Psychosocial impact of dental aesthetics among sudanese high school students

Objetivo: a estética dental é parte essencial da atratividade facial e desempenha um papel vital na vida social, bem como no bem-estar psicológico dos indivíduos. Este estudo teve como objetivo avaliar o nível de estética dental pela auto-avaliação do Componente Estético (CE) do Índice de Necessidade de Tratamento Ortodôntico (INTO) e o impacto psicossocial da estética dental utilizando o Questionário de Impacto Psicossocial da Estética Dental. Material e Métodos: um total de 192 estudantes do ensino médio (13-16 anos), distribuídos igualmente entre os sexos, participaram do estudo. Os estudantes responderam uma versão modificada do Questionário de Impacto Psicossocial da Estética Dental. A estética dental foi avaliada pelo Componente Estético do Índice de Necessidade de Tratamento Ortodôntico (autoavaliação). Os dados foram processados e analisados utilizando software”SPSS” (Statistical Package for Social Sciences) versão 17. O Teste t foi utilizado, com nível de significância de 5%. Resultados: todas as variáveis do questionário de impacto psicossocial mostraram uma diferença significativa com os grupos da avaliação do Componente estético (p < 0,05). Também foi encontrada uma diferença significativa entre os sexos. Conclusão: a auto-percepção da estética dental tem uma forte influência sobre a percepção psicológica, bem como com o bem-estar social dos indivíduos. Portanto a auto-percepção da estética dental talvez seja uma chave importante na decisão sobre a necessidade de tratamento ortodôntico. AbstRAct


INtRoDuctIoN
H umans are aware of facial and body aesthetics as there is plenty of evidence the appreciation of beauty or physical attractiveness in pre-historical archaeological artefact.Aesthetics is defined as the branch of philosophy dealing with beauty.In dentistry, a philosophy concerned especially with the appearance, function and symmetry of the face, oral cavity and the teeth [1].
Malocclusion is defined as an anomaly which causes disfigurement or which impedes function, and requires treatment, if the disfigurement or functional defect was likely to be an obstacle to the patient's physical or emotional wellbeing."Malocclusionmight be associated with; malalignment of individual teeth in each arch, mal-relationship of the dental arches relative to the normal occlusion (in anteroposterior, vertical or transverse planes) [2].
For the most time, orthodontists have considered dental health, function as well as the health of the supporting structures as the main goals of orthodontic treatment, however social and psychological wellbeing are now being included in the outcomes for the treatment of malocclusion [3,4].
It is believed that patient's expectations for orthodontic treatment are the improvement of social contact and dental self-confidence, this is supported by studies that focused on certain aspects of oral health related quality of life as it was found that individuals with malocclusion suffered from its negative impacts in relation to the oral health related quality of life and its domains, the reported impacts were greatest in younger people and those with a university education [5].Khan and Fida, stated that: "Being part of a social network, there is an inherent need for one to feel accepted" [6].
A various number of indices and investigations were developed to measure the degree of malocclusion and dental aesthetics [7][8][9][10].The Index of Orthodontic Treatment Need (IOTN) was developed by Brook and Shaw, it is a scoring system that ranks malocclusion based on occlusal traits for oral health and aesthetic impairment, Aesthetic Component (AC) of the IOTN has commonly been used to evaluate treatment need on aesthetic grounds assessed by dentists (operator-rated) or patients (selfrated) [7].
Ulrich Klages et al. developed a psychometric instrument for assessment of orthodontic specific aspects of quality of life, using a pool of 23 items dealing with the psychosocial impact of dental aesthetics and concluded that the proposed instrument, termed the 'Psychosocial Impact of Dental Aesthetics Questionnaire' (PIDAQ), meets the criteria of factorial stability across samples and criterionrelated validity and reliability, and might be a promising tool for further research and clinical application in orthodontics [9].
Worldwide several studies were carried out to identify the treatment needs of patients, their preferences and what is best for their outcomes of treatment.Other studies were conducted to discuss the prevalence and severity of malocclusion among different genders, age groups and even racial or ethnic groups [3,11,12].
Recently efforts were made to investigate and describe the problem of malocclusion in a more aesthetic point of view as well as its relationship with the self-confidence of individuals and also their social interactions in a community [13][14].
Several researches and studies were conducted to review the self-awareness of individuals on malocclusion to determine their treatment needs, rate their satisfaction with the treatment outcomes, however little remains said about the outcome of not treating malocclusions and poor dental aesthetics.Therefore this study aimed to assess the level of the dental aesthetics and its psychosocial impact among a sample of high school students in Khartoum, Sudan.

