
and parents' level of
education. The results showed a higher frequency of individuals without previous treatment
and a lower frequency of specialist-treated individuals in rural areas than in urban areas in the
county. The treatments
implied
substantial
improvements,
with a higher reduction
of
treatment need and a higher degree of success in patients from urban areas than from rural
areas (P < 0.01). There were no statistically significant differences according to gender,
socio-economic factors, or desire for further treatment. The results suggest a-greater degree
of tolerance towards malocclusions in individuals in rural areas than in urban area.
In A study to compare attitudes toward orthodontic treatment in British and American
communities'', two communities with historic difference in the availability and utilization of
orthodontic services were selected as survey sites (Lexington, Kentucky, and Cardiff,
9
Wales).Three-hundred
eighty-five sixth grade children (lIto
12 years of age) and 123 of
their parents were interviewed concerning dental aesthetics, treatment need, and knowledge
about attitudes toward, and value placed on orthodontic treatment. Although the Lexington
respondents had greater personal and indirect knowledge about such services, they did not
have more positive perceptions
about treatment: nor did they value straight teeth more
highly. There were no significant
differences
between the groups' judgment
of dental
aesthetics or assessment of treatment need. The differences in utilization of services in the
two Communities
could not be explained
in terms of differences
in attitude toward
malocclusion and orthodontic treatment
A study to determine whether an association existed between parents' attitudes to orthodontic
issues affecting themselves and their attitudes to possible orthodontic treatment for their child
was carried out in London, U.K.lO•
It consisted of an analytical
survey using a self-
administered questionnaire, taken in South East England of six-hundred parents of children
aged 9 years. The questionnaires were delivered to the parent with the help of their child's
school. Four hundred-and-thirty-seven
questionnaires were returned (73 per cent). The results
showed a significant association between desire by the parents for orthodontic treatment for
themselves
and perception of need in their child, parental satisfaction
with own dental
appearance and perception of need in their child, a parental history of orthodontic treatment
and determination to insist on their child's co-operation with orthodontic treatment'''.
In a study undertaken to investigate the desire and consciousness of orthodontic patients and
their parents on the content and effect of orthodontic treatment in Japan, the subjects were
362 post-treatment
patients and 353 of their parents, who answered the questionnaires.
Results obtained showed that 49%of the patients and l6%f the parents of the patients thought
of giving up the treatment while the patients were under the orthodontic treatment, the main
reasons were the discomfort of orthodontic appliances, long treatment period, and the absence
from school.55% of the patients felt uneasy about a change of the occlusion for the worse
after removal of the orthodontic appliances, and 60-70% of the patients and parents had
forgotten the necessity of the retainer after active orthodontic treatment Both patients and
parents hoped to finish the orthodontic treatment by the end of junior high school. About
50%ofthe parents preferred the university hospital and about 45% preferred a private dental
lO
office which was convenient for attending as an outpatient. About 70% of the patients and
parents were satisfied with occlusion after orthodontic treatment. and 33% of the patient's
and6l% of the parents were satisfied with the orofacial appearance after treatment. About 9%
of the patients hoped to keep secret their history of orthodontic treatment. About 35% of the
patients and 60% of the parents would recommend people with malocclusions
to receive
orthodontic treatment. About 80% of the patients would make their own children receive the
orthodontic treatment if needed. 90-95% of the patients and parents were pleased with
orthodontic treatment
11.
In Northern England, a study to determine the influence of social class, gender, and peers on
the uptake of orthodontic
compnsmg
treatment
five-hundred-and-forty
was performed.
A representative
15- and l6-year-old
adolescents
random
sample
were interviewed
in
school. The results indicate that familiarity with orthodontic appliances among a subject's
peer group has a greater influence on the uptake of orthodontic treatment than the subject's
social class or gender".
In a study to establish a sociocultural standard of reference for Norway related to the AC, a
sample of 137 children,
126 of their parents and 98 young adults were shown the
lOphotographs comprising the AC. The subjects were asked to assess the photographs for
dental attractiveness
and orthodontic treatment need on a four-category
rating scale. The
findings indicated that, in general, photographs with an increasing scale point were rated as
increasingly more unattractive. The majority (80-100 per cent) of the parents and young
adults rated the five photographs
treatment.
The
children
judgments.Photographs
were
on the unattractive
significantly
end of the scale to be in need of
less
critical
m
their
aesthetic
representing borderline need, identified for these groups to be scale
points 5 and6, have a potential in guiding patients and parents in making informed decisions
about aesthetic treatment need 13.
