Download Self-perception regarding the need for orthodontic treatment among

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Self-perception regarding the need
for orthodontic treatment among
impoverished schoolchildren in Brazil
L.S. MARQUES*, M.L. RAMOS-JORGE**, J. RAMOS-JORGE***,
L.J. PEREIRA*, S.M. PAIVA***, I.A. PORDEUS***
ABSTRACT. Aim The objectives of the present study were to assess predictive factors associated to self-perception
regarding the need for orthodontic treatment among 170 impoverished schoolchildren. Materials and methods A
cross-sectional study was conducted in public schools in the city of Belo Horizonte-MG (Brazil). Children’s selfperception regarding the need for treatment was assessed using the Aesthetic Component of the Index of
Orthodontic Treatment Need (IOTN-AC) and a questionnaire addressing biopsychosocial factors. The chi-square
test and multiple logistic regression were used in the data analysis. Results The predictive factors for the selfperception of orthodontic treatment need on the part of the impoverished schoolchildren included ridicule from
persons close to the children regarding the appearance of the teeth (OR 2.81; 95%CI 1.2 to 6.4), dissatisfaction
with oral aesthetics due to the alignment of the teeth (OR 2.45; 95%CI 1.1 to 5.4) and missing teeth (OR 3.02;
95%CI 1.0 to 9.23). Conclusion The alignment of the teeth, missing teeth and ridicule from others regarding the
appearance of the teeth are the factors that most strongly influence self-perception regarding the need for
orthodontic treatment among impoverished schoolchildren.
Key words: IOTN index; Orthodontic treatment; Orthodontic treatment need.
Introduction
A variety of social, cultural, psychological and
personal factors influences the perception of dental
appearance [Graber and Lucker, 1980; Baldwin, 1980;
Grzywacz, 2003; Mugonzibwa et al., 2004].
Dissatisfaction with dental appearance is the main
factor associated to the decision to undergo orthodontic
treatment [Bos et al., 2003]. It has been estimated that
80% of orthodontic patients seek services out of a
concern for aesthetics rather than for reasons related to
health or function [Albino et al., 1981; Brook and
Shaw, 1989; Richmond et al., 1995; Tang and So, 1995;
Birkeland et al., 1999; de Oliveira and Sheiham, 2004].
Thus, an individual’s self-perceived dental aesthetics
affects normative assessments regarding the need for
orthodontic treatment [de Oliveira and Sheiham, 2004].
There is a greater chance of malocclusion having an
impact on quality of living among schoolchildren who
have negative self-perceptions regarding their dental
aesthetics, and such children more frequently perceive
*Department of Orthodontics, University of Vale do Rio Verde, Três Corações, Brazil
**Department of Orthodontics and Paediatric Dentistry
Federal University of Vale do Jequitinhonha e Mucuri, Diamantina, Brazil
*** Department of Orthodontics and Paediatric Dentistry
Federal University of Minas Gerais, Belo Horizonte, Brazil
E-mail: [email protected]
EUROPEAN JOURNAL OF PAEDIATRIC
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the need for orthodontic treatment [de Oliveira and
Sheiham, 2004; Shaw et al., 1980]. A study carried out
in Brazil reported that schoolchildren having completed
orthodontic treatment had a better oral health-related
quality of life than those still in treatment or those
having never undergone treatment [de Oliveira and
Sheiham, 2004]. However, Brazilian public healthcare
services do not offer orthodontic treatment, thereby
rendering such treatment inaccessible to a large portion
of the population and restricting it to those who can
afford it. In such as context, little is known regarding
the effects (if any) of malocclusion on social interaction
and psychological wellbeing among individuals who
cannot enjoy the benefits of orthodontic treatment and
how such individuals perceive aesthetic alterations
stemming from malocclusion. Thus, it is important to
gain a better understanding of the biopsychosocial
aspects of malocclusion and its effect on quality of life
among such individuals, addressing the issue as a
public health problem. Information in this regard would
favour a better assessment of treatment needs and
priorities as well as allowing a better planning of the
resources needed to offer the population access to
orthodontic treatment.
