Indexing occlusions for dental

public health programs

A. S. Gray, D.D.S., D.D.P.H., M.Sc., F.R.C.D.K),* and
Arto Demirjian, D.D.S., M.3c.D.
Victorin, British Columbia, Canada

P ublic health can be defined as the scientific diagnosis and treatment

of the health needs of the community as an entity.l This suggests a cooperative
approach to the problem by the clinical practitioner on the one hand, supplying
the needed treatment services, and the public health practitioner on the other
hand, supplying the epidemiologic investigation and public health education
methods that will cause the population to seek the clinical services needed to
prevent, arrest, or correct such conditions.
One of the reasons such activities have not been well developed as a part of
dental health programs apparently has been the lack of a widely accepted index
of malocclusion that could be used with confidence by public health workers. This
index would also have to be accepted by the clinician as a measure of the amount,
of deviation from the normal condition a person presents.
Many attempts have been made over the years to create an index. It is t,he
purpose of this study to select the most promising o-f these and to compare them
with each other and with the subjective opinions of orthodontists. From this in-
vestigation, it is hoped that a method can be standardized which will provide a
descriptive analysis for use with persons in dental public health programs, and
with groups, for purposes of epidemiologic investigations.
From a review of the literature, it appears that reliable estimates of the
prevalence of malocclusion have been difficult to establish. This has probably
been due to the fact that most classifications and studies on the epidemiology of
malocclusion have been qualitative in nature and subjective in method. The most
commonly used qualitative assessment of malocclusion is the Angle2 classification
of malocclusion, so that Class IT, Division 2 paints a. word picture for most

*Assistant Director, Division of Dental Health Services, Department of Health,

Victoria, B.C., Canada.

191
192 Gray md Demirjinu Am. J. Orthocl.
August 1977

dentists. However, difficulty has been reported in achieving accord in classifica-

tion at times (for example, in cases where premature extraction of first molars
has presented a confusing picture). Difficulty has also been evident in separating
normal occlusions from Class I malocclusions. It may be true that, as Hellman
says, ideal occlusion is really only a useful myth and that it occurs seldom in
nature. This seems surely to be true if normal occlusion is supposed to approach
the ideal. What has been missing is a quantitative index which would establish
limits to show how far from ideal is still normal and to separate abnormal cases
according to different levels of severity and need for corrective treatment.
Most reliable assessments of malocclusion must be made on the permanent
dentition only, as the individual variations of growth patterns at the mixed-
dentition stage may improve or worsen the condition.
Angle’s classification, modified by the Dewey-Anderson3 method, best de-
scribes the qualitative state of an occlusion, particularly when the presence or
absence of mutilation from extraction is recorded. One review also suggests that
many subjective inconsistencies would be eliminated if ideal and normal cate-
gories were eliminated and qualitatively scored as Class I’s, with an additional
quantitative index which would enumerate how far each occlusion deviates from
the ideal. Such a system would be useful when one was working with individuals
and with groups on an epidemiologic basis.
The most promising of the quantitative methods which are available for
evaluating the severity of a malocclusion appear to be the Handicapping Labio-
lingual Deviation HLD) Index of Draker,4 the Treatment Priority Index (TPI)
method of Grainger,” the Occlusal Index (01) method of Summers,fi and the
AA0 Handicapping Malocclusion Assessment (HMA) developed by Salzmann’
when he was chairman of the Association’s Council on Orthodontic Health Care.
This study will compare the reproducibility and accuracy of the four systems
and the subjective assessments of orthodontists.

Study material and methods

The study sample was drawn from the children who are participating in the
mixed longitudinal growth and development study being carried out at the Re-
search Centre on Growth and Development, Faculty of Dentistry, University of
Montreal, under the direction of Arto Demirjian. These children form a random
sample of Montreal students of French-Canadian background of at least three
generations. Only children who were 12 pears of age and had shed all their decid-
uous teeth were included in the study. Another requisite was that adequate den-
tal models were available for each child. No sex differentiation was made.
None of the children had ever received orthodontic treatment, was receiving
orthodontic treatment, or had ever been presented for orthodontic treatment as
far as is known. From the 250 12-year-old children in this study, there were
eighty-two children whose models were considered adequate and who were out
of the mixed-dentition stage. These children, then, do not form a random sample
population but arc the ones who are developing dentally the fastest among those
in the growth study. Many of the children had occlusions that were mutilated
by premature extractions. A full range of dcnta.1 health was exhibited, from
children who were well cared for to those whose dental health had been neglected.
Volume 72 Indexing occlusions for public health programs 193
Number 2

