Abstract
CONTEXT:
Malocclusion is a common dental issue that can lead to significant oral health problems. However, patient management and treatment options for malocclusion can vary, and there is a lack of information regarding self-perception and barriers to orthodontic care.
AIMS:
This study aimed to assess the self-perception of malocclusion and explore barriers to orthodontic care among residents of Bandar Saujana Putra in Klang Valley, Malaysia.
SETTINGS AND DESIGN:
A cross-sectional study through the use of a validated questionnaire was distributed to the residents of Bandar Saujana Putra. Responses were collected from June 2021 to February 2022 via both online (Google Forms) and physical forms.
METHODS AND MATERIAL:
The questionnaire consists of four sections, which assessed the respondents' demographics, understanding and awareness toward malocclusion, and barriers to orthodontic care.
STATISTICAL ANALYSIS USED:
Responses were analyzed using the Pearson Chi-square test with IBM SPSS version 26.
RESULTS:
A total of 231 responses were collected from 83 (35.9%) males and 148 (64.1%) females. Females had a significantly higher level of awareness and knowledge regarding malocclusion compared to males (P < 0.05). The majority of the female respondents (83.8%) agreed that malocclusion can lead to dental caries (P = 0.02) and 60.8% of them identified “unpleasant appearance” as the main barrier to orthodontic treatment (P < 0.001).
CONCLUSIONS:
The findings suggest that clear braces could be a viable alternative for patients who are concerned with their appearance and may be a solution to the barrier of “unpleasant appearance.” Our study contributes to the existing literature on malocclusion and barriers to orthodontic care in Malaysia.
Keywords: Awareness, barriers, clear braces, malocclusion, orthodontic care
Introduction
Malocclusion is a condition where there are morphological differences in tooth position and arch relationship that can impact a person's appearance and well-being.[1,2] It is becoming an increasingly prevalent dental health problem, with etiologies ranging from hereditary factors to physical agents and diseases. Malocclusion can have negative psychological and social impacts on individuals, particularly during adolescence when appearance is highly prioritized.[3] Orthodontic treatment can improve both physical function and aesthetics, but lack of knowledge and financial limitations can prevent individuals from seeking treatment.[4,5,6,7] This research aims to investigate awareness and potential barriers to orthodontic treatment in the community.
Subjects and Methods
Study design and questionnaire
A cross-sectional study was conducted from June 2021 to February 2022 to assess the age and gender differences in the knowledge and awareness of malocclusion and barriers to orthodontic care among the residents of Bandar Saujana Putra (BSP), Jenjarom, Selangor. An ethical approval letter was obtained from the Research Management Centre of MAHSA University (Ethics no.: RMC/EC44/2021).
The validated questionnaire was obtained from Ashky et al.[8] The questionnaire was written in English and consisted of 20 questions, which were further divided into four sections comprising i) Demographic information, ii) Malocclusion and oral diseases, iii) Awareness toward malocclusion, and iv) Barriers to orthodontic treatment. The responses provided in the questionnaire were “Yes,” “No,” and “I don't know.” A convenience sampling technique was adopted for sample selection.
Available participants were given the option to fill in the questionnaire either manually or online via Google Forms. Only residents of BSP who agreed to answer the questionnaire with the age group 18–40 years old were included in this study. The exclusion criteria for this study are i) those who are residing outside of BSP, and ii) those with mixed dentition. A total of 68% of respondents filled out the physical form, while 32% did it online. Participation was purely voluntary without any force or bias. Participants have been assured that their information would be kept confidential.
Sample size determination
The sample size was determined using two proportions formula in PS: Power and Sample Size Calculation 3.1 portal at https://ps-power-and-sample-size-calculation.software.informer.com/3.1/. The two proportions formula is indicated below:
n = required sample size
α = level of statistical significance
1-β = power of the study
Zα = value of the standard normal distribution cutting off probability α in one tail for a one-sided alternative or α/2 in each tail for a two-sided alternative
Zβ = value of the standard normal distribution cutting off probability β
The calculated sample size required in this study is 210. However, after considering an estimate of 10% missing data, the sample size of the study was adjusted to 231.
Statistical analysis
Data analysis was conducted using IBM SPSS Version 26. Descriptive analysis, Pearson Chi-Square test, and independent t-test were performed. A P value of <0.05 is considered significant.
