British Journal of Orthodontics
ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19
The Subjective Need and Demand for Orthodontic Treatment Ann Holmes To cite this article: Ann Holmes (1992) The Subjective Need and Demand for Orthodontic Treatment, British Journal of Orthodontics, 19:4, 287-297, DOI: 10.1179/bjo.19.4.287 To link to this article: http://dx.doi.org/10.1179/bjo.19.4.287
Published online: 21 Jun 2016.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 34 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yjor19 Download by: [Australian Catholic University]
Date: 18 October 2017, At: 01:44
Briti. 0·00 I. The demand for treatment was seen irrespective of the Dental Health or Aesthetic Component Indices scores.
TABLE 6 Distribution of Child's Aesthetic Component Scores in response to question 3 (n = 955): What do you dislike most about your teeth? Response (number) Other reason Aesthetic Too Too Teeth score Nothing crooked spaced stick out /don't know Total I 2 3 4 5 6 7 8 9 10
Total
89 74 94 23 8 6 2 4 3 0
24 28 55 16 10 10 7 18 5 3
12 15 11 19 13 3 0 2 4 0
14 14 29 16 12 I 5 7 4 4
65 79 73 24 11 18 3 14 3 I
204 210 262 98 54 38 17 45 19 8
303
176
79
106
291
955
Subjective Orthodontic Treatment Need
BJO Not·ember /991
293
p E R
c
E N T
A
G
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
E
DEF. NO
PROB. NO
DON'T KNOW
PROB. YES
DEF. YES
RESPONSE -MALE
~FEMALE
FIG. 5 Sex distribution in response to question 4 (n=955): If it were necessary would you be prepared to have orthodontic treatment?
Dental Health Index. The demand for orthodontic treatment, response 'definitely yes' increased progressively with increasing dental health need (Fig. 6). Forty children (70·4 per cent) assessed as DHC grade I, no treatment need, would 'probably' or 'definitely' be prepared to accept orthodontic treatment compared with 93 (88·5 per cent) grade 5.
Child's Aesthetic Component rating. Fivehundred-and-seventy children (84·3 per cent), who rated themselves at the attractive end of the Aesthetic Component score scale, were prepared to accept orthodontic treatment (Table 8).
Dentist's Aesthetic Component rating. Fourhundred-and-ten children (84·5 per cent), who were rated at the attractive end of the Aesthetic Component score scale, scores l-3, were prepared to accept orthodontic treatment of an unspecified nature, responses 'probably' or 'definitely yes', if it Were thought necessary (Table 7).
A decision was made to complete the questionnaires by face to face interviews, rather than allowing the children to complete their own, in order to eliminate wastage through incorrectly completed or defaced forms. However, face to face interviews risk the introduction of bias since respondents may distort their answers in order make a more favourable
Discussion
SOr-----------------------------------------1 p E R
60
c
E
N
40
T
A G E
20
2 3 4 DENTAL HEALTH COMPONENT SCORE -
DEFINITELY NO
~ PROBABLY YES
~ PROBABLY NO
lillill
CJ
5
DON'T KNOW
DEFINITELY YES
FIG. 6 Distribution of DHC grades in response to question 4.
294
A. Holmes
BJO Vol. 19 No. 4
TABLE 7 Distribution of Dentist's Aesthetic Component Scores in response to question 4 (n = 955 ): /fit were necessary would you be prepared to have orthodontic treatment? Responses (number) Aesthetic Definitely score no I 2 3 4
6 7 8 9 10
6 15 16 16 2 7 2 3 0 0
4 3 3 6 2 3 0 3 0 0
Total
67
24
5
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
Probably no
Don't know
Definitely yes
Total
2 I I 0 0
12 30 40 43 14 6 8 9 I 0
60 124 144 135 61 42 23 51 10
87 180 218 209 84 60 34 67 11
5
5
46
163
655
955
5 8 15 9
5
Probably yes
TABLE 8 Distribution of Child's Aesthetic Component Scores in response to question 4 (n = 955 ): If it were necessary would you he prepared to have orthodontic treatment? Responses (number) Aesthetic Definitely score no
Probably no
Don't know
10 6 4 I I 0 0 2 0
9 7 23 2 2
9 10
16 15 16 7 3 3 0 2 3 2
Total
67
I 2 3 4
5 6 7
8
Probably yes
Definitely yes
Total
139 140 175 70 39 27 14 33
0
30 42 44 18 9 7 3 7 3
13
204 210 262 98 54 38 17 45 19
0
I
0
5
8
24
46
163
655
955
impression on the interviewer, gtvmg the most socially acceptable response to questions rather than a genuine answer. The child's perception of their dental appearance is of considerable importance in determining both treatment demand and the subsequent level of cooperation during treatment (Shaw, 1981). The finding, in the current study, that more females than males disliked the appearance of their teeth was despite the fact that both objective and subjective opinion suggested that the females in the sample had more attractive dentitions and less 'great' or 'very great' treatment need than the males. This difference between the sexes could be a reflection of the fact that standards of aesthetics and beauty are more clearly delineated for females.
