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 Table of Contents  
Year : 2018  |  Volume : 52  |  Issue : 2  |  Page : 89-93

Does socioeconomic status and family type influence oral health-related quality of life in individuals with malocclusion?

1 Additional Prof., Department of Orthodontics, Government Dental College, Gandhinagar, India
2 Additional Prof., Department of Periodontics, Government Dental College, Thrissur, India
3 Prof. and Head, Department of Oral Medicine and Radiology, Government Dental College, Gandhinagar, India
4 Principal and Prof., Department of Endodontics, PMS Dental College, Trivandrum, India
5 Joint Director of Medical Education and PhD Guide, Directorate of Medical Education, Government of Kerala, India

Date of Submission09-Oct-2017
Date of Acceptance10-Jan-2018
Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Elbe Peter
Department of Orthodontics, Government Dental College, Kottayam, Gandhinagar - 686 008, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jios.jios_224_17

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Background: Socioeconomic status of patients seeking orthodontic treatment is important in a developing country like India. No public funding is available at a large scale for the treatment of malocclusion. Aim: The aim of the study was to test the null hypothesis that there is no influence of socioeconomic status and family type on oral health-related quality of life (OHRQoL) among adolescents in central Kerala. Methodology: Four hundred and twenty higher secondary school students aged between 15 and 18 years took part in the study. A previously developed and validated psychometric tool with 20 items was administered. Normative malocclusion features and treatment needs were recorded. Statistical testing using Chi-square and logistic regression to predict the variables that influence OHRQoL was performed. Results: There was a significant association between socioeconomic status of the individuals and OHRQoL at both bivariate and multivariate analysis. Family type also showed a significant relation at bivariate level. Conclusions: The null hypothesis that there is no influence of socioeconomic status and family type on OHRQoL was rejected.

Keywords: Malocclusion, Oral Health-Related Quality of Life, psychometric tool

How to cite this article:
Peter E, Baiju R M, Sreela L S, Varghese N O, Varughese JM. Does socioeconomic status and family type influence oral health-related quality of life in individuals with malocclusion?. J Indian Orthod Soc 2018;52:89-93

How to cite this URL:
Peter E, Baiju R M, Sreela L S, Varghese N O, Varughese JM. Does socioeconomic status and family type influence oral health-related quality of life in individuals with malocclusion?. J Indian Orthod Soc [serial online] 2018 [cited 2019 May 19];52:89-93. Available from: http://www.jios.in/text.asp?2018/52/2/89/230154

  Introduction Top

Malocclusion is the third most common oral condition after dental caries and periodontal disease. The main reason for seeking orthodontic treatment is to improve esthetics.[1] Anatomic improvement in dental alignment and tooth position achieved by orthodontic treatment is reflected in the psychological and emotional well-being of patients.[2] This underlines the link between malocclusion and quality of life (QoL). Patient-reported outcome measures (PROMs) are the tools used to measure this intangible aspect of oral health. Many generic [3],[4],[5] and few condition-specific measures [6],[7],[8],[9],[10] were developed and validated for this purpose.

Liu et al.[11] and others [12] reported only a modest association between malocclusion and QoL. However, a recent systematic review by Dimberg et al.[13] noted a definite link between malocclusion and oral health-related quality of life (OHRQoL). The impact is most for the dimensions of emotional and social well-being. Socioeconomic factors are still important in many developing countries. In India, the fees for orthodontic treatment ranges from few thousand to even a lakh or more Indian rupees. Most of the studies estimating the prevalence of malocclusion demonstrated no difference between the prevalence and treatment need between individuals residing in urban and rural areas or between those belonging to higher and lower socioeconomic conditions.[14] However, in many states, orthodontists are concentrated in urban areas. Vedovello et al.[15] demonstrated that socioeconomic factors can influence OHRQoL among Brazilian adolescents. This study aimed to test the null hypothesis that there is no influence of socioeconomic status and family type on OHRQoL among adolescents in central Kerala population.

  Methodology Top

Ethics committee approval was obtained before conduct of the study from Government Dental College, Kottayam (IEC/M/02/2011/DCK/2). At all stages of examination and data collection, permissions from school authorities and informed consent from participants and parents were ensured.

