LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY FACULTY OF PUBLIC HEALTH DEPARTMENT OF PREVENTIVE MEDICINE PRASHANTH PRAKASH

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1 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY FACULTY OF PUBLIC HEALTH DEPARTMENT OF PREVENTIVE MEDICINE PRASHANTH PRAKASH QUALITY OF LIFE IN RELATION TO ORTHODONTIC PROBLEMS AMONG ADOLESCENT CHILDREN IN THE CITY OF CHENNAI, INDIA. Master Thesis Thesis supervisor: KAUNAS 2014 Prof. Dr.Apolinaras Zaborskis 1

2 SUMMARY Quality of life in relation to orthodontic problems among adolescent children in the city of Chennai, India. Prashanth Prakash Academic supervisor, Prof.Dr.Apolinaras Zaborskis, Professor, Department of Preventive Medicine, Faculty of Public Health, Lithuanian University of Health Sciences. Kaunas, 2014 AIM: To evaluate the prevalence of orthodontic problems and quality of life in relation to orthodontic problems among adolescent children in the city of Chennai, India. OBJECTIVES: To analyze the differences in the need for orthodontic treatment among children in the public and private schools; to analyze the need for orthodontic treatment among the various socioeconomic groups; to evaluate the Quality of Life (QoL) among the children; to analyze the relationship between Quality of Life (QoL) and the need for orthodontic treatment. METHODS: 200 children participated in the study, out of which 100 were from the private school and 100 from the public school from the city of Chennai, India. Two sets of questionnaires were used for the study, one was filled by the children and the other was filled by the researchers and trained dental assistants after doing a thorough dental examination and asking questions from the participants. This was carried out according to the recommendations of WHO oral health assessment. Statistical data was collected, recorded and analyzed using the software SPSS 17.0 for Windows. RESULTS: The private school children had more orthodontic problems than the public school children (49% and 44% respectively). The need for Orthodontic Treatment was the highest in children under the rich category (56.4%), followed by the children under the poor category (45.3%) and is least among the children under the average category (44.4%). The Quality of Life was found to be better among children in private schools than in public schools (90.6% and 89.0% respectively). Children who did not have a good quality of life had little or no need for 2

3 orthodontic when compared to children who had a good quality of life (60.0% and 53.4% respectively). CONCLUSION: Children from the private school who were mostly from the rich socioeconomic group had more orthodontic problems and need for orthodontic treatment. Inspite of the quality of life being better among children from the private school, they still had a definitive need for orthodontic treatment. A low quality of life and socio-economic status does not have a significant impact on the prevalence and need for orthodontic treatment. 3

4 LIST OF ABBREVIATIONS IOTN Index for Orthodontic Treatment Need QoL Quality of Life OHRQol Oral Health Related Quality of Life WHO World Health Organization SES Socio-economic ststus DAI Dental Aesthetic Index ICON Index of Complexity Outcome and Need AC Aesthetic Component 4

5 CONTENTS INTRODUCTION.6 1. AIM AND OBJECTIVES 9 2. REVIEW OF LITERATURE Orthodontic problems among adolescent children Reasons for orthodontic problems in adolescent children Different types of orthodontic problems among adolescent children Quality of Life (QoL) Orthodontic oral self-perceptions Index for Orthodontic Treatment Need (IOTN) MATERIALS AND METHODOLOGY Study population Organizing the survey Implementing the survey Measurement criteria RESULTS AND DISCUSSION Variables used to record the need for orthodontic treatment Index for Orthodontic Treatment Need (IOTN) Difference in the need for orthodontic treatment among children in public and private schools and among boys and girls The need for orthodontic treatment among the various socio-economic status groups Quality of Life (QoL) among the children Relationship between Quality of Life (QoL) and the Need for Orthodontic Treatment (IOTN) Binary logistic regression analysis 35 CONCLOSION...38 PRACTICAL RECOMMENDATIONS.39 LIST OF REFERENCES 40 QUESTIONNARIES..45 5

6 INTRODUCTION The oral-facial region is usually an area of significant concern for the individual because it draws the most attention from other people in interpersonal interactions and is the primary source of vocal, physical, and emotional communication. Orthodontic anomalies have been associated with psychosocial distress poor oral health condition and impaired chewing function and so should be regarded as a health problem. As a result, patients who seek orthodontic treatment are concerned with improving their appearance and social acceptance often more than they are with improving their oral function or health. Enhancing these aspects of quality of life is an important motive for undergoing orthodontic treatment. Oral health can affect the general health, well-being, education and development of children. In many of the countries, especially the developing and under developed, a large number of parents and children are unaware of the causes, occurrence and prevention of most of the common oral diseases. Among the oral diseases, the most common dental problems in mankind along with dental caries, gingival disease and dental fluorosis is orthodontic problems and malocclusion (Dhar V et al, 2007). Scientific research shows that orthodontic anomalies are one of the most common dental pathologies among children and adolescence as this age group between 12 to 15 years is when the permanent teeth begin to take its place (after the milk teeth fall) in the jaws it becomes common for the teeth to erupt in an irregular manner. The main expected benefits of orthodontic treatment relate to improvements appearance of the teeth and oral functions that will lead to improved psychological and social well-being. Diagnosis of orthodontic anomalies among children usually implies the detection of morphologic changes by the dental health professional. However, such an investigation is relatively expensive, and therefore cheaper alternatives are considered when trying to tackle orthodontic issues at public health level (Aiste K et al, 2010). Subjective, self-reported oral health measures are successfully employed in research among adult populations (Jarvinen S et al, 2001; Jokovic A et al,1997). Such measures are being successfully implemented in research on children also. Recent studies suggest that age-adjusted questionnaires for children are relatively valid and proper instruments for evaluation of oral health, demonstrating that 12-year-old children are 6

7 sufficiently aware about their oral health and its related factors (Gherunpong S et al, 2004). Information from self-reports by children in the form of questionnaires might help in planning effective strategies to promote oral health. Questions are usually based on socio-demographics, self-reports of behavior, knowledge and oral problems and a single-item measuring self-reported state and satisfaction with appearance of teeth. Several studies have provided evidence that with the use of schoolchildren s surveys, valuable information on dental issues including orthodontic problems, malocclusions, their prevalence, associations with socio-demographic factors, and potential needs for dental care, could be obtained (Aiste K et al, 2010). Such data are valuable in planning the needs of treatment of orthodontic pathology, possible workload of orthodontists in municipalities, and setting priorities for care in sensitive social groups to reduce health inequalities. According to World Health Organization, the main oral diseases should be subjected to periodic epidemiological surveys. The epidemiological data on orthodontic treatment need is of interest for dental public health programs, clinical treatment, screening for treatment priority, resource planning and third party funding (Brito DI et al, 2009). Appraisal of distribution of malocclusion and other orthodontic problems in childhood can facilitate efforts to prevent such a disorder and its consequences and make it possible to reduce the complexity of costly orthodontic treatment. In a country like India where inequalities exist within society, there is a clear demarcation between the various socio-economic groups in aspects such as awareness of health related issues and attitudes towards seeking treatment for the same due to factors such as financial stability and quality of life. Also, the availability of the public health facilities for treatment especially when it comes to dental needs such as orthodontic problems are very scarce and underdeveloped and hence people have to seek such treatment in the private hospitals which are dominant and very expensive. Children attending private schools hail from the middle and upper socio-economic group and those studying in the public schools are from the lower socio-economic group and hence there is a clear difference between awareness and seeking treatment for orthodontic problems among these children. This becomes a public health issue as children in the adolescent age group are more prone to develop orthodontic problems which require them to seek treatment which involves correction of this problem. Orthodontic treatment is very expensive and cannot be sought by those from the lower socio-economic group and hence it is very important to 7

8 evaluate factors such as quality of life, awareness, prevalence and the need for orthodontic treatment to plan for programs and treatment need for all without any discrimination. Hence the aim of this study is to find out the existence of orthodontic problems and the Quality of Life in relation to these orthodontic problems among and the need for orthodontic treatment among adolescent children in the city of Chennai, India. 8

