A.C. Carvalho*, S.M. Paiva*, A.C. Scarpelli*, C.M. Viegas*, F.M. Ferreira**, I.A.

Pordeus*
*Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil **Department of Estomatology, School of Dentistry, Universidade Federal do Paran, Curitiba, Brazil e-mail: anita.odontologia@hotmail.com

Prevalence of malocclusion in primary dentition in a population-based sample of Brazilian preschool children

ABSTRACT Aim The purpose of the present study was to assess the prevalence of malocclusion in the primary dentition in a randomised representative sample of Brazilian preschool children. Methods A cross-sectional survey was carried out in Belo Horizonte, Brazil, involving 1069 male and female preschool children from 60 to 71 months of age, randomly selected from public and private preschools and daycare centers. A questionnaire addressing demographic data was sent to parents/guardians in order to characterise the sample. The oral examination of the children was performed by a single, previously calibrated dentist (kappa inter-examiner agreement value = 0.82). The criterion for the categorisation of malocclusion was at least one of the following conditions: posterior crossbite, overjet (> 2 mm), anterior crossbite, anterior open bite and deep overbite. Univariate analysis was performed using the SPSS software programme. Results and Statistics The prevalence of malocclusion was 46.2%. Deep overbite was the most prevalent alteration (19.7% of the sample). Posterior crossbite was diagnosed in 13.1% of the children; 10.5% had accentuated overjet; 7.9% had anterior open bite; and 6.7% had anterior crossbite. Conclusion Malocclusion in primary dentition is becoming a significant problem. The prevalence in the present study was high, especially vertical and transversal malocclusions. Keywords Malocclusion; Preschool; Prevalence; Primary teeth.

facial muscles [Peres et al., 2007]. The aetiology of malocclusions is primarily genetic with environmental influences [Corruccini and Potter, 1980; Vig and Fields, 2000; Peres et al., 2007; Heimer et al., 2008]. The facial growth pattern is an important genetic factor that contributes to the development of malocclusions and also influences treatment [Heimer et al., 2008]. Studies suggest that malocclusions are also influenced by behavioural factors, such as eating soft foods, breathing infections, the premature loss of primary teeth and nonnutritive sucking habits [Kiliaridis et al., 1985; Peres et al., 2002]. A number of studies have investigated the prevalence of malocclusions in the primary dentition in different countries and populations, with prevalence values ranging from 26.0% to 87.0% in Brazil, India and Germany (Table 1) [Frazo et al., 2002; Ministry of Health, 2003; Katz et al., 2004; Stahl and Grabowski, 2004; da Silva Filho et al., 2007; Dhar et al., 2007; Grabowski et al., 2007; LeiteCavalcanti et al., 2007]. The high prevalence of malocclusion described in these studies as well as the variation in its value depends of the interpretation of what is malocclusion [Almeida et al., 2008]. This variation can be attributed to the interaction between genetic background and environmental factors as well as differences in the criteria for interpreting relevant occlusal deviations [Ogaard et al., 1994; Charchut et al., 2003; Ptren et al., 2003; Katz et al., 2004; Almeida et al., 2008]. There is increasing interest in the early diagnosis and treatment of malocclusions as well as a more comprehensive, rigorous assessment of the clinical dimensions [Almeida et al., 2008]. Studies have demonstrated an association between malocclusion/orthodontic treatment need and poor health-related quality of life [Cunningham and Hunt, 2001; Liu et al., 2009]. From a public health perspective, the assessment of malocclusion in the primary dentition should focus on its magnitude and severity as well as the prevention of occlusion problems later in life [Almeida et al., 2008]. Thus, evaluating the occlusal relation in the primary dentition is an important factor to the development of the permanent dentition [Gis et al., 2008]. It is believed that posterior crossbite is transferred from the primary to the permanent dentition [Harrison and Ashby, 2001; McNamara, 2002; Thilander and Lennartsson, 2002]. The aim of the present study was to evaluate the prevalence of malocclusion in the primary dentition of

