Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale

The Dental Aesthetic Index (DAI) is an orthodontic index based on socially defined aesthetic standards. It is useful in both epidemiological surveys to identify unmet need for orthodontic treatment and as a screening device to determine priority for subsidized orthodontic treatment. An earlier study established the score of 36 on the DAI scale to identify handicapping malocclusions. The purpose of the present study was to determine decision points on the DAI scale that identify malocclusion severity levels less severe than handicapping. Two sources of data were used: 1) The frequency distribution of DAI scores on a probability sample of 1306 study models representing the untreated occlusions found in half a million adolescents. 2) The per cent distribution of US youths aged 12–17 by specified case severity reported in an assessment of the occlusion of youths? by the National Center for Health Statistics (NCHS). The decision points separating specific case severities on the DAI scale were determined by relating the proportions of the NCHS population with specified case severities to the cumulative percentages of the frequency distribution of DAI scores on the 1306 models. The NCHS report found 45.8 per cent of the sample to have normal or minor malocclusion with no need or slight need for treatment. DAI scores 25 and below corresponded to that proportion of the sample. The NCHS report found 25.2 per cent of the sample to have definite malocclusion with treatment being elective. DAI scores between 26 and 30 corresponded to that proportion of the sample. The NCHS report found 13 per cent of the population to have severe malocclusion with treatment highly desirable. Fifteen per cent were included in this category. DAI scores 31 to 35 corresponded to that proportion of the sample.     

Malocclusion and orthodontic treatment need of handicapped individuals in South Canara,India

AIMS: To estimate the prevalence and the severity of malocclusion and treatment need for 329 handicapped individuals. SUBJECTS AND SETTING: 329 handicapped individuals aged 11-30 years, attending eight different nonresidential special schools of South Canara, India. METHOD: Examination and recording using the Dental Aesthetic Index (DAI). RESULTS: 53% had a dental appearance which required no orthodontic treatment, 24% had a definite malocclusion, where treatment was 'elective' and treatment for a further 12% was considered to be 'highly desirable'. The remaining subjects (11%) had a handicapping malocclusion where treatment was considered mandatory. CONCLUSIONS: The prevalence of definite and severe malocclusions was higher in the mentally subnormal individuals when compared to other handicapping conditions. Orthodontic services for the handicapped have generally been neglected.     

Assessment of orthodontic treatment needs in Brazilian schoolchildren according to the Dental Aesthetic Index (DAI)

OBJECTIVE: To assess the distribution, prevalence and severity of malocclusion and orthodontic treatment needs in schoolchildren from the northeast of Brazil aged between 13 and 15 years. RESEARCH DESIGN: Cross-sectional study. PARTICIPANTS: A sample of 600 adolescents (264 males and 336 females) randomly selected and representative of schoolchildren living in Recife (Brazil) was obtained from 12 public schools. METHOD: The need for orthodontic treatment was measured using the Dental Aesthetic Index (DAI). RESULTS: Most of the subjects (77%) were deemed to require orthodontic treatment. Only about 5.8% had a handicapping malocclusion that needed mandatory treatment. A severe malocclusion for which treatment was highly desirable was recorded in 47.5% of the adolescents and 23.7% had a definite malocclusion for which treatment was elective. Three main occlusal features were responsible for allocating subjects into the group of "orthodontic treatment required": crowding (47.3%), tooth loss (22.3%) and maxillary overjet of more than 3 mm (21.8%). There were no significant differences (p > 0.05) in mean DAI scores between males and females. CONCLUSIONS: 77% of adolescents from northeast Brazil were in need of orthodontic treatment for dental health reasons. The distribution of DAI scores among Brazilian adolescents is different from that reported in other populations. This study provides baseline data on the need and demand for orthodontic treatment among Brazilian students.     

Orthodontic treatment needs: comparison of two indices.