9 1. THE AIM AND OBJECTIVES Aim The aim of the present study was to ascertain the prevalence of orthodontic problems and quality of life in relation to orthodontic problems among adolescent children. Objectives The main objectives of this study are: 1) To analyze the differences in the need for orthodontic treatment among children in the public and private schools. 2) To analyze the need for orthodontic treatment among the various socioeconomic groups. 3) To evaluate the Quality of Life (QoL) among the children. 4) To analyze the relationship between Quality of Life (QoL) and the need for orthodontic treatment. 9

10 2. REVIEW OF LITERATURE 2.1. Orthodontic problems among adolescent children Initiation of the adolescent phase in human beings is accompanied by several physical developmental changes that characterize puberty which are mirrored in a person s oral cavity (mouth). This stage in the life of an individual, is a unique time, in terms of dental considerations, during which, dental caries rates increase from childhood; the first signs of periodontal disease occur (Casamassimo P et al, 1979); up to a third of facial growth occurs during a relatively short growth spurt; and the need for orthodontic therapy occurs. These changes brought about in the adolescent phase 2.2. Reasons for orthodontic problems in adolescent children Three types of changes which are particularly important are, the transition from primary to permanent teeth; skeletal and facial growth; and hormonal change. Between the ages of 10 and 12, a person s entire set of primary teeth has been replaced with permanent successors, second permanent molars erupt, and only the third molars remain to develop and erupt (Finn SB,1973). By ages 12 or 13, an individual s permanent teeth are usually stable. The face grows significantly during adolescence, leading to skeletal changes, completing almost all of the vertical growth that affects tooth position, facial contour, and space available for teeth. During this phase, it is common to undergo orthodontic treatment (Rarity DM,1980). This is that time in life of an individual when appearance begins to be important. Children often desire orthodontic treatment, at this stage as they begin to get conscious about changes in their aesthetic appearance and their parents perhaps even more so for their child. On the other hand some children, in spite of obvious facial appearances do not prefer to undergo treatment due to lack of awareness and access to dental care (in underdeveloped and developing countries) and fear to visit the dentist. The individual has also reached an age when she or he is considered to have achieved autonomy and is able to desire or decline orthodontic treatment. Hence, dentists with the patient and the parents, play the most important role in the decision process. Also, the role of public health services play an important role in educating the citizens about the importance of orthodontic treatment. 10

11 Orthodontics includes the study of the growth and development of the jaws and face particularly, and the body generally as influencing the position of teeth; the study of action and reaction of internal and external influences on the development and the prevention and correction of arrested and perverted development (Milton B et al, 1990). The benefits of orthodontic treatment are prevention of tissue damage, improvement in aesthetics and physical function. The uptake of orthodontic treatment is influenced by the desire to look attractive, self-esteem and self -perception of dental appearance (Mandeep KB et al, 2012). In every country, there is a need to identify the awareness levels of children with respect to oral health and the orthodontic treatment as children play an important role in inculcating healthy lifestyle practices to last for a lifetime. Pre-adolescents and adolescents would be benefitted with the knowledge about orthodontic treatment since early orthodontic treatment could be advantageous in preventing further malocclusion complications. Orthodontic problems which commonly occur in adolescents include: Malocclusion, Crowding of teeth, Changes in aesthetic appearance and profile. Such orthodontic problems worsen, and others become apparent later in adolescence (Roopa S et al, 2013). According to the American Dental Association, Public Dental Health is defined as the science and art of preventing and controlling dental disease and promoting dental health through community effort. When public orthodontic care of children and adolescents is evaluated, especially in developing countries, it is important to take a lot of factors into consideration. The most important being, education of the individual; awareness of the need for orthodontic treatment; socio-economic status; the availability and access to dental services; parents education level, income and awareness about the importance of dental care for their children; scarcity of dental services especially in rural areas; lack of public health services, facilities and personnel; lack of sources and interventions to seek a knowing about such problems. Hence it becomes important to study both the changes in orthodontic services as such and the perspective of the entire dental health care in a public health point of view. 11

12 2.3. Different types of orthodontic problems among adolescent children Malocclusion is the malpositioning of maxillary (upper jaw bone) and mandibular (lower jaw bone) teeth, a condition that can have both esthetic, functional, and emotional implications on an individual. Malocclusion is not a disease, but a morphological variation which may or may not be associated with a pathological condition (Nashashibi S et al, 1983). Pain and miseries are seldom acute in malocclusion and has a greater impact on society and individual in terms of quality of life, discomfort, social and functional limitations.( Ansai T et al,1993; Mclain JB et al,1985). The reasons to develop malocclusion could be genetic or environmental and/or combination of both the factors along with various local factors such as adverse oral habits, tooth anomalies, form and developmental position of teeth can cause malocclusion. (Miitchell L et al, 2001). Data from the World Health Organization show that malocclusion is the third most important condition in the ranking of oral health problems, outranked only by caries and periodontal disease (Mausner JS et al, 1985). Several studies have evaluated the prevalence of malocclusion in various populations and have reported different prevalence rates (39-98%). Prevalence of malocclusion varies from country to country and among different age and sex group. The prevalence of malocclusion in India varies from 20% - 43%. (Sureshbabu AM et al, 2005). In such a diverse and vast country like India, a large variation in prevalence of malocclusion exists in varying regions of the country. This can be due to variations in ethnicity, nutritional status, religious beliefs, and dietary habits (Kharbanda OP et al, 1991). There is a definite ethnic trend in the prevalence of the type of malocclusion in India from north to south of India. The prevalence of malocclusion in southern India is about 5%, and is much lower compared to the north which is 10 15% in. In addition, the southern population has an ethnic affinity for bimaxillary protrusion (Kharbanda OP, 2009). Studies on the prevalence of malocclusion in public health provide important epidemiological data to assess the type and distribution of occlusal characteristics of a given population, its treatment need and priority and the resources required to offer treatment. It is essential to identify and localize the wide range of deviations from occlusal development that may arise and that must be intercepted before the end of the active growth stage. As well as problems of a functional nature that arise from these morphological changes, which may become more complex skeletal problems in the future, aesthetic impairment often occurs, with serious psychosocial consequences for the developing individual. Assessment of malocclusion and 12

13 treatment needs for public health purposes are instrumental in determining the priorities for treatment in publicly subsidized dental services and to properly estimate the number of professionals to be recruited as well as the financial resources necessary to provide this treatment (Marcos AVB et al, 2010). The recognition of malocclusion as an important problem in the public dental health services for children implies a need for rational planning of preventive and therapeutic orthodontic measures. It is necessary to carry out epidemiologic studies of malocclusion in groups of boys and girls at various stages of development and from different socio-economic groups and geographic areas. Analysis of the prevalence rates of malocclusion in such groups may also contribute to an understanding of the causes of malocclusion (Helm S, 1968). In a developing country like India, malocclusion is still not considered to be a dental problem because more priority is given to the treatment of dental caries and periodontal diseases due to pain experienced by them. Most malocclusion cases are still not treated properly due to ignorance of patients, parents, inadequacy of resources, lack of knowledge about malocclusion and other influencing factors like literacy rate and socio-economic status. The level of dental health knowledge, positive dental health attitude, and dental health behavior are interlinked and associated with the level of education and income. Malocclusion results in various problems in the affected individuals, including lack of satisfaction with facial appearance, problems associated with the function of the masticatory system, dysfunction of the temporomandibular joint, problems with swallowing and speech, susceptibility to facial traumatic injuries and development of caries and periodontal problems (Proffit WR et al, 2007). In addition, the individuals with malocclusion will not be satisfied with their facial appearance, resulting in inappropriate social responses and development of emotional and mental problems. In other words, Oral Health-Related Quality of Life is disturbed in a large proportion of affected individuals (Azuma SH et al, 2008) Quality of Life (QoL) The quality of life is defined as a subjective judgment of an individual of his/her health status and in fact satisfaction or dissatisfaction with specific aspects of life, which are important for the individual (Kok VY et al, 2004). Disturbances in the normal somatic, psychosomatic and social functioning of individuals are considered important considerations in the evaluation of oral health. QoL is a somewhat intangible entity and there has been much debate as to how to define 13

