European Archives of Paediatric Dentistry

https://doi.org/10.1007/s40368-018-0333-0

SYSTEMATIC REVIEW

Association between malocclusion and dental caries in adolescents:

a systematic review and meta‑analysis
A. C. Sá‑Pinto1   · T. M. Rego1 · L. S. Marques1 · C. C. Martins2 · M. L. Ramos‑Jorge1 · J. Ramos‑Jorge2

Received: 16 June 2017 / Accepted: 25 February 2018

© European Academy of Paediatric Dentistry 2018

Abstract
Aim  To evaluate the scientific evidence regarding the association between malocclusion and dental caries in adolescents.
Methods  Searches were conducted of six electronic databases, complemented by manual searching of the reference lists
of the selected articles and grey literature. Two independent reviewers performed the selection of the articles, data extrac-
tion and the evaluation of the risks of bias through an assessment of methodological quality. Meta-analysis was performed
considering the mean decayed, missing and filled teeth (DMFT) index for caries and the Dental Aesthetic Index (DAI) for
malocclusion. Heterogeneity was tested using the ­I2 statistic and a random effect model was employed. Summary effect
measures were calculated as differences in means.
Results  The initial search retrieved 2644 studies, only 15 of which were selected for full-text analysis. Four cross-sectional
studies were included in the qualitative systematic review. Only one of these studies found no association between malocclu-
sion and dental caries. The meta-analysis of three studies demonstrated that a lower DAI value was significantly associated
with a lower mean DMFT index, except for the comparison of DAI 26–30 vs. 31–35.
Conclusions  Based on the studies analysed, the scientific evidence indicates an association between malocclusion and dental
caries.

Keywords  Malocclusion · Dental caries · Adolescent · Systematic review

Introduction
Dental caries is a multifactorial oral problem. While the
prevalence of this condition has diminished significantly
in recent years, caries remains a major public health con-
cern. Untreated caries in the permanent dentition affects
approximately 35% of the population worldwide (Marcenes
et al. 2013). Moreover, recent studies conducted in different
regions of the world report a prevalence rate of approxi-
mately 40% among adolescents (Khanal and Acharya 2014;
da Rosa et al. 2015; Chukwumah et al. 2016).
* A. C. Sá‑Pinto
anaclara_sa@live.com
1
Department of Pediatric Dentistry and Orthodontics,
School of Dentistry, Universidade Federal dos Vales
do Jequitinhonha e Mucuri, Rua da Glória, 187‑Centro,
Diamantina, MG 39.100‑000, Brazil
2
Department of Pediatric Dentistry and Orthodontics,
School of Dentistry, Universidade Federal de Minas Gerais,
Belo Horizonte, MG, Brazil
Higher sugar intake (Peres et al. 2016) and social condi-
tions, such as poverty and lower maternal education (Skinner
et al. 2014; Dusseldorp et al. 2015; Warren et al. 2017) have
been well established as some of the risk factors of dental
caries in adolescents. A recent cohort study also demon-
strated that tooth brushing is a strong factor related to the
development of later dental caries among this age group
(Warren et al. 2017). Malocclusion is also often considered a
risk factor for caries, as the inadequate alignment of the teeth
allows the build up of bacterial plaque and hinder its removal
(Pitts and Rimmer 1992; Allison and Schwartz 2003; Warren
et al. 2003; Stahl and Grabowski 2004; Gábris et al. 2006;
Hafez et al. 2012). However, a previous systematic review
was unable to identify an association between crowding of
the teeth and dental caries (Hafez et al. 2012), but those
authors did not perform a meta-analysis due to the degree
of heterogeneity of the data among the studies analysed. The
age groups in the primary studies ranged from children in the
primary dentition phase to adults aged older than 35 years.
Regardless of the criteria adopted for the dental exami-
nation, many studies have found an association between

