Prevalence of malocclusion and orthodontic treatment needs among Saudi primary school male children aged 6–12 years: A cross-sectional study

Saleh H Alwadei; Abdulrahman Ali Hattan; Khalid Faqihi; Ali Alhawiatan; Farhan Alwadei; Abdurahman Alwadei

doi:10.4103/jioh.jioh_159_22

ORIGINAL RESEARCH

Year : 2023 | Volume : 15 | Issue : 1 | Page : 106-112

Prevalence of malocclusion and orthodontic treatment needs among Saudi primary school male children aged 6–12 years: A cross-sectional study

Saleh H Alwadei¹, Abdulrahman Ali Hattan², Khalid Faqihi², Ali Alhawiatan³, Farhan Alwadei¹, Abdurahman Alwadei⁴
¹ Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
² Ministry of Health, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
³ Private Practice, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
⁴ Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Date of Submission	22-Jul-2022
Date of Decision	15-Dec-2022
Date of Acceptance	16-Dec-2022
Date of Web Publication	28-Feb-2023

Correspondence Address:
Dr. Saleh H Alwadei
Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jioh.jioh_159_22

Abstract

Aim: To evaluate the prevalence of malocclusion and the need for early orthodontic treatment (EOT) using dental health component (DHC) of the index of orthodontic treatment need (IOTN). Materials and Methods: In this cross-sectional study, clinical examination was performed on 357 male children, aged 6–12 years who were randomly selected from five public schools and one public pediatric dental clinic, in Al-Kharj province, Saudi Arabia. The examination assessed various occlusal parameters using IOTN, across the total sample and further between two subgroups (early and late mixed dentitions). Results: For the total sample 58.8% had Angle’s Class I malocclusion, 26.7% had Angle’s Class II, 9.8% had Angle’s Class III, while crowding was present in 44.5%. Over 1/4 of the younger group and 42.8% of the older group exhibited at least one feature indicating EOT: anterior crossbite, posterior crossbite, open bite, impinging overbite, ≥7 mm overjet, and Class III malocclusion. However, no statistical differences were found between the two groups (P > 0.05). According to DHC score, 77 participants (21.6%) were in definite OTN. The DHC score demonstrates its validity in identifying evidence-based malocclusion features as significant indicators for EOT. Compared to DHC, the esthetic component significantly overestimated lack of OTN and significantly underestimated definite OTN (P < 0.05). Conclusion: The prevalence of malocclusion and EOT need is generally similar among younger and older children, but the distribution is higher among older children. Orthodontic screening at early mixed dentition stage is essential.

Keywords: Index of orthodontic treatment need, interceptive, malocclusion, orthodontics, prevalence

How to cite this article:
Alwadei SH, Ali Hattan A, Faqihi K, Alhawiatan A, Alwadei F, Alwadei A. Prevalence of malocclusion and orthodontic treatment needs among Saudi primary school male children aged 6–12 years: A cross-sectional study. J Int Oral Health 2023;15:106-12

How to cite this URL:
Alwadei SH, Ali Hattan A, Faqihi K, Alhawiatan A, Alwadei F, Alwadei A. Prevalence of malocclusion and orthodontic treatment needs among Saudi primary school male children aged 6–12 years: A cross-sectional study. J Int Oral Health [serial online] 2023 [cited 2023 Apr 1];15:106-12. Available from: https://www.jioh.org/text.asp?2023/15/1/106/370746

Introduction

Dental malocclusion is a common oral health problem that affects adolescents and adults.^[1],[2]

Malocclusion is not considered a disease as many dental malocclusions can be regarded as normal biological variations. However, they may have some negative consequences on dentofacial development^[3] and patient’s psychological well-being and quality of life.^[4] Prevalence of dental malocclusion in a particular group can be a complex phenomenon, since it could be affected by several factors, including age difference, socio-economic status, ethnicity, and measurement tools. Thus, substantial variations exist across different epidemiological studies.^[2],[5]

The index of orthodontic treatment need (IOTN) is a verified tool that objectively assess orthodontic treatment needs (OTN) in children and adults.^[3],[6] This index combined two separate components; a clinical component which is the dental health component (DHC) and an esthetic component (EC). ^[3],[6],[7]