mAteRIAl AND methoD
First the study was proved by the research committee at the faculty of Dentistry, University of Medical Sciences and Technology and the Ministry of Education as well as from the selected high schools.From November 2014 to March 2015 the fieldwork was carried out by the main researcher.
The study population consists of 192 high school students aged 13 to 16 years old in 14 schools selected randomly from all the boys and girls high schools in Khartoum area, Sudan.
Students who have met the inclusion criteria; Sudanese nationality, students with no current or previous history of orthodontic treatment, no facial deformities or syndromes, no clear lesion in the anterior segment due to caries, filled or traumatic injuries or hypoplasia or fluorosis and the ones who agree to participate in the study,were selected randomly and all students were first informed about the aims of the study and all the steps which were required to collect the data.
Once consent had been obtained from the selected students, firstly, they were assessed for the severity of the dental aesthetics using the Aesthetic Component of the Index of Orthodontic Treatment Need (IOTN-AC).[7] They were presented with 10 colour photographs of anterior teeth showing varying degrees of malocclusionand asked to indicate which grade of photograph (1 to 10) they thought most closely resembled their own dentition (Appendix 1).
There was no time limit given to the participants for the self-rating of AC.The IOTN-AC self-rating was then used in grouping the subjects according to the grades that they had chosen, namely; IOTN-AC grade 1, IOTN-AC grade 2, IOTN-AC grade 3 and IOTN-AC grade 4 and above.
For assessing the impacts of the IOTN-AC grades chosen by the respondents, a modified version of the 'Psychosocial Impact of Dental Aesthetics Questionnaire' (PIDAQ) was used.[9]the questionnaire was self-administered by the subjects.A total of four variables including 'Dental Self-confidence', 'Social impact', 'Psychological impact' and 'Aesthetic concern' were assessed by a series of relevant statements (Appendix 2).
The data was processed and analyzed using computer software program "SPSS" (Statistical Package for Social Sciences) version 17.The results were then analyzed and correlated with those of the Aesthetic Component of the Index of Orthodontic Treatment Needs (IOTN-AC) and the final results obtained were presented in the form of tables and figures.T-test has been used, P-value of less than 0.05 was considered as significance.

Results
The study sample consisted of 192 students (13-16 years old) of whom 96 were selected from each gender.
In Figure 1, the majority of the students was found to have IOTN-AC grade 2 and very few reported to have IOTN-AC grade 4 and above.In Table 1 it clear that the 'Dental self-confidence' was found to be greatest in respondents with IOTN-AC grade 1 (mean value = 15.17) and least for IOTN-AC grades 4 and above (mean value = 3.33).'Social impact' was found to be highest with IOTN-AC grades 4 and above (mean value = 14.90) and lowest with IOTN-AC grade 1 (mean value= 4.80).'Psychological impact' was found to be greatest in greatest in respondents with IOTN-AC grades 4 and above (mean value = 15.33) and least for IOTN-AC grade 1 (mean value = 4.45).'Aesthetic concern' was found to be highest with IOTN-AC grades 4 and above (mean value = 9.00) and lowest with IOTN-AC grade 1 (mean value = 1.48).
For the male high school students, 'Dental self-confidence' was found to be greatest in respondents with IOTN-AC grade 1 (mean value = 18.60) and least with IOTN-AC grades 4 and above (mean value = 1.89).'Social Impact' was found to be greatest with IOTN-AC grades 4 and above (mean value = 9.63) and least with IOTN-AC grade 1 (mean value = 3.91).'Psychological Impact' was found to be highest with IOTN-AC grades 4 and above (mean value Table 1 -The Psychosocial Impact of Dental Aesthetics Questionnaire scores in comparison to the IOTN-AC groups for the students = 10.13) and lowest with IOTN-AC grades 1 (mean value = 3.26).'Aesthetic Concern' was found to be greatest with IOTN-AC grades 4 and above (mean value = 7.75) and least with IOTN-AC grade 1 (mean value = 1.31).
For the female high school students, 'Dental Self-Confidence' was found to be highest with IOTN-AC grade 1 (mean value = 11.17) and lowest with IOTN-AC grades 4 and above (mean value = 4.23).'Social Impact' was found to be greatest with IOTN-AC grades 4 and above (mean value = 18.15) and least for IOTN-AC grade 1 (mean value = 5.83).'Psychological Impact' was found to be greatest with IOTN-AC grades 4 and above (mean value = 18.54) and least with IOTN-AC grade 1 (mean value=5.83).'Aesthetic Concern' was found to be greatest with IOTN-AC grades 4 and above (mean value = 9.77) and least with IOTN-AC grade 1 (mean value = 1.67)Table 3.
An inter-gender significant difference among the high school students in relation to the 'Psychosocial Impact of Dental Aesthetics Questionnaire' scores (P-value < 0.05) was found as shown in table 4.