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malocclusion and dental caries (Hixon et al. 1962; Warren
et al. 2003; Gábris et al. 2006; Nobile et al. 2007; Mtaya
et al. 2009), whereas others have not been able to establish
such an association (Helm and Petersen 1989; Stahl and
Grabowski 2004). Thus, the relationship between maloc-
clusion and caries remains unclear, and no recent systematic
reviews have been conducted to address this clinical issue.
Moreover, both malocclusion and caries affect the quality of
life of adolescents (Peres et al. 2013; Krisdapong et al. 2013;
da Rosa et al. 2015).
The aim of the present study was to conduct a systematic
review and meta-analysis for the evaluation of scientific evi-
dence regarding the association between malocclusion and
dental caries in adolescents. The following was the Popu-
lation Exposure Comparison Outcome (PECO) question:
patients—individuals aged 11–20 years (permanent denti-
tion); exposure to the risk factor—malocclusion; compari-
son—absence of malocclusion; outcome: dental caries.
Materials and methods
The present review was performed in compliance with the
guidelines of the Preferred Reporting Items for System-
atic Reviews and Meta-Analyses (PRISMA) (Moher et al.
2009) (protocol number: PROSPERO CRD42016035513).
Searches were performed to retrieve cross-sectional,
case–control, cohort studies as well as clinical trials con-
ducted to evaluate whether the occurrence of malocclusion
is associated to dental caries in adolescents aged 11–20
years with permanent dentition. The statistical data could
be odds ratios (OR), prevalence ratios (PR), relative risk
(RR), Spearman’s correlation coefficients (ρ), 95% confi-
dence intervals (CI), p values or an analysis of the frequency
or absolute number of events (occurrence of dental caries)
considering groups with and without malocclusion.
The following databases were searched in December
2015 and again in May 2016: Pubmed (www.pubme​d.org);
Cochrane Library (http://www.cochr​ane.org/index​.html);
Web of Sciences (http://www.isikn​owled​ge.com); National
Institute for Health and Clinical Excellence (http://www.
nice.org.uk); Clinical Trials—USA National Institute of
Health (http://www.clini​caltr ​ials.gov) and Lilacs (www.
birem​e.br). The search strategy was used for the Pubmed,
Cochrane Library and Web of Sciences databases: [(dental
caries [mesh] OR caries OR tooth decay OR teeth cavity
OR dental cavity) AND (malocclusion [mesh] OR overjet
OR overbite OR open bite OR cross bite OR deep bite OR
Angle Class III OR Angle class II OR canine relationship
OR molar relationship OR dental aesthetic index OR crowd*
OR irregular* OR arch alignment OR malalign * OR ortho-
dontic treatment need)]. The searches of the National Insti-
tute for Health and Clinical Excellence, Clinical Trials and
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European Archives of Paediatric Dentistry
Lilacs databases were performed with the key words dental
caries AND malocclusion. No restrictions were imposed
regarding year of publication. A manual search was also
conducted of the reference lists of eligible studies and the
grey literature was searched for the identification of abstracts
presented at conferences, but not published in the form of
an article.
The articles were exported to the ­EndNote® program
(EndNote, Thomson Reuters, version x7), duplicates were
removed and the list provided by this program was ana-
lysed. At first, articles were selected based on the titles and
abstracts by two independent reviewers (ACSP and TMR).
After this selection, the reviewers sorted the studies for qual-
ity analysis based on a full text reading. Agreement between
the reviewers with regard to the eligibility criteria was deter-
mined using a sub-sample of 20% of the pre-selected articles
and was considered excellent (K = 0.95). Any divergences
were resolved by consensus with a third reviewer (JRJ).
When studies were not found, the authors were contacted
by e-mail or through Research Gate.
The following were the exclusion criteria: literature
reviews, letters to the editor, studies involving adolescents
with a disability, case reports, case series. Studies that did
not investigate malocclusion as a risk factor for dental caries,
that evaluated the treatment of malocclusion as a risk factor
for caries, as well as those that evaluated diagnostic methods
or health promotion and including those that considered an
outcome other than dental caries (such as periodontal dis-
ease). Quality of life studies and those that only investigated
one type of malocclusion (irregularity) were also excluded.
Only research reports published in English, Spanish, French,
Italian and Portuguese were considered. For a study to be
included in the present systematic review, the outcome
needed to be reported as mean caries index scores or cat-
egorized as the presence/absence of dental caries.
Data extraction
Descriptions were made of the characteristics of the studies,
such as country, study design, initial and final sample size,
criteria employed for the evaluation of malocclusion and
dental caries, statistical analysis and outcome. In cases of
lost or missing data, the authors were contacted by e-mail.
Evaluation of methodological quality
The methodological quality of the studies selected for inclu-
sion was evaluated by the reviewers in an independent fash-
ion. In cases of divergence, a discussion was held until a
consensus was reached. As only studies with a cross-sec-
