Comparison of knowledge, self-perception about malocclusion and orthodontic treatment need amongst undergraduate dental students

ABSTRACT

Introduction

Perception regarding malocclusion and esthetics is affected by knowledge, age, race, gender, social background, and exposure. This study compares knowledge and awareness of undergraduate dental students regarding malocclusion, its impact on oral and mental health, and students’ self- perceived need for orthodontic treatment.

Material and Methods

A multi-centre cross-sectional study evaluated 424 questionnaires. They were assessed and compared on knowledge, awareness, and self-perception regarding malocclusion. Results were reported in percentages and compared using chi-square test.

Results

Most of the respondents were females, (82.1%). 4th year students were most aware about malocclusion’s effects on caries (86.8%), plaque (98.1%) and gingivitis (85.8%), p-value was significant, 0.000. Mostly, 3rd year students favoured well-aligned teeth, 91.5%, (p = 0.431); 2nd year students mostly, regarded aligned teeth important for esthetics (96.2%) p = 0.042; 4th year students mostly reported self-perceived need for orthodontic treatment, 43.4% (p = 0.048) and thought malocclusion affected one’s self-esteem 86.8% (p = 0.031), acceptance amongst peers 51.9% (p = 0.000) and mental health 52.8% (p = 0.000).

Conclusion

Knowledge and self-perception regarding malocclusion did not have a direct relation with the level of education of the dental students studied.

KEYWORDS:

• Undergraduate dental students
• malocclusion
• knowledge
• self-perception

Introduction

The overriding influence of social media and cosmetic industry has led to masses wishing to improve their dental appearance which ultimately affects facial attractiveness. Knowledge and exposure pertaining to beauty standards have altered peoples’ self-perception which is related to age, gender, ethnicity, social background, exposure, and education. Literature suggests that a positive self-perception boosts one’s self-confidence, self-esteem and social interaction [1–9].

Previous studies reported self-perception of laymen, students from different fields, general dentists and orthodontists around different aspect of esthetics, and self-perceived need for treatment. A study on undergraduate dental students assessed their satisfaction with the appearance of their teeth, their arrangement, colour, importance of dental esthetics and their inclination towards orthodontic treatment [10]. Patients’ satisfaction with their dental esthetics was assessed based on the influence of their age, gender and level of education [11]. Undergraduate dental students’ perception towards tooth shade was also evaluated with their level of dental education [12,13]. This is important as the level of dental education determines the type of subjects the students have been exposed to. For instance, 1st and 2nd year of dental school comprises mainly basic medical subjects (Anatomy, Physiology, Pathology, Biochemistry, etc.) and two basic dental subjects revolving around Dental Materials, Oral Anatomy and Community Dentistry. However, 3rd year of dental school’s curriculum comprises Oral Pathology and Periodontology but, it is the final year of the dental education in which the students get substantial exposure to dental subjects encompassing clinical dentistry (Operative Dentistry, Oral Surgery, Prosthodontics and Orthodontics) involving esthetics, malocclusion and different procedures to correct dental diseases and occlusion. A study determined the knowledge and perception of senior dental students regarding the perception of dental aesthetics and compared the responses on the basis of dentistry year and gender [14]. Association between orthodontic treatment need and psychosocial status of the undergraduate students of a dental university was also assessed [15]. Another research studied dental aesthetics’ perceptions among future Arabian dental professionals [16]. A study evaluated smile appearance, self-perceived smile attractiveness, and psychological well-being amongst second and sixth year dental students at a dental university [17]. Comparison of awareness of variation from ideal esthetic standards among dental students at differing levels of training, general dental practitioners, and dental specialists has also been studied [18]. Finally, a study assessed perception of six esthetic components of the smile among dental students and influence of education’s level and gender on the students’ perception [19]. A clear scarcity of evidence was found regarding knowledge of malocclusion and its impact on undergraduate dental students with increasing level of education and its self-perceived importance for their own psychological well-being. It has not been studied till date whether improvement in knowledge affects the dental students’ inclination towards seeking orthodontics treatment or aligned teeth for their own selves.

