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J Am Dent Assoc, Vol 139, No 5, 598-604.
© 2008 American Dental Association |
RESEARCH |
Orthodontic Treatment Need and Demand
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ABSTRACT |
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 TOP ABSTRACT APPALACHIASUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Methods. Fifty-eight adolescents (ages 12–17 years) and 78 of their parents underwent an orthodontic examination as part of a larger study on oral health in two rural West Virginia counties. Two orthodontists used a standardized index to rate their need for orthodontic care. Participants were interviewed regarding their demand for and history of orthodontic care.
Results. The study results show that parents had a high rate of complete or partial edentulism, an infrequent history of orthodontic treatment, great unmet orthodontic need and less demand for orthodontic care than was suggested by their clinically determined need. The adolescents were similar to national norms with regard to orthodontic treatment history and need, but lower with regard to demand.
Conclusions. The adolescents’ similarity to general population norms with regard to previous orthodontic care and level of occlusal status is promising. Nevertheless, their lower recognition of a need for treatment suggests possible future oral health problems and a lower oral health quality of life. Their parents, however, were considerably worse off, in comparison with their adolescent children and adult comparison samples, with regard to orthodontic care and other oral health status measures.
Clinical Implications. Culturally sensitive psychoeducational methods to promote recognition of oral health needs may be required among adolescents in Appalachia to have an impact on oral health values and to prevent oral health problems. Issues of orthodontic care utilization and, perhaps, access to care need to be addressed among adults in Appalachia.
Key Words: Oral health disparities; Appalachia; West Virginia; orthodontics; access to care; utilization; treatment need; treatment demand
Abbreviations: IOTN: Index of Orthodontic Treatment Need. • NHANES III: Third National Health and Nutrition Examination Survey.
During the past decade, there has been increasing focus nationally on the oral health problems of specific population groups in the United States, as evidenced by the surgeon general’s report in 2000.1 Certain ethnic and cultural minority groups suffer greatly because of relatively greater amounts of oral disease. People who reside in rural areas are particularly vulnerable to oral health problems, given issues of utilization and access to care, primarily the result of geographic, economic and socio-cultural barriers.2
Oral health in West Virginia and elsewhere in Appalachia.
Despite presumed rampant oral health problems, virtually no comprehensive information is available to document the oral health status of people in West Virginia. Moreover, the need exists to conceptualize the broad array of factors, including oral health values,6 that may be creating the disproportionate burden of oral disease in this state, as well as in other areas of Appalachia. A major project (from the Center for Oral Health Research in Appalachia) is under way in West Virginia and Pennsylvania with the goal of documenting the extent of the problems and of elucidating the pathways leading to poor oral health in Appalachia.7
Utilization of oral health care services in West Virginia is extremely poor, as demonstrated by the fact that in 2006 the state had the greatest proportion of edentate people of any state or jurisdiction in the nation, and it was one of the states with the fewest annual oral health care visits.8
Social and cultural issues.
Cultural views on malocclusion and other psychosocial factors are known to influence the demand for orthodontic treatment.9 Data suggest that the demand for orthodontics is greater in urban rather than rural areas despite the need being the same.10,11 Certainly, social norms in West Virginia and other areas of Appalachia contribute to oral health values, perhaps based in part on less recognition of the importance of maintaining the natural dentition and a lower desire to change the occlusal status of one’s anterior (and other) teeth.6 Nevertheless, significant efforts are being made to improve the oral health and overall health of rural West Virginians and other Appalachian people.12 In spite of many health and social challenges faced by people in Appalachia, the region and its people possess many strengths, including values that emphasize self-determination, connection to one’s extended family and community, and spirituality, all of which may be health-protective factors.13
Orthodontics.