tional design were deemed eligible, the analysis of methodo-
logical quality was performed using the Newcastle–Ottawa
Scale for case–control studies (Wells et al. 2011) adapted
European Archives of Paediatric Dentistry
for the evaluation of cross-sectional studies (Herzog et al.
2013) (Table 2).
The risk of bias was evaluated for each study, as follows:
“Yes” for a low risk of bias (scored one point represented
by an asterisk) and “No” for a high risk of bias, for which no
score was attributed (Higgins and Altman 2012). Based on
the criteria of the Newcastle–Ottawa scale, the items evalu-
ated were exposure/non-exposure, representativeness of the
sample (assessed based on sample generation method, allo-
cation concealment and calculation of sample size), sample
selection (community, school, etc.), control for confounding
variables, blinding, data acquisition of the dependent vari-
able, description of biases and description of non-response
rate. The representativeness criterion was evaluated based on
the sampling methods. The presence of a random component
in the generation of the sequence was judged as a low risk of
bias. Allocation concealment was also used as a criterion for
the evaluation of representativeness. Thus, any method that
impeded the participants and researchers from determining
the allocation was judged as a low risk of bias.
Data synthesis
The Comprehensive Meta-Analysis Software (version 2) was
used for the meta-analysis (Borenstein et al. 2005). Only
studies with similar designs were included in the forest plot,
as meta-analysis can generate confusing results when differ-
ent study designs and variations in study designs are grouped
(Deeks et al. 2012). Thus, to avoid methodological and clini-
cal heterogeneity in the meta-analysis, only cross-sectional
studies with the same evaluation criteria for malocclusion
[Dental Aesthetic Index (DAI)] and dental caries [Decayed,
Missing and Filled Teeth (DMFT) index] and that presented
results in the form of mean and standard deviation for these
indices, were included in this analysis.
The heterogeneity among the studies was verified using
the ­I2 statistic and a sensitivity test was performed to test the
consistency of the data through the removal of outliers from
the datasets (Deeks et al. 2012). For the subgroup analysis
of the different DAI categories, a fixed-effects model was
used for low heterogeneity and a random effects model was
used for high heterogeneity. As values that exceed 50% are
considered indicative of considerable heterogeneity (Higgins
and Thompson 2002), the random effects model was used
for such cases (Borenstein et al. 2009). Mean differences
between individuals with different types of malocclusion,
a 95% CI and p-values were calculated in the forest plot. It
was not possible to extract data from one study (Singh et al.
2011) for meta-analysis. Thus, a narrative summary of this
study was performed.
Results
Characteristics of studies
The online search resulted in the retrieval of 2644 articles
and the manual search resulted in an additional two arti-
cles (Fig. 1). After the removal of duplicated reports, 1753
articles were analysed for pre-selection, 1738 of which
were excluded based on the titles and abstracts. Among
the remaining 15 articles selected for full-text analysis,
four were included in the present systematic review, three
of which were submitted to meta-analysis. All studies
included had a cross-sectional design. Table 1 displays the
characteristics of the studies, which were conducted in Iran
(Borzabadi-Farahani et al. 2011), India (Singh et al. 2011;
Baskaradoss et al. 2013) and Brazil (Feldens et al. 2015).
In all studies, the participants were recruited from
schools. Age ranged from 11 to 20 years and sample size
ranged from 509 to 1800 adolescents. All studies analysed
reported the representativeness of the sample. Consider-
ing DAI ≥ 26, the prevalence of malocclusion was similar
in the studies of Singh et al. (2011) and Baskaradoss et al.
(2013) (18.0 and 15.4%, respectively). Borzabadi-Farahani
et al. (2011) and Feldens et al. (2015) found a higher preva-
lence of malocclusion in the studied population, 45.5 and
67.6% respectively. In relation to the prevalence of dental
caries, the values were similar between Borzabadi-Farahani
et al. (2011) and Baskaradoss et al. (2013), 88.8 and 91.8%
respectively and between Singh et al. (2011) and Feldens
et al. (2015), 50.4 and 44.8% respectively.
Singh et al. (2011) conducted a study in the Udupi district
of India and did not collect data on socioeconomic status.
Borzabadi-Farahani et al. (2011), who conducted a study
in the city of Isfahan (Iran), and Baskaradoss et al. (2013),
who conducted a study in the city of Kanyakumari (India),
collected data on socioeconomic status, but did not perform
multivariate analysis, considering this variable as a con-
founding factor for the evaluation of the association between
malocclusion and dental caries. Feldens et al. (2015), who
conducted a study in the city of Osório (Brazil), controlled
for socioeconomic status in the multivariate analysis per-
formed to investigate this association.
Three of the four studies included in the present review
found a positive association between severe malocclusion
(treatment required) and dental caries (Singh et al. 2011;
Baskaradoss et al. 2013; Feldens et al. 2015). Only one study
(Borzabadi-Farahani et al. 2011) did not find such an asso-
ciation (p > 0.05).
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 European Archives of Paediatric Dentistry

