International Dental Journal (2004) 54, 138–142

Malocclusions and orthodontic

treatment needs in a group of
Spanish adolescents using the
Dental Aesthetic Index
Adela Baca-Garcia, Manuel Bravo, Pilar Baca,
Arturo Baca and Pilar Junco
Granada, Spain

Objective: To evaluate the prevalence of malocclusion and orthodontic The lack of consensus on a single
treatment need among Spanish adolescents and compare with other criterion for the absence or pres-
populations. Methods: The study sample comprised 744 schoolchildren ence of malocclusion hampers
from urban and rural populations in Granada province (Southern Spain), the epidemiological analysis of
aged from 14–20 years, who had received no orthodontic treatment. The this disorder. A number of differ-
measurement instrument was the Dental Aesthetic Index (DAI). ent indexes are in use, and there
Results: The mean DAI score of the whole series was 25.6 (SD, 7.94). The is currently no universally accepted
distribution of the four DAI grades was: DAI 1, no anomaly or malocclusion, instrument that enables comparison
58.6%; DAI 2, definite malocclusion, 20.3%; DAI 3, severe malocclusion, of the prevalence and incidence of
11.2%; DAI 4, very severe or disabling malocclusion, 9.9%. There were no malocclusion between populations1,2.
statistically significant differences in DAI score between genders or those
Since its development in 1986,
in rural vs. urban residence, but a significant difference was found between
the Dental Aesthetic Index (DAI)3
social classes, with subjects of low social class presenting the worst
scores (p<0.05). Conclusion: The distribution of DAI scores among Span-
has been used in an unmodified
ish adolescents is similar to that reported in other populations.
form to evaluate the incidence of
malocclusions in communities of
Key words: Dental Aesthetic Index (DAI), malocclusion, oral epidemiology different countries 4–9, and has
proven to be a simple, rapidly
applied, reliable index with high
validity. The DAI takes account of
both clinical and aesthetic aspects
of the occlusal situation and was
based on a social acceptability scale
for occlusal conditions previously
developed by the same authors10.
Although the acceptability of some
physical characteristics of the face
varies widely between racial and
cultural groups, the acceptability of
dental features appears to be much
more constant between cultures11.
In 1996, the same authors12 devel-
oped a DAI scale, establishing
four grades of malocclusion and
assigning priorities and orthodon-
Correspondence to: Dr. Adela Baca-García, Facultad de Odontología. Campus de Cartuja tic treatment recommendations to
s/n 18071 Granada, Spain. E-mail: abgbaca@ugr.es each grade, thus increasing the util-
© 2004 FDI/World Dental Press
0020-6539/04/03138-05
 139

ity of their index. The DAI was
included in the latest WHO oral
health survey in 199713, a major
step forward in its acceptance as a
universal method for the assess-
ment of malocclusions.
The DAI has been studied in
several different populations over
recent years but has been little used
to estimate the prevalence of
malocclusion in European countries,
especially in the Mediterranean area.
The application of the DAI to a
Spanish population would contrib-
ute to its validation as a standard
index of malocclusion worldwide.
The present study was designed
to assess the prevalence of
malocclusion among Spanish
adolescents by means of the DAI,
and to analyse any relationship
between the DAI score and the
gender, social level, and residential
setting (rural/urban) of the subjects.
Material and methods
The study sample comprised 848
students at high school or voca-
tional training school in Granada
province (Southern Spain) aged
14–20 years. For the recruitment,
all children within the age range of
the study, from 10 schools repre-
sentative of Granada city and
peri-urban setting, which has
370,000 inhabitants, were randomly
selected, from a total of 48 high
schools. Students were excluded
from the study if they wore an
orthodontic appliance or reported
a history of orthodontic treatment
(n=104, which represents 12.3%,
with non-significant differences
between social levels), following the
procedure proposed by Jenny et
al.14, providing 744 children for the
analysis.
Authorisation for the study was
provided by the directors of the
educational institutions and the
parents or guardians of those
subjects who were minors at the
time of the examination.
The examinations were perfor-
med at the schools, using a light-
weight portable examination light
(in the blue-white colour spectrum),
plane No. 5 mouth mirrors, and
periodontal probes conforming to
WHO specifications. Every student
received a report on their oral
situation.
The data were gathered follow-
ing WHO criteria13 and included:
age in years; gender; profession of
parents, to establish socioeconomic
status according to a 5-point scale
(I=high to V=low)15; residential
setting (rural/urban); and DAI-
measured dentofacial anomalies.
The DAI consists of 10 param-
eters related to dentofacial anoma-
lies according to three dimensions:
dentition, spacing, and occlusion.
The index was determined with
the use of a graduated WHO
probe, recording the nearest whole
millimetre to the measurement
obtained13.
The clinical data were gathered
by two previously trained examin-
ers, one as the main researcher and
the other for inter-examiner agree-
ment testing. The examinations to
test intra- and inter-examiner diag-
nostic agreements were carried out
in over 10% of the study sample
one week after the initial examina-
tion. The intraclass correlation
coefficient of the DAI was above
0.80 for both inter- and intra-
examiner agreements, an adequate
level according to the Landis and
Koch method16.
DAI results were analysed by