Virtually no information is available regarding orthodontic treatment demand and need in West Virginia and elsewhere in Appalachia. This issue may be particularly salient, given the all-too-frequent stereotypes of Appalachian people being partially or completely edentulous or having Class II malocclusion. Mal-occlusion of the anterior teeth has tremendous social impact in terms of perceived attractiveness, employability and school functioning.14 Johal and colleagues15 reported that occlusal traits such as increased overjet and spaced dentition have a negative effect on oral health quality of life among adolescents and their families.
Consequently, orthodontic issues may well be important in the Appalachian population, which historically has been beset with numerous educational, health and social disadvantages, including being the target of stereotypes. In orthodontics, both demand (that is, a patient’s and/or parent/caregiver’s desire for treatment) and need (clinically determined occlusal status), as well as other factors (for example, access to care, economic issues, psychosocial issues), determine whether a patient will receive treatment.14
Objectives and hypotheses.
Because little is known about occlusal status in the historically isolated, relatively homogenous Appalachian population, we designed this study to provide information about the need and demand for orthodontic treatment in this group. We hypothesized that there would be less use of orthodontic services in this West Virginia sample and similar need, but lower demand, for these services compared with levels in other studies and populations.
Assessment.
We used Angle’s system to classify patients, along with an assessment of crowding, overjet and overbite, as well as the presence of any anterior/posterior crossbite. In addition, we noted the absence of permanent dentition and the presence of any fixed or removable dental appliances. Similar to the conceptualization of Proffit and colleagues,14 we defined orthodontic treatment need as clinically determined malocclusion. We also defined orthodontic treatment demand as the desire to receive orthodontic care for oneself (or one’s child or significant other).
We quantified the need for orthodontic treatment by using the dental health component of the Index of Orthodontic Treatment Need (IOTN),18 as judged by an orthodontist (C.A.M.). Consistent with other research,19 IOTN categories included the following severity ratings:
A board-certified orthodontist (P.W.N.) served as the gold standard for the IOTN training of the assessing orthodontist (C.A.M.). The board-certified orthodontist later analyzed the paper record of the molar relationship data provided by the assessing orthodontist and made an independent IOTN rating. The two orthodontists were highly reliable in their IOTN assessments (r = .98, P < .01). They resolved any discrepancies in a consensus meeting. We indexed patients’ demand for orthodontic treatment according to an interview conducted by trained research assistants, who used Third National Health and Nutrition Examination Survey (NHANES III)20 wording. We also used NHANES III wording to interview participants regarding current or previous orthodontic treatment status.
Procedure.
We randomly selected potential participants from a list of active and inactive patients of a primary care medical center in the two-county study area. Clinic staff members telephoned these people to invite them to participate. We conducted the entire project protocol at the same primary care center. Each participant received monetary compensation for time and travel costs. Participants were part of a larger study by the Center for Oral Health Research in Appalachia of general health and behavioral and genetic factors in oral health. The research protocol at this rural primary care center involved an interdisciplinary team of dentists, psychologists, geneticists, microbiologists, nurses and other health care professionals who collected data for various behavioral, general health and oral health measures, including data from an orthodontic examination.
Ethical approval.
The Institutional Review Board at West Virginia University, Morgantown, approved the study protocol. All adult participants gave written informed consent for involvement in this study; adolescents gave written assent and we obtained written informed consent from their parents for them to participate.
Statistical methods.
A trained supervised research assistant entered data into a database, and we inspected them for missing values and outliers. We used Z tests for significance of differences between proportions to analyze results. We used the .05 level as the minimal standard for statistical significance.
APPALACHIA
TOP
ABSTRACT
APPALACHIA
SUBJECTS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
A unique and identifiable cultural group, the residents of Appalachia bear a disproportionate degree of oral disease. West Virginia is the only state among 13 in the region that is categorized as being encompassed entirely within Appalachia,3 and so it is an important source of information about the region. Referred to as a "neglected minority,"4 the Appalachian population historically has been identified as among this country’s most impoverished and often is depicted according to generally negative stereotypes.5
SUBJECTS AND METHODS
TOP
ABSTRACT
APPALACHIA
SUBJECTS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
Study population.
