Social Impact and Self-Perception of Malocclusion among Adolescents in a Tertiary Centre of Eastern Nepal

Introduction: Malocclusion, defined as an improper relationship between teeth in the opposite jaws, has been a prevalent disorder in recent decades. There has been an increased concern about dental appearance during childhood and early adulthood. Objective: To assess the social impact and self-perception of malocclusion among adolescents and to investigate whether the types and severity of malocclusion have any effect on adolescents’ social acceptance. Methods: A total of 301 participants were chosen from middle and high school with ages ranging from 12 to 19 years. After completion of the questionnaire to assess social impact, all the participants were examined using the Index of Orthodontic Treatment Need (IOTN). Results: Malocclusion severity has a negative correlation with satisfaction with dental appearance ( σ : -0.385; P-value: <0.001). Similarly, the severity of malocclusion has weak positive correlation with treatment needs ( σ : 0.156; P-value: 0.007) and social impact ( σ : 0.171; P-value: 0.003). Conclusions: Different subjective domains of social impact and self-perception are influenced by the severity of malocclusion among adolescents visiting tertiary care center in Eastern Nepal.


INTRODUCTION
Malocclusion, defined as an improper relationship between teeth in the opposite jaws, has been a prevalent disorder in recent decades. 1 There has been an increased concern about dental appearance during childhood, adolescence, and early adulthood. 2 general, societal forces define the norms for acceptable, normal, and attractive physical appearance. 3ysical attractiveness is considered as an important factor that affects social relationships.A person's physical appearance, together with his or her sexual identity, is often the most obvious personal characteristics accessible to others during social interaction. 4,5During interpersonal interaction, it is most common for individuals to focus on the other person's eyes and mouth and give less attention to other facial characteristics. 6e literature shows that most people focus on an individual's eyes and smile.Consequently, having an attractive smile is a large part of perceived beauty and thus social acceptance. 7The compromised esthetic and functional limitations of malocclusion have a great social impact on building good, stable relationships. 8,9Adolescents are usually apprehensive about their body image, which is an important part of psychological well-being and social acceptance.Peer rejection may cause several negative behaviors and an isolated social life. 10ere has been an overwhelming lack of evidence regarding the Nepalese context.This study intends to generate evidence in the Nepalese context in helping dentists to better understand how the patient's subjective opinion on their self-appearance can impact their psychological well-being.
Dr. Nidhi Giri, 1 Dr. Ujwal Gautam   The questionnaire consisted of seven items.Question one was related to the participant's perceived need for orthodontic treatment.Question two was related to the participant's satisfaction with his or her dental appearance.Similarly questions 3, 4, 5, 6, and 7 asked about the social impact of malocclusion.Each question contained a 4-point Likert scale, ranging from 1, "definitely," ranking down to 4, "not at all."This questionnaire was inspired by the social acceptance questionnaires from study conducted by Mandall et al 11 and Badran SA. 12 The sum of the scores described the self-perceived social impact of malocclusion on the participant.The questionnaire was translated into Nepali language and pre-testing was done in 25 participants prior to the study.

RESULTS
The total sample consisted of 301 students.Out of total sample 119 (39.5%) were males and 182(60.5%)were females, with mean age of 15.33 years.166 (55.1%) students attended private schools and 135 (44.9%) attended public schools.158 (52.5%) were high school students whereas 143 (47.5%) were secondary school students.(Table 1) The subjective domains of need of treatment, satisfaction with dental appearance and social impact of malocclusion were found to have significant association with several patient related characteristics like age, gender, level of education, type of school and type of malocclusion.(Table 5) The severity of malocclusion had statistically significant association with treatment need, satisfaction with dental appearance and social impact of malocclusion.(Table 6)   on their dental alignment, some people may be extremely confident, while others may be greatly impacted by even small misalignments.It may result in diminished confidence and self-worth when interacting with others.People may be sensitive to how malocclusion affects the aesthetics of their faces because it might be viewed as a component of their entire appearance. 13 social situations, some people with malocclusion may experience anxiety or unease, especially while smiling or speaking in front of others.Visible malocclusion may make children and teenagers more vulnerable to bullying and taunting, which can seriously harm their mental health.Some people with malocclusion may steer clear of social events or circumstances where they could be the center of attention in an effort to prevent humiliation or discomfort.Some people could have self-consciousness about the way they look, which might hinder their capacity to build close relationships.In more extreme situations, anxiety or depressive symptoms may be exacerbated by malocclusion-related worries about appearance and social relations.Therefore, it's critical to consider a person's subjective judgment while deciding the necessary course of treatment for malocclusion. 14e subjective treatment need of an individual was found to be associated with severity of malocclusion in this study.The findings in Nepalese population are similar to that in Argentine patients where high need for orthodontic treatment was reported among individuals with severe form of malocclusion. 15The different domains of treatment need, satisfaction with dental appearance and social impact of malocclusion were found to have a statistically significant association with severity of malocclusion in our study.The satisfaction with dental appearance was found to be negatively correlated with the severity of malocclusion.In adolescents, psychosocial impact of dental aesthetics is associated with presence of malocclusion as reported in another study by Iranzo-Cortes et al. 16 The study reported that psychosocial impact can be reduced with having previously worn an orthodontic device.
The different domains of treatment need, satisfaction with dental appearance and social impact of malocclusion, in this study, was found to be significantly associated with age, gender, education status, and school type of the children.The study employed OHIP-14 to assess the effects of malocclusion on physical and mental domains of QoL.A significant correlation between OHIP and the degree of malocclusion was found among Albanian children aged 17-21 years old. 21The results from a study by Feu et al. showed that Brazilian adolescents who sought orthodontic treatment were found to have lower OHQOL, more severe malocclusions, and reported cosmetic impairments. 22e study employed non-probability sampling to enroll the participants which may have introduced a selection bias.Further, enrollment of participants from a tertiary level private hospital with specialty service may have introduced a referral center bias.
Nonetheless, this study has provided an insight on the social impact and self-perception of malocclusion among adolescents.Further, it has explored the adolescents' social acceptance of the types and severity of malocclusion.

