ASSESSMENT OF ORTHODONTIC TREATMENT NEEDS OF SCHOOLCHILDREN FROM IASI ACCORDING TO INDEX OF ORTHODONTIC TREATMENT NEEDS (IOTN) AND DENTAL AESTHETIC INDEX (DAI) Oro-Dental Prevention, Iasi, Romania y of Dental Medicine, Department of ABSTRACT To assess the distribution, prevalence and severity of malocclusion and orthodontic treatment needs in schoolchildren from Iasi, 12 years old. A sample of 200 schoolchildren (92 males and 108 females) randomly selected was obtained from 4 public schools from Iasi, Romania. The need for orthodontic treatment was measured using the IOTN and DAI. The DAI most of the subjects (77%) were deemed to require orthodontic treatment. Only about 5.8% had a handicapping malocclusion that needed mandatory treatment. A severe malocclusion for which treatment was highly desirable was recorded in 23% of the schoolchildren and 23.7% had a definite malocclusion for which treatment was elective. There were no significant differences (p>0.05) in mean DAI scores between males and females. The IOTN/DHC: 15.3 % (95 % CI) of the 12-year olds need orthodontic treatment (grades 4 and 5). IOTN/AC: 11.4 % (95 % CI) in the 12-year olds need orthodontic treatment. No significant differences in the treatment needs proportions by gender were found (p>0.05). 77% of the adolescents from Iasi were in need of orthodontic treatment for dental health reasons. This study provides baseline data on the need and demand for orthodontic treatment among schoolchildren from Iasi. Key words: IOTN, DAI, orthodontic treatment need, schoolchildren INTRODUCTION A variety of occlusal indices have been developed to classify the treatment of malocclusion in groups according to urgency and the need of treatment [1]. The place of aesthetic and functional criteria in determining orthodontic treatment needs cannot be underestimated as these are major indications for patients seeking orthodontic services [2]. Dental appearance that deviates from social norms may have a negative impact on social and psychological functions. A previous report has demonstrated the high reliability and validity of this index [3], which also compares favourably with other indices [4, 5]. Being compared with other indices, the DAI (Dental Aesthetic Index) was more versatile, time-saving and simple to use [5]. This index can be used for different communities and populations without requiring any modification [6]. Unlike the DAI, the IOTN (Index of Orthodontic Treatment Needs) classifies malocclusions according to the presence of particular occlusal features which are considered important for dental health and aesthetics in order to identify individuals who would derive the most benefit from orthodontic treatment. This index includes an AC with 10 severity levels and a Dental Health Component (DHC) with 5 severity levels (Table 1). The two components are analysed separately and although they cannot be united into a single score, they can be combined to classify the patient as 27
following the modifications [7]. The Aesthetic Component consists of a scale of 10 colour photographs showing different levels of dental attractiveness, grade 1 representing the most attractive and grade 10 the least attractive dentitions (Fig. 1). IOTN 1 IOTN 2 IOTN 3 IOTN 4 IOTN 5 No need for treatment No/slight need for treatment Moderate/ borderline need for treatment Great need for treatment Great need for treatment Tabel 1. The Dental Health Component (DHC) has 5 Grades 1 6 2 7 3 8 4 9 5 10 Fig. 1. The Aesthetic Component of IOTN The DAI is an orthodontic index based on socially defined aesthetic standards [3]. It is useful both in epidemiological surveys to identify unmet need for orthodontic treatment and as a screening device to determine priority for public orthodontic treatment. This index integrates the psychosocial and physical elements of malocclusion. It is a regression equation that mathematically links with the objective physical measurements of the occlusal traits associated with malocclusion. The components of DAI regression equation are shown in Table 2. The logical regression equation, shown below, results in a numerical value that, according to the creators of the index, indicates the need for treatment as follows: up to 25 points: no treatment need; 26-30 points: treatment elective; 31-35 points: treatment highly desirable; 36 points or more: treatment mandatory. The aim of this study was to evaluate the distribution, prevalence and severity of malocclusion and orthodontic treatment needs in a sample of 12-years-old schoolchildren from the urban zone of Iasi using IOTN and the DAI. This data would allow comparison with previous and subsequent studies. 28
