Systematic Review

Orthodontics

Perception of malocclusion and

school performance in adolescents:
a systematic review

Ana Carla Souza COSTA(a) Abstract: This study aimed to assess the potential association between
Djessyca Miranda e PAULO(b) perception malocclusion and school performance in children and
Maria Tereza Campos VIDIGAL(b)
Walbert de Andrade VIEIRA(c)
adolescents. An electronic search was performed in ten databases.
Andres Felipe Millan CARDENAS(d) Based on the PECO acronym (Population, Exposition, Comparator, and
Luiz Renato PARANHOS(e) Outcome), the eligibility criteria included observational studies that
compared the school performance of children and adolescents with and
Universidade Ceuma, School of Dentistry,
(a)
without the perception of malocclusion. There were no restrictions on
Post-Graduate Program in Dentistry, São
the language or year of publication. Two reviewers selected the studies,
Luiz, MA, Brazil
extracted the data, and assessed the risk of bias by using the Joanna
Universidade Federal de Uberlândia – UFU,
(b)

School of Dentistry, Post-Graduate Program

Briggs Institute tool for cross-sectional studies. School performance
in Dentistry, Uberlândia, MG, Brazil was measured by analyzing student grades; levels of absenteeism;
Universidade Estadual de Campinas –
(c) and child or adolescent self-perception and/or the perception of
Unicamp, School of Dentistry of Piracicaba, parents, guardians, close friends, and teachers regarding the impact
Department of Restorative Dentistry, of malocclusion on school performance. The data were described
Piracicaba, SP, Brazil
narratively/descriptively. The search resulted in 3,581 registers, of
Universidade Ceuma, Department of Post-
(d)
which eight were included in the qualitative synthesis. These studies
Graduate Program in Dentistry, São Luis,
MA, Brazil were published between 2007 and 2021. Two studies concluded that
Universidade Federal de Uberlândia –
(e) there was no significant association between school performance and
UFU, School of Dentistry, Department perception of malocclusion, five studies found that only some of the
of Preventive and Community Dentistry, children with malocclusion had their school performance affected, and
Uberlândia, MG, Brazil
one study concluded that there was a significant association between
perception of malocclusion and low school performance. Considering
Declaration of Interests: The authors all variables and the very low certainty of evidence, the perception of
certify that they have no commercial or
malocclusion seems to negatively impact school performance when
associative interest that represents a conflict
of interest in connection with the manuscript. associated with external and subjective factors. Further studies using
additional measurement standards are required.

Keywords: Academic Performance; Adolescent; Child; Dental Occlusion.

Corresponding Author:
Luiz Renato Paranhos
E-mail: [email protected]
Introduction

Individuals undergo several physical and emotional changes from

https://doi.org/10.1590/1807-3107bor-2023.vol37.0033
birth to adulthood.1 Children and adolescents show a high worldwide
prevalence of malocclusion.2 This is associated with multiple factors such
as dental caries, pulpal and periapical lesions, dental trauma, abnormality
Submitted: February 11, 2022
of development, and oral habits.3 Moreover, on its own, facial growth from
Accepted for publication: October 17, 2022
Last revision: November 8, 2022 childhood to adolescence is unable to correct most of the malocclusions
of primary dentition.2

Braz. Oral Res. 2023;37:e033 1

 Perception of malocclusion and school performance in adolescents: a systematic review

Malocclusions constitute oral changes with a Inclusion criteria

global prevalence of 39% among adolescents.4 In some Population: Children and adolescents up to 19 years
phases of their development, children and adolescents old, according to the World Health Organization15
spend a considerable number of years in schools Exposition: Malocclusion perceived by the
and other education and training institutions.1 The individuals and/or their parents/guardians and
presence of oral disorders may affect the school life assessed using reliable methods, such as self-
of these individuals.5,6 Some explicit and extreme perception or dental indices
malocclusions may also be related to bullying in Comparator: Children and adolescents who did
childhood and adolescence.7 not report perceived malocclusion and without any
There is evidence that certain oral conditions, diagnosed malocclusion
such as caries, periodontal disease, tooth loss, and Outcome: School performance (grade analyses,
orofacial pain, may negatively affect oral health- level of absenteeism, and child or adolescent self-
related quality of life8,9 and school performance.10 perception or the perception of parents, guardians,
However, the primary evidence in the literature on and/or teachers regarding the impact of malocclusion
the role of malocclusion in the school performance on school performance)
of children and adolescents has not yet been Type of study: observational studies (cross-
gathered into secondary studies. Thus, the present sectional, case-control, or cohort studies)
systematic review aimed to investigate and expose There were no restrictions on language or year
the existing scientific evidence about the impact of publication.
of the perception of malocclusion on children and
adolescents’ school performance. Exclusion criteria
Studies with a sample of individuals with current
Methodology or previous orthodontic treatment
Studies with a sample of syndromic individuals
Protocol registration Studies assessing school performance using the
The protocol of this systematic review was perception of malocclusion images by third parties
described according to the Preferred Reporting Items Review articles, letters to the editor or editorials,
for Systematic Review and Meta-Analysis Protocols personal opi n ions, book chapters or books,
guidelines11 and registered in the International textbooks, case reports or case series, reports, and
Prospective Register of Systematic Reviews database congress abstracts
under number CRD42020172295 (https://www.crd. Studies with overlapping samples; when two or
york.ac.uk/prospero/). Moreover, this systematic more studies were conducted in the same place, by
review was reported according to the PRISMA the same authors, and in similar years, but published
(Preferred Reporting Items for Systematic Reviews in different journals or years. In this case, the most
and Meta-Analyses) guidelines12 and conducted recent study that best described the methodology
according to the norms of the Joanna Briggs Institute and results was considered.
manual for Evidence Synthesis13 and according to the
Conducting Systematic Reviews and Meta-Analyses Sources of information and search
of Observational Studies of Etiology guidelines.14 Electronic searches were performed in November
Research question and eligibility criteria 2020 and updated until June 2022 in the following
This systematic review aimed to answer the databases: Embase, LILACS and BBO, MedLine (via
following guiding question based on the PECO PubMed), SciELO, Scopus, and Web of Science. The
acronym (Population, Exposition, Comparator, BDTD, EASY, and WorldCat databases were used to
and Outcome): “Do children and adolescents with partially capture the “gray literature”. A manual search
malocclusion present lower school performance than was also performed using a systematized analysis
individuals without malocclusion?” of the list of references of eligible studies. Medical

