Original Article

Self‑Perception of Dental Esthetics, Malocclusion, and

Oral Health‑Related Quality of Life among 13–15‑Year‑Old
Schoolchildren in Bengaluru: A Cross‑Sectional Study
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Jesline Merly James, Manjunath P. Puranik1, K. R Sowmya1

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Department of Public Health Dentistry, Indira Gandhi Institute of Dental Sciences, Nellikuzhi, Kerala, 1Department of Public Health Dentistry, Government Dental College
and Research Institute, Bengaluru, Karnataka, India

Abstract
Introduction: Malocclusion is one of the common public health problems worldwide. The study aimed to assess the self‑perception of dental
esthetics, malocclusion, and oral health‑related quality of life (OHRQoL) and to determine the relation between them among 13–15‑year‑old
schoolchildren in Bengaluru. Materials and Methods: In this cross‑sectional study, 540 children were selected equally from government, aided,
and private schools in Bengaluru. Self‑perception of dental esthetics was measured using Oral Aesthetic Subjective Impact Scale (OASIS),
whereas malocclusion and OHRQoL were assessed using Dental Aesthetic Index and Oral Health Impact Profile‑14 (OHIP‑14), respectively.
Descriptive and analytical statistics was done using the SPSS 22. Analysis of variance, Kruskal‒Wallis test, and Pearson correlation test
were used. P < 0.05 was considered statistically significant. Results: The prevalence of malocclusion was found to be 29.63%. Among
schoolchildren, the mean OASIS scores (self‑perception) and OHIP‑14 scores were 14.62 ± 6.93 and 9.04 ± 8.07, respectively. There was a
significant difference among government, aided, and private schoolchildren regarding “definite malocclusion” and mean OHIP scores. Overall,
there was a significant weak correlation between the severity of malocclusion and OHIP scores ([r = 0.259], [P = 0.01]) as well as between the
severity of malocclusion and OASIS scores ([r = 0. 192], [P = 0.02]). Conclusion: The severity of malocclusion significantly correlated with
self‑perception of dental esthetics and OHRQoL among schoolchildren. Hence, there is a relation between self‑perception of dental esthetics
and malocclusion as well as malocclusion and OHRQoL.

Keywords: Dental Aesthetic Index, dental esthetics, malocclusion, oral health‑related quality of life, self‑perception

Introduction temporomandibular joint.[8] Since it has the potential to regulate

As most of the intellectual functions depend on perception, it
can be accounted as the sixth sense of man.[1] The overall social
attention and acceptance, self‑esteem, and societal well‑being of
a person are closely interlinked with esthetics and its personal
and social perceptions of the individual.[2] The role of facial
esthetics in human communication is very much significant.[3]
Irregularities in teeth positions and other malocclusions have
a huge impact on the beauty of the smile and quality of life.[4]
Globally, malocclusion stands third among various dental public
health problems.[5] It is not accounted as a disease but in a better
way expressed as a departure from the norms of esthetics.[6]
The etiological factors could be genetic, environmental, or
a combination of both along with various local factors.[7]
Studies have reported its ill effects on the periodontium and
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form and function, there are chances of impairment of the quality
of life of people.[9] Due to its higher prevalence and prevention
opportunities, it is considered a public health problem.[10]
It is widely acknowledged that one’s failure to satisfy
social standards of dental esthetics will generate negative
Address for correspondence: Dr. Jesline Merly James,
Department of Public Health Dentistry, Indira Gandhi Institute of Dental
Sciences, Kothamangalam, Nellikuzhi ‑ 686 691, Kerala, India.
E‑mail: jeslinemj@gmail.com
Submission: 31-12-2021 Revision: 24-01-2022
Acceptance: 18-04-2022 Published: 08-07-2022
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: James JM, Puranik MP, Sowmya KR.
DOI: Self‑perception of dental esthetics, malocclusion, and oral health‑related
10.4103/jnsm.jnsm_167_21 quality of life among 13–15‑year‑old schoolchildren in Bengaluru:
A cross‑sectional study. J Nat Sci Med 2022;5:262-7.