Studies identified through search

Manual search
of databases
Identification (n = 2644)
(n = 2)

Removal of duplicates
(n = 893)
Screening

Studies pre-selected Studies excluded

(n =1753) (n = 1738)

Full-text analysis Studies excluded for following reasons:

Eligibility

(n = 15) (n = 11)

• Some participants received

treatment, but treated and
Studies included in qualitative untreated groups were not
analysis compared (Helm and Petersen,
1989)
(n = 4) • Different age group (Katz, 1978)
• Authors did not evaluate
Inclusion

association between
Studies included in quantitative malocclusion and dental caries
analysis (Savara, 1955; Reyes, 2003;
Luján et al. 2007)
Meta-analysis • No evaluation of malocclusion
in absence of caries (Moura and
(n = 3)
Cavalcanti, 2007)
• Non-systematic review of
literature (Pappalardo et al.
1979)
• Evaluated malocclusion as
outcome (Adler, 1956; Mtaya et
al. 2009; Nalcaci et al. 2012)
• Only evaluated dental
irregularity (Addy et al. 1988)

Fig. 1  Screening of articles: four-phase PRISMA flow diagram for study selection, showing number of studies identified, screened, eligible and
included in review and meta-analysis

Diagnosis of dental caries examination of dental caries. Three studies (Singh et al.
2011; Borzabadi-Farahani et al. 2011; Feldens et al. 2015)
The studies analysed used the criteria established by the investigated the presence/absence of caries considering
World Health Organization (WHO 1997) for the clinical all components of the DMFT index. Borzabadi-Farahani

13
 Table 1  Characteristics of studies included in systematic review
Authors (Year) Country, design Local setting Initial sample Adolescents Adolescent’s age Dental exam Evaluation of Statistics (adjusted Outcomes (OR, 95%
Journal (final) with caries at dental examina- (calibration) malocclusion and for confounders) CI or p value)
(total) tion dental caries