I
0
I
Different aesthetic values may apply to females who may, therefore, be more conscious of their body image. The results are in agreement with Klima et al. (1979), who found females, aged 11-16 years, scored significantly lower in both body-image and self-concept satisfaction than did males of the same age group. Shaw ( 1981 ), in a study of factors influencing the desire for orthodontic treatment in 9-12-year-olds, also found that more females considered themselves of below average attractiveness and more than twice as many females as males were dissatisfied with their dental appearance. This perception of below average attractiveness is reflected in the demand for treatment, with twice as many females as males receiving orthodontic treatment (Shaw et al., 1979).
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
BJO Nm•ember /992
In the current study a greater percentage of females than males [51·7 v. 44·0 per cent], responded that they thought their teeth needed straightening. This correlates with the finding that the females in the study considered themselves to be dentally less attractive than the males. More children at the attractive end of the Aesthetic Component scale recognized they did not require orthodontic treatment. However, there were still a number of children at the attractive end of the aesthetic component scale who felt that they needed orthodontic treatment. This again probably reflects the diversity of aesthetic judgments. It is difficult to determine the reason why, in the current study, a higher proportion of females, compared with males, chose photographs at the attractive end of the Aesthetic Component scale, indicating a visual self-perception of dental attractiveness, but then responded negatively to question I. The Aesthetic Component Index may possibly be a more realistic, and therefore better, indicator of a child's self-perception of their dental attractiveness than a questionnaire since it may be less prone to bias, although this has yet to be proven. _In Shaw's [1981] study 48·0 per cent of children Wtth moderate to severe irregularities reported being 'very' or 'quite happy' with their dental appearance while 30·0 per cent failed to recognize their own dental photograph. In the current study only 2·9 per cent of children with Aesthetic Component scores of 6 or above, the unattractive half of the Aesthetic Component scale, liked the appearance of their teeth 'very much' or 'quite a lot'. This again may be an indication that the Aesthetic Component Index gives a more valid assessment of the child's level of satisfaction with their dental appearance. Graber and Lucker ( 1980) used questionnaires to study the ability of 481 I 0-13-year-olds to assess their dental attractiveness and their degree of selfsatisfaction with their dental appearance. The results suggested that children of this age group W~re capable of making objective aesthetic evaluations of their teeth, but there was a broad range of What was considered acceptable to the children. Only 96 children (20 per cent) in Graber and Lucker's study considered their teeth unattractive compared with 256 (26·8 per cent) in the current study. . Dissatisfaction with aesthetically pleasing dentitions and satisfaction with apparently severe aesthetic problems has been reported by other authors (Lewit and Virolainen, 1968; Shaw, 1981). The reasons for these diversities in opinion between the child and the dentist have been speculated upon. It has been suggested that there is a range ofmalocclu-
Subjective Orthodontic Treatment Need
295
sions which are considered acceptable and that this range must vary considerably between individuals and between the sexes (Shaw, 1981). The perception of aesthetics is dependent on an individuals aesthetic values, persons for whom dental appearance has a high priority will focus on seemingly minor irregularities. A child's under-rating of their dental attractiveness has been suggested as being a function of their self-esteem (Evans and Shaw, 1987), under-rating being associated with low self-esteem. However, this study failed to show that children who underrated their dental attractiveness were significantly more dissatisfied with their dental appearance, as judged by the response to question I, than those who over-rated it or accurately assessed it. Of the children who under-rate their Aesthetic Component scores, 72·5 per cent were satisfied with their dental appearance compared with 74·1 per cent of overcaters and 72·3 per cent of those who accurately assessed their Aesthetic Component score. Malmgren (1980), studying 147 children of a comparable age group, found that 89 children (60·5 per cent) thought that their teeth were out of place, but 110 (74·8 per cent) thought their teeth needed correction. Malmgren speculated that this discrepancy between children dissatisfied with their teeth, and those who thought they required orthodontic treatment may have been due to either a failure to understand the questions posed, or that the