Ullal Anand Nayak et al

ORIGINAL ARTICLE

The Relationship of Dental Aesthetic Index with

Dental Appearance, Smile and Desire for
Orthodontic Correction
1
Ullal Anand Nayak, 2Jasmin Winnier, 3Rupesh S
1
Professor, Department of Pedodontics, Modern Dental College and Research Center, Indore, Madhya Pradesh, India
2
Senior Lecturer, Department of Pedodontics, Dr DY Patil Dental College and Hospital, Navi Mumbai, Mumbai
Maharashtra, India
3
Senior Lecturer, Department of Pedodontics, Pushpagiri College of Dental Sciences, Perunduruthy, Kerala, India
Correspondence: Ullal Anand Nayak
Professor, Department of Pedodontics, Modern Dental College and Research Center, B-203 Staff Quarters, Airport Road, Gandhi
Nagar, Indore-453112, Madhya Pradesh, India, Phone: 9907044927; 0731-2882765, e-mail: [email protected]

Abstract of orthodontic care in the prevention of caries, periodontal

Objective: The purpose of this study was to determine the disease and temporomandibular joint disorders are
relationship between dental aesthetic index (DAI) and self beginning to be doubted. Orthodontic treatment is often
– satisfaction with dental appearance, smile and desire for carried out for aesthetic rather than functional
orthodontic care. considerations, since it is assumed that failure to meet social
Methods: A survey of 103 school children, 51 boys and 52 norms for dental aesthetics will have negative psychosocial
girls was carried out in Annamalai Nagar, Chidambaram. effects and these effects may well-exceed the biological
The subjects were interviewed using a questionnaire problems.1 Dentists predict that psychosocial component
consisting of questions concerning smile, dental appearance
of malocclusion will continue to be one of the strongest
and desire for orthodontic treatment. They were also assessed
motivator for orthodontic treatment.2
using the dental aesthetic index.
The measurement of malocclusion as a public health
Results: Statistically significant correlations were between
problem is extremely difficult since most orthodontic
subjective assessments of dental appearance and DAI
(P = 0.042) and need for orthodontic treatment and DAI treatment is undertaken for aesthetic reasons and it is very
(P = 0.045). The strongest correlations were found between difficult to estimate the extent to which malposed teeth or
DAI and comparative evaluations of dental appearance dentofacial malrelation constitute to a psychological hazard.2
(P < 0.005). Malocclusion has proved to be a difficult entity to define
Conclusion: This study has shown significant correlations since individual perceptions of what constitutes a
between DAI and subjective perceptions of dental malocclusion problem differs widely.3
appearance. Orthodontic indices were developed in the late 1960’s
Keywords: Dental aesthetic index, dental appearance, desire and the early 70s in order to assist professionals in
for orthodontic correction. categorizing malocclusion according to the level of treatment
need. These indices include Salzman’s handicapping
INTRODUCTION malocclusion assessment record (HAMAR),4 Summer’s
The traditional opinions regarding the major benefits of occlusal index (OI)5 and Graingers treatment priority index
orthodontic treatment have been challenged. The importance (TPI).6

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 The Relationship of Dental Aesthetic Index with Dental Appearance, Smile and Desire for Orthodontic Correction

