Assessing the Correlation Between

Malocclusion and Lowered Psychosocial Well-Being

By

Omar Oussama Khatib

A Thesis submitted to

the Faculty of Graduate Studies of

The University of Manitoba

in partial fulfillment of the requirements for the degree of

MASTERS OF SCIENCE

Department of Preventive Dental Science

College of Dentistry

Division of Orthodontics

University of Manitoba

Winnipeg, Manitoba

Copyright© 2015 by Omar Oussama Khatib

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 ABSTRACT

INTRODUCTION: Orthodontic treatment can include physical and/or psychosocial elements in

addition to straightening teeth.

OBJECTIVE: Of importance to this study was to explore the correlation between malocclusion

and psychosocial well-being from the perspective of younger patients, their caregivers, through

the inclusion of normative criteria.

MATERIALS & METHODS: A cross-sectional study design was employed. Data was

collected at a single point in time from a sample of prospective patients. Eighty-six patients and

their caregivers met the inclusion criteria and were asked to complete the questionnaires. The

mean age of patients included in the study was 13.57 +/- 1.57 years (55 females and 31 males).

Data was collected through clinical exams. Patients were assessed using the dental and aesthetic

component grades of the Index of Orthodontic Treatment Need (IOTN).

RESULTS: Caregivers’ satisfaction with the patient’s body image correlated with the patients’

satisfaction with their body image (p<0.05). Caregivers' satisfaction with tooth appearance

correlated with the IOTN aesthetic component grade (p<0.05). As the satisfaction score increases

(reflecting overall dissatisfaction with body image), the more likely that the patient actually

needs treatment. There is no significant correlation between patients’ satisfaction with their teeth

and IOTN dental and aesthetic component grades (p>0.05). Caregivers' motivation, in

comparison to the patients’ motivations to seek orthodontic treatment was significant (p<0.05).

No significant gender differences were found with regards to being bullied about dental

appearance (p>0.05).

CONCLUSION: Malocclusion does impact perceptions of psychosocial well-being.

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Acknowledgements

With boundless gratitude and appreciation, I would like to thank my supervising

committee who helped me bring this study into reality. I would like to extend my profound

gratitude to the following:

My deep gratitude goes first to Professor William A. Wiltshire who expertly guided me

through out my graduate education. Thank you for giving me the opportunity to fulfill my dream

of becoming an orthodontist. Dr. Wiltshire’s personal generosity helped me make my time at

University of Manitoba enjoyable. Dr. Wiltshire’s mentoring and encouragement have been

especially valuable.

My appreciation also extends to Dr. Robert Drummond who has been a great teacher and

mentor throughout my time time at the University of Manitoba. Thank you for your time and

effort in reviewing this thesis.

Last but not least, thank you Dr. Dieter Schönwetter. Dr. Schönwetter’s consistent

guidance, ample time spent, consistent advices and his early insights launched the greater part of

this thesis which helped me bring this study into success.

I take this opportunity to record my sincere thanks to all staff members and residents of

the Department of Orthodontics and the University of Manitoba for their help and

encouragement.

Above all, I am indebted to my family, whose value to me only keeps growing. I owe an

enormous debt of gratitude to my wife, Safia, and my two children Sana and Abdullah. Through

the struggles and trials of this thesis, they have been a constant joy. Thank you.

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Dedication

I would like to dedicate my thesis to my beloved parents Sanaa and Oussama Khatib, for their
love, endless support, encouragement and sacrifices.

I would also like to dedicate it to my beautiful wife, Safia, whose love and care for me and our
children made it possible for me to complete this work and to our two children, Sana and
Abdullah, the joys of my life.

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 Contents

Contents ............................................................................................................................... 5
List of Tables and Figures ....................................................................................................... 8
Chapter 1: Introduction ......................................................................................................... 9
Chapter 2: Literature Review ............................................................................................... 11
Psychological Dynamics of Orthodontic Treatment Need ............................................................... 11
Psychosocial Dynamics of Orthodontic Treatment Need ................................................................ 14
Bullying ................................................................................................................................................ 14
Developmental Influences and Bullying.............................................................................................. 16
Developed vs. Developing Countries and Bullying. ............................................................................ 17
Caregiving............................................................................................................................................ 17
Agreement Regarding Perceived Orthodontic Need - Caregivers versus Children. ........................... 18
Caregivers and Socioeconomic Status (SES). ...................................................................................... 18
Public Perceptions............................................................................................................................... 19
Societal Norms and Social Stereotyping ............................................................................................. 20
Social Acceptance. .............................................................................................................................. 20
Social Interactions. .............................................................................................................................. 21
Vocational, Educational, Intelligence, Romantic and Developmental Influences. ............................. 23
Developmental Differences. ............................................................................................................... 24
Normative Dynamics of Orthodontic Treatment Need ................................................................... 25
Indices for Assessing Perceived Need for Orthodontic Treatment..................................................... 26
Ideal Timing of Orthodontic Treatment Results ................................................................................. 28
Developmental Differences and Impact of Orthodontic Treatment .................................................. 28
Normative versus Patient and/or Caregiver Perceived Need ............................................................. 30
Gaps in the Literature ................................................................................................................... 31
Chapter 3: Purpose and Hypotheses .................................................................................... 34
Purpose ....................................................................................................................................... 34
Hypotheses .................................................................................................................................. 34
Chapter 4: Materials and Methods....................................................................................... 35
Research Ethics Approval.............................................................................................................. 35
Study Sample ............................................................................................................................... 35
Inclusion Criteria ................................................................................................................................. 35
Exclusion Criteria................................................................................................................................. 36
Sampling Methodology ................................................................................................................ 36
Methods .............................................................................................................................................. 37
Informed Consent ............................................................................................................................... 37
Clinical examination ............................................................................................................................ 38

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 Patient Self-Assessment Questionnaire .............................................................................................. 38
Caregiver Assessment Questionnaire ................................................................................................. 41
Pilot Study ........................................................................................................................................... 42
Coding of Data..................................................................................................................................... 43
Validity and Reliability of Clinical Exam, Patient Self-Assessment, and Caregiver Questionnaires .... 43
Index of Treatment Need - IOTN ................................................................................................... 43
The Dental Health Component (DHC) of the IOTN ............................................................................. 44
The Aesthetic Component (AC) of the IOTN ....................................................................................... 44
Validity and reliability of the IOTN ...................................................................................................... 45
Statistical Analysis ........................................................................................................................ 45
Descriptive Analyses..................................................................................................................... 45
Chapter 5: Results ............................................................................................................... 47
Reliability Tests ............................................................................................................................ 47
Socio-Demographic Data and Frequencies..................................................................................... 47
Patients and Caregivers ...................................................................................................................... 47
Clinical Examination Data ................................................................................................................... 48
Association Between IOTN and Demographic Variables .................................................................... 53
Parents’/Caregivers’ Questionnaire .................................................................................................... 54
Patients’ Questionnaire ...................................................................................................................... 61
Comparative Analysis ................................................................................................................... 67
Patient Versus Caregiver - Comparison .............................................................................................. 67
Male versus Female - Comparison ...................................................................................................... 74
Patients’’ Teeth Bullying Reports versus IOTN (DHC and AC) - Comparison ...................................... 81
Correlation Analysis ..................................................................................................................... 83
Chapter 6: Discussion .......................................................................................................... 86
Discussion of Obtained Findings ................................................................................................... 86
Hypothesis 1: A relationship exists between malocclusion and psychosocial well-being factors ...... 87
Hypothesis 2: A relationship exists ..................................................................................................... 88
Hypothesis 3: Children with severe malocclusion are more likely to have academic problems at
school than those with mild malocclusion.......................................................................................... 90
Hypothesis 4:....................................................................................................................................... 91
Hypothesis 5: Psychosocial impact of malocclusion is higher among girls than boys ........................ 93
Implications of Findings ................................................................................................................ 94
Educational Implications. .................................................................................................................... 96
Limitations and Weaknesses ......................................................................................................... 97
Recommendations for Further Research ....................................................................................... 98
Chapter 7: Conclusion ........................................................................................................ 100
References ........................................................................................................................ 102
Appendices ....................................................................................................................... 115
Appendix A. Research Ethics Approval ........................................................................................ 115
Appendix B. Amendment #1 Approval ........................................................................................ 117
Appendix C. Amendment #2 Approval ........................................................................................ 119

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Appendix D. Parent Information and Informed Consent .............................................................. 121
Appendix E. Incentive Prizes – Email Slip ..................................................................................... 125
Appendix F. Winner’s Email ........................................................................................................ 126
Appendix G. Clinical Examination Form ....................................................................................... 127
Appendix H. Patient Self-Assessment Questionnaire ................................................................... 129
Appendix I. Caregiver Assessment Questionnaire ........................................................................ 133
Appendix J. Index of Orthodontic Treatment Need Dental Health Component (IOTN DHC). Proffit et
al., 2007. .................................................................................................................................... 137
Appendix K. The Aesthetic Component (AC) of the IOTN. Proffit et al., 2007. ............................... 138
Appendix L. Correlation Tables ................................................................................................... 139
Appendix M. Principal Component Analysis – patient/caregiver satisfaction indices. ................... 181
Appendix N. Z-tests .................................................................................................................... 182
Appendix O. Journal Article ........................................................................................................ 185
Appendix P. Journal Article Submission Received ........................................................................ 199

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 List of Tables and Figures

Table 1. Components of clinical exam (adapted from Proffit et al., 2007). ................................. 39
Table 2. Socio-demographic data of patients and caregivers. ...................................................... 49
Table 3. Clinical examination results summary. ........................................................................... 50
Figure 1. Percentage of the presence of other facial and oral features. ........................................ 51
Figure 2. Percentage of respondents’ lip positions. ...................................................................... 51
Figure 3. Percentage of respondents’ according to IOTN Dental Health Grade. ......................... 52
Figure 4. Percentage of respondents’ according to IOTN Aesthetic Component Grade. ............. 53
Table 4. Caregivers’ reasons for seeking orthodontic treatment. ................................................. 55
Table 5. Caregivers’ satisfaction with children’s appearance and bullying experiences. ............ 57
Table 6. Caregivers’ responses to bullying experiences of their children as related to their
teeth/jaws/lips. ...................................................................................................................... 58
Table 7. Caregivers’ response to the psychosocial well-being associated with their children’s
teeth. ...................................................................................................................................... 60
Table 8. Caregivers’ response to the academic performance of their children at school. ............ 61
Table 9. Patients’ reasons for seeking orthodontic treatment. ...................................................... 62
Table 10. Patients’ satisfaction with appearance and bullying experiences. ................................ 63
Table 11. Patients’ satisfaction with appearance and bullying experiences. ................................ 65
Table 12. Patients’ response to the psychosocial well-being associated with their teeth ............. 66
Table 13. Patient/caregiver satisfaction comparison. ................................................................... 68
Table 14. Patient/caregiver bullying reports’ comparison. ........................................................... 69
Table 15. Patient/caregiver reports of specific bullying experiences. .......................................... 71
Table 16. Patient/caregiver answers to psychosocial questions.................................................... 72
Table 17. Patient/caregiver answers to bullying classmates about teeth. ..................................... 73
Table 18. Female/male satisfaction factors comparison. .............................................................. 75
Table 19. Female/male assessment of teeth crowding. ................................................................. 76
Table 20. Female/male bullying reports’ comparison. ................................................................. 77
Table 21. Female/male reports of specific bullying experiences. ................................................. 79
Table 22. Female/male answers to psychosocial questions. ......................................................... 80
Table 23. Female/male answers to bullying classmates about teeth. ............................................ 81
Figure 5. IOTN dental health component in relation to respondents’ answering “yes” to teeth
bullying. ................................................................................................................................ 82
Figure 6. IOTN aesthetic component in relation to respondents’ answering “yes” to teeth
bullying. ................................................................................................................................ 82
Table 24. Results of all correlations. ............................................................................................ 83

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 Chapter 1: Introduction

The reasons for pursuing orthodontic treatment have long been debated in the dental

community, making the task of defining orthodontics and malocclusion a complicated one.

Orthodontic treatment is best defined as the correction of teeth irregularities, whereas

malocclusion can include physical and/or psychosocial elements (Kang & Kang, 2014). From a

physical perspective, malocclusion is viewed as a “broad range of frequently occurring dental-

facial mal-relations, referring to physical deviations from ideal occlusal relations and

functioning” (Albino, Lawrence & Tedesco, 1994, p.82). Others stress that definitions of

malocclusion should include psychological characteristics (Cohen, 1970). Despite several studies

(Baylon, 2014; Dimberg, Arnrup, & Bondemark, 2014; Johal, Alyaqoobi, Patel, & Cox, 2014)

on the topic of malocclusion and psychological well-being, the reasons for pursuing orthodontic

treatment are still being debated. Ample dedicated effort has gone towards putting these

important debates into more logical and reliable conclusions in order to help answer questions

such as a) do patients’1 dental appearance help determine their overall well-being; b) do visible

deformities or malocclusions have a significant and negative influence on the psychological

conditions of those who suffer from them and finally; c) how do malocclusions affect the

potential for healthy psychological growth? Amidst all these debates, there is one consensus: the

relation between malocclusion and psychological wellbeing does exist. Hence, the need for

orthodontic treatment can be determined by psychological, social and normative factors.

Psychological factors include variables such as patients’ self-esteem, self-concept, and body

image. Social factors include social perceptions, expectations, bullying, and caregiver perceived

need. Normative factors include prevalence and severity and normative perceived need. The aim

1Note: the term “patient” will be referred to interchangeably with the term “children”
throughout this thesis and will describe the same cohort.

9
of the present study was to examine the relation between the psychosocial factors and

malocclusion, focusing on young patients (children or adolescents) as the more vulnerable

patient category with the most potential to benefit psychologically from early detection and

treatment.

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 Chapter 2: Literature Review

The literature on orthodontic treatment need can be divided into three categories. The

first, psychological, focuses specifically on the patient and includes factors such as the patients’

self-concept, self-esteem, and body image, and how each of these influence whether a patient

desires orthodontic treatment. The second, psychosocial, focuses on the perceptions and a range

of behaviors of others, from bullying to caregiving, which are intricately related to

developmental differences, SES, vocation, and education. The third, normative, involves

addressing the orthodontic treatment need based on expert opinion and examines indices that

attempt to combine both normative and psychosocial factors to determine treatment need. Each

of these perspectives is further discussed below.

Psychological Dynamics of Orthodontic Treatment Need

Psychological factors, which are patient specific, play a significant role in determining

orthodontic treatment need. These include a patient’s body image, self-esteem, self-concept and

self-image. Body image is defined as a person’s attitude towards his/her body. It includes how

people view themselves and how others view them. The way individuals view their body is a

significant factor in their feelings of safety and self-confidence (Samsonyanova, & Broukal,

2014). For example, a study by Helm et al., (1985) demonstrated that specific types of

malocclusion might adversely affect an individual’s body image.

Self-esteem refers to how one perceives his or her general sense of self-worth or own

value. Self-esteem can involve a variability of beliefs about the self, such as the evaluation of

one’s personal appearance, emotions, beliefs and behaviors (Johal et al., 2014). For example, a

study by Badran (2010), found that adolescents that had completed orthodontic treatment

exhibited superior self esteem than those who had not.

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 Body image is perceived as the way in which individuals perceive their body, which

plays an important role in the feeling of safety and self-confidence (Samsonyanova & Broukal,

2014). A number of studies (Amin & Hassan, 2010; Alley & Hildebrandt, 1988; Berscheid &

Gangestad, 1982; Goldstein, 1993; Hatfield & Sprecher, 1986; Peck & Peck, 1970; Peck & Peck,

1993) have shown that the perception of facial appearance by an individual not only affects body

image and self-perception, but also has a strong bearing on negative self-image. For instance, in

a study of 366 young orthodontic patients, malocclusions were found to correlate to

embarrassment and feeling self-conscious. Specifically, higher treatment need is directly linked

to increased social disadvantages. Amin and Hassan (2010) found that orthodontic patients with

greater clinically assessed orthodontic needs were more embarrassed and irritable with others as

compared to no or marginal orthodontic treatment needs. In another study, patients' dentofacial

satisfaction had a direct impact on their body image. Children who viewed themselves as having

attractive as compared to unattractive teeth, believed to have higher grades, better health,

slimmer bodies, more friends, and more money (Bos, Hoogstraten, & Prahl-Andersen, 2008). In

light of such findings, it becomes clear that dental perceived deformities and higher treatment

needs have directly been linked to psychosocial related issues. In each of the above cases, a

child’s need for orthodontic treatment may be driven in part by his/her perceptions of body

image, self-esteem, or overall self-perception.

It is not surprising that each of these psychological constructs also interact with each

other to further drive the needs for orthodontic treatment. For instance, adolescents and adults

tend to associate body image with a person’s confidence and level of self-esteem, as well as

his/her mental well-being. Negative body images have been known to be correlated with lower

12
self-esteem, which could lead to anxiety, depression, and even isolation (Kumpulainen &

Rasanen, 2000; Vilhjalmsson, Kristjansdotti & Ward, 2012).

In addition, the severity of malocclusion has a direct impact on a child’s psychological

well-being. For instance, Helm, Kreiborg, and Solow (1985) demonstrated that the majority of

those who suffer from malocclusions might have varying levels of negative body image and low

self-esteem, depending on the type and severity of their conditions. In their study, 977 Danish

young adults with malocclusions assessed their self-perception, self-image, and social well-

being. In a follow-up 15 years later, the study found that, first, specific types of malocclusions,

such as “conspicuous occlusal and space anomalies” (p.110), could negatively impact an

individual’s self-image and self-concept both in adolescence and adulthood. Second, although

individuals with malocclusion tended to have a compromised body image, dissatisfaction was

particularly expressed in certain types of malocclusions. These included overjets that were

greater than nine millimeters, severe crowding of teeth, and/or overbites greater than seven

millimeters. These malocclusions were found to be more detrimental to the sampled patients’

body image and self-esteem than other types. Other studies (Paula Jr, Silva, Campos, Nunez, and

Leles, 2011; Sardenberg, Martins, Bendo, Pordeus, Paiva, Auad, & Vale, 2013) found that a

higher psychosocial impact was associated with gingival smile, specifically showing more than 3

mm of gingival display and excessive anterior teeth display (i.e., anterior segment spacing and

anterior mandibular overjet). These findings were corroborated in a study (Martins-Júnior,

Marques & Ramos-Jorge 2012) that included 102 schoolchildren ages 8-10 years. The

researchers found that of those who presented with lower anterior irregularity ≥ 2 mm, 18.8%

felt sad and upper anterior irregularity ≥ 2 mm was associated to difficulty paying attention in

class (42.9%). However, a more recent study (Bellot-Arcis, Montiel-Company, & Almerich-

13
Silla, 2013) reported that the conditions associated to higher psychosocial impacts were impeded

eruption, increased overjet, increased overbite and tooth displacement.

Psychosocial Dynamics of Orthodontic Treatment Need

Research demonstrating the correlation between physical attractiveness, interpersonal

popularity, and social behaviors strongly indicates that malocclusion may have significant

psychosocial effects (Barocas & Daroly, 1972; Giddon, 1995; Goldman & Lewis, 1977;

Sardenberg, Martins, Bendo, Pordeus, Paiva, Auad, & Vale, 2013). The psychosocial dynamics

of orthodontic treatment need is best defined by behaviors including bullying and caregiving and

are often motivated by public perceptions, societal norms, social stereotyping, social acceptance,

social interaction, and social attractiveness. Psychosocial dynamics of orthodontic treatment need

are also found as a result of developmental differences, economics, education, intelligence,

vocation, and romance. Each of these is further described below.

Bullying. Bullying is one of the social responses to need for orthodontic treatment.

Bullying as defined by Al-Bitar et al., (2013) is an “aggressive behavior or intentional harm

carried out repeatedly in a relationship characterized by an imbalance of power”. This behavior

may manifest itself as physical aggression or verbal aggression such as gossip, rumors, and

social exclusion. The term bullying is synonymous with teasing, the latter referred to as a milder

type of aggressive behavior (Seehra, Fleming, Newton, & Dibiase 2011). In a study by Shaw,

Meek, and Jones (1980), 531 school children were asked to identify the most common target of

teasing. The results established that out of 14 facial features, teeth bullying was ranked as the

fourth most frequent target of teasing for children aged 9 to 12. Furthermore, Shaw et al., (1980)

also identified that teasing about teeth produced deeper feelings of being upset and harassment,

14
61% more than other types of teasing. In addition, half of the respondents who were teased about

their teeth reported verbal and/or physical intimidation.

In a recent Jordanian study (Al-Bitar et al., 2013) included 960 boys and girls, 433

respondents identified general physical characteristics and dentofacial features as the reasons for

being bullied. Another finding included a high prevalence of bullying reported by Jordanian

students, with a considerable number being targeted for their dentofacial appearance.

Furthermore, teeth were found to be the number one feature identified as the target for bullying,

with 50% of the bullied victims acknowledging its importance as a target. The dentofacial

features that were identified as targets for bullying included, those who had wide gaps between

teeth or a missing tooth (accounting for over 20%), those who had issues with the color and

shape of their teeth (20%) and those who had either prominent overbites or prominent anterior

teeth (19%). Other studies (Helm et al., 1985) reported that among young school children,

teasing was found seven times more often in the existence of malocclusion. Specifically, 50

percent of young school children presenting with overjet reported teasing.

Another study by Seehra, Fleming, Newton, and Dibiase (2011) reported that out of an

adolescent group of 336 participants referred for orthodontic assessment, the prevalence of peer

victimization in orthodontic patients with an untreated malocclusion aged between 10 and 14

years was 12.8%. In addition, being bullied was linked with Class II Division 1, increased

overbite and overjet, and a higher need for orthodontic treatment. Also, those who were being

bullied reported decreased levels of social competence, athletic competence, physical appearance

related self-esteem and general self-esteem.

