Correlation between the Perception of Personal Dental Appearance and the Residual Treatment Need amongst Underserved Indian Adolescents

Introduction

Well-aligned teeth and a pleasing smile reflect positive status at all social levels and irregularity or protruding teeth reflect negative status [1]. A malocclusion is considered as a deviation from the ideal occlusion, which may range from mild to considerable from the acceptable norm [2].

Increased concern over dental appearance has been observed during childhood and adolescence to early adulthood. The decision to start orthodontic treatment is primarily influenced by such concerns and psychological well-being [3]. Dentist predict that the psychological component of malocclusion will continue to be one of the strongest motivator for the orthodontic treatment and it is very difficult to estimate the extent to which malposed teeth or dento-facial mal-relation constitute a psychological hazard [4]. Thus, the measurement of malocclusion as a public health problem is extremely difficult since individual perceptions of what constitutes a malocclusion problem differs widely.

The relationship between professionally assessed and self-perceived treatment need is of interest to providers of public health services. Over the years, a variety of indices have been developed to assist professionals and amongst them, Dental Aesthetic Index and Index of Orthodontic Treatment Need are well-known indices for assessment of malocclusion and determination of treatment need.

Use of such indices allows the clinicians to assess the individuals with the greatest need of orthodontic treatment and individuals with little need for treatment taking in the consideration of availability of resources [5]. Thus, planning orthodontic treatment within a public health system requires the information regarding their aesthetic perception along with the need and demand for orthodontic treatment.

Hence, the present study was undertaken to assess the perception of dental attractiveness along with the need and demand for the orthodontic treatment amongst school children specially belonging to low socio-economic status, who are not able to afford the cost of dental treatment and to find the correlation between the demand and need for their orthodontic treatment.

Results

All the 1010 subjects responded to the questionnaire and agreed to participate in the clinical examination. A total of 360 (35.6%) of the subjects belonged to age group 12-15 years while 650 (64.4%) to 14-15 years of age. Male: Female ratio was 46:55 (Mean = 13.83 years ± 1.98) belonged to lower SES group and was verified by Kuppuswamy’s socioeconomic scale.

Graph 1 depicts the overall subjective perception of the subjects based on the questionnaire. Table 1 reveals the gender difference of significance in the opinions about the subjective perception of the occlusion amongst study subjects. In response to the question regarding the satisfaction with smile, 71% of subjects perceived their smile as pleasant and statistically significant difference (p<0.05) was found amongst the gender for the satisfaction with the appearance of their smile (question 1) (Table 1).

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Graph 1: Overall Subjective Perception of the subjects based on the Questionnaire.

* Pearson Chi-Square Significant (P<0.05) Table 1: Sex wise distribution of subjects according to the responses to questionnaire.

Sixty eight subjects liked the way their teeth look like (question 2). 76.4% of girls liked the way their teeth looked like compared with 56.5% of boys. This difference in perception amongst boys and girls was found to be statistically significant (p<0.05) (Table 1).

Approximately, 89% of the girls considered well- aligned teeth important for their facial appearance in comparison to 69% of boys (question 6). This difference amongst the opinion of boys and girls was again found to be statistically significant (p<0.05) (Table 1).

Their visual perception of subject occlusion was also assessed using 10 standard intra-oral occlusion photographs of aesthetic component (AC) of the Index of Orthodontic treatment need (IOTN) (Figure 1). Majority (88%) of the subjects, irrespective of age and sex, perceived photograph number 1 followed by photograph number 2 (8%) and photograph number 3 (4%) as the best photograph of occlusion while photograph number 10 is perceived as the worst occlusion (76%) followed by photograph number 9 (11%), photograph number 7 (5%), photograph number 6 (4%), photograph number 8 (3%) but mild difference in opinion was observed amongst age groups and sex for photograph number 4 .

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When the subjects were asked regarding the occlusion they would like to have amongst the 10 standard intra- oral photographs, majority of the subjects choose photograph number 1 (83%) followed by photograph number 3 (11%), photograph number 2 (5%) and photograph number 4 (1%) while the occlusion they would never like to have was that of photograph number 10 (58%), photograph number 8 (19%), photograph number 9 (14%), followed by photograph number 2, 4, 5 and 7 (1%).

When examined clinically, most of the subjects (74.3%) had a dental appearance that required some form of orthodontic treatment either elective/desirable/mandatory according to DAI (Graph 2). For the purpose of statistical analysis, the category of desirable treatment and mandatory treatment was combined. Table 2 shows the correlation between the DAI and the subjective perception with treatment need. Kappa statistics revealed negative correlations amongst the subjective perception of the subjects and their actual treatment need assessed by DAI. Even though the correlations were negative, they were not statistically significant.