Singh et al. (2011) India, cross-sec- School 945 (927) 467 12 years 1 dentist DAI; DMFT Spearman’s cor- Positive correlation
Community Dent tional relation found between
Health dental caries and
both severe and
handicapping
European Archives of Paediatric Dentistry

malocclusion
(r = 0.614, p ≤ 0.05
and r = 0.889,
p ≤ 0.01)
Borzabadi-Fara- Iran, cross-sec- School (748) 728 664 11–20 years 1 dentist DAI; DMFT Student’s t-test; Higher caries expe-
hani et al. (2011) tional ANOVA; Binary rience found in
Acta Odontol logistic regres- subjects in need of
Scand sion orthodontic treat-
ment (DAI > 30),
but difference did
not achieve signifi-
cance (p > 0.05)
Baskaradoss et al. India, cross-sec- School 1800 (1042) 1481 11–15 years 2 dentists DAI; DMFT Spearman’s rank- Children with mean
(2013) tional order correlation DAI scores > 35
Korean J Orthod coefficient (r) had significantly
greater car-
ies experience
(p < 0.001); mean
DAI scores signifi-
cantly correlation
with mean DMFT
scores (r = 0.368,
p < 0.05)
Feldens et al. Brazil, cross- School 700 (509) 228 11–14 years 1 dentist DAI; DMFT Poisson regression Adolescents with
(2015) sectional with robust vari- severe or handi-
Angle Orthod ance; Kruskal– capping maloc-
Wallis; Mann– clusion had 31%
Whitney greater probability
of having dental
caries (prevalence
ratio: 1.31; 95%
CI: 1.02–1.67)

DAI dental aesthetic index; DMFT decayed, missing, and filled teeth

13

Table 2  Newcastle-Ottawa
quality assessment
Singh et al. (2011)
Borzabadi-Farahani et al. (2011)
Baskaradoss et al. (2013)
Feldens et al. (2015)
Each * represents one point in the Newcastle-Ottawa quality assessment’s scale
et al. (2011) dichotomized the outcome as DMFT ≤ 8 and
DMFT > 8. Baskarados et al. (2013) evaluated the mean total
DMFT score as well as the mean score of each component
of the index (decayed, missing and filled teeth). In contrast,
Singh et al. (2011) did not describe mean DMFT scores for
each DAI category and was therefore excluded from the
meta-analysis.
Diagnosis of malocclusion
All four studies used the DAI for the evaluation of maloc-
clusion, which is also recommended by the World Health
Organization (WHO 2003). This index is used to evaluate
orthodontic treatment needs and furnishes four possible
results based on the score: ≤ 26—slight treatment need;
26–30—elective treatment need; 31–35—treatment is highly
desirable; and ≥ 36—treatment is required. All authors fol-
lowed this DAI categorization.
Evaluation of socioeconomic status
Three of the studies included in the present systematic
review evaluated the socioeconomic status of the sample
(Borzabadi-Farahani et al. 2011; Baskaradoss et al. 2013;
Feldens et al. 2015). For such, Borzabadi-Farahani et al.
(2011) analysed parents’ schooling, mother’s employment
status and number of residents in the home. Baskaradoss
et al. (2013) determined socioeconomic status based on the
Standard of Living Index and reports of household income
as well as both the possession of goods and household facil-
ities. Feldens et al. (2015) considered household income,
family structure and mother’s schooling.
Meta‑analysis
Meta-analysis was performed for three of the studies
included in the present review (Borzabadi-Farahani et al.
2011; Baskaradoss et al. 2013; Feldens et al. 2015), which
had quantitative variables that could be compared in rela-
tion to the DAI score (< 26 vs. 26–30; < 26 vs. 31–35; < 26
vs. ≥ 36; 26–30 vs. 31–35; 26–30 vs. ≥ 36; 31–35 vs. ≥ 36).
The meta-analysis demonstrated that individuals with a DAI
score lower than 26 (slight treatment need) had a lower mean
13
European Archives of Paediatric Dentistry
Selection (Max. Comparability Outcome (Max. Total*
5*) (Max. 2*) 3*)
*** *** 6/10
*** *** 6/10
*** *** 6/10
**** ** *** 9/10
DMFT index than those with a higher DAI score (DAI < 26
vs. DAI = 26–30: difference in means = −  0.34, 95% CI
− 0.51 to − 0.17; DAI < 26 vs. DAI = 31–35 difference in
means = − 0.35, 95% CI − 0.60 to − 0.11; and DAI < 26 vs.
DAI = 36 or more: difference in means = − 0.97, 95% CI
− 1.62 to − 0.33). Individuals with DAI = 26–30 (elective
treatment need) had a mean DMFT index similar to individ-
uals with DAI = 31–35 (difference in means = − 0.03, 95%
CI − 0.35–0.30) and lower than individuals with DAI ≥ 36
(difference in means = − 0.63, 95% CI − 1.18 to − 0.07).
Individuals with DAI = 31–35 (treatment is highly desirable)
had a lower mean DMFT index than those with DAI ≥ 36
(difference in means = − 0.67, 95% CI − 1.31 to − 0.02).
Evaluation of methodological quality
Table 2 shows a summary of the quality of the studies ana-
lysed. A high risk of bias was considered when an item did
not meet the criteria of the Newcastle–Ottawa scale. All
studies were judged as having a high risk of bias regard-
ing the description of the response rate or characteristics of
respondents and non-respondents. Only one study detailed
the sample size calculation (Feldens et al. 2015). The same
study was the only investigation to control for an important
confounding variable (socioeconomic status) for the evalu-
ation of the association between malocclusion and dental
caries. Confounding variables were identified in the Meth-
ods and Results sections as well as the tables in the studies
selected for the present review.
Discussion
Summary of evidence
The results of the meta-analysis demonstrated that individu-
als with a DAI score lower than 26 (slight treatment need)
had a lower DMFT index than individuals with higher DAI
scores (Fig. 2). The studies analysed exhibited methodo-
logical and clinical homogeneity (Cohn and Becker 2003).
However, the comparison of the mean DMFT index between
individuals with a DAI score equal to or greater than 36
and those with lower scores demonstrated a high degree of
European Archives of Paediatric Dentistry

