DOI: 10.1111/ipd.12146

How do children view other children who have visible enamel defects? SALLY A. CRAIG1, SARAH R. BAKER2 & HELEN D. RODD1 1

Unit of Oral Health and Development, and 2Unit of Dental Public Health, School of Clinical Dentistry, University of Sheffield, Sheffield, UK

International Journal of Paediatric Dentistry 2014 Background. Facial and dental appearance influ-

ences how individuals are perceived by others. Aim. This study aimed to determine whether

young people make judgements about other young people with visible enamel opacities. Design. Focus group findings were used to develop a social attribute questionnaire to capture young people’s dental appearance-related judgements. 547 pupils (aged 11–15 years), from two different schools, participated in the study. Half the participants were given full-face photographs of a boy and girl without an enamel defect, and the other half were given the same two photographs with the subjects’ incisors digitally modified to show

Introduction

Physical appearance may not only affect how individuals feel about themselves, but may influence how they are judged by others. Dion’s seminal work in the 1970s found that children who were considered to be ‘attractive’ were more likely to get away with misdemeanours than those considered ‘unattractive’, inferring that ‘unattractive’ children were perceived as being naughtier and/or less honest1. A later meta-analysis on beauty concluded that both attractive adults and children are judged more positively for a range of personal characteristics2. The associations between dentofacial appearance and social judgements were first investigated in the dental literature over three decades ago. Shaw et al showed 42 children and 42 adults photographs of a boy’s and Correspondence to: Professor Helen Rodd, Unit of Oral Health and Development, School of Clinical Dentistry, Claremont Crescent, Sheffield S10 2TA, UK. E-mail: [email protected]

enamel opacities. Participants completed the attribute questionnaire to rate the photographic subjects according to six positive and five negative descriptors using a four-point Likert scale. The total attribute score (TAS) could range from 11 (most negative) to 44 (most positive). Results. TAS was significantly lower for photographic subjects with enamel defects compared to the same subject with normal enamel appearance (P < 0.001, one sample t-test). Gender had a significant impact on TAS, with boys making more negative judgements than girls. Age and socioeconomic status did not have an effect. Conclusion. Young people may make negative psychosocial judgements on the basis of enamel appearance.

girl’s face with different dental appearances such as normal incisors, prominent incisors, crowded incisors, a missing lateral incisor, or unilateral cleft lip3. It was found, as predicted, that children with a normal dental appearance were judged more positively in terms of desirability as a friend, intelligence, and behaviour. The same methodology was applied to determine whether the presence of a dentofacial anomaly would unfavourably influence social and educational judgements made by school teachers about children4. Interestingly, this was not found to be the case. More recently, an American study used pictures of smiling teenagers, with and without well-aligned teeth to elicit a peer rating of their perceived athletic, social leadership, and academic abilities5. Significantly more positive ratings were ascribed for photographic subjects with ‘ideal’ smiles in relation to athletic performance, popularity, and leadership ability, but not academic performance. Having an attractive smile impacts on a range of psychosocial aspects, which may even include career opportunities6. In addition to desiring straight teeth, society’s

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expectations of having ‘white’ teeth are also high7. Even individuals with a normal tooth colour may seek to have unnaturally white teeth, as endorsed by the media and celebrity culture. It is therefore likely that people with an abnormal enamel appearance may be stigmatised in some way. Developmental defects of enamel are common, with a wide range of aetiologies and presentations8,9. Although subtle diffuse white enamel opacities may not be readily detectable by the public, demarcated brown, yellow, or cream opacities, such as those associated with molar incisor hypomineralisation, may be all too visible to others10,11. In a recent study exploring social judgements in relation to tooth colour, 180 adult females were shown a set of facial photographs of both males and females with standardised features, apart from their anterior teeth which were digitally altered to appear either normal, whitened, or decayed12. It was found that people with discoloured teeth were given lower ratings for a variety of personality traits including intellectual ability, social competence, satisfaction with relationships, and psychological adjustment. The authors concluded that tooth colour did exert an influence, for good or bad, on how an individual was viewed by others. To date, no studies have considered the impact of tooth colour on social perceptions in a young population. The aim of this study, therefore, was to ascertain whether or not young people make value judgements about other young people on the basis of them having a visible enamel defect. Specific objectives were to assess whether age, gender, or socio-economic status influence how children appraise other children with or without enamel defects. The key driver prompting this enquiry was to obtain data to support the need for clinical interventions for children with visible enamel opacities. Material and methods

