Self-perception and malocclusion and their relation to oral appearance and function

Transcription

1 459 Self-ercetion and malocclusion and their relation to oral aearance and function Auto-erceção e má oclusão relacionadas à aarência e a função bucal. ARTIGO ARTICLE Sílvia Helena de Carvalho Sales Peres Suzana Goya Karine Laura Cortellazzi Gláucia Maria Bovi Ambrosano Marcelo de Castro Meneghim Antonio Carlos Pereira Deartamento de Odontoediatria Ortodontia e Saúde Coletiva, Universidade de São Paulo. Alameda Octávio Pinheiro Brisola 9-75, Vila Universitária. 7- Bauru SP. shceres@us.br Faculdade de Odontologia de Piracicaba, Universidade de Caminas Abstract The aim of this study was to evaluate the relationshi between malocclusion and selfercetion of oral aearance/function, in /5- year-old Brazilian adolescents. The cluster samle consisted of 77 teenagers attending 4 urban ublic (n=6) and 5 rural ublic (n=7) schools in Maringá/PR. Malocclusion was measured using the Dental Aesthetic Index (DAI), in accordance with WHO recommendations. A arental questionnaire was alied to collect information on esthetic ercetion level and oral related to oral health. Univariate and multile logistic regression analyses were erformed. Multile logistic regression confirmed that for -yearold, missing teeth (OR=.865) and resence of oenbite (oen occlusal relationshi) (OR=.865) were risk indicators for seech caability. With regard to 5-year-old, resence of mandibular overjet (horizontal overla) (OR=4.6) was a risk indicator for seech caability and molar relationshi (OR=.66) was a risk indicator for chewing caability. The imact of malocclusion on adolescents life was confirmed in this study. Seech and chewing caability were associated with orthodontic deviations, which should be taken into consideration in oral health lanning, to identify risk grous and imrove community health services. Key words Malocclusion, Adolescent health, Self concet, Oral health Resumo Este estudo objetivou avaliar a relação entre a má oclusão e a autoerceção da aarência/função bucal em adolescentes brasileiros de /5 anos de idade. A amostragem foi robabilística, constituída or 77 adolescentes de escolas úblicas, sendo 4 urbanas (n=6) e 5 rurais (n=7), em Maringá/PR. A má oclusão foi medida or meio do Índice de Estética Dental (DAI), de acordo com os critérios da OMS. Foi alicado um questionário aos ais ara coletar informações sobre o nível de erceção estética e as variáveis relacionadas à saúde bucal. Análises univariada e de regressão logística múltila foram realizadas. A regressão logística múltila confirmou que ara anos, os dentes ausentes (OR=,865) e a resença de mordida aberta (OR=,865) foram indicadores de risco na caacidade de fala. Com relação aos 5 anos, a resença de overjet mandibular (OR=4,6) foi um indicador de risco ara a caacidade de exressão e a relação molar (OR=,66) foi um indicador de risco ara a caacidade mastigatória. O imacto da má oclusão na vida dos adolescentes foi confirmado neste estudo. A caacidade da fala e da mastigação esteve associada às alterações ortodônticas, as quais devem ser levadas em consideração no lanejamento de saúde bucal, ara identificar gruos de risco e ara melhorar os serviços de saúde. Palavras-chave Má oclusão, Saúde do adolescente, Autoimagem, Saúde bucal

