Pediatric Dentistry

Malocclusion and socioeconomic

indicators in primary dentition

Raulison Vieira de Sousa(a) Abstract: The aim of the present study was to determine the prevalence
Ana Karla de Almeida of malocclusion and associations with socioeconomic indicators among
Pinto-Monteiro(b)
Carolina Castro Martins(c) preschoolers. A cross-sectional study was conducted with 732 children
Ana Flávia Granville-Garcia(a) 3 to 5 years of age in the city of Campina Grande, Brazil. Three den-
Saul Martins Paiva(c) tists underwent a calibration exercise (K  =  0.85–0.90) and diagnosed
malocclusion based on the criteria proposed by Foster & Hamilton and
(a)
Department of Pediatrics, School of Grabowski et al. Parents/guardians answered a questionnaire addressing
Dentistry, Universidade Estadual da Paraíba sociodemographic aspects. Data analysis involved descriptive statistics
- UEPB, Campina Grande, PB, Brazil.
and bivariate Poisson regression (PR; α  =  5%). The prevalence of mal-
(b)
Department of Orthodontics, School of occlusion was 62.4%. The most frequent types were increased overjet
Dentistry, Universidade do Estado do Rio
Grande do Norte - UERN, Caicó, RN,
(42.6%), anterior open bite (21%) and deep overbite (19.3%). An associa-
Brazil. tion was found between malocclusion and age: the prevalence of maloc-
(c)
Department of Pediatrics, School of
clusion was greater among younger children, with the highest prevalence
Dentistry, Universidade Federal de Minas among 3-year-olds (PR = 1.116; 95%CI = 1.049–1.187). The prevalence
Gerais - UFMG, Belo Horizonte, MG, Brazil. of malocclusion was high. Mother’s schooling and household income
were not associated with malocclusion. Socioeconomic factors were also
not associated with the occurrence of malocclusion.

Descriptors: Malocclusion; Socioeconomic Factors; Income; Child;

Overbite.

Introduction
From a public health perspective, the assessment of malocclusion in
Declaration of Interests: The authors the deciduous dentition should focus on magnitude and severity as a
certify that they have no commercial or guide to establishing strategies aimed at preventing occlusal problems
associative interest that represents a conflict
later in life.1,2 Increased overjet, deep overbite, lateral crossbite and ante-
of interest in connection with the manuscript.
rior open bite are the most common types of malocclusion in the primary
dentition.3 Some malocclusions that arise at 3 years of age may improve
Corresponding Author: over subsequent years (open bite), whereas others may worsen (distoclu-
Ana Flávia Granville-Garcia
sion, lateral crossbite and unfavorable vertical occlusal conditions). 3,4
E-mail: [email protected]
Genetic factors, ethnic factors, nonnutritive sucking habits, impaired
nasal breathing and functional atrophy of the maxilla due to the under-
http://dx.doi.org/10.1590/S1806-83242013005000032
development of dental arches are frequently associated with malocclu-
Epub Dec 02, 2013
sion.5-8 Few epidemiological surveys have addressed the primary dentition
and even fewer studies have associated malocclusion with socioeconomic
indicators. Investigations of this type are important for the allocation of
Submitted: Mar 17, 2013
public funds for health services. Previous studies have generally evalu-
Accepted for publication: Sep 01, 2013
Last revision: Sep 14, 2013 ated only one type of malocclusion and one socioeconomic indicator.6,9
The World Health Organization recommends periodic surveys of the

Braz Oral Res., (São Paulo) 2014;28(1):1-7 1

 Malocclusion and socioeconomic indicators in primary dentition

main oral health problems. Epidemiological studies • no previous orthodontic treatment;