Two studies with a similar design had already been conducted by the research group to explore social judgements made by children in relation to visible incisor trauma and fixed orthodontic appliances13,14. Following on from

these, further ethical approval was sought from the University of Sheffield Research Ethics Committee to conduct this study (granted 30/11/2010). Written informed consent was obtained from the parents/guardians of all participants as well as the written assent of the young people themselves. Development of the social attribute questionnaire A short social attribute questionnaire had been previously developed with children to measure value judgements in relation to dental appearance13. The questionnaire employed 9 closed questions and a 4-point Likert scale response format. The internal consistency of this instrument was found be good with a Cronbach’s alpha of > 0.8. For the purposes of this study, however, it was felt that children’s views and descriptors specific to enamel defects should be incorporated within this non-condition-specific questionnaire. Two focus groups were conducted with a total of 12 children aged 11–16 years in informal settings. Participants were shown 12 different colour photographs (210 9 297 mm) of upper and lower anterior teeth in occlusion, with a variety of dental conditions including localised or generalised enamel opacities and enamel hypoplasia. Children were encouraged to describe their feelings and observations about the different pictures. Conversations were taped and transcribed verbatim. Subsequent content analysis revealed that two recurring judgements were made by focus group participants about photographic subjects with enamel defects: they were perceived as being ‘lazy’ and ‘not caring about his/her appearance’. These two descriptors were therefore added to the existing questionnaire to give a total of five negative and six positive attributes. Participants would be asked to rate the photographic subject for each of these 11 attributes. The total attribute score (TAS) was calculated by adding the participant’s responses for each attribute where the positive attributes scored 4, 3, 2, or 1 depending on how strongly the rater felt the photographic subject assumed this characteristic, and the scoring was reversed for the negative attributes. Thus, the potential TAS

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Children’s views on enamel defects

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Table 1. Sample response obtained from a female participant viewing a male photographic subject with enamel defects (score for each descriptor given in parenthesis). Strongly agree This This This This This This This This This This This

boy boy boy boy boy boy boy boy boy boy boy

is naughty is clever is rude is kind is honest does not care about his appearance is careful is lazy is confident is helpful is stupid

Agree U (score = 2) U (score = 3)

U (score = 1)

U (score = 4) U (score = 1)

U (score = 3) U (score = 3)

Disagree

U (score = 2)

Strongly disagree

U (score = 4)

U (score = 2) U (score = 3)

U Indicates tick placed by participant. Total attribute score = 28 in this example.

could range from 11, (the most negative), to 44, (the most positive). A working example of the scoring system is shown in Table 1. Photographic images Two photographs were selected to accompany the questionnaire: a full-face colour digital photograph of an attractive 11-year-old boy and a 15-year-old girl who had had excellent oral health and well-aligned arches. A brown localised enamel defect was then digitally superimposed onto the photographic subjects’ upper right central incisor and a white opacity placed on the upper left incisor, using a graphics editing software programme, ADOBE PHOTOSHOP CS6 (Adobe Systems Inc, San Jose, CA, USA) (Fig. 1). Participants During 2011, participants, aged 11–12 years (school year 7) and 14–15 years (school year 10), were sought from two schools with very different socio-economic and educational profiles to ensure that there was wide social and ethnic representation. School A was a large rural school in Derbyshire attended predominantly by white British children, with high educational attainment, and situated in a relatively affluent area (Index of Multiple Deprivation = 7.115). School B was a small inner city school in South Yorkshire, with over 80% of pupils from an minority ethnic group, low educational attainment, and in an area of

high deprivation (Index of Multiple Deprivation = 46.815). It was calculated that 190 participants from each year group would be needed to yield an 80% power to detect a significant difference in TAS according to the presence/absence of an enamel defect where a threshold for significance was set at 5%14. Information about the study, together with consent forms, was distributed to parents/ guardians of all year 7 and year 10 pupils 2 weeks prior to study commencement. On the day of data collection, a designated teacher distributed the questionnaire packs randomly to year 7 and year 10 class teachers. Each pack contained photographs of either subjects with enamel opacities or subjects without enamel opacities. Thus an equal number of whole classes responded to the questionnaires in relation to the presence or absence of enamel defects. There was no collusion between pupils in these different classes, so they were not aware that they were judging digitally modified photographs of the same subjects. Test–re-test reliability To assess test–re-test reliability of the questionnaire, 10% of participants were invited to complete the identical questionnaire 2–4 weeks after the initial one had been completed. Statistical analysis Data were analysed using the Statistical Package for Social Sciences (SPSS) v19 (IBM SPSS