14 it. QoL reflects physical, social, and psychologic functioning, Inability of commonly used tools to evaluate and quantify oral health, such as evaluation of the ability of patients to chew food and enjoy the taste of food items, has resulted in a new direction and attitude toward evaluation of oral health by new quantification tools such as OHQoL. Oral Health Related Quality of Life (OHRQoL) has important implications for clinical practice in dentistry and dental research. OHRQoL is an integral part of general health and wellbeing and is recognized by the WHO as an important segment of the Global Oral Health Program (WHO, 2003). This concept of health status embraces the biopsychosocial model of health into which symptoms, physical functioning, emotional and social well-being are incorporated (Kleinman, 1988). Quality of life (QoL), or individuals perceptions of their position in life in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns (WHOQOL, 1995), is now recognized as a valid parameter in patient assessment in nearly every area of physical and mental healthcare, including oral health. Further, the opportunity arose to consider how oral health affects aspects of social life, including self-esteem, social interaction, school and job performance, etc, all of which are parameters to access the Quality of Life of an individual. Researchers began to postulate how oral health is related to health-related quality of life (HRQoL) (Gift and Atchison, 1995) and to understand the interrelationships between and among traditional clinical variables (like diagnosis), data from clinical examinations, and person-centered, self-reported health experience. With increasing focus of health policy to address health promotion and disease prevention, HRQoL and OHRQoL have come to incorporate both positive and negative perceptions of oral health and health outcomes (Broder and Wilson-Genderson, 2007). Thus, assessments of oral health can reflect both negative impact and enhancement of self and well-being. For example, people may seek oral healthcare for preventive (e.g., cleanings) or elective (e.g., orthodontics) treatment. Assessment of OHRQoL allows for a shift from traditional medical/dental criteria to assessment and care that focus on a person s social and emotional experience and physical functioning in defining appropriate treatment goals and outcomes (Christie et al., 1993). Finally, OHRQoL is important because of its implications for oral health disparities and access to care. Unfortunately, socioeconomic and racial/ethnic oral health disparities constitute a major social problem (Petersen et al., 2005). Health disparities can be explained, in part, by limited 14

15 access to care. Locations within developing countries may have minimal dental health professionals, and rural areas often lack facilities offering dental services. In developed countries, treatment access is limited by high costs and sometimes by transportation difficulties (Sisson, 2007). OHRQoL can be useful in measuring the impact of oral health disparities on overall health and QoL. OHRQoL is utilized in health services research to examine trends in oral health and population-based needs assessment. Epidemiological survey research has examined trends in OHRQoL (e.g., dental caries, orthodontic treatment etc), identified individual and environmental characteristics that affect OHRQoL (e.g., income, education, etc.), and aided in needs assessment and health planning for population-based policy initiatives. OHRQoL has a multitude of substantive applications for the field of dentistry, healthcare, and dental research as we move from bench to applied science and person-centered approaches to measure treatment needs and efficacy of care. Patient-oriented outcomes like OHRQoL will enhance our understanding of the relationship between oral health and general health and demonstrate to clinical researchers and practitioners that improving the quality of a patient s well-being goes beyond simply treating dental maladies. OHRQoL research can be used to inform public policy and help eradicate oral health disparities (Sischo L and Bordre HL, 2011) Orthodontic oral self-perceptions A variety of social, cultural, psychological and personal factors influences the perception of dental appearance (Graber LW et al, 1980). Dissatisfaction with dental appearance is the main factor associated to the decision to undergo orthodontic treatment (Bos et al., 2003). It has been estimated that 80% of orthodontic patients seek services out of a concern for aesthetics rather than for reasons related to health or function (Albino et al., 1981). Thus, an individual s self-perceived dental aesthetics affects normative assessments regarding the need for orthodontic treatment (de Oliveira et al, 2004). Malocclusion has an impact on the quality of life among school children because of which the aesthetic facial appearance may be altered, hence such children have a negative self-perception on their aesthetic appearance and perceive the need for orthodontic treatment. A number of authors have suggested that children especially teenagers have developed a perceptual awareness towards their facial appearance and oral health. Facial appearance has shown to have a major impact on the psychological well-being of an individual. 15

16 People vary in their perceptions of their physical self and have emotional reactions to these perceptions (Pertschuk et al,1982). In determining the potential benefits of orthodontic treatment for an individual, the relation between physical appearance of an aesthetic deviation and the impact of such a deviation on self esteem and body image are important factors (Birkeland et al, 2000).The assessment of potential benefits of orthodontic treatment to the individual should include greater awareness towards the individuals psychosocial functioning and the patients own perspective on the need for orthodontic treatment. Some studies showed that, children with less perceptual awareness tend to be dissatisfied with their dental appearance and showed a greater need for orthodontic treatment. Some other studies showed opposite perception levels. Hence it can be drawn to a conclusion that whilst people seemed to be more aware of their orthodontic problems they did not perceive a need for orthodontic treatment to the same extent as the orthodontist. Despite the patients awareness level, the dentist or orthodontist s was seen to have a more critical view to consider whether treatment was needed. In a study among both adolescents and young adults, only percent of those normatively assessed as in need of orthodontic treatment actually perceived such a need (Koochek et al, 2001). And these figures were nearly identical to those derived from studies of orthognathic surgery patients, in which percent of those clinically assessed as requiring treatment reported that they perceived such a need for treatment (Bell R et al, 1985). A variety of social, economic, and cultural factors like, esthetic judgment, income, and availability of providers, may influence personal perception of the need for orthodontic treatment (N Gom et al, 2005). However, in developing countries, public healthcare services do not offer orthodontic treatment, making it inaccessible to a large proportion of the population who fall under the lower socioeconomic strata as they cannot afford expensive treatment in a private dental clinic and also lack of awareness which the public health services do not provide. In such a situation, not much is known regarding the effects of malocclusion on social and psychological wellbeing among individuals who cannot enjoy the benefits of orthodontic treatment and how such individuals perceive aesthetic alterations arising from malocclusion. Thus, it is important to gain a better understanding of the biopsychosocial aspects of malocclusion and its effect on quality of life among such individuals, addressing the issue as a public health problem. Information in this regard would favor a better assessment of treatment 16

17 needs and priorities as well as allowing a better planning of the resources needed to offer the population access to orthodontic treatment (Marques LS et al, 2009) Index for Orthodontic Treatment Need (IOTN) Orthodontic research has traditionally focused on hard clinician-driven outcome measures at the expense of subjective patient-driven measures. Based on this a number of orthodontic need indices, such as the Dental Aesthetic Index (DAI), the Index of Orthodontic Need (IOTN), and the Index of Complexity Outcome and Need (ICON), have been developed and used for assessing orthodontic treatment need (Georgios Tsakos, 2008). Majority of these indices assess not only severity of dental occlusion but also include evaluation of the aesthetics. The aesthetic component of the indices is more subjective and less readily measurable than the morphological characteristics. The subjectivity of indices used to record orthodontic anomalies, their questionable validity and reliability may contribute to inconsistency of results. An alternative approach to the use of indices is a registration of measurable occlusal characteristics such as overjet, overbite, crowding, crossbite (Antanas S; Kristina L, 2009). The Index of Orthodontic Treatment Need (IOTN), described by Brook and Shaw (1989) has been gaining national and international recognition as a method of objectively assessing treatment need. The IOTN is employed to determine the normative need in the population.this index ranks malocclusion in terms of the significance of various occlusal traits for the person's dental health and perceived aesthetic impairment with the intention of identifying those persons who would be most likely to benefit from orthodontic treatment. The Aesthetic Component (AC) of this indicator is recorded by visual clinical examination and photographs. This indicator shows the different levels of dental attractiveness from the scale of 1 to 10, with 1 being the most attractive and 10 the least attractive, according the arrangement of teeth. The principle is that any individual can be identified and rated according to this scale. The Dental Health Component of this indicator categorizes the detrimental effects of the various occlusal traits like overcrowding of teeth, gap between the teeth, problems in occlusion etc, in order of severity. All these occlusal traits have to be examined clinically and recorded separately. This component was developed to ensure validity and consistency in reporting the need for orthodontic treatment. 17

