European Archives of Paediatric Dentistry

, Volume 19, Issue 2, pp 73–82 | Cite as

Association between malocclusion and dental caries in adolescents: a systematic review and meta-analysis

  • A. C. Sá-Pinto
  • T. M. Rego
  • L. S. Marques
  • C. C. Martins
  • M. L. Ramos-Jorge
  • J. Ramos-Jorge
Systematic Review



To evaluate the scientific evidence regarding the association between malocclusion and dental caries in adolescents.


Searches were conducted of six electronic databases, complemented by manual searching of the reference lists of the selected articles and grey literature. Two independent reviewers performed the selection of the articles, data extraction and the evaluation of the risks of bias through an assessment of methodological quality. Meta-analysis was performed considering the mean decayed, missing and filled teeth (DMFT) index for caries and the Dental Aesthetic Index (DAI) for malocclusion. Heterogeneity was tested using the I2 statistic and a random effect model was employed. Summary effect measures were calculated as differences in means.


The initial search retrieved 2644 studies, only 15 of which were selected for full-text analysis. Four cross-sectional studies were included in the qualitative systematic review. Only one of these studies found no association between malocclusion and dental caries. The meta-analysis of three studies demonstrated that a lower DAI value was significantly associated with a lower mean DMFT index, except for the comparison of DAI 26–30 vs. 31–35.


Based on the studies analysed, the scientific evidence indicates an association between malocclusion and dental caries.


Malocclusion Dental caries Adolescent Systematic review 


Dental caries is a multifactorial oral problem. While the prevalence of this condition has diminished significantly in recent years, caries remains a major public health concern. Untreated caries in the permanent dentition affects approximately 35% of the population worldwide (Marcenes et al. 2013). Moreover, recent studies conducted in different regions of the world report a prevalence rate of approximately 40% among adolescents (Khanal and Acharya 2014; da Rosa et al. 2015; Chukwumah et al. 2016).

Higher sugar intake (Peres et al. 2016) and social conditions, such as poverty and lower maternal education (Skinner et al. 2014; Dusseldorp et al. 2015; Warren et al. 2017) have been well established as some of the risk factors of dental caries in adolescents. A recent cohort study also demonstrated that tooth brushing is a strong factor related to the development of later dental caries among this age group (Warren et al. 2017). Malocclusion is also often considered a risk factor for caries, as the inadequate alignment of the teeth allows the build up of bacterial plaque and hinder its removal (Pitts and Rimmer 1992; Allison and Schwartz 2003; Warren et al. 2003; Stahl and Grabowski 2004; Gábris et al. 2006; Hafez et al. 2012). However, a previous systematic review was unable to identify an association between crowding of the teeth and dental caries (Hafez et al. 2012), but those authors did not perform a meta-analysis due to the degree of heterogeneity of the data among the studies analysed. The age groups in the primary studies ranged from children in the primary dentition phase to adults aged older than 35 years.

Regardless of the criteria adopted for the dental examination, many studies have found an association between malocclusion and dental caries (Hixon et al. 1962; Warren et al. 2003; Gábris et al. 2006; Nobile et al. 2007; Mtaya et al. 2009), whereas others have not been able to establish such an association (Helm and Petersen 1989; Stahl and Grabowski 2004). Thus, the relationship between malocclusion and caries remains unclear, and no recent systematic reviews have been conducted to address this clinical issue. Moreover, both malocclusion and caries affect the quality of life of adolescents (Peres et al. 2013; Krisdapong et al. 2013; da Rosa et al. 2015).

The aim of the present study was to conduct a systematic review and meta-analysis for the evaluation of scientific evidence regarding the association between malocclusion and dental caries in adolescents. The following was the Population Exposure Comparison Outcome (PECO) question: patients—individuals aged 11–20 years (permanent dentition); exposure to the risk factor—malocclusion; comparison—absence of malocclusion; outcome: dental caries.