2 Braz. Oral Res. 2023;37:e033

 Costa ACS, Paulo DM, Vidigal MTC, Vieira WA, Cardenas AFM, Paranhos LR

Subject Headings, Health Sciences Descriptors, and and “OR” were used to refine the research strategy
Embase Subject Headingswere used to select keywords using several combinations. The search strategies for
used in the search strategies. Synonyms and free each database were based on their respective syntax
terms were also used. Boolean operators “AND” rules (Table 1).

Table 1. Strategies for database search

Database Search Strategy

Main Databases
(“malocclusion”/exp OR “malocclusion” OR “tooth crowding”/exp OR “tooth crowding” OR
“crossbite”/exp OR “crossbite” OR “cross bite”/exp OR “cross bite” OR “angle classification” OR
Embase “esthetics”/exp OR “esthetics” OR “aesthetics”/exp OR “aesthetics” OR “esthetics, dental”/exp
http://www.embase.com/ OR “esthetics, dental” OR “tooth”/exp OR “tooth” OR “teeth”/exp OR “teeth”) AND (“academic
performance” OR “school performance” OR “educational measurement” OR “educational test score”
OR “absenteeism” OR “student dropouts” OR “student dropout” OR “school dropout”)
((“Malocclusion” OR “Tooth Crowding” OR “Crossbite” OR “Cross Bite” OR “Angle Classification”
OR “Esthetics” OR “Aesthetics” OR “Esthetics, Dental” OR “Tooth” OR “Teeth”) AND (“Academic
LILACS and BBO
Performance” OR “School Performance” OR “Educational Measurement” OR “Educational Test Score”
http://lilacs.bvsalud.org/
OR “Absenteeism” OR “Student Dropouts” OR “Student Dropout” OR “School Dropout”)) AND
( db:(“LILACS” OR “BBO”))
#1 “Malocclusion”[Mesh] OR “Tooth Crowding”[tw] OR “Crossbite”[tw] OR “Cross Bite”[tw] OR
“Angle Classification”[tw] OR “Esthetics”[Mesh] OR “Aesthetics”[tw] OR “Esthetics, Dental”[Mesh] OR
“Tooth”[Mesh] OR “Teeth”[tw]
MEDLINE (via PubMed)
#2 “Academic Performance”[Mesh] OR “School Performance”[tw] OR “Educational
http://www.ncbi.nlm.nih.gov/pubmed
Measurement”[Mesh] OR “Educational Test Score”[tw] OR “Absenteeism”[Mesh] OR “Student
Dropouts”[Mesh] OR “Student Dropout”[tw] OR “School Dropout”[tw]
#1 AND #2
#1 (“Malocclusion” OR “Tooth Crowding” OR “Crossbite” OR “Cross Bite” OR “Angle
Classification” OR “Esthetics” OR “Aesthetics” OR “Esthetics, Dental” OR “Tooth” OR “Teeth”)
SciELO
#2 (“Academic Performance” OR “School Performance” OR “Educational Measurement” OR
http://www.scielo.org/
“Educational Test Score” OR “Absenteeism”)
#1 AND #2
(TITLE-ABS-KEY ((“Malocclusion” OR “Tooth Crowding” OR “Crossbite” OR “Cross Bite” OR “Angle
Classification” OR “Esthetics” OR “Aesthetics” OR “Esthetics, Dental” OR “Tooth” OR “Teeth”)) AND
Scopus
TITLE-ABS-KEY ((“Academic Performance” OR “School Performance” OR “Educational Measurement”
https://www.scopus.com/
OR “Educational Test Score” OR “Absenteeism” OR “Student Dropouts” OR “Student Dropout” OR
“School Dropout”)))
#1 TS= ((“Malocclusion” OR “Tooth Crowding” OR “Crossbite” OR “Cross Bite” OR “Angle
Classification” OR “Esthetics” OR “Aesthetics” OR “Esthetics, Dental” OR “Tooth” OR “Teeth”))
Web Of Science #2 TS= ((“Academic Performance” OR “School Performance” OR “Educational Measurement”
http://apps.webofknowledge.com/ OR “Educational Test Score” OR “Absenteeism” OR “Student Dropouts” OR “Student Dropout” OR
“School Dropout”))
#1 AND #2
Gray Literature
(Todos os campos:(“Malocclusion” OR “Tooth Crowding” OR “Crossbite” OR “Cross Bite” OR “Angle
Classification” OR “Esthetics” OR “Aesthetics” OR “Esthetics, Dental” OR “Tooth” OR “Teeth”) E Todos
BDTD
os campos:(“Academic Performance” OR “School Performance” OR “Educational Measurement”
http://bdtd.ibict.br/
OR “Educational Test Score” OR “Absenteeism” OR “Student Dropouts” OR “Student Dropout” OR
“School Dropout”))
((“Malocclusion” OR “Tooth Crowding” OR “Crossbite” OR “Cross Bite” OR “Angle Classification”
Easy OR “Esthetics” OR “Aesthetics” OR “Esthetics, Dental” OR “Tooth” OR “Teeth”) AND (“Academic
https://easy.dans.knaw.nL/ Performance” OR “School Performance” OR “Educational Measurement” OR “Educational Test Score”
OR “Absenteeism” OR “Student Dropouts” OR “Student Dropout” OR “School Dropout”))
((“Malocclusion” OR “Tooth Crowding” OR “Crossbite” OR “Cross Bite” OR “Angle Classification”
WorldCat OR “Esthetics” OR “Aesthetics” OR “Esthetics, Dental” OR “Tooth” OR “Teeth”) AND (“Academic
https://www.worldcat.org/ Performance” OR “School Performance” OR “Educational Measurement” OR “Educational Test Score”
OR “Absenteeism” OR “Student Dropouts” OR “Student Dropout” OR “School Dropout”))