children wanted to be treated even though they were not certain that there was something wrong with their teeth. There is also a possibility that the children in the current study distorted their answers in order make a more favourable impression on the interviewer, giving what they believed to be the most socially acceptable response. Helm et al. (1986) investigating, by means of a questionnaire, the effects of various occlusal traits on concern for dental appearance, found that extreme overjet and reverse overjet were a cause for concern in both sexes, as were conspicuous crowding and ectopically erupted maxillary canines. However, deep overbite, spacing and congenital absence of maxillary lateral incisors were a greater psychosocial problem for females. Other studies (Graber and Lucker, 1980) have found that overjet, because of its influence on facial features, appears to be more important to females while more localized crowding anomalies appear more important to males. Horowitz et al. ( 1971 ), investigating I0-12year-old children, and lngervall and Hedegard ( 1974), investigating 18-year-old males, found that the perception of irregular alignment and spacing was greater than the perception of overjets. Increased overjet accounted for 21 (20 per cent)
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
296 A. Holmes
children assessed as D H C grade 5 and 63 (31· 3 per cent) as grade 4. Dissatisfaction with dental appearance has been shown to be proportional to the degree of overjet (Gosney, 1986). This may possibly explain the higher levels of dissatisfaction in grades 4 and 5, although 12 ( 19 per cent) children in Gosney's study, with overjets of 8 mm or greater, were unconcerned about their increased overjet compared with 6 children (28·6 per cent) with an overjet of 9 mm or greater in the current study. This lack of concern with moderate to severe overjets may again reflect the diversity of aesthetic judgments amongst subjects or subjects may have a poor appreciation of their profile. It is interesting to note that the Aesthetic Component Scale does not show profile views. Thirty-one children (36·5 per cent) with a displacement of greater than 4 mm disliked their teeth because they were crooked, while 18 (21·2 per cent) failed to recognize a problem. This may be because the displacement affected a tooth in the buccal segments and may not therefore have been noticed or caused an aesthetic problem. The DHC is not a weighted index. A displaced tooth in the buccal segments scores the same as a similarly displaced tooth in the labial segments. Weightings add to the complexity of an index and, no matter how objective the measurement of occlusal traits, the addition of weightings adds to the subjectivity of the index and makes it's validity difficult to assess. Since the DHC is used in conjunction with the Aesthetic Component Index the patient would score higher on the Aesthetic Component Index if the displaced tooth was in the labial segment, obviating the need for an aesthetic weighting in the DHC. The actual level of unmet treatment need amongst the sample population was assessed, using the I.O.T.N., as 36·3 percent (Holmes, 1992). In this study 818 (85·7%) from the same sample population were prepared to accept orthodontic treatment of an unspecified nature. This compared with 78 children (53·1 per cent) in a questionnaire study by Malmgren (1980) in Sweden, in which the use of visible fixed appliances was stipulated. The high level of potential demand for treatment occurred amongst all the Dental Health and Aesthetic Component Indices grades. How much this represents a true potential demand for orthodontic treatment, reflecting the greater social acceptability of orthodontic treatment today, and how much respondents were led, by the need for social approval, into giving an assumed socially desirable response to question 4 is impossible to assess without a prospective study. It is extremely difficult to assess the validity of
BJO Vol. /9 No. 4
indices used in the evaluation of the subjective need and demand for orthodontic treatment (Malmgren, 1980). The motivation to seek and accept orthodontic treatment does not seem to correlate with either the dental health or aesthetic needs of the patient. This again emphasizes the problems in the perception of malocclusion and highlights the need to establish exactly what the patient dislikes most about their teeth when they attend for assessment. The patient's concept of their malocclusion may be at total variance with the professional assessment of their malocclusion. The dentist's advice appears to be the major motivating factor, for both the patients and parents, in seeking orthodontic treatment (Shaw et al., 1979; Gosney, 1986). Since both general dental practitioners and orthodontists have been shown to be at variance with the dental aesthetic values of lay people (Shaw et al., 1975), advice on orthodontic treatment need, which may be of aesthetic value only, should be exercised with caution.