15
 Furthermore, in a study of almost 500 orthodontic patients ages up to 16, Klages and

Zentner (2002) found that 44% of parents2 stated that their children had been teased due to their

teeth. The existence of severe overjet amplified the probability of teasing by 5.5 times; tooth

malalignment increased it by 2.4 times. In addition, DiBiase and Sandler (2001) stated that minor

variations in facial form, such as “buck teeth”, that elicited teasing or bullying, were more

harmful psychologically than the more significant deformities that evoked deep emotional

reactions such as pity or revulsion. A recent systematic review (Dimberg, Arnrup, & Bondemark,

2014) found that perceptible malocclusions, excessive overjet accompanied by incomplete lip

closure, crowded incisors, and large diastema have been associated with lowered self-esteem and

bullying among adolescents. Baylon (2014) stated that strong factors that may lead to a desire to

seek treatment might include social interactions such as bullying and teasing due to facial

appearance.

Developmental Influences and Bullying. A common conclusion from the literature is

that the perception of facial features, including dental appearance, is a major underlying factor

that influences the psychological condition and development from early childhood to adulthood

(Seehra, Newton, & DiBiase, 2011; Tung & Kiyak, 1998). While both genders receive bullying

indirectly, boys in general suffer more direct bullying when compared to girls. However, with

both genders, bullying and victimization can create feelings such as anxiety, insecurity, and even

loneliness (DiBiase & Sandler, 2001; Hawker & Boulton, 2000). Low self-esteem and

depression are also common characteristics of victims of bullying; feelings of depression can

persist even into adulthood. Furthermore, children victimized by bullying have a greater chance

of adopting more submissive roles in their social interactions; their social skills are often more

2Note: the term “parent” will be referred to interchangeably with the term “caregiver”
throughout this thesis and will describe the same cohort.

16
inhibited. This may cause underachievement in their learning environment further inhibiting their

educational process (Kumpulainen et al, 1998; Olweus, 1978). Consequently, with dental

appearance affecting those crucial social relations in a child’s early developmental years, the

correlation between treatment of dental malalignment and enhanced psychosocial development

might be comprehended (Baylon, 2014).

Developed vs. Developing Countries and Bullying. Bullying cases have been especially

common in the context of a learning environment, specifically in educational institutions.

Variations in the percentage and frequency of bullying against those who suffer from certain

physical conditions or deformities were found when developed and developing countries were

compared in a recent analysis of a global school data health survey (Al-Bitar et al., 2013).

Findings revealed that although bullying occurred frequently in developed countries in middle

school stages particularly (around 5% - 50% in high income countries), the frequency and

percentages was found to be quite higher in range when comparing with lower income and less

developed countries (a range of 20% - 58%). Therefore, present findings indicate that in a low-

income population, early treatment to merely improve the esthetics of obvious malocclusions,

rather than complete correction of misalignment, does produce psychosocial benefits (Proffit et

al., 2013).

Caregiving. Caregiving involves making certain decisions on the provision of dental

treatment and brings with it certain behaviors by the caregiver often in response to the oral health

condition of his/her child. Although studies focusing on perceived need from the standpoint of

the caregiver are minimal, yet they are of vital importance as it is often the caregiver that

determines treatment demand. One study (Wedrychowska-Szulc and Syrynska 2010) examined

caregiver perceived need and treatment motivation, found that 77% selected irregular teeth and

17
54% selected wanting their child to look ‘pretty’ as motivations for pursuing orthodontic

treatment. In addition, 64% of caregivers stated that they wanted treatment for their child out of

fear of potential future blame from the child that their caregiver neglected their duty to provide

them with orthodontic treatment. A recent study (Samsonyanova, & Broukal, 2014) reported that

aesthetics, precisely irregular positioning of the teeth and anterior crowding ≥2 mm, was the

main factor motivating caregivers to seek treatment. Caregivers consider that through

orthodontic treatment, their child would look pretty and therefore enhance their self-esteem

along with oral health.

Agreement Regarding Perceived Orthodontic Need - Caregivers versus Children.

Researchers have attempted to examine the perceived need of patients versus the caregivers’

perceived need. For example, a study (Bos, Hoogstraten, & Zentner 2010) assessing 182

orthodontic patients ages 8 to 15 and their parents found that parents’ reports on their children’s

OHRQoL of life were in overall agreement with reports of their children. However, parents, in

comparison to their children, reported a more positive outlook with regards to treatment

expectations, appearance of the children’s’ teeth and about the general health of their children.

Conversely, more recent studies (Abreu, Melgaco, Abreu, Lages, & Paiva, 2014; Hassan,

Hassan, & Linjawi, 2014) reported poor agreement between young patients and their caregivers

with regards to emotional and social impacts of malocclusion. These studies suggest that while

the patients’ perceived need is of vital importance, it cannot be used solely; therefore, they are

complementary to each other.

Caregivers and Socioeconomic Status (SES). A recent study (Piovesan, Marquezan,

Kramer, Bönecker, & Ardenghi, 2011) examined how SES and clinical conditions affect

caregivers’ perceptions and observations of their child’s oral health. The cross-sectional study

18
conducted in Brazil assessed a theoretical explanation that correlates SES and oral health based

on psychosocial variables and their effect on individual lifestyle decisions. This theory argues

that differences in psychological stress between socioeconomic backgrounds dictate the health

inequalities; lower socioeconomic groups have shown to experience a higher number of negative

life consequences, less social support and higher levels of antisocial behavior within the

community. The researchers found that caregivers from minority groups and those with greater

poverty levels or lower household incomes were more likely to rate their children’s oral health as

‘poor’ than those with a higher socio-economic status. This means that caregivers with lower

incomes or come from minority groups, are more likely to perceive their child’s oral health as

poor and therefore view a greater perceived need.

Public Perceptions. The concept of perfect teeth is firmly linked to a notion of beauty

that encompasses the ideas of wealth, goodness and happiness. Social expectations play a

significant role in molding cultural definitions of beauty and the literature on physical

attractiveness suggests that appearance may be a dominant source of social stereotyping (Adams,

1982; Berscheid, Dion, & Walster, 1972; Snyder, Tanake, & Berscheid, 1977) as well as an

important social cue used by others as a basis for social evaluation (Berscheid, 1981; Berscheid

& Walster, 1974; Dion, 1972). A classic study conducted by Macgregor (1951), found that

unconscious perceptions by others are key in molding an image personality. Research in social

psychology demonstrates that an unappealing and unattractive physical appearance may result in

unfavorable social responses as expressed through different facets of social interaction (Kenealy,

Frude, & Shaw, 1989). For example, almost 200 investigations have confirmed the effect of

facial attractiveness on several social settings; these include friendships, scholastic assessments,

and helping behavior (Adams, 1977). Klima, Wiltemann and McIver (1979), in their assessment

19
of various studies regarding malocclusion and its relation to social issues, provided important

and highly relevant insights on public perceptions of malocclusions. Dann and Broder (1995)

stated that public perceptions could be more impactful on psychological and social well-being

than a child’s own self-concept.

Societal Norms and Social Stereotyping. There are several explanations as to how

societal norms and stereotypes are formed. However, the most significant argument continues to

be the formation of cultural definitions of beauty and ideal esthetics. Snyder et al., (1977)

claimed that a smile and its quality and characteristics act as strong determinants of social

acceptance and attractiveness due to the significant role of the media. For example, Kiyak (2008)

stated that all TV heroes, actors and actresses, and other media and movie figures usually have

good looking, clean, aligned and white teeth, while villains have crooked and discolored teeth.

This observation was affirmed by Proffit et al., (2013) who found that, the typical image of an

individual who is not intelligent includes protruding upper incisor and a witch has a prominent

lower jaw that would produce a Class III malocclusion. Therefore, well-aligned teeth and an

aesthetically agreeable smile carry a positive standing among all social levels and ages, while

irregular or poorly aligned teeth carry a negative standing. Furthermore, tools of communication

or media channels help reinforce this image to society. As a result, people begin to evaluate

themselves and others using such standards and this is used to explain such public perceptions of

malocclusions versus normal occlusions. In addition, these images all shape and influence young

adolescent’s satisfaction and body image (Kiyak, 2008).

Social Acceptance. Empirical evidence suggests that individuals use facial appearance as

a way to infer a variety of characteristics about a person. For example, attractive facial

appearance in young children was found to be the most influential of 33 different characteristics

20
for social acceptance and popularity among peers (Young & Cooper, 1944). In addition, people

were more likely to link certain states of social well-being on the basis of facial characteristics

(MacGregor, 1951). The oral-facial area is typically of considerable significance for an

individual as it is the most noticeable during social interactions and is the main source of vocal,

emotional and physical communication. Consequently, patients seeking orthodontic treatment

are most likely concerned with enhancing their social acceptance and appearance, than they are

with improving their oral function or health (Kiyak, 2008).

Social Interactions. Adolescents with severe malocclusion were more psychosocially

disadvantaged and displayed more esthetic concerns than others (de Paula, Santoc, da Silva,

Nunes, & Leles, 2009). A more recent finding established that severe malocclusions may likely

become an impediment to social interactions (Proffit, Fields, & Sarver 2013). Therefore, social

responses based on the appearance of the face and teeth can severely affect an individual’s

outlook on life. In their literature review, Klima, Wiltemann and McIver (1979), stated that

malocclusions could give impressions of an individual’s personality. If the malocclusion is

highly perceptible, it can result in aversion, thereby obstructing the spontaneity of social

interaction. On the other hand, it was generally found that people, whether children, adolescents

or adults, tended to identify others with ideal, healthy looking teeth as more amicable than those

with visible malocclusions. In a study to assess patients’ main motivations for seeking

orthodontic treatment, 205 patients were surveyed. Results showed that achieving better

aesthetics was the main reason behind 86% of patients seeking orthodontic treatment; around

80% of the patients believed that orthodontic treatment would improve their social and mental

well-being (Al Fawzan, 2012).

21
 Social Attractiveness. Research by Secord and Jourard (1956) and Stricker (1970) noted

the correlations between social attractiveness and the condition of dental health and appearance

in individuals. Shaw (1981) found that both children and adults perceive faces with normal

occlusions as more physically appealing, smarter, more amicable, and preferred as friends than

identical faces with occlusal impairment. More than twenty years later, these results were

replicated by others (Eli, Bar-Tal, & Kostovetzki, 2001; Newton, Prabhu, & Robinson 2003;

Scapini, Feldens, Ardenghi, & Kramer, 2013). A more recent study by Henson et al., (2011)

examined whether dental esthetics influenced the perception of adolescents when judging a

peer’s social, athletic, academic and leadership abilities. The study found that ideal smile

esthetics was rated higher than non-ideal smile esthetics. On average, scores for the ideal smile

esthetics in athletic, social, and leadership skills were 10% higher than non-ideal smiles.

Shaw (1981) stated that, “dentofacial anomalies of sufficient severity to mar a child’s

facial attractiveness may represent an important social disadvantage” (p.413). Several studies

have linked specific types of malocclusion to social attractiveness and social disadvantages. He

examined whether a child’s dentofacial appearance could be linked to his or her social

attractiveness by asking 42 children and 42 adult respondents to assess photographs displaying

different dentofacial arrangements. The arrangements in the photographs included normal

incisors, prominent incisors, a missing lateral incisor, severely crowded incisors and a unilateral

cleft lip. The majority of observers had negative perceptions towards these images; however,

different types of malocclusion elicited different degrees of negativity and judgments. For

instance, observers showed the highest disfavor for cases of harelip when compared to other

malocclusions, while those with missing incisors were linked to a more aggressive and less

stable personality.

22
 Another similar study (Shaw, Rees, Dawe, & Charles, 1985) asked 800 young adults to

evaluate an individual's social characteristics based on dental alignment. The study found that

faces demonstrating a normal incisor relationship acquired the most favorable ratings for eight of

the ten characteristics. Four of eight characteristics that were statistically significant were social

class, friendliness, intelligence and popularity. Faces displaying prominent incisors were rated

highest for honesty and compliance; a unilateral cleft consistently drew low ratings. A more

recent study (Samsonyanova & Broukal, 2014) reported that Class II malocclusion might lead to

psychosocial problems such as mockery, negative stereotyping, and low self-confidence.

Therefore, the study recommends interceptive treatment with regards to this condition in order to

avoid social disadvantages.

Based on the above findings, psychosocial factors such as public perceptions, social

stereotyping, social acceptance, social interaction, and social attractiveness, all either impact or

are impacted by malocclusion. These factors may significantly affect patients’ treatment need or

help enhance patients’ psychosocial condition by enhancing their social acceptance and/or

attractiveness.

Vocational, Educational, Intelligence, Romantic and Developmental Influences.

Psychosocial dynamics also included perceptions related to economics, education, vocation, and

romance. For instance, several contributions from literature go as far as linking actual economic

prosperity and opportunities to ideal occlusions (Linn, 1966). Appearance is even known to

influence teachers’ expectations, student advancement in school, employment attainment and

obtaining a romantic mate (Proffit et al., 2013). Studies have proved that attractive individuals

are perceived as more intelligent (Landy & Sigall, 1977; Langlois, Kalakanis, Rubenstein,

Larson, Hallam, & Smoot, 2000; Nordholm, 1980) and more qualified at task completion

23
(Dipboyle, Avery, & Terstra, 1977). In an early study that encompassed 1,862 adults, more than

half rated dental appearance as having a significant role in determining how well an individual

could make social connections and friendships, or run for public office or achieve employment

(Linn, 1966). A more recent study aimed to conclude whether dental esthetics had an impact on

finding a job by evaluating perceptions of people responsible for the human resources divisions

of their companies (Pithon, Nascimento, Barbosa, Coqueiro Rda, 2014). 100 respondents were

asked regarding the persons’ probability of being hired, intelligence, honesty, and efficiency at

the workplace by assessing pictures of smiling individuals. Results found that people with ideal

dental esthetics were consistently viewed as more intelligent and had a greater probability of

being hired. However, with regards to honesty and efficiency, no significant differences were

found in the assessments. Finally, dental appearance was rated highly in relation to dating in

young people in their relationships with the opposite sex (Linn, 1966).

Developmental Differences. Dann and Broder (1995) examined 208 patients ages 7 to

15 and established that, due to Class II malocclusion being highly perceivable, this may lead to

psychosocial issues. Therefore, rationale for seeking treatment is that the enhancement of

conspicuous traits of malocclusion at an early phase may inhibit the development of poor self-

concept. A recent systematic review (Samsonyanova, & Broukal, 2014) reported that the main

motivational factor for children to undergo orthodontic treatment was aesthetics, specifically

crowding of teeth, large overbite, and missing teeth. Other factors reported by children included

the belief that orthodontic treatment may improve their quality of life, make it easier to get a job

and easier to find a romantic partner. In a similar study (Marques, Pordeus, Ramos-Jorge,

Filogonio, Filogonio, Pereira, & Paiva, 2009), 403 subjects, aged 14-18 years old were assessed.

Results indicated that, 72% believed orthodontic treatment could improve their lives, 41%

24
believed it made it easier to get a job, 27% believed it made it easier to find a partner, and 22%

associated it with status and 12% with teasing. For the sake of the present study, the focus is only

on children and adolescents and not on adults. There is a rich research field that focuses on the

adult with regards to body image and orthodontic treatment.

Normative Dynamics of Orthodontic Treatment Need

Dental malocclusion is the deviation from ideal occlusion. It is often seen in adolescents

showing characteristics, such as crooked, crowded or protruding teeth. Malocclusion not only

affects appearance, but may also cause problems in speech and function. In some cases,

malocclusion may interfere with oral hygiene leading to caries and gingivitis. Normative

orthodontic criteria are the main tools for evaluating the prevalence and severity of malocclusion

and are the main factors in determining orthodontic treatment need. Individuals with

malocclusion may require orthodontic treatment in order to improve oral health, dental function,

and aesthetics (Klages, Erbe, Sandru, Brullman & Wehrbein, 2014). Orthodontic treatment varies

from most other medical interventions as it aims to correct variations from an arbitrary norm

(Kang & Kang, 2014).

According to Klages et al., (2014), the average prevalence of adolescents’ malocclusion in

need of orthodontic treatment is estimated to between 40 and 60%. In addition, adolescents

undergoing orthodontic treatment are about 60% in countries providing dental care insurances.

Dimberg, Arnrup, and Bondemark (2014) reported a prevalence of malocclusions over 60% in

preschool children and 43 to 78% in schoolchildren. Moreover, the most common malocclusions

are anterior open bite, excessive over jet, Class II malocclusions, and posterior cross bite.

Crowded teeth due to space deficiency in the dental arches are more recurrent in older rather than

younger children. However, the frequency and prevalence of malocclusion may vary due to

25
differences in clinical indices and cutoff points. There are a number of clinical indices that are

used to discern need of orthodontic treatment need.

Indices for Assessing Perceived Need for Orthodontic Treatment. In efforts to identify

orthodontic treatment need, there has been considerable debate on how malocclusion should be

evaluated with regards to aesthetics and psychosocial factors. Several studies recognized that any

assessment of need for orthodontics should include aesthetics. For example, Hunt, Hepper,

Johnston, Stevenson, and Burden (2002) stated that accurate evaluations of dental aesthetics are

necessary if psychosocial implications of malocclusion are to be examined. In response, a

number of indices have been developed in attempts to standardize and quantify these evaluations.

These include the Eastman Esthetic Index (EEI; Howitt, Stricker, & Henderson, 1967), the

dental–facial attractiveness index (DFA; Tedesco, Albino, Cunat, Green, Lewis, & Slakter,

1983a; Tedesco, Albino, Cunat, Slakter, & Waltz, 1983b), the Dental Esthetic Index (DAI; Jenny

& Cons, 1996) and the Index of Orthodontic Treatment Need (IOTN; Hunt et al., 2002). Each of

these is further described below.

EEI –Eastman Esthetic Index. (EEI; Howitt, Stricker, & Henderson, 1967) was

developed as one of the first indices to consider the aesthetic aspects of malocclusion. However,

despite its novelty in measuring the degree of aesthetic impact associated with the malocclusion,

it failed to acquire widespread use as others. This was due to the fact that it lacked validity and

was only used as a supplement in few cases (Bourzgui 2012).

DFA- Dental–Facial Attractiveness Index. (DFA; Tedesco et al., 1983a; Tedesco et al.,

1983b). The DFA rating was innovative in that unlike other scales it didn’t not rely on layperson

perception, but used the child’s own perception as a measure of his or her occlusion. However,

26
much like the EEI, the DFA also did not achieve widespread (Tedesco et al., 1983; Tedesco et

al., 1983b).

DAI- Dental Esthetic Index. The DAI (Jenny & Cons, 1996) included social and

psychological factors along with traditional measures of malocclusion. The DAI scale combines

first the esthetic and physical aspects of occlusion into a numerical score using ten traits of

occlusion. The patient’s score is then placed on a scale to locate the point at which the score falls

between most and least socially acceptable dental appearance. The DAI assumes that the further

the score is from what is acceptable, the more likely the occlusal condition is physically and

socially detrimental to the patient (Cons, Jenny, & Kohout, 1986). This index has been

successfully employed in numerous studies including epidemiological studies to assess the

prevalence of malocclusion and orthodontic treatment need. Studies have suggested that the DAI

can be applied universally without any need for modification (Bourzgui 2012). Furthermore, the

DAI was integrated into the International Collaboration Study of Oral Health Outcomes by the

World Health Organization (WHO) (Scapini, Feldens, Ardenghi, & Kramer, 2013).

IOTN- Index of Orthodontic Treatment Need. The IOTN focuses on aesthetics as a

factor in determining the requirements of treatment. It consists of two separate components, the

aesthetic component (AC) and the dental health component (DHC) (Hunt et al., 2002). This

index grades patients based on the extent to which malocclusion affects their stomatognathic

system and according to their aesthetic perception of their own malocclusion, with the intent of

indicating which patients would gain most from orthodontic treatment (Bourzgui 2012). The

psychosocial indicator of treatment need was the major innovative aspect of the IOTN. The

United Kingdom currently utilizes the IOTN to arrange public orthodontic care services. The

IOTN’s reliability and validity has been widely verified, it is user friendly, and it is also one of

27
the most-frequently cited indices in the literature (Bourzgui 2012). Yet, despite these efforts to

standardize the evaluation of dental esthetics, the indices were met by disagreement among

orthodontists. The majority of indices proved unreliable, others limited in their scope, and others

simply met with disagreement creating a plethora of indices, yet no general consensus on a single

one as an agreed upon measure or method (Baylon, 2014).

Ideal Timing of Orthodontic Treatment Results. Before examining the impacts of

orthodontic treatment, it is important to consider the literature on when orthodontic treatment

might render the most impactful results, also called ‘ideal timing’. Kenealy, Kingdon, Richmond,

and Shaw (2007) stated that, generally, orthodontic treatment is initiated in early teens as reasons

that enhanced appearance will present long-term psychosocial benefits, and that enhanced

alignment will present long-term oral health benefits. Findings from a survey assessment (Tung

& Kiyak, 1998) of 75 children and their parents, revealed that the younger the patient is

receiving treatment, the more impactful the treatment is in terms of psychological consequences.

For example, in their study of 208 patients, ages 7 to 15, Dann and Broder (1995) highlighted

that early orthodontic treatment may provide important benefits for children experiencing teasing

and negative stereotyping. In addition, early orthodontic treatment to improve dentofacial

attractiveness may also help improve a child’s social interactions. One randomized controlled

trial (O’Brien et al., 2003), included 174 British children, aged 8-10 years old with Class II

Division I malocclusion, demonstrated increased self-esteem scores in both early mixed dentition

treatment and adolescent treatment groups upon completion of orthodontic care.

Developmental Differences and Impact of Orthodontic Treatment. Several studies

have cited improvement in the majority of Oral Health-Related Quality of Life (OHRQoL)

domains after undergoing orthodontic treatment (Agou, Malhotra, Tompson, Prakash, & Locker,

28
2008; Agou, Locker, Muirhead, Tompson, & Streiner, 2011; Zhang, McGrath, & Hagg, 2007).

Oral Health–Related Quality of Life (OHRQoL) is defined as the assessment of how oral

conditions affect a person’s overall health and well-being (Al-Omari, Al-Bitar, Sonbol, Al-

Ahmad, Cunningham, & Al-Omari, 2014). It is also defined as “the absence of negative impacts

of oral conditions on social life and a positive sense of dentofacial self-confidence” (Agou et al.,

2011, p. 369). One study (Seehra, Newton, & DiBiase, 2012) followed the progress of 43

adolescent patients aged 11 to 14 who had suffered from bullying specifically linked to their

malocclusion, to determine orthodontic treatment impact on bullying and their Oral Health-

Related Quality of Life (OHRQoL). The study asserted that orthodontic treatment not only had a

positive impact on those experiencing bullying, but also on their OHRQoL. Findings indicated

that 78% of participants reported significantly less frequency of bullying following initiation of

orthodontics. One case reported a continuation of being bullied after treatment and it was

reported that the appliance itself was the focus of the harassment.