Braz. Oral Res. 2023;37:e033 3

 Perception of malocclusion and school performance in adolescents: a systematic review

Study selection Risk of bias assessment

The search results were exported to the EndNote
Web™ software (Thomson Reuters, Toronto, Canada) Evaluation of methodological quality
for cataloging and removing duplicates. The results The studies were assessed for the risk of individual
obtained in the partial search of the “gray literature” bias using the JBI Critical Appraisal Tools for use in
were exported to Microsoft Word (Microsoft, the JBI Critical Appraisal Checklist for Analytical
Washington, USA) to manually remove duplicates. Cross-Sectional Studies.16 Two authors (ACC and DMP)
Before the selection of studies, a calibration exercise independently assessed each domain for the risk of
was performed when the examiners discussed the bias as recommended by the PRISMA statement.12
eligibility criteria and applied them to a sample of Each question could be answered as follows: “Yes,”
20% of the eligible studies to determine the inter- if the study did not present biases for the domain
examiner agreement. assessed in the question; “No,” if the study presented
After reaching an adequate level of agreement biases for the domain assessed in the question;
(kappa ≥ 0.81), the reviewers (ACC and DMP) “Uncertain,” if the study did not provide sufficient
performed a detailed analysis of the titles and information to assess the question bias; and “Not
abstracts of the studies, applying the inclusion and Applicable,” if the question did not fit in the study.
exclusion criteria mentioned above. Studies that
Evaluation of control statements for possible
did not meet these criteria were excluded. Next,
confounders and bias consideration
the full texts of the eligible preliminary studies
The control statements for possible confounders
were obtained and evaluated. In this phase, the
and risk of bias were evaluated based on the
excluded studies were listed separately, specifying
methodology described by Hemkens et al.17 First,
the reasons for their exclusion. Two eligible reviewers
eligible studies that mentioned only bivariate
independently performed the entire selection process.
analysis or did not report multivariate analysis
Disagreements were resolved by consulting with a
were excluded from this evaluation. Second, two
third reviewer (LRP).
independent reviewers (ACC and DMP) critically
appraised the remaining studies. The reviewers
Data extraction
were blinded, and a third reviewer (LRP) was
Two reviewers (ACC and DMP) independently
consulted in case of disagreements. Each article had
extracted data from eligible studies. A calibration
the Abstract and Discussion sections analyzed in
exercise was performed to ensure consistency consideration of confounders using six questions
between the two reviewers, in which information which were previously established. Only the sixth
was jointly extracted from one eligible study. A question considered the Conclusion section. If the
third reviewer (LRP) performed calibration. The conclusion section was absent, the last paragraph
following data were extracted: identification and of the Discussion section was considered.
characteristics of the study (author, year, country,
research location, and application of ethical criteria), Assessment of confounding factors
sample characteristics (number of participants, age The confounding factors were assessed based
group, sex distribution, and method of malocclusion on the methodology described by Wallach et al.18 It
analysis), and main outcome characteristics was conducted by two reviewers (ACC and DMP),
(school grades, absenteeism, relationship with independent and blinded. A third reviewer (LRP)
bullying, and assessment of school performance was consulted during disagreements. All studies
by parents or teachers). In case of incomplete included in the evaluation of control statements
or insufficient data, the corresponding author for possible confounders and bias consideration
was contacted via e-mail up to three times at had their Methods and Result sections analyzed.
weekly intervals. The aim was to list the variables included in each

