J. Adv Dental Research ORIGINAL RESEARCH All Right Res Reliability of Aesthetic component of IOTN in the assessment of subjective orthodontic treatment need Kalyani Trivedi * Tarulatha R Shyagali ** Jigar Doshi *** Yagnesh Rajpara # *M.D.S, Professor & Head, Dept of Orthodontics, Karnavati School of Dentistry, Gandhinagar. **M.D.S, Reader, ***M.D.S, Senior Lecturer, # Post Graduate Student, Dept of Orthodontics, Darshan Dental College, Loyara, Udaipur, India. Email: drkalyanimtrivedi@gmail.com Abstract: Objective: The purpose of this study was to estimate whether dental concern expressed by the grade of the Aesthetic Component [AC] chosen by subjects is reliable and whether it may be predictive for potential cooperation. Study Design: The study was carried out among 100 (50 boys and 50 girls) subjects aged 18 to 20 years, who visited Darshan Dental College & Hospital, Udaipur. Subjects were selected randomly who fall in said age group during the period of one month and was based on a clinical examination and questionnaire. The questionnaire contained items relating to the influence of the dentition on the general appearance, the subjective assessment of dental appearance, demand for orthodontic treatment, and any functional disorders. Clinical examination was carried out at Darshan Dental College & Hospital, Udaipur by the orthodontist. Results: The results indicate that using professional rating the Aesthetic component scale does not seem to be more precise or reliable than self-evaluation. The outcome shows that the Aesthetic component of the IOTN moderately reflects the subjective perception of dental aesthetics and demand for orthodontic treatment. Potential cooperation was there in 44% of the subjects as they readily agree to undergo orthodontic treatment if suggested. Conclusion: There was a significant agreement in the Aesthetic Component between the professional rating and Student s assessments, as 76 percent were consistent when considering the category criterion. Keywords: IOTN index, Aesthetic component Introduction: Aesthetics is a common reason for seeking orthodontic treatment 1.2.3 and its improvement is an essential treatment goal. 4,5,6 Therefore, the main criterion in the delivery of orthodontic treatment is poor dental aesthetics, as a direct consequence of occlusal irregularities 5,7. Epidemiological indices have been used to measure orthodontic treatment need from a clinician s viewpoint. Such measurements are important for health services planning and monitoring of population trends. There have been many attempts to develop indices of treatment need, based on a patient s dental appearance (e.g. DAI, Dental Aesthetic Index 8 ). Two recently developed orthodontic indices that are being used in orthodontic treatment need, priority, and evaluation of treatment success are the Index of Orthodontic Treatment Need and the Peer Assessment Rating. The Index of Orthodontic Treatment Need (IOTN), described by Brook and Shaw (1989) and Shaw et al., (1991) has been gaining national and international recognition as a method of objectively assessing treatment need. The index comprises two parts: Dental Health Component (DHC), which ranks malocclusions in terms of the significance of tooth irregularities for a person s dental health and the Aesthetic Component (AC), which takes into account the aesthetic impairment. In the present study the Aesthetic Component (AC) of the IOTN is used.
60 The Aesthetic component consists of a 10-grade scale illustrated by numbered colour intra-oral photographs. The photographs represent three treatment categories: no treatment need (grades 1-4), borderline treatment need (grades 5-7), and great treatment need (grades 8-10). The demand for orthodontic treatment is increasing in Udaipur and also in India as in the other countries. In India there are many dental colleges that provide orthodontic treatment. Beside these universities, there are many orthodontists working in different cities of India. But when the large geographic area and 100 crores population of India are considered, the subject universities and the orthodontists are not enough to provide a sufficient orthodontic treatment to serve all the needs. Therefore, there are long waiting times for the patients after they apply for orthodontic treatment. In this case, it is important to determine the patients who are in great need of treatment, and give a high priority to these patients in order to achieve a high standard for orthodontic treatment and reduce the waiting times. Aims of the present study was: 1.To evaluate the Aesthetic component grade in relation to the subjective perception of a person s own dental aesthetic and 2. To assess the reliability of the person s evaluation of the Aesthetic component by comparing it with the professional evaluation. Materials and methods: A hospital based study was conducted among 100 non dental undergraduates aged 18 to 20 years. In this study subjects who are currently undergoing or previously undergone orthodontic treatment were not included. The subjective assessment of dental appearance and need for orthodontic treatment was done on the basis of questionnaires filled in at Darshan Dental College & Hospital, Udaipur. The questionnaires are based on the influence of dentition on general appearance, Aesthetic, Treatment acceptance and functional disorder. Methods:- The subjects assessed their own occlusion using colour photographs of the Aesthetic Component during a clinical examination at Department of Orthodontics, Darshan Dental College & Hospital, Udaipur. The following question was asked: Here is series of 10 photographs showing a range of dental attractiveness, number 1 is the most and number 10 the least attractive arrangement of teeth. Where would you put your teeth on this scale? To make the assessment more reliable, a lip retractor and a mirror were provided. At the same time the orthodontist rated the student s occlusion using the AC component scale. 