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An epidemiological study on early orthodontic treatment need among eastern Saudi Arabian children in the mixed dentition stage – Scientific Reports


The present study investigated the early orthodontic treatment need in a sample of Saudi children from the Eastern region of Saudi Arabia and found that 88.7% of the sample presented either moderate or definite preventive and interceptive orthodontic treatment need, which implies high treatment need percentage in the present sample. Previous studies4,5,6,11,13 conducted in Saudi Arabia to evaluate orthodontic treatment need have shown variable results for definite treatment need ranging from 4.4 to 52.5%, which is lower than that found in the present study (59.4%). Yilmaz et al.14 had reported that 45.9% of 7–8-year-old and 56.9% of 9–10-year-old Turkish children showed definite orthodontic treatment need. Salim et al.15 in a study on Syrian refugee children in Jordan used dental health component of Index for Orthodontic Treatment Need (IOTN-DHC) and found 67.7% prevalence of moderate to severe need for orthodontic treatment. Bourzgui et al.10 had reported a higher need (86.3%) for orthodontic treatment in 8–10-year-old Moroccan schoolchildren. Another study conducted in Saudi Arabia using IOTN-DHC reported that 30.9% of 8- to 9-year-old Saudi children possessed definite need for orthodontic treatment5. However, comparison of these findings should be made with caution, as they were conducted in a different and/or wider range of age groups using IOTN index.

Studies reporting on the orthodontic treatment need using IPION index are scarce in the literature. Karaiskos et al.16 in a study on Canadian children reported that 37.1% of children in IPION-9 group scored ‘5’ or higher, indicating the need for preventive and interceptive orthodontic treatment. Another author had utilized the IPION-9 index to measure early orthodontic treatment need in a pediatric dental population in USA and found that moderate and definite treatment needs were seen in 16.36% and 70.91% of children, respectively17. A study conducted on Thai population18 with high caries prevalence using IPION index had reported that 96% of children aged 8–9 years with mixed dentition needed either moderate or definite preventive and interceptive orthodontic need. Another study in Syrian children19 identified that 28.4% and 59.6% of the children showed moderate and definite treatment need respectively, based on IPION-9 index components. To our knowledge, this is the first study conducted among Saudi children using IPION to evaluate the early orthodontic treatment need in the mixed dentition stage and as such, comparison of results from the present study with previous studies was limited.

This study found that according to the IPION-9 scoring system, 59.4% of the sample were in definite treatment need group and only 11.3% of them presented no treatment need. Other authors17,18,19,20,21 also have reported high definite orthodontic need in the IPION-9 age group. However, when caries was excluded to detect the impact of other traits, the percentage of sample with no treatment need had increased to 21.3% whereas 34.7% showed moderate treatment need and 43.9% showed definite treatment need. Although the percentage of definite treatment need decreased from 59.4 to 43.9% when the caries scores were excluded, it was still considered very high. Furthermore, in our study, if the moderate treatment need is also considered, 88.7% of the sample were in need of early orthodontic treatment. Majority of the children in this study needed high treatment needs irrespective of the caries component, a finding in accordance with a study on Syrian children19.

The high percentage of children with definite treatment need (59.4%) noted in this study could be related to the inclusion of children with permanent incisors erupted in the mouth, regardless of the age, high caries prevalence, and presence of more categories to be scored in IPION-9. The discrepancies between the findings in the studies may be due to the differences in sample selection, ethnic and racial diversity of populations studied, and the index used to assess the orthodontic treatment need. IPION-9 is usually used in children with relatively more advanced developmental age and has more categories and scores when compared to IPION-6. As a result, a higher percentage of sample in this age group may get included in the moderate and definite need categories19. Gender comparison showed no statistically significant relation with the treatment distribution needs in the present study (p = 0.513), which corroborates with most studies in the literature5,10,19,22. Hence, this finding concurs that preventive and interceptive orthodontic treatment needs are irrelevant to the gender regardless of population group. Contrary to this, Dias et al.23 found that the males had a need for orthodontic treatment more defined compared to females.

Proximal caries of posterior teeth and early tooth loss are the main components with high importance in IPION as they can result in early space loss due to tipping and/or rotation of adjacent teeth thereby resulting in malocclusion. More than half of the present study sample showed early loss of second primary molars, while 75.4% of children had caries affected first permanent molars. This finding corroborates with that of Almugla24 who had reported a high prevalence rate of missing first permanent molars (36.9%) in a study on children from a similar population group in Saudi Arabia and had attributed it to high caries prevalence, except that his study included a wider age group of 7- to 15-year-old children. The goal of this study was to see whether a significant need for early orthodontic treatment existed in the population studied and hence direct comparison of data with other studies is limited. Despite caries still being considered a significant problem in the population studied, a demonstrable need for early orthodontic intervention nevertheless exists even when caries was not counted. Furthermore, it was disturbing to note that children with early loss of primary molars presented no evidence of any space maintenance. This might be attributed to socioeconomic status and lack of awareness of the importance of space maintenance25. However, socioeconomic status was not assessed in the present study as a major proportion of the population utilize publicly funded healthcare services.

The IPION-9 can be considered an effective diagnostic tool in that it includes almost all characteristics that indicate the need for preventive and interceptive orthodontic treatment, such as dental crossbite, deep bite, open bite, crowding, missing teeth, and ectopic eruption26. In addition, it gives a high weighting score for some components such as proximal caries of second primary molar and first permanent molar compared to first primary molar1. However, its limitations are that it does not identify the type of preventive and interceptive orthodontic treatment15; radiographs are not assessed which might miss supernumerary teeth and absence of permanent incisors; and absence of permanent incisors is recorded by counting all incisors that are not clinically seen in the arch. Additionally, this index lacks assessment of oral habits and its role in the developing malocclusion. These might affect the estimation of the level of preventive and interceptive orthodontic treatment need27, and hence warrants modifications to the IPION to make it more effective and reliable. Rapeepattana et al.18 had suggested that grouping the IPION components into a caries and early loss component group, and an occlusal and functional component group, might aid in easy referral by identifying the type of treatment need between the groups. Vakiparta et al.28 recommended a policy of initiating early treatment only in subjects with definite need, and to follow-up on those with moderate need and give them time for spontaneous correction. On the contrary, other authors had opined that targeted early orthodontic treatment approach in the mixed dentition would be beneficial and could be considered as an acceptable alternative29,30. Reports on early orthodontic treatment need among children during mixed dentition stage is essential for planning treatment strategies as it provides a good juncture to consider interceptive orthodontics29,31,32.

One of the limitations in the present study was that the use of population sample derived from children visiting dental health care center in university setting may not represent the general population of similar age group, and hence limits the generalizability of the findings. Since orthodontic care in Saudi Arabia is publicly funded, implementation of early orthodontic treatment could pose a huge challenge. Generating such data could serve as a baseline for future studies involving larger samples and might be useful for planning publicly subsidized orthodontic treatment or could impact policy changes aimed to reduce barriers in accessing and utilizing early orthodontic treatment services at the community and system levels, through allocation of separate funds for the same. This when combined with efforts to increase awareness on the importance of early orthodontic treatment in children could motivate the parents to seek preventive and interceptive orthodontic services thereby improving oral health related quality of life in children and/or parents, and also reduce financial burden on public funded healthcare system in Saudi Arabia.



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