The DHC has five grades ranging from grade one, “No Need,” to grade five, “Very Great Need.” The EC relies on series of 10 photographs arranged according to their attractiveness and selected as being equidistantly spaced through the range of grades. Although early orthodontic treatment (EOT) remains a controversial topic, multiple studies have shown varying degrees for its needs.^{[3],[8],[9],[10]} Researchers have argued that early identification of malocclusion discrepancy and the initiation of simple orthodontic intervention may allow for greater potential of skeletal growth modification, improved self-esteem, better treatment outcome, more stable results, and reduced potential for traumatic injuries and complication related to severe crowding.^{[4],[10],[11],[12],[13]}

To implement public health programs aimed at minimizing or even preventing orthodontic problems, it is important to explore the prevalence and severity of malocclusions in children. Globally, the quality of digital educational information about EOT is generally insufficient. ^[14] Locally, only a generic digital educational awareness content exists (https://www.moh.gov.sa), without any scalable continuous implementation of public oral health programs specifically targeting the unidentified needs of Al-Kharj population. Also, a recent systematic review, indicated that, while several epidemiological studies have been conducted across different regions in Saudi Arabia, none has been conducted in Al-Kharj province, and only two studies included children in early mixed dentition stage, without assessing the feasibility of IOTN. Therefore, we aim to evaluate the prevalence of malocclusion and the need for EOT using the IOTN in a population of Saudi primary school male children in Al-Kharj Province.

Materials and Methods

This cross-sectional study was conducted between January 2018 and June 2018, in Al-Kharj province, Saudi Arabia, at five public primary schools and one Pediatric Dental Clinics (PDC) in the College of Dentistry at X University. Al-Kharj is a governorate in central Saudi Arabia, located in the southeast of the capital Riyadh, which covers an area of 19,790 km² to 4,890,215.5 acres, and has a population of 376,325 inhabitants, according to the statistics of the General Authority for Statistics for the year 2010 (https://www.stats.gov.sa). Besides obtaining permissions from the Ministry of Education and schools’ authorities, approval was obtained from the Ethics Committee of the College of Dentistry Research Center at X University (Registration No. 1439-03-002). To ensure proper sample representation of schools in Al-Kharj province, we used stratified randomization to select schools for this study, where a specific number was assigned to every public schools. Then, a randomization table was used to select the schools, whereby a total of five schools for boys were selected. In addition, PDC in the College of Dentistry at X University was selected because it represents the most visited dental center in the province, where patients from all five districts receive their dental treatments and regular check-ups. The schools’ principals were asked to participate in this study via a letter explaining the purpose of the study and seeking their permission to conduct the examination. The schools’ principals provided table listing their primary school students with an assigned number corresponding to each student. Then, a randomization table was used to select the students.

A required sample size of 384 subjects was estimated based on a statistical power calculation described by Pourhoseingholi et al.,^[15] considering a confidence level of 95%, a precision of 0.04 and 20% prevalence of malocclusion needing orthodontic treatment as reported in Saudi-based literature using IOTN.^[6] Out of 500 randomly selected children aged 6–12 years whom their parents/guardians were contacted, and 431 provided informed consent. To obtain parents’ permission, we provided them with detailed written information about the study, including examination procedures, and confidentiality measures taken to protect collected information. Out of 431 consented children, 357 met the eligibility criteria and participated. We only included children with the following criteria: (1) an age range of 6–12 years during mixed dentition stage, (2) no systemic health problems or any developmental anomalies, (3) no previous or active orthodontic treatment (OT), and (4) presented an informed consent signed by their parents/guardian. The sample was divided into two groups according to their dental development stage, group 1 (n = 130) represent early mixed dentition stage where none of the premolars have erupted, and group 2 (n = 227) represent late mixed dentition stage where at least one premolar has erupted.

