Analyzing the Role of Malnourishment in Malocclusion: A Cross-sectional Study.

BACKGROUND: Malocclusion is defined as an occlusion in which there is malrelationship between the arches in any of the three planes or anomalies in tooth position beyond normal limits, the etiology being multifactorial. Malnutrition may also be allied to malocclusion, predominantly crowding, due to insufficient space for the teeth to erupt in the correct place.
OBJECTIVES: The present study was conducted to investigate the role of diet as an etiological factor in the occurrence of malocclusion.
MATERIALS AND METHODS: Two hundred and twenty malnourished subjects were examined by a single experienced dental professional and the occlusal relationships were evaluated at a centric occlusion position by instructing the subject to swallow and then bite on the teeth together.
RESULTS: Ninety-eight subjects (44.54%) had Angle's Class I malocclusion with crowding: 18 (8.1%) presented with spacing. Angle's Class II division 1 malocclusion was evident in 52 subjects (23.63%), while Class II division 2 in 38 subjects (17.27%). Only 14 subjects (6.3%) presented with Angle's class III malocclusion.
CONCLUSION: Dietary factors and dentition measures from a subset 220 malnourished subjects found that malnourished subjects with basal metabolic index <18.5 had statistically significant relationships with the crowding variables. Copyright:

INTRODUCTION

“Physical beauty is a symbol of interior beauty.” Socially, well-aligned teeth and a pleasing smile reflect positive status, whereas irregular or malaligned teeth reflect negative status.[1] Psychological distress due to malocclusion is more frequently found in younger individuals. The severity of skeletal malocclusion is not related to the quality of life and speech and mastication efficiency. Possessing a higher level of attractiveness allows for more positive judgment and behavior evaluation by society.[2]

Ramfjord and Ash have defined ideal occlusion as “a state in which no neuro muscular adaptation is needed because no disturbing relationships are present.”[3] Malocclusion is defined as an occlusion in which there is a malrelationship between the arches in any of the three planes or anomalies in tooth position beyond normal limits.[4] The WHO in 1987 had incorporated malocclusion under the category of “Handicapping Dentofacial anomalies.”[5]

It is characterized by abnormal relationships among the dentition. It features the third highest prevalence among oral pathologies, secondarily to dental caries and periodontal disease and therefore ranks third among worldwide public health dental disease priorities.[6] Malocclusion may be associated with deficient chewing, speech enunciation, undesirable development of the jawbones, and unpleasing appearance. The prevalence of malocclusion is usually high among adolescents with permanent or mixed dentition.[7] According to the WHO, malocclusion is the third most prevalent oral health problem, following dental caries and periodontal diseases.[89]

Wide arrays of etiological factors have been proposed for malocclusion, genetic, ethnic, and environmental factors being the top major contributors. Class III malocclusion may be inherited, substantiating a strong relation between genetics and malocclusion.[1011] Moyers has categorized the etiologies of malocclusion into hereditary, developmental idiopathic, trauma, physical agents, habit, and diseases.[12] Buschang PH. have categorized the same into specific causes of malocclusion, environmental influences, and genetic influences.[13]

Malocclusion can be classified under three major divisions: general, proximal, and local.[8]

Classification of malocclusion

Edward angle, the father of modern orthodontics, classified malocclusion broadly into three types based on the relative position of the maxillary first molar. He described the maxillary first molar as the “key to occlusion.” According to him, occlusion is considered to be normal when the mesiobuccal cusp of the upper first molar occludes with the buccal groove of the lower first molar.[15]

Nutritional status is a measurement of the level to which the defined physiological needs for nutrients of an individual are being met by their dietary patterns. This status necessitates a review of dietary intake, biochemical markers of nutrient status, and anthropometric changes.[16] Malnutrition is a multifactorial disease which may set in as early as during the intrauterine life and childhood or may occur later in life due to poor nutrition or recurring episodes of chronic diseases or infections.[14] Malnutrition may also be allied to malocclusion, predominantly crowding, due to insufficient space for the teeth to erupt in the correct place. Tainted bone growth caused by poor nutrition could be reflected in reduced space for dental eruption.[15]

The aim of the present study was therefore to investigate the role of diet as an etiological factor in occurrence of malocclusion.

MATERIALS AND METHODS

Two hundred and twenty subjects, both male and female, ranging between 12 and 15 years of age were included in the study. The study comprised malnourished children with no evidence of any mental or physical condition and not under any medication. The children with systemic diseases and craniofacial anomalies (clefts and syndromes) and who underwent orthodontic treatment and had premature birth or low birth weight were excluded from the study. Demographic data of the participants were obtained from parents. Basal Metabolic Index (BMI)- it is a person's weight in kilograms divided by square of height in meters was calculated according to the following formula:

The WHO recommends BMI as a suitable indicator for evaluating the nutritional status of adolescents. It is an easy and widely used diagnostic tool to identify nutritional status and determines whether a person is underweight, healthy, or overweight.[10] All the subjects were examined by a single experienced dental professional after obtaining informed consent from the subjects and their parents.