The Index of Orthodontic Treatment Needs (IOTN) and the Dental Aesthetic Index (DAI) were developed and both claimed to contain the aesthetic and dental components in their criteria of assessing malocclusion. This study was undertaken to assess the reliability of these two indices in assessing orthodontic treatment needs. The indices were applied to 120 pre-treatment study models selected from orthodontic patient records treated at the Department of Orthodontics, University of North Carolina, United States of America. The sample consisted of 60 African-Americans (Black) and 60 American Caucasians (White), age ranged from 12 to 16 years (Mean 13.8). The results showed that the IOTN and the DAI were highly correlated and highly associated statistically (p < 0.0001). The findings of this study indicated that the two indices could be used consistently to identify orthodontic treatment needs in different ethnic groups and are capable of classifying the subjects according to their malocclusion severity for those subjects eligible for treatment in fund constrained situation.     

Malocclusion and orthodontic treatment need of secondary school students in Nigeria according to the dental aesthetic index (DAI)

The aims of this study were to measure the distribution, prevalence and the severity of malocclusion and treatment need amongst randomly selected (n = 703) rural and urban Nigerian children aged 12-18 years (mean 14.0 +/- 1.84) using the dental aesthetic index (DAI), and to assess whether malocclusion was affected by age, gender and socio-economic background. Data were collected according to the method recommended by WHO. Most of the children (77.4 per cent) had a dental appearance which required no orthodontic treatment. Over 13 per cent fell into the group where treatment for malocclusion is considered to be 'elective'. However, a substantial proportion (9.2 per cent) of the population had severe to handicapping malocclusion where treatment is 'highly desirable' or 'mandatory'. There were no statistically significant differences (P > 0.05) in DAI scores between age groups, gender and socio-economic background. This study also found that Nigerian adolescents had better dental appearance and less orthodontic treatment need compared with the Caucasian and Oriental populations.     

Malocclusion and orthodontic treatment need evaluated among subjects with Down syndrome using the Dental Aesthetic Index (DAI)

Objective:To determine the prevalence of malocclusion and need for orthodontic treatment among persons with Down Syndrome (DS).Materials and Methods:Study participants were 113 persons with DS from the selected community-based rehabilitation center who fulfilled the inclusion and exclusion criteria. Ten occlusal characteristics of the Dental Aesthetic Index (DAI) were measured on study models to determine the degree of malocclusion. A single score represented the dentofacial anomalies, determined the level of severity, and determined the need for orthodontic treatment.Results:Crowding in the anterior maxillary and mandibular arch was the main malocclusion problems among the subjects with DS. Comparison between age group and genders revealed no significant differences in four categories of orthodontic treatment need (P > .05).Conclusion:Most of the subjects with DS (94; 83.2%) had severe and very severe malocclusion, which indicated a desirable and mandatory need for orthodontic treatment.     

Orthodontic status and treatment need of 12-year-old children in South Africa using the Dental Aesthetic Index.

OBJECTIVE: The aim of this study was to determine the prevalence and severity of malocclusion and orthodontic treatment needs in a sample of 12-year-old South African school children using the Dental Aesthetic Index (DAI), and to assess the relationship between malocclusion and certain socio-demographic variables. METHODOLOGY: The sample comprised 6142, 12-year-old children attending school in seven of the nine provinces of South Africa. For each subject the standard demographic information such as gender, population group, location type and employment status of the parents was collected, after which an intra-oral examination for occlusal status using the DAI was performed. Before the survey, the examiners were calibrated and trained and only examiners with an agreement score greater or equal to 80 per cent were included in the final study. RESULTS: The results showed that 47.7 per cent of the children in the sample presented with good occlusion or minor malocclusion, just over 52.3 per cent presented with identifiable malocclusion, a DAI score larger than 26. Of these, 21.2 per cent had definite malocclusion, 14.1 per cent had severe malocclusion and 16.9 per cent had very severe or handicapping malocclusion. Malocclusion as defined in this study was found to be significantly associated with the different population groups in South Africa, with gender and with dentition stage, but not with the location type or the employment status of parents. CONCLUSIONS: The results of this study show a high prevalence of malocclusion in 12-year-old South African children. The findings provide reliable base-line data regarding the prevalence, distribution and severity of malocclusion as well as useful epidemiological data on the orthodontic treatment needs of 12-year-old children in South Africa.     

Is the Child Perceptions Questionnaire for 11–14 year olds sensitive to clinical and self‐perceived variations in orthodontic status?