The aim of the present study was to estimate
predictive factors regarding the self-perceived
aesthetics of malocclusion among impoverished
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MARQUES L.S. ET AL.
schoolchildren to whom orthodontic treatment is
inaccessible for financial reasons.
Subjects and Method
The study was conducted in the city of Belo
Horizonte, which is the capital of the state of Minas
Gerais in southeast Brazil. The city has approximately
3 million inhabitants and considerable economic and
socio-cultural disparities.
A cross-sectional study was carried out with 170
schoolchildren between 10 and 14 years of age, living
and studying in shanty towns and whose per capita
family income characterized a state of poverty. Four
public schools were chosen based on the distribution of
districts in the city (North, South, East, West) and a
second selection process was carried out for
participants based on the attendance list of each class.
The research team consisted of an orthodontist
(L.S.M.) and a dental assistant. Four schools were
visited from July to November 2007 for data collection
during the first stage of the study.
The following inclusion criteria were considered:
schoolchildren between the ages of 10 and 14 years,
with adequate physical, mental and psychological
health and having never undergone orthodontic
treatment. Only those children for whom the monthly
per capita family income did not surpass one-half of a
minimum salary (R$120 - US$ 40) were included.
The outcome was the child’s self-perceived need for
treatment using the Aesthetic Component of the Index
of Orthodontic Treatment Need (IOTN-AC) [Brook
and Shaw, 1989]. AC Grades 1 to 4 represent no need
or slight need for treatment; AC Grades 5 to 7 represent
a moderate to borderline need for treatment; and AC
Grades 8 to 10 represent a need or definite need for
orthodontic treatment. This variable was then
dichotomized in AC Grades ≤ 4 and AC Grades > 4.
The key independent variables were:
- child’s age at the time of data collection;
- child’s gender;
- satisfaction with oral aesthetics.
- causes of dissatisfaction with oral aesthetics:
missing teeth, colour of the teeth, shape of the teeth,
position of the teeth, mouth or facial deformity,
tooth decay;
- ridicule from other people regarding the appearance
of the teeth;
- desire for correcting the teeth;
- name-calling at school due to the teeth and/or
physical characteristics;
- embarrassment upon showing the teeth.
A pre-structured questionnaire was administered to
the children in the classroom. The questionnaire was
divided into 3 sections. The first section addressed
demographic characteristics, particularly age, gender
and socioeconomic level. The second section addressed
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the children’s awareness of their own occlusions,
including questions on the subjective need for
treatment, satisfaction with the appearance of their
teeth, causes of dissatisfaction with the appearance of
the teeth, ridicule from other people regarding the
appearance of the teeth, embarrassment upon smiling,
desire for orthodontic treatment and name-calling at
school. The third section addressed respondents’
perceptions regarding malocclusions and comprised
one question related to 10 inner-oral photographs
representing the IOTN-AC.
The economic level of family was determined using
the ABA-ABIPEME criteria for socioeconomic
classification in Brazil, including a set of
comprehensive questions on the possession of
household items, such as bathroom, radio, television,
washing machine, vacuum cleaner and car as well as
the presence of a full-time domestic servant and the
educational level of the head of the household.
Subjective issues were addressed with the following
questions.
1. Are you happy with the appearance of your front
teeth? (0=yes, 1=no); If not, why? (missing teeth,
colour of the teeth, shape, size, position of the teeth,
deformity of the mouth/face, tooth decay).
2. Have people been picking on you due to the
appearance of your teeth? (0=no, 1=yes).
3. Do you feel embarrassed showing your teeth?
(0=no, 1=yes).
The IOTN-AC was employed by introducing the
index in the following manner: “Here is a series of 10
photographs showing a range of dental attractiveness.
Number 1 is the most attractive and Number 10 the
least attractive alignment of teeth. Where would you
place your teeth on this scale?” The teacher briefly
introduced the investigator to the children, provided
comprehensive verbal instructions before handing out
the questionnaires and checked for possible
misunderstandings among the children before
collecting them. Administration and gauging of
complete Parts 1 and 2 of the questionnaire were
performed with the supervision of the dental assistant,
as the administration of the IOTN-AC to the children
(Part 3) was carried out by an orthodontist (LSM).