A total of 10 participants were examined by a co-investigator (X.X.), who had been previously trained in the use of IOTN, and then repeated 15 days later by the same co-investigator to determine intra-rater reliability. In each school, examinations were conducted by the same examiner (X.X.) in the same room with the most natural light, while participants seated on a portable dental chair. For each participant, assessment of dental occlusion lasted approximately 15 minutes and was carried out using latex gloves, mouth mirror, periodontal probes, calipers, cheek retractors, and a light source. During examination, X.X. completed a specific registration chart that included malocclusion features needed to determine the DHC [Table 1], and date of birth, facial profile, and lip competency. Also, two intraoral frontal photographs in maximum intercuspation were taken for evaluating the EC of IOTN. The operational definition for the study variables is presented in [Table 1]. The need for OT was also assessed by X.X for each participant using DHC and EC scales of the IOTN. In addition to impinging overbite, the need for EOT was determined when there is at least one of the malocclusion features specified by the American association of orthodontists.

Table 1: Variables and definitions

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Statistical analysis

Data analysis was done with SPSS Statistics for Windows (version 27.0; IBM, Armonk, NY). Intra class correlation coefficient was used to test the intra-rater reliability. The distribution of raw data was investigated using Shapiro–Wilk test of normality. Chi-square was used to compare indications of EOT parameters between early and late mixed dentition groups and to compare DHC and EC findings. Ordinal logistic regression analysis was conducted to assess factors associated with greater OTN using DCH scores as the dependent variable. P value for statistical significance was set at <0.05.

Results

Out of 413 consented children (86.2% response rate), 357 eligible children, aged 6–12 with a mean age of 9.89 ± 1.76 years, were included and examined without any dropout, 130 (36.4%) were in the early mixed dentition stage and 227 (63.6%) were in the late mixed dentition stage. Prevalence of malocclusion features among the entire sample is presented in [Table 2]. Comparison between early and late mixed dentition groups for the distribution of relevant parameters and IOTN is presented in [Table 3]. Despite an increasing trend of greater prevalence of malocclusion features among the older group, there were no statistically significant differences between early and late mixed dentition groups across all parameters (anterior and posterior crossbites, anterior open bite, impinging overbite, ≥7 mm overjet, CL III malocclusion) [Table 3].

Table 2: Prevalence of different facial/occlusal traits in the total sample (n = 357)

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Table 3: Comparison of the distribution/indications of early treatmen t parameters in the dental development subgroups

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Evaluation of treatment need

According to DHC score for the total sample, 202 participants (56.6%) had a slight need or did not need OT, while 78 participants (21.8%) were in borderline need for OT, of which 28 participants (21.5%) were in the early mixed dentition. Furthermore, 77 participants (21.6%) were in definite need for OT, of which 22 participants (16.9%) were in the early mixed dentition. Using DHC scores, comparison between early and late mixed dentition groups did not reveal statistically significant differences (P > 0.05). According to EC score, only 0.8% of the sample were in definite need of OT, while 3.7% had a borderline need, whereas most participants (95.5%) had a slight need or did not need OT. According to χ², comparison of OTN between DHC and EC score for the total sample revealed statistically significant differences χ² (1, n = 357 = 44.4, P ≤ 0.001). Post hoc comparisons using Bonferroni adjustment with adjusted residuals revealed statistically significant differences in the “no need” and “definite need” categories (P < 0.05). See [Table 4].

Table 4: Comparison of orthodontic treatment need between DHC and EC scores in the total sample (n = 357)

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Risk factors for greater orthodontic treatment need

Ordinal logistic regression analysis to evaluate possible risk factors for greater OTN are presented in [Table 5]. Regarding regression analysis assumptions, the likelihood ratio χ² test indicates significant improvement in fit of the fin model over the null/intercept model (χ²(7) = 42.227, P < 0.001), suggesting the assumption regarding model fit was not violated. However, Pearson χ² test and deviance test were both significant (χ²(53) = 100.811, P < 0.001 and χ²(53) = 90.268, P = 0.001, respectively), suggesting a violation of the assumption regarding model fit. As such, cautious interpretation is warranted. As displayed in [Table 5], impinging overbite, anterior open bite, anterior and posterior crossbites, ≥7 mm overjet were significant risk factors for greater OTN (P < 0.001 and <0.05). This suggests that children with these features were more likely to be in greater OTN. Class III malocclusion and being in the early mixed dentition stage were not risk factors for greater OTN (P > 0.05). The model also indicates the following:

Table 5: Ordinal logistic regression analysis of orthodontic treatment needs (n = 357)

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1 For every unit increase on having an impinging overbite and anterior open bite, there is a predicted increase of 1.96 and 2.00 in the log odds of a child presenting a greater OTN. The odds ratio indicates that odds of being in higher category on greater OTN by a factor of 7.13 and 7.42 for every unit increase on impinging overbite and anterior open bite, respectively.

