Orthodontic treatment need in the Italian child population

Orthodontic treatment need in the Italian child population C. GRIPPAUDO, E.G. PAOLANTONIO, R. DELI, G. LA TORRE* ABSTRACT. Aim To assess orthodontic treatment need in the Italian child population using the R.O.M.A. (Risk Of Malocclusion Assessment) Index. Study Design Observational study (cross-sectional). Materials, Methods and Results The ROMA Index was used in examining a sample of 420 children (214 males and 206 females; mean age: 9.3 years), none of whom had previously undergone orthodontic treatment. This basic sample was large enough to become the object of an epidemiological study and to be analysed through inferential statistics. After calculating the prevalence of malocclusion on the basis of the degrees of orthodontic risk determined by the Index, we evaluated the distribution of the most frequent characteristics, signs and symptoms within each risk grade. The percentage of children in each risk category was then worked out, together with its 95% confidence interval, in order to verify whether our results could be generalised to the reference population. Significantly, 50% of the examined children were classified as at moderate risk, as defined by grade 3 of the Index (non-severe alterations in dental and/or skeletal relationships, but tending to persist and often worsen with growth). Equally remarkably, a further 36% fell within grade 4 of the Index ( great risk ), presenting major craniofacial skeletal malformations and alterations of the occlusion, often in association with systemic or growth disorders likely to worsen the prognosis. Thus, since patients at moderate or great risk amounted to 86% of the basic sample, it appears that our estimate can be generalised to the reference population of Italian pre-adolescent children. Conclusion The study showed a high percentage of children at moderate or great risk (86%), and that this estimate can be generalised to the reference population of Italian pre-adolescent children. These findings should be taken into great account in devising strategies to improve patient service quality, whether in public or private settings, and also in planning preventive measures and interventions. KEYWORDS: Orthodontic treatment need index, Risk of malocclusion, Growing child. Introduction Many studies have reported the prevalence of malocclusions in children and adolescents of various ethnic groups. Review of the literature has shown that there are widely variable estimates of the prevalence, ranging from 45% [Kerosuo et al., 1988] to 93% [Lew et al., 1993]. This wide range may be due to differences between specific ethnic groups, as well as to discordances in recording methods and criteria used to establish treatment need. However, the estimates still represent the large number of individuals requiring orthodontic treatment. Several indices have been developed [Draker, 1960; Salonen et al., 1966; Cons and Jenny, 1966; Grainger, 1967; Salzmann, 1968; Summers 1971; Brook and Shaw, 1989; Danish Department of Orthodontics, Catholic University of the Sacred Heart, Rome, Italy *Epidemiology and Biostatistics Unit, Institute of Hygiene Catholic University of the Sacred Heart, Rome, Italy e-mail: c.grippaudo@rm.unicatt.it National Board of Health, 1990; Espeland, 1992; Russo et al., 1998; Daniels and Richmond, 2000] to identify the individuals in special need of orthodontic treatment (Table 1), on the grounds of the potential damage a detected malocclusion might cause [Taylor, 1993]. They are widely used in those countries where orthodontic treatment costs are partially or fully covered by the national health system and by most insurance companies. These indices are usually limited to estimating the incidence of the different problems detected, assigning each a score based on immediate treatment need. They have been criticised as not being easy to use, insofar as requiring a long time, complicated calculations and qualified staff for data collection [Tang and Wei, 1993]. Moreover, lacking components to grade skeletal problems, they seem really appropriate for use just in permanent dentition and in examining patients whose growth is already complete, rather than across all age ranges. However, in young patients orthodontic problems are not restricted to dental disorders, being often EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 9/2-2008 71