After evaluating the agreement of the instruments
(test-retest reliability), a pilot study was carried out with
25 schoolchildren (participants were not included in the
sample of the main study), in which all the instruments
proved to be easily understood by the children.
Statistical procedures
Ethical approval was obtained from the Ethics
Committee of the Federal University of Minas Gerais.
A letter was also sent to the parents/guardians of the
participants seeking consent for their cooperation in the
study. This letter also served to inform
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ORTHODONTIC TREATMENT NEED SELF-PERCEPTION
Boys (%)
Girls (%)
Total (Row %)
Total Column %
Cumulative %
AC-IOTN
Girls
Grades 1-4
64 (48.9)
67 (51.1)
131 (100.0)
77.1
77.1
Grades 5-7
18 (64.3)
10 (35.7)
28 (100.0)
16.5
93.5
Grades 8-10
3 (27.3)
8 (72.7)
11 (100.0)
6.5
100.0
p*
0.099
*chi-square test
TABLE 1 - Gender distribution among AC grades of the IOTN for impoverished schoolchildren.
Self-perceived Orthodontic Treatment Need (AC-IOTN)
Moderate or
No need or slight
definite need (%)
need (%)
Are you happy with the
appearance of your teeth?
- Yes
- No
Total (%)
8 (17.0)
31 (25.2)
39 (83.0)
92 (74.8)
47 (100.0)
123 (100.0)
If not, Why?
Missing teeth
- No
- Yes
31 (20.1)
8 (50.0)
123 (79.9)
8 (50.0)
154 (100.0)
16 (100.0)
Color of the teeth
- No
- Yes
30 (23.8)
9 (20.5)
96 (76.2)
35 (79.5)
126 (100.0)
44 (100.0)
χ1
p
1.28
0.256
7.31
0.007*
0.21
0.649
Shape of the teeth
- No
- Yes
25 (20.0)
14 (31.1)
100 (80.0)
31 (69.8)
125 (100.0)
45 (100.0)
2.31
0.128
Arrangement of the teeth
- No
- Yes
13 (14.3)
26 (32.9)
78 (85.7)
53 (67.1)
91 (100.0)
79 (100.0)
8.30
0.004*
37 (22.6)
2 (33.3)
127 (77.4)
4 (66.7)
164 (100.0)
6 (100.0)
Fisher
0.418
31 (23.3)
8 (21.6)
102 (76.7)
29 (78.4)
133 (100.0)
37 (100.0)
0.05
0.829
Mouth/facial deformity
- No
- Yes
Tooth Decay
- No
- Yes
*significant values
TABLE 2 - Frequency distribution of impoverished schoolchildren regarding self-perceived Orthodontic Treatment Need (ACIOTN) in relation to satisfaction with dental appearance.
parents/guardians as to the objectives of the study and
to assure them of the confidentiality of all information
collected. Only schoolchildren whose parents gave
written consent were included in the study.
Results
Descriptive analysis revealed that 72% of the
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schoolchildren were unhappy with the appearance of
their front teeth, due mainly to their alignment (46.5%).
About one fifth (21.8%) of the subjects reported that
others ridiculed the appearance of their teeth and
24.1% were embarrassed to show their teeth. A total of
60.0% of the participants reported name-calling at
school and 14 (8.2%) had received nicknames as a
result of their teeth. Most of the impoverished children
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Self-perceived Orthodontic Treatment Need
χ2
P
8.29
0.004*
Moderate or
No need or slight
Total (%)
definite need (%)
need (%)
Have other people been picking on you
due to the appearance of your teeth?
- No
- Yes
24 (18.0)
15 (40.5)
109 (82.0)
22 (59.5)
133 (100.0)
37 (100.0)
Are you embarrassed to show your teeth?
- No
- Yes
24 (18.6)
15 (36.6)
105 (81.4)
26 (63.4)
129 (100.0)
41 (100.0)
5.69
0.017*
Do you have a nickname at school?