4 Braz. Oral Res. 2023;37:e033

 Costa ACS, Paulo DM, Vidigal MTC, Vieira WA, Cardenas AFM, Paranhos LR

study and identify which variables were used to qualitative synthesis.10,21-27 Figure shows the details
perform adjustment, stratification, or matching of the study selection process.
between groups.
Adjustment variables were analyzed using Characteristics of the eligible studies
multivariate logistic regression analysis or Poisson’s The studies were published between 2007 and
regression. Stratification variables were those used 2021 and performed in five different countries:
in the sample selection to make strata. Matching Brazil,10,22,24,25 Chile,26 India,23 Mongolia,27and Peru.21 All
variables ensured compatibility of characteristics studies reported the following ethical criteria with the
between groups. In addition, variables considered approval of an ethics committee and/or application
possible confounding factors were set together in of a consent form to the research participants. The
their respective confounding domains. sample included 9,369 children and adolescents
allocated to public and private schools. The reported
Summary of measurements and synthesis ages varied between 3 and 19 years.
of results Malocclusion was assessed using the Dental
T he dat a col le c ted wer e orga n i z ed a nd Aesthet ic Index (DAI), 10,2 2,23,26 sel f-perceived
described descriptively or narratively (qualitative malocclusion,21 malocclusion exam for the presence
synthesis) according to the findings presented in of dentofacial features,24 the use of a Community
each study. School performance was measured by Periodontal Index (CPI) probe,25 and the Index of
analyzing student grades; levels of absenteeism; Orthodontic Treatment Need (IOTN).27 The tools used
and child or adolescent self-perception and/or the to measure the school performance of participants
perception of parents, guardians, close friends, and varied among grades,10,22,23,26,27 self-reports by
teachers regarding the impact of malocclusion on adolescents,21,25 and absenteeism.24
school performance. Table 2 details the information of each eligible
study.
Certainty of evidence
Two reviewers (WAV and MTCV) independently Summary of measurements and synthesis
ranked the overall strength of evidence using of results
the Grading of Recommendations, Assessment, Eight studies10,21-27 were included in the qualitative
Development and Evaluation tool.19 To assess the synthesis, and their outcomes are summarized below.
criteria in systematic reviews without meta-analyses, The study by Paula et al. 22 did not show a
the authors followed the adaptations proposed by sig nificant association between the need for
Murad et al.20 orthodontic treatment (assessed using the DAI)
and school performance, with an odds ratio (OR)
Results of 1.33 (0.87–2.03). Similarly, Julca-Ching and
Carruitero26 did not find a significant difference
Study selection in school performance scores between young
The electronic search identified 3,581 results individuals with normal occlusion and those with
distributed into nine electronic databases, including malocclusion, regardless of severity. Furthermore,
the “gray literature”. After removing duplicates, 3,098 both studies highlighted the potential association
results remained for the analysis. Careful reading of between the influence of external and subjective
the titles and abstracts excluded 3,071 results. Twenty- factors, especially related to family members
seven registers were sought for retrieval and three and socioeconomic conditions, and the impact of
were not retrieved. Twenty-four studies remained malocclusion on school performance.
for full-text reading. At this stage, 16 studies were Ortiz et al.10 reported that some adverse oral
excluded because they did not meet the inclusion conditions, such as malocclusion, as well as subjective
criteria. Thus, eight studies were included in the and socioeconomic factors, might have impacted

Braz. Oral Res. 2023;37:e033 5

 Perception of malocclusion and school performance in adolescents: a systematic review

Identification of studies via databases and registers Identification of studies via other methods

Records identified from: Records removed before screening:

Records identified from:
Main databases Gray literature Main databases:
• Reference’s list of eligible studies (n = 258)
Identification

(n = 3147) (n = 434) • Duplicate records removed • Studies in the reference list of a systematic
• Embase (n = 297) • BDTD (n = 21) by automation tools (n = 403) review (n = 43)
• LILACS and BBO (n = 4) • Easy (n = 62) • Duplicate records removed
• MedLine (via PubMed) • WorldCat manually (n = 80)
(n = 791) (n = 351) Gray literature:
• SciELO (n = 1322)
• Scopus (n = 652) • Duplicate records removed
• Web of Science (n = 81) manually (n = 0)

Reports sought Reports not

Records screened by title Results excluded after reading the
for retrieval retrieved
and abstracts (n = 3098) titles and abstracts (n = 3071)
(n = 1) (n = 0)

Reports assessed Reports

Records sought for
Records not retrieved (n = 3) for eligibility excluded
Screening

retrieval (n = 27)
(n = 1) (n = 1)

Full-text records assessed Records excluded, with reasons (n = 16):

for eligibility (n = 24) The sample did not match the age group
(n = 1)
Thesis that originated an elegible article
(n = 1)
Did not focus on the relationship between
malocclusion and schoo performance
(n = 14)
Included

Records included in:

• Qualitative synthesis (n = 8)

Figure. Flowchart depicting the study selection process (Preferred Reporting Items for Systematic Reviews and Meta-Analyses
flow diagram).

adolescents’ academic performance. Bernabé et al.21 performance of their children was affected by dental
observed that only 0.6% of the children analyzed appearance, 79% of teachers reported such perception,
reported some impact of malocclusion on their and 32.7% of the close friends of the students analyzed
education, with the impact intensity ranging from mentioned such a relationship. Badrakhkhuu et al.27
mild to moderate. also observed that schoolchildren in Mongolia with
In turn, Basha et al.23 found that 42% of students dental crowding, a type of malocclusion, might be
with malocclusion presented impact on school prone to poor academic performance, particularly
performance, with grades below average over the in arts and physical education.
last three years. Regarding the self-perceived impact, Neves et al.24 showed a prevalence of 8.5% in
20% of the students reported that school performance school absences due to oral problems. Lastly, Cunha
was affected by their dental appearance. As for et al.25 observed a significant association between
the perception of parents, 77% felt that the school malocclusion (such as accentuated overjet and