Author/Year Frazo et al. (2002) Katz et al. (2004) Stahl & Grabowski (2004) Brasil (2004) Leite Cavalcanti et al. (2007) Dhar et al. (2007) Grabowski et al. (2007) da Silva Filho et al. (2007)

Country Brazil Brazil Germany Brazil Brazil India Germany Brazil

Sample 985 330 1,225 26,641 342 188 766 2,016

Age 5-12 y 3y 4y 5y 3-5 5 to 7 4 3 to 6

Prev. 48.9% 49.7% 42.0% 36.4% 87.0% 26.0% 74.7% 73.2%

Introduction
Malocclusion is a developmental disorder of the craniofacial complex that affects the jaws, tongue and
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TABLE 1 - Prevalence of malocclusion in preschool children.

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CARVALHO A.C. ET AL. preschoolers in a randomised representative sample in the city of Belo Horizonte, MG, Brazil. the sample was re-examined during the data collection. The interval between the exams was 7 to 14 days.

Materials and methods

Sample characteristics
Belo Horizonte is the capital city of that state of Minas Gerais, which is located in south-eastern Brazil. The city has a population of 2,238,526 inhabitants, all of whom reside in urban areas [IBGE, 2010]. A population-based cross-sectional study was carried out. The sample was composed to 1069 children. The subjects were randomly selected through a two-stage sampling method. The first-stage was the randomisation of preschools and daycare centers (65.9% public and 34.1% private) and the second was the randomisation of the children. The calculation of the sample size involved a standard error of 5.0%, 95.0% confidence interval (CI) and a 36.46% prevalence of malocclusion [Ministry of Health, 2003]. This calculation determined a sample of 671 children. A correction factor of 1.4 was applied to increase the precision, as a multi-stage sampling method was adopted. The sample size was also increased by 20% to compensate for possible losses during the data collection. Thus, the minimal sample size to satisfy the requirements was estimated at 1127 individuals. Children ranging from 60 to 71 months of age and regularly enrolled in preschools and daycare centers were included in the sample. The exclusion criteria were the presence of permanent teeth and loss of any primary teeth, dental caries that affected the integrity of the mesiodistal diameter and previous orthodontic treatment.

Clinical data collection

The previously calibrated dentist performed the oral examination of each child at the preschools or daycare centers. The visual inspection of the participants teeth was carried out under natural light and in the knee-to-knee position. The examiner used individual cross-infection protection equipment and all the materials used were packaged and sterile. For the examination, a mouth mirror (PRISMA, So Paulo, SP, Brazil), a WHO probe (Golgran Ind. e Com. Ltda., So Paulo, SP, Brazil) and dental gauze were used. The clinical examination recorded aspects of overbite, overjet and crossbite. No radiography was used for the diagnosis. The criteria used for the diagnosis of the occlusion were based on findings from Foster and Hamilton [1969], Grabowski et al. [2007] and Oliveira et al. [2008]. Overbite was considered the vertical overlap of the incisors when the posterior teeth were in occlusion and was considered normal when at least one of the upper incisors overlapped the lower incisor by 2 mm [Grabowski et al., 2007]. Deep overbite was characterised by the maxillary teeth covering more than 2 mm of the vestibular surface of the mandibular teeth. Anterior open bite was considered the absence of vertical overlap covering the lower incisors [Grabowski et al., 2007]. Horizontal overlap of the incisors was considered overjet. Accentuated overjet was recorded if the upper incisors were at a distance of more than 2 mm from the lower ones [Foster and Hamilton, 1969; Grabowski et al., 2007]. Anterior crossbite was recorded when the lower incisors were observed in front of the upper ones [Foster and Hamilton, 1969; Oliveira et al., 2008]. Normal overjet was considered when positive incisor overjet did not exceed 2 mm measured on the primary upper central incisors [Foster and Hamilton, 1969]. To measure overbite and overjet, the examiner applied the WHO probe from the labial surface of the most anterior lower central incisor to the labial surface of the most anterior upper central incisor, parallel to the occlusal plane. Posterior crossbite was recorded when the upper primary molars occluded in lingual relationship to the lower primary molars in centric occlusion [Foster and Hamilton, 1969]. The criteria used for the diagnosis of malocclusion are summarised in Table 2. Positive overjet, anterior crossbite, deep overbite, anterior open bite and posterior crossbite all indicated malocclusion. The preschool children who exhibited at least one of these conditions were classified with malocclusion [Oliveira et al., 2008].