Fifty-eight adolescents participated in this study (age range, 12–17 years; 34 girls and 24 boys). They had a mean age of 14.6 years (standard deviation [SD] = 1.6 years). One or both of each adolescent’s biological parents (n = 78; age range, 32–54 years; 55 mothers and 23 fathers; mean age = 42.1 years; SD = 5.5 years) also participated. All participants were white; this is consistent with the population demographics of West Virginia, in which people belonging to ethnic and racial minorities make up less than 5 percent of the population.16 The child, the parent or both were patients of record at a single primary care medical center that served residents of Webster and Nicholas counties, West Virginia. These two counties have Beale codes (which indicate the degree of rurality or urbanization and population density) of 6 or greater (on a 1 to 9 scale, with a 9 indicating greater rurality), indicating that both counties are nonmetropolitan and appropriately classified as rural.17 Participants were part of a larger study of general health and behavioral and genetic factors in oral health.
RESULTS
TOP
ABSTRACT
APPALACHIA
SUBJECTS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
History of orthodontic care.
As shown in Figure 1
, we found that an approximately equal proportion of Appalachian adolescents in this study (17 [29.3 percent] of 58) had received (or currently were receiving) orthodontic treatment compared with the NHANES III sample of white adolescents (27.4 percent) in the same age range (12–17 years)19 (z = .32, P > .10). By contrast, of the 78 parents, only four (5.0 percent) had ever received orthodontic care (Figure 1). In the NHANES III sample, 22.2 percent of white adults (aged 18 to 50 years) reported a history of orthodontic treatment.21 In comparison with this national sample, a significantly lower proportion of Appalachian parents had ever received orthodontic treatment (z = 3.66, P < .01). Proportionally more of the Appalachian children had received orthodontic treatment compared with their parents (z = 3.89, P < .001).
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2), including five with a history of having received orthodontic treatment (Figure 2). An additional 12 were currently in treatment or had been in treatment in the past. The orthodontist assessed the remaining nine adolescents as having no orthodontic treatment needs. Of the 31 adolescents requiring care, 19 were evaluated as having a Class I malocclusion and 12 were evaluated as having a Class II malocclusion; no adolescents had a Class III malocclusion. The treatment needs of this sample of adolescents were similar to those of white adolescents in the NHANES III sample across all IOTN categories19 (z = .48, P > .10).
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2), including one with a history of orthodontic treatment (Figure 2
). An additional three parents (7.9 percent) were currently in treatment or had been in treatment. The orthodontist evaluated the remaining five parents (13.2 percent) as having no orthodontic needs.
Of the 30 parents requiring orthodontic care, 16 had a Class I malocclusion, 11 had a Class II malocclusion and three had a Class III malocclusion. Relatively fewer data are available regarding the orthodontic needs of adults relative to adolescents, but in comparison with an international sample22 in which 31.5 percent of adults demonstrated orthodontic need, our sample of Appalachian parents had more unmet needs (z = 4.74, P < .0001). Moreover, significantly fewer adolescents in our sample needed orthodontic treatment relative to their (dentate) parents (z = 1.97, P < .05). Figure 2 shows the data for Appalachian parents and their children.
Treatment demand.
We also evaluated the data regarding treatment demand for the 52 adolescents who underwent orthodontic examinations. As shown in Figure 3, 18 adolescents (34.6 percent) indicated a demand for treatment, including one (1.9 percent) for whom there was no documented need. Fourteen adolescents (26.9 percent) did not indicate a demand, although the orthodontic evaluation documented a need. We can compare this demand with other data23 showing a treatment demand of 47.6 percent among similarly aged subjects. In comparison, adolescents in this Appalachian sample expressed lower demand overall for orthodontic treatment (z = 1.88, P < .05 [one-tailed]).