The study was part of a larger ongoing survey, and the required sample from central Kerala comprising the districts of Kottayam and Thrissur was 420. This was based on the estimated prevalence of malocclusion of 49% in Kerala and a design effect of 2 due to stratified cluster sampling strategy. They were drawn from higher secondary schools of Kottayam and Thrissur districts. One rural and one urban area of each district were randomly selected. For each area, a complete list of government and private schools were prepared separately in alphabetical order. Two government and two private schools from each urban and rural area were randomly selected by lottery method from the list. Exclusion criteria were those who are not willing to participate, students staying in boarding or other shelters, those with cleft lip or palate, and those have completed or are presently undergoing orthodontic treatment or other syndromes.

Normative malocclusion features were recorded in an elaborate datasheet prepared according to a modified Ackerman–Proffit method. Orthodontic treatment needs were assessed using Index of Orthodontic Treatment Need–Dental Health Component [16] (IOTN–DHC) and dental aesthetic index (DAI).[17] OHRQoL was assessed using a newly developed and validated condition-specific psychometric tool (malocclusion-related QoL questionnaire) according to the criteria described previously.[18] The tool had 20 items and one global question. The questions were arranged in four domains: psychological domain (six questions) and a subdomain with two socioeconomic questions, orthodontic self-confidence scale (five questions), social impact (three questions), and functional limitations (four questions). Global question asked about how the individual rates the overall life quality based on dental alignment and occlusion. The response was recorded using a 5-point Likert scale that records the responses as 1 = not at all, 2 = no, 3 = occasionally, 4 = yes, and 5 = definitely yes.

Individuals were classified into higher and lower socioeconomic status based on the most widely used state government criteria, i.e., above and below poverty line (APL and BPL) method. Family type was assessed by determining the members residing with the individual in the family. They were considered joint families if at least one of the grandparents or maternal or paternal uncle or aunt resides with them, and all others where only parents and siblings stay together were considered nuclear family.

All examinations were performed using mouth mirror and community periodontal index of treatment needs probe following WHO Class III examination criteria by trained and calibrated examiners (kappa of 0.82–0.93 for interrater reliability and intraclass correlation coefficient – 0.88–0.98 for intraexaminer reliability) guided by principal investigator (EP). Questionnaire administration was done by the coinvestigator (BRM). Collected data were entered in Statistical Package for Social Sciences (SPSS for Windows, version 16.0, SPSS Inc., Chicago, IL, USA) for statistical analysis. Chi-square test with a significance level kept at P < 0.05 tested the difference between variables and multivariate analysis using logistic regression identified the most important factor influencing the QoL.

  Results Top

Four hundred and twenty individuals studying in 16 different higher secondary schools aged between 15 and 18 took part in the study. Summary of the demography of individuals is presented in [Table 1].
Table 1: Demographic features of the sample under study

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The most prevalent form of malocclusions and estimated treatment need assessed using IOTN–DHC and DAI are depicted in [Graph 1] and [Graph 2], respectively. About 65% of individuals showed no definite need (IOTN–DHC-1 and DAI-1) for treatment, while 22% (IOTN-2 and DAI-2) showed borderline need and 13% showed definite need (IOTN – 3, 4, and 5 and DAI – 3 and 4) for treatment. Class I malocclusion accounted for 73.7%, followed by Class II 21.2% and Class III 5.1%.

[Table 2] shows Chi-square test comparing the proportion of variables and a dichotomized category of OHRQoL. The scale had 20 items, each with a 5-point rating (1–5); hence, the minimum score was 20 and the maximum score was 100. Based on a split quartile method, a score below 37 was considered as good QoL, scores between 37 and 57 were average QoL, and scores above 58 were having a poor QoL. A median score of 47 was used to split the QoL score into two. Multivariate analysis using logistic regression predicting the most important factors contributing to the QoL is presented in [Table 3]. Out of the five variables considered for logistic regression, socioeconomic status (odds ratio [OR] – 1.97, 95% confidence interval [CI] – 1.21–3.20), malocclusion presence or absence (OR – 2.61, 95% CI – 1.11–6.12), and DAI (OR – 0.53, 95% CI – 0.34–0.81) showed significance at both bivariate and multivariate levels (P < 0.05).
Table 2: Comparing quality of life among individuals with various categories

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Table 3: Multiple logistic regression predicting the variables affecting quality of life among individuals

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  Discussion Top

The broadened definition of “health” by WHO resulted in a shift from biological to a biopsychosocial model for defining and studying health. This resulted in development and validation of various psychometric tools for demystifying the psychological health dimension. Use of such validated tool is recommended along with prevalence and orthodontic treatment need estimation.