18 MATERIALS AND METHODOLOGY 3.1. Study population. The survey was conducted in the city of Chennai, India. A total of 200 children participated in the survey between the age groups of 13 to 14 years. In each of these age groups an attempt was made to include equal number of male and female subjects. Out of these 200 children, 100 were from the private school which is situated in the city and 100 were from the public school which is located in the suburbs. The schools were selected based on the socioeconomic status. Children belonging to the low socio-economic groups were those studying in the public school and the high socio-economic group comprised of children studying in private school. The consent for examining of the children was obtained from the respective head master. The criteria for selection of the study subjects were that the children should be permanent residents of Chennai and should be full time students enrolled in the school. Depending on the conditions of the school, the exact arrangement for conducting the examination was determined. The subjects were examined on an upright chair in adequate natural light. A torch light was used to examine the oral cavity (mouth). Examination of the child was done by only one examiner to avoid inter-examiner variability. Recording of data was done by a two trained dental assistants who assisted throughout the study. Prior to the examination for orthodontic problems and dental caries, a questionnaire was filled by the subject to find out the personal data and oral hygiene habits. Tooth surface was dried and examination of the oral cavity was made using a dental mouth mirror, and dental probe. Calibration procedures were performed prior to and during the study to ensure that a consistent standard of the diagnosis was maintained. Re-examinations were carried out on approximately one in ten children selected at random to have a constant check on the inter examiner variability. The data was recorded on a performa and were entered into a computer Organizing the survey Obtaining ethical clearance and permission from the concerned authorities. The ethical clearance for the present study was obtained from the Lithuanian university of health science, Kaunas Lithuania, The Dental council of India and the Principals of the public and 18

19 private schools. The required official permission for the study was obtained from Health & Family Welfare Office of Chennai Tamil nadu and local medical officers of Primary Health Centers and Sub-centers. For examination of children in the rural areas, co-operation and oral consent was taken from school principle heads Scheduling. The present study was conducted from June 2013 to August A detailed monthly schedule of the survey was prepared well in advance and the concerned authorities were informed regarding examination place, date and timings. On an average 20 subjects were interviewed and examined on each day. Examination of each individual took approximately 8-10minutes Implementing the survey Informed consent. Consent from each study subject was taken after explaining the nature of the study Data collection. The data included questions related to socio-demographic characteristics, oral hygiene practices, adverse oral habits, some other habits like brushing teeth, frequency of dental visits etc Armamentarium. The following instruments and supplies were used for the study: 1) Plane dental mouth mirrors 2) Dental Explorers. 3) Dental Tweezers 4) Containers 5) Surgical scrub 6) Disposable tumblers 7) Chemical disinfectants 8) Towels 9) Gauze 10) Gloves and Mouth Masks 11) Survey Proforma Adequate number of sterilized instruments was made available during the survey and current recommendations and standards were followed for infection control. 19

20 3.4. Measurements and criteria: Table 1: Distribution between the number and percentage among gender, school and socioeconomic status: N % Gender Boys Girls School Private Public Socio-economic status Poor Average Rich Missing Table 1, shows that 100 (50.0%) children from the public school and 100 (50.0%) from the private school participated in the study, out of which, 112 (56.0%) boys and 88 (44.0%) were girls. Out of the 200 children who took part in the study, 86 (43.0%) were from the poor socio-economic group, 72 (36.0%) were from the average and 37 (18.5%) were fro the rich socio-economic group. Orthodontic problems such as aesthetic component, crowding, spacing between the teeth, cross-bite, open incisor bite, incisal overlap, upper and lower posterior teeth ratio of the sagittal direction (right and left). All the above variables were included in a new variable called Index for Orthodontic Treatment (IOTN). 20

21 Factors such as car, bedroom, holiday, family, father s and mother s job was included in socio-economic determinants and were recorded using self administered questionnaires. We have chosen to record the general quality of life to assess the impact of orthodontic problems and treatment procedures on the satisfaction in life, happiness level and health status according to their assessment. Factors such as health, happy and life were considered in Quality of Life and these factors were sub categorized into High (excellent, very good and good) and was indicated with the score 0 and Low (fair and poor) was indicated with score 1. This was recorded using self administered questionnaires. Orthodontic problems were grouped under Index for Orthodontic Treatment Need and were grouped as follows: Index for Orthodontic Treatment (IOTN) which was categorized into No or Little need for treatment (<7) and Definitive need for treatment ( >7) groups. Variables such as aesthetic component, crowding and spacing between teeth, cross bite, open incisor bite and incisor overlay, upper and lower posterior teeth saggital ratio of the right and left side were recorded for each subject to evaluate the necessity for the need of orthodontic treatment Statistical analysis: The data collected was analyzed using Statistical Package for Social Sciences for Windows, version 17 (SPSS Inc., Chicago, IL). Descriptive statistics (mean, proportion, standard deviation) were used to describe the characteristics of the sample. The chi-square test was used to explore the relationship between orthodontic problems and socio-economic status.the statistical significance was considered as P

22 4. RESULTS AND DISCUSSION This cross sectional study was conducted to assess the prevalence of orthodontic problems and the orthodontic treatment need using the Index for Orthodontic Treatment Need (IOTN) among 13 to 15 years old school children of Chennai city, India. In this event, 200 children were selected, out of which 100 belonged to the private school and 100 were from the public school. 112 boys and 88 girls were examined in this study. The reason for selecting the two categories of schools are because children from the lower socio-economic strata attend the public schools which are mostly located in the suburban areas and children attending the private schools were from the higher socio-economic strata which are located within the city. Children in the city would be more exposed to a varied lifestyles and would be more aware in terms of dental health and the need for treatment as compared to children who live in the suburbs. In this way it was easy to make a clear association between socio-economic status and orthodontic problems including the need for treatment. This is in agreement with similar studies which were conducted in India (Tak M et al, 2013). The present study was conducted among 12 years and 15 years age group as both the age groups are the index age group of pathfinder survey as per WHO Basic Oral Health Survey method. The 12 years age group was selected because this age is considered as a global monitoring age for caries for international comparisons and monitoring of disease trends. The 15 years age group was selected because at this age, the permanent teeth have been exposed to the oral environment for 3-9 years. This age is also important for the assessment of periodontal disease indicators in adolescents (WHO,1999). The present study seek to advocate the need to include an orthodontic focus in the public dental health services. In the studies of prevalence of orthodontic problems, one should always choose a well-defined sample, subjects with no prior history of orthodontic treatment and objective data collection (Thilander B et al, 2001). The present study could not fulfill such criteria as the sample size was very small. To calculate the difference in orthodontic problems among children in public and private schools, the Index for Orthodontic Treatment Need (IOTN) was used. 22

23 4.1.Variables used to record the need for orthodontic treatment Index for Orthodontic Treatment Need (IOTN) According to the IOTN index it is necessary to record variables such as aesthetic component, crowding and spacing between teeth, cross bite, open incisor bite and incisor overlay, upper and lower posterior teeth saggital ratio of the right and left side for each subject to evaluate the necessity for the need of orthodontic treatment. Table 2. Index for orthodontic treatment need (IOTN) variables IOTN GENDER TOTAL P VALUE COMPONENT Boys (N%) Girls (N%) (N%) Aesthetic 1 (0.9) 1 (1.1) 2 (1.0) <.005 component Crowding and 46 (40.7) 59 (67.8) 105 (52.5).852 spacing between teeth Cross bite 17 (15.0) 3 (3.4) 20 (10.0) <.001 Open incisor bite 20 (17.7) 11 (12.6) 31 (15.5).007 Upper posterior teeth saggital ratio right side and Lower posterior teeth saggital ratio left side 29 (25.7) 13 (14.9) 42 (21.0).327 According to table 2, the difference between boys and girls when it came to the variables such as aesthetic component, cross bite, open incisor bite and incisor overlay showed statistically significant results. 40.7% of boys and 67.8% girls showed crowding and spacing between their 23