262 © 2022 Journal of Nature and Science of Medicine | Published by Wolters Kluwer - Medknow
 James, et al.: Malocclusion and quality of life
psychosocial outcomes.[11] Malocclusion, in general, impairs
beauty and performance, and the services provided by an
orthodontist improve one’s oral and dental functions.[12] In
general, treatment is influenced more by demand than by
need.[13]
One of the important motivational factors to seek orthodontic
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treatment is dental esthetics.[14] In this aspect, the patient’s own
perception of dental appearance is of utmost importance.[15]
Therefore, assessments involving treatment need should render
sufficient weightage to esthetic aspects of malocclusion.[16]
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 06/24/2023
Studies have reported the prevalence of malocclusion,[5‑8,10‑13,17‑27] its
self‑perception, [14,16,28‑31] and the relationship between
malocclusion and oral health‑related quality of life (OHRQoL)
among children. [19,20,27] However, studies assessing the
relationship between malocclusion, self‑perception of dental
esthetics, and OHRQoL in children are scarce. Hence, this study
was conducted with an objective to evaluate the relationship
between self‑perception of dental esthetics, malocclusion,
and OHRQoL among 13–15‑year‑old schoolchildren in
Bengaluru. It was hypothesized that there is no relation between
self‑perception of dental esthetics, malocclusion, and OHRQoL.
Materials and Methods
A cross‑sectional study was conducted among 13–15‑year‑old
schoolchildren over a period of 5 months from February 2016
to June 2016 in Bengaluru. A protocol of the intended was
submitted to the Institutional Ethical Committee, Government
Dental College and Research Institute Bengaluru, India, and the
ethical clearance was obtained (GDC/ACM/PG/Ph. D/2015–
2016) on December 17, 2015. All the procedures involved in
this study adhered to the ethical guidelines of the Declaration
of Helsinki. The permission for the study was obtained from the
office of the Deputy Director of Public Instructions, Bengaluru.
The children were informed about the procedures involved
in the study. Voluntary participation was ensured, following
which written informed consent and assent were obtained from
the parents and children, respectively.
A pilot study was conducted among twenty
13–15 year–old‑schoolchildren to assess the feasibility of the
study, relevance of the pro forma, and to determine the sample size.
Considering the prevalence of malocclusion (60%), 95%
confidence level, and 80% power, the sample size of 512
obtained was rounded off to 540.
The study tools used were the Oral Aesthetic Subjective
Impact Scale (OASIS),[31] Dental Aesthetic Index (DAI),[32]
and Oral Health Impact Profile‑14 (OHIP‑14).[33] OASIS is
a 5‑item closed‑ended questionnaire scored on a seven‑point
Likert scale. DAI determines the severity of malocclusion
and treatment needs through the measurement of ten occlusal
traits. OHIP‑14 is a 14‑item closed‑ended questionnaire
scored on a five‑point Likert scale widely used for measuring
OHRQoL.
Journal of Nature and Science of Medicine  ¦  Volume 5 ¦ Issue 3 ¦ July-September 2022
Cross‑cultural validation of both questionnaires was performed
by means of back‑translation method. The questionnaires
were translated into the local language (Kannada) and
translated back to English by linguistic experts and checked
for its agreement. Further, it was assessed for readability and
comprehension on a group of twenty children during the pilot
study. Necessary corrections and modifications were made.
The principal investigator was trained and calibrated in the
Department of Public Health Dentistry, GDCRI, Bengaluru.
A training and calibration session on the recording of DAI
was performed on ten subjects from the outpatient department.
The examination was repeated on successive days on the
same subjects to determine consistency. The intra‑examiner
reliability was found to be good (κ =0.85).
List of schools was obtained from the office of the Deputy
Director of Public Instructions, Bengaluru. From this, four
government, four aided, and four private schools were selected
randomly. Forty‑five children were selected randomly from
each school based on the eligibility criteria to ensure a total
participation of 180 each from government, aided, and private
schools. Age and gender distributions were maintained equally
from each group of schools. Schoolchildren aged 13–15 years
with permanent dentition and those who can read, write, and
understand Kannada or English were included in the study,
whereas those children who were undergoing orthodontic
treatment currently or in the past and those with any systemic
diseases that may make oral health assessment difficult were
excluded from the study.
A specially designed structured pro forma was used to
collect the data. It consisted of three parts: the first part
included the child’s demographic profile and socioeconomic
status  (Modified Kuppuswamy scale).[34] The second part
consisted of OASIS and OHIP‑14 scales, and the third part
consisted of DAI.
The data were collected from children during school hours.
Demographic information and other details were obtained
by personal interview. OHIP‑14 and OASIS questionnaires
were distributed to the participants and instructions were
given. Questionnaires were collected back on the same day
and checked for its completeness. Oral examination of the
children was performed in classrooms on a comfortable chair
under natural light by the principal investigator and findings
were recorded by a trained assistant.
The armamentarium included: mouth mirror, Community
Periodontal Probe (CPI) probe, chip blower, tweezers, kidney
trays, gloves, mouth mask, disinfecting solution, cotton, and
cotton holders. Sufficient number of autoclaved instruments
was taken for the day‑to‑day examination. Infection control
and sterilization measures were observed throughout the study.
All possible efforts were made to reduce the incorporation of
bias in the study.
The data were entered into a Microsoft Excel sheet. The
descriptive and analytical statistics were performed with
263
 James, et al.: Malocclusion and quality of life

