The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
RESEARCH ARTICLE

Assessment of Orthodontic Treatment Need in Kosovar Children



Albena Reshitaj1, *, Krenar Reshitaj2, Betina Bytyqi2
1 Department of Dentistry, Faculty of Medicine, University of Prishtina, Prishtina, Kosova
2 Department of Medicine, Faculty of Medicine, University of Prishtina, Prishtina, Kosova

Abstract

Background:

To date, no survey was done in Kosovo for the identification of orthodontic treatment needs. The aim of this study is to assess the prevalence of orthodontic treatment need among Kosovar children of ages 11-13, using the DAI and the DHC-IOTN in the identification of orthodontic treatment need.

Methods:

A sample of 185 children (50.3% female, 49.7% male), aged between 11-13, was randomly selected from one elementary school in Prishtina. Orthodontic treatment need was measured using the Dental Aesthetic Index (DAI) and the dental health component of the Index of Orthodontic Treatment Need (DHC-IOTN).

Results:

Based on DAI, treatment was found as elective in 11.9 percent of the children. Treatment was found as highly desirable and mandatory in 5.9 percent and 4.3 percent of children, respectively. No gender-based significant differences were noted. According to IOTN DHC: 16.2 percent of children had borderline treatment need, while 66.5 percent had severe and extreme treatment need (grades 4 and 5). Again, no significant gender-based differences in the treatment need were found.

Conclusion:

High prevalence of orthodontic treatment need was identified in Kosovar children of ages 11-13, while no gender-based statistically significant differences were noted in the need for orthodontic treatment.

Keywords: Orthodontic treatment need, IOTN, DAI, Epidemiology, Orthodontics, Public health.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 321
Last Page: 324
Publisher Id: TOPHJ-12-321
DOI: 10.2174/1874944501912010321

Article History:

Received Date: 19/04/2019
Revision Received Date: 08/07/2019
Acceptance Date: 24/07/2019
Electronic publication date: 30/08/2019
Collection year: 2019

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© 2019 Reshitaj et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to the author at the Department of Dentistry, Faculty of Medicine, University of Prishtina, St. Mother Teresa, Kosova;
Tel: +38344311406; E-mail: albena.reshitaj@uni-pr.edu





1. INTRODUCTION

Several studies show that there is an increase in the prevalence of orthodontic anomalies, leading to an increase in the need for orthodontic treatment [1Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989; 11(3): 309-20.[http://dx.doi.org/10.1093/oxfordjournals.ejo.a035999] [PMID: 2792220] -11Manzanera D, Montiel-Company JM, Almerich-Silla JM, Gandía JL. Orthodontic treatment need in Spanish schoolchildren: An epidemiological study using the Index of Orthodontic Treatment Need. Eur J Orthod 2009; 31(2): 180-3.[http://dx.doi.org/10.1093/ejo/cjn089] [PMID: 19064676] ]. Most of the orthodontic patients are children and adolescents and information on the orthodontic treatment prevalence among this category allows national budget planning in the most convenient way. Orthodontic anomalies besides functional limitation cause psychological effect too [12Chestnutt IG, Burden DJ, Steele JG, Pitts NB, Nuttall NM, Morris AJ. The orthodontic condition of children in the United Kingdom, 2003. Br Dent J 2006; 200(11): 609-12.[http://dx.doi.org/10.1038/sj.bdj.4813640] [PMID: 16767131] ], thus emphasizing its importance of treatment. Information about the prevalence of malocclusion and early detection of malocclusion, as a result, early orthodontic treatment allows better national funds allocations.

Kosovo as a new state has no data about the prevalence of malocclusion or orthodontic treatment need, thus research articles on the epidemiology of malocclusion offer information on oral health anomalies among specific age population.

The need for orthodontic treatment is established using standardized indices, based on which the dental anomalies can be categorized. The index for assessing the orthodontic treatment priority was developed by Brook and Shaw and was later modified by Richmond [1Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989; 11(3): 309-20.[http://dx.doi.org/10.1093/oxfordjournals.ejo.a035999] [PMID: 2792220] , 13Janošević P, Stošić M, Janošević M, Radojičić J, Filipović G, Čutović T. Index of orthodontic treatment need in children from the Niš region. Vojnosanit Pregl 2015; 72(1): 12-5.[http://dx.doi.org/10.2298/VSP1501012J] [PMID: 26043584] ]. Today, this index is accepted as a standardized, valid, and reproducible index for the objective assessment of treatment need. The Index of Orthodontic Treatment Need (IOTN) has two components: Dental Health Component (DHC) and Aesthetic Concern (AC). The latter has 10 subcategories and is used only when the patient is assessed in DHC group 3.