Materials and methods

The present review was performed in compliance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al. 2009) (protocol number: PROSPERO CRD42016035513). Searches were performed to retrieve cross-sectional, case–control, cohort studies as well as clinical trials conducted to evaluate whether the occurrence of malocclusion is associated to dental caries in adolescents aged 11–20 years with permanent dentition. The statistical data could be odds ratios (OR), prevalence ratios (PR), relative risk (RR), Spearman’s correlation coefficients (ρ), 95% confidence intervals (CI), p values or an analysis of the frequency or absolute number of events (occurrence of dental caries) considering groups with and without malocclusion.

The following databases were searched in December 2015 and again in May 2016: Pubmed (; Cochrane Library (; Web of Sciences (; National Institute for Health and Clinical Excellence (; Clinical Trials—USA National Institute of Health ( and Lilacs ( The search strategy was used for the Pubmed, Cochrane Library and Web of Sciences databases: [(dental caries [mesh] OR caries OR tooth decay OR teeth cavity OR dental cavity) AND (malocclusion [mesh] OR overjet OR overbite OR open bite OR cross bite OR deep bite OR Angle Class III OR Angle class II OR canine relationship OR molar relationship OR dental aesthetic index OR crowd* OR irregular* OR arch alignment OR malalign * OR orthodontic treatment need)]. The searches of the National Institute for Health and Clinical Excellence, Clinical Trials and Lilacs databases were performed with the key words dental caries AND malocclusion. No restrictions were imposed regarding year of publication. A manual search was also conducted of the reference lists of eligible studies and the grey literature was searched for the identification of abstracts presented at conferences, but not published in the form of an article.

The articles were exported to the EndNote® program (EndNote, Thomson Reuters, version x7), duplicates were removed and the list provided by this program was analysed. At first, articles were selected based on the titles and abstracts by two independent reviewers (ACSP and TMR). After this selection, the reviewers sorted the studies for quality analysis based on a full text reading. Agreement between the reviewers with regard to the eligibility criteria was determined using a sub-sample of 20% of the pre-selected articles and was considered excellent (K = 0.95). Any divergences were resolved by consensus with a third reviewer (JRJ). When studies were not found, the authors were contacted by e-mail or through Research Gate.

The following were the exclusion criteria: literature reviews, letters to the editor, studies involving adolescents with a disability, case reports, case series. Studies that did not investigate malocclusion as a risk factor for dental caries, that evaluated the treatment of malocclusion as a risk factor for caries, as well as those that evaluated diagnostic methods or health promotion and including those that considered an outcome other than dental caries (such as periodontal disease). Quality of life studies and those that only investigated one type of malocclusion (irregularity) were also excluded. Only research reports published in English, Spanish, French, Italian and Portuguese were considered. For a study to be included in the present systematic review, the outcome needed to be reported as mean caries index scores or categorized as the presence/absence of dental caries.

Data extraction

Descriptions were made of the characteristics of the studies, such as country, study design, initial and final sample size, criteria employed for the evaluation of malocclusion and dental caries, statistical analysis and outcome. In cases of lost or missing data, the authors were contacted by e-mail.

Evaluation of methodological quality

The methodological quality of the studies selected for inclusion was evaluated by the reviewers in an independent fashion. In cases of divergence, a discussion was held until a consensus was reached. As only studies with a cross-sectional design were deemed eligible, the analysis of methodological quality was performed using the Newcastle–Ottawa Scale for case–control studies (Wells et al. 2011) adapted for the evaluation of cross-sectional studies (Herzog et al. 2013) (Table 2).

The risk of bias was evaluated for each study, as follows: “Yes” for a low risk of bias (scored one point represented by an asterisk) and “No” for a high risk of bias, for which no score was attributed (Higgins and Altman 2012). Based on the criteria of the Newcastle–Ottawa scale, the items evaluated were exposure/non-exposure, representativeness of the sample (assessed based on sample generation method, allocation concealment and calculation of sample size), sample selection (community, school, etc.), control for confounding variables, blinding, data acquisition of the dependent variable, description of biases and description of non-response rate. The representativeness criterion was evaluated based on the sampling methods. The presence of a random component in the generation of the sequence was judged as a low risk of bias. Allocation concealment was also used as a criterion for the evaluation of representativeness. Thus, any method that impeded the participants and researchers from determining the allocation was judged as a low risk of bias.