The dental aesthetic index (DAI)2 and the index of and confidentiality was stressed. Each subject was
orthodontic treatment need (IOTN)7,8 are both used for interviewed privately before being examined.
assessment of malocclusion and determination of treatment 1. Do you have a pleasant smile? Yes/No
need. The DAI, however, is a cross-cultural index.6 2. How much do you like the appearance of your smile?
In order to assess whether DAI provides reliable i. Very much
information regarding the subjects’ psychosocial desire for ii. Quite a bit
treatment, an interview schedule was used. Ten items were iii. Not much
included in the interview that asked for self-evaluation of iv. Not at all
dental appearance, satisfaction with smile and desire for 3. Do you like the way your teeth look? Yes/No
orthodontic care.2 4. How much do you like the way your teeth look?
With this background, the present study was conducted i. Very much
with the following aims and objectives: ii. Quite a bit
1. To assess the relationship between DAI and self- iii. Not much
satisfaction with smile. iv. Not at all
2. To assess the relationship between DAI and self- 5. Are your front teeth straight? Yes/No
satisfaction with dental appearance. 6. How would you consider your teeth as compared to
3. To assess the relationship between DAI and self- your entire face?
assessment of the relative appearance of teeth by the i. One of the nicest features of your face
subjects as compared to their face. ii. Better than average feature of your face
4. To assess the relationship between DAI and self- iii. Below average feature of your face
assessment of dental appearance compared to classmates iv. One of the poorest features of your face
and friends. 7. Are your teeth good looking? Yes/No
5. To assess the relationship between DAI and desire to 8. Compared to your classmates and friends how do you
undergo orthodontic treatment. think your teeth look?
i. Among the nicest
SUBJECTS AND METHODS ii. Better than average
iii. Below average
103 subjects (51 boys and 52 girls) who satisfied the
iv. Among the worst
following criteria were selected for the study.
9. Do your teeth need straightening? Yes/No
Inclusion criteria: 10. If it were possible would you want to wear braces to
1. Children between 13 to 16 years of age. straighten your teeth?
i. Definitely No
Exclusion criteria:
ii. Probably No
1. Children with mental or physical impairment.
iii. Probably Yes
2. Previous history of or currently undergoing orthodontic
iv. Definitely Yes
treatment.
The subject was then assessed by the DAI. All the 10
3. Subjects who had decided about orthodontic treatment
components were measured.
at the time of study.
Components of the DAI regression equation and their
Informed consent from relevant school authorities and
actual and rounded regression coefficients (weights):
verbal consent from participants were obtained. A single
examiner examined all the subjects. The examination was Number DAI components Actual Rounded
carried out in the subjects’ school, during daytime under weights weights
natural light with the help of Boley gauge, a sharp pencil, 1 Number of missing visible teeth 5.76 6
tongue blade and a millimeter ruler. The accepted methods (Incisors, canines and premolars)
in the maxillary and mandibular arches.
of infection control were maintained. The examiner asked
the following questions to each subject. The need for privacy Contd...

International Journal of Clinical Pediatric Dentistry, May-August 2009;2(2):6-12 7

Ullal Anand Nayak et al

Contd... • 26 to 30: Definite malocclusion; elective treatment.

Number DAI components Actual Rounded • 30 to 35: Severe malocclusion; treatment highly
weights weights desirable.
2 Assessment of crowding in the 1.15 1 • 36 and more: Handicapping malocclusion; treatment
incisal segments: 0 = No segment mandatory.
crowded, 1 = One segment crowded,
2 = Two segments crowded. RESULTS
3 Assessment of spacing in the 1.31 1
incisal segments: 0 = No segment Of the 103 subjects examined only 20% definitely needed
spaced, 1 = One segment spaced, orthodontic treatment according to the DAI.
2 = Two segments spaced.
In response to the question regarding satisfaction with
4 Measurement of any midline 3.13 3
diastema in mm smile, 83.5% of subjects were satisfied with the appearance
5 Largest anterior irregularity on the 1.34 1 of their smile, 63.1% stated that they liked the way their
maxilla in mm teeth looked. 70.8% felt that their teeth were better than
6 Largest anterior irregularity on the 0.75 1 average or one of the nicest features of their face. 66% felt
mandible in mm
that compared to their classmates and friends they had a
7 Measurement of anterior maxillary 1.62 2
overjet in mm better than average or one of the nicest dentitions and 35%
8 Measurement of anterior mandi- 3.68 4 responded that they would definitely wear braces if it would
bular overjet in mm improve their dental appearance (Table 1).
9 Measurement of vertical anterior 3.69 4 Statistically there was no agreement present between
openbite in mm
smile and dental aesthetic index P = 0.269 (Tables 2
10 Assessment of anteroposterior 2.69 3
molar relation: Largest deviation and 2A).
from normal either left or right, However, there was a minimal but statistically significant
0 = Normal, 1 = Half cusp either agreement between the index and the patients’ self-
mesial or distal, 2 = One full cusp satisfaction with their dental appearance P < 0.05 (Tables 3
either mesial or distal.
and 3A).
Constant 13.36 13 The relationship between DAI and the self-assessment
of relative appearance of teeth by the subjects as compared
to their face was highly statistically significant P < 0.005
The measured components of the DAI were multiplied
(Tables 4 and 4A).
by the regression coefficient (weights), the products are
added, and the constant number 13 was added to the total to TABLE 1: Questionnaire analysis
give the final DAI score. Score Q2 Q4 Q6 Q8 Q10
The treatment need according to the scores is divided 1 44.7% 30.1% 25.2% 20.4% 33%
into the following categories: 9 2 38.8% 33% 45.6% 45.6% 11.7%
• 25 and below: Normal or minor malocclusion with no 3 13.6% 29.1% 22.3% 32% 20.4%
or slight treatment need. 4 2.9% 7.8% 6.8% 1.9% 35%

TABLE 2: The relationship between DAI and Q2 (How much do you like the appearance of your smile?)

