European Journal of Orthodontics 14 (1992) 350-358
(£> 1992 European Orthodontic Society
Perception of malocclusion in 11-year-old children: a comparison between personal and parental awareness Lisen V. Espeland, Knut Ivarsson, Arild Stenvik, and Turid Album Alstad Department of Orthodontics, University of Oslo, Norway
Introduction
In children, desire for treatment is influenced by parental attitudes and values. Although social and psychological factors not related to the dental problem may be of importance in seeking treatment (Lewit and Virolainen, 1968; Baldwin, 1980), concern for appearance is a salient motivational factor (Albino et al., 1981; Tulloch et al., 1984; Gosney, 1986), and may prevail over dental health concerns (Gochman, 1975). It is apparently recognized by both children and parents that social adaptation and chances for success are improved by facial attractiveness (Linn, 1966; Dorsey and Korabik, 1977; Shaw et al., 1979). The influence of the social unit of the family on personal perception of dentofacial appearance has been emphasized by Albino and Tedesco (1988): 'The attitudes, beliefs and perceptions of parents and siblings provide a background against which the individual designs his or her self-perception of facial
appearance.' Agreement has been found between family members in evaluations of the child's dental attractiveness (Albino and Tedesco, 1988). Individuals' perception of their occlusal condition correlates with professional assessments of severity of malocclusion and treatment need, but the relationship is not a direct one (Katz, 1978; Shaw, 1981; Espeland et al., 1992). Perceived degree of malocclusion has been found to be a better predictor of desire for treatment than the actual morphological condition (Lewit and Virolainen, 1968; Albino et al., 1982). Parents' decisions about orthodontic treatment are in part a result of the advice from the orthodontist. The professional advice is not only based upon a morphological and functional analysis. It also includes evaluation of the aesthetic aspect of the dentofacial condition. In orthodontic counselling an understanding of how the patient and the parent perceive occlusal features is essential. To ensure an effective communication and to establish a basis
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SUMMARY In orthodontic counselling an understanding of how individuals perceive their occlusal features is important to ensure effective communication and for provision of adequate advice on treatment need. The purpose of the present study was to assess personal and parental awareness of malocclusion in children, and to examine whether agreement existed between children and their parents on assessments of malocclusion traits. Of 104 randomly selected fourth-grade children 99 presented themselves at a public dental clinic. Ninety-three accompanying parents attended. Awareness was assessed by comparing the opinion of parents and children on the presence or absence of anterior malocclusion with direct measurements on dental study casts. The subjects' abilities to identify a polaroid of the child's dentition in a panel of 17 alternative photographs were also used as a measure of awareness. The findings revealed a moderate level of awareness among both the children and their parents. About half of the children and the parents identified the child's photograph on the first attempt. About three-quarters of the traits recorded as marked/severe malocclusion and about half of the mild/moderate traits were recognized. A significant association existed between the number of correct reports on traits given by the children and the parents. However, agreement across professional, child, and parental assessments varied for the different traits. The results indicated that the individual's comprehension of professional terms may be unclear and that professionally defined cut-off points often do not coincide with norms existing within the actual family unit.
AWARENESS OF MALOCCLUSION
for realistic treatment decisions, it is important that the orthodontic problem is addressed in a way that is comprehensible to both the child and the parent. The purpose of the present study was to assess self- and parental awareness of the child's occlusion. Furthermore, the children's and the parents' reports on occlusal features were compared to examine whether child and parental perceptions parallel each other. Subjects and methods
Professional assessment of occlusion
Impressions for dental study casts were taken of all the children. Pretreatment casts were available for the two individuals who were wearingfixedappliances. On the casts six malocclusion traits in the anterior region were recorded: spacing of the upper anterior segment, crowding and irregularity of the upper and lower anterior segment, and overjet. The traits were recorded according to criteria adapted from Bjork et al. (1964), and cut-off points defining both mild/moderate and marked/severe malocclusion were applied (Table 1). Hence, each trait was recorded as either absent (normal occlusion), mild/moderate malocclusion, or marked/severe malocclusion. All the measurements were made by two observers. Disagreement between observers on 13 per cent of the 594 single traits resulted in repeated measurements until agreement was established. Assessment of awareness
The children and parents were interviewed separately with the use of questionnaires (Table 2).