on malocclusion are important in identifying occlu- • agreement to participate in the clinical exam.
sal changes during growth and in determining the
distribution of oral health conditions in a popula- Training and calibration exercise
tion.1,10 Moreover, malocclusion can exert an impact The theoretical phase involved a discussion of
on a child’s quality of life.3,11 diagnostic criteria for malocclusion and an analysis
Considering the scarcity of such investigations, of photographs. A specialist in orthodontics was the
the aim of the present study was to determine the gold standard in the theoretical framework and co-
prevalence of malocclusion and associations with so- ordinated this step, instructing three dentists on how
cioeconomic indicators among preschoolers in Brazil. to perform the exam. The clinical phase was per-
formed in a randomly selected preschool outside the
Methodology main sample. Each dentist examined 50 children and
Sample interexaminer agreement was tested. Thirty children
A cross-sectional study was conducted with 732 were reexamined after a seven-day interval to deter-
children 3 to 5 years of age, enrolled at 33 (15 pri- mine intraexaminer agreement. Kappa coefficients
vate and 18 public) preschools in the city of Campina were 0.85 and 0.90 for interexaminer and intraex-
Grande, Brazil. The participants were selected from a aminer agreement, confirming that the examiners
total population of 12,705 children in this age group were able to perform the epidemiological study.12
(corresponding to 6.6% of the population).
A two-phase sampling method was used to en- Pilot study
sure representativeness: A pilot study was conducted to test the meth-
1. random selection of preschools from each health odology. The children in the pilot study (n  =  40)
district (18 of 127 public schools and 15 of 122 were not included in the main sample. The results
private schools selected by lots); and revealed no misunderstandings regarding the ques-
2. random selection of children from each pre- tionnaire or need to change the method.
school.
Non-clinical data collection
The sample size was calculated considering a 4% Parents answered a questionnaire on sociode-
margin of error, 95% confidence level and 50.0% mographic data (mother’s schooling and monthly
prevalence rate of malocclusion. A correction fac- household income). Income was dichotomized based
tor of 1.2 was applied to compensate for the design on the Brazilian minimum wage (= US$ 312.50).
effect. The minimum sample size was estimated at
720 schoolchildren, to which 20% was added to Clinical data collection
compensate for possible losses, totaling 864 pre- The exams were performed at the selected pre-
schoolers. schools in the knee-to-knee position, aided by a por-
This study received the approval of the Human table lamp attached to the examiner’s head (Petzl,
Ethics Research Committee of the Universidade Es- Clearfield, USA). Individual cross-infection protec-
tadual da Paraíba - UEPB (00460133000-11). All tion equipment was used. Packaged and sterilized
parents/guardians received information regarding disposable mouth mirrors (Prisma, São Paulo, Bra-
the objectives, and signed terms of informed consent. zil) and WHO probes (Trinity, Campo Mourão,
Brazil) were used.
Eligibility criteria The clinical examination recorded aspects of
Inclusion criteria: overbite, overjet and crossbite using criteria recom-
• age 3 to 5 years; mended by Foster and Hamilton13 and Grabowski
• exclusively in the primary dentition phase; et al.,3 which have been used by other authors.14
• no loss of mesiodistal diameter due to caries; Horizontal overlap of the incisors was considered

2 Braz Oral Res., (São Paulo) 2014;28(1):1-7

 Sousa RV, Pinto-Monteiro AKA, Martins CC, Granville-Garcia AF, Paiva SM

overjet. The measurement (in millimeters) was per- Males, children four years of age, those who at-
formed with the teeth in centric occlusion and the tended public school and those whose parents re-
probe positioned parallel to the occlusal plane. No ported an income of 1 minimum wage or less ac-
distance between upper and lower incisors was de- counted for the highest percentages of the sample
fined as normal overjet (0  mm); increased overjet (Table 2).
was recorded when the distance was  >  2  mm, and Age was the only variable significantly associated
anterior crossbite was recorded when the distance with malocclusion, more prevalent among 3-year-
was < 0 mm.13 Anterior crossbite was recorded when olds (PR = 1.116; 95%CI: 1.049–1.187; Table 3).
the lower incisors were observed in front of the up-
per incisors.13 Anterior open bite was recorded in Discussion
the absence of contact between anterior teeth when The prevalence of malocclusion in the de-
posterior teeth were in occlusion.13 Normal overbite ciduous dentition was high in the present study
was defined when upper incisors overlapped lower (62.4%). Previous investigations report rates rang-
incisors by 2 mm. Overbite greater than 2 mm was ing from 36.46% to 87.0% in Brazilian studies14-17
designated deep overbite.3 Posterior crossbite was re-
corded when upper primary molars were occluded
in lingual relationship to lower primary molars in Table 1 - Prevalence of malocclusion and types of maloc-
clusion in 3-5-year-old children.
centric occlusion.13 The participant was diagnosed
with malocclusion when exhibiting at least one of Variables n %
the aforementioned conditions.3 Increased overjet 312 42.6
Anterior crossbite 16 2.2
Statistical analysis Deep overbite 141 19.3
Descriptive statistics were performed to describe Anterior open bite 154 21.0
the prevalence of malocclusion and characterize the Posterior crossbite (94.1% unilateral) 85 11.6
sample. Bivariate Poisson regression (PR) was used
Presence of malocclusion 457 62.4
to test associations between outcome (malocclusion)
and independent variables (age, sex, and socioeco-
nomic variables; p  <  0.05). Statistical analysis was
Table 2 - Sample characteristics related to socioeconomic
conducted using the Statistical Package for Social indicators.
Sciences (SPSS for Windows, version 18.0 SPSS Inc.,
Variable n %
Chicago, USA).
Age (years)