Smile scores

1 2 3 4 Total
DAI scores 1: No treatment need 29.1% 22.3% 7.8% .0% 59.2%
2: Elective treatment 9.7% 6.8% 1.9% 1.9% 20.4%
3: Treatment desirable 2.9% 5.8% 3.9% .0% 12.6%
4: Treatment mandatory 2.9% 3.9% .0% 1.0% 7.8%
Total 44.7% 38.8% 13.6% 2.9% 100%

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 The Relationship of Dental Aesthetic Index with Dental Appearance, Smile and Desire for Orthodontic Correction

TABLE 2A: Analysis

Value Approx.sig

Measure of agreement Kappa 0.070 0.269

TABLE 3: The relationship between DAI and Q4 (How much do you like the way your teeth look?)

Appearance of teeth scores

1 2 3 4 Total

DAI scores 1: No treatment need 20.4% 19.4% 16.5% 2.9% 59.2%

2: Elective treatment 6.8% 9.7% 1.9% 1.9% 20.4%
3: Treatment desirable 2.9% 2.9% 4.9% 1.9% 12.6%
4: Treatment mandatory .0% 1.0% 5.8% 1.0% 7.8%
Total 30.1% 33.0% 29.1% 7.8% 100%

TABLE 3A: Analysis

Value Approx. sig

Measure of agreement Kappa 0.112 0.042

TABLE 4: The relationship between DAI and Q6 (How would you consider your teeth as
compared to your entire face?)

Relative appearance of teeth

1 2 3 4 Total
DAI scores 1: No treatment need 20.4% 25.2% 11.7% 1.9% 59.2%
2: Elective treatment 1.9% 14.6% 2.9% 1.0% 20.4%
3: Treatment desirable 2.9% 2.9% 3.9% 2.9% 12.6%
4: Treatment mandatory .0% 2.9% 3.9% 1.0% 7.8%
Total 25.2% 45.6% 22.3% 6.8% 100%

TABLE 4A: Analysis

Value Approx.sig

Measure of agreement Kappa 0.169 0.002

TABLE 5: The relationship between DAI and Q8 (Compared to your classmates and
friends how do you think your teeth look?)

Comparative assessment of dental appearance

1 2 3 4 Total

DAI scores 1: No treatment need 16.5% 31.1% 11.7% .0% 59.2%

2: Elective treatment 1.0% 11.7% 6.8% 1.0% 20.4%
3: Treatment desirable 2.9% 1.9% 7.8% .0% 12.6%
4: Treatment mandatory .0% 1.0% 5.8% 1.0% 7.8%
Total 20.4% 45.6% 32.0% 1.9% 100%

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Ullal Anand Nayak et al

TABLE 5A: Analysis

Value Approx.sig

Measure of agreement Kappa 0.152 0.003

TABLE 6: The relationship between DAI and Q 10 (If it were possible would you want to
wear braces to straighten your teeth?)

Desire for orthodontic care

1 2 3 4 Total

DAI scores 1: No treatment need 25.2% 7.8% 12.6% 13.6% 59.2%

2: Elective treatment 4.9% 2.9% 3.9% 8.7% 20.4%
3: Treatment desirable 2.9% 1.0% 1.0% 7.8% 12.6%
4: Treatment mandatory .0% .0% 2.9% 4.9% 7.8%
Total 33.0% 11.7% 20.4% 35.0% 100%