2 46 Peres SHCS et al. Introduction It has been reorted that clinical (normative) and subjective (self-assessment) evaluation of malocclusion demonstrate a significant disarity. The dental ublic health team is obliged to recognize and understand this ga. Esthetic ercetion varies from erson to erson and is influenced by their ersonal exerience and social environment. For this reason, rofessional oinions regarding evaluation of facial esthetics may not coincide with the ercetions and exectations of atients or lay eole,. The anterior visible occlusion and examiner s level of education may be imortant for understanding the atient s ercetion when discussing the esthetic considerations of orthodontic treatment 3. An imortant motivational factor is to imrove dentofacial aearance 4,5. The relationshi between hysical aearance and ercetion of an esthetic deviation, and the imact of such a deviation on self-esteem and body image is an imortant issue in determining the benefits of orthodontic treatment. A variety of social, cultural and sychological factors, and ersonal norms influence the ercetion of hysical attractiveness 6,7. Studies in social sychology indicate that hysical attractiveness lays a major role in social interaction and influences the imression of an individual s social skill 7,8. The Dental Aesthetic Index (DAI) adoted by the World Health Organization has been used to assess malocclusion and determine treatment needs 9-, and has been integrated into all items of the International Collaboration Study of Oral Health outcomes and guidelines by the WHO,3. Self or atient oinions regarding orthodontic treatment needs have reviously been recorded for dental and facial aearance 6,4,5, and such concerns do not always concur with rofessional evaluations of treatment requirements 6,7. The aim of this study was to evaluate the relationshi between the dental aesthetic index (DAI) and self-ercetion of oral aearance and function in /5-year-old Brazilian adolescents. The study was aroved by the Research Ethics Committee of the Bauru Dental School, University of São Paulo. Written ermission was obtained from adolescents arents before starting the clinical examinations. Samle In total, a cluster samle comosed of 77 students, aged and 5 years, attending 3 reresentative ublic schools in Maringá, Brazil, were examined. The samle was organized by gender (34 girls, 377 boys) and age (4 -year-olds, 35 5-year-olds). The clusters were rural (n=) and urban (n=9) schools. Schools and grades were randomly selected. The cluster samling method was used admitting a samling error of 5%, mean dmft of.5 with standard deviation of.8, a confidence level of 95% and loss of %. Students who had orthodontic treatment or were currently wearing an orthodontic aliance were not included in the study. Examination methodology Clinical examination was erformed by one reviously calibrated examiner, outdoors, under natural light, using CPI robes ( ball oint ), mirrors #5 3 and air-drying. Before examination each children erformed tooth brushing suervised by a dental hygienist. Calibration A benchmark dental examiner ( Gold Standard ), exerienced in eidemiological surveys, conducted the calibration rocess that lasted 4 hours (4 sessions). Theoretical and ractical activities with discussions on the diagnostic criteria of malocclusion were erformed by two examiners (gold standard and main examiner). Aroximately % of the samle was re-examined in order to verify the intra-examiner reroducibility. Inter-examiner agreement was.85 exressed by the Kaa statistics. This value indicated reliability within accetable limits 8. Diagnostic criteria and codes Materials and method Ethical asects Professional treatment needs were obtained by assessing the teenagers using the DAI in accordance with the WHO guideline 3. All comonents of the index were assessed (Table ). One of the authors was reviously calibrated using re-examination of dental students.