DHC-IOTN has 5 categories, ranging from 1 (no need for treatment) to 5 (great need) and malocclusion is assessed based on the following characteristics: tooth loss, overjet, crossbite, displacement of the contact point, and overbite [13Janošević P, Stošić M, Janošević M, Radojičić J, Filipović G, Čutović T. Index of orthodontic treatment need in children from the Niš region. Vojnosanit Pregl 2015; 72(1): 12-5.[http://dx.doi.org/10.2298/VSP1501012J] [PMID: 26043584] ].

The dental aesthetic index (DAI) evaluates 10 occlusal characteristics: the number of missing teeth, overjet, negative overjet, diastema, anterior open bite, anterior crowding, anterior spacing, anterior irregularities (mandible and maxilla), and antero-posterior molar relationship [2Richmond S. A critical evaluation of orthodontic treatment in the general dental services of England and Wales 1990.]. DAI has four stages of malocclusion severity: a score lower than or equal to 25 (no or slight treatment need), a score between 26 and 30 (elective treatment need), a score between 31 and 35 (highly desirable treatment need), and a score greater than 36 (mandatory treatment) [13Janošević P, Stošić M, Janošević M, Radojičić J, Filipović G, Čutović T. Index of orthodontic treatment need in children from the Niš region. Vojnosanit Pregl 2015; 72(1): 12-5.[http://dx.doi.org/10.2298/VSP1501012J] [PMID: 26043584] ].

While DAI and DHC-IOTN are widely used instruments to determine malocclusion and the need for orthodontic treatment, Kosovo, to date, has not produced data to assess their validity and reproducibility in the identification of orthodontic treatment need of Kosovar children. Thus, the aim of this study is to assess the applicability of DAI and DHC-IOTN in the Kosovar context with the aim of assessing the prevalence of orthodontic treatment need among Kosovar children of ages 11-13.

2. MATERIALS AND METHODS

This study was carried out in accordance with recommendations of the Helsinki Declaration and was approved from the Research Ethics Committee of the University Dentistry Clinical Center of Kosovo (University of Prishtina) and Ministry of Education, Science and Technology of Kosovo. Written consent was taken from all subject’s parents.

A total of 247 subjects, aged 11-13, were examined in one elementary school in Prishtina. Out of this number 23 subjects were excluded due to history of orthodontic treatment, 36 subjects were excluded because of current orthodontic treatment, and 3 subjects withdraw from the study. The final sample consisted of 185 subjects (50.3% female), aged 11-13 (Fig. 1).

The sample size calculation was performed by considering the 54.3 percent prevalence of orthodontic treatment need, as measured by the DAI, with a confidence interval of 95% and 5% of level of precision [1Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989; 11(3): 309-20.[http://dx.doi.org/10.1093/oxfordjournals.ejo.a035999] [PMID: 2792220] , 14Laganà G, Masucci C, Fabi F, Bollero P, Cozza P. Prevalence of malocclusions, oral habits and orthodontic treatment need in a 7- to 15-year-old schoolchildren population in Tirana. Prog Orthod 2013; 14: 12.[http://dx.doi.org/10.1186/2196-1042-14-12] [PMID: 24326142] , 15Abdullah MS, Rock WP. Assessment of orthodontic treatment need in 5,112 Malaysian children using the IOTN and DAI indices. Community Dent Health 2001; 18(4): 242-8.[PMID: 11789703] ]. During sampling, the following exclusion criteria were applied: 1) No history of orthodontic treatment, 2) No ongoing orthodontic treatment.

Data on the overall oral condition were obtained for selected subjects. One researcher, an expert in orthodontics, previously trained and calibrated on the use of the index, gathered the following data for each participant: dental insufficiency, crowding, maxillary and mandibular median diastema, overjet, Angle’s classification, bite type, and other anomalies in the maxillary and mandibular anterior region. The examination was performed in natural light by means of a wood spatula, millimetric ruler, sterile gloves, and disinfectant.