In a study carried out to analyze the qualitative factors which influence young people's
acceptance of orthodontic care, qualitative data was volunteered as a response to open
questions in a self-administered
questionnaire. The study aimed to analyze and identify the
psychological factors influencing young people's behavior in relation to orthodontic care and
11
to gam an understanding
acceptance
of orthodontic
of the psychological
factors
which
care. The study was conducted
influence
adolescents'
in all Walsall and Dudley
secondary schools. The responses of the young people who were in year 10 of education with
an average age of 15.0 years demonstrated the importance of personal constructs. peer group
and media
perception,
influences,
appearance
parental
influences,
and self-image,
conflicting
and interpersonal
messages,
teasing,
relationships
symptom,
in determining
whether or not young people either seek and accept or reject orthodontic treatment. The study
concluded that it is essential that clinicians involve patients fully and honestly in discussions
concerning their orthodontic therapy in order to enable them to make a considered consent
14.
In a study aimed at exploring the knowledge and views regarding orthodontics of a group of I
-12-year-old girls attending a school in Southeast London and the terms that they used to
obtain the information, Dental Health Education sessions were used to investigate these aims.
Eight DHE sessions at a secondary school for girls were tape recorded. In order to raise the
issue of orthodontics and trigger the formation of questions during health education session a
worksheet containing true/false questions, a crossword puzzle regarding orthodontics and
some open ended questions was designed and sent to students. They were required to read
and complete the worksheet before each session. They were not required to return the
completed worksheets to the investigators but did return them to their teachers. The sessions
were tape recorded and supplemented by notes taken at the sessions by the investigator. A
total of eight DHE sessions, attended by 14 girls each, were tape-recorded.
Each tape-
recording was immediately transcribed verbatim and the data organized to single out the
orthodontic questions and discussions and categorize them. A total of I 17 girls aged I I -12year-old comprised the study group: 77%ere white and 23% black children. After reading the
transcripts several times, certain themes on orthodontics emerged. The results showed that
children questioned
different aspects of orthodontics.
Nine themes emerged from their
questions and discussions. They wanted to know why orthodontic treatment was carried out
and when was the right time to start treatment. They were very keen to find out the
differences between different orthodontic appliances. The psychosocial impacts of wearing
an orthodontic appliance, i.e., experience of pain as well as the need for extraction of some
permanent teeth as part of the treatment were of concern. They asked some questions on the
need for repair, adjustment and taking care of appliances. The etiology of malocclusion was
another theme that emerged. The students tended to ask questions and describe problems in
their own lay terms. The methodology used in this study provided an opportunity to assess
12
the information needs with regards to orthodontics of a group of children attending a school
in Southwark, London, UK. It was successful in discovering the views and concerns, and to
some extent' their knowledge regarding orthodontics and the terms pupils used in asking
questions and making comments'".
In a study to investigate the level of awareness of the risks and benefits of orthodontic
treatment among potential consumers and their referring dentists, parents of patients referred
for orthodontic treatment were issued with a questionnaire about the risks an-d benefits of
treatment and the reason the child had been referred. Study models were also made of the
child's teeth' The patients'
dentists were issued with a similar questionnaire.
The results
revealed that most of the parents were aware of the benefits of treatment in general and the
reason that their own child required it. This awareness was greater where the orthodontic
need on aesthetic grounds was greater. There was less awareness of the risks of treatment
though again this was greater among those with a greater need for treatment. When the
perceptions of the dentists were evaluated, they were more aware of the risks but were not
communicating this to the parents. It was concluded that since for some patients the risks of
treatment may outweigh the benefits, it would be helpful if dentists could provide this
information for patients before referral16.
A study investigating young people's perceptions of their orthodontic needs, demands and
their experience
of orthodontic
services was conducted
in Walsall and Dudley health
districts'", using a self-completed questionnaire. The subjects were 4812 individuals in year
10 of education (average age 15.0 years). Overall, the level of malocclusion perceived by the
young people was similar to that identified by dentists in the 1993 national survey of
children's dental health. The level of reported malocclusion by boys and girls, white and nonwhite students and students from the two districts was the same; however fewer students from
the less prosperous
neighbourhoods
reported having straight teeth, and more non-white
students with irregularities wanted to have
straight teeth. Although many young people reported having a malocclusion
the majority
were not concerned about it. The study revealed significant differences in experience of
treatment. Boy's, non-white students and students from less prosperous areas were less likely
to report having active orthodontic treatment. Access to specialist services was lower for the
non-white students and students from less prosperous areas. A higher proportion of students
13
treated with fixed appliances reported straight teeth after treatment than those treated by
extractions alone or by removable appliance therapy"
The
study will hope to add to the insight on the level of knowledge and awareness of
malocclusion and the treatment need in a population aged 9-12 years attending the V.O.N
dental teaching hospital.
