Well-aligned teeth and a pleasing smile reflect

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1 ORIGINAL ARTICLE Perceptions of dental attractiveness and orthodontic treatment need among Tanzanian children Emeria A. Mugonzibwa, DDS, a Anne M. Kuijpers-Jagtman, DDS, PhD, b Martin A. Van t Hof, PhD, c and Emil N. Kikwilu, DDS, M Dent d Dar es Salaam, Tanzania, and Nijmegen, The Netherlands The aim of this study was to assess the opinions of Tanzanian children on dental attractiveness and their perceptions of orthodontic treatment need in relation to their own dental attractiveness as measured by the aesthetic component (AC) of the index of orthodontic treatment need (IOTN). In a random sample of 386 school children (48% boys, 52% girls), aged 9 to 18 years, the subjective need was assessed by using a prestructured questionnaire, and attractiveness was scored by using 18 intraoral frontal photographs. Orthodontic treatment need was measured with the IOTN, and 11% of the children definitely needed orthodontic treatment (grades 8-10 of the AC with 4-5 of the dental health component [DHC]). The AC indicated that 11% of the children needed orthodontic treatment, whereas the DHC indicated 22%. Although 38% of the children said they needed treatment, 33% and 31% were unhappy with the arrangement and the appearance of their teeth, respectively. Most children (85%) recognized well-aligned teeth as important for overall facial appearance. Photographs showing severe deviations including crowding were regarded as the most unattractive, with older children tending to dislike them the most (P.0005). This suggests that, from the children s point of view, grades 8-10 of the AC and 4-5 of the DHC could be given the first priority when considering an orthodontic treatment policy in Tanzania. (Am J Orthod Dentofacial Orthop 2004;125:426-34) Well-aligned teeth and a pleasing smile reflect positive status at all social levels, and irregular or protruding teeth reflect negative status. 1,2 In each race and sex, some balance of facial features is viewed by the majority as pleasing to the eye. 3 The perception of beauty not only is an individual preference that could be influenced by training, but also might have cultural and ethnic biases. 4-6 Only a few studies have addressed the perception of malocclusion in the African cultural context. Otuyemi et al 7 showed that the perceptions of dental esthetics of Nigerian students were very similar to those of American groups. The scientific literature in all aspects of craniofacial biology and orthodontics is primarily based on white populations. However, population norms derived from white people might not be valid and accurate for other ethnic groups, and applying them to other populations could lead to clinical decisions that cause undesired and unexpected outcomes. Although dissatisfaction with dental appearance is broadly related to the severity of the occlusal irregularities, 1,8,9 there are differences in the recognition and evaluation of the dental features. 10 Some studies have reported that perceptions of malocclusion do not differ among various racial groups and cultural circumstances, 8,11-13 but African people living in Africa can have different malocclusion perceptions compared with other societies. For example, spacing (especially median diastema) is significantly disliked in white cultures, 14,15 but it is considered desirable and a sign of beauty in many African cultures. Between 18% and 51% of Tanzanian children have been reported to have some type of dental irregularity in the deciduous and permanent dentitions, It is generally understood that the evaluation of malocclusion must consider morphological and functional factors, as well as esthetic and psychological ones. 19,20 However, not all potential patients with dental irregua Senior lecturer, Department of Preventive and Community Dentistry, Faculty of Dentistry, Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania. b Professor and chair, Department of Orthodontics and Oral Biology, University Medical Center, Nijmegen, The Netherlands. c Biostatistician, Department of Cariology and Preventive Dentistry, University Medical Center, Nijmegen, The Netherlands. d Head and senior lecturer, Department of Preventive and Community Dentistry, Faculty of Dentistry, Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania. Reprint requests to: A. M. Kuijpers-Jagtman, DDS, PhD, Department of Orthodontics and Oral Biology, University Medical Center, University of Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands; , a.kuijpers-jagtman@dent.umcn.nl. Submitted, February 2003; revised and accepted, November /$30.00 Copyright 2004 by the American Association of Orthodontists. doi: /j.ajodo