For each subject, DAI and the DHC-IOTN values were classified according to the specific criteria of each index studied [2Richmond S. A critical evaluation of orthodontic treatment in the general dental services of England and Wales 1990., 13Janošević P, Stošić M, Janošević M, Radojičić J, Filipović G, Čutović T. Index of orthodontic treatment need in children from the Niš region. Vojnosanit Pregl 2015; 72(1): 12-5.[http://dx.doi.org/10.2298/VSP1501012J] [PMID: 26043584] , 16Ngom PI, Diagne F, Dieye F, Diop-Ba K, Thiam F. Orthodontic treatment need and demand in Senegalese school children aged 12-13 years. An appraisal using IOTN and ICON. Angle Orthod 2007; 77(2): 323-30.[http://dx.doi.org/10.2319/0003-3219(2007)077[0323:OTNADI]2.0.CO;2] [PMID: 17319769] ]. The aesthetic component of the IOTN was not assessed, as it presents poor association with the clinical condition [17Jamilian A, Kiaee B, Sanayei S, Khosravi S, Perillo L. Orthodontic treatment of malocclusion and its impact on oral health-related quality of life. Open Dent J 2016; 10: 236-41.[http://dx.doi.org/10.2174/1874210601610010236] [PMID: 27386009] ]. The instruments used were those recommended for each index, namely the periodontal probe for the DAI and the proper ruler for the DHC-IOTN.

In our study, DAI scores were dichotomized as “no need for treatment” (DAI ≤ 25) and “in need of treatment” (DAI > 25). Likewise, DHC-IOTN scores were classified into “no need for treatment (grades 1 and 2) and “in need of treatment” (grades 3,4, and 5).

Fig. (1)
Flow of sample selection.


2.1. Statistical Analysis

Data analysis was performed using the Statistical Package for Social Sciences (version 16.0, SPSS Inc., Chicago, Illinois, USA). Descriptive statistics were compiled for all variables. Crosstables and chi-square test was used to test the distribution differences between genders.

3. RESULTS

The need for orthodontic treatment in our sample is very high, according to IOTN DHC. When presented based on our dichotomous categorization, 82.7 percent of the subjects were in need of treatment, while 17.3 percent were in no need of treatment. It is worth noting that 47.6 percent of the sample had very severe malocclusion. No significant gender-based differences were noted regarding treatment need (p=0.215). A breakdown of distribution for each category is presented in Table 1.

Table 1
Distribution of IOTN among categories and according to gender.


Table 2
Distribution of DAI among categories and according to gender.


The dichotomization of DAI scores reveals that the majority of the schoolchildren have no treatment need (77.8%), while 22.2 percent of the sample needed treatment. In subcategories, treatment was highly desirable in 5.9 percent and mandatory in 4.3 percent of children. No significant gender-based differences were noted in treatment need based on DAI index (p=0.272). A breakdown of distribution for each category is presented in Table 2.

4. DISCUSSION

The prevalence of malocclusion and orthodontic treatment need found in our study is much higher than in European countries. According to DHC IOTN as an objective method, as much as 66.5 percent had definite treatment need because they were categorized in grades 4 and 5 of treatment need. Based on our dichotomous variables, 82.7 percent of the subjects were in need of treatment.

The prevalence of orthodontic treatment need varies among different countries. It is much lower in European countries. In France, Souames et al. found 21.3 percent of children needed orthodontic treatment [4Jenny J, Cons NC. Comparing and contrasting two orthodontic indices, the Index of Orthodontic Treatment need and the Dental Aesthetic Index. Am J Orthod Dentofacial Orthop 1996; 110(4): 410-6.[http://dx.doi.org/10.1016/S0889-5406(96)70044-6] [PMID: 8876493] ]. In Italy, Perillo et al. found similar results - the prevalence rate for (grades 4 and 5) was 27.3 percent of the total sample [5Jenny J, Cons NC. Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale. Aust Dent J 1996; 41(1): 43-6.[http://dx.doi.org/10.1111/j.1834-7819.1996.tb05654.x] [PMID: 8639114] ]. In Spain, Manzanera et al. found that 23.5 percent of 12-year-olds and 18.5 percent of 15- to 16-year-olds had a definite treatment need, while in the United Kingdom, Chestnut et al. in a sample of 12- to 15-year-old subjects, found 21 percent to 35 percent to have definite orthodontic treatment needs [6Richmond S, Shaw WC, O’Brien KD, et al. The development of the PAR Index (Peer Assessment Rating): Reliability and validity. Eur J Orthod 1992; 14(2): 125-39.[http://dx.doi.org/10.1093/ejo/14.2.125] [PMID: 1582457] , 7Buchanan IB, Downing A, Stirrups DR. A comparison of the Index of Orthodontic Treatment Need applied clinically and to diagnostic records. Br J Orthod 1994; 21(2): 185-8.[http://dx.doi.org/10.1179/bjo.21.2.185] [PMID: 8043567] ].