2 For every unit increase on having an anterior and posterior crossbite, there is a predicted increase of 1.09 and 1.08, respectively, in the log odds of a child presenting a greater OTN. The odds ratio indicates that odds of being in higher category on greater OTN by a factor of 2.98 and 2.95 for every unit increase on anterior and/or posterior crossbite.

3 For every unit increase on having an overjet of ≥7 mm, there is a predicted increase of 3.73 in the log odds of a child presenting OTN. The odds ratio indicates that odds of being in higher category on greater OTN by a factor of 41.50 for every unit increase on overjet of ≥7 mm.

Discussion

The development of dentition among participants was the main partition for which participants were further divided into two subgroups. In what follows, we discuss our findings according to prevalence of malocclusion traits among the total sample with more emphasis placed on the indications and need for EOT among early mixed dentition subgroup. For the total sample, we observed that 58.8% had Angle’s Class I malocclusion, 26.7% had Class II and 9.8% had Class III. This finding is in support of previous national studies,^[16] and close to comparable ethnicity.^[17] Such distribution pattern is also similar across different populations.^[2]

Crowding was the most common type of occlusal abnormality in our sample, which agrees with national studies.^[16] Such high percentage could be explained, partially, by premature loss of primary teeth (7%) without proper space maintenance intervention (0.6%) which will lead to loss of space. Furthermore, systematic review of national epidemiological studies reported high caries rate among Saudi children.^[18] In addition to the fact that treatment of mild and moderate crowding is not carried out during mixed dentition stage,^[19] such a problem could worsen in the permanent dentition stage due to decrease in arch length that requires arch length preservation.^[19] Therefore, oral hygiene prevention program is of paramount importance.

In support of previous national and international studies,^[2],[16] posterior crossbite in the present study was recorded in 15.4% of participants. It is recommended to start treatment of crossbites at an early stage, before the midpalatal suture begins to ossify, which may lead to growth problems and skeletal deviations if left untreated.^[10] Interestingly, our findings suggest that children with posterior crossbite were in greater OTN. Corroborating national studies, anterior crossbite was found in 5.8% of our participants, and such prevalence is higher than what is reported internationally.^[2],[16] Our result found anterior crossbite to be a significant indicator for greater OTN. There is a clinical consensus that early correction is indicated for anterior crossbite.^[10],[20]

Although we reported an increased overjet of >2 mm in over 50% of participants, we are more interested in, and concerned with, excessive overjet ≥7 mm, which was found in 7.8% of participants. Considering classifications with comparable severity of OJ (i.e., >6 mm), national studies reported lower percentage,^[16] while international studies with comparable ethnicity in Syrian children/adolescents reported higher percentage.^[17] Regarding excessive OJ ≥7 mm, EOT is effective in preventing or minimizing incisor trauma given the significant correlation between these two phenomena.^[12] This is supported by our results which demonstrated that ≥7 mm OJ to be the most significant indicator for greater OTN.

Similar to OJ, we reported an increased overbite of >2 mm among participants (7.8%), but we are more concerned with impinging overbite, which was present in 9.8% of participants. Although our finding seems to be higher than those reported by several Saudi studies,^[16] many epidemiological studies do not specify impinging overbite in their operational definitions of increased overbite.^[2],[16] When compared to studies that specified impinging overbite, higher severity (15.9%) was found in Germen children.^[3] Others recommended the need to consider impinging overbite as an additional indication of EOT to prevent palatal tissue trauma.^[10],[21] In support of such a recommendation, we found impinging overbite to be a significant indicator for greater OTN. The prevalence of open-bite (4.8%) was similar to previous findings among Saudi children.^[16] In agreement with our finding, the higher prevalence of open-bite among younger children has been reported in a previous review.^[2] Others highlighted the importance of timely and etiology-based diagnosis of anterior open-bite and the positive impact of OT for patients at an early age, especially when the associated habits can be eliminated.^[22]