2 American Journal of Orthodontics and Dentofacial Orthopedics Volume 125, Number 4 Mugonzibwa et al 427 larities, even those with extreme handicapping malocclusions or anatomic deviations from the normal, seek orthodontic treatment. Although some do not recognize that they have problems, others believe that they cannot afford or cannot obtain orthodontic treatment. Both perceived need and demand vary with social and cultural conditions, 13,21 but the most important motivation for orthodontic treatment is usually an improvement in appearance. 9,13,22 Information on the perception of malocclusion can be used to influence decision making on the orthodontic services to be provided, human resource training needs, the design of treatment facilities, continuing education for oral health personnel, public health programs, screening for treatment priority, and resource planning. This information can also be used for patient education and information. The aim of this study was to investigate the opinions of Tanzanian children about dental attractiveness and their perceptions of orthodontic treatment need. MATERIAL AND METHODS The study, conducted in Dar es Salaam, Tanzania, involved 400 children, aged 9 to 18 years, from a primary school and a secondary school. The 2 schools were randomly selected from the lists of 180 public primary and 4 coeducation secondary schools obtained from the City Council and the Ministry of Education authorities, respectively. School classes were randomly chosen, and 400 children (52% girls, 48% boys) were randomly selected for inclusion in the study. Inclusion criteria for the respondents were age at the time of the study (9-18 years), African Tanzanian origin, and willingness to participate. All respondents were asked to produce birth certificates, Maternal and Child Health birth cards, or other evidence for age verification. The Ministry of Education of Tanzania, the City Council of Dar es Salaam, and the school authorities gave permission to conduct the study in the selected schools; the parents and the respondents were given written information and then could decide whether to participate. All 400 children agreed to participate in the study. A prestructured questionnaire in Swahili was administered to the children in their classrooms. The questionnaire was divided into 3 sections. The first section asked for demographic characteristics, particularly age, sex, and parents education and employment status. The second section dealt with awareness of the children s own occlusions, including questions on their subjective need of treatment, satisfaction with the arrangement and appearance of their teeth, and the importance of well-aligned teeth. The questions were scaled and scored with 3 or 5 points, as follows: 1. Do you need orthodontic treatment? (1 yes, 2 no, and 3 do not know) 2. Are you happy with the arrangement of your anterior teeth? (1 very happy, 2 happy, 3 normal, 4 unhappy, and 5 very unhappy) 3. Are you happy with the appearance of your own teeth compared to the teeth of your peers? (1 very happy, 2 happy, 3 normal, 4 unhappy, and 5 very unhappy) 4. Do you consider well-aligned teeth important for overall facial appearance? (1 very important, 2 important, 3 does not matter, 4 not important, and 5 not important at all). The third section concerned the respondents perceptions of malocclusion and comprised questions related to 18 intraoral frontal photographs on which the respondents had to give an opinion about attractiveness. The first 10 intraoral photographs represented the aesthetic component (AC) of the index of orthodontic treatment need (IOTN). The AC rates a person s dental attractiveness on a 10-point scale, illustrated by intraoral photographs. 23 Eight other intraoral photographs were added to represent common malocclusions in Tanzania. The 18 photographs are shown in the Figure. The 2 questions for each photograph ( items) were as follows: 1. The arrangement of teeth in this photograph is: (1 very good looking, 2 good looking, 3 satisfactory, 4 not good, and 5 not good at all) 2. Would you be happy if the arrangement of your teeth was like that of the teeth in this photograph? (1 very happy, 2 happy, 3 normal, 4 unhappy, and 5 very unhappy). One investigator (E.A.M.) administered the questionnaire in the classroom on the scheduled days. The teacher gave a brief introduction about the investigator to the children. The investigator answered any questions. Subsequently, the investigator conducted a clinical examination of the participating children using the IOTN. 24 Of the 400 children, 295 (73.8%) (45% girls, 55% boys) participated in the clinical examinations; 2 extraoral and 3 intraoral photographs were also taken. Before the data collection, the investigator received thorough methodology training for IOTN measurements at the University of Manchester (United Kingdom) and the University of Nijmegen (The Netherlands). Intraexaminer and interexaminer consistency for the IOTN was studied by using double determinations from the dental casts of 20 children with 18 days between investigators (E.A.M. and A.M.K.J.); this was expressed as the kappa reliability coefficient.