OBJECTIVES: To assess the association between scores on the Child Perceptions Questionnaire for 11-14 year olds (CPQ11-14) and clinical and self-perceived measures of malocclusion. METHODS: Children were recruited from an orthodontic clinic just prior to starting orthodontic treatment. They completed a copy of the CPQ11-14 and a short questionnaire concerning their feelings about the condition of their teeth. Study models were taken and rated according to the Dental Aesthetic Index (DAI) and the Peer Assessment Rating (PAR) index by two sets of three examiners. Intra and inter-rater reliabilities for the two sets of examiners ranged from 0.80 to 0.99. CPQ11-14 scores were calculated for the full 35-item version and for 16 and 8-item short forms by summing the item response codes. The association between these scores, the DAI and PAR ratings and self-perceived measures of malocclusion were examined using appropriate parametric and nonparametric tests. RESULTS: Complete data were collected for 141 children, 63 boys and 78 girls. The mean age was 12.5 (SD = 1.0). DAI scores ranged from 17.0 to 58.0 with a mean of 35.0 (SD = 8.0). The distribution of subjects across the four severity categories was minor/none - 6.6%, definite - 35.2%, severe - 15.6% and handicapping 42.6%. PAR scores ranged from 8.0 to 66.0 with a mean of 31.4 (SD = 11.1). Eight percent had scores of 50 or above indicating marked deviation from an ideal occlusion. Both the long and the short forms of the CPQ11-14 identified substantial variability in the impacts of malocclusion. Correlations between CPQ11-14 scores and the orthodontic indices ranged from 0.26 to 0.31 (P < 0.01). There was a clear gradient in CPQ11-14 scores across four categories of the PAR based on quartiles. The gradient across the DAI categories was less clear. There were significant associations between all CPQ11-14 scores and the children's self-ratings of oral health, ratings of the extent to which the condition of the teeth affected life overall and expressions of happiness with the appearance and arrangement of the teeth. CONCLUSION: The results provide some evidence of the validity of the CPQ11-14 when used with children needing orthodontic treatment. However, because clinical samples are biased the study needs to be repeated in different treatment settings in order to confirm the utility of the measure.     

Orthodontic treatment need in Peruvian young adults evaluated through dental aesthetic index

The objectives of this study were to evaluate the frequency and severity of the malocclusion and treatment needs in Peruvian young adults. The second aim was to compare the orthodontic treatment needs according to sex and socio-economic status (SES). This cross-sectional study was conducted at the University Dental Clinic of a private university in Lima, Peru. A total of 267 freshmen (from 16 to 25 years old) were randomly selected from a pool of 780 students. Students wearing an orthodontic appliance or reporting a history of orthodontic treatment were excluded from the study. Clinical examinations were conducted using the Dental Aesthetic Index (DAI). Mann-Whitney and Kruskal-Wallis tests were used to compare the DAI scores according to sex and SES, respectively. The mean DAI score was 28.87 points (IC(95%) 27.77; 29.97, where IC indicates interval of confidence). Around one-third of the sample presented severe or very severe malocclusion, which implies a highly desirable or mandatory orthodontic treatment need. No statistically significant difference was found between the DAI scores according to sex (P = .592) and SES (P = .397). Approximately one-third of the evaluated Peruvian young adults would need orthodontic treatment according to the DAI. In this population, malocclusion was characterized by a relatively high frequency of missing teeth, appreciable dental crowding, and inadequate anteroposterior relationships.     

Longitudinal evaluation of the Treatment Priority Index (TPI)

The Treatment Priority Index (TPI) is an epidemiologic tool used to rank malocclusions and assess the need for orthodontic treatment. The purpose of this study was to (1) evaluate the predictability of the TPI as an indicator of malocclusion severity, (2) evaluate the effect of orthodontic treatment on TPI values, and (3) compare the results with a national survey of American children aged 6 to 11 years and 12 to 17 years conducted by the United States Public Health Service. The TPI was recorded annually in a young student population of Juniata County, Pa., from 1975 to 1979, and later in 1985. The mean values of the TPI did not reflect the range of severity in the population. For this reason the Malocclusion Severity Scale (Burlington Growth Center) was used to identify four groups in 1985. Each group was tracked back to 1975. Further evaluation investigated the role of individual factors contributing to malocclusion over time (tooth displacement and occlusal factors). The conclusions are as follows: (1) the TPI is a valid epidemiologic indicator of malocclusion but does not predict the severity of individual malocclusions in the permanent dentition, (2) TPI values decrease with orthodontic treatment, and (3) the average TPI values for this population were higher than the national average between 6 and 11 years of age and slightly lower in late adolescence, but lie within a treatment-need range of slight to elective. A characterization of treatment need relative to malocclusion severity that is different from the available scale is suggested.     