14
------------------------1
PROBLEM STATEMENT
There are various factors that contribute to malocclusion in the Kenyan population. Lack of
knowledge of orthodontic treatment and financial constrains contribute to an increase in
number of untreated patients.
STUDY JUSTIFICATION
Previous studies have been conducted to establish prevalence of malocclusion and treatment
need of the Kenyan population.
There has been an increased demand for orthodontic
treatment in the Kenyan society. This has been prompted by increased media campaign for
perfect dentitions and has also been influenced by the western world. It is necessary to
commence orthodontic treatment at a reasonably early age so as to minimise expenses,
achieve aesthetics and avoid placement of unsightly appliances in adulthood and also to
.
.
Improve on prognosis.
OBJECTIVES
General objective:
To determine knowledge and perception towards orthodontic treatment need in a population
aged 9-12 years attending the U.O.N dental teaching hospital.
Specific objective:
1. To determine knowledge and awareness of malocclusion.
2. To determine subjective orthodontic treatment need among 9-12 year olds attending the
U.O.N dental teaching hospital
HYPOTHESIS
More than 50% of patients attending the U.O.N dental hospital have malocclusion requiring
orthodontic treatment.
VARIABLES
Independent variables:
I.Age
2.Sex
Dependence variables:
I.Patients' compliance.
STUDY DESIGN
The study will be a descriptive cross-sectional study.
15
SAMPLING PROCEDURE
For this study a confidence level of 95% will be used and prevalence of 60%.
The formula for calculating the sample size is as follows.
N
=
Z2(p) (l-P)
C2
N- Sample size
P- Prevalence rate
C- 100-confidence level = 100-95 =5
Z- Normal value for the probability blevel = 1.96
N= 1.96*60(100-60)
5
=3.8416* 60* 40
25
= 9219.84
25
N = 368.8
nf=_n_
1+n/N
n=sample size
F= final size
N= population
Nf= 368
1+368
=58
70
STUDY AREA
The study will be carried out at the U.O.N dental hospital which is located within the capital
city of Nairobi. It is the dental teaching hospital for the U.O.N. and the national dental
referral hospital.
16
STUDY POPULATION
The study will comprise 9-12 year olds attending the paediatric and orthodontic clinics at the
V.O.N dental hospital.
SAMPLING CRITERIA:
Inclusion criteria.
I.All the patients who are present on the day of data collection.
2.All the patients who consent to this study.
Exclusion criteria.
I.All the patients absent on the day of data collection.
2.All the patients who do not consent to this study.
DATA COLLECTION
Questionnaires comprising close ended questions will be used for data collection. Before
administration they will be pre-tested for reliability after which any appropriate changes will
be made. T he questionnaires will then be administered.
LOGISTICS
1. Financial constrains.
2. Different literacy levels between different patients.
3. The research has to be carried out in a short period of time.
ETHICAL CONSIDERATIONS
1. All the information in the questionnaires will be treated as classified information.
2. No patient will be forced to consent in this study.
DATA ANALYSIS AND PRESENTATION
Data analysis will be performed manually.
The results obtained will be presented as tables, pie charts and bar graphs.
PERCEIVED BENEFITS
1. The evaluation of patients and the distribution
of malocclusion
types give valuable
information for planning an orthodontic service.
2. Partial fulfilment for the award of a Bachelor of Dental Science Degree at the VON.
17
BUDGET
ITEM
.$
Printing
COST /UNIT (KSHS)
UNITS
10/Page
100
I TOTAL
(KSHS)
1000
v
Typing
Stationery
Communication
10IPage
Binding
\
40/unit
300
2
l'
400
1-.)
~~..;.
150
~
...
600
) ..)
,.,"-:)1 ~ "", \.
6
2000
""'l.c""
Computer time
I/min
300
300
Internet services
lImin
600
600
?