The children were asked to describe their own teeth, and the parents to describe their child's teeth. Both the children and the parents were presented statements about the six malocclusion traits which were recorded from the casts, and they were asked to reject or confirm the statements. One observer was present to guide the respondents. The two children with fixed appliances were instructed to describe their occlusion according to their pretreatment condition. No mirror was available for the children and the parents were not allowed to inspect their offspring's teeth. No information about the child's dental status was given during the clinical examination. Personal and parental awareness were assessed by comparing the respondent's reports on the six traits with the casts. The cast recordings were used as a basis for assessing statements as correct or incorrect and the number of correct statements was used as a measure of awareness. Calculations were made on the basis of both the criteria defining marked/severe malocclusion and the criteria for mild/moderate malocclusion. Furthermore, agreement between recorded and reported data was calculated for each trait, and also assessed by a coefficient of agreement (Kappa) which corrects for chance agreement (Cohen, 1960). (Six parents did not complete all the six statements. Of a total of 558 statements 23 were not completed, and scores indicating absence of trait were assigned to these statements.) Awareness was also evaluated by a method adapted from Shaw (1981). Black-andwhite polaroids were taken of the child's anterior teeth. Both the child and the parent were asked to identify the child's dentition in a panel of 17 alternative standardized polaroids. The panel displayed different arrangements of anterior teeth representative for the actual age group (Fig. 1). The number of attempts necessary to depict the right photograph was recorded. Five or more attempts were recorded as identification inability. The details of the method have been described previously (Espeland and Stenvik, 1991). Statistical methods The Kolmogorov-Smirnov test was applied for analysis of differences between ordinal variables (Siegel and Castellan, 1988). Nominal variables were evaluated with the Chi-square test. The Kappa statistic was used for analysis of agree-
Downloaded from by guest on July 1, 2015
The surveyed groups comprised fourth grade children and one of their parents. The children were randomly selected from three schools in different areas of the city of Drammen, Norway. One-hundred-and-four families were requested in letters to participate in the study, and 99 children (48 girls, 51 boys) and 93 accompanying parents (82 mothers, 11 fathers) responded. Both the children and the parents presented themselves at a local public dental clinic. The children were from 9.8 to 11.6 years of age (mean age 10.7 years). Orthodontic treatment had been planned or recently initiated in 12 individuals. Only two children were wearing fixed appliances, and these two were not accompanied by a parent.
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L. V. ESPELAND ET AL.
Table 1 Criteria for mild/moderate and marked/severe malocclusion applied to dental casts of 99 children for the assessment of various traits. Mild/moderate malocclusion
Marked/severe malocclusion
Spacing Single anterior interdental spaces
1-2 mm
Crowding Anterior space deficiency measured between the mesial aspects of the canines
2-4 mm
24 mm
Irregularity Displacement: One or more of the six anterior teeth being out of normal arch alignment when measured at the incisal edge and/or Rotation: Rotation from normal arch alignment of one or more of the six anterior teeth and/or Tipping: Tipping from normal inclination of one or more of the six anterior teeth
1-2 mm
22 mm
15-30°
2 30°
15-30°
2 30°
Overjet The distance from the labio-incisal edge of the most prominent upper central incisor to the labial surface of the corresponding lower central incisor measured parallel to the occlusal plane
6-9 mm
29 mm
You are required to describe the arrangement of your own/your child's teeth by answering these questions which concern the six anterior teeth in the upper and lower jaws. Please underline YES or NO. 1. 2. 3. 4. 5. 6.
There are gaps between the upper front teeth The upper front teeth are crowded. The lower front teeth are crowded. The upper front teeth are irregular. The lower front teeth are irregular. The upper teeth are positioned too far in front of the lower teeth. (The overjet is too large).
ment between reported and recorded data (Cohen, 1960), and Spearman rank-order correlation coefficients were computed to examine association between variables. Results Forty-three individuals exhibited one or more traits recorded as marked/severe malocclusion and 47 were characterized by presence of only mild/moderate malocclusions. No traits were recorded in nine children. No differences in frequencies of traits existed between the sexes. Except for the children's abilities to identify the photograph of their own teeth no significant differences in awareness were observed between the sexes or between parents of girls and boys. A pooled analysis is, therefore, presented for most results.