3 46 Table. The standard DAI regression equation. DAI Comonents. Number of missing visible teeth (incisors, canines and remolars teeth in maxillary and mandibular arches).. Crowding in the incisal segment (=no segment crowded; = segment crowded; = segments crowded). 3. Sacing in the incisal segment (=no sacing; = segment saced; = segment saced). 4. Midline diastema in millimeters. 5. Largest anterior irregularity on the maxilla in millimeters. 6. Anterior maxillary overjet in millimeters. 7. Anterior mandibular overjet in millimeters. 8. Vertical anterior oenbite in millimetrs. 9. Anterior-osterior molar relation (largest deviation from normal either left or right): =normal; =/cus either mesial or distal; =one full cus or more either mesial or distal.. Constant. Total WHO, 997. Weight DAI score Ciência & Saúde Coletiva, 6(): , Questionnaire All teenagers received a semi-structured questionnaire to be answered according to their selfercetions and erceived esthetic of malocclusion. The goal of this questionnaire was to collect information about seech caability, chewing caability and reort of ain. Data Analyses Univariate analyses using the Chi-square test (χ ) at 5% significance level were erformed to test the influence of indeendent (oenbite, missing teeth, crowding, sacing, midline diastema, maxillary irregularity, mandibular irregularity, maxillary overjet, mandibular overjet, molar relation and gender on deendent (seech caability, chewing caability and reort of ain). The deendent (seech and chewing caability) were dichotomized into bad/regular and good/excellent while the deendent variable reort of ain was dichotomized into children with or without ain. The indeendent related to DAI comonents (Table ) were dichotomized according to absence (code ) and resence (code ). Next, multile logistic regression analyses using the stewise rocedure were erformed in order to identify the self-ercetion indicators. In order to eliminate that would make little contribution to the model, only the indeendent that showed significant association at <.5 in the univariate analysis were tested in regression model 9,. The logistic regression models were adjusted estimating the Odds Ratios (OR), their 95% confidence intervals (IC), and significance levels. All statistical analyses were erformed using the SAS software at 5% significance level. Results The Dental Aesthetic Index (DAI) was calculated using the scores exressed in Table. Tables, 3 and 4 resent univariate analyses, using Chi-square or the Fisher s Exact Test, associating deendent (seech caability, chewing caability and reort of ain) with indeendent cited in DAI classification (Table ). Table shows the statistically significant association (all at <.5 were tested in regression analysis) between seech caability and oenbite, missing teeth and sacing for - year-olds, while for 5-year-old samle seech caability was associated with maxillary irregularity, mandibular overjet and molar relationshi. In Table 3 a statistically significant association between chewing caability and mandibular irregularity can be found for year olds, as well as oenbite, maxillary overjet and molar relationshi for 5-year-olds. Reort of ain was statistically associated with missing teeth and mandibular irregularity for -year-olds, as well as mandibular overjet and gender for 5 year olds (Table 4). The data from the regression analyses confirmed most of these associations. For the - year-old samle, missing teeth (OR=.865) and resence of oenbite (OR=.865) were risk indi-

4 46 Peres SHCS et al. Table. Univariate analyses of the association between seech caability (dichotomization in bad/regular and good/ excellent) and malocclusion in -5 year-old adolescents. Deendent variable (Seech caability) years 5 years Indeendent Absence (), resence () bad, regular good, excellent bad, regular good, excellent Oenbite Missing teeth Crowding Sacing Midline diastema Maxillary irregularity Mandibular irregularity Maxillary overjet Mandibular overjet Molar relationshi Gender 7 (9.77) 6 (4.) 7 (9.77) 6 (4.) 57 (.4) 9 (.9) 5 (8.66) 6 (5.74) 56 (9.86) (.99) 5 (9.3) 5 (4.75) 54 (.38) (.5) 8 (5.8) 68 (.) 76 (.94) (.) 4 (.3) 35 (.) 37 (.33) 45 (79.67) 84 (8.3) 9 (6.) 84 (8.3) 9 (6.) 6 (79.86) 67 (77.9) 8 (8.34) 75 (74.6) 6 (8.4) 67 (77.) 7 (8.97) 76 (75.5) (79.6) 8 (78.85) 3 (74.9) 7 (79.88) 87 (79.6) 6 (.) 53 (78.87) 4 (8.) 