Journal of International Oral Health

: 2022  |  Volume : 14  |  Issue : 5  |  Page : 433--439

Prevalence of orthodontic and prosthodontic treatment needs in differently abled population—A systematic review

Subbaiah Pradeep1, Mysore Rajshekar Dakshayini2, Honne Manjunathappa Thippeswamy3, Nanditha Kumar2,  
1 Department of Orthodontics and Dentofacial Orthopeadics, JSS Dental College & Hospital, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India
2 Department of Prosthodontics, JSS Dental College & Hospital, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India
3 Department of Public Health Dentistry, JSS Dental College & Hospital, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India

Correspondence Address:
Dr. Honne Manjunathappa Thippeswamy
Department of Public Health Dentistry, JSS Dental College & Hospital, JSS Academy of Higher Education & Research, Mysuru, Karnataka


Aim: This systematic review assesses the severity and complexity of orthodontic treatment needs and prosthodontic requirements among differently abled population. Materials and Methods: An online search was conducted on Medline-PubMed, Cochrane database, and Embase databases from December 1980 to 2020. There were nine and five articles to determine the prevalence of malocclusion and prosthodontic treatment needs, after a thorough evaluation of the severity and complexity of orthodontic treatment needs and prosthodontic requirements for the differently abled population. Results: In this systematic review, the prevalence of orthodontic needs among individuals with special healthcare needs, specifically those with intellectual disability/Down syndrome/cerebral palsy, varied from 18.9% to 62.3%, and from 0% to 46.5% for prosthodontic treatment needs. Conclusions: This study concluded that differently abled individuals have orthodontic and prosthodontic needs far higher than their status. Malocclusion and missing teeth together can harm the individual’s “quality of life” in physical pain and social disabilities.

How to cite this article:
Pradeep S, Dakshayini MR, Thippeswamy HM, Kumar N. Prevalence of orthodontic and prosthodontic treatment needs in differently abled population—A systematic review.J Int Oral Health 2022;14:433-439

How to cite this URL:
Pradeep S, Dakshayini MR, Thippeswamy HM, Kumar N. Prevalence of orthodontic and prosthodontic treatment needs in differently abled population—A systematic review. J Int Oral Health [serial online] 2022 [cited 2022 Dec 4 ];14:433-439
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Full Text


The deviation from an ideal occlusion in individuals with differently abled individuals is an additional barrier to community acceptance. It compromises the facial esthetics of the stomatognathic system and all of its other aspects.[1],[2] The prevalence of severe malocclusion is exceptionally high among individuals with physical and mental disabilities.[3],[4]

In India, the Rights of Persons with Disabilities Act of 2011 is a robust legal instrument that deals with the rights of people with special healthcare needs (SHCN). In such individuals, oral health is often completely neglected because of their disability and psychological influence.[5],[6]

In such a unique healthcare needs population, oral health improvement begins with collecting epidemiological data, which aids in understanding community needs, identifying high-risk groups, planning treatment and prevention strategies, and monitoring the situation’s progress. Waldman[7] and Brook and Shaw[8] in 1989 stated that malocclusion could be quantified by recording two components: dental health and functional indications for treatment and esthetic impairment caused by the malocclusion. As a result, this method provides information on malocclusion traits and allows researchers to investigate the impact of socio-psychologic factors on the need and demand for orthodontic treatment.

Compared with regular children, not enough dental education has been provided to differently abled subjects about treatment needs. Systemic dysfunction in such individuals can predispose them to oral disease, which, in turn, can worsen the existing systemic illness. Therefore, it is essential to have an integral and multidisciplinary healthcare system provided by healthcare professionals, especially to encourage parents to seek dental treatment as dental education and preventative procedures appear beneficial.[9],[10]

Because such individuals may have involuntary behaviors that can harm their oral health, they may not actively maintain oral hygiene. They face numerous barriers to primary dental care, so malocclusion correction has hardly been addressed.[11] They require special attention not only for improved oral function but also for proper social coordination. As per the literature search, presently, no systematic reviews have been published on the prevalence of orthodontic and prosthodontic needs among the differently abled population. So, the present systematic review has been undertaken to assess the prevalence of orthodontic and prosthodontic status among the differently abled population.

 Materials and Methods

Information sources and search

A comprehensive electronic search using MeSH and free-text terms on Medline, Scopus, Web of Science, Cochrane Library, and Embase databases was conducted. The investigation was limited to English-language literature published between January 1980 and December 2020 with keywords such as malocclusion, mental retardation, differently abled individual, Index of Orthodontic Treatment Need, and prosthodontic need.