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Graph 2: Treatment Needs of the subjects according to Dental Aesthetic Index.

There was a negative although insignificant correlation between the professional needs and the felt needs of the subjects belonging to low socio-economic status. A statistically significant difference was also The study group of 12 to 15 years was taken as adolescence is said to be the age when an increase in awareness and facial aesthetics takes priority and children have a tendency to compare themselves with peers, models etc., [4, 6, 7]. This can be a major factor to demand for orthodontic services in a community. Also, it is known that the parent or the patient’s concerns of orthodontic treatment need, do not always agree with professional evaluations of the same [1, 4, 7]. Hence, a validated self-administered questionnaire was used to know the perceived needs of the children regarding their occlusion. Intra-oral standard photographs, an aesthetic component of Index of Orthodontic Treatment Need was also included to judge the dental attractiveness of the subjects in better terms as it is considered to be a valid representation of dental attractiveness. Furthermore, visual stimuli might be more useful than verbal descriptions in assessing the aesthetic perception amongst children [1, 8]. Low socio-economic status was specifically chosen to analyse the level of awareness, demand and felt need of the children belonging to this strata and the paucity of literature pertaining to this underprivileged group. Kuppuswamy’s socioeconomic scale was taken as it more elaborative, more precise, takes into account education, occupation and family income to calculate the socio-economic status. To overcome the limitation of income being affected by inflation and consequent fall in the level in rupee, a conversion factor was calculated for 2012 and subsequently the family income scale for 2012 was obtained. Although authors tried to overcome the expected limitations of the questionnaire survey by employing the visual assessment in addition to the questionnaire but still the results obtained might have been influenced by their demand characteristics and may have influenced the results.

The study employed Dental Aesthetic Index (DAI) to assess the professional need of the subjects for orthodontic treatment as it an international index, identifies occlusal traits & mathematically derives a single score. The reliability and validity of DAI has been well documented in various studies. It has been accepted by the WHO as a cross-cultural index [4].

The DAI has been compared with other treatment need indices in various studies [3, 4, 9, 10, 11, 12, 13, 14, 15]. It has been used in an epidemiological assessment of malocclusion and in evaluation of outcomes of orthodontic treatment. The results showed the out of the total 1010 subjects examined; almost 1/3rd (70%) of the study population required some degree of orthodontic treatment. This finding is in consistent with study by Marques, et al. while it is in contrast to other studies [9, 16].

The present study revealed that a negative association between DAI and the self-perception with smile but was not significant. This finding is in contrast to the results of Nayak, et al. (positive and insignificant). Thus, in the present study population, satisfaction with smile cannot be taken as an indicator of need for orthodontic treatment.

The correlation between DAI and self-satisfaction with dental appearance also turned out to be negative and insignificant. This was in agreement with the study by Yeh, et al. yet in contrast to other studies [4, 17]. The positive correlation was obtained between DAI and subject’s self- assessment of relative appearance of teeth as compared to their friends, corroborates with correlation found previously [4].

Analysis also revealed a weak, negative and insignificant relationship between DAI and the demand/ desire for orthodontic treatment. This finding is in contrast to study by Nayak, et al. (weak, positive and significant). The possible reasons for obtaining negative correlation between the two could be the lack of awareness about their occlusion; have never received any orthodontic advice or have never been to a dentist.

The study suggested that greater number of boys perceived themselves as having less attractive dentitions than girls which was statistically significant despite any objective evidence to support this point of view. Consequently, greater number of boys thinks that their teeth need orthodontic correction. Thus, the desire for treatment has been noted to be corresponding dissatisfaction with appearance. This finding is also in contrast to other studies where there no gender difference was reported [1, 3, 11, 18].

Thus, the results of the present study showed that the children belonging to low socio-economic status level of awareness of their malocclusions did not agree with their objectively determined orthodontic treatment need. The DAI and the satisfaction with dental appearance were found to be different from each other. This finding is in agreement with studies performed in other communities [5, 17] but in contrast to those found by Yeh, et al. Hence, the children belonging to low socio-economic status were less critical about their occlusion when compared with actual treatment needs.

Conclusion

Majority of the children were suffering from a severe and handicapping occlusion which requires a definitive / mandatory treatment. But the dearth of awareness and the funds to be applied in public health policies, particularly oral health, makes it necessary to restrict the available treatment to the most serious cases. As a result, at least priority based treatment must be afforded to persons with malocclusion which deems to be incapacitating, bearing in mind that India’s current social, political and economic situation.