24 teeth, the difference was not statistically significant. 25.7% of boys and 14.9% of girls showed a saggital ratio difference between the posterior teeth but the difference was not statistically significant. Boys Girls 67.8% 40.7% 0.9% 1.1% 15% 3.4% 25.7% 17.7% 12.6% 14.9% Aesthetic component crowding and spacing cross bite open incisorbite and incisor overlay upper and lower teeth sagittak ratio rightside and left side Figure 1: Differences among the IOTN variables between boys and girls. Figure 1 shows most of the orthodontic problems to be related to crowding and spacing which were more among girls (67.8%) than boys (40.7%). Many studies which have evaluated the need for orthodontic treatment among school children have used the IOTN index for Orthodontic Treatment Need (Col Prassana Kumar et al, 2012; Nicky A. Mandall et al, 2005). The IOTN has been gaining international recognition as a method of objectively assessing treatment need (Neslihan U and Esra E, 2001). Comparing all the orthodontic indices, it was found that IOTN was a reliable and user friendly index, which can be used for orthodontic surveys (Col Prasanna Kumar et al, 2013). 24

25 4.2. Difference in the need for orthodontic treatment among children in public and private schools and among boys and girls The need for orthodontic treatment was analyzed between children from the private and public school and among boys and girls using the Index for Orthodontic Treatment Need (IOTN). A total of 200 children were examined out of which 100 were from the private school and 100 were from the public school. 113 boys and 87 girls were examined. Table 3. Distribution in the need for orthodontic treatment among school type and gender IOTN TOTAL No or little need (N%) Definitive need (N%) P VALUE SCHOOL Private (51.0) 49 (49.0).285 Public (56.0) 44 (44.0) GENDER Boys (41.6) 66 (58.4) <.001 Girls (69.0) 27 (31.0) Table 3 shows that out of the 100 children examined in the public school, it was found that 56.0% were healthy and had no orthodontic problems that needed treatment, while 44.0% had orthodontic problems and needed treatment. Out of the 100 children examined in the private school, it is found that 51.0% were healthy and did not have any orthodontic problems that needed treatment, while 49.0% had orthodontic problems and needed treatment. Hence in this study, it is observed that children in the private school had more orthodontic problems than those in the public school. However the difference was not statistically significant. Out of the 200 participants in both the public and private schools, 69.0% of the girls did not have any orthodontic problems and 31.0% had orthodontic problems. 41.6% of boys did not have any orthodontic problems and 58.4% had orthodontic problems. Boys had more orthodontic problems than girls. The difference was statistically significant. 25

26 51% 49% No or little need 56% Definitive need 44% Private Public Figure 2: Differences in the need for orthodontic treatment among the private and public school Figure 2 shows that the children from the private school had a definitive need for orthodontic treatment (49%) when compared to the public school (44%). Boys Girls 69% 58.4% 41.6% 31% No or little need Definitive need Figure 3: Differences in the need for orthodontic treatment among boys and girl 26

27 Figure 3, shows that the boys had a definitive need for orthodontic treatment (58.4%) when compared to girls (31%). Literature comparing the Need for Orthodontic Treatment among public and private school children in India, is very limited as this differentiation is made to bring about the differences in socio-economic status. However there is a lot of literature among gender differences and the need for orthodontic treatment. The distribution with respect to males and females for orthodontic treatment need has been studied by several researchers. Hedayati and co-workers showed more findings of need for orthodontic treatment in males than females in Iranian children (Hedayati et al, 2007). Sanjeev S and his colleagues, also found that the difference between the IOTN values among boys and girls indicated that boys represented more need to treatment than girls but the difference was not statistically significant (Sanjeev S et al, 2007). Burden and co-workers, in their study used the IOTN index and found that significantly more males were in need of orthodontic treatment than females (Burden et al, 1994). These findings were in line with the present study. The reason why girls had lesser need for orthodontic treatment in our study when compared to boys may be because they gave more importance to their dental aesthetic appearance and took care of their teeth well. In a study by Shaw et al (1991), they found that the parents pay more attention to girls than boys concerning dental aesthetics. Neus Puertes-Fernández and co-workers, in their epidemiological study conducted in West Saharan school children found that there was no significant difference between the need for orthodontic treatment and gender among children (Neus Puertes et al, 2010). Also, a study done by Venkatesh B and his co-worker showed no correlation with the treatment needs and gender of (Venkatesh B and Gopu H, 2011). Another study done by Aiste Kavaliauskine and co-workers, demonstrated that girls reported orthodontic problems more often than boys (Aiste K et al, 2010). The findings of these studies were in contradiction with the present study. Generally in majority of the studies, when interpreting results, it was noted that in the study population, none of the children had been orthodontically treated. In most epidemiological studies, individuals with a previous or current history of orthodontic treatment were systematically excluded from the sample (Barnabe E et al, 2006; Seema D et al, 2013). Our study did not have this exclusion criteria, as the study population included children who have 27

28 previously undergone, undergoing and not undergone orthodontic treatment. Children who were undergoing or had already undergone orthodontic treatment were considered as those not having a need for treatment. Most of the studies have been performed by selecting schools randomly and examining its children, hence results interpreted are in general representing the entire study population. But in the present study we have included two categories of schools and differentiated the need for treatment based on the IOTN index. The existence of orthodontic problems with orthodontic treatment need and the perception of such need by the children reinforce the importance of including orthodontic treatment in public health policies. Such inclusion assumes adequate resource allocation, better use of human resources and professional creativity, and institutional liaison between public and private institutions The need for orthodontic treatment among the various socio-economic status groups According to the socio-economic status, the children from both the public and private schools were divided into three categories: poor, average and rich. Table 4. Index for Orthodontic Treatment Need among the various socio-economic groups IOTN groups Socio-economic Total (N%) status - SES (Scores) No or little need (N%) Definitive need (N%) Poor (0-1) 86 (44.1) 47 (54.7) 39 (45.3) P value Average (2-4) 72 (36.9) 40 (55.6) 32 (44.4) Rich (5-7) 37 (19.0) 16 (43.2) 21 (56.8) 28

29 According to table4, 43.2% of children under the rich category did not need orthodontic treatment and 56.8% needed orthodontic treatment. 55.6% of children under the average category do not need orthodontic treatment and 44.4% needed orthodontic treatment. 54.7% of children under the poor category needed orthodontic treatment and 45.3% do not need orthodontic treatment. However the difference was not statistically significant. No or little need Definitive need 54.7% 55.6% 56.8% 45.3% 44.4% 43.2% Poor Average Rich Figure 4: The need for orthodontic treatment among the various socio-economic groups. According to figure 4, the need for orthodontic treatment is the highest in children under the rich category (56.4%), followed by the children under the poor category (45.3%) and is least among the children under the average category (44.4%). Some studies have demonstrated that the need for orthodontic treatment (IOTN) did not significantly differ between subjects from different areas of living or socioeconomic backgrounds (Heidi Kerosuo et al, 2004; Ruhi Nalcaci et al, 2012). Other studies have revealed that the need for orthodontic treatment was greater among the deprived or lower socio-economic 29

30 status group (Tickle M et al, 1999; Prabu D et al, 2008). In the present study, children from the average socio-economic group had no need for orthodontic treatment followed by the low socioeconomic group. Children from the higher or rich socio-economic group had a definitive need for orthodontic treatment. The reason for this may be due to the easy availability and consumption of unhealthy diet and junk food among the children residing in the cities who study in the private school and hail from the higher socio-economic group. Since they consume more junk foods in an early stage, they are more prone to the development of dental caries resulting in the early loss of deciduous teeth and subsequent drifting and crowding of the permanent teeth when they erupt. When it comes to creating an awareness and planning of public health programs, more importance is given to targeting the lower socio-economic group, but according to the findings of the present study, importance should also be given to children from the higher socioeconomic group. 30