So far none of the studies assessed the knowledge and awareness regarding malocclusion, its effects on oral health and self-esteem amongst undergraduate dental students. A large sample of students from all four years of dental schools belonging to the same geographical region has not been studied till date. Our study aimed to assess and compare the knowledge of undergraduate dental students (of different levels) regarding malocclusion-its aetiology, impact on oral health status, mental health, self-esteem, confidence, acceptance amongst peers and self-perceived need for orthodontic treatment. Literature, till date only reported difference in self-perception related to tooth color/shade, arrangement of teeth, different components of smile and self-perceived need for treatment amongst undergraduate dental students or amongst laymen and dental professionals. This study could help by having an insight into the impact of design of dental courses taught to the students, its influence on their self-perception towards their own malocclusion and their desire to seek treatment. It can also help in the clinical setting by assessing the patients’ (coming from different educational backgrounds), their self-perceived need and motivation in seeking treatment and in their appropriate dealing and counselling.

Materials and methods

This was a cross-sectional, multi-centre study. Ethical approval was taken from two dental undergraduate colleges. 430 filled questionnaires were collected, out of which 424 were selected as 6 were incomplete. Convenience sampling was used, 106 questionnaires from each batch of 1st year to 4th year students were taken. Data was collected from the undergraduate dental students easily accessible to the researchers and who consented to participate.

Consent forms were signed by the students to confirm their willingness to participate in the study. Printed questionnaires were distributed amongst the participants. They were filled by 1st to 4th (final) year undergraduate students of two dental colleges. Data was entered in Excel sheet for analysis into the Statistical Package for the Social Sciences and analysed by the same software. Results were reported in percentages and shown in tables and graphs and compared using chi-square test. p < 0.05 was taken as significant. Questionnaires comprised the following sections, i.e.

1. Data of the participant (no personal information was collected)

2. Knowledge regarding relationship between malocclusion, dental caries, and gingivitis

3. Awareness of students towards malocclusion and their self-perceived need for orthodontic treatment

4. Knowledge regarding aetiology of malocclusion

Inclusion criteria:

• Undergraduate dental students from 1st, 2nd, 3rd, and 4th year of dental colleges

• Students who consented to participate in the study.

• Students who comprehended English language and could fill the forms independently.

Exclusion criteria:

• Students who did not consent to participate in the study

• Students with history of previous orthodontic treatment

• Students undergoing orthodontic treatment

• Students with cleft lip/palate or any other craniofacial anomaly

• Incomplete questionnaires

(Questionnaire attached):

Data of the participant

• Age: _____

• Gender: Male: □ Female: □

• Year of dental school: 1st year□ 2nd year □ 3rd year □ 4th year□

• Have you had/undergoing orthodontic (braces) treatment? Yes □ No □

Awareness towards the relationship between the malocclusion (malaligned teeth), dental caries and gum diseases:

• Do you think malocclusion can cause dental caries/cavities? Yes □ No □ Maybe □

• Do you think malocclusion can cause gingivitis/gum disease? Yes □ No □ Maybe □

Knowledge and awareness towards orthodontic needs:

• Do you think aligned teeth are important for esthetics?

Yes □ No □ Maybe □

• Do you feel that you need orthodontic treatment? Yes □ No □ Maybe □

• Do you think aligned teeth are important for good oral health?

Yes □ No □ Maybe □

• In your opinion, does malocclusion have an impact on a person’s self-esteem and confidence?

Yes □ No □ Maybe □

• In your opinion, does malocclusion have a role in a person’s acceptance amongst his/her peers or the society as a whole?

Yes □ No □ Maybe □

• In your opinion, does malocclusion have an impact on a person’s mental health?

Yes □ No □ Maybe □

• Do you think thumb/pacifier sucking can be a cause of malocclusion?

Yes □ No □ Maybe □

• Do you think bottle feeding beyond the age of mixed dentition can cause malocclusion?

Yes □ No □ Maybe □

• Does heredity play a role in causation of malocclusion?

Yes □ No □ Maybe □

• Do you think caries/cavities in early stages of dentition can contribute towards malocclusion?

Yes □ No □ Maybe □

• Can early loss of primary (milk) teeth cause malocclusion?

Yes □ No □ Maybe □

Results

Table 1 shows the results on the knowledge assessed of the students regarding malocclusion. Percentage of students who answered with ‘yes’ response was calculated. In response to malocclusion leading to dental caries, most of 4th year students answered correctly, 86.8%, followed by 3rd, 2nd and 1st year students showing increase in knowledge with increasing level of education, p-value was significant (0.000). The result showed expected increase in knowledge regarding dental caries resulting due to malocclusion with increase in level of dental education.

Table 1. Percentage of students from each undergraduate year responding with ‘yes’ (correct response) to the questions pertaining to knowledge on malocclusion.