Results 3 230 31.4

A total of 732 pairs of parents/guardians and chil- 4 341 46.6

dren participated in the present study, corresponding 5 161 22.0

to 84.72% of the total sample selected (n = 864). The Sex
loss of 132 children (15.28%) was attributed to ab- Male 384 52.5
sence from preschool more than three times on the Female 348 47.5
days scheduled for the clinical exams (n  =  76) and Type of preschool
lack of cooperation during the exam (n = 56). Private 353 48.2
The prevalence of malocclusion was 62.4%. A
Public 379 51.8
total of 42.6% of the children had increased over-
Income
jet, 2.2% had anterior crossbite, 19.3% had deep
≤ 1 minimum wage 368 50.3
overbite, 21% had anterior open bite and 11.6% had
> 1 minimum wage 364 49.7
posterior crossbite. Among the last group named,
Total 732 100.0
94.1% had unilateral posterior crossbite (Table 1).

Braz Oral Res., (São Paulo) 2014;28(1):1-7 3

 Malocclusion and socioeconomic indicators in primary dentition

Table 3 - Bivariate Poisson Malocclusion PR

regression of malocclusion Variable
and socioeconomic Present n (%) Absent n (%) p-value (1)
(95% CI)
variables. Sex
Female 216 (62.1) 132 (37.9) 1.00
0.847
Male 241 (62.8) 143 (37.2) 1.004 (0.962–1.049)
Age (years)
3 159 (69.1) 71 (30.9) 0.001* 1.116 (1.049–1.187)
4 215 (63.0) 126 (37.0) 0.017* 1.076 (1.013–1.142)
5 83 (51.6) 78 (48.4) 1.00
Type of school
Public 231 (60.9) 148 (39.1) 1.00
0.390
Private 226 (64.0) 127 (36.0) 1.019 (0.976–1.064)
Income
≤ 1 minimum wage 222 (60.3) 146 (39.7) 1.026 (0.983–1.072)
0.237
> 1 minimum wage 235 (64.6) 129 (35.4) 1.00
Mother’s schooling
≤ 8 years 202 (62.9) 119 (37.1) 1.005 (0.963–1.050)
0.806
> 8 years 255 (62.0) 158 (38.0) 1.00
(1)
 Bivariate Poisson regression; * significant at a 5.0% level.

and 26.06% to 74.7% in international studies.3,18,19 (3–5 years), with prevalence rates ranging from 6.0%
This divergence demonstrates that the prevalence of to 27.9%.1,19,21,23 Anterior open bite has been report-
malocclusion can vary across countries/regions. The ed to be associated with nonnutritive sucking habits,
differences may also be explained by differences in common in this phase of life.6,7,16,21,24 These habits
the age groups analyzed, the diagnostic criteria and may be related to cultural and economic differences
the nomenclature regarding malocclusion. This study across populations,7,25 which may influence the vari-
eliminated the confounder effect of no loss of mesio- ability in results.
distal diameter due to caries by excluding children Deep overbite was the third most frequent type
with this condition.7,14 of malocclusion (19.3%), in agreement with a pre-
Increased overjet was the most frequent type of vious survey using a similar methodology (19.7%).14
malocclusion (42.6%). Previous studies report rates There are also reports of lower prevalence rates in
ranging from 12.1% to 32%.20,21 This difference is Brazilian studies (7.0% to 13.2%). 20 In these studies,
likely due to the cutoff point used for the diagno- the diagnostic criterion was the “incisal tip of the
sis. In the present study, increased overjet was de- lower central incisors touching the palate in centric
fined as  ≥  2  mm, which is the same value used in occlusion”,13 unlike the present study, in which an
other studies. 3,4,10 However, a number of researchers overbite greater than 2 mm was designated as deep
use  ≥  3  mm. 22 This type of malocclusion does not bite.3 Prevalence rates in Germany are reported to
self-correct with age, primarily due to the impact of range from 24.3%4 to 33.2%.3 This divergence may
persistent, newly formed functional factors that dis- be related to ethnic differences, insofar as Brazil has
rupt dentition development. 3,4 a considerable degree of racial miscegenation,7 un-
Anterior open bite was the second most frequent like the German population.
type of malocclusion and is generally one of the most Posterior crossbite is believed to be transferred
frequently diagnosed conditions in this age group from the deciduous to the permanent dentition and