Pilot study
A pilot study was carried out at a daycare center with 88 preschoolers to test the methodology of the study and the comprehension of the instruments as well as to perform the calibration of the examiner. The data on the children in the pilot study were not included in the main study. The results demonstrated that there was no need to modify the questions or the methodology proposed. Calibration and training exercises were conducted in this step. The calibration consisted of theoretical and clinical steps. The theoretical step involved a discussion of the criteria for the diagnosis of malocclusion and the analysis of eight orthodontic dental models and photographs. A specialist in orthodontics (gold standard in the theoretical framework) coordinated this step, instructing a general dentist on how to perform the examination and diagnosis using the criteria for the different malocclusions. In the clinical step, the dentist examined eight previously selected children from 60 to 71 months of age. Inter-examiner agreement was tested by comparing the examiner with the gold standard. The interval between evaluations of the models and those of the children to test the intra-examiner agreement was seven to 14 days and all the eight children returned for re-examination in this step. Cohens kappa coefficient was used for data analysis on a person-byperson basis to test the agreement between examiners. To assess the reproducibility of the diagnostic criteria, 10% of

Non-clinical data collection

Following the clinical examination, a questionnaire addressing demographic data (childs date of birth, childs gender, parents/guardians schooling, place of residence, type of school) was sent to the parents/ guardians. For the determination of socioeconomic status, the Social Vulnerability Index (SVI) was used. The SVI measures the vulnerability of the population of Belo Horizonte by determining neighborhood infrastructure, access to work, income, sanitation services, healthcare services, education,
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Overbite Normal Deep overbite Anterior open bite Overjet Normal Accentuated Anterior crossbite Positive incisor overjet not exceeding 2 mm, measured on primary upper central incisors Upper incisors at a distance of more than 2 mm from lower incisors Lower incisors in front of upper incisors (negative overjet, absence of overbite) Upper incisors overlap lower incisors by 2 mm Maxillary teeth cover more than 2 mm of vestibular surface of mandibular teeth Absence of vertical overlap of lower incisors

out using the Statistical Package for Social Science (SPSS for Windows, version 17.0, SPSS Inc, Chicago, IL, USA). Interexaminer agreement was evaluated using Cohens kappa coefficient. Data analysis was carried out with the determination of descriptive statistics to describe the prevalence of malocclusion and characteristics of the sample.

Ethical considerations
The study received approval from the Research Ethics Committee of Universidade Federal de Minas Gerais, Brazil. Terms of informed consent were signed by the parents/guardians allowing their children to participate in the study.

Posterior crossbite Upper primary molars occluded in lingual relationship to lower primary molars in centric occlusion TABLE 2 - Criteria used for the diagnosis of malocclusion (Modified by Oliveira et al., 2008).

Results
The sample was composed of 1069 preschool children between 60 and 71 months of age (mean: 64.4 months). The response rate was 94.9%; 5.1% of the sample was lost either because children were absent from school on the day of the oral exam or because they refused to be examined. Cohens Kappa coefficient for inter-examiner agreement was greater than 0.82 and was tested by comparing the values of the examiner with the gold standard. Table 3 displays the characterisation of the sample. A total of 570 participants were boys (53.3%) and 499 were girls (46.7%). The mother was the most common caregiver, accounting for 86.2% of the sample, while other caregivers accounted for 13.8% (father, babysitter, brother, sister and grandparents). With regard to schooling, 68.9% of the parents/guardians had more than eight years of study and 31.1% had eight or fewer years. According to the Social Vulnerability Index (SVI), most of the children and families (55.8%) were socially less vulnerable, while 44.2% of the sample was socially more vulnerable. The majority of the parents/guardians (74.1%) reported that they received three times the minimum wage or less per month, while 25.9% reported receiving more than three times the minimum wage. Table 4 displays the oral characteristics diagnosed during the clinical examinations. The prevalence of malocclusion