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also illustrates that of the 38 dentate parents in the earlier analyses, 14 (36.8 percent) reported a demand for treatment, including two (5.2 percent) for whom no need was documented. Eighteen others (47.4 percent) did not report a demand, despite the orthodontic evaluation’s documenting a need, as indicated by the IOTN ratings. In comparison with an international sample22 in which 19.2 percent of adults indicated a desire for orthodontic treatment, proportionally more of this Appalachian sample of parents recognized their need for treatment (z = 2.02, P < .05). Although we found no difference in demand between Appalachian parents and their children (z = 0.22, P > .10), significantly more parents had an unrecognized need for treatment (that is, they had a need without a demand) relative to their children (z = 2.00, P < .05). |
DISCUSSION |
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TOPABSTRACTAPPALACHIASUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Compared with national, age-related norms,21 as well as with their children, disproportionally fewer Appalachian parents had received needed orthodontic care in the past (or present). Moreover, our study results showed a great deal of unmet need for orthodontic treatment among these adults, in comparison with a normative sample and the adolescents in our sample. Consistent with the high degree of treatment need, these parents reported more demand than did a normative sample, but they did not differ from their children in this regard. Nevertheless, parents had more unrecognized need for care than did their children.
Hypotheses. Our first hypothesis—that there would be less use of orthodontic services relative to age-appropriate segments of the general U.S. population—was confirmed in the adults, but not in the adolescents. The second hypothesis—that subjects would have similar need but lower demand than other populations—was supported only in part. Compared with data from other studies and populations, the adolescents in our study had similar treatment needs,19 while the adults had greater needs.22 The demand for orthodontic care was lower among these adolescents and greater among their parents relative to normative values.
Our study results indicate that there may be generational effects in that the trend to receive orthodontic care was higher in adolescents than in their parents and that treatment need among Appalachian adolescents was not greater than, but similar to, that found nationally.19 Nevertheless, the level of treatment demand still was significantly lower than published norms,23 which may be related to oral health values.6 Also, the demand for orthodontic treatment in this sample was much lower than the clinically identified need, which has lifelong implications for oral health status in terms of seeking necessary dental services. This lower demand may translate into less pursuit of oral health care services to improve occlusion later in life, which may be associated with poorer functionality and with lower oral health quality of life.
Despite high levels of clinically determined need, many parents did not indicate that they needed orthodontic care. This finding may be related to the relatively high number of parents who declined the orthodontic examination. Anecdotally, a number of these parents indicated to the researchers that instead of receiving this examination themselves, they wanted to ensure that the greatest focus was on their children’s oral health, even in this research-based evaluation in which no treatment was provided. As Heaton and colleagues2 suggested, there may be greater use of emergency rather than preventive oral health care services elsewhere in Appalachia; consequently, orthodontic treatment may be affected particularly. This disparity between Appalachia and other areas of the country in receiving preventive care among adults has psychosocial and oral health implications, which potentially are intergenerational. The adolescents in this study currently are at about the same level as adolescents of the same race and ethnicity across the United States with regard to their history of orthodontic care and treatment need.19 However, when they reach their parents’ ages, these adolescents’ relatively low present demand for treatment compared with that of similarly aged adolescents internationally23 may translate into a poorer objective oral health status.
Study limitations. Regarding limitations of this study, all participants had a connection to a primary care health center, so there may have been sampling bias. As with most other research, volunteers for an oral health study may differ from those who decline to participate. Although we assessed participants’ beliefs about their need for orthodontic treatment, it would have been helpful to include the esthetic component of the IOTN assessment, because that would have allowed another perspective on treatment need. These results must be viewed with some caution, given the relatively small sample size. Moreover, we cannot assume that these participants represented all of Appalachia. As with any cultural or racial/ethnic group, there is diversity within Appalachia as a region.
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CONCLUSIONS |
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TOPABSTRACTAPPALACHIASUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTAPPALACHIASUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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