	1st year	2nd year	3rd year	4th year	p-value
Knowledge about malocclusion	(%)	(%)	(%)	(%)
Do you think malocclusion can cause dental caries?	49.1	69.8	75.5	86.8	0.000
Do you think malocclusion can cause plaque accumulation?	62.3	71.7	90.6	98.1	0.000
Do you think malocclusion can cause gingivitis?	47.2	43.4	71.7	85.8	0.000

p < 0.05 was statistically significant.

Figure 1 shows the gender distribution of the research participants divided year wise according to their undergraduate level.

Figure 1. Percentage of gender distribution of research participants.

In Table 1, mostly, 4th year students responded correctly regarding malocclusion causing gingivitis, followed by 3rd, 1st and 2nd year students, showing varied results with increasing level of education, p-value was significant, 0.000, showing varying level of knowledge regarding aetiology of malocclusion with increasing level of education.

Table 2 (Figure 2) shows with increasing level, students favoured well-aligned teeth except for 4th year students who showed a decrease in inclination towards having well-aligned teeth, p-value was non-significant.

Figure 2. Responses of students (%) from each year as, ‘yes’, ‘no’ or ‘maybe’ to importance of aligned teeth for esthetics.

Table 2. Percentage of students from each year who responded with ‘yes’ to the questions on awareness around malocclusion.

	1st year	2nd year	3rd year	4th year	p-value
Awareness about malocclusion	(%)	(%)	(%)	(%)
Do you think teeth must be well aligned?	90.6	90.6	91.5	87.7	0.431
Do you think aligned teeth are important for esthetics?	85.8	96.2	91.5	86.8	0.042
Do you feel that you need orthodontic treatment?	37.7	25.5	20.8	43.4	0.048
In your opinion, does malocclusion have an impact on a person’s self-esteem and confidence?	65.1	77.4	80.2	86.8	0.031
In your opinion, does malocclusion have a role in a person’s acceptance amongst his/her peers or the society as a whole?	22.6	36.8	40.6	51.9	0.000
Does malocclusion have an impact on a person’s mental health?	24.5	46.2	37.7	52.8	0.000

p < 0.05 was statistically significant.

2nd year students mostly regarded aligned teeth important for esthetics followed by 3rd, 4th and 1st year students, p-value was significant, 0.042 showing 2nd year students were more conscious about their appearance which differed from the results of higher level of students. This suggested that increasing level of dental education does not necessarily make one self-conscious about one’s appearance pertaining to tooth alignment.

Students’ thoughts on their self-perceived need for orthodontic treatment showed a little less than half of the total strength of 4th year students, answered in the affirmative, 43.4% followed by 1st, 2nd and 3rd year students, p-value being non-significant, 0.048.

Table 3 shows the responses of students on the aetiology of malocclusion. They showed increased awareness around thumb/pacifier sucking and early caries. Whereas, bottle feeding, early loss of deciduous teeth and hereditary factors showed varied results with progression of knowledge.

Table 3. Percentage of students from each year who responded with ‘yes’ to the questions asked related to aetiology of malocclusion.

Questions related to the cause of malocclusion				1st year	2nd year	3rd year	4th year	p-value
				(%)	(%)	(%)	(%)
Do you think thumb sucking can be a cause of malocclusion?				61.3	68.9	77.4	92.5	0.000
Do you think bottle feeding beyond the age of mixed dentition can be a cause of malocclusion?				50.0	72.6	71.7	84.9	0.000
Do you think pacifier sucking can be a cause of malocclusion?				44.3	60.4	62.3	86.8	0.000
Does hereditary play role in the causation of malocclusion?				56.6	57.5	46.2	70.8	0.067
Do you think caries/cavities in the early stages of dentition can contribute towards malocclusion?				36.8	36.8	41.5	56.6	0.000
Can early loss of primary teeth cause malocclusion?				44.3	49.1	45.3	81.1	0.000

p < 0.05 was statistically significant.

In Figure 4, 86.8% of the students from 4th year regarded aligned teeth important for boosting self-esteem and confidence followed by 3rd, 2nd and 1st year students showing increase in awareness with level of education, p-value being significant, 0.031. A great number of students from the final year considered alignment of teeth important for one’s self-esteem which reflected increased awareness of students with higher level of dental education.

Table 2 shows almost half of the 4th year students, 51.9% considered aligned teeth impactful for acceptance amongst peers followed by 3rd, 2nd^, and 1st year students, again showing increase in awareness with progression of education, p-value being significant, 0.000. This reflected increased awareness of dental students regarding importance of aligned teeth for peer-acceptance with increasing level of dental education.