legal assistance and public transportation [Nahas et al., 2000]. There are five different classes; Classes I, II and III are comprised of families with greater social vulnerability, while Classes IV and V consist of families with the less vulnerability [Nahas et al., 2000; Serra-Negra et al., 2009]. The following socioeconomic indicators were also used: monthly family income (categorised based on the minimum wage used in Brazil one minimum wage is roughly equal to US$258.33) and parents/guardians schooling (categorised in years of study).

Statistical analysis
The data organisation and statistical analysis were carried

Childs characteristics Age (months) Gender Preschool 60 to 65 66 to 71 Male Female Private Public

Frequency n 661 408 570 499 365 704 Frequency n 556 513 922 147 737 332 596 473 277 792

% 61.8 38.2 53.3 46.7 34.1 65.9 % 52.0 48.0 86.2 13.8 68.9 31.1 55.8 44.2 25.9 74.1

Child's clinical disease Posterior Crossbite Overjet Anterior Open Bite Deep Overbite Anterior Crossbite Malocclusion Absent Present Normal Increased Absent Present Absent Present Absent Present Absent Present

Frequency n 929 140 957 112 985 84 858 211 997 72 575 494

% 86.9 13.1 89.5 10.5 92.1 7.9 80.3 19.7 93.3 6.7 53.8 46.2

Parents/Guardians characteristics Age (years)

18 to 33 34 to 71 Relationship to child Mother Other Years of schooling > 8 years 8 years Social Vulnerability Index Less vulnerable More vulnerable Month Family income > 3 times minimum wage 3 times minimum wage

TABLE 3 - Descriptive analyses of demographic characteristics of sample, Belo Horizonte, Brazil, 2009 (n=1069).
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TABLE 4 - Descriptive analyses of clinical characteristics of sample, Belo Horizonte, Brazil, 2009 (n=1069).

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CARVALHO A.C. ET AL. in the primary dentition was 46.2%. A total of 89.5% of the sample exhibited normal overjet and 10.5% exhibited accentuated overjet (> 2 mm). Anterior crossbite was absent in 93.3% of the children and present in 6.7%. Deep overbite was present in 19.7% of the sample and absent in 80.3%. Anterior open bite was present in 7.9% of the sample. The prevalence of posterior crossbite was 13.1%. (13.1%). These results are similar to those reported in previous studies [Karjalainen et al., 1999; Grabowski et al., 2007; Almeida et al., 2008; Macena et al., 2009]. Deep overbite generally interferes in the opening, protrusion and lateral movements of the mouth. The 19.7% prevalence of this condition is less than that reported a German study (33.2%) [Grabowski et al., 2007]. This difference may be due to the fact that the study cited was carried out on children with primary and early mixed dentition. Moreover, children with both permanent incisors and/or molars were accepted. The authors found a high proportion of accentuated overjet and deep overbite in the mixed dentition, suggesting that neither condition corrected itself [Grabowski et al., 2007]. In the present study, 10.5% of the children had accentuated overjet, which is lower than that reported in previous studies carried out with children of the same age with primary teeth, such as the 29.7% and 16.0% prevalence reported in studies conducted in Brazil [Katz et al., 2004; Almeida et al., 2008]. A study carried out with Finnish children reports a 26.0% prevalence of this condition [Karjalainen et al., 1999]. These differences may be due to the different methodology used by the authors, who considered an accentuated overjet to be that greater than 3 mm, in comparison to the 2 mm used in the present study for the determination of this condition. The prevalence of posterior crossbite was 13.1% in the present study. Previous studies report a frequency of this condition in the primary dentition ranging from 7.2% to 20.81% [da Silva Filho et al., 2007; Grabowski et al., 2007]. Posterior crossbite is one of the most prevalent malocclusions in the primary and early mixed dentitions [Petrn et al., 2003]. It is also believed that this condition can be transferred from the primary to the permanent dentition [Petrn et al., 2003; Almeida et al., 2008]. The majority of studies on posterior crossbite associate this alteration to nonnutritive sucking habits, as children with such habits tend to have a greater chance of exhibiting malocclusion than those without pacifier-sucking habits [da Silva Filho et al., 2007; Scavone et al., 2007; Gis et al., 2008; Macena et al., 2009]. The present study has some inherent limitations that should be addressed. Cross-sectional studies are carried out either at a single point in time or over a short period. Thus, associations identified in this type of study cannot be considered a causal relationship. Furthermore, Brazilian epidemiological studies in early childhood are limited due to the difficult access to children who are too young to attend daycare centers and schools [Macena et al., 2009].