Several studies (De Oliviera & Sheiham, 2004; Scapini, Feldens, Ardenghi, & Kramer,

2013; Silvola, Varimo, Tolvanen, Rusanen, Lahti, & Pirttiniemi, 2014) revealed that both

children and adults who underwent orthodontic treatment for malocclusion were more likely to

account lower OHRQoL impacts than those who had not undergone any treatment. Findings

show that the biggest differences concerned social and emotional factors, measures of well-

being, and social interactions that involved revealing one’s teeth such as smiling or laughing.

Another study (Badran, 2010) assessing 410 students, ages 14 to 16 years found that,

receiving orthodontic treatment was positively correlated with self-esteem in students. This

suggests that dental appearance is a critical factor and strongly predictive of self-esteem. This

study was supported in a more recent study (Johal et al., 2014) in which 61 participants reported

29
significant increase in self-esteem as a result of orthodontic treatment. In another study (Kang &

Kang, 2014), 860 adult patients (378 men and 482 women, aged 18–39 years) were examined;

found that, patients who underwent orthodontic treatment exhibited enhanced body image and

self-confidence.

Another study (Jung, 2010) findings show that gender may play a slight factor in

determining the possible extent of impact of orthodontic treatment on confidence levels. In one

study, over 4,500 patients were clinically examined for overcrowding and/or lip protrusions and

were asked to evaluate their level of self-esteem. Results revealed that post fixed orthodontic

treatment, patients, and particularly female patients, showed clear improvements in their levels

of confidence, self-esteem and body image. Another study (Gavric et al., 2015) found no

correlation between self-esteem and gender of the patients. Accordingly, it is viable to conclude

that the majority of literature on the impact of orthodontic treatment ascertains that patients who

have undergone fixed orthodontic treatment are less likely to have adverse physical and

psychosocial impacts related to their malocclusions (Bernabe, Sheiham, Tsakos, & de Oliveira,

2008).

Normative versus Patient and/or Caregiver Perceived Need. Normative perceived

need is usually based on examination of models and the measurement of cephalometric

radiographs and does not include patient perception. However, recent findings (Kang & Kang,

2014) show that while patients and orthodontists may have different observations of orthodontic

treatment need, patient perceived need is vital and may help supplement normative assessments.

For example, one study by Silvola et al., (2014) found that orthodontists are able to assess the

type of malocclusion and esthetics that have the most significant impact on patients’

psychological and social well-being, while other researchers (Klages, Erbe, Sandru, Brullman &

30
Wehrbein, 2014) showed that patients’ perception do not always coincide with that of their

orthodontist. These findings estimate that about 30% of adolescents rate their tooth alignment to

be more favorable, and 20% rate it worse than their orthodontist. In addition, findings also found

that one-fifth of successfully treated patients were not satisfied with their orthodontic treatment

results.

Furthermore (Spalj, Slaj, Varga, Strujic, & Slaj, 2010) findings also showed a weak

agreement between caregiver perceptions and clinically evaluated needs or orthodontist

perceived needs. The study stated that the difference in perceptions may be due to by parents’

over-scoring treatment need due to a sense of requirement to provide the best care for their

children. Yet, despite parent’s role in determining treatment demand, the study found that they

had the lowermost predictive value regarding children’s satisfaction with dental appearance;

importance of teeth to facial appearance, and their malocclusion related quality of life.

Literature findings show that three main factors affect the rate at which dental

professionals guide orthodontic treatment. First, Wedrychowska-Szulc and Syrynska (2010)

showed that the percentage of patients guided by dental professionals decreased by 20% with

increasing age. Second, other studies found that the frequency with which subjects visit their

dentist influences treatment demand. This may be because regular patients are more likely to

trust their dentists and to follow their professional advice. Finally, the third is socioeconomic

status; this may be due to the fact that low-income families lack the financial means to afford

orthodontic treatment.

Gaps in the Literature

The literature review demonstrates that many studies have focused on specific underlying

factors that are linked to malocclusion. These can be labeled as influencing factors and should be

31
the main influencers of any further research into the impact of malocclusion on a patient’s

psychosocial and emotional well-being. The main factors were identified as:

a) The link between type and severity of malocclusions and the probability of negative

social and personal perceptions, especially concerning the most visible of these types;

b) The extent to which negative perceptions can lead to higher probability of being

subject to both direct and indirect forms of harassment such as teasing, verbal abuse

and verbal or physical bullying;

c) Orthodontic treatment and its expected results and impact on improving the quality of

life of an individual and finally; and

d) What is the ideal timing to seek orthodontic treatment and what are the main

underlying motivations for patients who seek treatment?

In conclusion, the above literature all highlighted these factors as major dynamics of the relation

between malocclusion and psychosocial well-being. These factors all interlink to create a

framework for this research topic, to better formulate its design and infer its main findings.

While there are several studies that attempt to address the relation between orthodontic

treatment and psychosocial well-being, there is still no consensus on the topic. This is due to the

fact that while some studies reported a correlation between malocclusion and psychosocial

consequences, others denied such correlation. This may be owing to varying understandings of

what these impacts constitute, sample size, age, and the absence of uniform methods for

assessment (Hassan, Hassan, & Linjawi, 2014). Furthermore, while studies attempt to look at

different aspects of the topic, few consider the comprehensive factors as a whole. For example,

studies on caregiver perceived need or caregiver versus normative or patient perceived need were

minimal and lacked a dynamic approach. In addition, through literature examination, it was

32
found that there is a lack of theories put forth to address this topic and limited literature available

on bullying and malocclusion.

33
 Chapter 3: Purpose and Hypotheses

Purpose

In an attempt to address the gaps in research, the present study not only assessed the

correlation between malocclusion and lowered psychosocial well-being from the perspective of

younger patients, but also allowed for a more comprehensive approach through the examination

of the caregivers’ perception and through the inclusion of normative criteria. This study aimed to

support and add to the current literature on the topic in an attempt to someday assist in the

formation of a consensus. Furthermore, the current study hopes that findings on this topic may

facilitate a better assessment of treatment needs as well as contribute towards better healthcare

planning necessary for access to orthodontic treatment.

Hypotheses

1. A relationship exists between malocclusion and psychosocial well-being factors.

2. A relationship exists between malocclusion and bullying - when the severity of

malocclusion increases, the more bullying experiences are anticipated and expected.

3. Children with severe malocclusion are more likely to have academic problems at

school than those with mild malocclusion.

4. A child’s motivation to seek orthodontic treatment is associated with the caregiver’s

motivation to seek treatment.

5. Psychosocial impact of malocclusion is higher among girls than boys.

34
 Chapter 4: Materials and Methods

Research Ethics Approval

Ethical approval was attained from the University of Manitoba Health Research Ethics

Board (HREB), Bannatyne Campus, on May 7, 2014 - see Appendix A. Two minor amendments

were submitted. The first amendment allowed for the inclusion of screening patients in

conjunction with new patients assigned to new orthodontic residents at the University of

Manitoba. This amendment was approved on May 16, 2014 - see Appendix B. The second

amendment was submitted to increase the age range included in this study to satisfy the needed

sample size. This amendment was approved on August 21, 2014 – see Appendix C. Data

collection commenced subsequent to the initial ethics approval over a period of six months.

Study Sample

The present study aimed to reach a sample size of 85 patients and their caregivers. This

was based on the detection of a minimum simple correlation r (r=0.3) of N patients. Using a two-

sided test, 5% significance level test (α=0.05) with 80% power (β=0.2), which required a sample

size of approximately 85 (n=85).

Inclusion Criteria: Inclusion criteria included:

1. Patients needed to be between the ages of 11-16. Caregiver age range was not specified in

the study.

2. Both genders.

3. No previous orthodontic treatment.

The rationale for sample selection was based on:

35
 1. The majority of orthodontic patients fall within this age group (11-16). A younger age

group would not be as concerned nor be able to comprehend the concepts and questions

included in the study. An older age group was not suitable in this study as they preclude

caregivers.

2. Both genders were included to identify whether one was more concerned with

psychosocial problems than the other.

3. The history effect of previous orthodontic treatment that might have changed the patient’s

perspective and need for orthodontic treatment.

Exclusion Criteria: The rationale for excluding the group listed below was based on the fact

that they acquire their own special psychosocial problem and that there is research specifically

dedicated to these specific patients. In order to emphasize the importance of the psychosocial

problems for the group listed in the inclusion criteria, the exclusion criteria in the present study

included:

1. Patients with special health care needs.

2. Syndromes and craniofacial anomalies (e.g., cleft lip and palate).

3. Mentally handicapped patients.

4. Chronic medical conditions.

5. Respondents with language barrier difficulties.

Sampling Methodology

Selection of participants was based on screening of new patients assigned to new

orthodontic residents at the University of Manitoba in conjunction with new screening patients at

the Graduate Orthodontic Clinic at the University of Manitoba. Although stratified random

36
sampling was initially proposed, due to the difficulty of attainment of complete list of patients,

purposive sampling was employed. Purposive sampling was used whereby participants were

selected based on availability.

Methods. A cross-sectional study design was employed. Data was collected at a single

point in time from a sample of prospective patients.

Informed Consent - see Appendix D. Caregivers of patients eligible to participate in the

study were given the Parent Information and Informed Consent form by the principal

investigator. Due to the fact that study participants were under 18 years of age, in accordance

with Research Ethics Board guidelines, caregivers were asked to sign the consent form to allow

their child to participate in the study. The caregivers had an opportunity to read this form in the

waiting room as they waited for their child to be taken in for the appointment. Upon completion

of the clinical exam at the Graduate Orthodontic Clinic at the University of Manitoba, the

investigator inquired if the caregivers would like to participate in the study, and if they had any

questions. Upon agreement of participation in the study, the investigator then obtained the

informed consent. Thereafter, patients and their respective caregivers filled the questionnaires.

Incentive prizes were offered to elicit questionnaire participation. Prizes included a PC

tablet and gift cards. Questionnaire respondents were asked to provide an email address if they

wished to participate in the draw - see Appendix E. Winners were selected randomly and

contacted via email - see Appendix F. The ballots were locked in a black box until the draw,

which was held on October 1, 2015 at the University of Manitoba. Prizes that were not claimed

after seven days were given to a newly randomly selected winner. Once all prizes were claimed,

the ballots were destroyed.

37
 Clinical examination - see Appendix G. Clinical data was collected through an oral

examination to assess the severity of malocclusion. Dental examination of the subjects was

performed at the University of Manitoba Orthodontic Graduate Clinic (at Health Sciences

Centre). The principal investigator performed the examination using a dental mirror, explorer,

periodontal probe, and light. In addition, the use of dental casts and digital images for patients

was also employed. The clinical exam was comprised of several components, which provided a

summary of dentofacial features. Components used for the purpose of this study were extracted

from the clinical examination employed at the graduate orthodontic clinic at the University of

Manitoba. Components of the clinical examination are listed and described in Table 1 below.

Following the clinical examination, questionnaires were administered to the selected

patients and their caregivers. Both questionnaires and clinical exam were labeled with an

identification number in order to protect anonymity and to protect privacy for both, patients and

their respective caregivers.

Patient Self-Assessment Questionnaire. In a recent study, Al-Bitar et al., (2013)

employed a questionnaire that was modified from that of Shaw et al., (1980). For the purpose of

this study, the same questionnaire used by Al-Bitar was used but modified to meet other aspects

needed in the study. Upon completion of the questionnaire design by the principal investigator,

the questionnaire was then provided to Dr. Dieter Schönwetter, a psychometrician, for reviewing

and approval. As seen in Appendix H, a statistician also evaluated the questionnaire for its

validity.

38
Table 1. Components of clinical exam (adapted from Proffit et al., 2007).

Component Description

In the profile view (anteroposterior plane), the facial pattern is described as

Facial type
prognathic, retorognathic or orthognathic.

 An orthognathic facial type pattern denotes that the chin is normally

positioned and the profile, exclusive of the nose, is straight.

 In a prognathic facial type pattern, the chin is protrusive and facial concavity

is evident.

 A retrognathic pattern is represented by a retrusive position of the chin and

facial convexity is evident.

The relationship between two lines is examined, one dropped from the bridge
Profile type
of the nose to the base of the upper lip, and the second one from that point

downward to the chin.

As a result of these two lines, the patient is classified as convex, concave, or

straight.

Patient examined in the frontal view for bilateral symmetry in the facial fifths.
Facial

asymmetry

Nose size Nasal dorsum contour and nasal tip projection is measured on the profile view

of the patient. Noses are classified as normal – average, large, or small.

39
 Lip prominence is evaluated by relating the upper lip to a true vertical line
Upper and
passing through the concavity at soft tissue point A. Also, relating the lower
lower lips
lip to a similar true vertical line through the concavity between the lower lip

and chin. If the lip is considerably forward from this line, it is judged as

prominent; if the lip falls behind the line, it is judged as retrusive. If the lip

lies within this line, it is considered average.

Interlabial gap Considered present when both lips are incompetent (separated by more than 3

to 4 mm).

Space analysis, using the dental casts to measure the size of the teeth versus
Upper and
the space available for them. Classification used was either presence of
lower arch
spaces, mild crowding (1-4 mm), moderate crowding (4-7 mm), and severe
space analysis
crowding (>7 mm).

Midline Measurement of the space between the mesial surfaces of upper central

diastema incisor.

Overjet Defined as horizontal overlap of the incisors.

Overjet is classified as negative or reverse, edge-edge, normal (1-2mm), mild

(2-4 mm), moderate (4-6 mm), or severe (>6 mm)

Overbite Defined as the vertical overlap of the incisors.

Overbite is classified as normal (10-20%), mild (20-50%), moderate (50-80

40
 %), severe – impinging (100%), or openbite.

Anterior Occurs when maxillary incisors are displaced lingually or in children

crossbite developing a Class III jaw relationship.

Considered present when two or more teeth are in anterior crossbite.

Posterior Occurs when the maxillary posterior teeth are lingually positioned relative to

crossbite the mandibular teeth.

Considered present when two or more teeth are in posterior crossbite.

The ideal elevation of the lip on smile for adolescents is slightly below the
Smile line
gingival margin, so that most of the upper incisor can be seen. Up to 4 mm

display of gingiva in addition to the crown of the tooth, or up to 4 mm lip

coverage of the incisor crown, is acceptable. More than 4 mm of gingival

display is considered as a high/gummy smile line. Less than 4mm of gingival

display is considered as a low smile line.

The first section of the questionnaire involved the reason(s) behind the patient’s decision

to visit an orthodontist. The second section queried patient’s satisfaction regarding different body

parts. The third section focused on the personal experience of teasing and bullying directed at all

body parts first and then regarding dentofacial features specifically. The fourth part identified the

dentofacial feature’s effect on social life.

Caregiver Assessment Questionnaire. As seen in Appendix I, the caregiver assessment

questionnaire mirrored the patient self-assessment questionnaire; the significant difference

41
between them was the perspective from which the answers were given. This means that while

patients answer the questions based on how they view themselves, caregivers answered them

based on how they view their child (the patient). The purpose of giving both patients and

caregivers the same questions was to evaluate the similarities and differences between both

groups’ perception of treatment need.

Furthermore, a section regarding socio-economic status was added to the caregivers’

questionnaire. Ethnicity information was attained from the caregivers, allowing each patient to

be classified as Asian, Black, Caucasian, East Indian, First Nation, Hispanic, Metis, or other.

Another question included caregivers’ level of education (i.e., up to grade 8, up to grade 12, high

school diploma, some college, college diploma, some university, undergrad degree, or graduate

degree). The third question asked about their annual income (i.e., $0-25, $26-35, $36-45, $46-55,

$56-65, $66-75, $76-80, $81+, or if they refuse to answer). The purpose of including these

additional variables was to investigate whether ethnicity, level of education or annual income

had an effect on psychosocial factors regarding dentofacial features of patients.

Pilot Study. Before starting the research, a pilot study was undertaken with caregivers of

six patients from the graduate orthodontic clinic at the University of Manitoba to ensure that the

questions and language used were clear and easy to comprehend. The purpose of the pilot study

was to also ensure that patients’ caregivers took no longer than 10-15 minutes to compete all

sections of the questionnaire. After receiving satisfactory feedback from the patients, research

was instigated. Upon completion of the questionnaire design by the principal investigator, the

questionnaire was then provided to Dr. Dieter Schönwetter, a psychometrician, for reviewing and

approval. The questionnaire as seen in Appendix I was also provided to a statistician to approve

its validity.

42
 Coding of Data. In order to ensure that all data gathered from the same patient could be

tracked and linked, a unique code was given to each patient and the patient’s data, including the

patient’s self-assessment questionnaire, his/her caregiver’s questionnaire and clinical exam.

Validity and Reliability of Clinical Exam, Patient Self-Assessment, and Caregiver

Questionnaires

Inter-reliability assesses the degree to which measurements taken by different researchers

are similar, whilst intra-reliability assesses the degree to which measurements taken by the same

researcher are consistent. A second year orthodontic resident performed the clinical exam on

twelve randomly selected patients; results were compared with those found by the principal

investigator. Cohen’s Kappa test was used to measure inter-reliability and intra-reliability.

Reliability in questionnaires is associated with the fact that no matter how many times the

questionnaire is tested, it should yield the same results. Accordingly, the questionnaires were

pre-tested six times to assess the inter-reliability and intra-reliability of data using Cohen’s

Kappa test.

The questionnaires were designed by the principal investigator and reviewed by a

statistician and a psychometrician to ensure that the results were measurable and valid. Sixty

percent was the minimum rate of response that was deemed acceptable in order to be included in

the study.

Index of Treatment Need - IOTN

The IOTN is a widely used index created by Brook and Shaw (1989). It was the first

index that included a socio-psychological angle. It serves as a tool to determine the severity of

malocclusion along with the patient’s perception of his or her dental aesthetics. The IOTN

comprises two separate components, the dental health component (DHC) and the aesthetic

43
component (AC). The components are assessed separately and cannot be combined into a single

score. However, together, the components can help classify the patient’s treatment need (Bellot -

Arcís et al., 2012).

The Dental Health Component (DHC) of the IOTN. The DHC (Dental Health

Component) is the clinical component of the IOTN. This component categorizes patients into

five grades based on their occlusal features and their impact on the stomatognathic system as

seen in Appendix J. This component can be obtained directly through clinical examination of the

patient or through the use of models. The final score for the DHC was given to the patient given

the most severe trait. The DHC has five grades, from Grade 1 (no need for treatment) to Grade 5

(extreme need for treatment) (Bellot-Arcís et al., 2012). Later on, a proposed modification of the

IOTN was created. The modification comprised reducing the IOTN DHC grades to three: DHC

1-2 (little or no need for treatment); DHC 3 (moderate need for treatment); and DHC 4-5 (great

need for treatment) (Bellot-Arcís et al., 2012). It is important to note that for the purpose of this

study, the five grades of the IOTN DHC were employed and were not modified.

The Aesthetic Component (AC) of the IOTN. As seen in Appendix K, the aesthetic

component (AC) comprises a scale showing images of ten grades of dental aesthetics. The AC

was originally created to determine each patient’s aesthetic perception of his or her own

malocclusion. To create this component, 1000 intraoral photographs of 12-year-old children

were gathered and placed in order. Six non-dental judges rated the photographs. This resulted in

the scale of ten photographs showing different levels of dental esthetic (Bellot-Arcís et al.,

2012). A modification was later proposed to improve the AC component’s reliability and

efficiency. This modification was to decrease the number of IOTN AC grades from 10 to 3: AC

1-4 (little or no need for treatment); AC 5-7 (moderate need for treatment); and AC 8-10

44
 (definite need for treatment) (Bellot-Arcís et al., 2012). It is important to note that for the

purpose of this study, the 3 IOTN AC grading system was employed and was not modified. It

should also be noted that while the AC was originally created to be used by the patient to assess

his or her self, several studies noted good results and reproducibility when the dentist carries out

the AC (Bellot-Arcís et al., 2012). This may be due to the fact that it is considered difficult for

patients to decide which of the ten photographs most resemble their own teeth. Therefore, for the

purpose of this study, the principal investigator carried out the AC.

Validity and reliability of the IOTN. The IOTN is currently used in the United

Kingdom for classifying public orthodontic care services. The validity, reliability, and

reproducibility of the IOTN have been widely proved. It is also one of the most cited indices in

the literature (Bellot-Arcís et al., 2012). An early study by Richmond et al., (1995) established

the validity and reliability of the IOTN. In this study, 74 dentists and orthodontists evaluated the

treatment need of 256 models of orthodontic patients displaying different types of malocclusion.

Furthermore, other studies such as Alkhatib et al., (2005) and Hamdan (2004) also confirmed

that the IOTN is valid and reliable and also perceptive to the needs of patients. Mandall et al.,

(2000) and Birkeland et al., (1996) also noted that the IOTN is a reliable and reproducible index.

Statistical Analysis

The analysis of data was conducted using SPSS. Statistical analyses included the following:

Descriptive Analyses. Simple descriptive statistics of demographic and clinical

characteristics, such as means, variances and frequencies, were conducted. Contingency tables

were created and methods, which describe the strength of association between binary variables

(e.g., ‘yes’ and ‘no’), were used.

45
 Inferential Analyses. Correlation and agreement tests were done to compare patients

with their caregivers, males and females, and the severity of malocclusion and bullying about

teeth. Statistical tests used included Pearson correlation coefficient, Pearson chi-square, Gamma

correlations, and Z-tests to assess the equality between sample proportions. Cohen’s kappa

coefficient test was used to asses reliability tests.

46
 Chapter 5: Results

The analyses of data focused on the dental examination and patient/caregiver

questionnaires in order to determine any relationships between malocclusion and lowered

psychosocial well-being of patients aged 11-16 years old. Results are presented in three sections:

first section including socio-demographic data of patients; second section comprises statistical

comparisons between male and female participants, as well as between patients’ and their

caregivers’ questionnaire responses; and the third section includes correlations. The presentation

of data analyses results is preceded with the reliability tests for data collection instruments.