Finally, the DHC and EC scores reflected interesting findings regarding the evaluation of OTN. Considering great and very great need for OT (DHC 4 and 5), our findings (21.6%) are close to previous international and national studies,^[3],[16] but notably lower than comparable ethnicity.^[17] It is noteworthy that we only compared our finding to studies that used similar assessment tool. Compared to DHC, the EC significantly overestimated the lack of OTN and significantly underestimated the definite need for OT (P < 0.05). In support of previous evidence, our finding suggests that EC scale is an unnecessary part of IOTN when assessing mixed dentition, and it may be better applied to depict mal-occlusal features during permanent dentition.^[3]

To summarize, there is no significant difference in the prevalence of specific malocclusion features between early and late mixed dentition stages. The DHC score demonstrates its validity in identifying specific malocclusion features as significant indicators of EOT. Although we only included male children which may not reflect the actual prevalence of malocclusion for the central region community in Saudi Arabia, conflicting evidence exist regarding the impact of gender differences on the studied malocclusion features.^[16],[17] Nonetheless, such a limitation is more likely to overestimate the presence of malocclusion which will weaken the generalizability of our findings. Therefore, careful interpretation of our study findings is warranted. Our results were compared to those of previous national and international studies with dissimilar ethnicities. However, few contextual factors should be considered, including sample characteristics (size, age groups, gender, socioeconomic status, and ethnicity), type of measurement tools, and operational definition of associated malocclusion features. Further national multi-cities studies, using unified objective measurement tool, in Saudi Arabia are needed to produce more information that will take such studies to a higher level. Finally, future studies should also concentrate on evaluating; (1) the direct association between specific malocclusion features (e.g., crossbite, impinging bite, crowding) and oral health quality (e.g., periodontal disease, caries),^[21],[23] and (2) parents’ knowledge, awareness, and attitude toward their children’s dentofacial health regarding perceived treatment’s need, importance, and timing.^[24]

Conclusion

The prevalence of malocclusion and OTN is similar among younger and older children, but the distribution of most features is higher among older children. For the total sample, impinging overbite, anterior open bite, anterior and posterior crossbites, and ≥7 mm overjet were significant risk factors for greater OTN, indicating validity of DCH component in identifying evidence-based malocclusion features as significant indicators for EOT. Over 1/4 of the examined children in the early mixed dentition stage displayed dental features indicating EOT, while children in the late mixed dentition stage displayed greater definitive OTN. The EC of IOTN significantly overestimates the lack of OTN and significantly underestimates the definite need for OT. The high prevalence of malocclusion features indicating EOT among Saudi children at Al-kharj region is comparable with that of other regional Saudi studies. Therefore, orthodontic screening during early mixed dentition stage is essential.

Acknowledgement

No acknowledgment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors’ contribution

This is to signify that the authors of the above titled research have seen and approved the submission together with their contributions of this work. We, the authors, declare the originality of the authorship and that we have no conflict of interest.

Ethical policy and institutional review board statement

This statement is to signify that the authors obtained approval from the Research Ethical Committee of the College of Dentistry at Prince Sattam Bin Abdulaziz to conduct the study (IRB #1439-03-002). The study was approved on 12/20/2018 by a committee of three anonymous reviewers (i.e., faculty members working with the scientific research unit at the College of Dentistry). We, the authors, declare that all informed consents were obtained from all parents/guardians before commencement of the study, and that this research did not pose any risk to the participants where all procedures were carried out in accordance with the Helsinki Declaration of 1975, as revised in 2000.

This study is in accordance with the ethical standards of the College of Dentistry Research Center at XXX University (Registration no. 1439-03-002), and with the Helsinki Declaration of 1975, as revised in 2000. All parents/guardians signed the consent form before commencement of the study.

Patient declaration of consent

Nil.

Data availability statement

The datasets used during this study are available from the corresponding author on request.

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