Study name DAI Statistics for each study Difference in means and 95% CI
Difference Standard Lower Upper
in means error Variance limit limit p-Value
Borzabadi-Farahani et al., 2011 <26 vs. 26-30 -0,46 0,33 0,11 -1,10 0,18 0,157
Baskaradoss et al., 2013 <26 vs. 26-30 -0,36 0,10 0,01 -0,56 -0,16 0,000
Feldens et al., 2015 <26 vs. 26-30 -0,23 0,20 0,04 -0,63 0,17 0,258
-0,34 0,09 0,01 -0,51 -0,17 0,000
Borzabadi-Farahani et al., 2011 <26 vs. 31-35 0,01 0,43 0,19 -0,84 0,86 0,982
Baskaradoss et al., 2013 <26 vs. 31-35 -0,37 0,17 0,03 -0,69 -0,05 0,025
Feldens et al., 2015 <26 vs. 31-35 -0,41 0,21 0,05 -0,83 0,01 0,055
-0,35 0,13 0,02 -0,60 -0,11 0,005
Borzabadi-Farahani et al., 2011 <26 vs. 36 or more -0,67 0,44 0,20 -1,54 0,20 0,131
Baskaradoss et al., 2013 <26 vs. 36 or more -1,52 0,23 0,06 -1,98 -1,06 0,000
Feldens et al., 2015 <26 vs. 36 or more -0,64 0,21 0,05 -1,06 -0,22 0,003
-0,97 0,33 0,11 -1,62 -0,33 0,003
Borzabadi-Farahani et al., 2011 26-30 vs. 31-35 0,47 0,48 0,23 -0,48 1,42 0,331
Baskaradoss et al., 2013 26-30 vs. 31-35 -0,01 0,24 0,06 -0,49 0,47 0,967
Feldens et al., 2015 26-30 vs. 31-35 -0,18 0,25 0,06 -0,68 0,32 0,479
-0,03 0,17 0,03 -0,35 0,30 0,876
Borzabadi-Farahani et al., 2011 26-30 vs. 36 or more-0,21 0,50 0,25 -1,19 0,77 0,676
Baskaradoss et al., 2013 26-30 vs. 36 or more-1,16 0,33 0,11 -1,81 -0,51 0,000
Feldens et al., 2015 26-30 vs. 36 or more-0,41 0,25 0,06 -0,91 0,09 0,107
-0,63 0,28 0,08 -1,18 -0,07 0,026
Borzabadi-Farahani et al., 2011 31-35 vs. 36 or more-0,68 0,59 0,34 -1,83 0,47 0,245
Baskaradoss et al., 2013 31-35 vs. 36 or more-1,15 0,32 0,10 -1,78 -0,52 0,000
Feldens et al., 2015 31-35 vs. 36 or more-0,23 0,27 0,07 -0,75 0,29 0,389
-0,67 0,33 0,11 -1,31 -0,02 0,043