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(a)

(b)

(c)

(d)

Fig. 1. Photographic subjects used in the study: (a) boy without enamel defects; (b) girl without enamel defects; (c) boy with enamel defects digitally superimposed on his upper central incisors; (d) girl with enamel defects digitally superimposed on her upper central incisors.

software, Portsmouth, Hampshire, UK). Questionnaires which had more than 30% of responses missing were discarded. For questionnaires with < 30% missing data, the median value for the individual attribute (from analysis of the whole data set) was substituted for the missing value16. Computation of TAS revealed the data to be normally distributed; thus, parametric statistical tests (one sample t-test and linear regression analysis) were employed to determine whether there were any statistically significant differences in mean TAS according to the original research aims and objectives. The level of statistical significance was set at P < 0.05. Internal reliability was determined by calculating a Cronbach’s alpha coefficient. Test–retest reliability for completion of the questionnaire was

determined using the intraclass coefficient (ICC)17. Results

Response rates For school A, the overall school response rate was 67.2% (n = 316/470) and was 62.9% (n = 231/367) for school B. In total, there were 547 participants; 56% were female reflecting the higher proportion of girls attending the two schools as a whole. Figs 2 and 3 show these data together with details of the (small) number of parents who did not give consent for their child’s participation and the number of unusable questionnaires.

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Children’s views on enamel defects

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Total number of pupils Y7 = 233

Parental consent withheld Y7 = 1

Y10 = 1

Pupils Absent Y7 = 20

Y10 = 40

Blank or spoiled responses Y7 = 30

Y10 = 237

Numbers remaining Y7 = 232

Possible usable responses Y7 = 212

Possible usable responses Y7 = 182

Y10 = 161

Possible usable responses Y7 = 179

Y7 = 3

No child consent

Fig. 2. Flow diagram to show participation of school A pupils. Y7 = year 7 (11–12 year olds); Y10 = year 10 (14– 15 year olds).

Y10 = 196

Y10 = 35

>30% of content missing

Y7 = 2

Y10 = 236

Y10 = 11

Y10 = 150

Responses used Y7 = 177 (75.9%) Y10 = 139 (58.6%)

Total responses used in school A analysis = 316 (67.2%)

Properties of the questionnaire Test–re-test reliability, on the basis of 64 repeat questionnaires (11.7% of the total sample), was found to be good with an ICC of 0.78. Cronbach’s alpha was computed for questionnaire responses relating to each of the four different photographic subjects16. In all four cases, Cronbach’s alpha was > 0.80 (range = 0.80–0.86), indicating very good internal reliability. There were few floor and ceiling effects observed for the questionnaire. No more than three participants completed their questionnaire to give either a minimum or maximum

mean attribute score (TAS = 11 and 44), respectively, for any of the photographic subjects. Mean total attribute score The primary analysis was undertaken to determine whether there was a statistically significant difference in mean TAS ascribed to photographic subjects on the basis of the presence of incisor enamel defects. Table 2 shows the mean TAS for the male and female photographic subjects, with and without the enamel defects. It can be seen that mean TAS was almost identical on the basis of the gender of

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Total number of pupils Y7 = 207

Parental consent withheld Y7 = 0

Y10 = 0

Pupils Absent Y7 = 7

Y10 = 160

Numbers remaining Y7 = 207

Possible usable responses Y10 = 6

Blank or spoiled responses

Y7 = 200

Y10 = 4

No child consent Y7 = 14

Y10 = 109

Y10 = 45

>30% of content missing Y7 = 14

Y10 = 154

Possible usable responses Y7 = 165

Y7 = 35

Y10 = 160

Y10 = 11

Possible usable responses Y7 = 151

Y10 = 105

Responses used Y7 = 137 (66.1%)

Y10 = 94 (58.7%)

Total responses used in school B analysis = 231 (62.9%)

the photographic subject, but mean TAS was lower for subjects with enamel defects compared to those without enamel defects. This was found to be a highly statistically significant difference (P < 0.001, one sample t-test) for both the male and female photographs. Table 3 provides more details of TAS according to year group (age), gender, and school (proxy for socio-economic status). Overall, it can be seen that the lowest TAS (i.e., most negative evaluation) was 25.7, in the case of year 10 boys at school B viewing the male photographic subject with enamel defects. The highest TAS (i.e., most positive

