A new study shows that malocclusion is associated with bullying?

We all assume that malocclusion is associated with childhood bullying.  However, evidence of this relationship is unclear. This is an important issue and this new paper sheds some light on this problem.

In the introduction of this paper, the authors provide an excellent summary of the current understanding of bullying. Childhood bullying is a pervasive issue, with nearly one in three children reporting experiences of being bullied. A typical target for bullying is physical appearance, which leads us to consider the potential association between malocclusion and bullying. However, surprisingly, the evidence supporting this connection is not robust. Most research has focused on children who have been referred for orthodontic treatment, a group that typically has a higher prevalence of malocclusion than the general population. Additionally, these children may have been referred due to experiences of bullying. Other studies have relied on self-reported traits of malocclusion, which can further complicate the findings.

The authors of this study have attempted to address these issues. A team from the beautiful county of Kent, UK did this study. I have never been to Kent but I hear that it is nice.  The Journal of Orthodontics published the paper.

The paper is open-access, so anyone can read it, which is great.  

I would like to declare an interest, as I know the lead author well.

What did they ask?

They did this study to 

“Investigate the prevalence of self-reported bullying in a group of UK school children aged 10-14 years and to investigate the extent that bullying was associated with different traits of malocclusion”?

What did they do?

The team did a cross-sectional mixed methods study.

They recruited 10-14-year-olds from primary and secondary schools in London and the south-east of the UK. In the first stage of this process, the team approached the schools. If the schools agreed to participate, they invited the children to participate.

They collected data by visiting the schools in two stages. During the first visit, the psychological members of the team administered a series of questionnaires. This was followed by a visit during which the orthodontist recorded the clinical data.  

They started the data collection in December 2017 and finished in December 2019.

The Olweus bullying questionnaire, which is internationally recognised as valid, was used to measure bullying. The questionnaire included questions about the type of bullying that the respondents experienced.

The orthodontist collected data on the Index of Orthodontic Treatment Need (IOTN) and other features of malocclusion, such as overjet, overbite, and skeletal classification.

They classified a participant as being bullied if they reported being bullied two or three times a month in the last two months. 

Finally, they used the chi-squared test to analyse the data. This was appropriate.

What did they find?

A total of 16 out of 53 approached schools agreed to participate in the study. The research team aimed to collect data from 1,000 children; however, due to the COVID-19 pandemic, data collection had to be halted. Consequently, consent was obtained from 948 students. Of these, 768 completed the bullying questionnaires, and 755 were examined by the orthodontist. Despite the shortfall in numbers, a post hoc power calculation indicated that they had recruited an adequate sample size to ensure the study’s power.

Sixty-eight of the participants were bullied. There was no relationship between the prevalence of bullying with age, gender and ethnicity. 

When exploring the effects of malocclusion, researchers discovered a significant link between bullying and an overjet measurement exceeding 6 mm. Additionally, participants who had a greater need for treatment, as determined by the IOTN Dental Health Component and Aesthetic Components, reported higher instances of bullying.

Their conclusion was

“The prevalence of bullying in this population was 9.7%. Having an increased overjet and more severe malocclusion was associated with being bullied”.

What did I think?

It was great to see a study that was not the typical “orthodontic research project.” This type of study is becoming increasingly important as orthodontic research shifts away from measuring radiographs and study models.

The findings were logical and clinically significant. This is one of the first studies to show the link between malocclusion and bullying, which is particularly valuable when third-party payers question the need for orthodontic treatment. 

We must exercise caution, as we cannot definitively state that orthodontic treatment will reduce bullying. However, it is reasonable to suggest that removing the target of bullying might help resolve the issue. Nonetheless, we cannot promise a complete solution.

The authors discussed their study’s limitations, particularly concerning missing data. Although their sample size calculation addressed this issue, the small group size rendered subgroup analyses unfeasible.

The authors also discussed the potential differences between children who consented to participate and those who did not. They noted that the dental examination might discourage anxious children from taking part in the study. Importantly, anxiety is linked to bullying, which could have introduced bias in the findings.

I have thought about these issues. It is easy to find problems with this form of research, as it is not as “clean” as a trial or a study using a convenience sample. I have done several of these studies and they require a large amount of difficult work.  In this respect, the authors have done well. I just think that we need to acknowledge these possible problems when we interpret their conclusions.

Final comments

The British Orthodontic Society Foundation funded this study. This is an important funding source, and many important studies have been conducted involving this innovative scheme, which was set up by visionaries several years ago.

This study is an addition to the literature.