3 428 Mugonzibwa et al American Journal of Orthodontics and Dentofacial Orthopedics April 2004 Fig. Intraoral frontal photographs used in study. Data processing and analysis were carried out with the SPSS statistical package (SPSS, Chicago, Ill). Frequencies and means for various variables were obtained. Factor analysis, t test, multiple regression, and analysis of variance (ANOVA) were used to analyze the data. The 2 questions per intraoral photograph (18 photographs 2 questions 36 items) were subjected to principal component analysis, generating 4 factors that were checked by the Cronbach for reliability. Correlations between various variables including the 4 factors and both the AC and the dental health component (DHC) of the IOTN for the clinically examined children were calculated. A nonparticipation analysis for those who refrained from the clinical oral examination was done by using the t test for independent samples. RESULTS Of the 400 children who responded to the questionnaire, 14 (3.5%) were excluded from the analyses due to incomplete data. The distribution of the subjects according to age and sex is given in Table I. None of the children had been treated orthodontically. About three quarters 295 (73.8%) of the children who responded to the questionnaire also agreed to participate in the clinical examination. Twenty-six percent of

4 American Journal of Orthodontics and Dentofacial Orthopedics Volume 125, Number 4 Mugonzibwa et al 429 Table I. Number, age, and sex of children Age (y) Girls Boys Total n % n % n % Total Table II. Characteristics of respondents parents Mothers Fathers n % n % Educational status Primary education and below Secondary education University education Unknown Employment status Peasant and home job Traders / business Employed in office Unknown the children refrained from clinical examination mainly because they did not like the lip retractors used for the intraoral photographs. When a t test for independent samples was used to analyze the difference between children with and without clinical data, the only significant difference was age, with older children refraining more often from the clinical examination (P.003). Table II shows the education and employment status of the children s parents. About 31% of the mothers had primary education or less. The percentage of parents with university educations was relatively high compared with the general Tanzanian population. More than 60% of the mothers and 75.6% of the fathers had regular jobs. Both intraexaminer and interexaminer reproducibility for the AC of the IOTN was excellent, with kappa values ranging from 0.82 to 0.99 (SE 0.13) and 0.66 to 0.82 (SE 0.13), respectively. 25,26 For the DHC of the IOTN, both the intraexaminer and interexaminer reproducibility was almost perfect, with kappa values ranging from 0.71 to 0.81 (SE 0.12) and 0.90 to 0.91 (SE 0.09), respectively. Clinical AC and DHC scores for the children are shown in Table III. According to the AC, about 11% of the children who were examined clinically were found to need orthodontic treatment; more than one quarter of the children fell in the group of moderate/borderline need for orthodontic treatment. A higher proportion of children, 22%, needed orthodontic treatment (grades 4 Table III. Percentage and 95% confidence intervals of respondents clinical grades for AC and DHC of the IOTN (n 295) Treatment need n % 95% CI AC grades 1 4 No/slight need (54, 66) 5 7 Moderate/borderline need (24, 35) 8 10 Need (8, 15) DHC grades 1 No need (25, 36) 2 Little need (10, 19) 3 Borderline need (29, 40) 4 Need (19, 28) 5 Need 11 4 (2, 7) Table IV. Responses to questions on subjective treatment need and perception of malocclusion Questions N % % % Do you need orthodontic treatment? Are you happy with the arrangement of your anterior teeth? Are you happy with the appearance of your own teeth compared to the teeth of your peers? Do you consider wellaligned teeth important for overall facial appearance? Yes No Don t know Happy Normal Unhappy Important Doesn t Not matter Important and 5), according to the DHC. Moderate/borderline treatment need was found in 34% of the children. A definite need for orthodontic treatment was assessed in 11% of the children who had both grades 8-10 of the AC and 4-5 of the DHC. Table IV shows the frequencies of the questions on subjective need, satisfaction with the arrangement and the appearance of the teeth, and the importance of well-aligned teeth. Thirty eight percent of the children perceived that their own teeth needed orthodontic treatment. This subjective need was correlated with the objective need as measured by AC score 8-10 and DHC score 4-5, with correlation coefficients of 0.21 (P.001) and 0.13 (P.03), respectively. The influence of the DHC disappeared after correcting for the AC due to