39 (.86) 48 (79.4) (8.5) 8 (5.) 54 (8.6) (5.) (5.79) 35 (.) 48 (.) 8 (3.79) 45 (9.4) (6.67) 37 (6.5) 9 (5.68) 49 (8.77) 7 (8.9) 37 (8.5) 9 (9.39) (8.57) 44 (7.9) 53 (8.5) 3 (5.) 3 (8.6) 4 (9.5) 8 (8.95) 4 (75.) 36 (8.38) 6 (75.) (84.) 3 (78.79) 9 (8.) 5 (86.) 87 (8.6) 55 (83.33) 87 (83.48) 55 (74.3) (8.3) 3 (8.8) 63 (8.5) 79 (8.6) 3 (7.43) (8.8) 39 (8.85) 3 (5.) 4 (8.4) (8.95) cators for seech caability. As regards the 5- year-old samle, resence of mandibular overjet (OR=4.6) was a risk indicator for seech caability and molar relationshi (OR=.66) was a risk indicator for chewing caability (Tables 5 and 6). Discussion Botazzo resents how the roblems arising from the concet of collective buccal health are seen as having the same nature and can only be faced using analytical categories from collective health or the social theory of health. Concern over aearance and dental attractiveness aears to be affected by gender, social class and age 3,4. The lace of esthetic and functional criteria in determining orthodontic treatment need cannot be underestimated, as these are major indications for atients seeking orthodontic services. Due to the increasing global demand for orthodontic care, there is a need to develo methods to assess and grade malocclusion in order to rioritize treatment, articularly for ublicly funded rograms 5. Deviant occlusal traits are relatively easy to use, are identified by DAI, and link clinical and esthetic comonents mathematically to roduce a single score. The structure of the DAI consists of rominent traits of malocclusion, weighted on the basis of their relative imortance according to a anel of lay judges. The DAI combines hysical and esthetic asects of occlusion, including atient ercetions. The DAI equation loses some recision when regression coefficients are rounded, but this small sacrifice in recision is offset by convenience in many clinical and research alications 6. Moreover, its accetance by the WHO as index will encourage international comarisons. Eidemiological data concerning occlusal conditions have been accumulated by the WHO from all over the world using the DAI. The DAI is becoming a common standard for evaluating malocclusion, and WHO has recognized it as a cross-

5 463 Table 3. Univariate analyses of the association between chewing caability (dichotomization in bad/regular and good/ excellent) and malocclusion in -5 year-old adolescents. Indeendent Absence (), resence () bad, regular Deendent variable (Chewing caability) years 5 years good, excellent bad, regular good, excellent Ciência & Saúde Coletiva, 6(): , Oenbite Missing teeth Crowding Sacing Midline diastema Maxillary irregularity Mandibular irregularity Maxillary overjet Mandibular overjet Molar relationshi Gender 337 (95.) 5 (.) 337 (95.) 5 (.) 7 (95.76) 8 (94.9) 56 (95.5) 96 (95.5) 69 (95.39) 83 (95.4) 55 (95.5) 97 (96.4) 5 (94.34) (98.8) 9 (93.55) 33 (95.56) 346 (95.3) 6 (.) 87 (96.39) 65 (94.9) 7 (93.96) 8 (96.79) 7 (4.8) (.) 7 (4.8) (.) (4.4) 5 (5.8) (4.48) 5 (4.95) 3 (4.6) 4 (4.6) 3 (4.85) 4 (3.96) 5 (5.66) (.9) (6.45) 5 (4.44) 7 (4.68) (.) 7 (3.6) (5.7) (6.4) 6 (3.) (7.44) 3 (4.63) 84 (8.97) (5.) 7 (9.7) 6 (7.59) 63 (7.6) 3 (34.85) 75 (8.74) (9.73) 65 (9.) (8.38) 6 (3.5) 5 (5.5) 7 (4.48) 69 (6.95) 83 (8.4) 3 (5.) 4 (4.4) 44 (34.9) 4 (3.58) 44 (6.67) 93 (7.56) 9 (59.38) 6 (7.3) 6 (75.) 7 (7.83) 4 (7.4) 69 (7.84) 43 (65.5) 86 (7.6) 6 (7.7) 59 (7.98) 53 (7.6) 39 (69.5) 73 (74.49) 5 (59.5) 87 (73.5) 9 (7.58) 3 (5.) 3 (75.58) 8 (65.8) 9 (68.4) (73.33) cultural international index. Katoh et al. 7 confirmed that Jaanese and Native Americans showed significantly oorer dental esthetics than found in American white oulations 9,8. The resent study did not consider the samle in relation to nationalities or ethnic origins. However, average.