The final review excluded abstracts, letters, short communications, and chapters in textbooks; a single author has carried out the article selection, title and abstract screening, full-text screening, data extraction, and quality assessment independently. If there was any doubt in selecting an article, a decision was made after discussion with the coauthors and finalized. For data extraction, studies that met the inclusion criteria were gathered and combined. Quantitative and qualitative data were extracted for each included analysis, including the year of publication, author’s name, study design, sample size, the method of Index of Orthodontic Treatment Need-Dental Aesthetic Index (IOTN-DAI) assessment, the number of missing teeth, and the outcome of interest. The Center for Evidence-Based Medicine test of diagnostic accuracy of studies was used to assess the quality of evidence.[12] A flowchart of the selection of the articles is shown in [Table 1].{Table 1}

The literature search for malocclusion yielded 55 relevant articles, and for prosthesis status, found 11 unique articles. Duplicate records were then removed, leaving 35 and five articles, respectively. Twenty-six IOTN and six prosthesis status[13] records that did not meet the inclusion criteria and a full text that could not be found were omitted from the study. In the end, the review included nine studies for malocclusion and five studies for prosthetic status. A PRISMA[14] flow chart of the literature selection process is shown in [Figure 1].{Figure 1}

Results of data extraction and results of included studies

Orthodontic status

[Table 2] shows the demographic characteristics of the study population. The overall prevalence of orthodontic needs among children and youth with special healthcare needs (CYSHCN), including those with intellectual disability/Down syndrome/cerebral palsy ranged from 18.9% to 62.3%.{Table 2}

In 2016, a study was conducted on individuals with intellectual disability in Cape Town.[15] They found that malocclusion occurred in 18.9% of children aged 3–8 years and 36.5% in those aged 12–19 years. In a 2013 study conducted in India, it was 62.3% in adults and 37.6% in children.[16] Another survey conducted in Dharwad, India (2015) showed that within the 12–19 years age group, orthodontic treatment was indicated in 50.2% population. Special healthcare needs (CYSHCN) ranged from “elective” to highly desirable to mandatory.[17]

Prosthodontic status

In terms of prosthodontic status among differently abled populations, analysis and research literature indicate that additional research must implement innovative treatment methodologies that improve the oral health-related quality of life (OHRQoL) in such individuals.[6],[9],[10]

In the current review, because the prevalence and availability of literature were minimal, the IOTN-DAI missing tooth portion was evaluated[3],[15],[18],[19],[20],[21] [Table 3].{Table 3}

A cross-sectional study in Udaipur[18] assessed the prevalence of caries and treatment needs among 127 institutional subjects aged 5–22 years attending a differently abled school for the hearing impaired. The prevalence of missing tooth (Decay Missing Filled Index [DMFI]) within the 5–8 age group was 0% with 18 subjects, in 9–12 years (with 37 subjects), the prevalence was 0.16%, in 13–17 years (with 43 subjects), it was 0.33%, and the 18–22 year group (with 29 subjects) had the highest percentage of prevalence with 0.49%.

Another study by Desai et al. that assessed the dental treatment needs in special developmental schools in Melbourne showed that multidisabled children with congenital or acquired conditions who had one or two missing teeth were 16 of 300 subjects.[19]

A cross-sectional study conducted in Cape Town assessed the dental needs of children aged 3–19 years with intellectual disability, following the guidelines developed by Special Olympics Smiles (SOSS) and Centers for Disease Control (CDC), USA. Documented missing teeth in 46.5% of the participants and those in the 12–19 years age group presented the highest prevalence of missing teeth.[15]

Rao et al.[20] conducted a study using the WHO index to find caries prevalence among 524 disabled children aged between 3 and 30 years in Karnataka, India. In a mixed dentition, the missing tooth percentage was lowest at 0.96% compared with permanent dentition with missing teeth at 6.84%.


Orthodontic prevalence and treatment need

This review assessed the prevalence of orthodontic and prosthodontic needs in a differently abled population. The differently abled population requires special attention in terms of general health and oral health. Previous studies have shown that oral health is one of the most neglected components of medical treatment in differently abled populations in India and in other countries.[9]

Another study found that children’s time consumption, difficulty in treatment, uncooperative behavior, and professional barriers such as insufficient undergraduate and staff training were the most common barriers to treating patients with SHCN.[10]

Based on the review findings, 92% of children with Down syndrome had class III malocclusion and 9% of those had cerebral palsy. A tendency to a class III type skeletal base relationship in children with Down syndrome, and movement to a class II incisor relationship in children with cerebral palsy was observed.[22]

The presence of an Angle’s class I malocclusion was lowest among Indians at 14.3%, followed by 25.3% cases in the Spanish population, and noted the highest percentage of 46.8% in Brazilians.[16]

The lack of suitable universal methods for recording and grading malocclusion and the different criteria used to define malocclusion have made comparison of studies difficult.[21] None of the studies used IOTN for recording and analyzing malocclusion among mentally challenged individuals.[23],[24],[25] Even though an “ideal occlusion,” a hypothetical concept is rarely found in nature; the prevalence and severity of malocclusion and treatment need were higher in CYSHCN, particularly in individuals with Down syndrome.[15]

Angle’s class II malocclusion showed a higher prevalence percentage in SHCN of about 33.7%, and similar values of 24% and 25.5% were recorded, respectively.[26],[27]

Almost all studies reported the incidence of Angle’s class III malocclusion associated with anterior crossbite in up to 60% of individuals with Down syndrome.[27] Another study by Abeleira et al.[25] found that the incidence of class III with anterior and posterior crossbite in subjects with Down syndrome was 33.3% and 27.5%, respectively, and compared with those with cerebral palsy, it was 3.8% and 13.9%, respectively. Concerning dental health components, parents who have experienced orthodontic treatment are highly motivated and more often willing to participate in oral hygiene procedures.