C. GRIPPAUDO ET AL. INDICES AUTHORS YEAR Handicapping Labiolingual Deviation Index (HLDI) Draker HL 1960 Grade Index Scale For Assessment of Treatment Need (GISATN) Salonen L, Mohlin B, Gotzlinger B 1966 Dental Aestetic Index (DAI) Cons NC, Jenny J 1966 Treatment Priority Index (TPI) Grainger RM 1967 Handicapping Malocclusion Assessment Record (HMAR) Salzmann JA 1968 Occlusal index (OI) Summers CJ 1971 Index of Orthodontic Treatment Need (IOTN) Brook PH, Shaw WC 1989 Memorandum of Orthodontic Screening and Danish National Board of Health 1990 Indications for Orthodontic Treatment Need for Orthodontic Treatment Index (NOTI) Espeland LV, Ivarson K, Stenvik A 1992 Risk Of Malocclusion Assessment (ROMA) Index Russo E, Grippaudo C, Marchionni P, Deli R 1998 Index of Complexity, Outcome and Need (ICON) Daniels C, Richmond S 2000 TABLE 1 - Indices of orthodontic treatment need. accompanied by altered underlying bone relationships and closely related to cranio-facial growth and development. That is why the age and stage of development of the patient entail different degrees of risk of malocclusion, accompanied by negative effects on the masticatory function. The R.O.M.A. Index (Risk Of Malocclusion Assessment Index) [Russo et al., 1998] is a tool to assess treatment need in young patients. Taking into account the negative effects of malocclusion on both the dento-skeletal apparatus and on psycho-social wellbeing, the index, previously validated [Grippaudo et al., 2007], identifies five grades (Table 2), ranked in increasing order of malocclusion severity, or rather, according to whether there is a higher or lower risk of dysfunction. Unlike other indices, the R.O.M.A. Index was specifically devised for use in examining young patients, in an attempt to grade, beside malocclusions, also skeletal and functional aspects, which, in children, are determinants of oro-facial development. The index is also intended as a tool to prevent the patient s condition from worsening, to estimate the length of treatment, and to help choosing treatment timing. As a guide to clinical signs of malocclusion (which, once detected, entail a greater or lesser need for orthodontic intervention) it identifies five risk grades, ranked in increasing order of severity. The score is assigned based on the most severe feature noted during examination. The aim of this study is to assess the prevalence of malocclusion and the related orthodontic treatment need in a sample of Italian pre-adolescents using the R.O.M.A. Index. Materials and methods The R.O.M.A. Index was used in examining 420 children: 214 males and 206 females with a mean age of 9.3 years (range 4.4 to 12.7). In detail, 257 were patients of the Agostino Gemelli General Hospital in Rome: 214 of the Orthodontic Service located in the Department of Dentistry; 43 of the Paediatric Outpatient Department. The remaining 163 were primary school students (67 from Rome and 96 from Calabria). None of them had previously undergone orthodontic treatment. The patient sample was large enough to become the object of an epidemiological study and to be analysed through inferential statistics. To this purpose, this basic sample was divided into two sub-samples: the 214 children examined in the Department of Dentistry (sub-sample A), and the 206 examined in the Paediatric Outpatient Department or the two primary schools (sub-sample B). After calculating the prevalence of malocclusion on the basis of the degrees of orthodontic risk determined by the Index, we evaluated the distribution of the most frequent characteristics, signs and symptoms both within each risk grade and The percentage of children in each risk category was then worked out, together with its confidence interval, in order to verify whether our results could be generalised to the reference population. Results Analysis of the data (Table 3) showed that the percentage of grade 4 children was higher in sub- 72 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 9/2-2008