Transport
TOTAL COST
40/trip
)
600
2ft-
20/minute
4/Page
30
""1.'
300/ream
J"\\~
Photocopying
i
30
<$>0
I.)
~
;'n
1200
~..),.)
7000
18
APPENDIX
QUESTIOINNAIRE;
MALOCCLUSION
TREATMENT
AND
PERCEPTION
NEED IN A POPULATION
TOWARDS
ATTENDING
ORTHODONTIC
THE UNIVERSITY
OF
NAIROBI DENTAL TEACHING HOSPITAL
AGE:
SEX:
CLASS:
(TICK THE RESPONSE OF YOUR CHOICE)
1) What do you understand
by the term-crooked teeth?
(a) Decayed teethn
(b) Discoloured teethn
(c) Wrongly arranged teethe
(d) I do not knowo
2) Do you observe crooked teeth in your mouth?
(a) Yes, very much.o
(b) Yes, moderatelyo
(c) Am not suren
(d) Do not known
3) Do your age mates tease you about the appearance of your teeth?
(a) Yes, alwayso
(b) Yes, oftenn
(c) No, nevero
(d) Do not known
19
4) Have you observed crooked teeth in some of your family members or age mates?
(a) Yes
0
(b) Noo
(c) Do not bother lookingo
5) Do you think that your teeth are better arranged than those of your age mates?
(a) Yes, much bettero
(b) Yes, somewhat bettero
(c) Similar to most ofthemo
(d) Somewhat worseo
(e) Much worseo
(f) Do not know
0
6) Do you think it's important to correct crooked teeth?
(a) Yeso
(b) Noo
(c) Not sureo
7) If yes, how can they be corrected?
(a) Extraction D
(b) Wearing braces D
(c) I do not know D
8) Would you like your teeth straightened?
(a) Yeso
(b) Noo
(c) Not sureo
9) Would you accept any procedures to straighten your crooked teeth?
(a) Yeso
(b) Noo
(c) Not sureo
20
10) Have you had any treatment to correct of your teeth arrangement?
(a) Yes D
(b) No D
(If yes, go to question 12)
11) If no, what was the reason for not correcting the arrangement?
(a) Lack of money D
(b) Lack of information D
(c) I do not have crooked teeth D
(d) It does not bother me D
12) What was your reason for correcting your teeth arrangement?
(a) Enhance chewing D
(b) Enhance appearance D
(c) Enhance self esteem D
(d) Acquire strong teeth D
13) Who took the initiative to start the correction of your teeth arrangement?
(a) Parents D
(b) Myself D
(c) Relatives D
(d) Friends D
Maureen Macharia BDS III.
Thank you for your co-operation.
21
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rural Masaai
community
in Kenya. A review. Discovery and Innovation.
1994;
6:363-365.
2. Ng'ang'a,
P.M. A study of occlusal anomalies and tooth loss in children aged 13-
15 years in Nairobi. East Afr. Med. J. 1991; 68:980-988.
3. Kabue MM, Moracha JK, Ng'ang'a PM. Malocclusion
in children aged 3-6
years
in Nairobi, Kenya. East Afr Med J. 1995 Apr;72(4):21 0-2.
4. Ntuulo J, Amuseli E, Kiryowa H, Kyagulanyi P, Ntulume R, Davis B, Matthew R.
Assesment of orthodontic
schools in Kampala,
anomalies
amongst
Uganda.International
12-15 year old children
in urban
Association For Dental Research. 2004
Aug; 18:22.
5. Otuyemi OD, Ogunyinka A, Dosumu 0, Cons NC, Jenny J. Malocclusion
orthodontic
treatment
and
need of secondary school students in Nigeria according to
the dental association Index (DAI).Int Dent J. 1999 Aug;49(4):203-10.
6. Mugonzibwa EA, Kuijpers-Jagtman
dental attractiveness
AM, Van 't HofMA, Kikwilu EN. Perceptions
and orthodontic
treatment
need among Tanzanian
Am J Orthod Dentofacial Orthop. 2004 Apr;125(4):426-33;
7. Onyeaso
treatment
CO. Orthodontic
need assessed
concern
by Dental
Odontostomatol.Trop.2003Mar;26(1
of parents
Aesthetic
Index
of
children.
discussion.
compared
with
orthodontic
(DAI) in Ibadan,
Nigeria.
01): 13-20.
8. Bergstrom K, Halling A, Huggare J. Orthodontic
treatment
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