Symptoms and signs of temporomandibular disorders before, during and after orthodontic treatment

The relationship between orthodontic treatment and symptoms and signs of temporomandibular disorders (TMD) was studied prospectively and longitudinally in 65 adolescent girls with Class II malocclusion. The subjects received orthodontic fixed appliance treatment with the straight-wire technique combined with or without extractions and were examined for symptoms and signs of TMD before, during, after, and finally one year post-treatment. Both symptoms and signs of TMD showed considerable fluctuations over the three-year period within the individuals. The general tendency was a decreased prevalence of symptoms of TMD over the three years. The prevalence of pain on mandibular movement and tenderness to palpation of the masticatory muscles was significantly less common during and after orthodontic treatment than before. Clinically registered TMJ clicking increased slightly over the three year period. One orthodontic treatment effect when normalizing Class II malocclusions with fixed appliances was a decreased prevalence of functional occlusal interferences. We concluded that the orthodontic treatment either with or without tooth extractions did not increase the risk for TMD or worsen pre-treatment signs of TMD. Subjects with Class II malocclusion and pre-treatment signs of TMD of muscular origin seemed rather to benefit functionally from orthodontic treatment in a three-year perspective.     

Orthodontic treatment need and demand in a group of Nigerian adults: a teaching hospital-based study.

Adults may be less influenced by peer perceptions and are, generally, more stable in their concerns about appearance compared to adolescents. This study aimed at assessing the level of objective orthodontic treatment need and demand for such care among the Nigerian adults in a referral centre (University College Hospital, Ibadan) as well as their social class. The Dental Aesthetic Index was used to assess the objective orthodontic treatment need while the social class of the subjects was according to the Registrar General's social class. During the study period (January 2001-September 2002), 49 adults aged 20-55 years with mean age of 25+ 6.3 (SD) years accounting for 27.5% of all orthodontic patients were seen. Equal proportions of the subjects had normal or minor malocclusions needing no treatment or slight treatment need and very severe or handicapping malocclusions with treatment considered mandatory (32.6% each). Next were severe malocclusions with treatment highly desirable accounting for 20.4%, followed by definite malocclusions with treatment elective (14.3%). Majority (71.4%) of the subjects was of the middle class families.     

Comparison of orthodontic treatment outcomes in educational and private practice settings

An accredited graduate orthodontic program provides advanced specialty education to meet standards of care mandated by the ADA, including both didactic and clinical components with defined outcome measures. To quantify these measures, the quality of care provided by graduate orthodontic students was compared to that of orthodontists in private practice. The quality of care was studied in two different delivery settings in the Columbus, Ohio, area-private practice orthodontists (PPO) and the OSU graduate orthodontic clinic (GOC). The Peer Assessment Rating (PAR) Occlusal Index was used as a measure of malocclusion severity and post-treatment occlusal outcome. Quality of care was measured using post-treatment PAR, percent PAR reduction, and treatment duration. At baseline, no differences were seen in the gender and pre-PAR scores of patients treated by the PPO and GOC, but statistically significant differences were seen in patients' pre-treatment age, race, and starting dentition. When the post-treatment occlusal results were compared, no statistically significant differences were seen in post-PAR scores and percent PAR reduction between the PPO and GOC. A statistically significant difference was seen in treatment duration (p = 0.002), which was longer in the PPO even after controlling for confounding factors such as pre-treatment age, gender, race, starting dentition, and treatment stages. Our conclusion is that there was no statistically significant difference in the occlusal outcome between the PPO and GOC, but there was a significant difference in the treatment duration.     