Data synthesis

The Comprehensive Meta-Analysis Software (version 2) was used for the meta-analysis (Borenstein et al. 2005). Only studies with similar designs were included in the forest plot, as meta-analysis can generate confusing results when different study designs and variations in study designs are grouped (Deeks et al. 2012). Thus, to avoid methodological and clinical heterogeneity in the meta-analysis, only cross-sectional studies with the same evaluation criteria for malocclusion [Dental Aesthetic Index (DAI)] and dental caries [Decayed, Missing and Filled Teeth (DMFT) index] and that presented results in the form of mean and standard deviation for these indices, were included in this analysis.

The heterogeneity among the studies was verified using the I2 statistic and a sensitivity test was performed to test the consistency of the data through the removal of outliers from the datasets (Deeks et al. 2012). For the subgroup analysis of the different DAI categories, a fixed-effects model was used for low heterogeneity and a random effects model was used for high heterogeneity. As values that exceed 50% are considered indicative of considerable heterogeneity (Higgins and Thompson 2002), the random effects model was used for such cases (Borenstein et al. 2009). Mean differences between individuals with different types of malocclusion, a 95% CI and p-values were calculated in the forest plot. It was not possible to extract data from one study (Singh et al. 2011) for meta-analysis. Thus, a narrative summary of this study was performed.


Characteristics of studies

The online search resulted in the retrieval of 2644 articles and the manual search resulted in an additional two articles (Fig. 1). After the removal of duplicated reports, 1753 articles were analysed for pre-selection, 1738 of which were excluded based on the titles and abstracts. Among the remaining 15 articles selected for full-text analysis, four were included in the present systematic review, three of which were submitted to meta-analysis. All studies included had a cross-sectional design. Table 1 displays the characteristics of the studies, which were conducted in Iran (Borzabadi-Farahani et al. 2011), India (Singh et al. 2011; Baskaradoss et al. 2013) and Brazil (Feldens et al. 2015).

In all studies, the participants were recruited from schools. Age ranged from 11 to 20 years and sample size ranged from 509 to 1800 adolescents. All studies analysed reported the representativeness of the sample. Considering DAI ≥ 26, the prevalence of malocclusion was similar in the studies of Singh et al. (2011) and Baskaradoss et al. (2013) (18.0 and 15.4%, respectively). Borzabadi-Farahani et al. (2011) and Feldens et al. (2015) found a higher prevalence of malocclusion in the studied population, 45.5 and 67.6% respectively. In relation to the prevalence of dental caries, the values were similar between Borzabadi-Farahani et al. (2011) and Baskaradoss et al. (2013), 88.8 and 91.8% respectively and between Singh et al. (2011) and Feldens et al. (2015), 50.4 and 44.8% respectively.
Fig. 1

Screening of articles: four-phase PRISMA flow diagram for study selection, showing number of studies identified, screened, eligible and included in review and meta-analysis

Table 1

Characteristics of studies included in systematic review

Authors (Year) Journal

Country, design

Local setting

Initial sample (final)

Adolescents with caries (total)

Adolescent’s age at dental examination

Dental exam (calibration)

Evaluation of malocclusion and dental caries

Statistics (adjusted for confounders)

Outcomes (OR, 95% CI or p value)

Singh et al. (2011)

Community Dent Health

India, cross-sectional


945 (927)


12 years

1 dentist


Spearman’s correlation

Positive correlation found between dental caries and both severe and handicapping malocclusion (r = 0.614, p ≤ 0.05 and r = 0.889, p ≤ 0.01)

Borzabadi-Farahani et al. (2011)

Acta Odontol Scand

Iran, cross-sectional


(748) 728


11–20 years

1 dentist


Student’s t-test; ANOVA; Binary logistic regression

Higher caries experience found in subjects in need of orthodontic treatment (DAI > 30), but difference did

not achieve significance (p > 0.05)

Baskaradoss et al. (2013)

Korean J Orthod

India, cross-sectional


1800 (1042)


11–15 years

2 dentists


Spearman’s rank-order correlation coefficient (r)

Children with mean DAI scores > 35 had significantly greater caries experience (p < 0.001); mean DAI scores significantly correlation with mean DMFT scores (r = 0.368, p < 0.05)