RESULTS

The present study comprised 220 children ranging from 12 to 15 years of age. Of 220 subjects, 136 were female and 84 were male. Table 1 shows the distribution of malocclusion. Of 98 subjects presenting with crowding, 52 (53%) were female, whereas 46 (46.9%) were male. Spacing was evident in 12 males (66.66%) and 6 females (33.33%). Of 52 subjects with Angle's Class II division 1 malocclusion, 36 (69.23%) were male, whereas 16 (30.76%) were female. Thirty-eight subjects with Angle's Class II division 2 comprised 26 (68.4%) males and 12 (31.57%) females. Nine (64.28%) subjects of 14 with Angle's Class III malocclusion were male, whereas 5 (35.71%) were female. Majority of the subjects in our study presented with Angle's Class I malocclusion with crowding (44.54%), followed by Angle's Class II division 1 malocclusion in 23.63% subjects, Angle's Class II division 2 malocclusion in 17.27% subjects, Angle's Class I malocclusion with spacing in 8.1% cases, and the least number of patients had Angle's Class III malocclusion, i.e., 6.3%.

Table 1

Distribution of different kinds of malocclusion

Type of malocclusion	Male (%)	Female (%)	Total (%)
Angle’s Class I malocclusion with spacing	46 (47)	52 (53)	98 (44.54)
Angle’s Class I malocclusion with spacing	12 (66.66)	6 (33.33)	18 (8.1)
Angle’s Class II division 1 malocclusion	36 (69.23)	16 (30.76)	52 (23.63)
Angle’s Class II division 2 malocclusion	26 (68.4)	12 (31.57)	38 (17.27)
Angle’s Class III malocclusion	9 (64.28)	5 (35.71)	14 (6.3)
Total	129 (58.63)	91 (41.36)	220 (100)

DISCUSSION

Malocclusion has a huge brunt on an individual and society as it brings in discomfort with alteration in the quality of life and social and functional precincts.[1112]

Dentoalveolar adaptations refer to the alterations in the position of teeth. These compensations usually maintain normal interarch relations; however, they may be negative which may attribute to a high prevalence of malocclusion.[13] The etiology of malocclusion is alleged to be multifactorial. It may be associated with inherited or environmental factors or an amalgamation of both.[14]

The association between nutrition and oral health can alter the growth of craniofacial bones which leads to inadequate space for teeth to erupt, resulting in crowding and impactions.[15] BMI categorizes the nutritional status in the form of being underweight, healthy, overweight, and obese.[16] BMI is easy to measure, economical, and has a good correlation with the fat mass and the association with morbidity and mortality.[17]

It is believed that malnutrition may be associated with crowding, which may be defined as misalignment of the teeth due to deficient space for them to erupt in line of the alveolar crest.[18] Our findings were partially in concordance with the study conducted by Thomas et al.[8] to investigate the association between nutritional status and reduced space for dental eruption (crowding) in permanent dentition. An association between low height-for-age and crowding was only observed in adolescents with a prolonged history of mouth breathing. No association was observed between underweight and crowding. It was thus concluded that malnutrition was associated with crowding in permanent dentition among mouth-breathing adolescents.[18] The findings of our study were also contrary to the one conducted by Kaushal et al.[17] to evaluate the association of malnutrition with malocclusion, dental caries, enamel hypoplasia, and salivary flow in mixed dentition stage. The study was conducted on 120 subjects in Rajasthan. In their study, there was no significant relationship between malnutrition with dental crowding, spacing, and crossbite; however, there was a statistically significant relationship between malnutrition with dental caries and salivary flow. Furthermore, there was a significant relationship present between enamel hypoplasia and malnutrition.[17]

Angle's Class II division 1 malocclusion was present in 23.63% of subjects and Angle's Class II division 2 malocclusion was present in 17.27% of subjects. As per the review conducted by Barao K et al.,[18] nutrition has a bearing on the development of orofacial structures. Breastfeeding is critical for the development of orofacial musculature which further influences the overall growth of dentofacial structures. Subjects on a soft diet presented with narrow jaws attributed to underdeveloped muscles and supporting structures. A positive correlation was seen between nonconsumption of coarse and fibrous foods and increased incidence of Class II malocclusion.[18]

Angle's Class I malocclusion with spacing was present in 8.1% of cases. Spacing is characterized by interdental spaces and lack of contact points between the teeth. It may be localized or generalized. The etiology of spacing may be multifactorial.

CONCLUSION

This study found that malnourished subjects with BMI <18.5 had statistically significant relationships with the crowding variables. Several other factors were found to be associated with malocclusion but were not statistically significant. Further research is needed to better determine the nature of the relationships between dietary factors and malocclusion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.