Discussion
Epidemiological studies are important to understand the distribution of oral health conditions in different populations and individuals [Almeida et al., 2008]. The aim of the present study was to determine the prevalence of malocclusion in the primary dentition. At least one type of malocclusion was found in 46.2% of the children examined. This prevalence is different to that described in other studies carried out in Brazil, such as the 49.7% reported for the city of Recife, 36.4% reported in a representative study of Brazil as a whole, 48.9% in the city of So Paulo, 73.2% in the city of Bauru and 87.0% in the city of Campina Grande [Frazo et al., 2002; Ministry of Health, 2003; Katz et al., 2004; da Silva Filho et al., 2007; Leite-Cavalcanti et al., 2007]. The prevalence was also different from that reported in studies carried out in different countries, such as the 26.0% prevalence reported for India and 42.0% to 74.7% prevalence reported for Germany [Stahl and Grabowski, 2004; Dhar et al., 2007; Grabowski et al., 2007]. Direct comparison of the results from different studies is hindered by the variety of nomenclatures used to classify malocclusions and the application of different diagnostic criteria [Grabowski et al., 2007]. The sample selection method and sample size are important when comparing results. Other difficulties that arise when attempting to describe and interpret data on malocclusion in the primary dentition involve the inclusion of children with mixed and permanent dentition within the sample, differences in the measurement of specific disorders, the lack of a specific index for assessing malocclusion in the primary dentition and the identification of cases and noncases from an epidemiological perspective [Almeida et al., 2008]. Thus, the development of a standardised measurement is very important to assess malocclusion in the primary dentition, as there is no available occlusal index for such an assessment. Moreover, the assessment of morphological deviations alone is insufficient when evaluating the progress of malocclusion [Grabowski et al., 2007]. It is important to mention that there is an index especially developed to assess treatment need in young patients [Grippaudo et al., 2007; Grippaudo et al., 2008]. The Risk of Malocclusion Assessment Index` (ROMA Index) was developed and validated for use in Italian children. Thus, we strongly encourage further studies to carry out the cross-cultural validation for its use in other countries and cultures. So, it can be used in large surveys all around the world. In the present study, the most prevalent type of malocclusion was deep overbite (19.7%), followed by increased overjet (10.5%) and posterior crossbite

Conclusion
The present study offers evidence that malocclusion is a problem in Brazilian preschool children. The prevalence of malocclusion was high among the children analyzed, suggesting that malocclusion is a public health problem in this population. Thus, an early intervention is indicated to prevent worsening and stimulating well-balanced dento dental and skeletal growth.
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Aknowledgement
This study was supported by the National Council for Scientific and Technological Development (CNPq), the Ministry of Science and Technology and the Research Foundation of the State of Minas Gerais (FAPEMIG), Brazil.

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