8 Statistical procedures:- A chi-square test was applied to evaluate any significant differences between two independent samples (analysis of sex differences, comparison of Aesthetic Component distribution with satisfaction with dental aesthetics and with desire for treatment). A probability at the 5 per cent level or less (P < 0.05) was considered statistically significant. Comparisons of the two aggregated samples were made using the chi-square test (for determining differences between frequencies of yes/no answers, and testing the consistency of assessment between children and examiner). Discussion: The Simple 10 Point rating scale [SCAN] scale was created on the basis of intraoral photographs of the dentition of 12-year-old children 9. On the other hand, previous studies carried out using the IOTN have indicated that assigning own dentition to the Aesthetic Component scale is a difficult task, particularly for younger patients. 10 Because of these reasons in the present study a young students group is chosen. At this stage of dental development the occlusion exhibits some characteristic traits which are reflected in the Aesthetic Component photographs. These features were found by the examined students in their own dentition. This fact was considered to be helpful in assessing aesthetics with superior reliability. The teenagers attach great importance to an attractive dental appearance. 11,12 Psychological reports indicate that facial attractiveness is the most important feature for overall appearance especially the oral region 13,14. Most of the students examined expressed satisfaction with their dental aesthetics (63%; Table5). Similar results were obtained by Graber and Lucker (1980) 6. However, this percentage is significantly lower than the percentage of children who classified themselves in the no treatment need category (grades 1-4; Table 1). Satisfied children selected grade 1 or 2 on the Aesthetic Component scale significantly more frequently than dissatisfied individuals (Table 10). It would appear that the separate interpretation of grades 1-2 and 3-4 gives a more realistic perception of dental aesthetics (e.g. 1-2 no need, 3-4 slight need ; as was originally established by Brook and Shaw, 1989). The alternative would be to move the category borderline need two grades lower. Espeland and Stenvik 11 in their study reported that a more reliable self-evaluation is made by older subjects, which is in accordance with the present study. Present study showed that in 98 percent of people a pleasant dentition was perceived as an important factor in the general appearance. This percentage is relatively low compared to the study done by Izabela Grzywacz 15, but higher than the study done by Graber and Lucker. 6
61 Results: The results of the assessment of aesthetics using the AC scale of the students and orthodontist are presented in Table 1. TABLE.1: Assessment of Aesthetic Component [AC]. AC grade Student s evaluation Orthodontist s evaluation 1-4 (no need) 5-7 (borderline need) 8-10 (great need) Male Female Total Male Female Total 45(45%) 48(48%) 93(93%) 40(40%) 38(38%) 78(78%) 3(3%) 1(1%) 4(4%) 10(10%) 8(8%) 18(18%) 2(2%) 1(1%) 3(3%) - 4(4%) 4(4%) Only 3 males and 1 female classified themselves in the category borderline treatment need (grades 5-7). Two males and one female classified themselves in the category great treatment need (grades 8-10). Among the group 93(93%) students classified themselves in the category no treatment need (grades 1-4).Where as the orthodontist placed 78(78%) students in the category no treatment need (grades 1-4), 18(18%) students in the category borderline treatment need (grades 5-7) and only 4(4%) students in the category great treatment need (grades 8-10). Despite these differences the consistency of evaluation in the Aesthetic Component scale according to students and orthodontist was high considering the category criterion (76%; Table 2). TABLE.2 : Category wise student s Vs Orthodontist s evaluation. Category wise student s v/s Orthodontist s evaluation Student s evaluation Orthodontist s evaluation 1-4 (no need) 5-7 (borderline need) 8-10 (great need) Total 1-4 76(76%) 15(15%) 2(2%) 93(93%) (no need) 5-7 1(1%) 2(2%) 1(1%) 4(4%) (border line need) 8-10 1(1%) 1(1%) 1(1%) 3(3%) (great need) Total 78(78%) 18(18%) 4(4%) 100(100%) Tables 3-8, shows the answers obtained to the questionnaire and the distribution between the sexes. Except two all the students examined felt that dental aesthetics was an important element of their general appearance (Table 3). 27(27%) subjects reported their dental appearance to be inadequate (Table 4). Satisfaction with dental aesthetics was expressed by 63 percent (Table 4). 57% subjects expressed a wish to change some of the features of their dentition (Table 5). Among the features mentioned were: Size (2 subjects); Colour (28 subjects); Shape (2 subjects) and arrangement of teeth (15 subjects) ; Six subjects indicated a desire to change some other than given features and only five subjects want to change multiple features (Table 9). Two subjects (2%) stated that they had functional disorders (Table 6) while 20 percent of students felt they had a need for treatment (Table 7). 44% subjects gives positive answer to start the orthodontic treatment if someone suggest. Positive answers comes more frequently from males(27%) (Table 8).