Reliability Tests

The intra-reliability and inter-reliability coefficients verified the statistical reliability of

findings. Inter-reliability coefficient was used to assess the degree to which measurements made

by different orthodontic residents were similar; the Cohen’s kappa coefficient for this study

ranged from 0.636 to 0.739, which falls within the “substantial agreement” category (range of

0.61-0.80). Intra-reliability referred to the degree of consistency of the principal investigator’s

measurements. To identify that coefficient, the orthodontic resident (principal investigator) was

asked to perform the examination twice on 12 patients, with a three-month gap between the two

measurements. Here, the Cohen’s kappa coefficient was again used in the determination of test-

retest reliability, yielding the results of 0.571 to 1.000. Hence, the intra-reliability level was

assessed as high as well, guaranteeing both types of reliability at sufficient degrees.

Socio-Demographic Data and Frequencies

Patients and Caregivers. The initial sample size constituted 99 patients, but only 86 of

them completed the questionnaires as deemed acceptable, yielding an 86% response rate. As

47
seen in Table 2, the average age of participants was 13.57 +/- 1.57 years old; 55 (64%) were

female and 31 (36%) were male. Ethnicity of respondents was prevalently Caucasians (50%),

followed by Asians (8.6%). The composition of caregiver respondents was quite varied. Seventy-

seven were parents, seven were the patient’s guardians, and two more persons had other

relationships to the patients. The majority of caregivers (24.4%) held a college diploma as their

highest verifiable education degree, and the largest percentage (24.4%) had annual income

higher than $81,000.

Clinical Examination Data. A summary of the clinical examination findings is

presented in Table 3. The most dominant facial type among patients was the retrognathic one

(52.3%), followed by a mesognathic facial type (37.2%). The most dominant form of upper and

lower arch crowding was a mild form (1-4mm). A mild overjet (37.2%) and moderate overbite

(37.2%) were also among the most frequently diagnosed malocclusion features. Finally, the

smile line was most often assessed as average (64% of respondents).

Considering other facial and oral features of malocclusion among respondents, the most

frequent was facial asymmetry (36%), and interlabial gap (26.7%). As seen in Figure 1, midline

diastema was diagnosed in only 18.6% of the sample, while anterior and posterior crossbites

were even less frequent (7% and 9.3% of cases, respectively).

As seen in Figure 2, another aspect of examination related to the lip position of

respondents. An average lip position was more frequent for upper lips, with 61.6% having it,

counter 24.4% of retruded lip and only 14% of protruded lip positions. As for lower lips,

overwhelming 54.7% of respondents had protruded position of their lower lip and 44.2% had an

average lip position. Notably, retruded lower lip position was extremely rare, accounting for only

1.2% of cases.

48
Table 2. Socio-demographic data of patients and caregivers.

Demographic Data Possible Answers Frequency Demographic Data Possible Answers Frequency
Age 11 11 (12.8%) Caregiver’s highest Up to grade 8 4 (4.7%)
12 12 (14%) level of education Up to grade 12 10 (11.6%)
13 17 (19.8%) High school 14 (16.3%)
14 20 (23.3%) Some college 7 (8.1%)
15 15 (17.4%) College Diploma 21 (24.4%)
16 11 (12.8%) Some university 13 (15.1%)
Undergrad degree 8 (9.3%)
Graduate degree 9 (10.5%)

Ethnicity Asian 16 (8.6%) Caregiver’s income 0-25 5 (5.8%)

Black 8 (9.3%) (thousands) before 26-35 10 (11.6%)
Caucasian 43 (50%) taxes 36-45 13 (15.1%)
East Indian 6 (7%) 46-55 8 (9.3%)
First Nation 1 (1.2%) 56-65 5 (5.8%)
Hispanic 2 (2.3%) 66-75 5 (5.8%)
Metis 4 (4.7%) 76-80 4 (4.7%)
Other 6 (7%) 81+ 21 (24.4%)
I refuse to answer 14 (16.3%)

49
Table 3. Clinical examination results summary.

Clinical Exam Possible Answers Frequency Clinical Exam Possible Answers Frequency
Facial type Mesognathic 32 (37.2%) Profile type Straight 22 (25.6%)
Retrognathic 45 (52.3%) Convex 58 (67.4%)
Prognathic 9 (10.5%) Concave 6 (7%)
Upper arch Mild (1-4mm) 55 (64%) Lower arch Mild (1-4mm) 45 (52.3%)
crowding Moderate (4-7mm) 24 (27.9%) crowding Moderate (4-7mm) 33 (38.4%)
Severe (>7mm) 7 (8.1%) Severe (>7mm) 8 (9.3%)

Overjet Negative 3 (3.5%) Overbite Normal (10-20%) 17 (19.8%)

Edge-edge 4 (4.7%) Mild (20-50%) 19 (22.1%)
Normal (1-2mm) 24 (27.9%) Moderate (50-80%) 32 (37.2%)
Mild (2-4mm) 32 (37.2%) Severe-impinging 12 (14%)
Moderate (4-6mm) 14 (16.3%) (100%)
Severe (>6mm) 9 (10.5%) Open bite 6 (7%)

Smile line Average 55 (64%)

High/Gummy 10 (11.6%)
Low 21 (24.4%)

50
Figure 1. Percentage of the presence of other facial and oral features.

Posterior Crossbite (2
9.3 teeth or more)
Atenrior Crossbite (2
7
teeth or more)
Midline Diastema
Present 18.6

Interlabial Gap
26.7

Facial Asymmetry
36

Figure 2. Percentage of respondents’ lip positions.

1.2
Retruded
24.4

54.7 Lower Lip

Protruded
14 Upper Lip

44.2
Average
61.6

51
 The final physical examination of patients with malocclusion referred to diagnosing the

need for orthodontic treatment in accordance with the IOTN guidelines – both in terms of dental

and aesthetic health components. As seen in Figure 3, the majority of patients (41.9%) were

graded as borderline need for treatment according to the IOTN dental health grade followed by

severe need for treatment (22.1%), and no need for treatment (2.3%). According to the IOTN

aesthetic component grading system – Figure 4, 34.9% of patients were graded as borderline

need for treatment and one-third of patients (32.6%) were graded as definite need for treatment

or no need for treatment (32.6%).

Figure 3. Percentage of respondents’ according to IOTN Dental Health Grade.

Extreme Need for Treatment 14

Severe Need for Treatment 22.1

Borderline Need for Treatment 41.9

Mild Need for Treatment 19.8

No Need for Treatment 2.3

52
Figure 4. Percentage of respondents’ according to IOTN Aesthetic Component Grade.

Definite Need for Treatment 32.6

Borderline Need for Treatment 34.9

No Need for Treatment 32.6

Association Between IOTN and Demographic Variables. The relation between IOTN

dental health and aesthetic guidelines for treatment and patients’ ethnicity showed that 66.7% of

those requiring treatment and 36.8% of those with a severe need of treatment were both

Caucasian. The second largest ethnic group severely needing treatment was Asians – 26.3%. In

accordance with the IOTN aesthetic scale, the majority of those definitely needing treatment

were also Caucasian, which nevertheless may be explained by the dominant majority of

Caucasians constituting the overall sample of this study. In terms of gender, 45.5% of female

patients and 35.5% of male patients were in moderate need of treatment, (IOTN dental health

scale), while eight girls (14.5% of the female sample) and four boys (12.9% of the male sample)

were in extreme need of treatment. In accordance with the IOTN aesthetic guidelines, 16 girls

(29.1%) and 12 boys (38.7%) were diagnosed with a definite need for treatment.

53
 The findings of IOTN guidelines and the age of respondents showed that the group of

patients with an extreme need of treatment was most numerous among 12- and 13-year-olds,

while severe need for treatment was most common for 13- and 14-year-olds according to IOTN

dental health component. In accordance with the IOTN aesthetic component guide, the most

numerous category of patients with a definite need of treatment was 13-14 years old, while at the

same time the largest category of patients not requiring treatment also belonged to 14-year-old

patients.

Parents’/Caregivers’ Questionnaire. Caregivers were asked about their reasons for

seeking orthodontic treatment for their children. As seen in Table 4, the main reasons are either

because of self-diagnosis of their child having crooked teeth (75.6%), or according to dentist’s

recommendations (55.8%). The reason of correcting appearance is also quite frequent (38.4%);

caregivers acted as initiators of orthodontic treatment (20.9%). Notably, very few noted that their

children have difficulties speaking, eating, or problems with classmates harassing them because

of unattractive appearance (only 7% and 3.5% accordingly).

The next section focuses on caregivers’ satisfaction with their children’s appearance. As

seen in Table 5, caregivers expressed the highest degree of satisfaction with their children’s

height, eyes, nose, ears, and lips, as well as chins. The lowest level of satisfaction was expressed

regarding jaws and teeth, which is natural because of the questionnaire’s completion at the

orthodontist’s office, which supposes that patients are children with certain dental or dentofacial

problems. Z-test was implied to assess the agreement with caregivers regarding teeth satisfaction.

The result was statistically significant (p<0.05) meaning that there is more agreement with

caregivers being dissatisfied about their children’s teeth – see Appendix N.

54
Table 4. Caregivers’ reasons for seeking orthodontic treatment.

Reasons Yes No Reasons Yes No

Crooked teeth 65 (75.6%) 21 (24.4%) Classmates laugh at crooked teeth 3 (3.5%) 83 (96.5%)

To correct appearance 33 (38.4%) 53 (61.6%) Referred by the dentist 48 (55.8%) 38 (44.2%)

Difficulties speaking/eating 6 (7%) 80 (93%) Caregiver wanted the child to visit an 18 (20.9%) 68 (79.1%)
orthodontist

55
 As seen in Table 5, the results were further correlated with instances of bullying based on

a certain aspect of appearance experienced by patients. Interestingly, very few cases of bullying

were reported by caregivers regarding children’s jaws or chins; the largest number of bullying

experiences related to children’s teeth (22.1%), followed by weight (16.3%) and height (12.8%).

As seen in Table 6, specific teeth-related bullying problems were further clarified with

caregivers. Only 19 respondents who indicated the existence of certain bullying problems in

previous questions were further surveyed regarding the presence of these specific bullying

experiences. These 19 caregivers reported that their children have been victims of bullying as a

result of the appearance of their teeth, jaws, and lips. The most frequent subject of bullying

includes front teeth sticking out (16.3%) and crooked teeth (16.3%). Five caregivers stated that

their children experienced bullying regarding the shape and color of their teeth. None

experienced bullying regarding their children’s chin’s far back position or insufficient covering

of bottom teeth by top teeth.

56
Table 5. Caregivers’ satisfaction with children’s appearance and bullying experiences.

Degree of Satisfaction Bullying

Satisfaction Very Satisfied Satisfied Dissatisfied Very I don’t care Yes No

Factors Dissatisfied

Height 59 (68.6%) 23 (26.7%) 3 (3.5%) --- --- 11 (12.8%) 75 (87.2%)

Weight 54 (62.8%) 26 (30.2%) 5 (5.8%) --- --- 14 (16.3%) 72 (83.7%)

Strength 51 (59.3%) 31 (36%) 2 (2.3%) --- 1 (1.2%) 6 (7%) 80 (93%)

Hair 58 (67.4%) 25 (29.1%) 1 (1.2%) --- 1 (1.2%) 5 (5.8%) 81 (94.2%)

Eyes 61 (70.9%) 23 (26.7%) 1 (1.2%) --- 1 (1.2%) 5 (5.8%) 81 (94.2%)

Nose 62 (72.1%) 21 (24.4%) 1 (1.2%) --- 1 (1.2%) 3 (3.5%) 83 (96.5%)

Ears 65 (75.6%) 19 (22.1%) --- --- --- 4 (4.7%) 82 (95.3%)

Lips 62 (72.1%) 21 (24.4%) 2 (2.3%) --- --- 2 (2.3%) 84 (97.7%)

Jaws 53 (61.6%) 23 (26.7%) 7 (8.1%) 1 (1.2%) 1 (1.2%) 3 (3.5%) 83 (96.5%)

Chin 59 (68.6%) 22 (25.6%) 2 (2.3%) 2 (2.3%) --- 3 (3.5%) 83 (96.5%)

Teeth 8 (9.3%) 23 (26.7%) 48 (55.8%) 7 (8.1%) --- 19 (22.1%) 67 (78%)

57
Table 6. Caregivers’ responses to bullying experiences of their children as related to their teeth/jaws/lips.

Bullying Yes No Bullying Yes No

experiences experiences
Bullied about top 14 (16.3%) 5 (5.8%) Bullied about 2 (2.3%) 17 (19.8%)
front teeth sticking bottom front teeth
out sticking out

Bullied about chin 2 (2.3%) 17 (19.8%) Bullied about chin --- 19 (22.1%)
sticking out is far back

Bullied about 3 (3.5%) 16 (18.6%) Bullied about shape 5 (5.8%) 14 (16.3%)

having a gap or color of teeth
between front teeth

Bullied about being 3 (3.5%) 16 (18.6%) Bullied about top --- 19 (22.1%)
unable to close lips teeth not covering
comfortably bottom teeth

Bullied about 3 (3.5%) 16 (18.6%) Bullied about 14 (16.3%) 5 (5.8%)

showing too much crooked teeth
gum

58
 Caregivers were also referred to the psychosocial aspect of their children’s malocclusion

and dental problems. They were asked about problems that teeth created for their children, and

whether correction of occlusion could result into better academic performance, self-esteem, and

other positive psychosocial changes. As the findings in Table 7 suggest, caregivers denied that

their children have nicknames at school that were related directly to the appearance of their teeth;

15% of caregivers reported that their children had been physically bullied before. A number of

caregivers (39.5%) believed that straight teeth are associated with improved school performance

and many more (75.6%) associated improved appearance of teeth with life success, self-esteem

in public (87.2%), and personal self-confidence (86%). Z-tests were implied to assess the

agreement between the caregivers’ sample regarding straight teeth improving the children’s’

feeling in public, boosting confidence and increasing chances of success in life. Results of the Z-

tests were all statistically significant (p<0.05) demonstrating that the majority of caregivers agree

on the implication of their children having straight teeth on their psychosocial well-being. Z-test

was also implied to assess the agreement on if straight teeth will improve school performance;

the result of this test was also statistically significant (p<0.05) with the majority of the caregivers

agreeing that straight teeth has no influence on their children’s academic performance – see

Appendix N.

59
Table 7. Caregivers’ response to the psychosocial well-being associated with their children’s teeth.

Psychosocial Questions Yes No Psychosocial Questions Yes No

Has a nickname in school 0 (0%) 86 (100%) Straight teeth will improve 75 11

because of being bullied or how you feel about yourself (87.2%) (12.8%)
teased about teeth in public

Physically bullied 13 73 Straight teeth will improve 34 52

(15.1%) (84.9%) school performance (39.5%) (60.5%)

Caregivers said something 48 38 Having straight teeth will 74 (86%) 12 (14%)

about teeth (55.8%) (44.2%) boost confidence

Hide teeth when smiling 31 (365) 55 (64%) Straight teeth will increase 65 21
chances of success in life (75.6%) (24.4%)

60
 Finally, caregivers were asked to rate their children’s academic performance. As seen in

Table 8, the overall accounts of academic performance were positive.

Table 8. Caregivers’ response to the academic performance of their children at school.

Grade Academic Performance

Poor 1 (1.2%)

Fair 2 (2.3%)

Good 23 (26.7%)

Very good 39 (45.3%)

Excellent 21 (24.4%)

Patients’ Questionnaire. Patients were also asked about their needed for orthodontic

treatment. As seen in Table 9, the most frequently reported reasons were having crooked teeth

(73.3% of patients), caregivers’ initiative (58.1%), and dentist’s referral (47.7%). Among other

frequently cited reasons, patients named their wish to correct appearance (40.7% of cases).

As seen in Table 10, patients were asked about their degree of satisfaction regarding

different physical aspects and whether they were bullied about any of them. The highest degree

of satisfaction was reported by patients in relation to their eyes, hair, ears, and lips, whereas the

lowest satisfaction was noted regarding weight, strength, nose, jaws, chin, and teeth. Z-test was

statistically significant (p<0.05), demonstrating that the majority of patients agree on

dissatisfaction regarding their teeth – see Appendix N. As for bullying, 20 patients stated they

were bullied about their teeth and 19 reported being bullied about weight.

61
Table 9. Patients’ reasons for seeking orthodontic treatment.

Reasons Yes No Reasons Yes No

Crooked teeth 63 23 Classmates laugh at crooked teeth 4 (4.7%) 82

(73.3%) (26.7%) (95.3%)

To correct appearance 35 51 Referred by the dentist 41 45

(40.7%) (59.3%) (47.7%) (52.3%)

Difficulties speaking/eating 7 (8.1%) 79 Caregiver wanted the child to visit an 36 50

(91.9%) orthodontist (41.9%) (58.1%)

62
Table 10. Patients’ satisfaction with appearance and bullying experiences.

Degree of Satisfaction Bullying

Satisfaction Very Satisfied Satisfied Dissatisfied Very I don’t care Yes No

Factors Dissatisfied

Height 20 (23.3%) 49 (57%) 10 (11.6%) --- 7 (8.1%) 11 (12.8%) 75 (87.2%)

Weight 14 (16.3%) 52 (60.5%) 11 (12.8%) 5 (5.8%) 4 (4.7%) 19 (22.1%) 67 (77.9%)

Strength 14 (16.3%) 49 (57%) 15 (17.4%) 1 (1.2%) 7 (8.1%) 10 (11.6%) 76 (88.4%)

Hair 26 (30.2%) 49 (57%) 9 (10.5%) --- 2 (2.3%) 4 (4.7%) 82 (95.3%)

Eyes 31 (36%) 46 (53.5%) 5 (5.8%) --- 4 (4.7%) 3 (3.5%) 83 (96.5%)

Nose 21 (24.4%) 46 (53.5%) 8 (9.3%) 2 (2.3%) 9 (10.5%) 3 (3.5%) 83 (96.5%)

Ears 24 (27.9%) 47 (54.7%) 4 (4.7%) --- 11 (12.8%) 4 (4.7%) 82 (95.3%)

Lips 24 (27.9%) 48 (55.8%) 8 (9.3%) --- 6 (7%) 3 (3.5%) 83 (96.5%)

Jaws 20 (23.3%) 46 (53.5%) 8 (9.3%) 4 (4.7%) 8 (9.3%) 2 (2.3%) 84 (97.7%)

Chin 22 (25.6%) 47 (54.7%) 6 (7%) 2 (2.3%) 9 (10.5%) 4 (4.7%) 82 (95.3%)

Teeth 4 (4.7%) 14 (16.3%) 45 (52.3%) 19 (22.1%) 4 (4.7%) 20 (23.3%) 66 (76.4%)

63
 Table 11 displays questions related to specific bullying experiences patients had in

relation to the state of their teeth, jaws, and lips. The only aspect of bullying that was not

reported by any child was bullying about bottom teeth sticking out. All other bullying types such

as that about top teeth sticking out, having crooked teeth, showing too much gum when smiling,

etc. were all reported by several respondents. The most frequent bullying types were having

crooked teeth – 18.6% of patients, and shape and color of teeth – 10.5%. Front teeth sticking out

was also a common form of bullying for 9.3% of the sample.

Table 12 refers to various aspects of well-being related to patients’ appearance and teeth.

More than a half of the sample indicated that they heard some unpleasant comments about their

teeth from their parents/caregivers, and half of the respondents reported hiding teeth when

smiling. Interestingly. only three respondents (which constitutes 3.5% of the sample) claimed

that they had a nickname at school due to their dental problems. Z-test was statistically

significant (p<0.05) meaning that the majority of the patients did not relate academic

performance to malocclusion. The overwhelming majority of patients associated straight teeth

with improved public image, school performance, stronger self-confidence, and success in life.

Z-tests were statistically significant (p<0.05) regarding straight teeth improving patient’s feeling

about themselves in public, and boosting their confidence – see Appendix N.

64
Table 11. Patients’ satisfaction with appearance and bullying experiences.

Bullying Yes No Bullying Yes No

Experiences Experiences
Bullied about top 8 (9.3%) 12 (14%) Bullied about --- 20 (23.3%%)
front teeth sticking bottom front teeth
out sticking out

Bullied about chin 3 (3.5%) 17 (19.8%) Bullied about chin 2 (2.3%) 18 (20.9%)
sticking out is far back

Bullied about 6 (7%) 14 (16.3%) Bullied about 9 (10.5%) 11 (12.8%)

having a gap shape or color of
between front teeth teeth

Bullied about 2 (2.3%) 18 (21%) Bullied about top 4 (4.7%) 16 (18.6%)

being unable to teeth not covering
close lips bottom teeth
comfortably

Bullied about 1 (1.2%) 19 (22.1%) Bullied about 16 (18.6%) 4 (4.7%)

showing too much crooked teeth
gum

65
Table 12. Patients’ response to the psychosocial well-being associated with their teeth

Psychosocial Questions Yes No Psychosocial Questions Yes No

Has a nickname in school because of 3 (3.5%) 83 (96.5%) Straight teeth will improve how 56 (65.1%) 29 (33.7%)
being bullied or teased about teeth you feel about yourself in public

Physically bullied 13 (15.1%) 73 (84.9%) Straight teeth will improve school 27 (31.4%) 59 (68.6%)
performance

Caregivers said something about teeth 44 (51.2%) 42 (48.8%) Having straight teeth will boost 66 (76.7%) 20 (23.3%)
confidence

Hide teeth when smiling 43 (50%) 43 (50%) Straight teeth will increase chances 39 (45.3%) 47 (54.7%)
of success in life

66
Comparative Analysis

The present section compares research findings on the basis of three comparative

dimensions – patient versus caregiver opinions, female versus male gender of participants, and

patients’ teeth bullying reports versus IOTN (DHC and AC).3

Patient Versus Caregiver - Comparison. As seen in Table 13, the first comparative analysis

was conducted on the basis of satisfaction degrees of children and caregivers with various

aspects of children’s appearance, and the extent to which the opinions of caregivers and patients

coincide. The highest level of satisfaction is recorded for children’s hair, eyes, ears, and lips,

while the lowest level of shared satisfaction (7%) is for the children’s teeth. Moreover, counter to

very low percentages of dissatisfaction of both children and caregivers with various aspects of

appearance (3.5% maximum), the shared dissatisfaction for the condition of children’s teeth

appeared 46.6%.