MALOCCLUSION RISK ASSESSMENT TABLE 2 - R.O.M.A. Index. GRADE 5 Systemic Problems Malformation syndromes 5a Congenital malformations 5b GRADE 4 Systemic Problems Postural/orthopaedic problems 4c Medical/auxological problems 4d Familial tendency for malocclusion 4e Facial or mandibular asymmetries 4f Articular dysfunctions 4g Sequelae of traumas or surgery of the cranio-facial district 4j Maxillary hypodevelopment or mandibular hyperdevelopment (OVJ <0 mm) 4k Maxillary hyperdevelopment or mandibular hypodevelopment (OVJ >6 mm) 4h Mandibular hypo- or hyperdivergence 4i Scissor bite 4m Anterior or posterior cross-bite >2mm 4n Displacement >4 mm 4o Open-bite >4 mm 4p Hypodontia of permanent dentition 4q GRADE 3 Maxillary hypodevelopment or mandibular hyperdevelopment (OVJ >0 mm) 3k Maxillary hyper- or mandibular hypodevelopment (3 mm<ovj<6 mm) 3h Caries and early loss of deciduous dentition 3l Anterior or posterior cross-bite >1 mm 3n Displacement >2 mm 3o Open-bite >2 mm 3p OVB >5mm 3r GRADE 2 Maxillary hyper- or mandibular hypodevelopment (0 mm<ovj<3 mm) 2h Anterior or posterior cross-bite <1 mm 2n Displacement >1 mm 2o Open-bite >1 mm 2p Permutation anomalies 2s Poor oral hygiene 2t Normal mesial or distal occlusion (up to a cuspid) 2u Functional Problems Functional asymmetries 2v Bad habits 2w Mouth breathing 2x GRADE 1 None of the problems listed above N sample A than in sub-sample B (43% vs 29%). Indeed, sub-sample A included more individuals classified in higher risk categories (grade 3 = 43%; grade 4 = 43%; grade 5 = 4%), being comprised of patients of the Department of Dentistry, most of whom had deliberately come to the Clinic to undergo orthodontic treatment. In sub-sample B, 59% of the children were at moderate risk and 29% at great risk, and none at extreme risk. The cumulative percentage frequency of grades 1 and 2 was 12%, close to that in sub-sample A (11%). The 95% confidence intervals relating to the largest groups are narrow enough to suggest that the percentage estimates can be generalised to the reference population of each sub-sample (Table 3). In the basic sample, the main disorders were maxillary hyperdevelopment/mandibular hypodevelopment (4h, 3h, 2h) and increased overbite (3r) (Fig. 1). There was a considerable frequency of problems relating to oral hygiene and bad habits in the lower grades of the index (Fig. 2), but these do not necessarily imply dento-skeletal disharmony. And, indeed, it was the higher risk grades that included more skeletal and dental problems (Fig. 3, 4). In this regard, it is quite remarkable that 50% of the examined children were classified as at moderate risk, as defined by grade 3 of the Index (non-severe alterations in dental and/or skeletal relationships, but tending to persist and often worsen with growth). Significantly, a further 36% fell within grade 4 of the Index ( great risk ), presenting major cranio-facial skeletal malformations and alterations of the occlusion, often in association with systemic or growth disorders likely to worsen the prognosis (Fig. 5). Thus, since patients at moderate or great risk 0,14 0,12 0,1 0,08 0,06 0,04 0,02 0 2h 2t 2u 3h 3l 3n 3r 4h FIG. 1 - Characteristics of the most frequent malocclusions EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 9/2-2008 73

C. GRIPPAUDO ET AL. GRADE PATIENTS PERCENTAGE < 95% CI LIMIT > 95% CI LIMIT SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE A B A B A B A B 1 1 3 0% 1% 0% 0% 1% 2% 2 23 22 10% 11% 6% 6% 14% 15% 3 91 121 43% 59% 36% 52% 50% 66% 4 91 60 43% 29% 36% 23% 50% 35% 5 9 0 4% 0% 2% 0% 6% 0% TOTAL 214 206 TABLE 3 - Inference in sub-samples A and B. G R A D E 2 G R A D E 4 2 20 % 2 1 % 28% 2 0 % 2 20 % 22% 26% 1 10 % 0 % 6 % 3 % 6% 4% 5% 1 % 2 h 2 n 2 o 2 p 2 s 2 t 2 u 2 v 2 w 2 x 1 10 % 0% 3% 1% 13% 11% 2% 1% 0% 6% 6% 7% 4 c 4 d 4 e 4 f 4 g 4 j 4 k 4 h 4 m 4 n 4 o 4 p FIG. 2 - Distribution of the characteristics of risk grade 2 FIG. 4 - Distribution of the characteristics of risk grade 4 G R A D E 3 45% 40% 35% 25% 20% 1 10% 0 % 42 % 21 % 12 % 11 % 9 % 2 % 3 % 3 k 3 h 3 l 3 n 3 o 3 p 3 r FIG. 3 - Distribution of the characteristics of risk grade 3 FIG. 5 - Distribution of risk grades amounted to 86% of the basic sample, it appears that our estimate can be generalised to the reference population of Italian pre-adolescent children. Discussion Unlike other European and North American indices of orthodontic treatment need, the ROMA Index specifically targets the problems of patients in the age of development. Being intended not only to measure the severity of the malocclusion, but also to provide information regarding the best time for intervention, it is a useful tool for making concise clinical diagnosis, planning therapy and choosing treatment timing. For 74 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 9/2-2008