5 430 Mugonzibwa et al American Journal of Orthodontics and Dentofacial Orthopedics April 2004 Table V. Factors for respondents opinions on 18 intraoral frontal photographs Factor Description Photographs Factor loadings in own factor (Range) Crohnbach s 1 Normal 1, Spacing with overbite 2 mm or open bite 12, 13, 14, 15, 16* Spacing with overbite 2 mm 3, 4, 5, 6, 7, Severe deviations including crowding 8, 10, 11, 17, *Photograph showing open bite without spacing having factor loading of Table VI. Scores for questions about respondents opinions on 18 intraoral photographs (higher scores indicate less attractive occlusion) Photograph number Factor Attractiveness* Mean SD Happiness** Mean SD Overall Mean SD 1 Normal Spacing with overbite 2 mm Spacing with overbite 2 mm or open bite Severe deviations including crowding *Scale (1 very good looking, 2 good looking, 3 satisfactory, 4 not good, and 5 not good at all) **Scale (1 very happy, 2 happy, 3 normal, 4 unhappy, and 5 very unhappy). the high correlation between the AC and the DHC (r 0.58). The parents education and employment variables had no influence on subjective treatment need. About one fifth of the children were unhappy with the arrangement or the appearance of their teeth (17% and 23%, respectively). The satisfaction with arrangement and appearance of teeth showed a significant correlation with the AC and the DHC of the IOTN, ranging from 0.22 to 0.26 (all P.0001). After correcting for the AC, the correlation with the DHC disappeared. The satisfaction was not correlated with the children s age or sex and parental education or occupation. The importance of well-aligned teeth was recognized by 85% of the children (58% rated this very important, and 27% rated it important). This variable was significantly correlated with age (r 0.14, P.006); older children considered well-aligned teeth more important. No significant correlation with other background variables was found. A principal component analysis generated 4 factors for the respondents opinions on the attractiveness of 18 intraoral photographs that could be clearly interpreted, as shown in Table V. The analyses reduced the 36 items (18 photographs 2 questions) to 4 factors: normal occlusion, spacing with overbite 2 mm or open bite, spacing with overbite 2 mm, and severe deviations including crowding. The 4 factors had high reliability coefficients (Cronbach ranging from 0.70 to 0.89). Table VI shows the mean scores for the children s opinions on attractiveness of the 18 intraoral frontal photographs. Generally, the children considered severe deviations including crowding (factor 4) as unattractive. They generally liked the photographs of normal occlusions (factor 1), and the means of the opinions about spacing with overbite 2 mm (factor 2) and

6 American Journal of Orthodontics and Dentofacial Orthopedics Volume 125, Number 4 Mugonzibwa et al 431 overbite 2 mm or open bite (factor 3) fell in the middle of the scale with a tendency toward unattractiveness. For the question would you be happy if the arrangement of your teeth was like this photograph? the answers were comparable. ANOVA and regression analyses were applied to explain the attractiveness of the photographs sum scores from the background variables age, sex, AC, DHC, parental education, and parental occupation. Older children tended to dislike severe deviations (including crowding) the most. The parents education and employment variables had no statistically significant influence on the children s opinions of dental attractiveness. DISCUSSION In this cross-sectional study, perceptions of orthodontic treatment need and opinions on dental attractiveness among Tanzanian children were evaluated in randomly selected school children aged 9 to 18 years in Dar es Salaam. The study was conducted in public schools, which generally have children from a wide range of social backgrounds. The sample does not represent the whole Tanzanian population of this age group but, rather, gives an overview of the potential Tanzanian orthodontic service consumers in an urban area. The response rate to the questionnaire was 100%, and 96.5% of the returned questionnaires could be used in the data analyses. However, 26% of the children who filled out the questionnaire refrained from the clinical examination because they were uncomfortable with the clinical picture taking. The reasons were teasing by other children when the lip retractors were used, distrust of the future use of the photographs, and HIV precautions. On analyzing the nonparticipating children, it was found that older children tended to refrain more often from clinical examination than younger ones. No other differences were found, so that the nonparticipating subjects did not appear to bias the results of the study. Intraoral photographs were used to judge the dental attractiveness by the respondents. It has been previously shown that dental photographs can be valid representations of dental attractiveness. 