YES YES YES YES YES YES
NO NO NO NO NO NO
Number of correct statements When the criteria defining marked/severe malocclusion were applied as cut-off point for the professional assessment of malocclusion, a significant difference existed in number of correct statements made by the children and the parents (P
(£> 1992 European Orthodontic Society
Perception of malocclusion in 11-year-old children: a comparison between personal and parental awareness Lisen V. Espeland, Knut Ivarsson, Arild Stenvik, and Turid Album Alstad Department of Orthodontics, University of Oslo, Norway
Introduction
In children, desire for treatment is influenced by parental attitudes and values. Although social and psychological factors not related to the dental problem may be of importance in seeking treatment (Lewit and Virolainen, 1968; Baldwin, 1980), concern for appearance is a salient motivational factor (Albino et al., 1981; Tulloch et al., 1984; Gosney, 1986), and may prevail over dental health concerns (Gochman, 1975). It is apparently recognized by both children and parents that social adaptation and chances for success are improved by facial attractiveness (Linn, 1966; Dorsey and Korabik, 1977; Shaw et al., 1979). The influence of the social unit of the family on personal perception of dentofacial appearance has been emphasized by Albino and Tedesco (1988): 'The attitudes, beliefs and perceptions of parents and siblings provide a background against which the individual designs his or her self-perception of facial
appearance.' Agreement has been found between family members in evaluations of the child's dental attractiveness (Albino and Tedesco, 1988). Individuals' perception of their occlusal condition correlates with professional assessments of severity of malocclusion and treatment need, but the relationship is not a direct one (Katz, 1978; Shaw, 1981; Espeland et al., 1992). Perceived degree of malocclusion has been found to be a better predictor of desire for treatment than the actual morphological condition (Lewit and Virolainen, 1968; Albino et al., 1982). Parents' decisions about orthodontic treatment are in part a result of the advice from the orthodontist. The professional advice is not only based upon a morphological and functional analysis. It also includes evaluation of the aesthetic aspect of the dentofacial condition. In orthodontic counselling an understanding of how the patient and the parent perceive occlusal features is essential. To ensure an effective communication and to establish a basis
Downloaded from by guest on July 1, 2015
SUMMARY In orthodontic counselling an understanding of how individuals perceive their occlusal features is important to ensure effective communication and for provision of adequate advice on treatment need. The purpose of the present study was to assess personal and parental awareness of malocclusion in children, and to examine whether agreement existed between children and their parents on assessments of malocclusion traits. Of 104 randomly selected fourth-grade children 99 presented themselves at a public dental clinic. Ninety-three accompanying parents attended. Awareness was assessed by comparing the opinion of parents and children on the presence or absence of anterior malocclusion with direct measurements on dental study casts. The subjects' abilities to identify a polaroid of the child's dentition in a panel of 17 alternative photographs were also used as a measure of awareness. The findings revealed a moderate level of awareness among both the children and their parents. About half of the children and the parents identified the child's photograph on the first attempt. About three-quarters of the traits recorded as marked/severe malocclusion and about half of the mild/moderate traits were recognized. A significant association existed between the number of correct reports on traits given by the children and the parents. However, agreement across professional, child, and parental assessments varied for the different traits. The results indicated that the individual's comprehension of professional terms may be unclear and that professionally defined cut-off points often do not coincide with norms existing within the actual family unit.
AWARENESS OF MALOCCLUSION
for realistic treatment decisions, it is important that the orthodontic problem is addressed in a way that is comprehensible to both the child and the parent. The purpose of the present study was to assess self- and parental awareness of the child's occlusion. Furthermore, the children's and the parents' reports on occlusal features were compared to examine whether child and parental perceptions parallel each other. Subjects and methods
Professional assessment of occlusion
Impressions for dental study casts were taken of all the children. Pretreatment casts were available for the two individuals who were wearingfixedappliances. On the casts six malocclusion traits in the anterior region were recorded: spacing of the upper anterior segment, crowding and irregularity of the upper and lower anterior segment, and overjet. The traits were recorded according to criteria adapted from Bjork et al. (1964), and cut-off points defining both mild/moderate and marked/severe malocclusion were applied (Table 1). Hence, each trait was recorded as either absent (normal occlusion), mild/moderate malocclusion, or marked/severe malocclusion. All the measurements were made by two observers. Disagreement between observers on 13 per cent of the 594 single traits resulted in repeated measurements until agreement was established. Assessment of awareness
The children and parents were interviewed separately with the use of questionnaires (Table 2).