MALOCCLUSION RISK ASSESSMENT this study, we tested it on a sample of 420 Italian children, in order to assess orthodontic treatment need in the Italian child population. The management and planning of orthodontic treatment within public health settings require precise information on the treatment needs of the population. The results of this study show that 86% of the examined children were at moderate or great risk, and that this estimate can be generalised to the reference population of Italian pre-adolescent children. These findings should be taken into great account in devising strategies to improve patient service quality, whether in public or private settings, and also in planning preventive measures. The observation of a large number of child patients with major orthodontic problems confirms that intervention is often needed before the pubertal peak and the end of occlusal development. In such cases, early therapy is also intended as a preventive measure, to avoid more complex treatment in the future and worsening case prognoses. Conclusion R.O.M.A. index is a new tool, created to evaluate the priorities of orthodontic treatment in childhood. Its goal is to answer the questions: why and when is the time to start an orthodontic treatment? It takes into account the importance of the signs of malocclusion at the present and in a future perspective. The authors are testing it to evaluate its efficiency and find out how it can be improved in the future. References Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. European Journal of Orthodontics 1989; 11: 309-20. Cons NC, Jenny J. Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale. Australian Dent J 1966; 41: 43-6. Daniels C, Richmond S. The development of the Index of Complexity, Outcome and Need (ICON). Journals of Orthodontics 2000; 27:149-62. Danish National Board of Health. Memorandum of orthodontic screening and indications for orthodontic treatment. P.O. Box 2020, DK-1012 Copenhagen K, 1990. Draker HL. Handicapping labiolingual deviations: a proposed index for public health purposes. Am J Orthod 1960; 46: 295-305. Espeland LV, Ivarson K, Stenvik A. A new Norwegian index of orthodontic treatment need related to orthodontic concern among 11-years old and their parents. Comm Dent Oral Epid 1992; 20: 274-9. Grainger RM. Orthodontic treatment priority index. PHS publication no 1000, Series 2, No 25. US Government Printing Office, Washington, 1967. Grippaudo C, Paolantonio EG, Deli R, La Torre G. Validation of the Risk Of Malocclusion Assessment (ROMA) Index. European Journal Of Paediatric Dentistry 2007; n.3 (8): 136-42. Kerosuo H, Laine T, Kerosuo E, Nagassapa D, Honkala E. Occlusion among a group of Tanzanian and Finnish urban schoolchildren. Community Dentistry and Oral Epidemiology 1988; 16 :306-309. Lew KK, Foong WC, Loh E. Malocclusion prevalence in an ethnic Chinese population. Australian Dental Journal 1993; 38: 442-449. Russo E, Grippaudo C, Marchionni P, Deli R. Il ROMA index come metronomo della terapia ortodontica nel paziente in crescita. Procedings National Congress of SIDO, Firenze, 28-31 oct. 1998. Salonen L, Mohlin B, Gotzlinger B, Hellden L. Need and demand for orthodontic treatment in adult Swedish population. European Journal of Orthodontics 1992; 14 : 359-68. Saltzmann J A 1968 Handicapping malocclusion assessment to establish treatment priority. American Journal of Orthodontics and Dentofacial Orthopedics 54: 749-65. Summers CJ. A system for identifying and scoring occlusal disorders. Am J Orthod 1971; 59: 552-67. Taylor N G. Orthodontic in the Netherlands. British Dental Journal 1993; 23: 333-35. Tang ELK, Wei SHY. Recording and measuring malocclusion: a review of the literature. American Journal of Orthodontics and Dentofacial Orthopedics 1993; 103: 344-50. EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 9/2-2008 75