Results and Discussion
This study was intended i) to identify the awareness and knowledge regarding malocclusion and orthodontic needs in BSP with association to the difference in gender and age groups and ii) to study the possible barriers toward orthodontic treatment and their significance across age and gender. Due to Covid-19 restrictions, our research design is limited to only questionnaires. Responses from residents of BSP were gathered with a total of 231 responses comprising 83 (35.9%) male and 148 (64.1%) female. The majority of the respondents aged ranging from 18 to 25 years (60.2%) followed by 26 to 30 years (19.5%), 31 to 35 years (9.9%), and 36 to 40 years (10.4%). The demographic characteristics of participants are summarized in Table 1.
Table 1.
Demographic characteristics of the participants
| Age |
|||||||||
|---|---|---|---|---|---|---|---|---|---|
| 18–25, n (%) | 26–30, n (%) | 31–35, n (%) | 36–40, n (%) | Total, n (%) | |||||
| Gender | |||||||||
| Female | 88 (38.1) | 30 (13.0) | 13 (5.6) | 17 (7.4) | 148 (64.1) | ||||
| Male | 51 (22.1) | 15 (6.5) | 10 (4.3) | 7 (3.0) | 83 (35.9) | ||||
| Total | 139 (60.2) | 45 (19.5) | 23 (9.9) | 24 (10.4) | 231 (100.0) | ||||
As we aimed to assess and compare the level of awareness and knowledge among the participants, the responses “No” and “I don't know” were combined into a single answer as “No” for the Chi-square test analysis. Most of the participants are well aware that malocclusion can give rise to dental caries formation and cleaning difficulty that could further lead to periodontal problems. In addition, the majority of the respondents are also aware that thumb sucking habits and early primary teeth extraction affect overall oral health dysfunction, which includes malocclusion. This is incongruent with previous literature, which supported that bad habits can interfere with the position of the teeth and the normal pattern of skeletal growth, further causing malocclusion.[9] Overall, there were significant differences between the youth and the older age group and between the male and female groups in terms of their general awareness and knowledge regarding malocclusion (P < 0.05) [Tables 2 and 3].
Table 2.
Association between age (18–25 years vs. >25 years) regarding knowledge and awareness toward malocclusion
| Questions | Chi-Square (df) | P |
|---|---|---|
| Do you think malocclusion (teeth misalignment) can cause dental caries (tooth decay)? | 26.840 (6) | <0.001 |
| Do you think malocclusion (teeth misalignment) can cause plaque accumulation? | 3.060 (6) | 0.801 |
| Do you think malocclusion (teeth misalignment) can cause gingivitis (gum inflammation)? | 18.286 (6) | 0.006 |
| Do you think malocclusion (teeth misalignment) can make dental brushing more difficult? | 7.233 (6) | 0.300 |
| Are you aware of the importance of aligned teeth? | 26.271 (6) | <0.001 |
| Do you think teeth must be well aligned? | 7.675 (6) | 0.263 |
| Do you think aligned teeth are important for facial appearance? | 14.967 (6) | 0.021 |
| Do you feel that you need orthodontic treatment? | 18.521 (6) | 0.005 |
| Did anyone advise you to align your teeth? | 9.538 (6) | 0.146 |
| Did you visit an orthodontist before? | 12.683 (6) | 0.048 |
| Thumb sucking can cause malocclusion to anterior teeth. | 18.221 (6) | 0.006 |
| Early extraction of primary teeth can cause malocclusion. | 37.923 (6) | <0.001 |
| Genetics can be the main reason for malocclusion. | 23.963 (6) | 0.001 |
Chi-square test, P<0.05 (Statistically significant)
Table 3.