27 Furthermore, visual stimuli might be more useful than verbal descriptions in communicating with children. According to the AC of the IOTN, Tanzanian children had a higher need of treatment than did British and Turkish children (2% and 5%, respectively) The objective need for orthodontic treatment according to the DHC in this study was 22% similar to that reported for British children, 29 but lower than the 32% to 53% reported by various researchers using the same index in British children and other populations. 28,30-33 The only African study using the IOTN reported a lower need for treatment 13% for Nigerian children aged 12 to18 years. 34 With regard to the 2 components of the IOTN, 22% of the children needed orthodontic treatment on the basis of the DHC compared with 11% for the AC. A definite need for orthodontic treatment (grades 8-10 of the AC and grade 4-5 of the DHC) was found in 11% of the children; this is close to the reported need among young adults in Finland. 34 The results on objective need for orthodontic treatment in this study provide baseline data for planning orthodontic services in Tanzania. In the present study, 38% of the children expressed a subjective need for orthodontic treatment. The subjective orthodontic treatment need was related to the objective treatment need (AC and DHC) but was influenced more by the AC than the DHC, indicating that the children in this age group can make objective evaluations of their teeth. On the other hand, 12% of the subjects did not know whether they needed orthodontic treatment. This could be due to the children s lack of exposure to orthodontics and perhaps language barriers that resulted in misunderstanding the questions. Also, this could be attributed to low frequencies of malocclusion reported among Tanzanian children 18,34-37 and inexperience with or unavailability of organized orthodontic care in the country. In earlier studies, it was found that perceived need of orthodontic treatment varies with social and cultural conditions. 13,21 It has been suggested that the public s assessment of dental irregularity and perception of psychological and sociological implications of malocclusion become more critical when orthodontic services are readily available. 13 In populations whose general perceived need and use of dental services and orthodontic treatment exposure are low, it is necessary to investigate the perceptual awareness of malocclusion before an orthodontic care system is developed. Some children were unhappy with both the arrangement (17%) and the appearance (23%) of their teeth, although satisfaction was correlated with their clinical grades of the AC and the DHC. The children who were unhappy with the arrangement and appearance of their teeth had higher clinical scores of the AC. This has also been shown in other studies in which dissatisfaction with dental appearance was generally related to the severity of the occlusal irregularities. 1,8,9,38 This finding underlines the usefulness of the AC when evaluating need for treatment. Most children (85%) recognized the importance of well-aligned teeth for overall facial appearance. This agrees with a number of authors 10,13,19 who suggested that teenagers have developed an oral perceptual aware-

7 432 Mugonzibwa et al American Journal of Orthodontics and Dentofacial Orthopedics April 2004 ness. Concern over appearance and facial attractiveness seems to develop during adolescence. The subjects in the present sample might have been well aware of their own physical appearance of which dental appearance is an essential component. It was surprising that sex was unrelated to satisfaction with dental appearance. Earlier studies have shown that girls are more particular in their self-evaluations, 1,39 are more often dissatisfied with their dental arrangements, 40 and value dental appearance highly. 41 Although our results might reflect cultural and educational differences, other explanations could be that the frequency of malocclusion in the Tanzanian population is low, 18,34-37 whereas orthodontic treatment, which can increase orthodontic awareness, 41 is uncommon. This study indicated that photographs of severe deviations including crowding were perceived as less attractive. The results parallel previous studies with photographs that show crowding. 