Figure 5 shows a little more than half of the strength of the 4th year students, 52.8% thought alignment of teeth influenced mental health followed by 2nd, 3rd and 1st year students showing varying results in awareness regarding the matter with progression of education, p-value being significant, 0.000. This also reflected the increasing awareness of students with increasing level of education regarding the impact of aligned teeth on one’s mental well-being.

Figure 5. Responses of students (%) from each year as, ‘yes’, ‘no’ or ‘maybe’ to malocclusion’s impact on mental health.

Discussion

Perception, besides being related with age, gender, ethnicity and exposure, also correlates with the level of dental education and years of experience in the particular field [20,21]. It is of paramount importance to get an insight into the perception and self-perception related to esthetics of the budding dentists who would be ultimately giving dental care to patients and the community. Perception, esthetic demands, and perceived need for orthodontic treatment vary amongst individuals and between dentists and lay people. It determines dentists’ approach towards treatment, its planning, execution and aligning their own knowledge and perception with the patients’ demands [22].

This study highlights the knowledge and awareness of the undergraduate dental students with regard to aetiology and effects of malocclusion (on oral and mental health), self-perceived importance of well-aligned teeth and need for orthodontic treatment. It shows the association of the knowledge (related to malocclusion) gained with their self-perception and need for orthodontic treatment with increasing levels of education-from 1st to 4th (final) year dental undergraduate programme. First, questionnaire recorded demographic data-age, gender (Figure 1), and year of under graduation from two dental schools, thus, being a multi-centre study. Secondly, the questionnaire recorded responses related to knowledge on malocclusion’s effects on development of dental caries, plaque accumulation and gingivitis (Table 1). Percentage of students responding with ‘yes’ to these questions was assessed and associated with the level of education (as the correct response was ‘yes’ for all the questions). The results showed increasing number of students responding correctly from junior to senior level, showing a linear increase in knowledge with the level of education. p-value was significant, 0.000 for all the questions from this section. These results could not be compared with previous studies as no such parameter was assessed in any study reported to date. The results reflected positive improvement in knowledge with increasing level of education of undergraduate dental students (Table 1).

Third section assessed knowledge of the students regarding the aetiology of malocclusion (Table 3). When thumb sucking and early caries being aetiological factors were assessed, final year students showed most knowledge (92.5%) which progressively showed a decline from 3rd (77.4%) to 2nd (68.9%) to 1st year (61.3%) where 1st and 2nd year students showed same level of knowledge. Pacifier sucking as an aetiological factor also showed the same pattern. When bottle feeding beyond the age of mixed dentition was assessed as an aetiological factor, final year students showed the most awareness, 84.9%, followed by that of 2nd year 72.6%, 3rd year 71.7% and least by the 1st year students 50.0%. Interestingly, early caries as being an aetiological factor was realized by 56.6%, slightly more than one half of final year students; p-value was significant for all the above, 0.000, showing significant differences in responses of students from different years of education. Slightly more 2nd year students were aware of the importance of bottle feeding as an aetiology than 3rd year students, 72.6%, 71.7%, respectively; awareness regarding the other aetiological factors, thumb sucking, pacifier sucking and caries showed improvement with increasing levels of dental education, p-value being significant at, 0.000 showing 1st year students lacking awareness more than the higher levels and most of the final year students having the most awareness regarding negative effects of bottle feeding on the dentition. These responses showed variable awareness of dental students which were not in line with their levels of education and expected increase in knowledge. This reflects the deficiency on part of the dental education or course not imparting knowledge to all the students equally or could also be a shortcoming on part of the students who fail to gain the required knowledge being imparted to them while progressing through the years of dental education. The results of knowledge with regard to aetiological factors, such as prolonged bottle feeding, hereditary factors and premature loss of primary teeth did not show linear improvement in knowledge with increase in level of dental education. When asked about the hereditary factors playing a role in causation of malocclusion, final year students were most knowledgeable 70.8%, followed by 2nd year students 57.5%, 1st year students 56.6% and least by 3rd year students 46.2%; p-value being non-significant, 0.067. When early loss of deciduous teeth as an aetiology was assessed, final year students showed the highest level of knowledge 81.1%, followed by 2nd year students 49.1%, 3rd year 45.3% and least by the 1st year students 44.3%; p-value was significant, 0.000. These results could not be compared with the existing literature as no relevant studies were found.