Feldens et al. (2015)

Angle Orthod

Brazil, cross-sectional


700 (509)


11–14 years

1 dentist


Poisson regression with robust variance; Kruskal–Wallis; Mann–Whitney

Adolescents with severe or handicapping malocclusion had 31% greater probability of having dental caries (prevalence ratio: 1.31; 95% CI: 1.02–1.67)

DAI dental aesthetic index; DMFT decayed, missing, and filled teeth

Singh et al. (2011) conducted a study in the Udupi district of India and did not collect data on socioeconomic status. Borzabadi-Farahani et al. (2011), who conducted a study in the city of Isfahan (Iran), and Baskaradoss et al. (2013), who conducted a study in the city of Kanyakumari (India), collected data on socioeconomic status, but did not perform multivariate analysis, considering this variable as a confounding factor for the evaluation of the association between malocclusion and dental caries. Feldens et al. (2015), who conducted a study in the city of Osório (Brazil), controlled for socioeconomic status in the multivariate analysis performed to investigate this association.

Three of the four studies included in the present review found a positive association between severe malocclusion (treatment required) and dental caries (Singh et al. 2011; Baskaradoss et al. 2013; Feldens et al. 2015). Only one study (Borzabadi-Farahani et al. 2011) did not find such an association (p > 0.05).

Diagnosis of dental caries

The studies analysed used the criteria established by the World Health Organization (WHO 1997) for the clinical examination of dental caries. Three studies (Singh et al. 2011; Borzabadi-Farahani et al. 2011; Feldens et al. 2015) investigated the presence/absence of caries considering all components of the DMFT index. Borzabadi-Farahani et al. (2011) dichotomized the outcome as DMFT ≤ 8 and DMFT > 8. Baskarados et al. (2013) evaluated the mean total DMFT score as well as the mean score of each component of the index (decayed, missing and filled teeth). In contrast, Singh et al. (2011) did not describe mean DMFT scores for each DAI category and was therefore excluded from the meta-analysis.

Diagnosis of malocclusion

All four studies used the DAI for the evaluation of malocclusion, which is also recommended by the World Health Organization (WHO 2003). This index is used to evaluate orthodontic treatment needs and furnishes four possible results based on the score: ≤ 26—slight treatment need; 26–30—elective treatment need; 31–35—treatment is highly desirable; and ≥ 36—treatment is required. All authors followed this DAI categorization.

Evaluation of socioeconomic status

Three of the studies included in the present systematic review evaluated the socioeconomic status of the sample (Borzabadi-Farahani et al. 2011; Baskaradoss et al. 2013; Feldens et al. 2015). For such, Borzabadi-Farahani et al. (2011) analysed parents’ schooling, mother’s employment status and number of residents in the home. Baskaradoss et al. (2013) determined socioeconomic status based on the Standard of Living Index and reports of household income as well as both the possession of goods and household facilities. Feldens et al. (2015) considered household income, family structure and mother’s schooling.


Meta-analysis was performed for three of the studies included in the present review (Borzabadi-Farahani et al. 2011; Baskaradoss et al. 2013; Feldens et al. 2015), which had quantitative variables that could be compared in relation to the DAI score (< 26 vs. 26–30; < 26 vs. 31–35; < 26 vs. ≥ 36; 26–30 vs. 31–35; 26–30 vs. ≥ 36; 31–35 vs. ≥ 36). The meta-analysis demonstrated that individuals with a DAI score lower than 26 (slight treatment need) had a lower mean DMFT index than those with a higher DAI score (DAI < 26 vs. DAI = 26–30: difference in means = − 0.34, 95% CI − 0.51 to − 0.17; DAI < 26 vs. DAI = 31–35 difference in means = − 0.35, 95% CI − 0.60 to − 0.11; and DAI < 26 vs. DAI = 36 or more: difference in means = − 0.97, 95% CI − 1.62 to − 0.33). Individuals with DAI = 26–30 (elective treatment need) had a mean DMFT index similar to individuals with DAI = 31–35 (difference in means = − 0.03, 95% CI − 0.35–0.30) and lower than individuals with DAI ≥ 36 (difference in means = − 0.63, 95% CI − 1.18 to − 0.07). Individuals with DAI = 31–35 (treatment is highly desirable) had a lower mean DMFT index than those with DAI ≥ 36 (difference in means = − 0.67, 95% CI − 1.31 to − 0.02).