Conclusion
The demand for orthodontic treatment, of an unspecified nature, assessed by means of a questionnaire, was 85·7 per cent, exceeding both the objective and subjective levels of treatment need. Females were, in general, more dissatisfied with their dental appearance than their male counterparts, despite the lack of evidence of greater objective treatment need. This dissatisfaction with dental appearance was reflected in both a higher level of subjective treatment need and demand amongst females in the sample. The Aesthetic Component Scale of the I.O.T.N. may be a better indicator of an individuals perception of their level of dental attractiveness and occlusion than questioning alone can reveal. When used in conjunction with the Dental Health Component of the I.O.T.N. it may provide valuable insight into guiding the patient towards an amicable decision on the necessity for orthodontic treatment.
Acknowledgements
The author would like to acknowledge the help received from many sources, in particular Mr R. A. Heesterman and his staff for their help in setting up this project, and providing access and assistance for the school visits. Thanks are also due to Professor W. C. Shaw and his staff for their help in the use of the I.O.T.N., and in the analysis of the computer data.
BJO November /992
References
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
Brook, P.H. and Shaw, W.C. (1989) The Development of an index of orthodontic treatment priority, European Journal of Orthodontics, 11, 309-320. Evans, R. and Shaw, W.C. (1987) Preliminary evaluation of an illustrated scale for rating dental attractiveness European Jou;nal of Orthodontics, 9, 314-318. Gosney, M.B.E. (1986) An investigation into some of the factors influencing the desire for orthodontic treatment, British Journal of Orthodontics, 13, 87-94. Graber, L.W. and Locker, G.W. (1980) Dental esthetic self-evaluation and satisfaction, American Journal Orthodontics and Dentofacial Orthopaedics, 77, 163-173. Helm, S., Petersen, P.E., Kreiborg, S. and Solow, B. (1986) Effect of separate malocclusion traits on concern for dental appearance, Community Dentistry and Oral Epidemiology, 14, 217-220. Holmes, A. (1992) The Prevalence of orthodontic treatment need, British Journal o.f Orthodontics, 19, 177-182. Horowitz, H.S., Cohen, L.K. and Doyle, J. (1971) Occlusal relations in children in an optimally fluoridated community IV. Clinical and social-psychological findings, The Angle Orthodontist, 41, 189-201.
Subjective Orthodontic Treatment Need
297
lngervall, B. and Hedegard, B. (197~) . Awareness of malocclusion and destre of orthodontic treatment in 18-year-old Swedish man, Acta Odontologica Scandinavica, 32,93-101. Kllma R.J., Wittemann, J.K. and Mclver, J.E. (1979) . Body image, self-concept, and the orthodontic patient, American Journal Orthodontics and Dentofacial Orthopaedtcs, 75, 507-516. Lewlt, D.W. and Virolainen, K. (1968) Conformity and independence in adolescents' motivation for orthodontic treatment, Child Development, 39, 1189-1200. Malmgren, 0. (1980) Studies on the need and demand for orthodontic treatment, Swedish Dental Journal (Supplement), 6, 1-121. Shaw, W.C. (1981) Factors influencing the desire for orthodontic treatment, European Journal Orthodontics, 3, 151-162. Shaw, W.C., Grabe, M.J. and Jones, B.M. (1979) The expectations of orthodontic patients in South Wales and St. Louis, Missouri, British Journal of Orthodontics, 6, 203-205.
ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19
The Subjective Need and Demand for Orthodontic Treatment Ann Holmes To cite this article: Ann Holmes (1992) The Subjective Need and Demand for Orthodontic Treatment, British Journal of Orthodontics, 19:4, 287-297, DOI: 10.1179/bjo.19.4.287 To link to this article: http://dx.doi.org/10.1179/bjo.19.4.287
Published online: 21 Jun 2016.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 34 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yjor19 Download by: [Australian Catholic University]
Date: 18 October 2017, At: 01:44
Briti. 0·00 I. The demand for treatment was seen irrespective of the Dental Health or Aesthetic Component Indices scores.