Fig. 3. Flow diagram to show participation of school B pupils. Y7 = year 7 (11–12 year olds); Y10 = year 10 (14–15 year olds).

evaluation) was 32.8, in the case of both year 7 and year 10 girls at school B viewing the male photographic subject without enamel defects. Linear regression analysis was conducted to determine whether there were any significant differences in mean TAS (dependant variable) according to the independent variables: gender; year group (age), and school (socio-economic group) of the rater. The gender of the photographic subjects was collapsed as previous analysis had shown that mean TAS was the same for male and female photographic subjects; however, analysis was conducted

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Children’s views on enamel defects

Table 2. Mean total attribute score (TAS), SD, and range for each photographic subject.

Photographic subject Boy without enamel defects Boy with enamel defects Girl without enamel defects Girl with enamel defects

Participants (n)

Mean TAS

SD

Range

276

31.5*

4.59

11–44

271 274

29.1 31.4*

5.02 5.19

11–44 11–44

271

29.3

5.17

11–41

*Significant difference (P < 0.05. one sample t-test) between photographic subject of same gender with/without enamel defect.

Table 3. Mean total attribute scores (TAS) for male and female photographic subjects, with and without enamel defects, according to school, year group, and gender of raters.

School/ participants School A participants Y7 boys Y7 girls Y10 boys Y10 girls School B participants Y7 boys Y7 girls Y10 boys Y10 girls School A participants Y7 boys Y7 girls Y10 boys Y10 girls School B participants Y7 boys Y7 girls Y10 boys Y10 girls

TAS (n, SD, range) for male photograph subject

TAS (n, SD, range) for female photograph subject

Without enamel defects

Without enamel defects

31.9 (45, 3.37, 17–38) 32.6 (46, 2.91, 24–39) 29.0 (31, 6.85, 11–44) 30.0 (43, 3.72, 20–36) Without enamel defects

30.9 (45, 4.34, 22–40) 32.4 (46, 5.49, 15–44) 30.6 (30, 5.83, 11–44) 32.0 (43, 2.75, 22–38) Without enamel defects

31.4 (33, 6.17, 11–41) 32.8 (22, 4.40, 23–40) 31.1 (28, 4.60, 20–41) 32.8 (28, 3.34, 26–43) With enamel defects

29.4 (32, 8.34, 11–43) 31.0 (22, 4.97, 20–39) 31.1 (28, 5.13, 22–41) 32.7 (28, 2.68, 27–37) With enamel defects

29.5 (32, 4.29, 22–39) 29.7 (54, 4.13, 20–38) 26.7 (30, 6.20, 11–39) 30.5 (35, 3.95, 18–37) With enamel defects

28.6 (32, 4.29, 21–36) 31.2 (54, 3.77, 20–41) 27.3 (30, 7.43, 11–39) 30.9 (35, 4.37, 18–38) With enamel defects

30.1 28.8 25.7 29.0

26.9 29.6 26.6 30.0

(36, (46, (13, (25,

6.26, 5.00, 6.07, 3.44,

14–44) 14–38) 12–36) 21–36)

(36, (46, (13, (25,

6.56, 3.90, 6.14, 2.96,

12–39) 22–40) 11–33) 24–35)

TAS, mean total attribute score; n, number of participants; SD, standard deviation.

separately on the basis of the presence or absence of an enamel defect as this had been found to have a significant effect on TAS. The key finding was that female raters gave a significantly different (higher) TAS than their male counterparts for photographic subjects both with and without an enamel defect (P ≤ 0.002). Year group and school, however,

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did not have any significant effect on mean TAS. Discussion

Within the accepted limitations of the study design, our findings suggest that young people do make negative value judgements about other young people on the basis of their dental appearance when they have visible enamel defects. To some extent, this was a predictable outcome, given that several previous studies, using similar methodologies, have also demonstrated that negative social judgements are made when dental appearance differs from expected norms13,18,19. The wider appearance literature, led by Rumsey and Harcourt, has also highlighted the negative public perceptions shown towards individuals with facial differences20. This present study also found that boys were significantly more negative in their social judgements than were their female peers. This finding is consistent with two previous studies conducted by the same research group, where female adolescents were more positive than males in ascribing value judgements about children with incisor trauma or orthodontic appliances13,14; however, it should be noted that, in the linear regression models, gender accounted for a very small proportion (< 5%) of the difference in mean TAS for subjects with and without enamel defects. Clearly, there were factors, other than gender, that may have influenced why participants made the social judgements that they did. One can only hypothesise that factors such as an individual’s beliefs, values, past dental experience, and their own dental attractiveness also had an effect on how young people make appearance-related judgements about their peers. Ideally, the researchers would have liked to have spoken to some of the respondents to ask them why they gave the scores that they did, in order to gain a more meaningful insight into their thought process when making a social judgment. Another point worth making is that although a statistically significant difference was found in TAS for subjects with and without enamel opacities, the actual numerical difference in