This is similar to the situation that faces dental public health workers in the
field.
We first classified each case according to whether or not it represented a
mutilated occlusion and qualitatively assessed each case by the Angle-Dewey-
Anderson method.
Next, all cases were assessed quantitatively by the objective systems as de-
veloped by Draker, Grainger, Summers, and Salzmann. These will be referred to
in the future as the HLD, TPI, 01, and HMA indexes. The cases were assessed
again by the same four methods, but a month later, so as to test for reprodueibil-
ity of the scores with each system.
Three orthodontists were then invited to assess each case subjectively as to
its relative need for correction of the occlusion by using the following grouping
and grading system. The grade allowed the orthodontist to rank all the cases more
sensitively than just by the group and this, in turn, made analysis of the data
easier. The orthodontists met together with us to discuss the grading system and
then were asked not to discuss it further among themselves after agreement was
reached. Written instructions for grading the occlusions were given each ortho-
dontist :

WRITTEN INSTRUCTIONS FOR GRAOING OCCLUSIONS

Each set of casts is to be given a grade from 0 to 10. To assist in grading, the
grades are distributed throughout five groups which are defined as follows:

Group Grade Definition

A 0 Classic normal occlusion

B 1 Only slight need for any

2 correction to the occlusion

4 Desirable to correct the

5 occlusion but probably
6 elective to the patient

7 Highly desirable to
8 correct the occlusion
9

E 10 Essential to correct the

occlusion

You are asked to judge the occlusion as to the need for correction based on
esthetics, function, implications of future periodontal disease, and the over-all
longevity of the dentition unless treated.

Do not take into account the etiology; treatment cost, treatment plan, or
difficulty in treatment; whether the case would be better treated by prosthetics
than orthodontics; whether relapse of orthodontics would occur.

Results

The orthodontists were handicapped by not having their usual diagnostic tools
at hand ; nor could they examine the facial profile and lip contours, cheek the
194 Gray rind Demirjia?~ Am. J. Orthod.
August 1977

tongue and speech, or consult radiographs. They had only the casts from which
to work.
Table I shows Spearman’s ranking correlations between the judgments of the
three orthodontists. A few cases of glaring discrepancy illustrate why the cor-
relations were not higher. These cases were marked low by one doctor and high
by another. On investigation, these cases turned out to be mostly mutilated by
first molar extractions with distal drifting of the premolars. It is apparent that
one orthodontist believes that this is extremely dangerous to the future occlusion
of the child.
Table II illustrates the personal error and the reproducibility inherent in our
use of the four objective systems. All the methods were considered to be highly
reproducible and with an acceptable margin for error. One system did not ap-
pear to have any advantage over another, when two sets of rankings made 1
month apart were compared. However, this table does indicate that the systems
are not free from error in their use.
Table III shows the comparison of the four object,ive methods with the arith-
metic average of the orthodontic scores, hereafter called the (‘standard.” The
HLD method was considerably lower than the other three, which are all quite
similar. The Occlusal Index has the best correlation with the “standard.”
Table IV compares the correlation between the three sensitive systems. The
TPI and 01 are highly correlated, which is to be expected since they were devel-
oped from the same idea. The correlations between HMA and the other two
systems are also fairly high but would indicate that there are some differences.
The three systems as a whole are more closely correlated than are the three sub-
jective scores as given by the orthodontists in Table I.
Table V shows the result of tests of concordance between the three ortho-
dontists, the three objective methods, and their combinations. The objective
methods arc more in concordance than are the three orthodontists.

Discussion

The results of this study must of necessity be expressed in generalities, for

we are dealing with the rela.tionship of two variables. There is no way in which
we can tell which judgment is actually the closest to the truth. If every patient
had been given a full examination by the orthodontists, with cephalograms, radio-
graphs, soft-tissue analysis, growth predictions, and other diagnostic aids, then
we would be in a position to draw more specific conclusions. What we have dem-
onstrated is that, when only the occlusal relationship of the erupted teeth is
taken into consideration, the subjective evaluation of the degree of need for
occlusal correction by orthodontists will show variation if judgments are made
in an unbiased situation.
The public health hygienist and dentist cannot expect to perform better than
this in a short field type of examination. At the same time, they cannot refer
everyone they examine for an orthodontic examination. The purpose behind the
study was to see if the methods proposed for objectively evaluating occlusion, in
anticipation of government-sponsored orthodontic treatment for handicapping
malocclusions, could serve as evaluation tools on which to base referrals in a com-
munity dental health education program.
 Indexing occlusions for public health program 195

Table I. Spearman’s ranking correlations between the judgments of the three orthodontists’

Spearman’s ranking
Orthodontist correiation
First doctor and second doctor 0.4434
First doctor and third doctor 0.7258
Second doctor and third doctor 0.5008
All significant at p < 0.001 level.

Table II. Spearman’s ranking correlations showing the ability of the objective Systems to
reproduce the same ranking when used by the author one month later

Spearman’s ranking
System correlation
HLD 0.93
TPI 0.91
01 0.91
HMA 0.92
All significant at p < 0.001 level.

Tattle Ill. Spearman’s ranking correlations between the four objective methods and
the averaged “standard” of the orthodontists

Spearman’s ranking
Svstem correlation
HLD 0.57
TPI 0.18
01 0.80
HMA 0.72
All significant at p < 0.001 level.