TABLE 6 Distribution of Child's Aesthetic Component Scores in response to question 3 (n = 955): What do you dislike most about your teeth? Response (number) Other reason Aesthetic Too Too Teeth score Nothing crooked spaced stick out /don't know Total I 2 3 4 5 6 7 8 9 10
Total
89 74 94 23 8 6 2 4 3 0
24 28 55 16 10 10 7 18 5 3
12 15 11 19 13 3 0 2 4 0
14 14 29 16 12 I 5 7 4 4
65 79 73 24 11 18 3 14 3 I
204 210 262 98 54 38 17 45 19 8
303
176
79
106
291
955
Subjective Orthodontic Treatment Need
BJO Not·ember /991
293
p E R
c
E N T
A
G
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
E
DEF. NO
PROB. NO
DON'T KNOW
PROB. YES
DEF. YES
RESPONSE -MALE
~FEMALE
FIG. 5 Sex distribution in response to question 4 (n=955): If it were necessary would you be prepared to have orthodontic treatment?
Dental Health Index. The demand for orthodontic treatment, response 'definitely yes' increased progressively with increasing dental health need (Fig. 6). Forty children (70·4 per cent) assessed as DHC grade I, no treatment need, would 'probably' or 'definitely' be prepared to accept orthodontic treatment compared with 93 (88·5 per cent) grade 5.
Child's Aesthetic Component rating. Fivehundred-and-seventy children (84·3 per cent), who rated themselves at the attractive end of the Aesthetic Component score scale, were prepared to accept orthodontic treatment (Table 8).
Dentist's Aesthetic Component rating. Fourhundred-and-ten children (84·5 per cent), who were rated at the attractive end of the Aesthetic Component score scale, scores l-3, were prepared to accept orthodontic treatment of an unspecified nature, responses 'probably' or 'definitely yes', if it Were thought necessary (Table 7).
A decision was made to complete the questionnaires by face to face interviews, rather than allowing the children to complete their own, in order to eliminate wastage through incorrectly completed or defaced forms. However, face to face interviews risk the introduction of bias since respondents may distort their answers in order make a more favourable
Discussion
SOr-----------------------------------------1 p E R
60
c
E
N
40
T
A G E
20
2 3 4 DENTAL HEALTH COMPONENT SCORE -
DEFINITELY NO
~ PROBABLY YES
~ PROBABLY NO
lillill
CJ
5
DON'T KNOW
DEFINITELY YES
FIG. 6 Distribution of DHC grades in response to question 4.
294
A. Holmes
BJO Vol. 19 No. 4
TABLE 7 Distribution of Dentist's Aesthetic Component Scores in response to question 4 (n = 955 ): /fit were necessary would you be prepared to have orthodontic treatment? Responses (number) Aesthetic Definitely score no I 2 3 4
6 7 8 9 10
6 15 16 16 2 7 2 3 0 0
4 3 3 6 2 3 0 3 0 0
Total
67
24
5
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
Probably no
Don't know
Definitely yes
Total
2 I I 0 0
12 30 40 43 14 6 8 9 I 0
60 124 144 135 61 42 23 51 10
87 180 218 209 84 60 34 67 11
5
5
46
163
655
955
5 8 15 9
5
Probably yes
TABLE 8 Distribution of Child's Aesthetic Component Scores in response to question 4 (n = 955 ): If it were necessary would you he prepared to have orthodontic treatment? Responses (number) Aesthetic Definitely score no
Probably no
Don't know
10 6 4 I I 0 0 2 0
9 7 23 2 2
9 10
16 15 16 7 3 3 0 2 3 2
Total
67
I 2 3 4
5 6 7
8
Probably yes
Definitely yes
Total
139 140 175 70 39 27 14 33
0
30 42 44 18 9 7 3 7 3
13
204 210 262 98 54 38 17 45 19
0
I
0
5
8
24
46
163
655
955
impression on the interviewer, gtvmg the most socially acceptable response to questions rather than a genuine answer. The child's perception of their dental appearance is of considerable importance in determining both treatment demand and the subsequent level of cooperation during treatment (Shaw, 1981). The finding, in the current study, that more females than males disliked the appearance of their teeth was despite the fact that both objective and subjective opinion suggested that the females in the sample had more attractive dentitions and less 'great' or 'very great' treatment need than the males. This difference between the sexes could be a reflection of the fact that standards of aesthetics and beauty are more clearly delineated for females.
I
0
I
Different aesthetic values may apply to females who may, therefore, be more conscious of their body image. The results are in agreement with Klima et al. (1979), who found females, aged 11-16 years, scored significantly lower in both body-image and self-concept satisfaction than did males of the same age group. Shaw ( 1981 ), in a study of factors influencing the desire for orthodontic treatment in 9-12-year-olds, also found that more females considered themselves of below average attractiveness and more than twice as many females as males were dissatisfied with their dental appearance. This perception of below average attractiveness is reflected in the demand for treatment, with twice as many females as males receiving orthodontic treatment (Shaw et al., 1979).