DAI components 1. Number of missing visible teeth (incisors, canines and premolar teeth in the maxillary and mandibular arches) 2. Crowding in the incisal segments: 0 = no segments crowded, 1 = 1 segment crowded, 2 = 2 segments crowded 3. Spacing in the incisal segment: 0 = no spacing, 1 = 1 segment spaced, 2 = 2 segments spaced 4. Midline diastema (mm) 5. Largest anterior irregularity on the maxilla (mm) 6. Largest anterior irregularity on the mandible (mm) 7. Anterior maxillary over jet (mm) 8. Anterior mandibular over jet (mm) 9. Vertical anterior open bite (mm) 10. Antero- Table 2. Components of the DAI regression equation [3] MATERIALS AND METHODS This study was conducted in 4 municipal public schools in different districts of the Iasi city, selected by sampling from a list of all the municipal schools supplied by the Educational Department. The sample consisted in 200 schoolchildren, comprising 92 boys (44%) and 108 girls (56%), 12 years old at the time of the clinical examination. No differentiation was made in terms of social class as those attending public schools in Iasi and they belong to low social level families. For calculating the sample the following parameters were employed: 4% margin of error, confidence interval of 95% and an estimated 50% prevalence of malocclusions. Individuals presenting a previous history of orthodontic or orthopaedic treatment, those undergoing treatment or with syndromes and those whose complete permanent dentition did not include at least the first permanent molar at the time of the clinical examination, were excluded from the study. The examinations were conducted with permission from the education authorities and head teachers, and with informed consent of All data on malocclusion were collected by one dentist calibrated at the Department of Oro-Dental Prevention, Faculty of Dental Medicine and Pharmacy Iasi. Oral examinations were conducted to register all the necessary malocclusion features to obtain the DAI and the IOTN (over jet, overbite, anterior and posterior cross bite, open bite, displacement of the teeth, diastema, impeded eruption, hypodontia, clefts lip and/or palate, and molar relationship), as well as personal details (name, age, and gender). Each subject was examined and scored for the five components of Dental Health Component (DHC) (Table 1), ten components of the AC (Fig. 1) of IOTN and the DAI (Table 2), according to the standard conventions [3]. Distance was measured in whole millimetres using WHO periodontal probes. The examiner used gloves and mask throughout the clinical examinations. The subjects were examined at school during class hours in a predetermined order. Data analysis was carried out on a personal computer using SPSS (the Statistical Package for Social Sciences) software for Windows, Version 14. The chi-square test was used to test the distribution differences between the genders. RESULTS A high level of reliability in applying IOTN and the DAI was achieved by the examiner. A Kappa value of 0.90 indicates an excellent agreement. Orthodontic treatment needs according to the IOTN 29
Table 3 shows the different IOTN/DHC: 15.3 % (95 % CI) of the 12-year old presented grades 4 and 5 DHC, a definite need for orthodontic treatment. No significant differences in treatment needs proportions by gender were found (p > 0.05). According to the IOTN/AC, the treatment need was 11.4 % (95 % CI) for the 12-years old schoolchildren (AC grade 8-10). No significant differences in the treatment need proportions by gender were found (p > 0.05) (Table 4). IOTN (DHC) 12 years old (n = 200) %(95% CI) Grade 1. Normal or minor malocclusion. No need Grade 2. Minor malocclusion. Little need Grade 3. Moderate malocclusion. Borderline need Grade 4. Severe malocclusion. Needs treatment Grade 5. Very severe malocclusion. Needs treatment 20.7 (18.8-22.6) No need; 32.3 (27.4-37.2) 84,7 31.7 (26.9-36.7) 11.0 (12.4-20.1) Definite need; 4.3 (2.2-6.5) 15,3 Table 3. Distribution of the IOTN Dental Health Component (DHC) levels of orthodontic IOTN (AC) 12-year-olds (n = 200) % (95% CI) AC grades 1 4. No need 75.1 (66.3 83.9) AC grades 5 7. Moderate need. 13.5 (9.2 17.8) AC grades 8 10. Definite need. 11.4 (8.5 14.2) Table 4. Distribution of the IOTN Aesthetic Component (AC) levels in the examined Orthodontic treatment need according to the DAI Table 5 shows the distribution by age and gender, according to orthodontic treatment needs. As may be seen in the table, the majority of the schoolchildren were classified we compared the need for treatment between males and females, we noted that the number was greater for the females, while the frequent among the males. However, the associations found were not regarded as statistically significant (p<0.05). Table 6 presents the distribution of the treatment needs in the entire population sample according to the DAI. Most of the subjects (77%) had a dental appearance that required orthodontic treatment. Only 5.8% had a handicapping malocclusion that needed mandatory treatment. A severe malocclusion with treatment being highly desirable was recorded in 23% of the subjects and 23.7% had a definite malocclusion with treatment being elective. No need for treatment or a as observed in 47.5% of the subjects. 12 years old M F n 92 103 No treatment need (%) 19.7 24.9 Treatment elective (%) 75.8 68.9 Treatment highly desirable (%) 4.5 6.2 Table 5. DAI Index Orthodontic Treatment Need according to gender and age 30
DAI score Severity levels Frequency % < or = 25 Minor or no anomaly / NTN 46 47.5 26-30 Definite malocclusion / Elect 47 23.7 31-35 Severe malocclusion / HD 95 23.0 > or = 36 Handicapping malocclusion / mandatory 12 5.8 TOTAL 200 100.0 Table 6. Orthodontic treatment needs of Iasi schoolchildren according to the DAI Three main occlusal features were responsible for allocated subjects into the crowding (47.3%), tooth loss (22.3%) and maxillary over jet greater than 3 mm (21.8%) (Fig. 2). Fig. 2. Distribution of occlusal features into DISCUSSION The percentage of children in need of orthodontic treatment was in this study comparable with that encountered in most investigations that used the DAI [6, 8, 9 and 10] or IOTN [11, 12, 13 and 14]. It was higher than that found in an African population [15] but lower than in Turkish [16] and Japanese [17] populations. It should be pointed out that, irrespective of the index employed in assessing treatment need (DAI or IOTN), the results obtained were not similar but there were no statistically significant differences in the proportion considered in need of treatment: 15.3 % with the IOTN and 28,5 per cent with the DAI in 12-years-old. Johnson et al. (2000) [19] also found that both indices assessed the same number of children with malocclusions requiring orthodontic treatment, but not all were ranked similarly by each index. Previous studies [18 and19] found significant correlations between them. The differences found in the determination of orthodontic treatment need depending on which particular index (DAI or IOTN) has been used to reinforce the point of view of some authors [20 and 21] that normative measures should be used in combination with quality-of-life questionnaires to cover the malocclusion dimension of oral health. In the present study of among 12 years old schoolchildren the prevalence of malocclusion between genders was statistically not significant. This is consistent with the study among 12-15 years old schoolchildren of Davangere city, India [22], Nigerian population aged 12-18 years old [23]. CONCLUSION The prevalence of malocclusion in the present study was 77%. At present, orthodontic care is generally provided on the basis of payment by the trained orthodontists, which makes it rather expensive and unaffordable. REFERENCES 1. Otuyemi and Jones, Methods of assisting and grading malocclusion, Australian Dental Journal 14: 21-27, 1995 2. Onyeaso C, Aderinokun G. The relationship between dental aesthetic index (DAI) and perceptions of aesthetics, function and speech amongst secondary school children in Ibadan, Nigeria, International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of 31
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