The next comparison focused on the frequency of reported bullying by children versus

their caregivers. As seen in Table 14, the degree of caregivers’ and children’s responses

regarding bullying was quite high, with the most pronounced discrepancies in questions

regarding weight, height, strength, and teeth – the most frequent aspects of appearance facing

bullying. Unfortunately, 11.6% of children reported bullying about which their caregivers did not

know, while interestingly, 10.5% of caregivers reported their children’s bullying experiences that

children, in their turn, denied.

3
Note: very dissatisfied and dissatisfied were combined in one group as well as very satisfied
and satisfied

67
Table 13. Patient/caregiver satisfaction comparison.

Satisfaction Patient - Patient – Patient – Patient –

Factors Satisfied Dissatisfied Satisfied Dissatisfied
Don’t Care Missing
Caregiver – Caregiver – Caregiver – Caregiver –
Satisfied Satisfied Dissatisfied Dissatisfied
Height 67 (77.8%) 9(10.5%) 1 (1.2%) 1 (1.2%) 7 (8.2%) 1 (1.2%)

Weight 63 (73.2%) 15 (17.5%) 2 (2.4%) 1 (1.2%) 4 (4.7%) 1 (1.2%)

Strength 60 (69.8%) 15 (17.5%) 1 (1.2%) 1 (1.2%) 8 (9.4%) 1 (1.2%)

Hair 72 (83.7%) 9 (10.4%) 1 (1.2%) --- 3 (3.5%) 1 (1.2%)

Eyes 75 (87.3%) 5 (5.9%) 1 (1.2%) --- 4 (4.7%) 1 (1.2%)

Nose 65 (75.6%) 10 (11.7%) 1 (1.2%) --- 9 (10.5%) 1 (1.2%)

Ears 69 (80.2%) 4 (4.7%) --- --- 11 (12.8%) 2 (2.3%)

Lips 70 (81.5%) 7 (8.1%) 2 (2.3%) --- 6 (7 %) 1 (1.2%)

Jaws 60 (69.7%) 8 (9.4%) 5 (5.9%) 3 (3.5%) 9 (10.5%) 1 (1.2%)

Chin 65 (75.6%) 7 (8.1%) 3 (3.5%) 1 (1.2%) 9 (10.5%) 1 (1.2%)

Teeth 6 (7%) 24 (27.9%) 12 (14%) 40 (46.6%) 4 (4.7%) ---

68
Table 14. Patient/caregiver bullying reports’ comparison.

Bullying Experiences Patient – Yes Patient - No Patient - Yes Patient – No

Caregiver - Yes Caregiver – Yes Caregiver – No Caregiver – No

Bullied about height 6 (7%) 5 (5.8%) 5 (5.8%) 70 (81.4%)

Bullied about weight 11 (12.8%) 3 (3.5%) 8 (9.3%) 64 (74.4%)

Bullied about strength 3 (3.5%) 3 (3.5%) 7 (8.1%) 73 (84.9%)

Bullied about hair 3 (3.5%) 2 (2.3%) 1 (1.2%) 80 (93%)

Bullied about eyes 1 (1.2%) 4 (4.7%) 2 (2.3%) 79 (91.9%)

Bullied about nose 1 (1.2%) 2 (2.3%) 2 (2.3%) 81 (94.2%)

Bullied about ears 2 (2.3%) 2 (2.3%) 2 (2.3%) 80 (93%)

Bullied about lips --- 2 (2.3%) 3 (3.5%) 81 (94.2%)

Bullied about jaws --- 3 (3.5%) 2 (2.3%) 81 (94.2%)

Bullied about chin --- 3 (3.5%) 4 (4.7%) 79 (91.9%)

Bullied about teeth 10 (11.6%) 9 (10.5%) 10 (11.6%) 57 (66.3%)

69
 Next, comparisons of patients and their caregivers regarding specific bullying

experiences they had regarding children’s teeth, jaws, or chins were conducted. As seen in Table

15, answers of only ten pairs were compared given the provision of affirmative answers to

questions about overall bullying. What stands out is that three patients denied being bullied

because of their front teeth sticking out, while their caregivers considered that their children were

bullied for that reason. At the same time, seven children reported being bullied because of their

crooked teeth, which was supported by their caregivers.

As seen in Table 16, comparisons of patients’ and their caregivers’ responses to

psychosocial questions related to their psychological discomfort, problems with academic

performance, and psychosocial gains associated with improved appearance of their teeth were

also tested. Only 3.5% of the sample (3 respondents) reported having a nickname at school,

which is a small percentage. 22.1% of children and caregivers reported that children try to hide

teeth when smiling, while 27.9% more children confided to doing that while their caregivers

either denied it, or did not notice that. More than 65% of children and caregivers agreed that

straight teeth are likely to boost a child’s confidence and 34.9% - it would increase chances of

success in life. Notably, a weaker association was found between straight teeth and school

performance, with only 17.4% children and caregivers agreeing on that point.

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Table 15. Patient/caregiver reports of specific bullying experiences.

Bullying Experiences Patient - Yes Patient - No Patient - Yes Patient – No

Caregiver – Yes Caregiver – Yes Caregiver – No Caregiver – No

Bullied about top teeth sticking out 3 (30%) 3 (30%) 1 (10%) 3 (30%)

Bullied about bottom teeth sticking out --- 1 (10%) --- 9 (90%)

Bullied about chin sticking out 1 (10%) 1 (10%) 1 (10%) 7 (70%)

Bullied about chin being far back --- --- --- 10 (100%)

Bullied about crooked teeth 7 (70%) 2 (10%) --- 1 (10%)

Bullied about shape and color of teeth 3 (30%) 2 (10%) 1 (10%) 5 (50%)

Bullied about having a gap between front teeth 1 (10%) 1 (10%) 1 (10%) 7 (70%)

Bullied about top teeth not covering bottom teeth --- --- 2 (20%) 8 (80%)

Bullied about showing too much gum when --- 1 (10%) --- 9 (90%)
smiling

Bullied about being unable to close lips 1 (10%) 1 (10%) 1 (10%) 7 (70%)
comfortably

71
Table 16. Patient/caregiver answers to psychosocial questions.

Psychosocial Questions Patient - Yes Patient - No Patient - Yes Patient – No Missing

Caregiver – Yes Caregiver – Yes Caregiver – No Caregiver – No

Have a nickname at school being of --- --- 3 (3.5%) 83 (96.5%) ---

being bullied or teased about teeth

Physically bullied 8 (9.3%) 5 (5.8%) 5 (5.8%) 68 (79.1%) ---

Parents ever commented about 26 (30.2%) 22 (25.6%) 18 (20.9%) 20 (23.3%) ---

appearance of teeth

Hide teeth when smiling 19 (22.1%) 12 (14%) 24 (27.9%) 31 (36%) ---

Having straight teeth will boost 56 (65.1%) 18 (20.9%) 10 (11.6%) 2 (2.3%) ---
confidence

Having straight teeth will improve how 49 (57%) 25 (29.1%) 7 (8.1%) 4 (4.7%) 1 (1.2%)
you feel about yourself in public

Straight teeth will improve school 15 (17.4%) 19 (22.1%) 12 (14%) 40 (46.5%) ---
performance

Straight teeth will increase chances of 30 (34.9%) 35 (40.7%) 9 (10.5%) 12 (14%) ---
success in life

72
 The next portion of comparison was undertaken between patients’ and caregivers’

responses regarding whether the respondents ever bullied their classmates about teeth. Notably,

despite having dental problems and suffering a variety of psychosocial problems about it, 11.7%

of respondents denied bullying other people, while their caregivers stated otherwise – see Table

17.

Table 17. Patient/caregiver answers to bullying classmates about teeth.

Question Patient - Yes Patient - No Patient - Yes Patient – No

Caregiver – Caregiver – Caregiver – Caregiver –
Yes Yes No No
Have you ever bullied your 1 (1.2%) 10 (11.7%) 1 (1.2%) 74 (84.9%)

classmates about teeth?

Only one respondent confided to bully another classmate about teeth, which was not

known to his/her caregiver, and one child reported bullying another person, which was known by

his/her caregiver. Ten caregivers stated that their children bullied their classmates about their

teeth while their children denied. The rest of the sample agreed on non-involvement in bullying –

see Table 17.

The final portion of comparison was to relate the association between caregivers’ and

patients’ satisfaction index related to body image conducted with the help of Principal

Component Analysis – see Appendix M. The findings showed that both children and their

caregivers tend to give much importance to each of the named aspects of appearance in the

formation of self-image and self-esteem. Importantly, for children, their perceptions about lips

(0.842), chin (0.793) and jaws (0.771) were among the most important aspects contributing to

73
their satisfaction with appearance, while for caregivers, these aspects were also among the most

important contributors to the child’s self-image. Satisfaction index for teeth was the lowest –

0.374 for children, and 0.086 for caregivers – which suggests a considerably low satisfaction

level regarding teeth in children’s appearance, according to both caregivers’ and patients’

assessments – see Appendix M.

Male versus Female - Comparison. The comparison of patient’s answers based on the male

versus female criterion was also conducted in accordance with the same structure, starting with

the extent of boys’ and girls’ satisfaction with certain aspects of their appearance. Findings from

Table 18 suggest that 80% of females (44 persons, 51.5% of the total sample, and 80% of the

female sample), in contrast to 64.52% of males (20 persons, 23.3% of the total sample, and

64.52% of the male sample), were dissatisfied with the appearance of their teeth - see in Table

18. Z-test showed statistically significant results indicating that females are much more

preoccupied with their appearance and are much more skeptical about their physical

attractiveness – see Appendix N.

74
Table 18. Female/male satisfaction factors comparison.

Satisfied Dissatisfied Don’t Care

Satisfaction Female Male Female Male

Factors

Height 45 (52.4%) 24 (27.9%) 5 (5.8%) 5 (5.8%) 7 (8.1%)

Weight 39 (45.4%) 27 (31.4%) 13 (15.2%) 3 (3.5%) 4 (4.7%)

Strength 39 (45.4%) 24 (27.9%) 11 (12.8%) 5 (5.9%) 7 (8.1%)

Hair 47 (54.6%) 28 (32.6%) 6 (7%) 3 (3.5%) 2 (2.3%)

Eyes 48 (55.7%) 29 (33.7%) 4 (4.7%) 1 (1.2%) 4 (4.7%)

Nose 41 (47.7%) 26 (30.3%) 7 (8.1%) 3 (3.5%) 9 (10.5%)

Ears 43 (50%) 28 (32.6%) 3 (3.5%) 1 (1.2%) 11 (12.8%)

Lips 46 (53.5%) 26 (30.2%) 4 (4.7%) 4 (4.7%) 6 (7%)

Jaws 39 (42.3%) 27 (31.4%) 9 (10.5%) 3 (3.5%) 8 (9.3%)

Chin 42 (48.8%) 27 (31.4%) 5 (5.8%) 3 (3.5%) 9 (10.5%)

Teeth 8 (9.3%) 10 (11.6%) 44 (51.2%) 20 (23.3%) 4 (4.7%)

75
 Next, comparison of the degree of teeth crowding was conducted to see how subjective

males and females were regarding their teeth. The findings seen in Table 19 suggest that males

seem to treat the crowding of their teeth less than females do; none of the male respondents

characterized his crowding as severe, in contrast to two female respondents. Moreover, when

respondents were asked to compare the appearance of their teeth to their face, 69% of females

stated that their teeth were less attractive than their face, while 58% of males stated the same.

Table 19. Female/male assessment of teeth crowding.

Gender Minimal + ++ +++ Severe Missing

crowding Crowding

Female 7 (8.1%) 11 23 10 2 (2.3%) 2 (2.3%)

(12.8%) (26.7%) (11.6%)

Male 4 (4.7%) 3 (3.5%) 15 8 (9.3%) ---- 1 (1.2%)

(17.4%)

As seen in Table 20, bullying experiences were also compared. Males are less frequently

bullied on a variety of appearance traits in comparison to females whose bullying on the subject

of weight, strength, eyes, nose, ears, etc. is more common. Nevertheless, bullying on the subject

of teeth is quite widespread both for male and female respondents, with 14 females and six male

patients reporting being bullied about their teeth.

76
Table 20. Female/male bullying reports’ comparison.

Female Male

Bullying Factors Yes No Yes No

Bullied about height 5 (5.8%) 50 (58.1%) 6 (7%) 25 (29.1%)

Bullied about weight 14 (16.3%) 41 (47.7%) 5 (5.8%) 26 (30.2%)

Bullied about strength 6 (7%) 49 (57%) 4 (4.7%) 27 (31.4%)

Bullied about hair 2 (2.3%) 53 (61.6%) 2 (2.3%) 29 (33.7%)

Bullied about eyes 3 (3.5%) 52 (60.5%) ---- 31 (36%)

Bullied about nose 2 (2.3%) 53 (61.6%) 1 (1.2%) 30 (34.9%)

Bullied about ears 4 (4.7%) 51 (59.3%) --- 31 (36%)

Bullied about lips 3 (3.5%) 52 (60.5%) --- 31 (36%)

Bullied about jaws 2 (2.3%) 53 (61.6%) --- 31 (36%)

Bullied about chin 4 (4.7%) 51 (59.3%) --- 31 (36%)

Bullied about teeth 14 (16.3%) 41 (47.7%) 6 (7%) 25 (29.1%)

77
 Twenty patients who reported being bullied were further asked specific questions about

bullying experiences specifically related to teeth, jaws, or chins. Their responses reveal that 83%

of males and 79% of females from the targeted sample were bullied because of their crooked

teeth. Though other types of bullying were less frequent, they were still present, more for female

respondents, which is also important to note when assessing the psychosocial impact of

malocclusion of patient’s well-being – see Table 21.

As seen in Table 22, a comparison between psychosocial well-being and association of

psychosocial problems with crooked teeth has been conducted. Findings indicate that 82%

female and 68% male respondents associated having straight teeth with better self-confidence,

while 69% of female respondents and 58% male respondents stated that straight teeth would

assist them in feeling better in public. Z-tests were statistically significant (p<0.05) with regards

to females agreeing more on straight teeth providing them with improvement on how they feel

about themselves in public and that it will boost their confidence. No statistical significance

(p>0.05) were found with regards straight teeth having and effect on increasing chances of

success in life between male and female patients – see Appendix N.

78
Table 21. Female/male reports of specific bullying experiences.

Bullying Experiences Female Male

Yes No Yes No

Bullied about top teeth sticking out

5 (25%) 9 (45%) 3 (15%) 3 (15%)
Bullied about bottom teeth sticking out
--- 14 (70%) --- 6 (30%)
Bullied about chin sticking out
3 (153%) 11 (55%) --- 6 (30%)
Bullied about chin being far back
2 (10%) 12 (60%) --- 6 (30%)
Bullied about crooked teeth
11 (55%) 3 (15%) 5 (25%) 1 (5%)
Bullied about shape and color of teeth
6 (30%) 8 (40%) 3 (15%) 3 (15%)
Bullied about having a gap between front teeth
6 (30%) 8 (40%) --- 6 (30%)
Bullied about top teeth not covering bottom
teeth 4 (20%) 10 (50%) 1 (5%) 5 (25%)

Bullied about showing too much gum when

smiling 1 (5%) 13 (65%) --- 6 (30%)

Bullied about being unable to close lips

comfortably 1 (5%) 13 (65%) 1 (5%) 5 (25%)

79
Table 22. Female/male answers to psychosocial questions.

Psychosocial Questions Female Male

Yes No Yes No

Have a nickname at school being of being bullied or

teased about teeth 1 (1.2%) 54 (62.8%) 2 (2.3%) 29 (33.7%)

Physically bullied
5 (5.8%) 50 (58.1%) 8 (9.3%) 23 (26.7%)
Parents ever commented about appearance of teeth
28 (32.6%) 27 (31.4%) 16 (18.6%) 15 (17.4%)
Hide teeth when smiling
28 (32.6%) 27 (31.4%) 15 (17.4%) 16 (18.6%)
Having straight teeth will boost confidence
45 (52.3%) 10 (11.6%) 21 (24.4%) 10 (11.6%)
Having straight teeth will improve how you feel
about yourself in public 38 (44.2%) 17 (19.8%) 18 (20.9%) 12 (14%)

Straight teeth will improve school performance

18 (20.9%) 37 (43%) 9 (10.5%) 22 (25.6%)
Straight teeth will increase chances of success in
life 23 (26.7%) 32 (37.2%) 16 (18.6%) 15 (17.4%)

80
 As seen in Table 23, the overwhelming majority of respondents never bully their

classmates about teeth. Nevertheless, one male and one female respondent still confided to

involving in classmates’ bullying on the subject of crooked teeth.

Table 23. Female/male answers to bullying classmates about teeth.

Question Female - Yes Female - No Male - Yes Male - No

Have you ever bullied your

1 (1.2%) 54 (62.8%) 1 (1.2%) 30 (34.9%)
classmates about teeth?

Patients’’ Teeth Bullying Reports versus IOTN (DHC and AC) - Comparison. Another

essential aspect of interest in comparative analysis was the relationship between an objective

IOTN assessment of the need of orthodontic treatment and reports about patient’s bullying

experiences. Interestingly, out of 20 patients bullied about teeth, 40% had a moderate need for

treatment, 25% were diagnosed with severe need for treatment, 10% had an extreme need for

treatment, and only 5% did not need treatment at all – in accordance with the IOTN dental health

scale – Figure 5. As for the IOTN aesthetic scale, out of the sample of 20 patients, six patients

who reported being bullied about teeth appeared not to need treatment (30%). 35% of the bullied

patients were diagnosed with either a definite need or a borderline need for treatment for

aesthetic purposes – Figure 6.

81
Figure 5. IOTN dental health component in relation to respondents’ answering “yes” to teeth
bullying.

Extreme need for treatment 2

Severe need for treatment 5

Moderate/borderline need for treatment 8

Mild/little need for treatment 4

No need for treatment 1

Figure 6. IOTN aesthetic component in relation to respondents’ answering “yes” to teeth

bullying.

Definite need for treatment 7

Borderline need for treatment 7

No need for treatment 6

82
Correlation Analysis

Correlation analysis was further conducted to determine the relationships between

various aspects of clinical conditions and psychosocial experiences of patients and their

caregivers. Table 24 provides a summary of the correlational findings. A full list of correlation

tables is found in Appendix L. First, a statistically significant correlation was found between

caregivers’ satisfaction with the child’s teeth and the IOTN aesthetic guidelines. The higher the

dissatisfaction of caregivers with the child’s teeth, the higher is the actual need for treatment.

Table 24. Results of all correlations.

Correlated Variables Test Used Results

IOTN dental health grade + Pearson Correlation Significant correlation
IOTN aesthetic component (P<0.0.5).
grade.

Child satisfaction index + Pearson Correlation Significant correlation

caregiver Satisfaction Index. (P<0.0.5).

Child’s satisfaction with Pearson Correlation No significant correlation.

teeth + IOTN dental health
grade.
Child’s satisfaction with Pearson Correlation No significant correlation.
teeth + IOTN aesthetic
component grade
Caregiver’s Satisfaction with Pearson Correlation No significant correlation.
teeth + IOTN dental health
grade.
Caregiver’s satisfaction with Pearson Correlation Significant correlation
teeth + IOTN aesthetic (P<0.0.5).
component grade.
Caregiver’s satisfaction with Spearman's rho No significant correlation.
teeth/chin/jaws/lips +
income
Caregivers’ motivation to Pearson Correlation No significant correlation.
seek orthodontic treatment +
income.
Caregiver’s motivation to Gamma Significant correlation

83
seek orthodontic treatment+ (P<0.05) between caregivers
child’s motivation to seek and their children in regards
orthodontic treatment. to their motivation to seek
orthodontic treatment with
respect to crooked teeth and
referral by the dentist. No
significant correlation with
respect to other motivation
factors.
Patient/caregiver satisfaction Gamma No significant correlations
comparison. between patients and
caregivers with respect to
satisfaction factors.
Patient/caregiver bullying Gamma Significant correlation
reports’ comparison. (P<0.0.5) with respect to
height, weight, and teeth. No
significant correlation with
respect to other physical
factors.
Male/female assessment of Pearson’s chi-square No significant correlation.
teeth crowding.
Gender + being bullied Pearson Correlation No significant correlation.
about teeth.
Male/female satisfaction Pearson’s chi-square No significant correlations
factors comparison. between males and females
with respect to satisfaction
factors except for teeth
(P<0.05).
Male/female bullying Pearson’s chi-square No significant correlation.
reports’ comparison.
Severity of malocclusion Pearson Correlation No significant correlation.
(IOTN dental health grade)
+ being bullied about teeth.
Severity of malocclusion Pearson Correlation No significant correlation.
(IOTN aesthetic component
grade) + being bullied about.
teeth

Second, a significant correlation was identified between the caregiver and child’s

motivation to seek orthodontic treatment. Third, a significant correlation was identified between

caregivers’ and child’s satisfaction with body image. Finally, the researcher found no correlation

84
between the respondents’ gender bullying factor, which shows that gender is an insignificant

factor in terms of having bullying experiences.

85
 Chapter 6: Discussion

The first section of this chapter reviews the findings according to each primary

hypothesis, and relates them to reviewed research. The second section presents implications of

the obtained findings, followed by an overview of study limitations and weaknesses. The chapter

concludes with recommendations for further research that address this study’s limitations and

expand the body of existing knowledge on the subject of relationship between malocclusion and

psychosocial well-being of children and adolescents.

Discussion of Obtained Findings

The present study was based on the initial premise that malocclusion affects a person’s

self-esteem and body image negatively (DeBiase & Sandler, 2001; Pithon et al., 2014), which

causes a variety of psychosocial problems and degrades the person’s well-being (Helm et al.,

1985; Sardenber et al., 2013). To verify that relationship, the researcher formulated five

hypotheses:

1. A relationship exists between malocclusion and psychosocial well-being factors.

2. A relationship exists between malocclusion and bullying - when the severity of

malocclusion increases, the more bullying experiences are anticipated and

expected.