However, prevalence rates of orthodontic treatment need in Asian and African countries seem to be quite high. Abdullah and Rock reported prevalence for an objective orthodontic treatment need of 47.9 percent for a Malaysian sample of 12- to 13-year-old schoolchildren [10Perillo L, Masucci C, Ferro F, Apicella D, Baccetti T. Prevalence of orthodontic treatment need in southern Italian schoolchildren. Eur J Orthod 2010; 32(1): 49-53.[http://dx.doi.org/10.1093/ejo/cjp050] [PMID: 19706641] ].

Similarly, Ngom et al. found that 42.6 percent of a Senegalese sample, with 12- to 13-year-old adolescents, was categorized as grade 4 or 5 of the DHC of the IOTN [11Manzanera D, Montiel-Company JM, Almerich-Silla JM, Gandía JL. Orthodontic treatment need in Spanish schoolchildren: An epidemiological study using the Index of Orthodontic Treatment Need. Eur J Orthod 2009; 31(2): 180-3.[http://dx.doi.org/10.1093/ejo/cjn089] [PMID: 19064676] ].

Studies from the region show great differences. The study conducted in Serbia by Janošević et al. shows similar results to those of other European Counties, with 27.4 percent of children having a definite need for orthodontic treatment [8Freer E, Freer TJ. Variations in treatment need using four screening methods. Aust Orthod J 1999; 15(4): 214-8.[PMID: 11933355] ]. The study conducted in Albania by Lagana et al. found that 41.2 percent of respondents had the need for orthodontic treatment in Tirana [9Souames M, Bassigny F, Zenati N, Riordan PJ, Boy-Lefevre ML. Orthodontic treatment need in French schoolchildren: An epidemiological study using the Index of Orthodontic Treatment Need. Eur J Orthod 2006; 28(6): 605-9.[http://dx.doi.org/10.1093/ejo/cjl045] [PMID: 17095742] ]. This prevalence is quite high, but much lower then the one found in our study.

Our findings show that Kosovar children aged 11-13 years old have more malocclusion than their counterparts in neighboring countries. It is well known that causes of malocclusion are multifactorial with genetics having a key role; however, lack of preventive measures and oral health promotion programs as well as lack of systemic dental control causes premature tooth loss, this, in turn, causes malocclusion. Higher prevalence of orthodontic treatment need tells us that more children will require orthodontic therapy in the future.

The low prevalence of definite need for orthodontic treatment in developed countries can be attributed to early prevention measures [9Souames M, Bassigny F, Zenati N, Riordan PJ, Boy-Lefevre ML. Orthodontic treatment need in French schoolchildren: An epidemiological study using the Index of Orthodontic Treatment Need. Eur J Orthod 2006; 28(6): 605-9.[http://dx.doi.org/10.1093/ejo/cjl045] [PMID: 17095742] ]. On the other hand, the high prevalence of orthodontic need in developing countries, including our country, can be the result of the lack of appropriate dental health information, therefore lack of early intervention, as well as the low economic status of the majority of the population.

While our study is the first one to evaluate the orthodontic treatment need in Kosovar children of specific ages in Prishtina, the early results reveal the need for an interceptive orthodontic treatment. The assessment of orthodontic treatment needs across the population provides data that would enable policymakers to develop a national program for prevention and early orthodontic treatment. It is very important to assess orthodontic anomalies in a population so that planning of public health care expenditures and services can ensure coverage and accessibility in the most efficient way possible.

CONCLUSION

High prevalence of orthodontic treatment need was identified in Kosovar children of ages 11-13, while no gender-based statistically significant differences were noted in the need for orthodontic treatment.

This means that in the future, national budget funding for orthodontic treatment should be higher as treatment cost will burden the health budget.