- No
- Yes
18 (26.5)
21 (20.6)
50 (73.5)
81 (79.4)
68 (100.0)
102 (100.0)
0.80
0.372
Do you have a nickname at school due to
your teeth?
- No
- Yes
32 (20.5)
7 (50.0)
124 (79.5)
7 (50.0)
156 (100.0)
14 (100.0)
6.32
0.012*
Would you like to correct your teeth to
improve the appearance?
- No
- Yes
7 (21.9)
32 (23.2)
25 (78.1)
106 (76.8)
32 (100.0)
138 (100.0)
0.02
0.874
*significant values
TABLE 3 - Frequency distribution of impoverished schoolchildren regarding self-perceived Orthodontic Treatment Need (ACIOTN) in relation to the social impact of dental appearance and the desire for orthodontic treatment.
(81.2%) wished to receive orthodontic treatment.
Tables 2 and 3 display the frequencies of the
responses regarding the self-perceived need for
orthodontic treatment (IOTN-AC) in relation to the
independent variables. Through univariate analysis
(chi-square test), statistically significant differences
were found between the IOTN-AC and the following
variables: unhappy with appearance of the teeth due to
their alignment and missing teeth; feeling embarrassed
when showing the teeth; ridicule from other people
regarding with the appearance of the teeth; and having
received a nickname at school due to the teeth.
Multivariate analysis, unconditional logistic
regression
The final adjusted logistic regression model included
the following variables: ridicule from other people
regarding the appearance of the teeth, alignment of the
teeth and missing teeth (Table 4). Table 4 shows that
children who were ridiculed by the people close to
them because of the appearance of their teeth had a
2.81-fold greater chance of a self-perceived need for
orthodontic treatment when compared to children who
did not suffer such ridicule. Among children
dissatisfied with the alignment of their teeth, the chance
of having a self-perceived need for orthodontic
treatment was 2.45-fold greater when compared to
children that were not dissatisfied with the alignment of
128
their teeth. Subjects who were dissatisfied with their
appearance due to missing teeth had a 3.02-fold greater
chance of having a self-perceived need for orthodontic
treatment than those who were not dissatisfied with
their facial appearance due to missing teeth.
Discussion
The main factors that influence a self-perceived need
for orthodontic treatment among schoolchildren with a
very low socioeconomic level were dissatisfaction with
the facial appearance due to missing teeth or the
alignment of the teeth as well as ridicule from other
people regarding the appearance of the teeth.
The Index of Orthodontic Treatment Need (IOTN) is
one of the most widely used occlusal indices around the
world and incorporates both a Dental Health
Component (DHC) and an Aesthetic Component (AC).
In the present study only the IOTN-AC was used, as
this a safer and more reliable method than DHC in
relating IOTN to the self-perceived need for
orthodontic treatment [Kerosuo et al., 2004]. As a
visual aid, IOTN-AC has a number of advantages over
verbal descriptions, especially when the subjects under
study are children [Stenvik et al., 1997]. When dealing
with information related to morphology and the
aesthetic significance of variability, visual stimuli may
be more comprehensible as communication tools than
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ORTHODONTIC TREATMENT NEED SELF-PERCEPTION
Variables
Unadjusted
OR (95% C.I.)
P
Adjusted
OR (95% C.I.)
Have other people been picking on you due to
the appearance of your teeth?
- No
- Yes
1.00
3.09 (1.40-6.83)
0.005*
1.00
2.81 (1.23-6.41)
0.014*
Unhappy with arrangement of the teeth?
- No
- Yes
1.00
2.94 (1.38-6.24)
0.005*
1.00
2.45 (1.12-5.37)
0.025*
Unhappy with tooth loss?
- No
- Yes
1.00
2.31 (1.00-5.41)
0.050*
1.00
3.02 (1.00-9.23)
0.050*
P
*significant values
TABLE 4 - Results of multiple logistic regression on self-perceived Orthodontic Treatment Need (AC-IOTN) among 170
impoverished schoolchildren. Belo Horizonte, Brazil.
verbal descriptions. This is particularly true for children
due to variations in their level of cognitive
development. Thus, standardised dental photographs
can be used as a valid representation of dental
attractiveness [Howells and Shaw, 1985].