31 4.4. Quality of Life (QoL) among the children The Quality of Life was analyzed among boys and girls and among the private and public schools. Table 5: Distribution of Quality of Life among school type and gender Gender Quality of Life (QoL) High Low (N%) (N%) P value Boys 95 (86.4) 15 (13.6) Girls 81 (94.2) 5 (5.8) 0.05 School Private 87 (90.6) 9 (9.4) 0.44 Public 89 (89.0) 11 (11.0) Table 5, shows that the Quality of Life (QoL) is higher for girls (98.4%) when compared to boys (86.4%). However, the difference is not statistically significant. The Quality of Life (QoL) is higher among children in private schools (90.6%) than in public schools (89.0). However the difference is not statistically significant. 31

32 86.4% Quality of life -high 94.2% Quality of life -Low 90.6% 89% % 9.4% 11% Boys Girls Private Public Figure 5: Quality of Life (QoL) among gender and school. Figure 5 shows that the Quality of Life (QoL) is higher for girls and among children in private schools. Studies done by Abu A et al and Kok YV et al have also shown similar results, with no statistical significance. In a study done by Navabi et al, they observed no significant relationship between gender and QoL in the subjects (Navabi N et al, 2012). de Oliveria and Sheiham reported that sex significantly affects the impact of orthodontic problems on QOL, and women were 1.22 times more likely to have an impact than men. They have concluded that, gender differences cannot be considered as predicting factors for QoL (de Oliveira CM and Sheiham A 2004). One study has evaluated the Quality of Life among Sudanese school children attending the public and private school and have found that children from the private schools had a better quality of life compared to children attending the public school (Nazik MN et al,2010). Girls seemed to exhibit a better general quality of life as they may seem to be more happier and take care of their health and well being when compared to boys. The quality of life seemed to be better in private schools as most of them hail from the higher socio-economic status group, their parents are well educated and are financially sound and they seemed to have a better lifestyle when compared to children from public schools who hail from the lower socio- 32

33 economic group who comparatively do not have a better lifestyle. Hence quality of life is a very important factor when it comes to conducting public health programs, as more focus should be given to improving the quality of life and health situation, aiming at providing free health care Relationship between Quality of Life (QoL) and the Need for Orthodontic Treatment (IOTN) The association between quality of life and the need for orthodontic treatment has been shown. Children who have a good quality of life have been recorded as high and those having a poor quality of life have been recorded as low. Table 6: Association between Quality of Life and Need for Orthodontic Treatment IOTN QoL No or little Definitive need need High 94 (53.4) 82 (46.6) Low 12 (60.0) 8 (40.0) P value In table 6, children who did not have a good quality of life, had little or no need for orthodontic treatment (60%), when compared to children who had a good quality of life (53.4%). Whereas children who had a good quality of life had a definitive need for orthodontic treatment (46.6%) when compared to those who did not have a good quality of life (40.0%). However, the difference was not statistically significant. 33

34 No or little need Definitive need 53.4% 46.6% 60% 40% Quality of life-high Quality of life-low Figure 6: Association between quality of life and the need for orthodontic treatment Most of the studies have shown that, children who had a need for orthodontic treatment had a significantly worse Qol score compared to those who did not need treatment (O Brien et al, 1998; Mandall N et al, 2001; Fox D et al, 2000; Kok YV et al, 2000). Study done by Navabi et al (2012), have shown an improvement in function and appearance of the child and an improvement in quality of life who had previously undergone orthodontic treatment. In contrast, Taylor believes despite the fact that orthodontic treatment improves appearance, oral functions and the social health of the patients, it does not seem to exert a significant influence on their general quality of life (Taylor et al, 2009). It has long been recognized that people seek and undergo orthodontic treatment not because of the anatomic irregularities or to prevent the destruction of tissue within the oral cavity, but because of the consequences of the aesthetic impairment caused by orthodontic problems and malocclusion. Thus, malocclusion and orthodontic care have become a quality-oflife (QoL) issue. Some studies have shown that self-consciousness and embarrassment and the general feeling of less satisfaction in life were significantly associated with higher orthodontic treatment need in both males and females. On the other hand it did not affect the ability of the patient to do their job or function effectively. Therefore it may be assumed that patients with 34

35 orthodontic problems may suffer from aesthetic and social problems which is related to quality of life rather than impairment of daily activities Binary logistic regression analysis: Table 7: Socio-Economic Status, School, Quality of Life and Index for Orthodontic Treatment. GENDER: Girls Boys N% Crude model Odds ratio (CI) Ref 3.12( ) Adjusted model Odds ratio (CI) Ref 1.83( ) SCHOOL: Private Public Ref 0.81( ) Ref 0.85( ) SOCIO-ECONOMIC STATUS: Poor Average Rich Ref 0.63( ) 0.61( ) Ref 0.91( ) 1.07( ) QUALITY OF LIFE (QoL): High Low Ref 0.76( ) Ref 0.55( ) The relative risk of the need for orthodontic treatment adjusted for confounding is estimated for the various categories of gender, school type, socio-economic status and quality of life. The evaluation of socio-economic status revealed insignificant differences among the subgroups in low, average, and rich categories, 45.3%, 44.40%, and 56.8% of schoolchildren, respectively, reported for the need for orthodontic treatment ( df=1;p=0.429). However, children from the rich socio-economic status group, reported a definitive need for orthodontic treatment 35

36 when compared to the average and poor groups.the relative risk of the need for orthodontic treatment is calculated for the average and rich socio-economic group, keeping the poor socioeconomic group as reference category. No elevation in risk is observed in the average group. The relative risk is 0.91( ). However, there is a slight elevation in risk for the rich socioeconomic group. The relative risk is 1.07( ). The evaluation for gender revealed significant differences among boys and girls, 58.4% and 31.0% of boys and girls, respectively, reported for the need for orthodontic treatment ( df=1; P<0.001). Boys reported a definitive need for orthodontic treatment when compared to girls. The relative risk of the need for orthodontic treatment is calculated for girls keeping boys as the reference category. No elevation in the risk is observed. The relative risk is 0.32( ). The evaluation for school type revealed insignificant differences among private and public schools, 49.0% and 44.0% of private and public school children, respectively, reported for the need for orthodontic treatment ( df=1; P=0.285). Private school children reported a definitive need for orthodontic treatment when compared to public school children. The relative risk of the need for orthodontic treatment is calculated for public school keeping private school as the reference category. No elevation in the risk is observed. The relative risk is 0.85( ). The evaluation for Quality of Life (QoL) revealed insignificant differences among high and low groups. 46.6% and 40.0% of school children from the high and liw groups, respectively, reported for the need for orthodontic treatment (df=1; P=0.375). The high group reported a definitive need for orthodontic treatment when compared to the low group. The relative risk of the need for orthodontic treatment is calculated for girls keeping boys as the reference category. No elevation in the risk is observed. The relative risk is 0.32( ). The association between the need for orthodontic treatment and gender, school type, socioeconomic factors and quality of life was analyzed more in detail employing binary logistic regression model (Table 8). The analysis involving gender, school type, socio-economic factors and quality of life revealed that the prevalence of orthodontic treatment need was significantly associated only with gender where boys were 1.83 times more likely in need of orthodontic treatment when compared to girls. Other factors were not significantly associated with orthodontic treatment needs. 36

37 However, our study had some limitations. In most epidemiological studies, individuals with a previous or current history of orthodontic treatment are systematically excluded from the sample (Bernabé and Flores-Mir, 2006; Manzanera et al., 2008). This leads to underestimation of the real treatment need of the population being studied, a fact that needs to be taken into account when making comparisons. 37

38 CONCLUSSIONS 1. Children from the public school had a lower need for orthodontic treatment than those in the private school and girls had a lower need for orthodontic treatment than boys. 2. Children from the average socio-economic status category had a lower need for orthodontic treatment followed by the poor and finally by the rich socio-economic status category. 3. Girls had a better Quality of Life when compared to boys and children from the private schools had a better Quality of Life than those from the public school. 4. Children who have a good quality of life had lower need for orthodontic treatment when compared to children who do not have a good quality of life. 38