62 TABLE.3: Answer obtained from question one; Do you agree that healthy and properly arranged teeth are important for your general appearance? Q1 Yes 50(50%) 48(48%) 98(98%) No - 1(1%) 1(1%) Do not - 1(1%) 1(1%) know TABLE.4: Answer obtained from question two; Do you think your dental appearance is good? Q2 Yes 31(31%) 32(32%) 63(63%) No 15(15%) 12(12%) 27(27%) Do not know 4(4%) 6(6%) 10(10%) TABLE.5: Answer obtained from question three; Do you like to change something in your teeth? Q3 Yes 30(30%) 27(37%) 57(57%) No 17(17%) 23(23%) 40(40%) Do not know 3(3%) - 3(3%) TABLE.6: Answer obtained from question four; Do you have any problem in speaking, chewing Or facial muscle pains due to your teetharrangement? Q4 Yes 1(1%) 1(32%) 2(2%) No 49(49%) 49(49%) 98(98%) Do not know - - - TABLE.7: Answer obtained from question five; Do you think you need an orthodontic treatment? Q5 Yes 12(12%) 8(8%) 20(20%) No 31(31%) 39(39%) 70(70%) Do not 7(7%) 3(3%) 10(10%) know
63 TABLE.8: Answer obtained from question six; Would you readily agree for an orthodontic treatment if someone suggests you? Q6 Yes 27(27%) 17(17%) 44(44%) No 18(18%) 31(31%) 49(49%) Do not know 5(5%) 2(2%) 7(7%) TABLE.9: Desire of the students to change the features Students want to change the SEX Total features Male Female Size 2-2 Colour 14 14 28 Shape 2 2 Arrangement 7 8 15 Other 1 4 5 Multiple 4 1 5 Size,shape, Colour 2 - Size,colour 1 Shape,colour 1 1 Total 30 27 57 TABLE 10: Aesthetic component grade based on satisfaction with aesthetic Satisfaction with aesthetic AC grade(students evaluation) Total 1 2 3 >3 Yes 18 21 18 6 63 No 7 7 6 7 27 Do not know 1 2 3 4 10 It is essential to emphasize that 93.0 percent of the investigated group classified themselves in the category no treatment need according to the AC scale (grades 1-4; Table 1). These results suggest that dental concern expressed using the AC correlates moderately with a demand for treatment. A similar conclusion using the AC was found in earlier studies. 15, 16 One of the most frequent factors reported by the students was the desire to improve aesthetics. Additional factors were: a concern about dental health, and trust in the parents or orthodontist s decision. The assessment of treatment need made by children was almost half (Table 7) than the desire to start treatment (Table 8) and is not significant. Which suggest slight fear to undergo treatment in the present study. One should not forget to discuss the fact that only 2 students (2%) noticed any functional disorders which were perceived to be connected with malocclusion (Table
64 6). It confirmed the hypothesis that it is not malfunction of the masticatory system that is the main reason for seeking orthodontic care but aesthetic impairment. 3 Professional rating using the Aesthetic Component scale does not seem to be more precise than self-evaluation. 16-20 There was significant agreement between the professional examiner s and the children s assessments, as 76 percent of them were consistent when considering the criterion of treatment category (not the exact grade; Table 2). The correlation between the grade of the Aesthetic Component ascribed by the orthodontist and child in this study was slightly lower compared with the results of previous study. 15,19-22 Conclusion:- There was a significant agreement in the AC between the professional rating and the children s assessments, as 76 percent were consistent when considering the category criterion. The criteria of the AC scale moderately reflect a subjective perception of dental aesthetics in the study group, as 93% of the subjects placed themselves in the same treatment category (grades 1-4: no treatment need ). It would appear that the separate interpretation of grades 1-2 and 3-4 gives more realistic perception of dental aesthetics and more accurately correlates with demand for treatment (e.g. 1-2 no need, 3-4 slight need ). The alternative would be to move the category borderline need two grades lower. References:- 1. Dorsey J, Korabick K. Social and psychosocial motivation for orthodontic treatment. Am J Orthod 1997;72: 460. 