the Statistical Package for the Social Sciences (SPSS Inc.,
Chicago, IL, United States) version 22 software. software.
Percentages, means, and standard deviations were computed.
Statistical tests such as analysis of variance, Kruskal‒Wallis
test, and Pearson correlation test were applied between the
subgroups. P < 0.05 was considered statistically significant.
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The overall mean OHIP score for schoolchildren was
9.04  ±  8.07. Overall, there was a significant difference in
OHIP scores between the subgroups and for most of the
questions [Table 3].
OASIS scores increased with an increase in the severity of
malocclusion. The highest mean OASIS score was found

among very severe/handicapping malocclusion group (mean

Results score = 22.89 ± 3.36). A statistically significant difference was
The present study included 540 schoolchildren of the age found between OASIS scores and severity of malocclusion in all
group of 13–15 years in which the participants were distributed subgroups except for the severe malocclusion group [Table 4].
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equally in all the three age groups gender‑wise. Majority of Regarding the severity of malocclusion and OASIS scores,
the schoolchildren belonged to lower‑middle class. significant moderate and weak correlation were observed for
overall study population ([r = 0. 474], [P = 0.02]) and with
Most of the schoolchildren chose responses between
no/minor malocclusion category ([r = 0. 192], [P = 0.02]),
extreme scores of OASIS scale. Overall, there was a
respectively.
significant difference between the subgroups and for all the
questions [Table 1]. As the severity of malocclusion increased, OHIP
scores also increased, and the highest mean score was
The prevalence and severity of malocclusion in each subgroup
observed among very severe/handicapping malocclusion
are given in Table 2. Overall, there was no significant mean
group (mean score = 31.33 ± 6.45). The difference in
DAI difference between the subgroups.
OHIP scores was found to be statistically significant
between the subgroups for the definitive malocclusion
Table 1: Mean Oral Aesthetic Subjective Impact Scale category [Table 5]. With respect to the severity of
scores among schoolchildren malocclusion and OHIP scores, there was overall weak
Mean±SD Overall P
significant correlation ([r = 0. 259], [P = 0.01]) as well as with
no/minor malocclusion category ([r = 0. 218], [P = 0.03]).
Government Aided Private
school school school
Q1: How do you feel about the appearance of your teeth?
Discussion
2.98±1.82 2.72±1.47 .10±1.41 2.60±1.62 <0.001 Studies reported in the literature employing OASIS, DAI, and
OHIP‑14 are scarce in the literature. Hence, comparisons are
Q2: Have you found that people have commented on the
appearance of your teeth? made wherever possible.
2.86±0.1.52 3.29±1.33 2.96±1.06 3.04±1.33 <0.006 Many studies have been done in the age groups that ranged
Q3: Have you found that people have teased you about the from 11 to 35 years and the sample size varied from 50 to
appearance of your teeth? 3003.[5‑27] The present study included 540 schoolchildren of
2.71±1.40 3.17±1.21 2.93±1.11 2.75±1.23 0.002 13–15 years in which the participants were distributed equally
Q4: Do you try to avoid smiling because of the appearance of your in all the three age groups in Bengaluru city. In other studies,
teeth? the participants comprised urban and rural subgroups.[23,25] The
2.80±1.42 3.16±1.19 2.83±1.14 2.94±1.26 0.015 equal number of participants were recruited gender‑wise.[17] The
Q5: Do you ever cover your mouth because of the appearance of
difference between subgroups was observed for self‑perception
your teeth? of dental esthetics, malocclusion, and OHRQoL which might
2.79±1.42 3.71±1.18 2.88±1.12 2.95±1.25 0.01 be attributed to age, gender, and social class.
Overall score Increase in OASIS score is indicative of higher self‑perception
14.14±6.34 16.01±8.99 13.71±4.53 14.62±6.93 0.004 and concern about dental esthetics. For most of the questions,
SD: Standard deviation higher mean OASIS scores were found among aided