Prosthodontic prevalence and treatment needs

In the prosthetic status literature search, no studies specifically mentioned missing teeth, so in this review, we have considered a missing component in dmft/DMFT teeth in the studies of SHCN.

Children with intellectual disability between the ages of three and nineteen were included in a cross-sectional study in Cape Town, where their dental needs were evaluated using standards established by the SOSS and the CDC of the United States. Documented missing teeth were in 46.5% of the participants, and those in the 12–19 years age group presented the highest prevalence of missing teeth.[15]

Jain et al. in 2008 noted an increased missing tooth percentage with older deaf and mute subjects of 20–22 years (0.62%), which is similar to the findings by Rao et al. on hearing-impaired subjects who showed a higher value with an increase in age of 3.49%.[3],[18],[20]

Rao et al.[20] compared the missing percentage in eight handicapped children with primary, mixed, and permanent dentition and concluded that higher values were found in the permanent dentition than in the mixed and primary dentition. He also found a higher missing teeth component in visually impaired subjects, and the least was noted in medically handicapped individuals.

In a cross-sectional study by Mohan Das et al.[28] in 76 children, 47 males and 29 females, aged 5–18 years, had never visited a dentist (80.26%). Among those who visited the dentist, most of them visited when they had dental pain (14.47%).

Nevertheless, the results of our study highlight the gap in prosthetic status and treatment needs in the differently abled population. The above findings indicate that a problem-oriented approach to dental service usage exists where the treatment is sought only to relieve pain by getting the tooth extracted. Another reason might be the costs of dental treatment. Generally, tooth extraction is cheaper than restorations or root canal therapy and is therefore preferred by lower socioeconomic groups. The replacement of the lost teeth is further avoided because of higher costs, a lack of time, and a low oral health priority, thereby leaving the person partially or completely edentulous. The cost of dental treatment has been established as a major barrier to receiving dental care. In a study by Shigli et al.,[29] most of the participants provided financial reasons for not replacing the lost teeth. Money was reserved primarily for general health care rather than dental health care. This indicates a low priority toward oral health.

Mihai et al.[30] stated that the quality of life, social relationships, and oral function of dental health components can improve orthodontic treatment considerably. The satisfaction perceived is often very high, and these children’s parents had stated that they would repeat orthodontic treatment in the future, if necessary. The oral dysfunction and parafunction of the masticatory system were hypothesized as being responsible for the increased prevalence of malocclusion in differently abled individuals.[31],[32]

Children who required assistance with tooth brushing had higher missing teeth compared with other special intellectuals. Higher unmet needs may also be indicative of the barriers to dental care experienced by individuals with disabilities, such as a lack of access, fear, and a lack of motivation.[33] These findings emphasize the need for preventive care in these disabled children.

A cross-sectional study was conducted at Almada, Portugal[34] to assess the impact of malocclusion on OHRQoL patients seeking orthodontic treatment. First, malocclusion treatment needs measured via the Index of Complexity Outcome and Need did not show an association with OHRQoL. Second, either as a continuous or as a categorical variable, missing teeth were the most impactful confounding variable toward the OHRQoL. The results also presented age as a significant variable in this equation, suggesting further considering this construct in OHRQoL research in orthodontic patients.

In the current review, the most significant barriers encountered by dentists while providing dental care for SHCNs were the lack of training and the requirement of long-term commitment. The present review findings show that the need for orthodontic and prosthodontic treatment was high. Therefore, we recommend future intervention research to evaluate ways to improve access to preventive dental care for SHCNs. Additional strategies may be needed to improve the oral health behaviors of such populations.

The scope of this systematic review provides insight into treatment planning and policy making in special healthcare needs (CYSHCN).


This systematic review concluded that differently abled individuals have orthodontic and prosthodontic needs far higher than their status. It can be supposed that most of these subjects do not receive oral rehabilitation, which may be due to their unwillingness to cooperate, a low priority for dental care, a lack of motivation, poor socioeconomic status of parents/guardians, higher treatment costs, and a lack of experience and knowledge among dental professionals regarding the treatment of such individuals. In terms of physical pain and social disabilities, malocclusion and missing teeth can have a negative impact on an individual’s “OHRQoL.”


We are grateful for the support provided by JSS Dental College & Hospital, JSSAHER, Mysuru.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Authors’ contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by SP, HMT, MRD, and NK. The first draft of the article was written by SP, and all authors commented on previous versions of the article. All authors read and approved the final article.

Ethical policy and institutional review board statement

Not applicable.

Patient declaration of consent

Not applicable.

Data availability statement

Not applicable.


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