The children were asked to describe their own teeth, and the parents to describe their child's teeth. Both the children and the parents were presented statements about the six malocclusion traits which were recorded from the casts, and they were asked to reject or confirm the statements. One observer was present to guide the respondents. The two children with fixed appliances were instructed to describe their occlusion according to their pretreatment condition. No mirror was available for the children and the parents were not allowed to inspect their offspring's teeth. No information about the child's dental status was given during the clinical examination. Personal and parental awareness were assessed by comparing the respondent's reports on the six traits with the casts. The cast recordings were used as a basis for assessing statements as correct or incorrect and the number of correct statements was used as a measure of awareness. Calculations were made on the basis of both the criteria defining marked/severe malocclusion and the criteria for mild/moderate malocclusion. Furthermore, agreement between recorded and reported data was calculated for each trait, and also assessed by a coefficient of agreement (Kappa) which corrects for chance agreement (Cohen, 1960). (Six parents did not complete all the six statements. Of a total of 558 statements 23 were not completed, and scores indicating absence of trait were assigned to these statements.) Awareness was also evaluated by a method adapted from Shaw (1981). Black-andwhite polaroids were taken of the child's anterior teeth. Both the child and the parent were asked to identify the child's dentition in a panel of 17 alternative standardized polaroids. The panel displayed different arrangements of anterior teeth representative for the actual age group (Fig. 1). The number of attempts necessary to depict the right photograph was recorded. Five or more attempts were recorded as identification inability. The details of the method have been described previously (Espeland and Stenvik, 1991). Statistical methods The Kolmogorov-Smirnov test was applied for analysis of differences between ordinal variables (Siegel and Castellan, 1988). Nominal variables were evaluated with the Chi-square test. The Kappa statistic was used for analysis of agree-
Downloaded from by guest on July 1, 2015
The surveyed groups comprised fourth grade children and one of their parents. The children were randomly selected from three schools in different areas of the city of Drammen, Norway. One-hundred-and-four families were requested in letters to participate in the study, and 99 children (48 girls, 51 boys) and 93 accompanying parents (82 mothers, 11 fathers) responded. Both the children and the parents presented themselves at a local public dental clinic. The children were from 9.8 to 11.6 years of age (mean age 10.7 years). Orthodontic treatment had been planned or recently initiated in 12 individuals. Only two children were wearing fixed appliances, and these two were not accompanied by a parent.
351
352
L. V. ESPELAND ET AL.
Table 1 Criteria for mild/moderate and marked/severe malocclusion applied to dental casts of 99 children for the assessment of various traits. Mild/moderate malocclusion
Marked/severe malocclusion
Spacing Single anterior interdental spaces
1-2 mm
Crowding Anterior space deficiency measured between the mesial aspects of the canines
2-4 mm
24 mm
Irregularity Displacement: One or more of the six anterior teeth being out of normal arch alignment when measured at the incisal edge and/or Rotation: Rotation from normal arch alignment of one or more of the six anterior teeth and/or Tipping: Tipping from normal inclination of one or more of the six anterior teeth
1-2 mm
22 mm
15-30°
2 30°
15-30°
2 30°
Overjet The distance from the labio-incisal edge of the most prominent upper central incisor to the labial surface of the corresponding lower central incisor measured parallel to the occlusal plane
6-9 mm
29 mm
You are required to describe the arrangement of your own/your child's teeth by answering these questions which concern the six anterior teeth in the upper and lower jaws. Please underline YES or NO. 1. 2. 3. 4. 5. 6.
There are gaps between the upper front teeth The upper front teeth are crowded. The lower front teeth are crowded. The upper front teeth are irregular. The lower front teeth are irregular. The upper teeth are positioned too far in front of the lower teeth. (The overjet is too large).
ment between reported and recorded data (Cohen, 1960), and Spearman rank-order correlation coefficients were computed to examine association between variables. Results Forty-three individuals exhibited one or more traits recorded as marked/severe malocclusion and 47 were characterized by presence of only mild/moderate malocclusions. No traits were recorded in nine children. No differences in frequencies of traits existed between the sexes. Except for the children's abilities to identify the photograph of their own teeth no significant differences in awareness were observed between the sexes or between parents of girls and boys. A pooled analysis is, therefore, presented for most results.
YES YES YES YES YES YES
NO NO NO NO NO NO
Number of correct statements When the criteria defining marked/severe malocclusion were applied as cut-off point for the professional assessment of malocclusion, a significant difference existed in number of correct statements made by the children and the parents (P