% of adolescents had no abnormality or minor malocclusion requiring no or slight orthodontic treatment need. The results of the resent study were no correlation with the studies by Brazilian Oral Health Survey--3 9 (58.%) and Frazão et al 3 in São Paulo (7.3%) and Marques et al 3 in Belo Horizonte (6.%). The differences may have occurred through the methods of samle selection and the criteria used for diagnosis. A oint to be considering is miscegenation existing in southern region, which may in some way have contributed to the occurrence of a lower revalence of malocclusion in Maringá-PR. The reasons for imroved self-image are robably the result of age-related conditions 3, rather than the effects of orthodontic treatment. The attern of no change in self-esteem corroborates the finding in another study 33. Orthodontic treatment may enhance body image, and articularly facial image 34. The results of this study showed that gender did not significantly influence an adolescent s orthodontic esthetic self-ercetion in - and 5-year-old eole (Tables, 3 and 4), however, malocclusion measured by DAI, can strongly influence the ercetion of esthetic aearance. In this study, a statistically significant relationshi between self-erceived malocclusion and oral aearance/function in adolescents was verified. Missing teeth, oenbite resence, mandibular overjet and molar relationshi were risk indicators to seech and chewing caability. These findings indicate that the DAI can identify deviant occlusal traits, which suggests that community rograms involving orthodontic treatment should take it into consideration during trials. The association between a subject s ercetions of malocclusion and the DAI score was weak but significant in some. Molar relationshi discreancy was the only variable associated with oorer conditions of chewing caability, which suorts the findings of Onyeaso and

6 464 Peres SHCS et al. Table 4. Univariate analyses of the association between reort of ain (dichotomization in without and with) and malocclusion in -5 year-old adolescents. Deendent Variable (reort of ain) years 5 years Indeendent Absence (), resence () without with without with Oenbite Missing teeth Crowding Sacing Midline diastema Maxillary irregularity Mandibular irregularity Maxillary overjet Mandibular overjet Molar relationshi Gender 6 (63.84) (8.) 3 (65.5) 7 (46.67) 8 (63.96) 57 (66.8) 76 (65.67) 6 (6.39) 83 (64.89) 55 (63.) 7 (63.43) 68 (67.33) 7 (64.53) 67 (64.4) 6 (83.87) (6.7) 33 (64.9) 5 (83.33) 7 (65.46) (63.43) 5 (63.9) 3 (65.78) 8 (36.6) 3 (.) 3 (34.75) 8 (53.33) (36.4) 9 (33.7) 9 (34.33) 39 (38.6) 99 (35.) 3 (36.78) 98 (36.57) 33 (3.67) 94 (35.47) 37 (35.58) 5 (6.3) 6 (37.8) 3 (35.8) (6.67) 67 (34.54) 64 (36.57) 67 (36.8) 64 (34.) (66.9) 8 (56.5) 9 (65.5) 6 (75.) 6 (67.8) 35 (6.34) 5 (64.66) 46 (69.7) 69 (64.75) 7 (7.97) 5 (66.96) 46 (6.6) 9 (64.5) 67 (68.37) 5 (59.5) 7 (66.8) 9 (65.7) 6 (.) 5 (66.86) 8 (7.8) 8 (6.5) 6 (7.3) 88 (33.8) 4 (43.75) (34.48) (5.) 79 (3.9) 3 (39.66) 8 (35.34) (3.3) 9 (35.5) (7.3) 74 (33.4) 8 (37.84) 7 (35.5) 3 (3.63) 7 (4.48) 85 (33.) (34.93) (.) 57 (33.4) 45 (35.7) 53 (39.85) 49 (9.7) Table 5. Stewise logistic regression for -year-old adolescents. Indeendent Deendent variable seech caability (bad, regular) n % OR 95% CI Missing teeth absence resence Oenbite absence resence Table 6. Stewise logistic regression for 5-year-old adolescents. Indeendent Deendent variable seech caability (bad, regular) n % OR 95% CI Mandibular overjet absence resence Molar relationshi absence resence