6 Braz. Oral Res. 2023;37:e033

 Table 2. Main characteristics of the eligible studies
Author, year ref Sample Mean age ± SD Number and Assessment of Type or grade of malocclusion Assessment of
(country) (♂/♀) (Age range) type of school malocclusion assessed (%) school performance

Perceived malocclusion (36.3%): Self-assessment

· Position of teeth (28.4%) Condition-specific impacts were
Bernabé et al., 2007 805 11.96 ± 0.63 Four public
Self-perceived · Spacing of teeth (16.3%) reported during interview with
(Peru)21 (393/412) (11-12) schools
· Deformity of the mouth or face adolescents using the Child-OIDP
(1.6%) questionnaire.

de Paula et al., 2015 515 12 ± 0 Private and Dental Aesthetic School records were assessed to obtain
DAI grade 3 and 4 (24.3%)
(Brazil)22 (225/290) (12) public schools Index (DAI) students’ grades.

Self-assessment and assessment of

Basha et al., 2016 366 nr Dental Aesthetic parents, teachers, friends, and
nr DAI grade 3 and 4 (nr)
(India)23 (185/181) (14-15) Index (DAI) School records to obtain students’
grades

Dentofacial features (34.8%):

· Increased overbite greater than 2
Eighteen public mm School absenteeism assessed within
Neves et al., 2016 836 3.96 ± 0.78
and fifteen Malocclusion exam · Increased overjet greater than 2 mm B-ECOHIS questionnaire self-reported
(Brazil)24 (431/405) (3-5)
private schools · Anterior open bite by the parents.
· Anterior crossbite
· Posterior crossbite

Dentofacial features (52.8%):

Community · Maxillary overjet lesser than 1 mm
da Cunha et al., 2019 5162 14.79 ± 1.53 School failure questionnaire self-
nr Periodontal Index · Maxillary overjet greater than 3 mm
(Brazil)25 (2255/2907) (15-19) reported by the adolescents.
(CPI) probe* · Mandibular overjet
· Anterior open bite

DAI grade 1 (12.2%)

Julca-Ching and
147 14.54 ± 1.76 One private Dental Aesthetic DAI grade 2 (42.9%) School records were assessed to obtain
Carruitero, 2019
(132/15) (12-18) school Index (DAI) DAI grade 3 (28.6%) students’ grades.
(Chile)26
DAI grade 4 (16.3%)

Dentofacial features (32.6%):

· Increased overjet (3.8%)
· Reverse overjet (1.6%)
Index of Orthodontic
Badrakhkhuu et al., · Deep bite (1.7%)
767 11.3 ± 1.9 Two public Treatment Need School records were assessed to obtain
2021 · Anterior crossbite (9.4%)
(336/431) (nr) schools (IOTN) and dental students’ grades.
(Mongolia)27 · Posterior crossbite (6.8%)
casts
· Scissor bite (4.2%)
· Crowding (21.1%)
· Hypodontia (4.6%)

Ortiz et al., 2021 771 12 ± 0 Twenty public Dental Aesthetic School records were assessed to obtain

Braz. Oral Res. 2023;37:e033

DAI grade 2, 3, and 4 (49.5%)
(Brazil)28 (361/410) (12) schools Index (DAI) students’ grades.
nr: not related to the study; SD, standard deviation; * CPI probe was used to perform measurements.
Costa ACS, Paulo DM, Vidigal MTC, Vieira WA, Cardenas AFM, Paranhos LR

7
 Perception of malocclusion and school performance in adolescents: a systematic review

open bite) and school performance, directing the methodology. Table 4 shows more details about the
measurement to school failure (OR, 1.40 (1.31–1.50)) methodological evaluation of the eligible studies.
after adjusting for confounding factors.
Table 3 shows the main outcomes and quantitative Evaluation of control statements for possible
results regarding the presence of malocclusion and its confounders and bias consideration
impact on school performance in each eligible study. All eight eligible studies were analyzed, and
three studies were excluded for mentioning only
Risk of individual bias of the studies bivariate analysis or not reporting multivariate
analysis. After this, five studies10,22,24,25,27 were included
Methodological quality of the eligible studies in the evaluation of control statements for possible
Only two studies24,26 met all criteria from the confounders and bias consideration. Only one study27
checklist. Three studies21,23,26 did not meet the fifth, did not mention the term “confounding” and only
sixth, and eighth question criteria because they two studies27,28 mentioned the term “bias”. Only two
lacked proper confounding acknowledgement and studies10,25,28 mentioned non-adjusted variables that
did not perform multivariate analysis to adjust for were not measured. The results of four studies10,22,24,27
their variables, showing high potential biases in their were possibly affected by confounding factors.

Table 3. Main outcomes of the eligible studies

Impact of
Presence of
malocclusion
Author ref malocclusion Main outcomes
on school
(%)
performance

Self-perceived malocclusion primarily affected psychological and social everyday

Bernabé et al.21 36.3 0.6 activities. These findings provide further evidence to support the importance of
psychological and social components of oral health on children’s lives.