39 PRACTICAL RECOMMENDATIONS 1. Monitoring. Orthodontic problem are very common especially among adolescent children. In India, awareness of orthodontic problems and the need for treatment is less especially in the suburban and rural areas compared to the city. The schools pay attention towards awareness and education among both private and public schools. Monitoring in routine basis should be done every month. The need and demand of orthodontic treatment is important for planning public orthodontic and dental services. 2. Health education. The lessons of health education should be implemented into teaching curriculum starting from kindergarten and primary schools and higher secondary schools. It is important to provide for children the appropriate knowledge and skills. The education of children, parents and teachers regarding orthodontic problems and when to undertake treatment is important. 3. Schools. The role of school health service should be increased. They should concentrate more on oral health promotion programs on nutrition.the school can incorporate oral health promotion as an integral part of schools curricula 4. Oral health. Oral health professional can plan, propose and implement school oral health promotion activities as part of building up oral health promotion in schools. 5. Parents and family health services. Parents need more health education on the matters related with nutrition, dental problem etc so that they could take the responsibility towards their children regarding treatment. Family dentist also should take integrated efforts with school health services to educate and instruct parent s on health promotion matters of their children. 39

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45 QUESTIONNARIES CHILDREN'S ORAL HEALTH AND RELATED QUALITY OF LIFE INVESTIGATION FORM TO BE FILLED BY STUDENTS Dear students, Thank you for participating in this study. In response to this questionnaire, it will help us learn more about children's oral health. This will allow dentists and researchers to explore, deeper children's teeth and other oral diseases organ to disclose their reasons for selecting the best treatment. This will be useful as healthy teeth are very important for good health and your happiness. How to fill in the questionnaire? Carefully read each question. In response to it, the box, which is near or below the most likes you the answer. For each question tick only one box, otherwise we will not be able to count your answers. If it is difficult to choose a single answer, so think, at that moment which answer is accurate. In other cases, write a response to the points marked. Please reply to the questions yourselves. After filling the form, insert it in an envelope, stick and give it yourself to the school visiting doctors. We promise that no one at school and parents (guardians) will know your answers. Thank you in advance for honesty and sincerity. The study by the Lithuanian University of Health Sciences The study coordinator Prashanth Prakash 45

46 1) Today's date: Day... Month... Year Questions about yourself 2) When were you born? I was born on: Day... Month... Year... 3) Who are you: a boy or a girl? 4) Which class do you study in? In brackets, write the letter and class, for example, 7 (A) class, if any. I am studying in... (...) classroom 5) Where do you live? Questions about General health and happiness 6) How would you describe your health? 46

47 7) In general, how you feel thinking about your current life? 8) The picture drawn ladder: At the top of the ladder is score 10 if you are most satisfied with your life, at the bottom is 0 if you are least satisfied with your life. Where on the ladder do you feel you standing now? Mark the box that best reflects your position. 10 Most satisfied with life

48 0 least satisfied with life Oral health status and complaints 9) How would you describe your oral health? Mark one box for each row very good well average poor very bad a) Dental b) Lip c) Gum d) Stomatitis e) Jaws and joints 10) During the past three months as part of a mouth organ Thee plagued health disorders? Mark one box for each row Just not a trouble A little somewhat distressed distressed weary It is very tiring a) Dental b) Lip c) Gum d) Stomatitis e) Jaw and joints 48

49 11) In the last three months of the dry felt an organ pain? Mark one box for each row never once or twice sometimes often almost every day a) Dental b) Lip c) Gum d) Stomatitis e) Jaw and joints 12) During the past three months has your mouth had such problems? Mark one box for each row once or Never Sometimes often twice almost every day a) When cleaning your teeth, do your gums bleed b) Sores or wounds on the lips c) Mouth sores or wounds d) Bad breath from mouth e) Does food get caught between your teeth f) Are your teeth sensitive to hot, cold or sweets 49

50 13) During the past 3 months due to dental or oral condition, do you...? Mark one box for each row Never Once or twice Sometimes Often Almost every day a) Tear and chew solid food like apple and meat b) Take longer time than others to chew the food c) Could not drink or eat anything hot or cold d) Could not drink through a straw e) Could not be opened wide 14) During the past 3 months due to dental or oral condition you...? Mark one box for each row If this was not associated with dental or oral condition, note the answer "Never" Never Once or twice Sometimes Often Alm ost every day a) Breathing through the mouth b) Could not form words c) Blogs slept d) headaches e) In general, you feel ill (nausea, felt fatigue, etc.). Questions about your feelings and emotions 15) During the past 3 months due to dental or oral condition You are...? Mark one box for each row If this was not associated with dental or oral condition, note the answer "Never" 50

51 Never Once or twice sometimes often Almost everydy a) Cries, suddenly excited b) Lack of courage, self-confidence c) You were embarrassed, felt ashamed d) Were you nervous, irritable, angry e) you feel lonely f) Do you feel,others are thinking badly about your teeth or mouth g) Do you feel,your teeth or mouth does not look as nice as the other h) Do you feel, your teeth or mouth are not as healthy as other i) Did you feel dejected because of their teeth or mouth j) Do you feel,you stand out from the rest thanks to their teeth or mouth appearance 51

52 Questions about school, friends and leisure time 16) During the past 3 months due to dental or oral condition You are...? Mark one box for each row If this is not related to the teeth or mouth, note the answer "Never Never Once or twice Sometimes Often Almost every day a) Avoiding school b) Could not concentrate at school c) Could not concentrate with homework d) Avoid loud talking in class or read e) Avoid attending sports, choir or other circles, get-togethers or school trips f) Avoid talking with your friends g) Avoid eating when other people were around h) Avoid smile or laugh when you are around other children were i) In general, avoid being with other children j) It was hard to play wind musical instruments (if you play) 52

53 17) During the past 3 months due to dental or oral condition...? Mark one box for each row If this is not related to the teeth or mouth, note the answer "Never" Never Once or twice sometimes often Once or twice a) Other kids made fun of You b) Other children avoid you c) Other children asked what happened to your teeth or mouth Remember the last 3 months How do you take care of their teeth and mouth 18) How often do you brushing your teeth with a toothbrush and toothpaste? 19) Have you noticed that brushing your teeth with a toothbrush and toothpaste, it is difficult to clean your teeth? (eg dental remains of food) 53

54 20) What kind of toothbrush you use? 1 A simple one al 21) What kind of toothpaste you use? 22) Do you rinse your mouth with mouthwashes? 1 Never 2 Sometimes 23) Do you use sanitary thread (floss) between the teeth to clean? 1 Never 2 Sometimes ften 24) Do you use toothpicks to clean between the teeth? 1 Never 2 Sometimes ften 54

55 Treatment / Healing 25) Do you have a filled tooth? 1 Yes 2 No 26) Do you have rotten teeth that need to be treated? doctor 27) Over the last 12 months, you visited the dentist? 28) If "Yes", visited the why? Mark all that apply. If "No", skip this question. undergo prophylactic ) How much do you fear dental treatment? 55

56 30) Have you ever noticed that your teeth are irregularly placed, or did you notice a bad bite? 31) Do you wear / wore dentures? ore. Write how much time wore:... How long have wearing ) Do you wear / wore braces?... 33) If you wear / wore dentures or braces, how much do you think this treatment has helped you (improved health, appearance or other)? plate or braces 56

57 Diet and smoking Remember the last 3 months 34) How often do good or eat these foods? Mark one box for each line. Never Less than once a week Weekly 2-4 days a week 5-6 days a week Every day, once a day Every day, several times a day a) fruit b) green vegetables c) cooked vegetables d) Candies, chocolate e) Cakes, brownies, cookies f) Coca-Cola and othe carbonated soft drinks g) various energy drinks h) Milk, yogurt, cottage cheese, cheese and other dairy product 35) Have you ever smoked (at least one cigarette)? 1 Yes 2 Not 36) How often do you smoke? 57

58 Questions about your parents and family 37) How often do you talk to parents about your dental and oral health? Mark one box for each row Veryeasy Easy It is difficult It is very difficult Do not have or see this person a) The father b) The stepfather (sponsor) c) with mom d) The stepmother (Patron) 38) Overall, how easy is it to talk to your parents, about the different things that are important to you and made you worried about? Mark one box for each row Very easy Easy It is difficult Very difficult Do not have or see this person a) The father b) The stepfather (sponsor) c) with mom d) The stepmother (Patron) 39) Does your family have a computer? 58