Table 1 Frequency distribution malocclusion traits according to DAI components

(n=744)

DAI component Frequency (%)

Missing teeth >1 26 (3.5)

Crowding (incisal segments) 0 176 (23.6)
1 240 (32.2)
2 328 (44.1)
Spacing (incisal segments) 0 644 (86.5)
1 80 (10.7)
2 20 (2.6)
Midline diastema (mm) >1 73 (9.8)
Anterior maxillary irregularity (mm) 0 290 (40.2)
1–2 287 (38.5)
>3 167 (22.4)
Anterior mandibular irregularity (mm) 0 203 (27.3)
1–2 330 (44.3)
>3 211 (28.3)
Overjet (mm) 0–3 597 (80.2)
>4 147 (19.8)
Reversed overjet (mm) >0 34 (4.5)
Open-bite (mm) >0 27 (3.6)
Molar relationship normal 422 (56.7)
one-half cusp 217 (29.2)
one full cusp 105 (14.1)

Baca-Garcia et al.: Epidemiology of malocclusion using the DAI

140

Table 2 Distribution of DAI scores and orthodontic treatment needs of Spanish students (n=744).

DAI score Severity levels Frequency %

< 25 (Grade 1) Normal or minor malocclusion; 436 (58.6)

No treatment need or slight need
26–30 (Grade 2) Definite malocclusion; 151 (20.3)
Treatment elective
31–35 (Grade 3) Severe malocclusion; 83 (11.2)
Treatment highly desirable
> 36 (Grade 4) Very severe (handicapping) malocclusion; 74 (9.9)
Treatment mandatory

Table 3 Frequency, Mean, standard deviations, and statistical correlation of DAI score with
sociodemographic variables.

Variable N % DAI (mean ± SD) Significance

Sex
Male 351 (47.2) 25.5±7.8 texp=0.27 (742 gl)
Female 393 (52.8) 25.7±8.0 p=0.785
Social level
High + medium-high (I+II) (A) 103 (14.6) 25.5±9.1 F exp=4.692, p=0.003
Medium (III) (B) 375 (53.2)) 24.9±6.5 A=B=C; D¹A;B y C
Medium-low (IV) (C) 139 (19.6)) 26.0±8.2
Low (V) (D) 88 (12.4) 28.4±11.3
Residence
Urban 611 (81.9) 25.8±8.2 texp=1.40 (241.41 gl)
Peri-urban 133 (18.1) 24.6±6.3 p=0.162

gender and residential setting with
the Student’s t test, and by social
level with ANOVA; the SPSS-
Windows v.10.01 software pack-
age (SPSS Inc, Chicago, IL) was
used. The 95% confidence inter-
vals were also calculated in order
to compare the mean DAI
obtained between this and other
studies. The absence of overlap
between two intervals was inter-
preted as a statistically significant
difference (p<0.05).
Results
The mean age of the 744 adoles-
cents studied was 15.9 years
(SD=1.53; range, 14-20 yrs); 47%
were male and 87% lived in an
urban residential setting. More than
half of the sample (53%) belonged
to social level III (medium).
Table 1 displays the scores for
each DAI parameter. Absence of
anterior teeth with aesthetic impair-
ment was only observed in 26
(3.5%) of the students. There was a
clear predominance of adolescents
with crowding in one or two
segments over those with spacing.
International Dental Journal (2004) Vol. 54/No.3
The low prevalence in Spanish
adolescents of midline diastema
(9.8%), reversed overjet (4.5%), and
open-bite (3.6%) should be high-
lighted.
More than half the adolescents
presented DAI grade 1 (58.6%),
i.e., a minor malocclusion or no
anomaly, with no need or slight
need for orthodontic treatment.
Table 2 shows the distribution and
percentage of adolescents with each
DAI grade. The mean DAI of the
whole series was 25.6 (SD, 7.94).
Table 3 exhibits the distribution
of the adolescents by gender, social
level, and residential setting and the
influence of these parameters on
the DAI score. Statistically signifi-
cant differences were only found
for social level; higher DAI scores
were presented by adolescents of
low social level versus the other
three levels, between which there
were no significant score differences.
Discussion
The DAI appears to be one of the
most promising candidates for an
index of malocclusion that can be
universally applied without the need
for modifications or adaptations
to different ethnic or cultural
settings. Authors who compared
the DAI with other malocclusion
indexes used in epidemiological
studies confirmed it to be a valid,
reliable, and easily applied instru-
ment17,18. It has been successfully
used in numerous studies, which
found no differences in the percep-
tion and acceptance of occlusal
conditions among populations in
America (white and native
populations), Australia, Thailand,
Germany, Japan, Nigeria, and
Singapore (Chinese and Malay
populations)4,7. Cons et al. concluded
that the DAI can be used to assess
orthodontic treatment needs in
both industrialised and developing
countries19.
Nevertheless, the DAI is not
exempt from drawbacks: it fails to
detect certain occlusal disorders that
may have major aesthetic impact,
such as deep bites or posterior
cross-bites, and it takes no account
of the shape, size, or colour of
teeth and gums. Moreover, the DAI
was designed for application in
 141