Furthermore, self-perception of students regarding the importance of well-aligned teeth and its impact was evaluated (Table 2, Figure 2). Mostly, 3rd year students, 91.5%, showed inclination towards a well-aligned dentition, 1st^, and 2nd year (90.6%) students less so and same in number, while, final year students were least critical (87.7%) with p value being non-significant, 0.431. This corroborated with another study where > 90% of the students thought alignment of dentition was important for esthetics [10]. When asked about the importance of aligned teeth for esthetics, mostly 2nd year students regarded aligned teeth vital for esthetics, 96.2%, followed by 3rd ⁽91.5%), 4th (86.8%) and 1st year (85.8%) students with p value being non-significant, 0.042. Self-perception regarding the need for treatment was assessed and results showed that amongst all the students, 4th year students mostly perceived the need for orthodontic treatment for themselves (43.4%), followed by 1st (37.7%), 2nd (25.5%) and 3rd year students (20.8%) with p value being significant at 0.048, showing 1st and 4th year students more critical of their appearance than others (Figure 3). This is in contrast to a study where 72.3% of the students were satisfied with their smile [23] but in slight accordance to a study where 31.2% wished to change the arrangement of their teeth [10] and also to a study where satisfaction with one’s appearance was shown to increase with the level of education, 33.3% [11,24]. This reflects that increase in education or awareness does not necessarily make one more self-conscious and it could be because of differing status of malocclusion of each student, social and economic background and exposure to media and their own belief system.

Figure 3. Responses of students (%) from each year as, ‘yes’, ‘no’ or ‘maybe’ to their self-perceived need for orthodontic treatment.

When enquired about the impact of malocclusion on one’s self-esteem, 86.8% of the 4th year students in this study realized the importance of aligned teeth for uplifting one’s self-esteem and confidence (Table 2, Figure 4) followed by 3rd (80.2%), 2nd (77.4%) and 1st year students (65.1%) with p value being significant at 0.031. With increasing education, more students showed agreement in this regard. This is in accordance with the results of a previous study where minor irregularities in dental esthetics was affecting peoples’ self-confidence [25], and another, which showed 61.5% of dental students felt their dental appearance affected their quality of life [26]. When asked about the importance of aligned teeth for one’s acceptance amongst peers, nearly half (51.9%) of 4th year students showed agreement (Table 2) followed by the junior years, 3rd year (40.6%), 2nd year (36.8%) and 1st year (22.6%) with p value being significant at 0.000. This result could not be compared with any of the previous studies as to our knowledge, it has not been assessed before. Malocclusion’s impact on one’s mental health was assessed where 52.8% of 4th year students thought tooth alignment impacted mental health, followed by 2nd (46.2 %), 3rd (37.7%) and 1st year students (24.5%) with p value being significant at 0.000. This corroborated with a study where impaired dental esthetics was deemed to be the reason for negative stereotypes, stigmatization, and disturbed psychological health [3, 27–30].

Figure 4. Responses of students (%) from each year as, ‘yes’, ‘no’ or ‘maybe’ to malocclusion’s impact on self-esteem.

The limitation of this study was that the students’ self-perceived need for treatment could vary depending on the severity of their malocclusion which was not cross-checked by any specialist for association and students’ socioeconomic status was not considered which could have impacted their self-perception.

Conclusion

• Increasing level of knowledge in undergraduate years did not show a linear improvement in knowledge related to malocclusion amongst undergraduate dental students and did not make them more critical of their appearance related to alignment of their teeth.

• Increasing level of dental education made students content with their dental appearance.

• Students became critical in certain aspects of dental esthetics with progression of dental education.

• Increase in the level of dental education did not increase the self-perceived need for orthodontic treatment.

• Malocclusion was thought to affect one’s self-esteem, confidence, and psychosocial well-being.

Authors’ contributions

HS: Conception, design, manuscript writing and supervision of data collection and statistical analysis.

RA: Design, supervision of data collection, manuscript writing

MUG: Supervision of data collection, statistical analysis, manuscript writing

AA: Statistical analysis, design, manuscript writing

RS: Data collection, manuscript writing

SAH: Data collection, manuscript writing

Ethics approval and consent to participate

Ethical approval was taken from Institutional Review Boards of two dental undergraduate institutes.

Informed Consent to participate was taken on a printed (informed) consent form.

All experiments were performed in accordance with relevant guidelines and regulations (such as the Declaration of Helsinki).

Disclosure statement

No potential conflict of interest was reported by the author(s).