Assessment of the validity of HLD (CalMod) in identifying orthodontic treatment need

Cooke M, Gerbert B, Gansky S, Miller A, Nelson G, Orellana M. Assessment of the validity of HLD (CalMod) in identifying orthodontic treatment need. Community Dent Oral Epidemiol 2010; 38: 50–57. © 2009 John Wiley & Sons A/S   Abstract – 
Objective:  The purpose of this study was to assess the validity of the Handicapped Labio-Lingual Deviation index with California modifications, HLD (CalMod), in identifying handicapping malocclusions.
Methods:  A set of 153 study casts representing all types of malocclusion was utilized in this study. Models were randomly chosen the UCSF Division of Orthodontics clinic. Treatment need was determined by the HLD (CalMod) index and by a panel of 13 orthodontists, conventionally established as the 'gold standard'. Spearman Rank correlation analysis was used to evaluate the correlation between HLD (CalMod) and the gold standard. The Classification and Regression Tree (CART) modeling was used to determine the HLD (CalMod) cut-off point of orthodontic treatment need according to the gold standard.
Results:  A Spearman Rank correlation Coefficient of 0.71 demonstrated a moderately high correlation between HLD (CalMod) and the gold standard. The CART modeling determined a value of 18.5 as the cut-off point of HLD (CalMod) for orthodontic treatment need, considerably lower than the cut-off point of 26 currently used by Medi-Cal. At a value of 26 points as the cut-off HLD (CalMod) displayed a low sensitivity (25.9%) and high specificity (96.8%).With a cut-off point of 18.5, specificity decreased to 55.6% while sensitivity increased dramatically to 92.9%.
Conclusion:  Our results show that the HLD (CalMod) with a cut-off point of 26 fails to indentify a considerable percentage of handicapping malocclusions. More studies should be done assessing the efficacy of the HLD (CalMod) in identifying handicapping malocclusion.     

Eligibility for publicly funded orthodontic treatment determined by the handicapping labiolingual deviation index

INTRODUCTION: Access to orthodontic care for Medicaid patients has been limited, in part because of orthodontists' reluctance to treat severe malocclusions for low reimbursements. Limited orthodontic treatment in the mixed dentition (phase 1 treatment) has been proposed to address this issue, because the intent of phase 1 treatment is to improve or prevent severe malocclusions. Orthodontists might be more willing to provide shorter, simpler treatment. The purpose of this study was to determine whether phase 1 treatment would reduce malocclusion severity to the extent that eligibility for subsequent Medicaid-funded treatment was significantly reduced. METHODS: Eligibility was determined by the handicapping labiolingual deviation (HLD) index, which is used by several states for this purpose. Eligibility was also determined with the index of complexity, outcome, and need (ICON). This allowed us to compare these 2 indexes. Pre-phase 1 and post-phase 1 index scores were calculated by using study casts from 193 patients treated at the University of Washington orthodontic clinic and the Odessa Brown Children's Dental Clinic, both in Seattle. RESULTS: Using the HLD index, we found that eligibility for orthodontic treatment decreased by 62% after phase 1 treatment. This change was statistically significant at P < .0001. The ICON found significantly more treatment need before phase 1 (90%) than did the HLD index (35%) (P < .0001). CONCLUSIONS: Early interceptive treatment significantly reduces eligibility for comprehensive Medicaid-funded orthodontic treatment. The HLD index is a useful tool for determining Medicaid eligibility.     

Malocclusion severity in Asian men in relation to malocclusion type and orthodontic treatment need.