This study was part of a large study designed to estimate the prevalence of malocclusion and OHRQoL among adolescents aged between 15 and 18 years in Kerala. The data collected pertaining to central Kerala comprising of Kottayam and Thrissur districts were subjected to analysis owing to the observation of a link between socioeconomic status and family type with OHRQoL.

The observed prevalence of malocclusion was similar to many studies conducted in South India.[19] Treatment need estimated using IOTN and DAI showed good agreement [Graph 2].

Most widely accepted and used means of categorization of individual's socioeconomic status in Kerala by the state government is BPL and APL method. For all welfare benefits by the government, this method is followed and every individual knows which category he/she belongs to, hence easy to apply. This method was used in this study also. Studies have shown that Kuppuswamy scale is not a reliable method to categorize socioeconomic status.[20] Family type was defined as nuclear when it consists of father and/or mother and siblings and joined if any other member like grandparents or maternal or paternal uncle or aunt stays along with them.

This study showed no significant difference in the prevalence of malocclusion between gender, school type, place of residence, socioeconomic status, and family type. This finding was similar to those reported by others.[14],[19],[21] However, when compared with OHRQoL scale, there was a significant difference in socioeconomic status and family type. Vedovello et al.[15] and Silva et al.[22] have demonstrated that socioeconomic and other contextual factors are important in OHRQoL. This may be directly linked to the access to care and affordability for orthodontic treatment.

However, family type had not been subjected to study before. Children with malocclusions are teased and bullied in schools, leading to considerable amount of psychological trauma.[23] The presence of multiple members in family especially elders may buffer this impact due to malocclusion. This was evident in this study where children coming from joint family showed no significant difference in malocclusions but demonstrated a better OHRQoL than those from nuclear family. However, this coping mechanism and other factors such as the improvement in QoL following orthodontic treatment and the difference in compliance levels exhibited by children of different family type need further study.

Multivariate analysis demonstrated that presence of malocclusion, a high DAI score, and socioeconomic status are important predictors for a poor QoL. However, at the multivariate level, the influence of family type was not found to be a significant predictor.

Socioeconomic status is still a barrier for orthodontic treatment in India. There is no public aid for orthodontic treatment as it is considered cosmetic in nature, apart from those delivered at government-run tertiary health-care centers. This can force patients to seek orthodontic care delivered at a lower cost, especially those by a general practitioner.

This study is unique in the sense that it generated a new hypothesis regarding the influence of family type on OHRQoL. In a state like Kerala where the rate of urbanization is rapid, most family is nuclear. Isolation of children from the community and public interactions due to the influence of social media is a universal phenomenon. Children cannot tolerate insults and teasing even to a minimal extent. Exposure of such situation in a family by siblings and other related members even as a joke can condition the children and prepare psychologically for such future events. As this finding was anecdotal in this study, well-designed study with a defined research question can shed more light in this aspect.

  Conclusions Top

The null hypothesis that there is no relation between socioeconomic status and family type in OHRQoL in individuals with malocclusion is rejected. The importance of family type and its influence in malocclusion-related QoL has not been studied before. The presence of elders and other related members may be acting as a buffer reflecting a better QoL among individuals living in joint family. In a fast developing country like India, the economic barrier is still a hindrance to orthodontic treatment as reflected in their QoL status. This study cautions that the uptake of patients for treatment by governmental institutions at a reduced cost solely by normative orthodontic index is arbitrary, rather a PROM should be supplemented. The importance of QoL assessment cannot be overlooked as stated by Padmanabhan,[24] “if there is a defect on the soul, it cannot be corrected on the face, but if there is defect on the face and one corrects it, it can correct a soul.” It was surprising to note that the family type too has an influence in potential worsening of oral health-related QoL; hence, further studies regarding this aspect are warranted.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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