7 465 Aderinokun. The statistical association between malocclusion and seech caability verified in this study does not suort the findings of Shue- Te Yeh et al 35. The analyses revealed (Table 4) an association between self-ercetion relating to reort of ain and malocclusion, exressed by mandibular irregularity, which seems to confirm the interaction between functional asects of occlusion and ain (<.). Thus, DAI scores could be significantly associated with ercetion of need for treatment 36. The answers to the questionnaire indicated that the adolescents in the samle reorted leasant esthetics as an imortant factor for sychosocial well being. In general, this study showed that orthodontic treatment is acceted as an imortant art of the health service, esecially due to the sychological imact of malocclusion on self-esteem. These findings highlight the imortance of introducing a ercetual measure of the esthetic imact of malocclusion, in addition to measuring normative orthodontic treatment need. Since the DAI has been acceted by the WHO, more clinic-based studies (demand oulations) should be encouraged across the globe. This could be helful in assessing the severity of malocclusions being treated in several arts of the world, as this is different from eidemiological reorts, at least for the uroses of comarison 5. The malocclusion ercetion measured by the DAI was associated with three deendent (seech caability, chewing caability and reort of ain), which could suggest that in future studies, there may be value in ursuing further refinement of ways to measure these traits, as these may be imortant dimensions of oral health ercetions, and otential targets for interventions with the aim of imroving use of and access to care. Conclusions The imact of malocclusion on adolescents lives was confirmed in this study. Seech and chewing caability were associated with orthodontic deviations, which should be taken into consideration in oral health lanning, to identify risk grous and imrove community health services. Ciência & Saúde Coletiva, 6(): , Collaborations Referências SHC Sales-Peres articiated in the theoretical design, construction methodology, writing and research, as well as the review the final text; S Goya articiated in the research; KL Cortellazzi and GMB Ambrosiano articiated in the statistical analysis; MC Meneghim and AC Pereira articiated in the review the final text. Acknowledgements The authors would like to gratefully acknowledge to all uils and staff of schools that took art in the study Albino JEN, Laurence SD, Tedesco LA. Psychological and social effects of treatment. J Behav Med 994; 7():8-98. Pogrel MA. What are normal esthetic values? J Oral Maxillofac Surg 99; 49(9): Flores-Mir C, Silva E, Barriga MI, Lagrave MO, Major PW. Lay erson s ercetion of smile aesthetics in dental and facial views. J Orthodont 4; 3(3):4-9. Gosney MBE. An investigation into some of the factors influencing the desire for orthodontic treatment. Brit J Orthodont 986; 3(): Birkeland K, Katle A, Lovgreen S, Boe OE, Wisth PJ. A longitudinal study among - and 5-yearolds and their arents on factors influencing the decision about orthodontic treatment. J Orofacial Ortho 999; 6(5):9-37. Jenny J. A social ersective of dentofacial esthetics and orthognathic surgery. Angle Orthod 975; 54():8-35. Baldwin DC. Aearance and aesthetic in oral health. Community Dent Oral Eidemiol 98; 8(5): Shaw WC. The influence of children s dentofacial aearance on their social attractiveness as judged by eers and lay adults. Am J Orthod 98; 79(4):

8 466 Peres SHCS et al Ansai T, Miyazaki H, Katoh Y, Yamashita Y, Takehara T, Jenny J, Cons NC. Prevalence of malocclusion in high school students in Jaan according to the dental Aesthetic Index. Community Dent Oral Eidemiol 993; (5): Estioko LJ, Wright FAC, Morgan MV. Orthodontic treatment need of secondary school children in Heidelberg, Victoria: an eidemiological study using the DAI. Community Dent Health 994; (3): Onyeaso CO, Aderinokun GA. The relationshi between dental aesthetic index (DAI) andercetions of aesthetics, function and seech amongst secondary school children in Ibadan, Nigeria. Int J Paediatr Dent 3; 3(5): World Health Organization (WHO). International Collaboration Study of Oral Health Outcomes (IC- SII), Document Oral Data Collection and Examination Criteria. Geneva: WHO; 989. World Health Organization (WHO). Oral Health Surveys: Basic methods. 