The results of this study showed that socioenvironmental factors, subjective

perceptions, and oral health status of children - particularly carious lesions, have
de Paula et al.22 24.3 38.4
an important impact on school performance, demonstrating the need for planning
public health dentistry based on intersectoral public policies.

Untreated gross dental malocclusion significantly affects the psychosocial well-

Basha et al.23 100 20.2 being of adolescents, who may avoid participating in social activities and tend to
underperform in school.

The prevalence of preschool absenteeism due to oral problems was 8.5 %

and associated with the occurrence of cavitated dental caries. Further studies,
Neves et al.24 34.8 8.5
especially investigations with a longitudinal design, are needed to garner a better
understanding of this problem.

Oral disorders and social factors were associated with school failure in adolescents.
A successful school trajectory was a strong determinant of health; therefore, actions
da Cunha et al. 25
87.76 nr
between the educational and health sectors must be developed for adolescents,
especially those who fit this profile.

The need for orthodontic treatment in school-going children did not show an
Julca-Ching and impact on academic performance, self-esteem, and bullying scores. The need for
52.8 26.8
Carruitero26 orthodontic treatment, as measured by the Dental Aesthetic Index, did not prove to
be a determining factor in the presence of such variables in school-going children.

School-going children in Mongolia with dental crowding may be prone to poor

academic performance, particularly in arts and physical education. Further
Badrakhkhuu et al.27 32.6 nr
randomized controlled trials are needed to determine whether the treatment of
crowding boosts academic performance.

Adverse oral conditions as well as subjective and socioeconomic factors impacted

Ortiz et al.28 42.5 nr
adolescents’ academic performance.
nr, not related to the study.

8 Braz. Oral Res. 2023;37:e033

 Costa ACS, Paulo DM, Vidigal MTC, Vieira WA, Cardenas AFM, Paranhos LR

Four studies22,24,25,27 reported the need for caution to match groups; this matching variable was present
when interpreting their results. Only one study27 in two studies.10,22
included limitations in the Conclusion section. The
results of the evaluation of the control statements for Certainty of evidence
confounders and bias consideration are presented The certainty of evidence was classified as
in Table 5. “very low” and downgraded due to the risk of bias,
inconsistency, and indirectness (Table 7).
Assessment of confounding factors
Eighty-six variables were identified in the studies Discussion
included in this analysis. They were classified into five
domains: dentofacial features, school environment, The present systematic review aimed to assess
sociodemographic and socioeconomic factors, whether adolescents with malocclusion tend to
residential environment, and dental services. The have lower school performance than those without
domain with the most variables was the dentofacial malocclusion. The evidence from the studies included
feature domain with 20 different variables. The most in the qualitative synthesis suggests that this dental
frequent variables were age, sex, and family income, condition affects student performance when associated
which were present in all studies. There was high with external factors, especially those related to family
heterogeneity among all studies, as well as their members and socioeconomic conditions.
variables within the school environment, residential School performance can be assessed by using
environment, and dental services domains. Some several indicators. The quantitative indicators relate
variables had similar meanings; thus, they were set to the grades obtained by students in evaluations,
together in standardized terms for better analysis. tests, and homework, the approval rate,22 and levels of
The confounding domains identified in the eligible absenteeism.25 Indicators obtained from self-perception
studies are presented in Table 6. or the perception of parents, guardians, teachers, or
In addition, 59 continuous and categorical variables close friends are considered qualitative indicators
were used as adjustment variables. Age and sex were because they depend on a subjective interpretation
used for adjustment in three studies and were the and the individual judgment of a situation.28 Therefore,
most commonly used variables within the adjusted the analysis of school performance is associated with
variables. Only one study24 used stratification variables: objective factors and organic, cognitive, psychological,
school district and school type. Only age was used socioeconomic, and educational factors.29 The eligible

Table 4. Risk of bias assessed with the Joanna Briggs Institute Critical Appraisal Tools for use in the JBI Critical Appraisal Checklist
for Analytic Cross-Sectional Studies
Authorsref Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8
Bernabé et al. 21
U √ -- -- -- -- U --
de Paula et al. 22
U √ √ √ √ √ √ √
Basha et al. 23
√ U √ √ -- -- √ --
Neves et al.24 √ √ √ √ √ √ √ √
da Cunha et al. 25
U U √ √ √ √ √ √
Julca-Ching and Carruitero 26
√ √ √ √ -- -- √ --
Badrakhkhuu et al. 27
√ √ √ √ √ √ √ √
Ortiz et al.28 U √ √ √ √ √ √ √
Q1) Were the sample inclusion criteria clearly defined? Q2) Were the study participants and environment described in detail? Q3) Was the
exposure measured both valid and reliable? Q4) Were the criteria used for measuring the condition objective? Q5) Were confounding factors
identified? Q6) Were there any strategies to handle confounding factors? Q7) Were the results valid and reliable? Q8) Was there proper
statistical analysis? √, Yes; --, No; U, Unclear.