2,15,42 Contrary to these previous reports, in the present study, spacing fell in the middle of the scale with only a tendency toward unattractiveness. The respondents perceived photographs 1 and 2 of normal occlusions as attractive. Our finding supports the premise that people seem to share a common basis for dental esthetic judgment regardless of nationality, age, sex, or occupation. 12,43 Although orthodontics is not a well-established oral health discipline in Tanzania, television, films, newspapers, and magazines all provide daily reinforcement for facial stereotypes. CONCLUSIONS Tanzanian children with a higher objective need of treatment had also a higher subjective need of treatment and were unhappy with the arrangement and appearance of their teeth. Most children recognized that well-aligned teeth are important for facial appearance. Children perceived severe deviations as the most unattractive, suggesting that, from the children s point of view, grades 8-10 of the AC and 4-5 of the DHC could be given the first priority when considering a nationwide orthodontic treatment policy in this society with limited resources. More studies involving children from different areas of the country, especially rural settings, are recommended. REFERENCES 1. Shaw WC. The influence of children s dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981;79: Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthod 1985;87: Bravo LA. Soft tissue facial profile changes after orthodontic treatment with four premolars extracted. Angle Orthod 1994;64: Farrow AL, Zarrinnia K, Azizi K. Bimaxillary protrusion in black Americans: an esthetic evaluation and the treatment considerations. Am J Orthod Dentofacial Orthop 1993;104: Polk MS, Farman AG, Yancey JA, Gholston LR, Johnson BE, Regennitter FJ. Soft tissue profile: a survey of African-American preference. Am J Orthod Dentofacial Orthop 1995;108: Mantzikos T. Esthetic soft tissue profile preferences among the Japanese population. Am J Orthod Dentofacial Orthop 1998;114: Otuyemi OD, Ogunyika A, Dosumu O, Cons NC, Jenny J, Kohout FJ, et al. Perceptions of dental aesthetics in the United States and Nigeria. Community Dent Oral Epidemiol 1998;26: Tedesco LA, Cunat JJ, Lewis EA, Slaker MJ. A dentofacial attractiveness scale. Am J Orthod 1983;83: Burden DJ, Pine CM. Self-perception of malocclusion among adolescents. Community Dent Health 1995;12: Shaw WC, Lewis HG, Robertson NRE. Perception of malocclusion. Br Dent J 1975;138: Kiyak HA. Comparison of esthetic values among Caucasians and Pacific Asians. Community Dent Oral Epidemiol 1981;9: Cons NC, Jenny J, Kohout FJ, Freer TJ, Eismann D. Perceptions of occlusal conditions in Australia, the German Democratic Republic and the United States of America. Int Dent J 1983;33: Tulloch JFC, Shaw WC, Smith A. A comparison of attitudes towards orthodontic treatment in British and American communities. Am J Orthod 1984;85: Helm S, Petersen PE, Kreiborg S, Solow B. Effect of separate malocclusion traits on concern for dental appearance. Community Dent Oral Epidemiol 1986;14: Kerosuo H, Hausen H, Laine T, Shaw WC. The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Eur J Orthod 1995;17: Kerosuo H. Occlusion in the primary and early mixed dentition in a group of Tanzanian and Finnish children. J Dent Child 1990;57: Kerosuo H, Laine T, Honkala E, Nyyssönen V. Occlusal characteristics among groups of Tanzanian and Finnish urban school children. Angle Orthod 1991;6: Mugonzibwa EA, Kuijpers-Jagtman AM, Eskeli R, Laine-Alava MT, Van t Hof MA. Occlusal characteristics and anomalies in African and Caucasian children. Eur J Orthod 2004; in press. 19. Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of dental features among school children. Br J Orthod 1980;7: Mandall NA, Wright J, Conboy FM, O Brien KD. The relationship between normative orthodontic treatment need and measures of consumer perception. Community Dent Health 2001;18: Wheeler TT, McGorray SP, Yurkiewicz L, Keeling SD, King GJ. Orthodontic treatment demand and need in third and fourth grade schoolchildren. Am J Orthod Dentofacial Orthop 1994;106: Birkeland K, Boe OE, Wisth PJ. Relationship between occlusion and satisfaction with dental appearance in orthodontically treated and untreated groups. A longitudinal study. Eur J Orthod 2000;22: Evans R, Shaw WC. Preliminary evaluation of an illustrated scale for rating dental attractiveness. Eur J Orthod 1987;9:314-8.