INTRODUCTION: The purpose of this study was to assess the severity of malocclusion in young Asian men in relation to types of malocclusion and orthodontic treatment need. METHODS: Study models of 339 male army recruits (age, 17-22 years) with no history of orthodontic treatment were assessed. The peer assessment rating (PAR) index was used to determine the severity of their malocclusions. Logistic regression and receiver operating characteristics (ROC) curves were performed to evaluate the PAR index in relation to treatment need assessed by the dental health component (DHC) and the esthetic component (EC) of the index of orthodontic treatment need. RESULTS: The mean PAR scores were 17, 20, 28, and 18 for Class I, Class II Division 1, Class II Division 2, and Class III, respectively. PAR scores were highly correlated with DHC and EC scores (P < .001). An increase of 1 point in the PAR score significantly increased the likelihood of orthodontic treatment need for dental-health reasons or esthetic impairment (by 1.17 times [95% CI 1.13-1.21] or 1.25 times [95% CI 1.19-1.31]). The areas under the ROC curves for PAR index were 84% and 94% for the DHC and EC assessments, respectively, suggesting that PAR scores were better predicators of esthetic than dental health impairment for assessing Asian malocclusions. The optimum cutoff points were PAR scores of 17 and 20 for dental health and esthetic impairment, respectively. CONCLUSIONS: Class II malocclusions were more severe than Class I or III in Asian men. Malocclusions with definite treatment need had PAR scores that were significantly greater than those with borderline, little, or no need. ROC curves showed that the PAR index had an acceptable level of validity with the professional assessment of orthodontic treatment need in Asian malocclusions. The optimum cutoff PAR scores were 17 and 20 in relation to DHC and EC assessment, respectively. The PAR index was more predictive of esthetic than dental health need.     

Perception of personal dental appearance in Nigerian adolescents

BACKGROUND: The purpose of this study was to investigate the relationship among Nigerian adolescents' awareness of malocclusion, their satisfaction with personal dental appearance, and the severity of their occlusal irregularities. MATERIAL: The sample consisted of 577 randomly selected secondary school adolescents-306 (53%) boys and 271 (47%) girls aged 12 to 17 years (mean age, 14.73 +/- 1.12). A pretested questionnaire was used to assess the subjects' awareness of malocclusion and satisfaction with personal dental appearance; the actual severity of malocclusion was determined by using the dental aesthetic index (DAI), performed by an orthodontist in a school environment under natural illumination. RESULTS: Statistically significant, negative, weak correlations were found between awareness of malocclusion and satisfaction at the various DAI scores as follows: < or =25 (r = -0.3774, P < .001), 26 to 30 (r = -0.4305, P < .001), 31 to 35 (r = -0.5137, P < .001), and > or =36 (r = -0.5104, P < .001). Analysis of variance (ANOVA) did not show a significant value of any of the 3 factors. Multivariate analysis with age as the covariate did not show a significant effect. Also, the association between socioeconomic status and the variables was not significant ( P > .05). Generally, no statistically significant sex differences were found in relation to the DAI scores, awareness, or satisfaction ( P > .05). CONCLUSIONS: Significant, negative, weak correlations were found between Nigerian adolescents' awareness of malocclusion and satisfaction with personal dental appearance at the various severity levels of malocclusion. It would be worthwhile to assess such a relationship with the index of orthodontic treatment need in the Nigerian population.     

Orthodontic treatment need,self‐esteem,and oral health‐related quality of life among 12‐yr‐old schoolchildren

The aim of this study was to investigate the association between orthodontic treatment need and oral health‐related quality of life (OHRQoL) among 12‐yr‐old children. The study also assessed whether self‐esteem modifies and/or moderates this relationship. Cross‐sectional data on 406 schoolchildren aged 12 yr were analyzed. Data on socio‐economic and demographic characteristics, dental pain, self‐esteem, and OHRQoL were collected using validated questionnaires. Orthodontic treatment need was assessed, through dental examinations, using the dental aesthetic index (DAI). Multiple negative binomial regression and path analysis were used to estimate the association of orthodontic treatment need and self‐esteem with OHRQoL. A modifying effect of self‐esteem on the relationship between DAI and OHRQoL was observed. Self‐esteem did not mediate the abovementioned relationship. Children with lower scores of self‐esteem had worse OHRQoL among those with lower orthodontic treatment need (a DAI score of < 31). However, self‐esteem did not influence the association between DAI and OHRQoL in children with greater orthodontic treatment need (a DAI score of ≥ 31). Self‐esteem attenuated the impact of malocclusion on OHRQoL in children with minor or definite malocclusion, but not among those with severe or very severe malocclusion. Self‐esteem appears to buffer the impact of malocclusion on OHRQoL in children with minor orthodontic treatment need.