3. Children with severe malocclusion are more likely to have academic problems at

school than those with mild malocclusion.

4. A child’s motivation to seek orthodontic treatment is associated with the

caregiver’s motivation to seek treatment.

5. Psychosocial impact of malocclusion is higher among girls than boys.

86
 Hypothesis 1: A relationship exists between malocclusion and psychosocial well-

being factors. Malocclusion has been strongly associated with various aspects of psychosocial

well-being of respondents, which the findings of this study verify. The psychosocial well-being

of a child with dental problems is negatively affected in a variety of ways: experiences of

bullying at school, caregivers’ negative remarks, as well as personal low self-evaluation and

complexes. This study showed that respondents often associate their malocclusion with serious

flows in their appearance and many of them find support for their psychological fears in the

negative attitude of people surrounding them. The study’s findings indicate that most of the

surveyed patients are dissatisfied with the appearance of their teeth. The majority of both

caregivers and patients agree on dissatisfaction of teeth. Patients reported being bullied because

of various dental problems such as crooked teeth, shape and color of their teeth, teeth sticking

out, etc. Very few caregivers and patients indicated that classmates laugh at the child because of

problems with teeth, while a third of parents and a little more than a third of the patients came to

the orthodontist to correct the patient’s appearance. Moreover, the majority of patients and

caregivers agree that straight teeth do improve psychosocial factors. These findings are

consistent with claims of Alley and Hildebrandt (1988), Berscheid and Gangestad (1982), Peck

and Peck (1993), and a more recent study of Amin and Hassan (2010) about facial appearance

being a very influential component of the overall self-image determining self-esteem. They also

support the findings of Baylon (2014) about children’s close psychological association of self-

perception with dental appearance.

It is evident that malocclusion and other dental problems are related to psychosocial well-

being and self-esteem; few respondents (patients and caregivers) requested orthodontic treatment

because of objective problems with eating and/or speaking, while one third of the surveyed

87
patients were diagnosed with an objective need for treatment according to the IOTN dental

health guidelines. Counter to the IOTN aesthetic guidelines for treatment stating that one third of

the sample do not need treatment at all, the overwhelming majority of the study sample’s

caregivers and patients claimed that the teeth of the patients were crooked and require treatment.

Here, it is evident that perception is more powerful than objective medical criteria. These

findings are consistent with Helm et al., (1985) and Sardenberg et al., (2013) about a strong

association of malocclusion with a negative body image that may be subjectively worse than the

real state of affairs is.

Moreover, a notable effect of malocclusion on respondents’ psychosocial well-being may

be seen in their association of straight teeth with better self-confidence in public, life success,

and overall attractiveness of their appearance. Moreover, the satisfaction index for teeth was the

lowest for both patients and their caregivers, which suggests a considerably low satisfaction level

regarding teeth in patient’s appearance, according to both caregivers’ and patients’ assessments.

As for public presence and life success, most patients and their caregivers agreed with the

statement that straight teeth will increase the patient’s confidence, that it will improve the

patient’s self-perception in public, and less so, that it will increase chances for success in life.

Such observations support previously made claims about public self-confidence and association

of dental health with life success of Badran (2010), Kang and Kang (2014), and Johal et al.,

(2014).

Hypothesis 2: A relationship exists between malocclusion and bullying - when the

severity of malocclusion increases, the more bullying experiences are anticipated and

expected. A vital aspect of poor psychosocial well-being is a concept of bullying; patients with

problems with appearance are likely to experience bullying, which also contributes to their

88
psychosocial problems, shyness, and poor self-esteem. Based on this study, having a

malocclusion was identified as being related to bullying, with more than one fifth of patients

confessing to being bullied about dental appearance followed by bullied about weight. Out of the

overall sample, some patients reported being physically bullied, which is obviously ruinous for

the child’s self-image and self-esteem.

In addition, it is essential to note more than half of the bullied sample either needed no

treatment, or little treatment or moderate/borderline treatment according to the IOTN dental

health guidelines. These milder forms of malocclusion are still powerful enough to attract

bullying regarding patients’ teeth which may be due to having less than ideal physical (dental)

characteristics. In terms of the IOTN aesthetic guidelines, one third of the bullied sample did not

need treatment and just more than third of the sample needed definite treatment. The present

evidence suggests that not only children with a severe need for treatment, visible, and easily

detectible dental problems suffer from bullying, but also children who have milder forms of

malocclusion and even those who do not meet the objective treatment need criteria. Those

findings were further correlated and showed no statistical significance between the severity of

malocclusion according to IOTN dental and aesthetic guidelines and patients experiencing

bullying related to teeth. Such findings indicate the need for considering even mild forms of

malocclusion as possible sources of negative psychosocial experiences and problems for

children, which increases the need to consider orthodontic treatment for a child to improve their

quality of his/her school life and peer interactions.

The present research findings support or align with prior findings of Shaw et al., (1980)

about teeth-related bullying being much more abusive than other forms of bullying about height,

weight, hair, and other elements of appearance. Al-Bitar et al., (2013) also found out that

89
bullying about teeth is a quite common, and even a dominant, form of bullying at school because

of the visible imperfections of children’s facial appearance. Such bullying experiences intensify

anxiety, depression, and poor self-image among children, causing lower self-esteem, loneliness,

and insecurity feelings further deteriorating the psychosocial well-being and emotional health of

children (DiBiase & Sandler, 2001; Hawker & Boulton, 2000).

Hypothesis 3: Children with severe malocclusion are more likely to have academic

problems at school than those with mild malocclusion. The majority of patients were ranked

as performing excellently or very good at school according to their caregiver’s evaluation. Thus,

children with malocclusion may not experience a negative impact of their unattractive oral

appearance, low self-esteem, and bullying experiences on their academic progress. Due to the

insufficient sample size of patients experiencing serious problems with academic performance, it

is not possible to validate the presence of a correlation between severity of malocclusion and

academic performances. On the other hand, Z-test negates this hypothesis and showed that there

is no relation between malocclusion and academic performance. The majority of patients’ and

caregivers’ perceptions of malocclusion had no effect on academic performance. Therefore, the

findings do not validate a hypothesis about academic performance’s dependence on having

straight teeth. Moreover, these findings do not support prior research indicating that attractive

appearance and straight teeth help individuals to succeed. However, one should keep in mind that

all those issues are also of psychological nature, and there is no direct biological association

between straight teeth and better academic performance. On the other hand, studies of

Kumpulainen et al. (1998) and Olweus (1978) suggested that students with malocclusion may

have under-achievements in academic performance because of their psychosocial problems

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distracting them from studies and reducing their self-esteem, overall well-being, and causing

depression and isolation.

Moreover, it is possible to identify the potential impact of straight teeth on school

performance that caregivers and patients see. Very few of the caregivers and patients agreed that

straight teeth may improve school performance. Moreover, few children considered straight teeth

able to help them improve their school performance, while their caregivers responded otherwise.

Almost half of the total respondents (caregivers and their children), denied any association

between straight teeth and improved school performance, which suggests that self-esteem and

psychological aspects such as self-confidence, positive self-image, confidence in social

interactions, etc. are much more closely associated with straight teeth, while their connection

with academic success is recognized by much fewer persons. Thus, a considerable portion of the

sample associating straight teeth with academic success are compliant with the suggestions of

Landy and Sigall (1977), Langlois et al. (2000), and Pithon et al. (2014). These studies proved

that people associate physical attractiveness, including straight teeth, with higher levels of

intelligence and better aptitude to task completion, which would infer improved school

performance.

Hypothesis 4: A child’s motivation to seek orthodontic treatment is associated with the

caregiver’s motivation to seek treatment. Alignment of caregivers’ motivation to seek

orthodontic treatment for their children was validated with respect to crooked teeth and referral

by the dentist. This was also supported with numerous data about child’s self-reported dental

health problems and recognition of those problems by caregivers. Having crooked teeth was

recognized by most of the patients and their caregivers, which suggests that caregivers are quite

realistic, and even critical, about their children’s dental appearance. Dentist referral motivated

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over half of the caregivers and almost half of the patients to seek treatment. Although fewer

caregivers viewed themselves as being the motivators of visiting an orthodontist, more of the

patients stated that they came to seek orthodontic treatment upon their caregivers’ wish. These

findings support prior research of Wedrychowska-Szulc and Syrynska (2010) and Samsonyanova

and Broukal (2014) who found that caregivers’ wish for their children to look attractive as

motivating them to seek orthodontic treatment, and determining their children’s need for

treatment on their own.

Interestingly, caregivers often become negative contributors to children’s poor

psychosocial well-being in case they have serious orthodontic problems. In many cases,

caregivers appear to comment on their children’s appearance negatively, and they often become

the primary initiators of visits to a dentist for correction of children’s appearance. In this study,

more than half of patients and caregivers reported commenting about their children’s crooked

teeth, which may exert a strong psychological pressure on children. A significant correlation

between the patients’ satisfaction with their body image and their caregivers’ satisfaction

validates this claim. Children who feel the discontent of caregivers about their teeth may

experience much worse levels of dissatisfaction with their self-image, which leads to aggravation

of their psychosocial problems. Is it possible that caregivers’ negative comments about their

children’s dental appearance may predispose the child to bullying experiences?

These observations substantiate the claims of Abreu et al. (2014), Hassan et al. (2014),

and Piovesan et al. (2011) about a frequent disagreement of patients and their caregivers about

the objective need for treatment. Spalj et al. (2010) associated such a disagreement with parents’

subjective perceptions of their responsibility to provide their children with the best possible care,

while this study did not find any plausible evidence for such claims. In some cases, caregivers’

92
assessment of children’s dental health was more critical than children’s self-assessment, but

these findings are insufficient to make conclusions about caregivers’ subjectively higher

assessment of treatment need.

Despite the increasing body of literature regarding the connection of caregivers’ socio-

economic status and their subjective perceptions of children’s need for dental treatment, the

present study did not support these aspects. Hence, the claims of Piovesan et al. (2011) in this

regard were not supported.

Hypothesis 5: Psychosocial impact of malocclusion is higher among girls than boys.

Preoccupation with physical appearance and gravity of psychosocial problems associated with

malocclusion was found to be higher for girls, which validates the present hypothesis. The

majority of female patients agreed that straight teeth would improve how they would feel in

public and would boost their confidence. The most general assessment showed that female

sample in contrast to male sample were more dissatisfied with the condition and appearance of

their teeth. Moreover, female respondents tended to evaluate their teeth crowding and teeth

problems more critically; more females characterized their crowding as severe. These findings

support the claims of Jung (2010) who also observed females to be much more preoccupied with

their malocclusion and other dental problems.

In the present study, no significant correlation was found between bullying, self-esteem

and gender which was supported by the claims of Gavric et al., (2015). Females turned out to be

bullied because of poor dental appearance much more frequently in this study. Females also

reported specific bullying experiences related to teeth more frequently with regards to teeth

sticking out, chin sticking out or being too far back, shape and color of teeth, showing too much

gum and having crooked teeth as well. Hence, it is true that females were bullied much more

93
frequently in this study but such values were insufficient to conclude that females are more

bullied regarding their teeth when compared to males.

Implications of Findings

The present study indicated that children experience a variety of psychosocial problems

associated with unappealing appearance because of dental problems. Very few respondents from

the surveyed sample sought orthodontic treatment because of medical problems such as hardship

eating or speaking, while the overwhelming majority of patients reported their wish to correct

appearance and to get rid of crooked teeth as the primary reason for their visit to an orthodontist.

Therefore, it is possible to conclude that malocclusion sometimes presents more of a

psychological problem rather than a purely medical problem. That is why its treatment has to be

approached from a variety of aspects, not only dental treatment but also active psychological

work with the patient to restore his or her self-esteem, self-confidence, and a positive self-image.

The findings of this research also suggest that the instances of bullying and harassment

regarding a variety of dental problems are very frequent. While both caregivers and patients

acknowledged a wish to improve appearance with the help of orthodontic correction of

occlusion, the core reason for a wish to improve appearance may be seen in the problems with

classmates, bullying, and overall poor social functioning because of poor self-image, isolation,

and anxiety. Moreover, which is distressing, caregivers often aggravate the situation by also

acting as bullies. More than a half of the caregivers’ and patients’ sample agreed that caregivers

commented about appearance of patients, which may act as an additional negative contributor to

children’s worsening quality of life, impaired self-perception, depression, and other

psychological challenges.

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 Together with caregivers’ direct contribution to the child’s negative self-image, and the

direct association of caregivers’ dissatisfaction with the child’s appearance and the child’s

dissatisfaction with his or her appearance, caregivers’ motivation for treatment is usually

subjectively higher than that of children. On the one hand, it may be assessed as a positive

phenomenon because children do not have funds and independence for making autonomous

decisions regarding pursuit of orthodontic treatment. On the other hand, caregivers’ higher

preoccupation with the child’s malocclusion and other dental problems may often serve as a

strong negative contributor to child’s poor self-image.

Hearing comments from caregivers about his or her crooked teeth, the child’s

dissatisfaction with personal appearance may get exacerbated, which is not as easily corrected as

malocclusion is in some instances. Acquiring deeply rooted and long-lasting psychological

problems related to caregivers’ dissatisfaction with the child’s appearance might become a

dangerous trend towards low self-esteem, absence of self-confidence, impaired social activities,

and other interpersonal and internal problems in the child’s adulthood. Hence, it is recommended

that caregivers, in line with adequate assessment of their children’s necessity for orthodontic

treatment, refrain from thoughtless comments about the child’s appearance to avoid exacerbation

of psychological traumas.

Another important implication of this study is that both caregivers of patients with

malocclusion, and patients with malocclusion have very strong expectations regarding

orthodontic treatment, considering that straight teeth may help children resolve the entire

complex of their psychosocial problems. This way, all respondents assessed the potential of

straight teeth to boost the child’s confidence, increase chances for life success, and add

confidence in public very highly, which suggests that people with malocclusion develop a variety

95
of problems with social interactions and interpersonal relationships. In addition, being bullied

because of teeth is also a very strong factor affecting children’s social confidence and self-image;

therefore, eliminating the physical object of teasing is considered to help children regain a

confident place in their social environment and receive better competitive chances in life. These

associations have been most often supported by empirical evidence examining unconscious

association of positive personal characteristics such as intellect, intelligence, and ability to

perform tasks with more pleasing physical appearance. Therefore, it seems reasonable that

children experiencing bullying and a variety of other problems related to their poor dental health

naturally expect to get rid of those problems once their malocclusion is corrected.

Finally, it is vital to point out the gender-related implication of this study. In support of

prior research findings recognizing females as more preoccupied with their dental appearance,

this study also showed that females tended to assess their dental problems more critically, and

were more critical about their need for orthodontic treatment. An interesting observation made

within this study is that females reported being bullied about teeth more often than males did,

which suggests that higher expectations about attractiveness of female appearance make females

a readier target for bullying in case they do not comply with the beauty ideal. However, the

current study showed no significant statistical correlation when correlating gender and teeth

bullying. This indicates that there are no differences in gender with regards to teeth bullying.

Therefore, the study findings do not support previous research findings which reveled the

females are more targeted for teeth bullying when compared to males.

Educational Implications. In this study, some patients with no/little need of treatment

did experience bullying regarding teeth. Therefore, caregiver and patient education should be

implied in an attempt to avoid any further teeth bullying experiences. Both caregivers and

96
patients would be recommended therapy about self-image and self-esteem to help them deal with

distorted dental perceptions in order to align it with the standard of orthodontic treatment.

Caregivers’ awareness of the effects of their negative remarks regarding their children’s teeth

must be employed to avoid aggravating the already existing psychosocial experiences. Educating

caregivers and patients will negate the distorted perceptions of body image and dental

appearance attained from the media and Hollywood.

Limitations and Weaknesses

The present study has several limitations and weaknesses that need to be taken into

account when evaluating the validity, reliability, and overall academic value of obtained

findings. First, the purposive sampling method is a limitation of this study because it is the most

convenient sampling technique but it reduces the credibility of findings. The researcher decides

whom to include in the sample, and determines the setting for sampling, which weakens the

study’s generalizability. Using a random sampling technique would guarantee a much higher

level of study’s credibility, but taking into account that patients with specific dental problems

had to be included into the sample; using a purpose sampling method may be justified. In case a

variety of settings are included, the variability of the sample size may be guaranteed, and the

findings obtain higher credibility, universality, and generalizability. This weakness may be

addressed through further replicated studies in a variety of settings with the use of the same data

collection instrument to compare findings and produce more generalizable findings.

Another limitation of this study was the low sample size of bullied patients. The

decreased sample size prevented the researcher from achieving the necessary statistical power to

conduct meaningful correlation tests. Further research with a larger sample of bullied patients is

needed to validate further correlations.

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 Finally, it is essential to note that the cross-sectional nature of this study may also serve

as a limitation. Such a study provides only a snapshot of the current situation and psychosocial

well-being of patients with malocclusion and their parents. However, longitudinal approach to

observing patients undergoing orthodontic treatment might yield a much richer dataset for

analyzing the dynamics of patients’ changing psychosocial well-being, and the extent to which

their expectations regarding orthodontic treatment came true in the progress of treatment.

Therefore, further research is required to assess this dimension of orthodontic treatment’s

association with psychosocial health and well-being of patients.

Recommendations for Further Research

Given the findings of this study and its methodological strength, some recommendations

for further research are formulated to inform this field of research interest, and to clarify some

observations made in this study. The first most notable finding was about the disagreement of

patients and their caregivers regarding the gravity of dental health problems. Caregivers tended

to be more skeptical about their children’s dental health, and their perceptions about the need for

treatment were objectively higher than those of patients and the IOTN dental health and aesthetic

guidelines. The present fact requires further analysis to clarify the reasons for which caregivers

are so skeptical about their children’s dental health, and to determine the psychological impact of

such assessment of patients’ appearance on the patients’ self-esteem and perception of their

condition.

Second, a larger sample size of bullied patients is needed to test further correlations and

indicate which bullying factors are of great importance to the patients and their caregivers. An

overall larger sample would further detect the presence of a correlation between a specific gender

and teeth bullying in order to support previous research regarding females being more targeted

98
for teeth bullying than males. Therefore, it is vital to conduct further studies to identify the

rationale behind females’ higher concerns about their dental health, be it an objective concern

about female appearance or an effort to counter frequent bullying experiences. Standards of

beauty and expectations regarding appearance are much more stringent for females, so it is vital

to develop a clear and comprehensive understanding of female motives for seeking orthodontic

treatment and female exposure to bullying as a key determinant of psychosocial problems.

The final observation that requires further research is that of high and diverse

expectations that both caregivers and their parents have for orthodontic treatment. This study, as

well as many others, identified the aspects of improvement of social, psychological, and physical

functioning and relationships that patients and their caregivers expect after treatment. There are

also many studies revealing significant improvements in the overall psychosocial functioning

and self-perception among patients who have already undergone orthodontic treatment and

improved the physical appearance of their teeth. However, there is still not enough data on

whether the initial expectations are met with the help of orthodontic treatment, or children

require additional psychological assistance to get rid of their complexes, anxieties, and fears

associated with the well-established low self-esteem and bullying experiences. These

psychological problems may remain after the physical signs of malocclusion disappear.

Therefore, there is a need to study these issues to determine the entire complex of assistance that

patients may require alongside with orthodontic treatment.

99
 Chapter 7: Conclusion

Physical appearance has always been an important aspect of any individual’s self-image,

and it has a profound impact on the way in which this individual is perceived by surrounding

people. Hence, since times immemorial, people have been trying to enhance their appearance and

achieve better attractiveness to achieve their life goals such as having friends and active social

life, finding a mate, and making a good career. Obviously, physical, especially facial, appearance

is not everything that a person needs to succeed in life, and personal qualities of character as well

as professional skills are also highly valued in various domains of human activity. Nevertheless,

research has shown that attractive people tend to be perceived much more favorably than those

with visible defects of physical appearance.

Because of such intense attention of the media and the society to physical attractiveness,

the human self-image may be seriously damaged in case an individual has certain inborn or

acquired flaws in appearance. Malocclusion is one of such aspects; there are many cases in

which people are born with certain dental defects, and until recently, they have been analyzed

and perceived only from a medical standpoint. That is, whether the degree of malocclusion

presents any specific challenges for a person in eating, speaking, etc. Only recently, the in-depth

and profound psychosocial impact of dental problems has come to be better understood.

Unfortunately, people even with mild forms of malocclusion start experiencing serious

psychological complexes about the defects of their appearance in childhood, which may be

deepened and fuelled by negative peer comments, bullying, and parents’ dissatisfaction with the

child’s appearance. Such experiences definitely result in the eroded self-image, low self-esteem,

anxiety, depression, and social isolation, which exacerbate some other age-specific problems

such as social performance of children.

100
 Despite the common opinion about the degree of malocclusion having an effect on

incidence of bullying, this study has shown that children with even the mildest forms of dental

problems may experience bullying at school because of certain defects in their dental

appearance. This research revealed that severity of malocclusion is not correlated with teeth

bullying. Both peers and caregivers of a child with dental problems may become the source of

stress and depression for a child who has not received any orthodontic treatment. Girls’

experience an even greater pressure because of traditionally higher beauty demands for them

posed both by parents and by the community. Furthermore, children may not be sincere with

their parents about being bullied at school for their crooked teeth, so caregivers should carefully

consider the indirect indicators of their children’s psychosocial problems such as low self-

esteem, low confidence, social isolation, problems with academic performance, having few

friends, and others to initiate treatment and help their children restore normal social functioning.

In connection with these findings, the community should consider the psychosocial

dimension of having aesthetic dental problems such as malocclusion more seriously, since such

problems (no matter how insignificant they seem from a medical viewpoint) may produce a

strong destructive impact on the child’s well-being, thus affecting his or her quality of life in

adulthood. It is vital to keep in mind that the ideal timing for orthodontic treatment is in the

child’s middle age from 11 to 15 years old, while treatment of malocclusion problems of adults

is a much lengthier and more complicated task. Hence, it is the primary task of caregivers to

consider the need for treatment objectively, not only through the prism of dental health but also

from the viewpoint of aesthetic attractiveness of the child’s appearance, and the child’s

subjective perceived need for orthodontic treatment.