Association between gender (male vs. female) regarding knowledge and awareness toward malocclusion
| Questions | Chi-Square (df) | P |
|---|---|---|
| Do you think malocclusion (teeth misalignment) can cause dental caries (tooth decay)? | 7.683 (2) | 0.021 |
| Do you think malocclusion (teeth misalignment) can cause plaque accumulation? | 0.301 (2) | 0.860 |
| Do you think malocclusion (teeth misalignment) can cause gingivitis (gum inflammation)? | 0.422 (2) | 0.810 |
| Do you think malocclusion (teeth misalignment) can make dental brushing more difficult? | 0.643 (2) | 0.725 |
| Are you aware of the importance of aligned teeth? | 5.410 (2) | 0.067 |
| Do you think teeth must be well aligned? | 1.477 (2) | 0.478 |
| Do you think aligned teeth are important for facial appearance? | 1.532 (2) | 0.465 |
| Do you feel that you need orthodontic treatment? | 7.246 (2) | 0.027 |
| Did anyone advise you to align your teeth? | 1.357 (2) | 0.507 |
| Did you visit an orthodontist before? | 3.204 (2) | 0.202 |
| Thumb sucking can cause malocclusion to anterior teeth. | 6.008 (2) | 0.050 |
| Early extraction of primary teeth can cause malocclusion. | 2.234 (2) | 0.327 |
| Genetics can be the main reason for a malocclusion. | 0.465 (2) | 0.793 |
Chi-square test, P<0.05 (Statistically significant)
Youth have the highest awareness and knowledge regarding malocclusion in comparison to other age groups. They contributed to a higher percentage of respondents who answered “Yes” in questions regarding oral problems which is caused by malocclusion [Table 4, Questions 1-4]. Youth also demonstrated better knowledge regards to the etiology of malocclusion. At least half of the youths (50.6%) were aware that thumb sucking habit can cause malocclusion [Table 4]. Although their awareness level is high, the majority of the youth (33.3%) do not visit orthodontists for consultation. They may think that it is not needed as 29.4% of them feel that they do not require any orthodontic treatment [Table 4]. This study supported the relevance between the oral health and psychological well-being of young people.[10]
Table 4.
General awareness and knowledge regarding malocclusion based on age groups
| Questions | 18–25, n (%) |
26–30, n (%) |
31–35, n (%) |
36–40, n (%) |
||||
|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | Yes | No | |
| 1. Do you think malocclusion (teeth misalignment) can cause dental caries (tooth decay)? | 122 (52.8) | 17 (7.4) | 33 (14.3) | 12 (5.25) | 11 (4.8) | 12 (5.2) | 17 (7.4) | 7 (3.03) |
| 2. Do you think malocclusion (teeth misalignment) can cause plaque accumulation? | 124 (53.7) | 15 (6.5) | 38 (16.5) | 7 (3.03) | 18 (7.8) | 5 (2.2) | 20 (8.7) | 4 (1.7) |
| 3. Do you think malocclusion (teeth misalignment) can cause gingivitis (gum inflammation)? | 108 (46.8) | 31 (13.4) | 22 (9.5) | 23 (10.0) | 13 (5.6) | 10 (4.3) | 13 (5.6) | 11 (4.8) |
| 4. Do you think malocclusion (teeth misalignment) can make dental brushing more difficult? | 129 (55.8) | 10 (4.3) | 40 (17.3) | 5 (2.2) | 22 (9.5) | 1 (0.4) | 19 (8.2) | 5 (2.2) |
| 5. Are you aware of the importance of aligned teeth? | 132 (57.1) | 7 (3.03) | 34 (14.7) | 11 (4.8) | 19 (8.2) | 4 (1.7) | 17 (7.4) | 7 (3.03) |
| 6. Do you think teeth must be well aligned? | 120 (51.9) | 19 (8.2) | 41 (17.7) | 4 (1.7) | 20 (8.7) | 3 (1.3) | 18 (7.8) | 6 (2.6) |
| 7. Do you think aligned teeth are important for facial appearance? | 132 (57.1) | 7 (3.03) | 34 (14.7) | 11 (4.8) | 21 (9.1) | 2 (0.9) | 21 (9.1) | 3 (1.3) |
| 8. Do you feel that you need orthodontic treatment? | 71 (30.7) | 68 (29.4) | 12 (5.2) | 33 (14.3) | 7 (3.03) | 16 (6.9) | 9 (3.9) | 15 (6.5) |
| 9. Did anyone advise you to align your teeth? | 59 (25.5) | 80 (34.6) | 14 (6.1) | 31 (13.4) | 4 (1.7) | 19 (8.2) | 7 (3.03) | 17 (7.4) |
| 10. Did you visit an orthodontist before? | 62 (26.8) | 77 (33.3) | 11 (4.8) | 34 (14.7) | 5 (2.2) | 18 (7.8) | 8 (3.5) | 16 (6.9) |
| 11. Thumb sucking can cause malocclusion to anterior teeth | 117 (50.6) | 22 (9.5) | 31 (13.4) | 14 (6.1) | 17 (7.4) | 6 (2.6) | 12 (5.2) | 12 (5.2) |
| 12. Early extraction of primary teeth can cause malocclusion | 107 (46.3) | 32 (13.9) | 24 (10.4) | 21 (9.1) | 11 (4.8) | 12 (5.2) | 11 (4.8) | 13 (5.6) |
| 13. Genetic can be the main reason for malocclusion. | 76 (32.9) | 63 (27.3) | 15 (6.5) | 30 (13.0) | 6 (2.6) | 17 (7.4) | 10 (4.3) | 14 (6.1) |