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these mean scores was small, being approximately 2. Had the sample size been smaller, the study may not been sufficiently powered to identify this statistically significant difference. Interestingly, numerical differences of between 2 and 3 in mean TAS were also found in a previous investigation which explored judgements in relation to incisor trauma13. Raters’ age did not appear to influence views of their peers suggesting that 11- to 12-yearolds make similar social judgements, in relation to enamel defects, as do 14- to 15-yearolds. This is in keeping with the findings by Henson and colleagues, whose study found that age was not a significant predictor of how children (aged 10–16 years) viewed other children with ideal and non-ideal smiles5. The investigators had postulated that children of lower socio-economic status (school B participants) would themselves have poorer dental health and lower expectations for treatment and may therefore be more generous in their social judgements of others with poorer dental appearance. Interestingly, the study findings did not support this view. An acknowledged limitation of the study, in this respect, was the categorisation of all participants according to their school’s postcode and not their individual home postcodes. In retrospect, it would have been interesting to see whether ethnicity rather than socio-economic status affected children’s views. School B had a large and diverse ethnic minority population, including Somalis, some of whom are known to have severe dental fluorosis as they were born in certain regions of East Africa. On reviewing the wider literature, however, ethnicity does not appear to have an effect on dental appearance-related judgements5,21. The use of photographs to elicit social judgements, as in the present study, may be subject to criticism as it could be seen as an artificial and contrived methodology. In real life, people make judgements about others not only on facial appearance, but on the basis of dynamic facial expressions and voice. Previous studies have therefore sought to validate the use of static 2D photographs compared to other methods. Rhodes and colleagues compared the use of static images of faces with dynamic

video clips in ratings about men’s attractiveness22. Interestingly, they found no differences in how people rated the photo versus the same subject in a video clip and thus concluded that the use of static images was valid for the purposes of social science research. It would appear that humans are able to make very rapid and robust judgements about facial attractiveness from 2D images. Another observational study used 2D and 3D rotating images of women’s faces to determine whether these were rated differently for attractiveness by male participants23. The researchers therefore concluded that judgements made about women’s attractiveness from 2D images were valid and provided similar information as did the 3D images. An important reason for undertaking this research was to highlight the wider psychosocial impacts for children who have visible enamel defects. Negative responses of those around young people with poor dental appearance may profoundly affect the way they act, even influencing future long-term development, and life chances5,24,25. Indeed, the preliminary focus group discussions, based on photographs of individuals with enamel defects (including amelogeneisis imperfecta, dental fluorosis, and molar incisor hypomineralisation), incited misconceptions that these people did not care about their teeth or their appearance. Greater awareness of the clinical and emotional needs of young people with enamel defects should be fostered amongst the general dental profession and commissioners of dental services. Although early referral and intervention for malocclusions are in evidence, practitioners may be more reluctant to provide treatment for enamel opacities. Indeed, there is often a suggestion that children should wait to rectify any cosmetic concern until they are older, thus having to face some difficult teenage years with poor dental aesthetics. The appearance of some enamel defects can be greatly improved by simple non-invasive procedures such as microabrasion, tooth whitening products, and composite restorations11,26. One must therefore question the barriers to provision of these treatments to young people, which may include clinical concerns, financial,

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Children’s views on enamel defects

or legal constraints. It is hoped that the continued emergence of literature relating to the relationship between oral health and children’s overall well-being will help to shape more child-centred dental services in the near future. Acknowledgements

The authors would like to acknowledge the help of Dr Melanie Hall with the focus group discussions and the two schools (Lady Manners, Bakewell and Firvale, Sheffield) who participated in the study. Thanks are also given to HB and JB for allowing their photographs to be used for the purposes of this research.

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Conflict of interest

The authors confirm that there has been no conflict of interest in undertaking and reporting this research.