101
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 Appendices

Appendix A. Research Ethics Approval

115
116
Appendix B. Amendment #1 Approval

117
118
Appendix C. Amendment #2 Approval

119
120
Appendix D. Parent Information and Informed Consent

121
122
123
124
Appendix E. Incentive Prizes – Email Slip

125
Appendix F. Winner’s Email

126
Appendix G. Clinical Examination Form

127
128
Appendix H. Patient Self-Assessment Questionnaire

129
130
131
132
Appendix I. Caregiver Assessment Questionnaire

133
134
135
136
Appendix J. Index of Orthodontic Treatment Need Dental Health Component (IOTN
DHC). Proffit et al., 2007.

137
Appendix K. The Aesthetic Component (AC) of the IOTN. Proffit et al., 2007.

138
Appendix L. Correlation Tables.

Child satisfaction index and caregiver satisfaction index.

Correlations
ChildSatisfact ParentSatisfac
ionIndex tionIndex
ChildSatisfactionInde Pearson
1 .995**
x Correlation
Sig. (2-tailed) .000
N 86 86
ParentSatisfactionInd Pearson
.995** 1
ex Correlation
Sig. (2-tailed) .000
N 86 86

Child’s Satisfaction with Teeth + IOTN dental health grade.

Pearson Correlation Coefficients, N = 86 Prob > |r| under H0: Rho=0

P_q1 C_q1

P_q1 1.00000 0.03640

139
P_q1 0.7394

C_q1 0.03640
1.00000
C_q1 0.7394

Child’s Satisfaction with Teeth + IOTN Aesthetic Component Grade

Pearson Correlation Coefficients, N = 86 Prob > |r| under H0: Rho=0

P_q2 C_q2

P_q2 -0.01661
1.00000
P_q2 0.8793

C_q2 -0.01661
1.00000
C_q2 0.8793

Caregiver’s Satisfaction with teeth + IOTN dental health grade

Pearson Correlation Coefficients, N = 86 Prob > |r| under H0: Rho=0

p_Q3 C_Q3

140
p_Q3 0.15486
1.00000
p_Q3 0.1545

C_Q3 0.15486
1.00000
C_Q3 0.1545

Caregiver’s Satisfaction with teeth + Aesthetic Component Grade

Pearson Correlation Coefficients, N = 86 Prob > |r| under H0: Rho=0

p_q4 C_q4

p_q4 0.22657
1.00000
p_q4 0.0359

C_q4 0.22657
1.00000
C_q4 0.0359

Caregiver’s Satisfaction with teeth/Chin/jaws/lips + Income

141
 Q7KSatisfactionre Income in Q7HSatisfactionre Q7JSatisfactionre Q7ISatisfactionreg
gardingChildsTeet thousands before gardingChildsLips gardingChildsChin ardingChildsJaws
h_P tax _P _P _P

Spearman's rho Q7KSatisfactionregardingChild Correlation Coefficient 1.000 -.063 .306** .347** .379**
sTeeth_P
Sig. (2-tailed) . .567 .004 .001 .000

N 86 86 86 86 86

Income in thousands before tax Correlation Coefficient -.063 1.000 -.021 .007 -.043

Sig. (2-tailed) .567 . .846 .952 .692

N 86 86 86 86 86

Q7HSatisfactionregardingChild Correlation Coefficient .306** -.021 1.000 .839** .732**

sLips_P
Sig. (2-tailed) .004 .846 . .000 .000

N 86 86 86 86 86

Q7JSatisfactionregardingChilds Correlation Coefficient .347** .007 .839** 1.000 .802**

Chin_P
Sig. (2-tailed) .001 .952 .000 . .000

N 86 86 86 86 86

Q7ISatisfactionregardingChilds Correlation Coefficient .379** -.043 .732** .802** 1.000

Jaws_P
Sig. (2-tailed) .000 .692 .000 .000 .

N 86 86 86 86 86

Caregivers’ motivation to seek orthodontic treatment + Income

142
Pearson Correlation Coefficients, N = 86 Prob > |r| under H0: Rho=0

p_q5_income p_q5a p_q5b

p_q5_income 0.08756 -0.10244

1.00000
0.4227 0.3480
Q4AnnualHouseholdIncome

p_q5a 0.08756 0.16601

1.00000
0.4227 0.1266
Q6AReasonforseekingOrthodonticTreatmentCrookedTeeth

p_q5b -0.10244 0.16601

1.00000
0.3480 0.1266
Q6BReasonforseekingOrthodonticTreatmentCorrectAppearance

p_q5c -0.02290 0.29524 -0.06675

0.8343 0.0058 0.5414
Q6CReasonforseekingOrthodonticTreatmentDifficultySpeaking

p_q5d -0.07056 0.05902 -0.00818

Q6DReasonforseekingOrthodonticTreatmentClassmateslaughatteet 0.5185 0.5893 0.9404
h

p_q5e -0.02521 -0.04042 -0.19045

0.8178 0.7117 0.0790
Q6EReasonforseekingOrthodonticTreatmentReferredbyaDentist

p_q5f 0.04527 0.29557 0.19997

0.6789 0.0057 0.0649
Q6FReasonforseekingOrthodonticTreatmentParent

Pearson Correlation Coefficients, N = 86 Prob > |r| under H0: Rho=0

143
 p_q5c p_q5d p_q5e p_q5f

p_q5_incom
e -0.02290 -0.07056 -0.02521 0.04527
0.8343 0.5185 0.8178 0.6789
Q4AnnualHou
seholdIncome

p_q5a
Q6AReasonfor 0.29524 0.05902 -0.04042 0.29557
seekingOrthod 0.0058 0.5893 0.7117 0.0057
onticTreatment
CrookedTeeth

p_q5b
Q6BReasonfor
-0.06675 -0.00818 -0.19045 0.19997
seekingOrthod
0.5414 0.9404 0.0790 0.0649
onticTreatment
CorrectAppear
ance

p_q5c
Q6CReasonfor
0.03135 0.09360 0.25148
seekingOrthod 1.00000
0.7745 0.3914 0.0195
onticTreatment
DifficultySpea
king

144
p_q5d
Q6DReasonfor
0.03135 -0.07250 0.01377
seekingOrthod 1.00000
0.7745 0.5071 0.8998
onticTreatment
Classmateslaug
hatteeth

p_q5e
Q6EReasonfor
0.09360 -0.07250 0.07875
seekingOrthod 1.00000
0.3914 0.5071 0.4711
onticTreatment
ReferredbyaDe
ntist

p_q5f
Q6FReasonfor 0.25148 0.01377 0.07875
1.00000
seekingOrthod 0.0195 0.8998 0.4711
onticTreatment
Parent

Caregiver’s Motivation to seek orthodontic treatment + Child’s Motivation to seek orthodontic treatment

145
  Crooked teeth

Test of H0: Gamma = 0

ASE under H0 0.2407

Z 2.8972

One-sided Pr >
0.0019
Z

Two-sided Pr >
0.0038
|Z|

 Correct appearance

Test of H0: Gamma = 0

ASE under H0 0.2115

Z 1.8763

One-sided Pr >
0.0303
Z

Two-sided Pr >
0.0606
|Z|

 Difficulty speaking/eating

146
 Test of H0: Gamma = 0

ASE under H0 0.5190

Z 1.6709

One-sided Pr >
0.0474
Z

Two-sided Pr >
0.0947
|Z|

 Classmates laugh at teeth

Test of H0: Gamma = 0

ASE under H0 0.8442

Z 0.8461

One-sided Pr >
0.1987
Z

Two-sided Pr >
0.3975
|Z|

 Referred by dentist

147
 Test of H0: Gamma = 0

ASE under H0 0.1729

Z 3.9082

One-sided Pr >
<.0001
Z

Two-sided Pr >
<.0001
|Z|

 Parents

Test of H0: Gamma = 0

ASE under H0 0.2523

Z 1.5687

One-sided Pr >
0.0584
Z

Two-sided Pr >
0.1167
|Z|

148
Gender + Being bullied about teeth.
Pearson Correlation Coefficients, N = 86 Prob > |r| under H0:
Rho=0

Sex P_q7

Sex -0.06932
1.00000
Sex 0.5259

P_q7 -0.06932
1.00000
Q10KBulliedorteasedaboutTeeth 0.5259

IOTN DHC + IOTN AC + being bullied about teeth.

Pearson Correlation Coefficients, N = 86 Prob > |r| under H0: Rho=0

pt_q19 c_q19a c_q19b

pt_q19 -0.05812 0.03411

1.00000
0.5950 0.7552
pt_q19: Patients: Bullied about teeth

-0.05812 0.84834
c_q19a 0.5950
1.00000
<.0001

149
c_q19a: Clinical: IOTN DHC

c_q19b 0.03411 0.84834

1.00000
0.7552 <.0001
c_q19b: Clinical: IOTN AC

Male/female satisfaction factors comparison.

 Height

Statistic DF Value Prob

Chi-Square 1 0.8705 0.3508

Likelihood Ratio Chi-

1 0.8439 0.3583
Square

Continuity Adj. Chi-

1 0.3388 0.5605
Square

Mantel-Haenszel Chi-
1 0.8595 0.3539
Square

Phi Coefficient 0.1050

Contingency Coefficient 0.1044

150
Cramer's V 0.1050

 Weight

D Valu
Statistic Prob
F e
2.725 0.098
Chi-Square 1
6 8

Likelihood Ratio Chi- 2.956 0.085

1
Square 9 5

Continuity Adj. Chi- 1.854 0.173

1
Square 1 3

Mantel-Haenszel Chi- 2.692 0.100

1
Square 3 8

-
Phi Coefficient 0.182
3

0.179
Contingency Coefficient 4

151
 -
Cramer's V 0.182
3

 Strength

Statistic DF Value Prob

Chi-Square 1 0.2573 0.6120

Likelihood Ratio Chi-

1 0.2620 0.6088
Square

Continuity Adj. Chi-

1 0.0470 0.8283
Square

Mantel-Haenszel Chi-
1 0.2541 0.6142
Square

Phi Coefficient -0.0571

Contingency Coefficient 0.0570

Cramer's V -0.0571

152
  Hair

Statistic DF Value Prob

Chi-Square 1 0.0552 0.8142

Likelihood Ratio Chi-

1 0.0559 0.8131
Square

Continuity Adj. Chi-

1 0.0000 1.0000
Square

Mantel-Haenszel Chi-
1 0.0546 0.8153
Square

Phi Coefficient -0.0256

Contingency Coefficient 0.0256

Cramer's V -0.0256

 Eyes

Statistic DF Value Prob

Chi-Square 1 0.6313 0.4269

153
Likelihood Ratio Chi-
1 0.6892 0.4064
Square

Continuity Adj. Chi-

1 0.0995 0.7524
Square

Mantel-Haenszel Chi-
1 0.6236 0.4297
Square

Phi Coefficient -0.0877

Contingency Coefficient 0.0874

Cramer's V -0.0877

 Nose

Statistic DF Value Prob

Chi-Square 1 0.2874 0.5919

Likelihood Ratio Chi-

1 0.2954 0.5868
Square

Continuity Adj. Chi-

1 0.0347 0.8522
Square

154
Mantel-Haenszel Chi-
1 0.2837 0.5943
Square

Phi Coefficient -0.0611

Contingency Coefficient 0.0610

Cramer's V -0.0611

 Ears

Statistic DF Value Prob

Chi-Square 1 0.3328 0.5640

Likelihood Ratio Chi-

1 0.3525 0.5527
Square

Continuity Adj. Chi-

1 0.0024 0.9607
Square

Mantel-Haenszel Chi-
1 0.3283 0.5666
Square

Phi Coefficient -0.0666

155
Contingency Coefficient 0.0665

Cramer's V -0.0666

 Lips

Statistic DF Value Prob

Chi-Square 1 0.5926 0.4414

Likelihood Ratio Chi-

1 0.5759 0.4479
Square

Continuity Adj. Chi-

1 0.1481 0.7003
Square

Mantel-Haenszel Chi-
1 0.5852 0.4443
Square

Phi Coefficient 0.0861

Contingency Coefficient 0.0857

Cramer's V 0.0861

156
  Jaws

Statistic DF Value Prob

Chi-Square 1 1.0858 0.2974

Likelihood Ratio Chi-

1 1.1420 0.2852
Square

Continuity Adj. Chi-

1 0.5177 0.4718
Square

Mantel-Haenszel Chi-
1 1.0719 0.3005
Square

Phi Coefficient -0.1180

Contingency Coefficient 0.1172

Cramer's V -0.1180

 Chin

Statistic DF Value Prob

Chi-Square 1 0.0080 0.9287

157
Likelihood Ratio Chi-
1 0.0080 0.9285
Square

Continuity Adj. Chi-

1 0.0000 1.0000
Square

Mantel-Haenszel Chi-
1 0.0079 0.9291
Square

Phi Coefficient -0.0102

Contingency Coefficient 0.0102

Cramer's V -0.0102

 Teeth

Statistic DF Value Prob

Chi-Square 1 3.5773 0.0586

Likelihood Ratio Chi-

1 3.4711 0.0624
Square

Continuity Adj. Chi-

1 2.6063 0.1064
Square

158
Mantel-Haenszel Chi-
1 3.5337 0.0601
Square

Phi Coefficient -0.2089

Contingency Coefficient 0.2045

Cramer's V -0.2089

Patient/caregiver bullying reports’ comparison.

 Height

Test of H0: Gamma = 0

ASE under H0 0.3547

Z 2.5026

One-sided Pr >
0.0062
Z

Two-sided Pr >
0.0123
|Z|

159
  Weight

Test of H0: Gamma = 0

ASE under H0 0.2284

Z 4.2234

One-sided Pr >
<.0001
Z

Two-sided Pr >
<.0001
|Z|

 Strength

Test of H0: Gamma = 0

ASE under H0 0.4997

Z 1.5420

One-sided Pr >
0.0615
Z
0.1231
Two-sided Pr >

160
|Z|

 Hair

Test of H0: Gamma = 0

ASE under H0 0.5434

Z 1.8099

One-sided Pr >
0.0352
Z

Two-sided Pr >
0.0703
|Z|

 Eyes

Test of H0: Gamma = 0

ASE under H0 0.9002

Z 0.9066

161
One-sided Pr >
0.1823
Z

Two-sided Pr >
0.3646
|Z|

 Nose

Test of H0: Gamma = 0

ASE under H0 0.9399

Z 0.9638

One-sided Pr >
0.1676
Z

Two-sided Pr >
0.3351
|Z|

 Ears

Test of H0: Gamma = 0

162
ASE under H0 0.6681

Z 1.4238

One-sided Pr >
0.0772
Z

Two-sided Pr >
0.1545
|Z|

 Lips

Test of H0: Gamma = 0

ASE under H0 0.8870

Z -1.1274

One-sided Pr <
0.1298
Z

Two-sided Pr >
0.2596
|Z|

163
  Jaws

Test of H0: Gamma = 0

ASE under H0 0.9608

Z 0.9912

One-sided Pr >
0.1608
Z

Two-sided Pr >
0.3216
|Z|

 Chin

Test of H0: Gamma = 0

ASE under H0 0.9197

Z 0.9356

One-sided Pr >
0.1747
Z
0.3495
Two-sided Pr >

164
|Z|

 Teeth

Test of H0: Gamma = 0

ASE under H0 0.2588

Z 2.8098

One-sided Pr >
0.0025
Z

Two-sided Pr >
0.0050
|Z|

Male/female bullying reports’ comparison.

 Height

Statistic DF Value Prob

Chi-Square 1 1.8724 0.1712

1 1.7985 0.1799
Likelihood Ratio Chi-

165
Square

Continuity Adj. Chi-

1 1.0653 0.3020
Square

Mantel-Haenszel Chi-
1 1.8506 0.1737
Square

Phi Coefficient 0.1476

Contingency Coefficient 0.1460

Cramer's V 0.1476

 Weight

Statistic DF Value Prob

Chi-Square 1 1.0017 0.3169

Likelihood Ratio Chi-

1 1.0383 0.3082
Square

Continuity Adj. Chi-

1 0.5332 0.4653
Square

166
Mantel-Haenszel Chi-
1 0.9901 0.3197
Square

Phi Coefficient -0.1079

Contingency Coefficient 0.1073

Cramer's V -0.1079

 Strength

Statistic DF Value Prob

Chi-Square 1 0.0767 0.7818

Likelihood Ratio Chi-

1 0.0758 0.7831
Square

Continuity Adj. Chi-

1 0.0000 1.0000
Square

Mantel-Haenszel Chi-
1 0.0758 0.7830
Square

Phi Coefficient 0.0299

Contingency Coefficient 0.0299

167
Cramer's V 0.0299

 Hair

Statistic DF Value Prob

Chi-Square 1 0.3543 0.5517

Likelihood Ratio Chi-

1 0.3408 0.5593
Square

Continuity Adj. Chi-

1 0.0038 0.9506
Square

Mantel-Haenszel Chi-
1 0.3502 0.5540
Square

Phi Coefficient 0.0642

Contingency Coefficient 0.0641

Cramer's V 0.0642

168
  Eyes

Statistic DF Value Prob

Chi-Square 1 1.7520 0.1856

Likelihood Ratio Chi-

1 2.7429 0.0977
Square

Continuity Adj. Chi-

1 0.5064 0.4767
Square

Mantel-Haenszel Chi-
1 1.7317 0.1882
Square

Phi Coefficient -0.1427

Contingency Coefficient 0.1413

Cramer's V -0.1427

 Nose

Statistic DF Value Prob

Chi-Square 1 0.0099 0.9206

169
Likelihood Ratio Chi-
1 0.0100 0.9202
Square

Continuity Adj. Chi-

1 0.0000 1.0000
Square

Mantel-Haenszel Chi-
1 0.0098 0.9211
Square

Phi Coefficient -0.0107

Contingency Coefficient 0.0107

Cramer's V -0.0107

 Ears

Statistic DF Value Prob

Chi-Square 1 2.3645 0.1241

Likelihood Ratio Chi-

1 3.6853 0.0549
Square

Continuity Adj. Chi-

1 1.0090 0.3152
Square

170
Mantel-Haenszel Chi-
1 2.3370 0.1263
Square

Phi Coefficient -0.1658

Contingency Coefficient 0.1636

Cramer's V -0.1658

 Lips

Statistic DF Value Prob

Chi-Square 1 1.7520 0.1856

Likelihood Ratio Chi-

1 2.7429 0.0977
Square

Continuity Adj. Chi-

1 0.5064 0.4767
Square

Mantel-Haenszel Chi-
1 1.7317 0.1882
Square

Phi Coefficient -0.1427

171
Contingency Coefficient 0.1413

Cramer's V -0.1427

 Jaws

Statistic DF Value Prob

Chi-Square 1 1.1541 0.2827

Likelihood Ratio Chi-

1 1.8148 0.1779
Square

Continuity Adj. Chi-

1 0.1084 0.7420
Square

Mantel-Haenszel Chi-
1 1.1407 0.2855
Square

Phi Coefficient -0.1158

Contingency Coefficient 0.1151

Cramer's V -0.1158

172
  Chin

Statistic DF Value Prob

Chi-Square 1 2.3645 0.1241

Likelihood Ratio Chi-

1 3.6853 0.0549
Square

Continuity Adj. Chi-

1 1.0090 0.3152
Square

Mantel-Haenszel Chi-
1 2.3370 0.1263
Square

Phi Coefficient -0.1658

Contingency Coefficient 0.1636

Cramer's V -0.1658

 Teeth

Statistic DF Value Prob

Chi-Square 1 0.4133 0.5203

173
Likelihood Ratio Chi-
1 0.4216 0.5161
Square

Continuity Adj. Chi-

1 0.1422 0.7061
Square

Mantel-Haenszel Chi-
1 0.4085 0.5227
Square

Phi Coefficient -0.0693

Contingency Coefficient 0.0692

Cramer's V -0.0693

Patient/caregiver satisfaction comparison.

 Height

Test of H0: Gamma = 0

ASE under H0 0.8801

Z 0.8672

0.1929
One-sided Pr >

174
Z

Two-sided Pr >
0.3858
|Z|

 Weight

Test of H0: Gamma = 0

ASE under H0 0.7204

Z 0.4926

One-sided Pr >
0.3112
Z

Two-sided Pr >
0.6223
|Z|

 Strength

Test of H0: Gamma = 0

ASE under H0 0.6815

175
Z 1.4673

One-sided Pr >
0.0711
Z

Two-sided Pr >
0.1423
|Z|

 Hair

Test of H0: Gamma = 0

ASE under H0 1.0307

Z -0.9702

One-sided Pr <
0.1660
Z

Two-sided Pr >
0.3319
|Z|

 Eyes: Row or column sum zero. No statistics computed for this table

176
  Nose

 Test of H0: Gamma =

0

ASE under H0 1.0234

Z -0.9771

One-sided Pr <
0.1643
Z

Two-sided Pr >
0.3285
|Z|

 Ears

Test of H0: Gamma = 0

ASE under H0 1.0933

Z -0.9147

One-sided Pr <
0.1802
Z

177
Two-sided Pr >
0.3603
|Z|

 Lips

Test of H0: Gamma = 0

ASE under H0 0.8533

Z 0.8289

One-sided Pr >
0.2036
Z

Two-sided Pr >
0.4071
|Z|

 Jaws

Test of H0: Gamma = 0

ASE under H0 0.4273

Z 1.7976

178
One-sided Pr >
0.0361
Z

Two-sided Pr >
0.0722
|Z|

 Chin

Test of H0: Gamma = 0

ASE under H0 0.6123

Z 1.2359

One-sided Pr >
0.1082
Z

Two-sided Pr >
0.2165
|Z|

 Teeth

Test of H0: Gamma = 0

179
ASE under H0 0.2764

Z -0.3289

One-sided Pr <
0.3711
Z

Two-sided Pr >
0.7422
|Z|

Male/female assessment of teeth crowding.