Braz. Oral Res. 2023;37:e033 9

 Perception of malocclusion and school performance in adolescents: a systematic review

Table 5. Evaluation of control statements for possible confounders and bias consideration
Section Question Possible answers with explanation N (%)

Specific: if the authors used the exact term “confounding” 2 (40%)

Is the term “confounding”
mentioned in the Abstract or Alluded: if the authors used a similar term or phrase 2 (40%)
Discussion?
No: if the authors used neither the exact nor similar term 1 (20%)

Is the term “bias” used in the Yes: if the authors used the term “bias” 2 (40%)
Abstract or Discussion? No: if the authors did not use this term 3 (60%)
Yes: if there was a specific mention of non-adjusted variables with no
0
reasons presented
Not measured: if there was a specific mention of non-adjusted variable
2 (40%)
not being measured
Is there any specific mention of
non-adjusted variables in the Other reasons: if there was a specific mention about non-adjust variables,
0
Abstract or Discussion? with plausible reasons for not adjusting them
Abstract and
No reasons: if there was a specific mention about non-adjusted variables,
Discussion 0
with implausible reasons for not adjusting them
No: if there was no mention about any non-adjusted variable 3 (60%)
Likely: if the authors used terms such as “likely” or convincing statements
1 (20%)
implying that the confounders were not controlled

Is there any mention about Possibly: if the authors used terms such as “possibly” or unsure statements
4 (80%)
confounders affecting results in suggesting that the confounders were or were not controlled
the Abstract or Discussion? Unlikely: if the authors used terms such as “unlikely” or convincing
0
statements suggesting that the confounders were controlled
No mention: if there was no mention of this possibility 0

Is there any statement on Yes: if there was explicit mention about the need for caution in interpretating
4 (80%)
the need for caution in the results obtained in the study
interpretating the results? No mention: if there was no mention about this need for caution 1 (20%)

Does the Conclusion Yes: if there was a mention of this limitation 1 (20%)
Conclusion include any limitation about
confounders? No: if there was no mention of this limitation 4 (80%)

studies of this review showed high heterogeneity for and teachers to that of students and close friends
the tools for measuring school performance among showed that, in most cases, adults did not understand
the young people assessed. the situations and difficulties that children and
In this context, the presence of abnormal dentofacial adolescents faced in school.23
characteristics, such as malocclusion, may negatively However, the neutral results of those impacts on
interfere with the school performance of individuals, school performance from other eligible studies22,26
as suggested by some of the eligible studies.10,21,24,25,27 In highlighted the strong influence of external and
general, poor health conditions of students might harm subjective factors when dealing with different adverse
their cognitive development and participation in school situations on behavioral changes and decreased school
activities, increasing the levels of absenteeism,30 which performance, such as poor family socioeconomic
corroborates the negative impact of malocclusion conditions, 31 low level of education of parents or
on school performance.10,21,24,25,27 In studies that used guardians,31 household overcrowding,32,33 and the
qualitative indicators,21,23 there was a focus on the type of school attended by the child or adolescent.22
self-perception of students with malocclusion and Eligible studies were conducted in different
the perception of parents, teachers, and close friends. countries, with major socioeconomic and cultural
Divergent results from the perceptions of parents factors that might have influenced the results. For

10 Braz. Oral Res. 2023;37:e033

 Costa ACS, Paulo DM, Vidigal MTC, Vieira WA, Cardenas AFM, Paranhos LR

Table 6. Confounding domains identified in selected studies

Confounding domain Description Examples

Increased overjet; Reverse overjet; Deep bite; Anterior crossbite;

Posterior crossbite; Scissors bite; Crowding; Decayed teeth;
Dentofacial features in general, occlusal
Missing tooth; Dental caries; Severity of dental caries; Avulsion
1 Dentofacial features traits, dental caries, traumatic dental injuries,
and/or luxation; Discoloration; Enamel-dentin fracture; Enamel
periodontal changes, and oral impacts
fracture without trauma; Toothache; Bleeding on probing; DAI;
DMFT index; OIDP.

School type; School location; School district; School

absenteeism; School failure; Overall score; Arts score;
School administrative and infrastructural
Language score; Mathematics score; Physical education
2 School environment characteristics, school absenteeism, school
score; Science score; Social science score; Distraction in class;
failure, and school performance parameters
Difficulty in doing homework; Difficulty in speaking or reading
aloud in class; Verbal bullying; IDEB.

Sociodemographic Sociodemographic and socioeconomic Age; Sex; Family income; Father’s education; Mother’s
3
and socioeconomic characteristics education; Ethnicity.

Number of people in house; House ownership; House

overcrowding; Children living with both biological parents;
Parents’ perception on general health; Parents’ perception on
Residence Residence environment characteristics, and
4 oral health; Children’s perception on general health; Children’s
environment psychosocial perceptions of parents and children
perception on oral health; Children’s perception on happiness;
Children’s perception on community cooperation; Children’s
perception on community safety.

5 Dental services Accessibility and frequency of dental services Accessibility; Reason for access; Access within the last 6 months.
DAI, Dental Aesthetics Index; DMFT, Decayed, Missing, and Filled Teeth; OIDP, Oral Impacts on Daily Performance; IDEB, Basic Education
Development Index.