More effective oral health education and promotion programs are needed in Kosovo.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study was approved from the Research Ethics Committee of the University Dentistry Clinical Center of Kosovo (University of Prishtina) and Ministry of Education, Science and Technology of Kosovo.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

Written consent was taken from all subject’s parents.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest, financial, or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989; 11(3): 309-20.[http://dx.doi.org/10.1093/oxfordjournals.ejo.a035999] [PMID: 2792220]
[2] Richmond S. A critical evaluation of orthodontic treatment in the general dental services of England and Wales 1990.
[3] Cons NC, Jenny J, Kohout FJ, Songpaisan Y, Jotikastira D. Utility of the dental aesthetic index in industrialized and developing countries. J Public Health Dent 1989; 49(3): 163-6.[http://dx.doi.org/10.1111/j.1752-7325.1989.tb02054.x] [PMID: 2769634]
[4] Jenny J, Cons NC. Comparing and contrasting two orthodontic indices, the Index of Orthodontic Treatment need and the Dental Aesthetic Index. Am J Orthod Dentofacial Orthop 1996; 110(4): 410-6.[http://dx.doi.org/10.1016/S0889-5406(96)70044-6] [PMID: 8876493]
[5] Jenny J, Cons NC. Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale. Aust Dent J 1996; 41(1): 43-6.[http://dx.doi.org/10.1111/j.1834-7819.1996.tb05654.x] [PMID: 8639114]
[6] Richmond S, Shaw WC, O’Brien KD, et al. The development of the PAR Index (Peer Assessment Rating): Reliability and validity. Eur J Orthod 1992; 14(2): 125-39.[http://dx.doi.org/10.1093/ejo/14.2.125] [PMID: 1582457]
[7] Buchanan IB, Downing A, Stirrups DR. A comparison of the Index of Orthodontic Treatment Need applied clinically and to diagnostic records. Br J Orthod 1994; 21(2): 185-8.[http://dx.doi.org/10.1179/bjo.21.2.185] [PMID: 8043567]
[8] Freer E, Freer TJ. Variations in treatment need using four screening methods. Aust Orthod J 1999; 15(4): 214-8.[PMID: 11933355]
[9] Souames M, Bassigny F, Zenati N, Riordan PJ, Boy-Lefevre ML. Orthodontic treatment need in French schoolchildren: An epidemiological study using the Index of Orthodontic Treatment Need. Eur J Orthod 2006; 28(6): 605-9.[http://dx.doi.org/10.1093/ejo/cjl045] [PMID: 17095742]
[10] Perillo L, Masucci C, Ferro F, Apicella D, Baccetti T. Prevalence of orthodontic treatment need in southern Italian schoolchildren. Eur J Orthod 2010; 32(1): 49-53.[http://dx.doi.org/10.1093/ejo/cjp050] [PMID: 19706641]
[11] Manzanera D, Montiel-Company JM, Almerich-Silla JM, Gandía JL. Orthodontic treatment need in Spanish schoolchildren: An epidemiological study using the Index of Orthodontic Treatment Need. Eur J Orthod 2009; 31(2): 180-3.[http://dx.doi.org/10.1093/ejo/cjn089] [PMID: 19064676]
[12] Chestnutt IG, Burden DJ, Steele JG, Pitts NB, Nuttall NM, Morris AJ. The orthodontic condition of children in the United Kingdom, 2003. Br Dent J 2006; 200(11): 609-12.[http://dx.doi.org/10.1038/sj.bdj.4813640] [PMID: 16767131]
[13] Janošević P, Stošić M, Janošević M, Radojičić J, Filipović G, Čutović T. Index of orthodontic treatment need in children from the Niš region. Vojnosanit Pregl 2015; 72(1): 12-5.[http://dx.doi.org/10.2298/VSP1501012J] [PMID: 26043584]
[14] Laganà G, Masucci C, Fabi F, Bollero P, Cozza P. Prevalence of malocclusions, oral habits and orthodontic treatment need in a 7- to 15-year-old schoolchildren population in Tirana. Prog Orthod 2013; 14: 12.[http://dx.doi.org/10.1186/2196-1042-14-12] [PMID: 24326142]
[15] Abdullah MS, Rock WP. Assessment of orthodontic treatment need in 5,112 Malaysian children using the IOTN and DAI indices. Community Dent Health 2001; 18(4): 242-8.[PMID: 11789703]
[16] Ngom PI, Diagne F, Dieye F, Diop-Ba K, Thiam F. Orthodontic treatment need and demand in Senegalese school children aged 12-13 years. An appraisal using IOTN and ICON. Angle Orthod 2007; 77(2): 323-30.[http://dx.doi.org/10.2319/0003-3219(2007)077[0323:OTNADI]2.0.CO;2] [PMID: 17319769]
[17] Jamilian A, Kiaee B, Sanayei S, Khosravi S, Perillo L. Orthodontic treatment of malocclusion and its impact on oral health-related quality of life. Open Dent J 2016; 10: 236-41.[http://dx.doi.org/10.2174/1874210601610010236] [PMID: 27386009]

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