Meanwhile, the female has a higher level of awareness and knowledge regarding malocclusion in comparison to the male. More female participants answered “Yes” in the questionnaire thus suggesting that they know the etiology of malocclusion as well as the problems that could arise from the condition if it is left untreated [Figure 1]. There is also a significant difference between males and females in question number 1. “Do you think malocclusion (teeth misalignment) can cause dental caries (tooth decay)?” 8. “Do you feel that you need orthodontic treatment?” 10. “Did you visit an orthodontist before?” and 11. “Thumb sucking can cause malocclusion to anterior teeth.” These findings were supported by a previous study that was done similarly in Saudi Arabia. The team reported that there is a statistical difference found between males and females in terms of their awareness and knowledge related to orthodontic treatment needs.[8] One possible explanation for this difference is that females may have a higher level of consciousness toward malocclusion as it is often associated with facial features and aesthetics. Misaligned teeth can impact the appearance of the face, and females may be more aware of these issues due to societal expectations around beauty and attractiveness. Additionally, females may be more proactive about seeking orthodontic treatment to address these concerns.
Figure 1.
Gender differences in awareness and knowledge level among respondents who answered “Yes”. This figure depicts the gender-based analysis of respondents who answered “Yes” to a series of questions related to malocclusion (teeth misalignment) and its potential consequences. The questions encompassed various aspects, including the relationship between malocclusion and dental caries, plaque accumulation, gingivitis, difficulty in dental brushing, the importance of aligned teeth, impact on facial appearance, need for orthodontic treatment, advice received on teeth alignment, previous visits to an orthodontist, and factors contributing to malocclusion (Table 3 detailed the list of questions)
Overall, the finding is that females have a higher level of awareness and knowledge regarding malocclusion and highlights the importance of providing adequate education and information to both male and female patients. By addressing the knowledge gap, orthodontic treatment can be made more accessible and effective for all individuals seeking to improve their dental health and appearance.
The results from Figure 2 suggest that the barriers to seeking orthodontic treatment are multifactorial. While cost was identified as the primary barrier for most participants, other factors such as maintaining good oral hygiene, long-term treatment, multiple visits, and transportation difficulties were also perceived as obstacles. Notably, socioeconomic status emerged as a critical factor, as individuals from lower socioeconomic backgrounds were less likely to pursue orthodontic treatment due to the high cost involved. This finding is consistent with previous research conducted in Jordan, where patients from lower socioeconomic backgrounds reported lower satisfaction with their dental aesthetics and a higher perceived need for orthodontic treatment.[11]
Figure 2.
Gender differences in barriers to orthodontic care among respondents. This figure illustrates the gender-based analysis of barriers to orthodontic care reported by the respondents to identify and understand the obstacles that individuals face when seeking orthodontic treatment. The questionnaire included a series of questions addressing various potential barriers, such as cost and affordability, multiple dental visits and transportation difficulties, the duration of long-term treatment, concerns about unpleasant appearance, and the need for good oral hygiene maintenance
Interestingly, more than half of the respondents (52.4%) disagreed that orthodontic treatment had an unpleasant appearance [Figure 2]. Orthodontic braces are increasingly popular among young people. Furthermore, alternative treatment options such as custom-made removable plastic aligners have emerged as viable options for those seeking orthodontic treatment without the use of traditional braces and wires.[12] The finding that maintaining good oral hygiene is perceived as a barrier to orthodontic treatment is noteworthy as well. While orthodontic treatment is intended to improve dental health and function, it may require individuals to modify their oral hygiene routine and invest more time in cleaning their teeth and braces. The need for regular cleaning and maintenance can be especially challenging for individuals with busy lifestyles or those who struggle to establish good oral hygiene habits. Additionally, the use of orthodontic appliances can make it difficult to clean teeth properly, which can lead to plaque build-up and increase the risk of tooth decay and gum disease.