2. Shaw WC, O Brien KD, Richmond S. Quality control in orthodontics: factors influencing the receipt of orthodontic treatment. British Dental Journal 1991b;19:66-68. 3. Tang ELK, So LLY. Correlation of orthodontic treatment demand with treatment need assessed using two indices. Angle Orthod 1995;65:443-450. 4. Birkeland K, Bøe OA, Wisth PJ. Relationship between occlusion and satisfaction with dental appearance in orthodontically treated and untreated groups - A longitudinal study. Eur J Orthod 2000;22:509-518. 5. Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989;11:309-320. 6. Graber LW, Lucker GW.Dental esthetic selfevaluation and satisfaction. Am J Orthod 1980;77: 163-173. 7. 13. Richmond S et al. The relationship between Index of Orthodontic Treatment Need and consensus opinion of a panel of 74 dentists. British Dental Journal 1995;178:370-374. 8. Jenny J, Cons NC. Comparing and contrasting two orthodontic indices, the Index of Orthodontic Treatment Need and the Dental Aesthetic Index. Am J Orthod 1996;110:410-416 9. Evans R, Shaw W. Preliminary evaluation of an illustrated scale for rating dentalattractiveness. Eur J Orthod 1987;9:314-318. 10. Holmes A. The prevalence of orthodontic treatment need. Brit J Orthod 1992;19:177-182. 11. Espeland LV, Stenvik A. Orthodontically treated young adults: awareness of their own dental arrangement. Eur J Orthod 1991a;13:7-14. 12. Helm S, Kreiborg S, Solow B. Psychosocial implications of malocclusion: a 15-year follow-up study in 30-year-old Danes. Am J Orthod 1985;87:110-118. 13. Baldwin DC. Appearance and aesthetics in oral health. Community Dentistry and Oral Epidemiology 1980;8:244-256. 14. Shaw WC, Addy M, Ray C. Dental and social effects of malocclusion and effectiveness of orthodontic treatment: a review. Community Dentistry and Oral Epidemiology 1980;8:36-45 15. Izabela Grzywacz. The value of the aesthetic component of the Index of Orthodontic Treatment Need in the assessment of subjective orthodontic treatment need. Eur J Orthod 2003;25 : 57-63 16. Birkeland K, Bøe OA, Wisth PJ. Orthodontic concern among 11-year-old children and their parents compared with orthodontic treatment need assessed by Index of Orthodontic Treatment Need. Am J Orthod 1996;110:197-205 17. Shaw WC. Richmond S, Brook P, Stephens CD. Quality control in orthodontics: indices of treatment need and treatment standards. British Dental Journal 1991a;9:107-112 18. Mourad S, Francis B, Nil Z et al., Orthodontic treatment need in French schoolchildren: an epidemiological study using the IOTN index. Eur J Orthod 2006;28(6):605-609. 19. Hedayati Z, HR Fattahi, SB Jahromi. The use of orthodontic treatment need in an Iranian Population. JISPPD; 2007:25(1):10-14. 20. Parviz P, Zahra M, Roya N. the use of orthodontic treatment need index (IOTN) in a referred Iranian Population. Research Journal of Biological Sciences; 2009:4(4):438-443. 21. Brozabadi FA,Eslamipour F. The relationship between the ICON and the Dental and Aesthetic components of IOTN index. World J Orthod. 2010;11(1):43-8. 22. Ngom PI, Diagne F. Diop-Ba K, Thiam F. orthodontic treatment need and demand in
65 Senegalese school children aged 12-13 years. An appraisal using IOTN and IOCN. Angle Orthod. 2007; 77(2):323-30. Source of Support: Nil Conflict of Interest: Not Declared Received: October 2010 Accepted: December 2010
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