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
BJO Nm•ember /992
In the current study a greater percentage of females than males [51·7 v. 44·0 per cent], responded that they thought their teeth needed straightening. This correlates with the finding that the females in the study considered themselves to be dentally less attractive than the males. More children at the attractive end of the Aesthetic Component scale recognized they did not require orthodontic treatment. However, there were still a number of children at the attractive end of the aesthetic component scale who felt that they needed orthodontic treatment. This again probably reflects the diversity of aesthetic judgments. It is difficult to determine the reason why, in the current study, a higher proportion of females, compared with males, chose photographs at the attractive end of the Aesthetic Component scale, indicating a visual self-perception of dental attractiveness, but then responded negatively to question I. The Aesthetic Component Index may possibly be a more realistic, and therefore better, indicator of a child's self-perception of their dental attractiveness than a questionnaire since it may be less prone to bias, although this has yet to be proven. _In Shaw's [1981] study 48·0 per cent of children Wtth moderate to severe irregularities reported being 'very' or 'quite happy' with their dental appearance while 30·0 per cent failed to recognize their own dental photograph. In the current study only 2·9 per cent of children with Aesthetic Component scores of 6 or above, the unattractive half of the Aesthetic Component scale, liked the appearance of their teeth 'very much' or 'quite a lot'. This again may be an indication that the Aesthetic Component Index gives a more valid assessment of the child's level of satisfaction with their dental appearance. Graber and Lucker ( 1980) used questionnaires to study the ability of 481 I 0-13-year-olds to assess their dental attractiveness and their degree of selfsatisfaction with their dental appearance. The results suggested that children of this age group W~re capable of making objective aesthetic evaluations of their teeth, but there was a broad range of What was considered acceptable to the children. Only 96 children (20 per cent) in Graber and Lucker's study considered their teeth unattractive compared with 256 (26·8 per cent) in the current study. . Dissatisfaction with aesthetically pleasing dentitions and satisfaction with apparently severe aesthetic problems has been reported by other authors (Lewit and Virolainen, 1968; Shaw, 1981). The reasons for these diversities in opinion between the child and the dentist have been speculated upon. It has been suggested that there is a range ofmalocclu-
Subjective Orthodontic Treatment Need
295
sions which are considered acceptable and that this range must vary considerably between individuals and between the sexes (Shaw, 1981). The perception of aesthetics is dependent on an individuals aesthetic values, persons for whom dental appearance has a high priority will focus on seemingly minor irregularities. A child's under-rating of their dental attractiveness has been suggested as being a function of their self-esteem (Evans and Shaw, 1987), under-rating being associated with low self-esteem. However, this study failed to show that children who underrated their dental attractiveness were significantly more dissatisfied with their dental appearance, as judged by the response to question I, than those who over-rated it or accurately assessed it. Of the children who under-rate their Aesthetic Component scores, 72·5 per cent were satisfied with their dental appearance compared with 74·1 per cent of overcaters and 72·3 per cent of those who accurately assessed their Aesthetic Component score. Malmgren (1980), studying 147 children of a comparable age group, found that 89 children (60·5 per cent) thought that their teeth were out of place, but 110 (74·8 per cent) thought their teeth needed correction. Malmgren speculated that this discrepancy between children dissatisfied with their teeth, and those who thought they required orthodontic treatment may have been due to either a failure to understand the questions posed, or that the children wanted to be treated even though they were not certain that there was something wrong with their teeth. There is also a possibility that the children in the current study distorted their answers in order make a more favourable impression on the interviewer, giving what they believed to be the most socially acceptable response. Helm et al. (1986) investigating, by means of a questionnaire, the effects of various occlusal traits on concern for dental appearance, found that extreme overjet and reverse overjet were a cause for concern in both sexes, as were conspicuous crowding and ectopically erupted maxillary canines. However, deep overbite, spacing and congenital absence of maxillary lateral incisors were a greater psychosocial problem for females. Other studies (Graber and Lucker, 1980) have found that overjet, because of its influence on facial features, appears to be more important to females while more localized crowding anomalies appear more important to males. Horowitz et al. ( 1971 ), investigating I0-12year-old children, and lngervall and Hedegard ( 1974), investigating 18-year-old males, found that the perception of irregular alignment and spacing was greater than the perception of overjets. Increased overjet accounted for 21 (20 per cent)