8 American Journal of Orthodontics and Dentofacial Orthopedics Volume 125, Number 4 Mugonzibwa et al Richmond S, O Brien D, Buchanan B, Burden DJ. An introduction to occlusal indices. Manchester: Mandent Press; Cohen J. A coefficient of agreement for nominal scales. Educ Psych Meas 1960;20: Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33: Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiological use. Am J Orthod 1985;88: Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989;11: Burden DJ, Holmes A. The need for orthodontic treatment in a child population of the United Kingdom. Eur J Orthod 1994;16: Ucuncu N, Ertugay E. The use of the index of orthodontic treatment need (IOTN) in a school population and referred population. J Orthod 2001;28: Holmes A. The prevalence of orthodontic treatment need. Br J Orthod 1992;19: So LL, Tang EL. A comparative study using the occlusal index and the index of orthodontic treatment need. Angle Orthod 1993;63: Otuyemi OD, Ugboko VI, Adekonya-Sofowora CA, Ndukwe KC. Unmet orthodontic treatment need in rural Nigerian adolescents. Community Dent Oral Epidemiol 1997;25: Kerosuo H, Kerosuo E, Niemi M, Simola H. The need for treatment and satisfaction with dental appearance among young Finnish adults with and without a history of orthodontic treatment. J Orofac Orthop 2000;61: Mugonzibwa EA, Mumghamba E, Rugarabamu P, Kimaro S. Occlusal and space characteristics among 12-year-old school children in Bukoba and Moshi, Tanzania. African Dent J 1990; 4: Mugonzibwa EA. Variation in occlusal and space characteristics in a series of 6- to 18-year-olds, in Ilala district, Tanzania. African Dent J 1992;6: Mugonzibwa EA. Occlusion survey in a group of Tanzanian adults. African Dent J 1993;7: Mandall NA, McCord JF, Blinkhorn AS, Worthington HV, O Brien KD. Perceived aesthetic impact of malocclusion and oral self-perception in year-old Asian and Caucasian children in Greater Manchester. Eur J Orthod 1999;21: Holmes A. The subjective need and demand for orthodontic treatment. Br J Orthod 1992;19: Pietila T, Pietila I. Dental appearance and orthodontic services assessed by year-old adolescents in eastern Finland. Community Dent Health 1996;13: Baldwin DC. Appearance and aesthetics in oral health. Community Dent Oral Epidemiol 1980;8: Soh G, Lew K. Assessment of orthodontic treatment needs by teenagers in an Asian community in Singapore. Community Dent Health 1992;9: Cons NC, Jenny J. Comparing perceptions of dental esthetics in the USA with eleven ethnic groups. Int Dent J 1994;44: COMMENTARY Despite the difficulties of conducting this type of study, the authors have provided some important epidemiologic data on objective and subjective orthodontic need in a sample of African students that might be useful to the government of Tanzania, local dental health professionals, and the World Health Organization. The only qualification might be that this sample appears to be from an upper-class group of urban students with relatively educated parents and might therefore be different from the general population of Tanzania. This study also provides further evidence of the often considerable gap between orthodontically defined need and patients perceived need for treatment. Even though the IOTN extends beyond clinically identifiable morphological and functional factors by including the AC, several concerns still remain for this and similar studies that have attempted to relate clinicians objective assessments to patients subjective perceptions. 1,2 Except for the quantitative linear, angular, or proportional measurements that can be made objectively by clinician examiners, all other evaluations are qualitative and subjective, whether by clinicians or patients ratings, rankings, or categorization. A related problem for this study could be the comparison of the examiners evaluations of the AC with the patients perceptions using an expanded AC. Both evaluations are subjective, but they apparently were using different criteria. The validity and reliability of these instruments might have been compromised because the clinician examiners used the original 10 photos, but the students were asked to respond to 8 additional photos that reflected specific deviations found in Tanzania. It would be interesting to know more about the responses to the 8 additional photos. Moreover, one can question whether Tanzanian students know what alignment or orthodontic treatment is. Worldwide, orthodontists have struggled with the paradox of diagnosis and treatment being based on morphological considerations, while patient decisions are based on expectation and satisfaction with esthetic outcome and other subjective factors. 