March 11, 2024

Is bullying about malocclusion a problem?

Almost one in three students report bullying at school. This may have significant short- and long-term effects on their mental and physical health. A recent study from the UK highlights the significance of malocclusion to bullying.

It is well-established that certain features of malocclusion, such as crooked teeth, can make students a target for bullying. Teasing is often a motivator for orthodontic treatment. Surprisingly, this area of orthodontic care has not been extensively studied. A team from the beautiful County of Kent in the UK did this study. The Journal of Orthodontics published the paper.

I would like to declare a conflict as I know Andrew DiBiase well. However, I have not carried out a research project with him.

What did they ask?

They asked this question.

“What is the prevalence of self-reported bullying in a group of UK children aged 10-14, and was this associated with the different traits of malocclusion”?

What did they do?

They did a mixed-method, cross-sectional study. The study had several components

They recruited a sample of children from schools in South East UK. The study team selected this group to represent a wide range of backgrounds.  

The study team then collected the data directly from the children in their schools:

  • They used the  Oleus bullying questionnaire to measure the prevalence and nature of any bullying
  • An orthodontic examination included the Index of Orthodontic Treatment Need (IOTN) and relevant information on their malocclusion, for example, the overjet, overbite, crowding, incisor show at rest and skeletal relationship.

The team classified a child as being bullied if they reported being bullied 2-3 times a month. They analysed the data further using the Chi-squared statistic. 

What did they find?

Sixteen schools agreed to take part in the study. They wanted to recruit 1000 participants into the study. Unfortunately, they had to stop data collection because of the COVID-19 pandemic, and they recruited 948 students. Seven hundred sixty-eight completed the bullying questionnaires, and 755 attended the clinical examination. This resulted in a final sample of 698 who had the questionnaire and clinical examination.

  • They identified 68 bullied children. 
  • There was no relationship to bullying with age, gender and ethnicity. 
  • However, there was a higher prevalence of bullying in mixed-sex schools compared to single-sex schools.
  • The overall prevalence of bullying was 9.7%

When they looked at the effects of malocclusion, they found

  • There was a significant relationship and increased overjet of greater than 6mm
  • IOTN Dental health component grade five was related to bullying.
  • IOTN Aesthetic components 9-10 were not independent of bullying.

Their conclusion was 

“There was a prevalence of bullying of 9%. The prevalence of malocclusion and the need for orthodontic treatment using IOTN DHC grades 4 and 5 was 42%. Having an increased overjet and high IOTN DHC and AC scores was associated with being bullied”.

What did I think?

This study on the effects of malocclusion on children was well done and required a lot of work.

It was intriguing to note that the findings of this study were somewhat consistent with a few other studies conducted in this field. Therefore, they certainly contribute to our understanding. The main takeaway from this paper is that bullying is linked with the characteristics of severe malocclusion.

The study’s authors did a commendable job acknowledging some of its limitations. Most of these limitations were related to the sample size. However, a sample size calculation indicated that the sample size was sufficient. Nevertheless, many participants dropped out of the study before completing both components. This suggests that the study might have some degree of bias. However, the size and direction of such a bias is unknown.

It is important to note that the authors did not conduct a multivariate analysis to control confounding factors. Therefore, we can only conclude that there was a link between malocclusion and bullying. However, it’s crucial to remember that correlation does not imply causation. Knowing that the team intends to perform a multivariate analysis in a potential new paper is encouraging.

I look forward to reading the results of this analysis.

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Have your say!

  1. Thank you Prof O’Brien for posting this important paper.

    My first thought/question was, as increased dental overjet and severity of IOTN were the two most frequent and statistically significant malocclusion traits identified as being associated with bullying, why weren’t these unfortunate children not identified and treated orthodontically/dentofacial orthopedically earlier in their lives? According to Bishara, McNamara, Buschang, Nanda et al,, transverse, sagittal and vertical skeletal malocclusion phenotypes are often first discernible as being reliably persistent by age 4 (i.e., prior to the eruption of their 6 yr molars); so I am curious Dr. O’Brien, nowadays with this paper in hand, and others related similar to it RE the topic of bullying and worsening malocclusion in kids, might this persuade you, and maybe/hopefully some of your readers, that maybe intervening earlier than at a double-digit age, might be in a child’s/parent’s better short- and long-term health interest…..and certainly a more medically defensible/scientifically-supportable position to take?

    Thanks for considering


    • Thanks for your comments. Being teased and bullied is an indication for early interceptive treatment and is provided by most orthodontists. I certainly used to do this when I was practising.

      I am not sure why some of this sample of children did not have orthodontic treatment to see if the bullying would reduce. Most orthodontic treatments in the UK are free on the National Health Service. However, access to care and seeking treatment are influenced by socioeconomic status, and this may have been an obstacle for these children and their families. The authors did not report SES, and I wonder if this is being done in a follow-up study.

      Please see this reference and our conclusions to an early treatment of Class II malocclusion study.

      Results showed that early treatment with Twin-block appliances resulted in an increase in self-concept and a reduction of negative social experiences. The subjects also reported treatment benefits that could be related to improved self-esteem.

  2. Thank you for calling attention to this very important topic. There are numerous articles demonstrating the positive psychosocial impact of orthodontic treatment on the bullying of young kids (four cited below). I echo Kevin Boyd’s comment that we should be looking to treat these kiddos at a younger age than we typically do, as we could have a much more profound impact on their psychosocial health and well-being with mixed dentition treatment. Further, as I mentioned in my blog post (link below), many times kids who are being bullied won’t report it out of shame, fear, and/or embarrassment.

    Anyone who has ever treated a Phase I case in which there was a great esthetic improvement knows that the patient feels much better about themself once they have a beautiful smile. This is true regardless of their age. We live in an image-obsessed society and kids are brutal to one another. Therefore, I’m not sure why so many docs feel that aesthetic improvement must wait until a patient is in the permanent dentition. In my opinion, when necessary, we should give preadolescent kiddos the option of providing the confidence that comes with a great smile. To be clear, that’s not to say we need to straighten every malaligned tooth of every 7-year-old. But we should recognize and be sensitive to those who have a handicapping malocclusion at a young age and be willing to assist them.

    Here is the blog on this topic that I published back in 2022. (

    -Seehra J, Neweon JG, Dibiase AT. Interceptive orthodontic treatment in bullied adolescents and its impact on self-esteem and oral health-related quality of life. Eur J Orthod 2013;35:615-621.
    -Dimberg L, Arnrup K, Bondemark L. The impact of malocclusion on the quality of life among children and adolescents: a systematic review of quantitative studies. Eur J Orthod 2015;37:238-47.
    -Dutra SR, Pretti H, Martins MT, Bendo CB, Vale MP. Impact of malocclusion on the quality of life of children aged 8 to 10 years. Dental Press J Orthod 2018;23:46-53.
    -Martins-Júnior PA, Marques LS, Ramos-Jorge ML. Malocclusion: social, functional and emotional influence on children. J Clin Pediatr Dent 2012 Fall;37(1):103-8.

    • Thanks for the comments. Yes, being teased and bullied is an indication for early intervention and is current practice. Please see my comments to Kevin Boyd.

  3. This is a useful study to highlight the association of orthodontic treatment need and bullying.
    It would have been interesting if they had asked the children if their teeth was a source of bullying, however. Bullying is a very complex issue and bullies will often pick on certain children for anything. Even having orthodontic treatment can be a source of bullying!

    Perhaps a qualitative study interviewing some of these children would show the true impact of malocclusion on bullying and the subsequent beneficial effect of orthodontic treatment?

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