4 Braz Oral Res., (São Paulo) 2014;28(1):1-7

 Sousa RV, Pinto-Monteiro AKA, Martins CC, Granville-Garcia AF, Paiva SM

can have long-term effects on the growth and devel- tors and malocclusion, in agreement with findings
opment of the teeth and jaws. 25 This type of maloc- reported in previous studies.6,9 It seems that another
clusion has been associated with nonnutritive suck- factor unassociated to social class has occurred,
ing habits, mouth breathing and hypertrophy of the namely the greater participation of women in the
adenoids and tonsils.5,21,26 Posterior crossbite was workforce, with a consequent reduction in breast-
the fourth most common type of malocclusion diag- feeding and greater susceptibility to the adoption of
nosed (11.6%), with most cases occurring unilateral- nonnutritive sucking habits.7,25 Moreover, genetic
ly (94.1%). The literature reports rates ranging from and environmental factors can affect children6 re-
11.6% to 13.4%.3,14 In a national survey carried out gardless of social class.
in Brazil, the prevalence of posterior crossbite was This study has limitations that should be consid-
21.9%, ranging from 10.1% to 25.3% among its dif- ered, particularly the fact that the socioeconomic
ferent regions. 20 Since Brazil is a large country with data were collected using a questionnaire, and that
considerable climate differences, a cold, wet climate the information contained in the parents’ report
in some regions may favor the development of al- may display a degree of bias, especially with regard
lergies and breathing difficulties, the consequences to household income.
of which may be mouth breathing and malocclu- The present study offers a profile of malocclu-
sion. 27,28 Indeed, higher prevalence rates of this type sion in the primary dentition. Malocclusion is not
of malocclusion (19.9% to 25.3%) have been report- dependent on socioeconomic indicators and should
ed in these regions. 20 However, the city of Campina be investigated in all children, regardless of social
Grande is located in the northeastern region of the class. Although the data suggests that malocclusion
country, with a warm, humid climate, where aller- may decrease with age, and that self-correction is
gies and breathing difficulties are less common. possible, it constitutes a public health problem, as
Anterior crossbite was the least common type of can be seen in the high prevalence found in the pres-
malocclusion, in agreement with findings described ent study. The prevention of malocclusion should be
in previous studies (0.1% to 6.7%).3,14,21 The rate re- prioritized in public polices to avoid possible del-
ported in a national survey was 2.8%, ranging from eterious consequences to the permanent dentition.
1.4% to 3.6% among the different regions. 20 Moreover, the prevention of malocclusion is less
Age was the only variable associated with maloc- costly than its treatment at an older age.
clusion, in agreement with findings reported in the
literature.3,4,9,25 The greater prevalence of malocclu- Conclusion
sion at younger ages suggests self-correction over The prevalence of malocclusion in the primary
time.3,4 However, these findings should be viewed dentition was high. Increased overjet and anterior
with some latitude, seeing that any type of occlusal open bite were the most common types. Malocclu-
abnormality was considered malocclusion; this could sion was significantly associated with age, but not
also be considered a limitation to the present study. with socioeconomic indicators.
A number of authors argue that anterior open bite is
a type of malocclusion that regresses with age.3 Acknowledgments
Sex was not associated with malocclusion, as This study was supported by the Universida-
confirmed in previous studies.6,25 Whereas a number de Estadual da Paraíba - UEPB and the following
of authors argue that children with greater purchas- Brazilian funding agencies: Coordenação de Aper-
ing power and those whose mothers have a lower feiçoamento de Pessoal de Nível Superior (CAPES
schooling level are more likely to develop malocclu- - Ministério da Educação), Fundação de Amparo
sion due to greater access to and frequency of paci- à Pesquisa do Estado de Minas Gerais (FAPEMIG)
fier use, 29,30 no significant associations were found and Conselho Nacional de Desenvolvimento Cien-
in the present study between socioeconomic indica- tífico e Tecnológico (CNPq/471-790-2011/7).

Braz Oral Res., (São Paulo) 2014;28(1):1-7 5

 Malocclusion and socioeconomic indicators in primary dentition

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