-4,00 -2,00 0,00 2,00 4,00

Favors lower DAI/ Favors higher DAI

Fig. 2  Forest plot of meta-analysis for three cross-sectional studies

heterogeneity (DAI < 26 vs. DAI ≥ 36: ­I2 = 75.91%; DAI
26–30 vs. DAI ≥ 36: ­I2 = 49.86%; DAI 31 to 35 vs. DAI ≥ 36:
­I2 = 59.13%).
The literature reports several factors related to the higher
prevalence of caries experience among individuals with
malocclusion. One of the most common is dental crowding,
which leads to the build up of bacterial plaque for a pro-
longed time, resulting in a greater frequency of dental caries
(Warren et al. 2003; Gábris et al. 2006). Unlike a previous
review, which only investigated one type of malocclusion
(crowding) as a risk factor for the development of caries
(Hafez et al. 2012), studies that addressed the severity of
different types of malocclusion were included in the present
review. This is important, as malocclusion involves a set of
occlusal abnormalities. Thus, the identification of a greater
risk of dental caries as a result of more severe malocclusions
can contribute to the indication for orthodontic treatment
(Helm and Petersen 1989).
Among the studies analysed, only one (Borzabadi-Fara-
hani et al. 2011) found no association between malocclusion
and caries (p > 0.05). While there is no scientific evidence
regarding the reason why severe malocclusion (treatment
required) constitutes a greater risk for the occurrence of
caries, some hypotheses could be raised. It is possible that
severe malocclusion can contribute both to plaque build-up
as to the difficulty of its removal. This permanence of dental
plaque over an extended period of time contributes to the
development of dental caries (Fejerskov, 2004). Thus, the
acquisition of additional data, such as a plaque index and
oral hygiene habits, could contribute to the clarification of
this relationship in future studies (Feldens et al. 2015).
The possibility of an association between malocclusion
and dental caries can occur in both directions, malocclu-
sion as an exposure for dental caries and dental caries as an
exposure for malocclusion. This possibility is a feature of the
cross-sectional design, which does not allow the determina-
tion of the order of occurrence of these conditions (Feldens
et al. 2015). Thus, besides the studies evaluating maloc-
clusion as an independent variable and dental caries as an
outcome, some studies have demonstrated that adolescents
with dental caries are more likely to exhibit malocclusion
(Gábris et al. 2006; Frazão and Narvai 2006; Nobile et al.