CONCLUSIONS
Malocclusion can have a negative impact on satisfaction of children with dental appearance.The perceived treatment need is found to be correlated with malocclusion and this perception often increases with complexity of malocclusion as shown in the study.Similarly, malocclusion has a negative social impact which can also increase with the severity.

METHODS
This was a crosssectional study conducted in the department of Orthodontics at Nobel Medical College Teaching Hospital, Biratnagar, Nepal.All middle and high school students from 12 to 19 years old age visiting the department were prospective participants.Patients having orthodontic treatment needs as determined by IOTN were included in the study whereas students who had craniofacial anomalies and were undergoing orthodontic treatment were excluded from the study.The sample size of the study was 301 adolescents based on total enumeration technique.All participants were informed about the study and written consent was obtained from the parents and verbal assent was obtained from the participants.This study was approved by the ethical committee of the Nobel Medical College Teaching Hospital, Biratnagar, Morang, Nepal (Ref.IRC-NMCTH 624/2022) on May 4, 2022.The study duration lasted for one year, from July 2022 to July 2023.
All the participants were then examined by NG using the IOTN DHC (Index for Orthodontic Treatment Needs Dental Health Component) for categorizing the participants' condition, according to the severity of the malocclusion, into five grades: Grade 1: no treatment need; Grade 2: mild/little need; Grade 3: moderate need; Grade 4: severe need; and Grade 5: extreme need of treatment.The type of malocclusion was also recorded using the following parameters: overjet, anterior overbite, anterior cross bite, anterior open bite, crowding and spacing.Descriptive statistics were presented as mean (SD) or median (IQR) for continuous outcomes while categorical outcomes were presented as frequency (proportion).Association of need for treatment, satisfaction with dental appearance and social impact of malocclusion with patient characteristics and severity of malocclusion were evaluated using appropriate inferential statistics.The level of significance was set at p<0.05.

DISCUSSIONA
person's confidence and self-esteem may be impacted by aesthetic concerns caused by malocclusion, particularly when they are selfconscious about the way their smile looks.Furthermore, the way that the alignment of their jaw and teeth affects the appearance of their face may have negative social or psychological effects on certain individuals.It's crucial to remember that every individual can experience malocclusion in a very different way psychologically.Depending Study byBirkeland et al. has shown that factors like differences in social class, economic considerations, individuals' perception of psychosocial benefits, and attitudes to appliances contribute to the perception of the adolescents towards the treatment seeking behavior for orthodontic malocclusion.17Dental Aesthetic Index (DAI) used to determine socially defined esthetic standards among secondary school students revealed significant, negative, weak correlation between adolescents' awareness of malocclusion and satisfaction with personal dental appearance at various malocclusion severity levels.2However, this study employed IOTN in determining the orthodontic treatment needs in Nepalese children.Nonetheless, a statistically significant association has been demonstrated between two indices as both indices have demonstrated similar potential to determine orthodontic status of the subjects and their need for orthodontic treatment.18,19The DAI is employed for its simplicity in use but has its own limitation as it does not take into account the buccak crossbite, posterior openbite, central line discrepancies, or a deep overbite, factors which may have considerable impact on treatment complexity.Another study by Dalaie et al showed negative impact of malocclusion severity on the Quality of Life (QoL).20A significant correlation between borderline and definite need for orthodontic treatment, determined by IOTN-Dental Health Component (DHC), was observed with Oral health related quality of life measure as assessed by OHIP-14 scores in the study.

Table 1 :
Demographic characteristics of the participants.

Table 2 :
Distribution of Likert responses to the questionnaire items.

Table 3 :
Type of malocclusion among study participants.

Table 4 :
Severity of malocclusion among study participants.

Table 5 :
Association of patient characteristics with need of treatment, satisfaction with dental appearance and social impact of malocclusion.

Table 6 :
Association between different domain scores with severity of malocclusion.