TABLE 6A: Analysis

Value Approx.sig

Measure of agreement Kappa 0.139 0.045

There relationship between DAI and the self-assessment that point indicate malocclusion for which treatment is
of dental appearance as compared to classmates and friends mandatory. The recommended treatment cut off point for
was highly statistically significant P < 0.005 (Tables 5 Dental Aesthetic Index is 31.13 In the present study, a
and 5A). majority of the patients were below the cut off point,
There was also a statistically significant relationship delineating the group of children who were definitely in
present between the index and the willingness of the subject need of orthodontic treatment.
to accept orthodontic treatment P < 0.05 (Tables 6 and 6A). The DAI has been compared with other treatment need
indices in various studies.1,9-11,13-15 It has been used in an
DISCUSSION epidemiological assessment of malocclusion in Japan12 and
The DAI was developed by Cons, Jenny and Kohout in in evaluation of outcomes of orthodontic treatment.16 In
1987.2 It is a relatively simple index; it can be obtained addition, it has also been used along with structured
intraorally, without the use of radiographs in about two questionnaires regarding appearance, biting/chewing,
minutes. The reliability and validity of DAI has been well speech and orthodontic treatment need.11,6
documented in various studies.1,9,10 It has been accepted by However, the patient’s opinions regarding orthodontic
the WHO as a cross-cultural index.6 It was integrated into treatment need cannot be underestimated, as it is the patient
the items of International collaboration study of oral health who receives treatment and needs to gain satisfaction from
outcomes by the WHO in 1989.11,12 Although DAI is easy improved aesthetics and function or both.11 Also it is known
to use, there is lack of assessment traits such as buccal cross that the parent or the patients’ concerns of orthodontic
bite, open bite, centerline discrepancy and deep bite.11 treatment need, do not always agree with professional
Though these may not be important from a dental aesthetic evaluations of the same. 6,17 In addition, orthodontic
point of view, they could affect the need for orthodontic treatment is primarily influenced by demand and not always
treatment.9 by need.17 Hence, in the present study, the relationship of
The cut off point of any treatment need index is the value Dental Aesthetic Index with selected questions, which reflect
below which the severity of malocclusion is so minor that the psychosocial need for orthodontic treatment, was
there is no definite need for treatment and all values above assessed.

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 The Relationship of Dental Aesthetic Index with Dental Appearance, Smile and Desire for Orthodontic Correction

Adolescence is the age when increase in awareness and assessed by DAI was 20.4% where as the demand was
facial aesthetics takes priority and adolescent children have 35%. Elham (2004)22 found 49% demand for orthodontic
a tendency to compare themselves with peers, models, etc. treatment among school children in North Jordan. The
The age group of subjects in the present study was 13 to 16 relatively high number of persons expressing desire for
years. Hence, the questionnaire used in our study was aimed treatment may reflect a professional trust or a basic general
at children in this adolescent age group to assess their faith in service.18,19,23,24 Such an attitude to the dental service
awareness of dental appearance and to evaluate their makes it possible that the child and the parent will follow
relationship with an objective measure of aesthetics (DAI). advice from dentist.18
The present study revealed that the association between In the present study, significant correlations were
DAI and self-satisfaction with smile was not significant. observed between subjective assessments of dental
This, however, is in contrast to the results of Cons et al.2 appearance and objective assessment of dental aesthetics
Thus, in the present population, dissatisfaction with smile using DAI. However, future investigations in this regard
cannot be taken as an indicator of need for orthodontic are warranted, taking into consideration other variables that
treatment. may influence the orthodontic treatment demand such as
There was a weak but significant correlation between rural/urban variation, proximity of dentist/orthodontist/
DAI and self-satisfaction with dental appearance, which is dental college, socioeconomic status and parental education.
in agreement with the study by Onyeaso et al,6 but is in
contrast to the study by Yeh et al,11 which showed no CONCLUSION
significant relationship. The following conclusions were drawn from the present
The strongest correlations in this study were found study:
between DAI and the subjects’ self-assessment of relative 1. The correlation between dental aesthetic index and
appearance of teeth as compared to their face and the self- satisfaction with smile was not statistically significant.
assessment of dental appearance compared to their 2. A significant but weak association was present between
classmates and friends, corroborates with the correlation dental aesthetic index and satisfaction with dental
found previously.2 appearance.
The analysis also revealed a weak but statistically 3. A strong statistically significant association was present
significant relationship between DAI and desire for between dental aesthetic index and self-assessment of
orthodontic care. relative appearance of teeth by the subjects as compared
Hamdan AM (2004)17 reported that twice as many to their face.
females presented for orthodontic consultation than males. 4. A strong statistically significant association was present
Holmes (1992) suggested that greater number of females between dental aesthetic index and self-assessment of
perceived themselves as having less attractive dentitions than dental appearance relative to classmates and friends.
males despite any objective evidence to support this view. 5. A weak statistically significant association was present
Also 75% of subjects who seek orthodontic treatment do so between dental aesthetic index and desire for orthodontic
for aesthetic reasons and girls are more likely to recognize care.
dental irregularities and place more importance on this than
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