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Why this paper is important to paediatric dentists ● Findings from this study reveal the misconceptions that some young people may have about the causes of enamel opacities: thinking they were due to an affected individual being ‘lazy’ or ‘not caring about their appearance,’ Paediatric dentists need to promote greater understanding of, and tolerance towards, developmental enamel conditions within our society. ● The study also provides paediatric dentists with quantitative evidence that young people may make negative social judgements about others on the basis of visible enamel defects. These data may be of use when justifying appropriate dental treatment for this patient group.

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on social perceptions of adolescents judged by peers. Am J Orthod Dentofacial Orthop 2011; 140: 389–395. Zebrowitz L, Montepare J. Social psychological face perception: why appearance matters. Soc Personal Psychol Compass 2008; 2: 1497–1517. Samorodnitzky-Naveh GR, Grossman Y, Bachner YG, Levin L. Patients’ self-perception of tooth shade in relation to professionally objective evaluation. Quintessence Int 2010; 41: e80–e83. Chadwick B, Pendry L. Non-Carious Dental Conditions in Children’s Dental Health in the United Kingdom 2003. London: Office for National Statistics, 2004: 1–28. Schluter PJ, Kanagaratnam S, Durward CS, Mahood R. Prevalence of enamel defects and dental caries among 9-year-old Auckland children. NZ Dent J 2008; 104: 145–152. Da Costa-Silva CM, Ambrosano GM, Jeremias F, De Souza JF, Mialhe FL. Increase in severity of molar-incisor hypomineralization and its relationship with the colour of enamel opacity: a prospective cohort study. Int J Paediatr Dent 2011; 21: 333–341. Rodd HD, Abdul-Karim A, Yesudian G, O’Mahony J, Marshman Z. Seeking children’s perspectives in the management of visible enamel defects. Int J Paediatr Dent 2011; 21: 89–95. Kershaw S, Newton JT, Williams DM. The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and “whitened” teeth. Br Dent J 2008; 204: E9. Rodd HD, Barker C, Baker SR, Marshman Z, Robinson PG. Social judgements made by children in relation to visible incisor trauma. Dent Traumatol 2010; 26: 2–8. Patel A, Rodd HD, Baker SR, Marshman Z, Robinson PG, Benson PE. Are social judgements made by children in relation to orthodontic appliances? J Orthod 2010; 37: 93–99. Geoconvert Tool Crown Copyright (2006); http:// geoconvert.mimas.ac.uk. Pallant J. SPSS Survival Manual. Ch 9. 4th edn. Columbus, OH: McGraw-Hill Education; 2010. Lexell JE, Downham DY. How to assess the reliability of measurements in rehabilitation. Am J Phys Med Rehabil 2005; 84: 719–723. Newton JT, Prabhu N, Robinson PG. The impact of dental appearance on the appraisal of personal characteristics. Int J Prosthodont 2003; 16: 429–434. Williams DM, Chestnutt IG, Bennett PD, Hood K, Lowe R. Characteristics attributed to individuals with dental fluorosis. Community Dent Health 2006; 23: 209–216. Rumsey N, Harcourt D. Body image and disfigurement: issues and interventions. Body Image 2004; 1: 83–97. Xu F, Wu D, Toriyama R, Ma F, Itakura S, Lee K. Similarities and differences in Chinese and Caucasian adults’ use of facial cues for trustworthiness judgments. PLoS One 2012; 7: e34859.

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22 Rhodes G, Lie HC, Thevaraja N et al. Facial attractiveness ratings from video-clips and static images tell the same story. PLoS One 2011; 6: e26653. 23 Tigue CC, Pisanski K, O’Connor JJ, Fraccaro PJ, Feinberg DR. Men’s judgments of women’s facial attractiveness from two- and three-dimensional images are similar. J Vis 2012; 12: Pii: 3. 24 Hunt O, Hepper P, Johnston C, Stevenson M, Burden D. Professional perceptions of the benefits of orthodontic treatment. Eur J Orthod 2001; 23: 315–332.

25 Coffield KD, Phillips C, Brady M, Roberts MW, Strauss RP, Wright JT. The psychosocial impact of developmental dental defects in people with hereditary amelogenesis imperfecta. J Am Dent Assoc 2005; 136: 620–630. 26 Nixon PJ, Robinson S, Gahan M, Chan MF. Conservative aesthetic techniques for discoloured teeth: 2. Microabrasion and composite. Dent Update 2007; 34: 160–162.

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How do children view other children who have visible enamel defects?

Facial and dental appearance influences how individuals are perceived by others...
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