Table 2: Distribution of schoolchildren according to dentofacial anomalies by the level of severity and treatment needs
DAI score Treatment needs Government Aided school Private school Overall
school (n=180) (n=180) (n=180)
No abnormality/minor malocclusion (≤25) No/slight treatment need 113 (62.77) 115 (63.88) 152 (84.44) 380 (70.37)
Definitive malocclusion (25-30) Treatment elective 35 (19.44) 52 (28.88) 21 (11.67) 108 (20)
Severe malocclusion (31-35) Treatment highly desirable 17 (9.44) 9 (5) 5 (2.77) 31 (5.74)
Very severe or handicapping malocclusion (>36) Treatment mandatory 15 (8.33) 4 (2.22) 2 (1.11) 21 (3.88)
Mean DAI score 24.47±6.42 24.71±4.29 23.82±3.62 24.33±4.93
DAI: Dental Aesthetic Index

264 Journal of Nature and Science of Medicine  ¦  Volume 5  ¦  Issue 3  ¦  July-September 2022
 James, et al.: Malocclusion and quality of life

In the present study, the overall prevalence of malocclusion

Table 3: Mean Oral Health Impact Profile scores among
was about 30%.
schoolchildren
Mean±SD Overall P
The prevalence of no abnormality/minor malocclusion in
the literature ranges from 48% to 82.8%. [5‑7,10‑12,17,18,21‑25]
Government Aided Private In the present study, nearly 70% of schoolchildren had no
school school school
abnormality/minor occlusion with no/slight treatment need
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Q1: Have you had trouble pronouncing any words because of which is comparable to that in other studies (70.8%).[17]
problems with your teeth, mouth, or dentures?
0.54±0.87 0.52±0.68 0.35±0.58 0.47±0.72 0.04 The prevalence of definite malocclusion ranges from 9.9%
to 26%.[5‑7,10‑12,17,18,21‑25] In the present study, nearly 20% had
Q2: Have you felt that your sense of taste has worsened because
definite malocclusion with elective treatment needs. The result
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of problems with your teeth, mouth, or dentures?

0.41±0.65 0.37±0.52 0.20±0.53 0.33±0.58 <0.001
is comparable to some studies (19.2%–20.4%).[11,17]
Q3: Have you had painful aching in your mouth? The prevalence of severe malocclusion in the literature ranges
0.92±1.10 0.77±0.94 0.79±0.99 0.83±1.01 0.502 from 3.5% to 12.7%.[5‑7,10‑12,17,18,21‑25,35,36] About 6% had severe
Q4: Have you found it uncomfortable to eat any food because of malocclusion in the current study. The result is comparable to
problems with your teeth, mouth, or dentures? some studies (6.4%–6.5%).[10,24]
1.03±1.09 0.68±0.90 0.50±0.77 0.74±0.95 <0.001 The prevalence of very severe/handicapping malocclusion
Q5: Have you been self‑conscious because of your teeth, mouth, ranges from 0.5% to 22%.[5‑7,10‑12,17,18,21‑25,36] Nearly 4% had very
or dentures? severe/handicapping malocclusion with mandatory treatment
1.07±1.02 0.77±0.85 0.65±0.92 0.83±0.95 <0.001 need. This is comparable to a study (4.4%).[24,35]
Q6: Have you felt tense because of problems with your teeth,
OHIP score reflects OHRQoL and an increase in OHIP
mouth, or dentures?
score indicates poor OHRQoL. The mean OHIP score for
0.84±0.90 0.92±0.75 0.49±0.77 0.75±0.83 <0.001
schoolchildren was 9.04 ± 8.07 and lies between that reported
Q7: Has your diet been unsatisfactory because of problems with in the literature ([13.74 ± 8.12][19] and [7.42 ± 6.88][20]).
your teeth, mouth, or dentures?
0.71±1.03 0.60±0.75 0.35±0.72 0.55±0.86 <0.001 The increase in the severity of malocclusion is
Q8: Have you had to interrupt meals because of problems with associated with an increase in OASIS and OHIP scores.
your teeth, mouth, or dentures? Furthermore, there was a significant weak correlation
0.72±0.99 0.61±0.78 0.32±0.67 0.55±0.84 <0.001 between the severity of malocclusion and OHIP
scores (overall [r = 0.259], [P = 0.02]) which is in line
Q9: Have you found it difficult to relax because of problems with
your teeth, mouth, or dentures? with another study (r = 0.176, P = 0.031).[19] Significant
1.05±0.99 0.99±0.82 0.71±0.72 0.92±0.86 <0.001
moderate correlation was observed between the severity of
malocclusion and OASIS scores ([r = 0. 474], [P = 0.02]).
Q10: Have you been a bit embarrassed because of problems with
your teeth, mouth, or dentures? Thus, the increase in the severity of malocclusion is associated
0.84±0.99 0.92±0.81 0.48±0.85 0.74±0.91 <0.001 with an increase in OASIS and OHIP scores, suggestive of
Q11: Have you been a bit irritable because of problems with your interrelationship between malocclusion, self‑perception, and
teeth, mouth, or dentures? quality of life.
0.83±1.07 0.71±0.76 0.59±0.87 0.71±0.91 0.059
In this study, it was found that there is a relationship
Q12: Have you had difficulty doing your usual jobs because of between self‑perception of dental esthetics (OASIS)
problems with your teeth, mouth, or dentures? and malocclusion (DAI) as well as malocclusion and
0.77±0.81 0.53±0.72 0.31±0.70 0.54±0.77 <0.001 OHRQoL (OHIP‑14). Hence, the null hypothesis is rejected.
Q13: Have you felt that life in general was less satisfying because Further studies are suggested in other populations in different
of problems with your teeth, mouth, or dentures? regions.
0.76±1.02 0.54±0.75 0.46±0.83 0.59±0.88 0.008
However, the study has few limitations. The cross‑sectional
Q14: Have you been totally unable to function because of
design and inherent biases in the questionnaire study limit its
problems with your teeth, mouth, or dentures?
generalizability. DAI measures almost all the occlusal traits,
0.70±0.92 0.52±0.71 0.31±0.58 0.51±0.76 <0.001
but it does not consider few anomalies such as posterior
Overall scores crossbite, posterior open bite, midline deviations, or deep
11.18±10.32 9.44±8.52 6.51±6.46 9.04±8.07 <0.001 bite. Therefore, there can be underestimation of the severity
SD: Standard deviation
of malocclusion in patients with these dentofacial problems.
schoolchildren, suggestive of higher perception and concern on For superior uniformity and accuracy, it is better to have a
dental esthetics and malocclusion. However, studies assessing standardized cutoff point for OASIS/OHIP scores. OASIS is
OASIS in the age group of 13–15 years are lacking. a subjective scale with responses only at the extremes of the