Evaluation of methodological quality

Table 2 shows a summary of the quality of the studies analysed. A high risk of bias was considered when an item did not meet the criteria of the Newcastle–Ottawa scale. All studies were judged as having a high risk of bias regarding the description of the response rate or characteristics of respondents and non-respondents. Only one study detailed the sample size calculation (Feldens et al. 2015). The same study was the only investigation to control for an important confounding variable (socioeconomic status) for the evaluation of the association between malocclusion and dental caries. Confounding variables were identified in the Methods and Results sections as well as the tables in the studies selected for the present review.
Table 2

Newcastle-Ottawa quality assessment


Selection (Max. 5*)

Comparability (Max. 2*)

Outcome (Max. 3*)


Singh et al. (2011)





Borzabadi-Farahani et al. (2011)





Baskaradoss et al. (2013)





Feldens et al. (2015)





Each * represents one point in the Newcastle-Ottawa quality assessment’s scale


Summary of evidence

The results of the meta-analysis demonstrated that individuals with a DAI score lower than 26 (slight treatment need) had a lower DMFT index than individuals with higher DAI scores (Fig. 2). The studies analysed exhibited methodological and clinical homogeneity (Cohn and Becker 2003). However, the comparison of the mean DMFT index between individuals with a DAI score equal to or greater than 36 and those with lower scores demonstrated a high degree of heterogeneity (DAI < 26 vs. DAI ≥ 36: I2 = 75.91%; DAI 26–30 vs. DAI ≥ 36: I2 = 49.86%; DAI 31 to 35 vs. DAI ≥ 36: I2 = 59.13%).
Fig. 2

Forest plot of meta-analysis for three cross-sectional studies

The literature reports several factors related to the higher prevalence of caries experience among individuals with malocclusion. One of the most common is dental crowding, which leads to the build up of bacterial plaque for a prolonged time, resulting in a greater frequency of dental caries (Warren et al. 2003; Gábris et al. 2006). Unlike a previous review, which only investigated one type of malocclusion (crowding) as a risk factor for the development of caries (Hafez et al. 2012), studies that addressed the severity of different types of malocclusion were included in the present review. This is important, as malocclusion involves a set of occlusal abnormalities. Thus, the identification of a greater risk of dental caries as a result of more severe malocclusions can contribute to the indication for orthodontic treatment (Helm and Petersen 1989).

Among the studies analysed, only one (Borzabadi-Farahani et al. 2011) found no association between malocclusion and caries (p > 0.05). While there is no scientific evidence regarding the reason why severe malocclusion (treatment required) constitutes a greater risk for the occurrence of caries, some hypotheses could be raised. It is possible that severe malocclusion can contribute both to plaque build-up as to the difficulty of its removal. This permanence of dental plaque over an extended period of time contributes to the development of dental caries (Fejerskov, 2004). Thus, the acquisition of additional data, such as a plaque index and oral hygiene habits, could contribute to the clarification of this relationship in future studies (Feldens et al. 2015).

The possibility of an association between malocclusion and dental caries can occur in both directions, malocclusion as an exposure for dental caries and dental caries as an exposure for malocclusion. This possibility is a feature of the cross-sectional design, which does not allow the determination of the order of occurrence of these conditions (Feldens et al. 2015). Thus, besides the studies evaluating malocclusion as an independent variable and dental caries as an outcome, some studies have demonstrated that adolescents with dental caries are more likely to exhibit malocclusion (Gábris et al. 2006; Frazão and Narvai 2006; Nobile et al. 2007; Mtaya et al. 2009). Longitudinal studies are required to clarify the validity of this association.