13

2007; Mtaya et al. 2009). Longitudinal studies are required
to clarify the validity of this association.
In terms of the limitations of the selected studies, most
failed to detail the calculation of the sample size (Singh et al.
2011; Borzabadi-Farahani et al. 2011; Baskaradoss et al.
2013). Although two studies (Singh et al. 2011; Baskara-
doss et al. 2013) reported the calculation of the sample
size, they failed to give more details about this process. The
lack of a sample size calculation lowers the level of evi-
dence, as there is no knowledge of whether the number of
participants was sufficient to detect a significant associa-
tion when such an association indeed exists. It is important
to highlight that, although most studies (Singh et al. 2011;
Borzabadi-Farahani et al. 2011; Baskaradoss et al. 2013)
failed to give details of the calculation of the sample size,
they gained credit in the representativeness item, because the
criteria used to assess the quality of the studies evaluates the
degree of representation and the sample size calculation an
in independent way. The modified Newcastle–Ottawa scale
assess how the data may represent through the presence or
not of the sample randomisation or by the participation of
all subjects of the population in question. Thus, as all of the
analysed studies reported the randomisation of the sample,
a point of representation was assigned to them.
The evaluation of socio-economic status is fundamental in
studies addressing risk factors for dental caries. Researches
have found that individuals with a lower socioeconomic
status have a greater prevalence rate of dental caries (Piove-
san et al. 2010; Ramos-Jorge et al. 2014; Pinto-Sarmento
et al. 2016). Thus, when addressing the possible association
between malocclusion and dental caries, researchers should
control for socio-economic status in any multivariate analy-
sis, as this is an important confounding factor. It is possible
that socio-economic status and malocclusion are synergistic
as risk factors for dental caries. Badran et al. (2014) found
that individuals with a low socioeconomic status exhibited
a greater normative need for orthodontic treatment. Among
the studies included in the present review, only one (Feldens
et al. 2015) controlled for socio-economic status in the mul-
tivariate analysis. The authors found that individuals with
a low socio-economic status and a DAI score equal to or
greater than 36 (treatment required) had a greater preva-
lence rate of dental caries (Feldens et al. 2015). The fact that
severe malocclusion remained associated with dental caries
after controlling for socio-economic status demonstrated that
these variables exert an influence in an independent manner.
A high risk of bias was found due to the failure to describe
the response rate or characteristics of the respondents and
non-respondents, which weakens the reliability of a study,
as it is not possible to determine whether the non-response
rate was acceptable, or whether the characteristics of the
respondents and non-respondents differed in such a manner
as to exert an influence on the results.
13
European Archives of Paediatric Dentistry
Intra-examiner and inter-examiner agreement was deter-
mined in all four studies (Singh et al. 2011; Borzabadi-Far-
ahani et al. 2011; Baskaradoss et al. 2013; Feldens et al.
2015). This determination is an important aspect with regard
to the credibility of the findings, as it ensures agreement
among the researchers throughout the data acquisition pro-
cess. Failure to determine intra-examiner and inter-examiner
agreement could result in detection bias and furnish dubious,
unreliable data.
The present systematic review involved a search of differ-
ent electronic databases with no restriction imposed regard-
ing the year of publication. Efforts were also made to find
studies in the grey literature for which the full text was not
published in order to minimize the interference of publica-
tion bias. However, language bias may have occurred due
to the restriction of some languages, as significant results
are generally published in English (Wulaerhan et al. 2014).
The findings of the present systematic review and meta-
analysis underscore the importance of oral health promo-
tion strategies directed at preventing malocclusion. Besides
being associated with functional and aesthetic limitations
(Almeida et al. 2014; Choi et al. 2016), malocclusion may be
an important associate factor for dental caries in adolescents.
Conclusion
The scientific evidence based on this sytematic review sug-
gests an association between malocclusion and dental caries,
since individuals with a lower DAI score also had a lower
DMFT index. As that only four valid cross-sectional studies
were identified, further longitudinal studies with controls
for possible confounding variables are needed to confirm
this evidence.
Acknowledgements  This study was supported by the following Brazil-
ian fostering agencies: National Council for Scientific and Technologi-
cal Development (CNPq), Ministry of Science and Technology, State
of Minas Gerais Research Foundation (FAPEMIG) and Coordination
for Improvement of Higher Education Personnel (CAPES).
Compliance with ethical standards 
Conflicts of interest  There are no conflicts of interest associated with
this publication.
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