Journal of Nature and Science of Medicine  ¦  Volume 5 ¦ Issue 3 ¦ July-September 2022 265
 James, et al.: Malocclusion and quality of life

Table 4: Mean Oral Aesthetic Subjective Impact Scale scores according to the severity of malocclusion among
schoolchildren
DAI score Mean±SD Overall P
Government school Aided school Private school
No abnormality/minor malocclusion (≤25) 10.52±3.56 14.24±9.91 13.12±4.04 12.62±5.83 <0.001
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Definitive malocclusion (25-30) 14.13±6.38 16.01±8.97 13.74±4.56 14.62±6.61 0.004

Severe malocclusion (31-35) 21.41±4.47 23.29±4.30 23.80±5.06 22.83±4.61 0.54
Very severe or handicapping 26.93±3.67 25.00±3.74 16.75±2.68 22.89±3.36 0.001
malocclusion (>36)
SD: Standard deviation, DAI: Dental Aesthetic Index
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Table 5: Mean Oral Health Impact Profile scores according to the severity of malocclusion among schoolchildren
DAI score Mean±SD Overall score P
Government school Aided school Private school
No abnormality/minor malocclusion (≤25) 6.49±5.74 6.31±4.41 5.65±5.27 6.15±5.17 0.36
Definitive malocclusion (25-30) 11.57±10.01 9.47±8.49 6.21±6.20 9.00±8.70 <0.001
Severe malocclusion (31-35) 23.18±6.75 25.29±1.97 20.25±2.87 23.24±5.59 0.36
Very severe or handicapping malocclusion (>36) 32.60±6.33 27.33±7.11 31.33±3.51 31.33±6.45 0.24
SD: Standard deviation, DAI: Dental Aesthetic Index

continuum. This might make it difficult for the respondents to
exercise the options appropriately. Hence, further studies are
required to assess the applicability of OASIS questionnaire.
OHIP is not exclusively meant to measure the oral impacts or
the influence of malocclusion. Therefore, there are chances
of imprecise reporting of responses as the questionnaire
considers all the oral conditions. Hence, the individual and
social differences and the resultant responses to the questions
might affect the study outcomes.
Individual perceptions change over time and treatment
which may be assessed through longitudinal studies. None
of the existing quality of life tools measures the impact of
malocclusion exclusively. A better tool that measures the
impact of malocclusion exclusively should be developed in
this regard. As the conditions and factors analyzed in this study
vary with ethnicity, the generalizability of the study is limited
only to a similar population.
Conclusion
The mean OASIS score and OHIP scores were 14.62 ± 6.93
and 9.04 ± 8.07, respectively. The prevalence of malocclusion
was found to be 29.63%. The severity of malocclusion
significantly correlated with self‑perception of dental esthetics
and OHRQoL among schoolchildren.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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