Table IV. Spearman’s ranking correlations between the three sensitive objective methods

Spearman’s ranking
Systems correlation
TPI and 01 0.88
TPI and HMA 0.60
01 and HMA 0.67
All significant at p < 0.001 level.

Table V. Tests of concordance between the orthodontists; the objective systems and their
combination9

Judges Cancordance coefficient

Three orthodontists 0.72
TPI/OI/HMA 0.81
Three orthodontists and TPI/OI/HMA 0.78
All significant at p < 0.001 level.
196 Gray alld Demirjia?t Am. J. Oythod.
August 1977

All the objective methods may be used in the mouth or on models. The HIJl)
system was discarded early from the investigation because, although it is highly
reproducible, it distinguishes only the very worst cases and tends to lump all the
other into a common pool. This makes it unacceptable for over-all field use.
The TPI method is highly reproducible and correlated fairly well with the
“standard” in ranking order. It has a high correlation with the 01, as would be
expected since they both originated from the data provided from the Burlington
Study. The advantages of this method may be that the forms designed for use
are fairly simple and the weighting system can be taken off the form. The dis-
advantages are that its value is expressed in decimals, which is always harder
to work with than whole numbers. Also, very close and careful examination is
required as subjective decisions are required in deciding whether the molar rela-
Con is distal or mesial by half a cusp or more than half a cusp and on each side.
This gives three possible steps in each direction-normal, half a cusp, and more
than half a cusp-and mistakes and inconsistencies are certainly possible.
Such instruments as Boley gauges or other measuring devices are needed to
measure the overjet and overbite, as well as keen subjective judgment in deter-
mining whether some teeth are rotated more than 45 degrees or displaced more
than 2 mm. Again, mistakes are possible. The care needed to make these decisions
requires someone who is well acquainted with occlusion. If mistakes are made
they arc serious for wide differences in weighting factors result from the deci-
sions made. In public health field work, tither a large supply of forms would
need to be carried into each school and the calculations made then or large
amounts of clerical time would be needed to calculate the scores afterward.
The 01 is so similar to the TPI that everything said about the TPI also ap-
plies to it. In fact, the 01 is slightly more complicated to use and would require
even more calculations and clerical time. It is highly reproducible and correlated
more closely with the “standard” than the other methods. However, we cannot
tell whether or not this means it is a better method to use than the others, for
the truth is not known and its superiority in correlation is not striking. Both the
01 and TPI would take very careful calibration of examiners to be used with
consistency, in our opinion, particularly if employed by dental hygienists or any
health workers other than dentists.
The HMA method is also highly reproducible and is sensitive over the entire
range of occlusions. It correlates fairly highly with the “standard” as well but
not quite as closely as the TPI and 01.
The advantages of this method for public health field use are many, however.
It requires no instruments other than a mirror and explorer, as no measurements
are made. Subjective decisions are not as critical as the other two methods, as only
full-cusp discrepancies are noted. If errors are made, they are not usually serious
because the weighting system applied is only to the anterior region and mostly
for esthetics.
Study of this method as outlined in the review of the literature and the re-
cording form will illustrate the complex assessment that seems to be given to
the occlusion with ease, as it includes such things as spacing and missing poste-
rior teeth, which were left out of the other methods. Probably its greatest advan-
 Indexing occlusions for public health progranls 197

tage is that once the method has been really learned, no actual recording form is
needed and the HMA score can quickly be calculated on scratch paper and then
entered beside the student’s name. In this way, it more closely resembles the us(~
of the T)MF Index. The disadvantages of this method arc few. The main nnc
would be that a training program would be necessary to teach people how to use’
it. However, once they had learned to use it, the possibility of making mistakes
is not as large as with the other methods, and anyone who does learn this spstcm
will become well rersed in looking at occlusions.

REFERENCES
1. McGxvran, E. G. : What is public health dentistry? In Easlick, Kenneth A.: The praeticcl
of dental public health, Ann Arbor, 1956, University of Michigan School of Public Health,
pp. 5-12.
2. Angle, E. H.: Malocclusion of the teeth, ed. 7, Philadelphia, 1907 S. 8. White Dental Mfg.
co.
3. Dewey, M.: Practical orthodontia, ed. 4, St. Louis, 1919, The C. V. Mosbp Cornpan?-,
pp. 45-69.
4. Draker, H. L.: Handicapping labio-lingual deviations, a proposed index for public health
purposes, AM.J'.ORTKOD.~~: 295-305,196O.
5. Grainger, R. M.: Orthodontic treatment priority index, National Centre for health statistics
series 2, No. 25, U.S. Dept of Health Education & Welfare, December, 1967.
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index, Doctor of Public Health Thesis, University of Michigan, Ann Arbor, 1966.
7. Salzmann, J. A.: Handicapping malocclusion assessment to establish treatment priority,
A&J. ORTHOD. 54: 749-765,196s.
8. Ferguson, G. A.: Statistical analysis in psychology and education, New York, 1959, McGraw
Hill Book Company, Inc., pp. 180, 188.

Parlimmt B&dings
l’iotoria, B.C.