Given these challenges, orthodontic patients must receive adequate education and support to maintain good oral hygiene during treatment. Orthodontists should guide proper brushing and flossing techniques, as well as recommend suitable oral hygiene products such as interdental brushes and mouthwashes. Furthermore, regular dental check-ups and cleanings can help prevent oral health problems and ensure that any issues are promptly addressed. By addressing the barrier of maintaining good oral hygiene, orthodontic treatment can be made more accessible and effective for individuals seeking to improve their dental health and appearance.
Although there is no significant difference between age groups regarding barriers toward orthodontic care because the P value is more than 0.05 [Table 5], there are significant differences between genders as most of the responses have a P value of <0.05 [Table 6].
Table 5.
Association between age (18–25 years vs. >25 years) regarding barriers toward orthodontic care
| Questions | Chi-Square (df) | P |
|---|---|---|
| Cost and affordability? | 9.256 (6) | 0.160 |
| Multiple dental visits and transportation difficulty? | 6.844 (6) | 0.336 |
| Long-term treatment? | 8.282 (6) | 0.218 |
| Unpleasant appearance? | 4.383 (6) | 0.625 |
| Require good oral hygiene maintenance? | 3.346 (6) | 0.764 |
Chi-square test, P<0.05 (Statistically significant)
Table 6.
Association between gender (male vs. female) regarding barriers toward orthodontic care
| Questions | Chi-Square (df) | P |
|---|---|---|
| Cost and affordability? | 2.984 (2) | 0.225 |
| Multiple dental visits and transportation difficulty? | 14.125 (2) | <0.001 |
| Long-term treatment? | 9.710 (2) | 0.008 |
| Unpleasant appearance? | 29.022 (2) | <0.001 |
| Require good oral hygiene maintenance? | 1.716 (2) | 0.424 |
Chi-square test, P<0.05 (Statistically significant)
Overall, our study indicated that there is a significant association between age and gender in the knowledge and awareness of malocclusion. Responses from most females and younger age groups showed a higher level of awareness and knowledge regarding malocclusion as compared to their male and older age group counterpart. There are also various factors serving as barriers for the respondent (s) from getting appropriate orthodontic care.
One limitation of most questionnaire studies is that the participants will need to have a considerable amount of education for accurate responses. This falls the same to this study as some participants did not fully understand the dental terms and thus explanation will have to be provided. And when it comes to an online questionnaire, it is disadvantageous as we could not provide the necessary explanation if ever needed. Besides, there is a possibility that participants were dishonest with their knowledge and picked only the most relevant answer instead of reflecting their true understanding. Some respondents may also have questionnaire fatigue and tend to answer randomly without meticulous reading. Nonetheless, the reliability of this study can be improved by having equal distribution of respondents for each gender and group age. Additional demographic parameters and the conduct of a clinical examination may further expand the significance of this study.
It is important to instill knowledge and awareness of malocclusion among society to reduce the risks of further complications such as caries, poor oral hygiene, and plaque accumulation. From this study, we reported that females have higher awareness and self-consciousness regarding malocclusion than males. We also noted that the majority of the female respondents considered “unpleasant appearance” as the barrier to orthodontic treatment. By having the necessary knowledge and awareness, malocclusion interception can be done at an early age using removable, myofunctional appliances in replacement of conventional fixed metal braces. Above and beyond, recent technologies such as clear braces can also be an alternative to most patients who have concerns with their appearance on conventional metal braces. Improvement on recent orthodontic treatment can be done based on this research so that it can be more affordable and patient-compliance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The authors would like to extend their gratitude to the residents of Bandar Saujana Putra, Jenjarom, who participated in this study.
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