Statistic DF Value Prob

Chi-Square 4 2.9906 0.5594

Likelihood Ratio Chi-

4 3.7514 0.4407
Square

Mantel-Haenszel Chi-
1 0.0082 0.9278
Square

Phi Coefficient 0.1865

Contingency Coefficient 0.1833

Cramer's V 0.1865

180
Appendix M. Principal Component Analysis – patient/caregiver satisfaction indices.

Item Patients Caregivers

Satisfaction Index Satisfaction Index
Factor Loadings Factor Weights Factor Loadings Factor Weights
Height 0.663 0.137 0.997 0.105
Weight 0.539 0.112 0.998 0.105
Strength 0.538 0.111 0.997 0.105
Hair 0.669 0.139 0.998 0.105
Eyes 0.664 0.138 0.998 0.105
Nose 0.583 0.121 0.997 0.105
Ears 0.711 0.147 0.739 0.078
Lips 0.842 0.175 0.998 0.105
Jaws 0.771 0.160 0.996 0.105
Chin 0.793 0.164 0.997 0.105
Teeth 0.374 0.077 0.086 0.009
Percentage of 43.858% 86.404%
Cumulative
Variance Explained
Extraction Method: Principal Component Analysis.
Rotation Method: Varimax with Kaiser Normalization.

181
Appendix N. Z-tests

Teeth satisfaction among patients’ sample

Sample 1 Sample 2 Difference
Sample proportion 0.7441 0.2093 0.5348
95% CI (asymptotic) 0.6519 - 0.8363 0.1233 - 0.2953 0.3855 - 0.6841
z-value 7
P-value <0.0001

Straight teeth will improve school performance (patients’ answers).

Sample 1 Sample 2 Difference

Sample proportion 0.3139 0.686 0.3721
95% CI (asymptotic) 0.2158 - 0.412 0.5879 - 0.7841 0.2227 - 0.5215
z-value 4.9
P-value <0.0001

Straight teeth will improve how you feel about yourself in public (patients’ answers).

Sample 1 Sample 2 Difference

Sample proportion 0.6511 0.3372 0.3139
95% CI (asymptotic) 0.5504 - 0.7518 0.2373 - 0.4371 0.1645 - 0.4633
z-value 4.1
P-value <0.0001

Having straight teeth will boost confidence (patients’ answers).

Sample 1 Sample 2 Difference

Sample proportion 0.7674 0.2325 0.5349
95% CI (asymptotic) 0.6781 - 0.8567 0.1432 - 0.3218 0.3855 - 0.6843
z-value 7
P-value <0.0001

Teeth Satisfaction regarding caregivers’ sample.

Sample 1 Sample 2 Difference

Sample proportion 0.6395 0.3604 0.2791
95% CI (asymptotic) 0.538 - 0.741 0.2589 - 0.4619 0.1297 - 0.4285
z-value 3.7
P-value 0.0003

182
Straight teeth will improve how you feel about yourself in public (caregivers’ answers).

Sample 1 Sample 2 Difference

Sample proportion 0.6395 0.3604 0.2791
95% CI (asymptotic) 0.538 - 0.741 0.2589 - 0.4619 0.1297 - 0.4285
z-value 3.7
P-value 0.0003

Having straight teeth will boost confidence (caregivers’ answers).

Sample 1 Sample 2 Difference

Sample proportion 0.86 0.14 0.72
95% CI (asymptotic) 0.7867 - 0.9333 0.0667 - 0.2133 0.5706 - 0.8694
z-value 9.4
P-value 0

Straight teeth will increase chances of success in life (caregivers’ answers).

Sample 1 Sample 2 Difference

Sample proportion 0.756 0.244 0.512
95% CI (asymptotic) 0.6652 - 0.8468 0.1532 - 0.3348 0.3626 - 0.6614
z-value 6.7
P-value <0.0001

Straight teeth will improve school performance (caregivers’ answers).

Sample 1 Sample 2 Difference

Sample proportion 0.395 0.605 0.21
95% CI (asymptotic) 0.2917 - 0.4983 0.5017 - 0.7083 0.0606 - 0.3594
z-value 2.8
P-value 0.0059

Male/female satisfaction regarding teeth

Sample 1 Sample 2 Difference

Sample proportion 0.8 0.3225 0.4775
95% CI (asymptotic) 0.6943 - 0.9057 0.158 - 0.487 0.2647 - 0.6903
z-value 4.4
P-value <0.0001

Having straight teeth will boost confidence (M/F comparison).

183
 Sample 1 Sample 2 Difference
Sample proportion 0.523 0.244 0.279
95% CI (asymptotic) 0.391 - 0.655 0.0928 - 0.3952 0.0616 - 0.4964
z-value 2.5
P-value 0.0119

Having straight teeth will improve how you feel about yourself in public (M/F comparison).

Sample 1 Sample 2 Difference

Sample proportion 0.442 0.209 0.233
95% CI (asymptotic) 0.3108 - 0.5732 0.0659 - 0.3521 0.022 - 0.444
z-value 2.2
P-value 0.0305

Straight teeth will increase chances of success in life (M/F comparison).

Sample 1 Sample 2 Difference

Sample proportion 0.267 0.186 0.081
95% CI (asymptotic) 0.1501 - 0.3839 0.049 - 0.323 -0.1064 - 0.2684
z-value 0.8
P-value 0.3969

184
Appendix O. Journal Article

Correlation between Malocclusion and Diminished Psychosocial Well-Being

ABSTRACT

OBJECTIVE: To assess the correlation between malocclusion and psychosocial well-being

from the perspective of younger patients, their caregivers, through the inclusion of normative
criteria.
MATERIALS & METHODS: A cross-sectional study design was employed. Data was
collected at a single point in time from a sample of prospective patients who were asked to
complete the questionnaires. The mean age of patients was 13.57 +/- 1.57 years (55 females and
31 males). Data collection was undertaken through clinical exams, and each patient was assessed
via the Index of Treatment Need (IOTN), both dental health and aesthetic components.
RESULTS: Patients' satisfaction with body image correlated with their caregivers' satisfaction
with their children’s’ body image (p<0.05). Caregivers' satisfaction with tooth appearance
correlated with the IOTN aesthetic component grade (p<0.05). There is no significant correlation
between children’s satisfaction with their teeth and the IOTN dental and aesthetic component
grades (p>0.05). Caregivers' motivation, in comparison to their children’s motivations to seek
orthodontic treatment was the same (p<0.05). No significant gender differences were found with
regards to being bullied about dental appearance (p>0.05).
CONCLUSIONS: Highest degree of dissatisfaction regarding different physical aspects is
dental appearance; bullying experiences are also higher regarding dental appearance with no
gender difference. Even patients with mild forms of malocclusion according to IOTN dental
health and aesthetic components, suffer from bullying. Malocclusion significantly impacts
perceptions of psychosocial well-being and even mild forms of malocclusion may lead to
bullying and negative personal perceptions about appearance.

INTRODUCTION AND LITERATURE REVIEW

The reasons for pursuing orthodontic treatment have long been debated in the dental community,
making the task of defining orthodontic need a complicated one. Orthodontic treatment is best

185
defined as the correction of teeth irregularities, whereas malocclusion can include physical
and/or psychosocial elements1. From a physical perspective, malocclusion is viewed as a “broad
range of frequently occurring dental-facial mal-relations, referring to physical deviations”2.
Whereas others stress that definitions of malocclusion should include psychological
characteristics3. Despite several studies4, 5, 6 on the topic of malocclusion and psychological well-
being, the reasons for pursuing orthodontic treatment are still being intently debated.

While there are several studies that attempt to address the relation between orthodontic treatment
and psychosocial well-being, there is still no consensus on the topic. This is due to the fact that
while some studies reported a correlation between malocclusion and psychosocial consequences,
others denied such correlation. This may be owing to varying understandings of what these
impacts constitute, sample size, age, and the absence of uniform methods for assessment7.

Helm et al.,8 demonstrated that the majority of those who suffer from malocclusions have
varying levels of negative body image and low self-esteem, depending on the type and severity
of their conditions. Badran9 found that adolescents that had completed orthodontic treatment
exhibited superior self esteem than those who had not. A number of studies10-15 have shown that
the perception of facial appearance by an individual not only affects body image and self-
perception, but also has a strong bearing on negative self-image.

Shaw16 found that both children and adults perceive faces of subjects with normal occlusions, as
being more physically appealing, smarter, more amicable, and preferable as friends, than
identical faces with occlusal impairment. More than twenty years later, those results were
replicated by other researchers17-19. In a study by Shaw et al.20, 531 school children were asked to
identify the most common target of teasing. The results established that out of 14 facial features,
teeth were ranked as the fourth most frequent target of teasing for children aged 9 to 12. In a
recent Jordanian study21 that included 960 boys and girls, teeth were found to be the number one
feature identified as the target for bullying, with 50% of the bullied victims acknowledging its
importance as a target.

186
The aim of the present study was to examine the relation between the psychosocial factors and
malocclusion, focusing on young children and adolescents, as the more vulnerable patient
category with the most potential to benefit psychologically from early detection and treatment.
Furthermore, the current study hopes that findings on this topic may facilitate a better assessment
of treatment needs as well as contribute towards better healthcare planning necessary for access
to orthodontic treatment.

MATERIALS AND METHODS

Ethical approval was attained from the University Health Research Ethics Board. A cross-
sectional study design was employed; data was collected at a single point in time from a sample
of prospective patients at the University. Prior to commencement of the questionnaires, all
caregivers had signed consent forms agreeing to allow their children to participate in the study.
86 patients (ages 11-16) and their caregivers met the inclusion criteria and were asked to
complete the questionnaires. Exclusion criteria included: Patients with special health care needs,
syndromes and craniofacial anomalies (e.g., cleft lip and palate), mentally handicapped patients,
and respondents with language barrier difficulties. Caregivers of children and adolescents
eligible to participate in the study were given the “Parent Information and Informed Consent”
form. Incentive prizes were offered to elicit questionnaire participation.

Clinical Examination
Clinical data was collected through an oral examination to assess the severity of malocclusion.
Dental examination of the subjects was performed at the applicable Graduate Orthodontic Clinic.
In addition, the use of dental casts and digital images for patients was employed. The clinical
exam was comprised of several components, which provided a summary of dentofacial features.
At the end of the clinical exam, patients were given a specific Index of Treatment Need (IOTN)
dental health and aesthetic component grade. Following the clinical examination, questionnaires
were administered to the selected patients and their caregivers.

Patient Self-Assessment Questionnaire

187
In a recent study, Al-Bitar et al.,21 employed a questionnaire that was modified from that of Shaw
et al.,20. For the purpose of this study, the same questionnaire used by Al-Bitar was used, but
modified to meet other aspects needed in the study. The first section of the questionnaire
involved reason(s) behind the patient’s decision to visit an orthodontist. The second section
queried patient’s satisfaction regarding different body parts. The third section focused on the
personal experience of teasing and bullying directed at all body parts first and then regarding
dentofacial features specifically. The fourth part identified the dentofacial feature’s effect on
social life. The questionnaires were completed at the university in the absence of the study
investigators.

Caregiver Assessment Questionnaire

The caregiver assessment questionnaire mirrored the patient self-assessment questionnaire; the
significant difference between them was the perspective from which the answers were given.
Furthermore, level of education was attained from the caregivers as well as their annual income.
The questionnaires were completed at the university in the absence of the study investigators.

Validity and Reliability of Clinical Exam, Patient Self-Assessment, and Caregiver

Questionnaires
Cohen’s Kappa test was used to measure inter-reliability and intra-reliability. The questionnaires
were designed by the principal investigator and reviewed by a statistician and a psychometrician
to ensure that the results were measurable and valid.

Index of Treatment Need – IOTN

The widely used IOTN, created by Brook and Shaw in 198922, is the first index to include
malocclusion measurements along a socio-psychological angle. The IOTN comprises two
separate components, the dental health component (DHC) and the aesthetic component (AC).

The DHC is the clinical component of the IOTN. This component categorizes patients into five
grades (from Grade 1-no need for treatment, to Grade 5-extreme need for treatment)23 based on
their occlusal features and their impact on the stomatognathic system.

188
The AC comprises a scale showing images of 10 dental malocclusions. These images are divided
into three grades: AC 1-4 (little or no need for treatment); AC 5-7 (moderate need for treatment);
and AC 8-10 (definite need for treatment)23; this grading system was employed in this study.
However, it should be noted that while the AC was designed to be used by the patient to assess
his or her perception of their own malocclusion, several studies noted good results and
reproducibility when the dentist carries out the AC23. Therefore, in this study the principal
investigator carried out the AC.

Statistical Analysis
Statistical software, SAS 9.2 (SAS Institute Inc. Cary, NC), was used to analyze the data. Simple
descriptive statistics of demographic and clinical characteristics were conducted. Correlation and
agreement tests were done to compare patients and their caregivers, males and females, and the
severity of malocclusion and bullying about teeth. Statistical tests used included Pearson
correlation coefficient, Pearson chi-square, Gamma correlations, and Z-tests. Cohen’s kappa
coefficient test was used to assess reliability tests.

RESULTS

The intra-reliability and inter-reliability coefficients verified the statistical reliability of findings.
Cohen’s kappa coefficient testing inter-reliability ranged from 0.636 to 0.739. To identify the
intra-reliability coefficient, the principal investigator performed the examination twice on 12
patients, with a three-month gap between the two measurements. Here, the Cohen’s kappa
coefficient ranged from 0.571 to 1.000.

The analyses of data focused on the dental examination and patient/caregiver questionnaires in
order to determine any relationships between malocclusion and psychosocial well-being. The
initial sample size constituted 99 patients, but only 86 of the completed questionnaires were
deemed acceptable, yielding an 86% response rate. The average age of participants was 13.57 +/-
1.57 years old; 55 (64%) were female and 31 (36%) were male.

Clinical Examination

189
The physical examination of patients consisted of diagnosing the need for orthodontic treatment
in accordance with the IOTN guidelines – both in terms of DHC and the AC. The majority of
patients (41.9%) were graded as borderline need for treatment according to the IOTN DHC,
followed by severe need for treatment (22.1%), and no need for treatment (2.3%). According to
the IOTN AC, 34.9% of patients were graded as borderline need for treatment and one-third of
patients (32.6%) were graded as definite need for treatment or no need for treatment (32.6%).

Comparative Analysis
The first comparative analysis was conducted on the basis of the degrees of satisfaction of
children and caregivers have with various aspects of children’s appearance, and the extent to
which the opinions of caregivers and patients coincide. The lowest level of shared satisfaction
(7%) was recorded for children’s teeth. Moreover, shared dissatisfaction for the condition of
children’s teeth was 46.6%. The next comparison focused on the frequency of reported bullying
by children versus their caregivers. The degree of caregivers’ and children’s responses regarding
bullying was high, with weight, height, strength, and teeth which were identified as the traits
most associated to bullying.

Comparative analysis on males versus females was also conducted. Findings show that 80% of
females, in contrast to 64.5% of males, were dissatisfied with the appearance of their teeth. The
Z-test showed statistically significant results indicating that females are more preoccupied with
their appearance and are more skeptical about their dental attractiveness. Bullying experiences
were also compared. Males were less frequently bullied on a variety of appearance traits in
comparison to females, whose bullying on the subject of weight, strength, eyes, nose, ears, etc.
was more common. Nevertheless, bullying on the subject of teeth is quite widespread both for
male and female respondents, with 14 females and six male patients reporting being bullied
about their teeth.

Another aspect of the comparative analysis was the relationship between the IOTN assessment of
the need of orthodontic treatment and children’s reported bullying. Interestingly, out of 20
children bullied about teeth, 40% had a moderate need for treatment, 25% were diagnosed with
severe need for treatment, 10% had an extreme need for treatment, and only 5% did not need

190
treatment at all – in accordance with the IOTN DHC. As for the IOTN AC, 30% of children who
reported being bullied about teeth appeared not to need treatment. 35% of the bullied children
were diagnosed with either a definite need or a borderline need for treatment for aesthetic
purposes.

Correlation Analysis
Correlation analysis was conducted to determine the relationships between various aspects of
clinical conditions and psychosocial experiences of patients and their caregivers. A summary of
correlated variables in this study are presented in Table 1.

Table 1. Results of correlations.

Correlated Variables Test Used Results

Child’s satisfaction with Pearson Correlation No significant correlation.
teeth + IOTN dental health P=0.7394
grade.
Child’s satisfaction with Pearson Correlation No significant correlation.
teeth + IOTN aesthetic P=0.8793
component grade
Caregiver’s Satisfaction with Pearson Correlation No significant correlation.
teeth + IOTN dental health P=0.1545
grade.
Caregiver’s satisfaction with Pearson Correlation Significant correlation.
teeth + IOTN aesthetic P=0.0359*
component grade.
Caregivers’ motivation to Pearson Correlation No significant correlation.
seek orthodontic treatment P>0.05
+ income.
Caregiver’s motivation to Gamma Significant correlation
seek orthodontic between caregivers and
treatment+ child’s their children in regards to
motivation to seek their motivation to seek
orthodontic treatment . orthodontic treatment with
respect to crooked teeth
(P=0.0038*) and referral by
the dentist (P<.0001*). No
significant correlation with
respect to other motivation
factors (P>0.05).
Patient/caregiver Gamma No significant correlations

191
 satisfaction comparison. between patients and
caregivers with respect to
satisfaction factors (P>0.05).
Patient/caregiver bullying Gamma Significant correlation
reports’ comparison. (P<0.0.5*) with respect to
height, weight, and teeth.
No significant correlation
with respect to other
physical factors.
Gender + being bullied Pearson Correlation No significant correlation.
about teeth. (P=0.5259)
Male/female satisfaction Pearson’s chi-square No significant correlations
factors comparison. between males and females
with respect to satisfaction
factors (P>0.05) except for
teeth (P=0.0586*).
Severity of malocclusion Pearson Correlation No significant correlation.
(IOTN dental health grade) + P=0.5950
being bullied about teeth.
Severity of malocclusion Pearson Correlation No significant correlation.
(IOTN aesthetic component P=0.7552
grade) + being bullied
about. teeth
Table 1. Results of correlations. (*p≤0.05).

DISCUSSION

Research has verified that malocclusion is strongly associated with various aspects of
psychosocial well-being. The psychosocial well-being of a patient with dental problems is
negatively affected in a variety of ways: experiences of bullying at school, caregivers’ negative
remarks, as well as low self-evaluation and complexes. Our study’s findings indicate that most of
the surveyed patients are dissatisfied with the appearance of their teeth. The majority of both,
caregivers and patients, agree on dissatisfaction concerning their dental appearance. Patients
reported being bullied because of various dental problems such as crooked teeth, shape and color
of their teeth, teeth sticking out, etc. Moreover, the majority of patients and caregivers agree that
straight teeth do improve psychosocial factors. These findings are consistent to previous claims11,
12, 14
, and a more recent study of Hassan and Amin10 about facial appearance being an influential

192
component of the overall self-image determining self-esteem. They also support the findings of
Baylon4 about children’s close psychological association of self-perception with dental
appearance.

Based on our study, having a malocclusion was identified as being related to bullying, with more
than one fifth of patients reporting being bullied about dental appearance - Fig. 1. In addition, it
is vital to note that more than half of the bullied sample either needed no treatment, or minor or
moderate/borderline treatment, according to the IOTN dental health guidelines. It is clear that
even milder forms of malocclusion are still significant enough to attract bullying regarding
patients’ teeth, which may be due to having less than ideal dental appearance. In terms of the
IOTN aesthetic guidelines, one third of the bullied sample did not need treatment and just more
than third of the sample needed definitive treatment. The present evidence suggests that, not only
children with a severe need for treatment, visible, and easily detectible dental problems suffer
from bullying, but also children who have milder forms of malocclusion and even those who do
not meet the IOTN treatment need criteria. These findings were further correlated and showed no
statistical significance between the severity of malocclusion according to IOTN guidelines and
patients experiences related to teeth bullying. The present research findings support prior
findings20, 21 that teeth-related bullying is much more abusive than other forms of bullying about
height, weight, hair, or other physical attributes. Such bullying experiences intensify anxiety,
depression, and poor self-image among children, causing lower self-esteem, loneliness, and
insecurity feelings further deteriorating the psychosocial well-being and emotional health of
children24, 25.
Figure 1. Patients’ responses to bullying factors

25
Number of patients

20
15
10
5
0

Physical traits

193
Alignment of caregivers’ motivation to seek orthodontic treatment for their children was
validated in this study with respect to crooked teeth and referral by the dentist. Having crooked
teeth was recognized by most of the patients and their caregivers, which suggests that caregivers
are realistic, and even critical, about their children’s dental appearance. Dentist referral
motivated over half of the caregivers and almost half of the patients to seek treatment. Although
fewer caregivers viewed themselves as being the motivators of visiting an orthodontist, more of
the patients stated that they came to seek orthodontic treatment upon their caregivers’ wish.
These findings support prior research of Wedrychowska-Szulc and Syrynska26 and
Samsonyanova and Broukal27.

Preoccupation with physical appearance and psychosocial problems associated with

malocclusion was found to be higher for girls. The majority of female patients agreed that
straight teeth would improve how they would feel in public and would boost their confidence.
The most general assessment showed that females in contrast to males were more dissatisfied
with the condition and appearance of their teeth - Fig. 2. These findings support the claims of
Jung28 who also observed females to be much more preoccupied with their malocclusion and
other dental problems. In the present study, no significant correlation was found between
bullying, self-esteem and gender which was supported by the claims of Gavric et al.,29.

Figure 2. Male versus female dissatisfaction responses to physical factors.

194
 50
45
40
Number of patients

35
30
25
20
Female
15
10 Male
5
0

Physical traits

The present study included the purposive sampling. Using a random sampling technique would
guarantee a higher level of study credibility. It is essential to note that the cross-sectional nature
of this study may also serve as a limitation. A longitudinal approach to observing patients
undergoing orthodontic treatment might yield a richer dataset for analyzing the dynamics of
patients’ changing psychosocial well-being, and the extent to which their expectations regarding
orthodontic treatment were validated in the progress of treatment.

CONCLUSIONS

 Highest degree of dissatisfaction regarding different physical aspects is dental appearance;

bullying experiences are also higher regarding teeth, followed by weight, height and strength.
 No difference between genders with respect to dental appearance and bullying.
 Even patients with mild forms of malocclusion according to IOTN dental and aesthetic
components suffer from bullying.
 Patients and caregivers are in agreement about reasons to seek orthodontic treatment.
 Malocclusion impacts perceptions of psychosocial well-being.

195
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Appendix P. Journal Article Submission Received

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