In terms of the limitations of the selected studies, most failed to detail the calculation of the sample size (Singh et al. 2011; Borzabadi-Farahani et al. 2011; Baskaradoss et al. 2013). Although two studies (Singh et al. 2011; Baskaradoss et al. 2013) reported the calculation of the sample size, they failed to give more details about this process. The lack of a sample size calculation lowers the level of evidence, as there is no knowledge of whether the number of participants was sufficient to detect a significant association when such an association indeed exists. It is important to highlight that, although most studies (Singh et al. 2011; Borzabadi-Farahani et al. 2011; Baskaradoss et al. 2013) failed to give details of the calculation of the sample size, they gained credit in the representativeness item, because the criteria used to assess the quality of the studies evaluates the degree of representation and the sample size calculation an in independent way. The modified Newcastle–Ottawa scale assess how the data may represent through the presence or not of the sample randomisation or by the participation of all subjects of the population in question. Thus, as all of the analysed studies reported the randomisation of the sample, a point of representation was assigned to them.

The evaluation of socio-economic status is fundamental in studies addressing risk factors for dental caries. Researches have found that individuals with a lower socioeconomic status have a greater prevalence rate of dental caries (Piovesan et al. 2010; Ramos-Jorge et al. 2014; Pinto-Sarmento et al. 2016). Thus, when addressing the possible association between malocclusion and dental caries, researchers should control for socio-economic status in any multivariate analysis, as this is an important confounding factor. It is possible that socio-economic status and malocclusion are synergistic as risk factors for dental caries. Badran et al. (2014) found that individuals with a low socioeconomic status exhibited a greater normative need for orthodontic treatment. Among the studies included in the present review, only one (Feldens et al. 2015) controlled for socio-economic status in the multivariate analysis. The authors found that individuals with a low socio-economic status and a DAI score equal to or greater than 36 (treatment required) had a greater prevalence rate of dental caries (Feldens et al. 2015). The fact that severe malocclusion remained associated with dental caries after controlling for socio-economic status demonstrated that these variables exert an influence in an independent manner.

A high risk of bias was found due to the failure to describe the response rate or characteristics of the respondents and non-respondents, which weakens the reliability of a study, as it is not possible to determine whether the non-response rate was acceptable, or whether the characteristics of the respondents and non-respondents differed in such a manner as to exert an influence on the results.

Intra-examiner and inter-examiner agreement was determined in all four studies (Singh et al. 2011; Borzabadi-Farahani et al. 2011; Baskaradoss et al. 2013; Feldens et al. 2015). This determination is an important aspect with regard to the credibility of the findings, as it ensures agreement among the researchers throughout the data acquisition process. Failure to determine intra-examiner and inter-examiner agreement could result in detection bias and furnish dubious, unreliable data.

The present systematic review involved a search of different electronic databases with no restriction imposed regarding the year of publication. Efforts were also made to find studies in the grey literature for which the full text was not published in order to minimize the interference of publication bias. However, language bias may have occurred due to the restriction of some languages, as significant results are generally published in English (Wulaerhan et al. 2014).

The findings of the present systematic review and meta-analysis underscore the importance of oral health promotion strategies directed at preventing malocclusion. Besides being associated with functional and aesthetic limitations (Almeida et al. 2014; Choi et al. 2016), malocclusion may be an important associate factor for dental caries in adolescents.


The scientific evidence based on this sytematic review suggests an association between malocclusion and dental caries, since individuals with a lower DAI score also had a lower DMFT index. As that only four valid cross-sectional studies were identified, further longitudinal studies with controls for possible confounding variables are needed to confirm this evidence.



This study was supported by the following Brazilian fostering agencies: National Council for Scientific and Technological Development (CNPq), Ministry of Science and Technology, State of Minas Gerais Research Foundation (FAPEMIG) and Coordination for Improvement of Higher Education Personnel (CAPES).

Compliance with ethical standards

Conflicts of interest

There are no conflicts of interest associated with this publication.


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Copyright information

© European Academy of Paediatric Dentistry 2018

Authors and Affiliations

  1. 1.Department of Pediatric Dentistry and Orthodontics, School of DentistryUniversidade Federal dos Vales do Jequitinhonha e MucuriDiamantinaBrazil
  2. 2.Department of Pediatric Dentistry and Orthodontics, School of DentistryUniversidade Federal de Minas GeraisBelo HorizonteBrazil

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