A number of researchers have studied gender
distribution in the need for orthodontic treatment [Tang
and So, 1995; Burden et al., 1994; Kerosuo et al., 2000;
Uçuncu and Ertugay, 2001]. In the present study,
differences between the IOTN-AC values of boys and
girls were not statistically significant. This result is in
agreement with those from previous studies [Kerosuo
et al., 2004; Uçuncu and Ertugay, 2001]. A number of
studies reported a higher normative treatment need for
males than females [Burden et al., 1994; Kerosuo et al.,
2000], but no gender differences regarding the selfperceived need for treatment [Tang and So, 1995;
Kerosuo et al., 2000; Uçuncu and Ertugay, 2001;
Bergstrom et al., 1998; Ugur et al., 1998].
Despite the findings that 72% of the schoolchildren
with an extremely low socioeconomic level were
dissatisfied with the appearance of their front teeth - due
mainly to alignment (46.5%) - and 81.2% desired
orthodontic treatment, most of the subjects classified
themselves in the “no treatment need” category (Grades
1 to 4) (77.1%). Similar results have been reported in
other studies [Grzywacz, 2003; Mandall et al., 2000; Al
Yami et al., 1998; Ingervall and Hedegard, 1974; Pietila
and Pietila, 1996]. Al Yami et al. found that 77.5% of the
children classified themselves in Grades 1 to 4 (IOTNAC). Ingervall and Hedegard found that only 4% of a
group of 18-year-old Swedish males considered
themselves as requiring orthodontic treatment, although
orthodontists estimated that 60% were in need.
Grzywacz found that only 5 boys (6.0%) classified
themselves in the category “borderline treatment need”
(Grades 5 to 7); the remaining children chose Grades 1
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to 4 (“no treatment need”) and none of the children
placed their own dentition in the category “great
treatment need” (Grades 8 to 10). Similar results were
obtained in a study by Pietila and Pietila. Mandall et al.
found that 94.0% of the subjects perceived the
alignment of their anterior teeth to be acceptable (IOTNAC 1 to 4). The discrepancy between dissatisfaction
with the dental appearance and the perceived need for
orthodontic treatment suggests that Brazilian children
are demanding with regard to facial aesthetics and that
the IOTN-AC may underestimate the real subjective
need for orthodontic treatment. Furthermore, cultural
norms for acceptable dental alignment may differ
between countries and it is likely that grades of
attractiveness and cut-off points for treatment need vary
as well [Kiyak, 1981; Stenvik et al., 1997].
In the present study, children for whom people close
to them picked on the appearance of their teeth, those
who were dissatisfied with the alignment of their teeth
and those who were dissatisfied with their appearance
due to missing teeth had greater chances of perceiving
a need for orthodontic treatment through IOTN-AC. A
number of studies have found that the appearance of the
teeth [Gosney, 1986; Kilpelainen et al., 1993; Tung and
Kiyak, 1998] and the influence of friends at school are
important factors in the self-perceived need for
orthodontic treatment and in seeking such treatment.
Shaw et al. [1980] report the strong impact that a
nickname received at school due to dental
characteristics exercises on a child's emotional state,
causing him/her sadness and to become the victim of
ridicule by friends. Ingervall and Hedegard found that
the desire for orthodontic treatment and the selfperception of malocclusions were more frequent in
individuals with missing anterior teeth.
In conclusion, the present study provides evidence
that the main factors influencing the self-perceived
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need for orthodontic treatment among schoolchildren
with a very low socioeconomic level are dissatisfaction
with the appearance of the mouth due to missing teeth
or the alignment of the teeth as well as ridicule from
other people regarding the appearance of the teeth. The
results suggest that the development of public health
policies that favour the access of the population to
orthodontic treatment should be considered. Preventive
programs, such as orientation given to parents,
fluoridation of the public water supply and the use of
fluoridated toothpaste, may favour the occlusal
situation of young patients in a variety of ways.
Furthermore, problems such as the early loss of
primary or permanent teeth (which is very common
among children with a very low socioeconomic level),
open bite and crossbite may be intercepted or
prevented.
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