4 th ed. Geneva: WHO; 997. Eseland LU, Ivarsson K, Stenvik A, Alstad TA. Percetion of malocclusion in -year-old children: a comarison between ersonal and arental awareness. Eur J Orthod 99; 4(5): Onyeaso CO, Sanu OO. Psychosocial imlications of malocclusion among -8 year old secondary school children in Ibadan. Odontostomatol Tro 5; 8(9): Lewit DW, Virolainen K. Conformity and indeendence in adolescents motivation for orthodontic treatment. Child Dev 968; 39(4):89. Onyeaso CO. Orthodontic Treatment Comlexity and Need in a Grou of Nigerian Patients: The Relationshi between the Dental Aesthetic Index (DAI) and the Index of Comlexity, Outcome, and Need (ICON). J Contem Dent Pract 7; 8(3): Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 977; 33(): Lucas SD, Portela MC, Mendonça LL. Variations in tooth decay rates among children 5 and years old in Minas Gerais, Brazil. Cad Saude Publica 5; (): Tagliaferro EPS, Pereira AC, Meneghim MC, Ambrosano GMB. Assessment of dental caries redictors in a seven-year longitudinal study. J Publ Health Dent 6; 66(3): SAS User s Guide: Statistics. Version 8.. Cary (NY): SAS Institute Inc.;. Botazzo C. Sobre a bucalidade: notas ara a esquisa e contribuição ao debate. Cien Saude Colet 6; ():7-7. Horowitz HS, Vohen LK, Doyle J. Occlusal relations in children born and reared in an otimally fluoridated community. (IV) Clinical and socio-sychological findings. Angle Orthod 97; 4(3):89. Jenkins PM, Feldman BS, Stirrus DR. The effect of social class and dental features on referrals for orthodontic advice and treatment. Br J Orthod 984; (4): Onyeaso CO, BeGole EA. Orthodontic Treatment Need in an Accredited Graduate Orthodontic Center in North America: A Pilot Study. J Contem Dent Pract 6; 7():-5. Cons NC, Jenny J, Kohout FJ. DAI: the Dental Aesthetic Index. Iowa City: College of Dentistry University of Iowa; 986. Katoh Y, Ansai T, Kitakyushu TT, Fukuoka YY, Niigata HM, Jenny J, Cons NC. A comarison of DAI scores and characteristics of occlusal traits in three ethnic grous of Asian origin. Int Dent J 998; 48(4): Jenny J, Cons NC, Kohout FJ, Jakobson J. Differences in need for orthodontic treatment between native Americans and the general oulation based on DAI scores. J Public Health Dent 99; 5(4): Brasil. Ministério da Saúde (MS). Secretaria de olíticas de Saúde. Deartamento de Atenção Básica. Área Técnica de Saúde Bucal. Projeto SB Brasil: condições de saúde bucal da oulação brasileira. Resultados rinciais. Brasília: Ministério da Saúde; 4. Frazão P, Narvai PC, Latorre MRDO, Castellanos RA. Prevalência de oclusoatia na dentição decídua e ermanente de crianças na cidade de São Paulo, Brasil, 996. Cad Saude Publica ; 8(5):97-5. Marques LS, Barbosa CC, Ramos-Jorge ML, Pordeus IA, Paiva SM. Prevalência da maloclusão e necessidade de tratamento ortodôntico em escolares de a 4 anos de idade em Belo Horizonte, Minas Gerais, Brasil: enfoque sicossocial. Cad Saude Publica 5; (4):99-6. Alsaker F, Olweus D. Global self-evaluations and erceived instability of self in early adolescence: a cohort longitudinal study. Scand J Psychol 993; 34(): Korabik K. Self-concet changes during orthodontic treatment. J Al Soc Psychol 994; 4():-34. Varela M, Garcia-Camba JE. Imact of orthodontics on sychologic rofile of adults atients: a rosective study. Am J Orthod Dentofacial Ortho 995; 8():4-48. Shue-Te Yeh M, Koochek AR, Vlaskalic V, Boyd R, Richmond S. The relationshi of rofessional occlusal indexes with atients ercetions of aesthetics, function, seech, and orthodontic treatment need. Am J Orthod Dentofacial Ortho ; 8(4):4-48. Jenny J, Cons NC. Establishing malocclusion severity levels on The Dental Aesthetic Index (DAI) scale. Aust Dent J 996; 4(): Artigo aresentado em 8/3/ Arovado em 9/6/ Versão final aresentada em 3/6/