Downloaded by [Australian Catholic University] at 01:44 18 October 2017
296 A. Holmes
children assessed as D H C grade 5 and 63 (31· 3 per cent) as grade 4. Dissatisfaction with dental appearance has been shown to be proportional to the degree of overjet (Gosney, 1986). This may possibly explain the higher levels of dissatisfaction in grades 4 and 5, although 12 ( 19 per cent) children in Gosney's study, with overjets of 8 mm or greater, were unconcerned about their increased overjet compared with 6 children (28·6 per cent) with an overjet of 9 mm or greater in the current study. This lack of concern with moderate to severe overjets may again reflect the diversity of aesthetic judgments amongst subjects or subjects may have a poor appreciation of their profile. It is interesting to note that the Aesthetic Component Scale does not show profile views. Thirty-one children (36·5 per cent) with a displacement of greater than 4 mm disliked their teeth because they were crooked, while 18 (21·2 per cent) failed to recognize a problem. This may be because the displacement affected a tooth in the buccal segments and may not therefore have been noticed or caused an aesthetic problem. The DHC is not a weighted index. A displaced tooth in the buccal segments scores the same as a similarly displaced tooth in the labial segments. Weightings add to the complexity of an index and, no matter how objective the measurement of occlusal traits, the addition of weightings adds to the subjectivity of the index and makes it's validity difficult to assess. Since the DHC is used in conjunction with the Aesthetic Component Index the patient would score higher on the Aesthetic Component Index if the displaced tooth was in the labial segment, obviating the need for an aesthetic weighting in the DHC. The actual level of unmet treatment need amongst the sample population was assessed, using the I.O.T.N., as 36·3 percent (Holmes, 1992). In this study 818 (85·7%) from the same sample population were prepared to accept orthodontic treatment of an unspecified nature. This compared with 78 children (53·1 per cent) in a questionnaire study by Malmgren (1980) in Sweden, in which the use of visible fixed appliances was stipulated. The high level of potential demand for treatment occurred amongst all the Dental Health and Aesthetic Component Indices grades. How much this represents a true potential demand for orthodontic treatment, reflecting the greater social acceptability of orthodontic treatment today, and how much respondents were led, by the need for social approval, into giving an assumed socially desirable response to question 4 is impossible to assess without a prospective study. It is extremely difficult to assess the validity of
BJO Vol. /9 No. 4
indices used in the evaluation of the subjective need and demand for orthodontic treatment (Malmgren, 1980). The motivation to seek and accept orthodontic treatment does not seem to correlate with either the dental health or aesthetic needs of the patient. This again emphasizes the problems in the perception of malocclusion and highlights the need to establish exactly what the patient dislikes most about their teeth when they attend for assessment. The patient's concept of their malocclusion may be at total variance with the professional assessment of their malocclusion. The dentist's advice appears to be the major motivating factor, for both the patients and parents, in seeking orthodontic treatment (Shaw et al., 1979; Gosney, 1986). Since both general dental practitioners and orthodontists have been shown to be at variance with the dental aesthetic values of lay people (Shaw et al., 1975), advice on orthodontic treatment need, which may be of aesthetic value only, should be exercised with caution.
Conclusion
The demand for orthodontic treatment, of an unspecified nature, assessed by means of a questionnaire, was 85·7 per cent, exceeding both the objective and subjective levels of treatment need. Females were, in general, more dissatisfied with their dental appearance than their male counterparts, despite the lack of evidence of greater objective treatment need. This dissatisfaction with dental appearance was reflected in both a higher level of subjective treatment need and demand amongst females in the sample. The Aesthetic Component Scale of the I.O.T.N. may be a better indicator of an individuals perception of their level of dental attractiveness and occlusion than questioning alone can reveal. When used in conjunction with the Dental Health Component of the I.O.T.N. it may provide valuable insight into guiding the patient towards an amicable decision on the necessity for orthodontic treatment.
Acknowledgements
The author would like to acknowledge the help received from many sources, in particular Mr R. A. Heesterman and his staff for their help in setting up this project, and providing access and assistance for the school visits. Thanks are also due to Professor W. C. Shaw and his staff for their help in the use of the I.O.T.N., and in the analysis of the computer data.
BJO November /992
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