3 Only if the clinician and the patient can communicate about expectations of treatment outcome by responding to the same representation of the patient s facial morphology can the clinician develop an acceptable treatment plan. 4 Therefore, a more standardized procedure is needed for relating objective need to subjective demand that can be used for comparisons across sex, age, and ethnocultural group. One psychophysical possibility suggested earlier by Giddon et al, 5 which differs from the binary tabulation of perceptions by questions in this article, is to represent the relationship graphically with anthropometric data such as millimeters of overjet on the X-axis and percentages of clinicians or patients responding as attractive or acceptable on the Y-axis to each X increment while holding all other variables constant. The resulting slopes and 50% (point of

9 434 Mugonzibwa et al American Journal of Orthodontics and Dentofacial Orthopedics April 2004 subjective equivalence) intercepts can then be used to compare various groups of patients or clinicians. This procedure can also provide the anthropometric bases for other subjective classifications of physical appearance, such as pretty, beautiful, and ugly. Ultimately, a database of subjective or perceived need can be created to complement those based on objective need. Although the authors contend that their finding supports the premise that people seem to share a common basis for dental esthetic judgment regardless of nationality, age, sex, or occupation, there are still some obvious differences from similar studies in Western countries. As pointed out by the authors, diastemata are not of great concern to these Tanzanian students and might be a mark of distinction, perhaps more so in less Westernized segments of the population. The correlation of 0.14 between well-aligned teeth with age is not impressive, regardless of significance. Their finding of no apparent sex differences is also striking; this is quite different from Western countries, in which female adolescents are considerably more concerned than males about appearance generally and the orofacial area specifically. This disparity could, however, be due to the relatively lower influence of the Western-dominated media, which emphasize an attractive smile with well-aligned teeth without diastemata. Finally, these authors provide further evidence that clinicians should be sensitive to cultural differences between what they and their patients consider esthetically pleasing, particularly when the clinicians training and cultural background differ from those of their patients. 6-8 Donald B. Giddon, DMD, PhD Wellesley, Mass Am J Orthod Dentofacial Orthop 2004;125: /$30.00 Copyright 2004 by the American Association of Orthodontists. doi: /j.ajodo REFERENCES 1. Grzywacz I. The value of the aesthetic component of the index of orthodontic treatment need in the assessment of subjective orthodontic treatment need. Eur J Orthod 2003;25: Hunt O, Hepper P, Johnston C, Stevenson M, Burden D. The aesthetic component of the index of orthodontic treatment need validated against lay opinion. Eur J Orthod 2002;24: Giddon DB. Orthodontic applications of psychological and perceptual studies of facial esthetics. Semin Orthod 1995;1: Miner RM, Anderson NK, Giddon DB. Comparison of children s computer-imaged profiles as perceived by patient, parent and clincian. American Association of Orthodontists On-Site Program, Toronto, Ontario, Canada, May 5, p. 62, #5. 5. Giddon DB, Mosier M, Colton T, Bulman JS. Quantitative relationship between perceived and objective need for health care. Dentistry as a model system. Public Health Rep 1976;91: Hall D, Taylor RW, Jacobson A, Sadowsky PL, Bartolucci A. The perception of optimal profile in African Americans versus white Americans as assessed by orthodontists and the lay public. Am J Orthod Dentofacial Orthop 2000;118: Park YS, Evans CA, Viana G, Giddon DB, Anderson NK. Profile preferences of Korean-American orthodontic patients and orthodontists. Abstract #110, American Association of Dental Research, San Antonio, Tex, March 13, Scott JH, Johnston LE Jr. The perceived impact of extraction and nonextraction treatments on matched samples of African American patients. Am J Orthod Dentofacial Orthop 1999;116: RECEIVE THE JOURNAL S TABLE OF CONTENTS EACH MONTH BY To receive the tables of contents by , send an message to majordomo@mosby.com Leave the subject line blank and type the following as the body of your message: Subscribe ajodo_toc You may sign up through our website at You will receive an message confirming that you have been added to the mailing list. Note that TOC s will be sent when a new issue is posted to the website.