Table 7. Summary of findings by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) for the
outcomes of the systematic review
Certainty assessment
Summary of results
Impact Certainty
Number Study Risk of Other
Inconsistency Indirectness Imprecision
of studies design bias considerations
CHANGES IN PULPAL BLOOD FLOW (ORME)
8 Cross-sectional Seriousa Seriousb Seriousc Not serious none Two studies concluded that ⨁
studies there was no significant Very Low
association between
school performance and
perception of malocclusion,
five studies found that
only part of the children
with malocclusion had
their school performances
affected, and one study
concluded that there was
a significant association
between perception of
malocclusion and low
school performance.
a – The majority of the studies presented import bias due to confounding factors.
b – The studies presented divergent results.
c – The main outcome was assessed using different tools that indirectly evaluated school performance.
GRADE Working Group grades of evidence
High certainty: Very confident that the true effect is close to the estimated effect.
Moderate certainty: Moderately confident in the estimated effect; the true effect is likely close to the estimated effect, but it may be
substantially different.
Low certainty: Limited confidence in the estimated effect; the true effect may be substantially different from the estimated effect.
Very low certainty: Very little confidence in the estimated effect; the true effect may be substantially different from the estimated effect.

Braz. Oral Res. 2023;37:e033 11

 Perception of malocclusion and school performance in adolescents: a systematic review

example, low- and middle-income countries, such and school performance. It is important to highlight
as Brazil and India, still present concerns about them because of their potential roles as causes,
child labor, which can affect the physical and mental effects, or coincidences without any relationship.
health of this population.34 In poor families, it may However, inferences about the roles of each variable
be common to observe children and adolescents are limited to be made based on observational
working to help their parents or relatives with monthly studies.14 Therefore, further studies with longitudinal
bills. These less privileged conditions may also be and controlled designs are necessary to better
related to typical public health and social questions, understand this association.
which are already associated with impaired school This review had a few limitations. First, different
performance: dental caries and worse oral health,35 observational designs might have affected the presence
altered sleep time,36 and less access to proper schooling of divergences among the individual results of
resources and equipment,37 especially in the recent the studies, especially regarding the absence of
online study methods.36 standardization of the tools for assessing malocclusions.
All eligible studies were cross-sectional. This Most studies10,22-27 were based on dental professionals’
type of study can lead to limitations when analyzing perception measurements to assess malocclusions,
outcomes, as they analyze exposure and outcome such as the DAI, malocclusion exam, IOTN, and the
at the same time, which impairs the inference of use of a CPI probe. Only one study21 subjectively
causality.38 Furthermore, observational studies do not measured malocclusion using Child Oral Impacts
present permutability between their study groups, on Daily Performances, with the self-perception of
because of the lack of randomized variables.39 On individuals. Subjective measurements may be subject
the other hand, as the focus is on malocclusions, it to the influence of individual experiences, considering
may favor a cause-and-effect interpretation, as they that the same condition may be understood differently
can be considered as inborn characteristics of the by each individual. Moreover, the assessment of
individuals.38 However, it is still not a longitudinal several school performance indicators was verified
design to better estimate the exact correlation of the among the studies and some of them 21,23,26 did not
variables studied. This could also underestimate the perform analyses to deal with confounding factors
role of confounding factors. associated with the outcomes. Thus, owing to the
Some potential biases in the eligible studies lack of measurement standards, the results may not
should be acknowledged. First, the performance of reflect the true impact of malocclusion on school
only bivariate analysis or the lack of multivariate performance. Further studies with the application of
analysis in observational studies are common and more standardized and better-designed methodologies
dangerous pitfalls. Observational studies have a high are encouraged to address such limitations. Another
risk of presenting several uncontrolled confounders, significant limitation worth noting is that malocclusion
which limits their results.14 Multivariate analysis is a may relate to other factors that can also affect school
reliable statistical test to provide proper adjustment performance, such as bullying.40 The lack of analysis
of variables, reducing the potential confounding of confounding factors was a bias identified in part
influence.38 Secondly, this reduction is unfortunately of the eligible studies and deserves attention when
not absolute, and the interpretation of results should interpreting the results.
be performed with caution. Although there was Some strengths of this systematic review must
acceptable prudence in selected studies regarding be highlighted, such as its preparation according
this caution, they lacked proper acknowledgement to specific instructions12 and caution to minimize
of non-adjusted variables and inclusion of limitations biases. Moreover, this is the first systematic review to
in the Conclusion section. specifically assess the impact of malocclusion on the
The confounding domains identified in the school performance of children and adolescents. The
selected studies brought up some confounders to be evidence summarized may be useful for the decision-
considered in the association between malocclusion making of governments and school administrators,

12 Braz. Oral Res. 2023;37:e033

 Costa ACS, Paulo DM, Vidigal MTC, Vieira WA, Cardenas AFM, Paranhos LR

especially regarding the need to establish a partnership the limitations of this systematic review, the results
between schools and dental professionals in an attempt may not accurately reflect the impact of malocclusion
to provide better oral health and higher access to on school performance. Nevertheless, the findings
dental treatments, such as orthodontic treatment to provide important data to encourage health actions
correct malocclusions. toward the development of oral health care programs
for students, aiming to improve their quality of life
Conclusion physically and psychologically, and consequently,
their school performance.
The very low certainty evidence suggests that
the perception of malocclusion negatively affects the Acknowledgment
school performance of students when associated with This study was partially financed by Capes
external factors, especially those related to family (Finance Code 001). We are thankful for the support
members and socioeconomic conditions. Considering from CNPq and Fapemig.

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