Table 4 Mean, standard error (SE) and 95% confidence intervals of DAI scores on different
populations

Study Population n Age Mean DAI SE 95% CI

14
Jenny et al. 1991 White American 1337 13–18 26.5 0.20 26.1 to 26.9
Native American 485 13–18 31.8 0.35 31.1 to 32.4
Ansai et al . 1993 4 Japanese 409 15–18 30.5 0.41 29.7 to 31.6
Estioko et al . 1994 5 White Australian 268 12–16 24.1 0.39 23.3 to 24.8
Katoh et al. 1998 6 Japanese 1029 15–29 30.1 0.25 29.6 to 30.6
Chinese in Taiwan 176 18–24 25.9 0.41 25.0 to 26.7
Native American 485 13–18 31.8 0.35 31.1 to 32.4
Otuyemi et al. 1999 8 Nigerian 703 12–18 22.3 0.22 21.8 to 22.7
Esa et al . 20019 Malay, Chinese and 1512 12–13 24.6 0.17 24.2 to 24.9
Indian in Malaysia
Present study Spanish 744 14–20 25.6 0.29 25.0 to 26.2

Table 5 Distribution of DAI grades in four different populations.

Study Population DAI 1 DAI 2 DAI 3 DAI 4

Estioko et al . 1994 5 White Australian 63.4 18.7 11.9 6.0

Otuyemi et al 1999 8 Nigerian 77.4 13.4 5.5 3.7
Esa et al . 20019 Malay, Chinese, Indian in Malaysia 62.6 19.6 10.6 7.2
Present study Spanish 58.6 20.3 11.2 9.9

individuals with permanent denti-
tion and is recommended for use
in children above 12-years-old,
whereas the prevalence of
malocclusion and care needs must
often be assessed in children with
mixed dentition. This may be a
limitation to its value as a universal
instrument, suggesting that more
than one epidemiological index
would need to be used. On the
other hand, its authors have
demonstrated that, although best
suited to permanent teeth, the DAI
can be applied to mixed dentition20.
Table 4 shows the comparison
between the present results and
those reported in different
populations by authors who also
used the DAI to measure
malocclusion. Wearers of ortho-
dontic appliances and individuals
with a history of orthodontic treat-
ment were excluded from all these
studies, with the exception of one
investigation9 that only excluded
those under orthodontic treatment
at the time of the examination. The
similarity of the age intervals and
methodologies used by these stud-
ies means that their results can be
compared. According to these stud-
ies, Nigerians presented significantly
fewer dentofacial anomalies (lower
DAI score) compared with white
Americans, Australians and Span-
iards, and therefore had less need
for orthodontic treatment. Ansai et
al.4 and Katoh et al.6 reported that
Japanese and native American
populations, both peoples of
Asiatic origin, showed significantly
higher overall DAI scores versus
the other populations, suggesting
that occlusal differences may be
genetically determined. The Span-
ish adolescents in the present study
presented a significantly similar
degree of dentofacial anomaly
(DAI score) to that reported for
Caucasians in America 14 and
Chinese in Taiwan6.
The scant studies that have
described the percentage distribu-
tion of the four DAI grades
presented similar results to those
observed in the present study. The
most marked differences were
between the percentages of Nige-
rian adolescents and those of the
other populations, an expected
result given the lower DAI score
of the former (Table 5).
Among the sociodemographic
indicators studied, only the social
level was significantly associated
with the DAI score (Table 3). Ansai
et al.4 and Esa et al.9 found signifi-
cantly worse scores in individuals
from urban versus rural areas.
Although the present adolescents
from a peri-urban setting also
showed a tendency to a better score
in the present study, the differences
did not reach significance.
The DAI score of Spanish
adolescents is similar to that
reported for Caucasians in America
and Chinese in Taiwan. However,
further studies are required to
determine whether malocclusion
patterns are reasonably homoge-
neous among ethnic and national
groups.
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