59 40) Does your family have a car? 1.No 41)How many times in the past 12 months you together with your family, went on trips (vacation)? 1. Never 4 more than 2 times 42) Do you have your own room? 1. yes 2. no 43) How well off do you think your family is? not at all well off 44) Does your father have a job? 59

60 44). Does your mother have a job? 2 No Questions about your abilities 45) The table shows the wide variety of claims about your abilities. After reading each statement, note how many agree with him or disagree Mark one box for each line. Strongly agree Agree Disagree Strongly disagree a) I feel that I am inferior to other b) It seems to me that I have more good qualities c) Overall, I think that I am a loser d) I am able to everything as well as many other e) I feel that I have little to be proud of f) About myself I feel good g) Overall, I am a self-satisfied h) I prefer a more self-respect i) Sometimes, I feel to be useless to anyone j) Sometimes I think that I am nothing? 60

61 CHILDREN S ORAL HEALTH RELATED QUALITY OF LIFE RECORD FORM FOR ORAL HEALTH EXAMINATION SCHOOL... CLASS... ID Today s date: / / 201 DAY MONTH YEAR 2. Date of birth: / / DAY MONTH YEAR 3. Gender 1 Boy 2 Girl 4. Ask the child if the following questionnaires were completed: A. For child himself B. For parents (guardians) 1 Yes 1 Yes 2 No 2 No 61

62 Top / Right Bottom / Right M O D B L M O D B L 0 whole surface is health 1 intact surface active decay (smear) 2 active decay, the surface enamel defect 3 active decay, deep enamel dentine defect 4 intact surface stabilized decay (smear) 5 stabilized decay, the surface enamel defect 6 stabilized decay, deep enamel dentine defect A. Dental bone condition seal 8 seal + active decay 9 seal + stabilized decay 10 extracted tooth decay on 11 extracted tooth for orthodontic purposes 12 retained tooth 13 sealants Top / Left Bottom /Left 62

63 A1. Oral Hygienic Index (by Silness & Loe) 4 points assessment 0 No plaque 1 The small amount of plaque at cervical region 2 Plaque is clearly visible at cervical region and interdental space 3 Thick deposits of plaque on the surface of the tooth to the gum and interdental spaces which are clearly visible and run through probe A2. Assessment of periodontal status (CPITN index) 0 Healthy 1 Bleeding on probing 2 Stones 3 A pocket of 4-5 mm 4 6 mm pockets and deeper 5 Missing sextant A3. Dental fluorosis classification (by Thylstrup & Fejerskov) The upper jaw The lower jaw Central incisors Lateral incisors Canines First premolars Second premolars First molars Second molars A4. Discoloration or damaged tooth Discoloration Hipoplasia Tetracycline Erosion Attrition 63

64 B. Tooth position and occlusal evaluation B1. Lateral teeth ratio (Angle class): Ratio of the first molars: Right 1 Angle I 2 Angle II 3 Angle III Left 1 Angle I 2 Angle II 3 Angle III B2. Ratio of the canines 1 Angle I 2 Angle II 3 Angle III 1 Angle I 2 Angle II 3 Angle III B3. No teeth (solving of adentae, ectopic and retained teeth) Mark observed disturbances Classification Criteria 0 No changes 1 Retained tooth (excluding third molars) 5.i Did not spring up teeth due to crowding, dislocation, overcomplement tooth, ankylosing deciduous teeth, and other pathological reasons 2 Mild hipodontia 4.h Missing one tooth in any quadrant and required orthodontic treatment prior to restorations or gaps closing to avoid the prosthesis 3 Severe hipodontia 5.h Missing more than one tooth in any quadrant and required orthodontic treatment prior to restorations 4 Partially appearance 4.t Partially appearance of teeth, leaning and of teeth blocked the adjacent tooth 64

65 B3. No teeth (solving of adentae, ectopic and retained teeth) Mark observed disturbances 5 Overcomplement tooth 4.x Extra teeth 6 Milk tooth ankylosis 5.s B4. Horizontal mouth overlay (HMO):... mm Classification 1 A small positive, competent lips 2 A small positive incompetent lips Criteria 2.a 3.5 mm <HMO 6 mm, lip competent 3.a 3.5 mm <HMO 6 mm, lip incompetence 3 Medium positive 4.a 6 mm <HMO 9 mm 4 Bright positive 5.a HMO > 9 mm 5 Slightly negative 2.b -1 mm HMO < 0 mm 6 Average negative free speech and chewing problems 3.b -3.5 mm HMO < -1 mm, no speech and chewing problems 7 Bright negative free speech and chewing problems 4.b HMO < -3.5 mm, no speech and chewing problems 8 On average, the negative, with a speech and chewing problems 4.m -3.5 mm HMO < -1 mm, is a speech and chewing problems 9 Bright negative, with speech and chewing problems 5.m HMO < -3.5 mm, is a speech and chewing problems B5. Lips 0 Competent 65

66 B5. Lips 1 Incompetent B6. Chewing disorders 0 No 1 Yes B7. Speech disorders 0 No 1 Yes B8. Cross-bite (CB) 0 No 1 Yes B9. CB:... mm Measured distance (CB) between the retruded contact surface and the intermound surface B10. CB location B11. CB functional disorders 1 Front 0 No 2 Right side 1 Yes 3 Left side 4 Single tooth 66

67 B12. Classification Criteria 0 No changes 1 A small front or side 2.c CB 1 mm 2 Average front or side 3.c 1 mm < CB 2 mm 3 Bright front or side 4.c CB > 2 mm 4 Lateral lingual 4.l One-sided or double-sided lateral lingual CB without functional occlusal contacts B13. Displacement of the contact points (DCP):... mm (crowding). Measured distance between the two most crowded permanent teeth Classification Criteria 0 No changes 1 Small 1.- DCP 1 mm 2 Noticeable 2.d 1 mm < DCP 2 mm 3 Quite a bit 3.d 2 mm < DCP 4 mm 4 Bright 4.d DCP > 4 mm (pronounced shift in the point of contact) 67

68 B14. Vertical moth overlay (VMO):... mm Classification Criteria 0 No changes 1 Increased OB, deep bite 2 Increased OB, deep bite 3 Increased OB, deep bite 2.f VMO 3.5 mm no contact with the gums 3.f Deep bite, reaching the gums or palate, no injuries 4.f Deep bite, reaching the gums or palate with trauma 4 Front or side open bite 2.e 1 mm < VMO 2 mm 5 Front or side open bite 3.e 2 mm < VMO 4 mm 6 Front or side open bite 4.e VKP > 4 mm B15. Lip or cleft palate and other anomalies 1 No 2 Yes (5.p) B16. Pre-normal or post-normal occlusion without other abnormalities 1 No 2 Yes (2.g) B17. Photo 1 Was made 2 Was not made 68

69 B18. Aesthetic component (1...10)... Dental component of the ICON index 1 A. Crowding B. Spaces between the teeth 0 < 2 mm 0 < 2 mm 1 From 2.1 to 5 mm 1 From 2.1 to 5 mm 2 From 5.1 to 9 mm 2 From 5.1 to 9 mm 3 From 9.1 to 13 mm 3 > 9 mm 4 From 13.1 to 17 mm 5 > 17 mm 5 Retained teeth 3 A. Open incisors bite B. Incisors overlay 0 Edge to edge 0 <1/3 1 < 1 mm 1 From 1/3 to 2/3 2 From 1.1 to 2 mm 2 From 2/3 to the full 3 From 2.1 to 4 mm 3 Full 4 > 4 mm 4 The upper and lower posterior teeth ratio from front to back (in arrow direction): Right Left 0 The upper lateral teeth in contact with the protuberance of lower teeth: Angle I, II, III 0 1 Any tuberosity ratio but not in thalamus to the thalamus 1 2 Thalamus to the thalamus 2 69

70 PHOTOGRAPHS Public school Private school 70