Psychosocial impact of dental aesthetics among sudanese high school students
Abualella M et al.

DIscussIoN
This is a cross section study carried out among high school Sudanese students to assess the level of dental aesthetics by the self-rated Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN) and the psychosocial impact of dental aesthetics using the 'Psychosocial Impact of Dental Aesthetics Questionnaire' (PIDAQ).The results revealed that Self-perceived dental aesthetics has a strong influence on the psychological as well as the social wellbeing of individuals The majority of the Sudanese students rated themselves as IOTN-AC grade 2 which corresponds to the values obtained by Munizeh Khan Et al. in a study among 120 Pakistani adults of more than 18 years old in which the majority of respondents rated themselves as IOTN-AC grade 2 [6].However it is in contrast with Klages et al. findings which reported that the majority of respondents had IOTN-AC grade 1. [9]IOTN-AC grade 4 was the least to be found among the Sudanese students which was in line with the results recorded by Bellot-Arcísina study among 627 Spanish adolescents (age group: 12-15) and with another study among 194 Dutch university students (age group: 18-30 years ) by Klages et al. [13,17] When the two genders were compared, the majority of the students reported to have IOTN-AC grade 2 and the least number reported to have IOTN-AC grade 4 and above.Although the IOTN-AC findings were almost similar for the two genders, it is in the way each was affected that the significant difference was noted.'Dental Self-Confidence' entity of the questionnaire aims to assess the level of acceptance of individuals' dental appearance and it was observed that in the present study the level of 'Dental Self-Confidence' follows an inversely proportional relationship with the grades of the IOTN-AC where in higher IOTN-AC grades the level of 'Dental Self-Confidence was noted to decrease.Similar findings were observed by Khan and Fida, Klages et al. and Klages et al. [6,9,13] The study showed the strong association between the higher grades of the 'Aesthetic Component' of the 'Index of Orthodontic Treatment Need' (indicating poor dental aesthetics) and the increase in the scores of the 'Social Impact', 'psychological Impact', and 'Aesthetic Concern' entities of the 'Psychosocial Impact of Dental Aesthetics Questionnaire' which concluded the strong influence of disturbed dental aesthetics on the psychosocial wellbeing of individuals which corresponds to the findings obtained by de Paula et al., among 301 Brazilian adolescents (age group: 13-20) [14].
A significant difference was found between male and female students in terms of the impact of dental aesthetics on the psychosocial wellbeing and similar observations were found by Bellot-Arcís et al. among 627 Spanish adolescents (age group: 12-15) and on the other hand Yaghma Masood et al. has concluded that no significant difference was found between males and females regarding the impact of malocclusion on the quality of life among 323 Malaysian young adults (age group: 15-25) [5,17].
It was also reported that females were affected more negatively by disturbed aesthetics where as positive impact was found to be higher in the male students which could be explained by the long known concept of females having to show beauty and thus are more negatively affected and on the other hand males having to show masculinity therefore are not affected as negatively as females are and so have higher dental self-confidence.
The variation in the results among different study populations may be partially attributed to differences in the sample size, man power, ethnic background as well as the age of the study samples.
Remains strong the relationship between malocclusion and the psychosocial wellbeing of individuals regardless of their age as clarified by the present study, for this reason it is wise and advisable to use self-perception of dental aesthetics in the determination of treatment need along with the dentists' perception of the aesthetic problem for this reason the IOTN-AC is a reliable tool for assessing the severity of malocclusion from the eyes of the patients rather than the dentists' alone.
One can conclude that individuals with disturbed dental aesthetics may have a reduced or less than normal performance in the social domain and therefore the education domain which affect ones latter life.Further research with additional tools for assessment of self-perceived dental aesthetics must be set up to provide more knowledge about the psychosocial impacts of dental aesthetics among different populations with larger sample sizes and age groups.

Figure 1 -
Figure 1 -Distribution of IOTN-AC scores among the students.

Table 2 -
The 'Psychosocial Impact of Dental Aesthetics Questionnaire' scores in comparison to the IOTN grades for the males

Table 3 -
The 'Psychosocial Impact of Dental Aesthetics Questionnaire' score in comparison to the IOTN grades for the females

Table 4 -
The 'Psychosocial Impact of Dental Aesthetics Questionnaire' scores among gender