INTRODUCTION

Over the last two decades, most industrialized countries have seen a steady increase in the number of orthodontic treatments.1 But reports on different European populations suggest that treatment rate of adolescents and young adults may vary from 15% to as high as 63%, depending on age, country, and area of sampling.2–11

Orthodontic treatment rate is determined not only by the prevalence and severity of the malocclusion but also by other influencing factors such as gender,14–6 socioeconomic status112 and ethnic origin,12 as well as availability and funding of the orthodontic services.18912 Girls, in general, are treated more frequently than boys.4–6 But although subjects of higher socioeconomic groups are overrepresented among consumers of self-financed orthodontic services,12 the effect of this variable is unclear when treatment is available at no cost.613–15 It has been established that better availability of health care services may result in increased use and demand of services.16 Accordingly, district-level differences in uptake of orthodontic treatment have been observed to correlate strongly with the distribution of the orthodontic manpower in the areas.12817

The major motivation for seeking orthodontic treatment is a desire to improve dental appearance.118 But the range of the occlusal and dental variations that is perceived as acceptable or normal has been found to be fairly wide and to vary among individuals, societies, and cultures.121920 Subjects of rural areas, characterized by a lower uptake of orthodontic treatment, have been found to be more tolerant to the presence of malocclusions than subjects in urban areas with high frequency of treatment.221 An association between the desire for treatment and the professional assessment of malocclusion severity has been demonstrated.2223 But there is a general agreement that the subjective treatment need, as estimated by both adolescents and adults, is lower than the objective need as estimated by dentists.34924–26

Kuwait has provided free-of-cost oral health care since the 1970s.27 Orthodontic treatment is included, but it is available only to Kuwaiti citizens and is provided by specialists employed by the Ministry of Health. Resident aliens are limited to private treatment options. No general rationing of the access to care according to the severity of malocclusion or age has been implemented.

A study of adolescent males in Saudi Arabia suggested that 40% of the subjects were in need of comprehensive orthodontic treatment according to the criteria of the Norwegian Health Service.28 But information on issues like distribution of orthodontic services, satisfaction with dentofacial appearance, or desire for treatment of Arab populations in the Middle East is very limited. Such information is mandatory for appropriate planning of the public treatment services.

Our aims were to explore orthodontic treatment experience, subjective need for treatment, and perceptions of teeth and dental appearance among urban and rural high school students in Kuwait. The specific aims were to analyze the influence of different background factors such as funding system, area of living, age, gender, ethnicity, and socioeconomic status on orthodontic treatment experience among Arab teenagers.

MATERIALS AND METHODS

RESULTS

The majority (79%) of the subjects were Kuwaiti citizens. The remaining were resident Arabs without citizenship (5%) or with citizenship of neighboring Arab countries (16%). The non-Kuwaiti subjects represented 45% in Jahra as opposed to only 5% in Capital.

Treatment experience

Kuwaitis

Subjects in Capital had undergone orthodontic treatment significantly more often than those in Jahra, whereas no district-level difference could be detected in the frequency of subjects on the waiting list (Table 1). In both districts, the number of subjects on the waiting list was more than the number of subjects who had undergone treatment, a total of 119 and 80 subjects, respectively (Table 1). Girls had received treatment significantly more often than boys, 12% and 6%, respectively (P < .05).

TABLE 1.  Orthodontic Treatment Experience Among Kuwaiti and non-Kuwaiti High School Students in Jahra and Capital, N = 1076^a

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The mean age at the start of treatment was 13.3 years (SD, 1.5), with no significant difference between Jahra and Capital. The youngest age at treatment start was 9 years (one subject), and only five subjects (6%) had started treatment at the age of 9 or 10 years. The majority (73%) of the subjects had started treatment at 13–15 years of age. The mean age of subjects on the waiting list was 15.0 years (SD, 0.81).

The majority (80%) of the treatments were provided in the specialist clinics operated by the Ministry of Health, and the remaining were performed in private clinics in Kuwait or elsewhere. The main part (87%) of the treatments was a result of the subjects' own or their parents' initiative. The effect of dentist referral as a source was 13% in Capital and 0% in Jahra. Half of the 80 subjects with orthodontic treatment experience were still under active appliance therapy.

Non-Kuwaitis

Only five (2%) of the non-Kuwaitis had received orthodontic treatment, which was significantly lower than the corresponding number for Kuwaitis (P = .001) (Table 1).

Perceptions and subjective treatment need

No significant differences in views were detected between Kuwaitis and non-Kuwaitis regarding the variables in Table 2. About two-thirds of the subjects were very or rather satisfied with their dental alignment (Table 2). The subjects from Jahra were significantly less satisfied than those from the capital (P < .05), but the satisfaction did not differ significantly between genders or among the SES groups, neither did it differ between subjects with or without orthodontic treatment experience (P > .05). Satisfaction with dental health was significantly higher (P < .05) among subjects of lower SES than among those of higher SES. Girls rated the importance of teeth for facial appearance higher than did boys (P < .001).

TABLE 2.  Percentage Distribution of Answers to Questions 3–6 of the Questionnaire According to Score (see Materials and Methods). Score 1 Denotes the Most Positive and Score 4 the Most Negative End of the Answers; Score 5 = No Opinion. N = 1076

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The Kuwaitis in Capital expressed subjective need for orthodontic treatment more often than the Kuwaitis in Jahra (Table 3). Among non-Kuwaitis, the difference was not statistically significant (Table 3). Subjective treatment need did not differ between genders or SES groups, neither for Kuwaitis nor for non-Kuwaitis (P > .05). The major reported reason for treatment need was a bad or a nonattractive alignment of the teeth (59%).

TABLE 3.  Percentage Distribution of Self-Reported Need for Treatment in Jahra and Capital (Question 12) among Kuwaiti and non-Kuwaiti Students. Subjects Who Had Received Treatment Did Not Answer This Question. Six Answers Missing. N = 985^a

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Variables affecting treatment experience

Among Kuwaitis, the odds of being on the waiting list was 18-fold for those with reported subjective treatment need as opposed to those without (P < .001) and about twofold for those dissatisfied with their tooth alignment in contrast to those who were satisfied (P < .05) (Table 4). The odds of receiving orthodontic treatment were about twofold for females vs for males and also for subjects from Capital vs from Jahra (P < .05) (Table 5).

TABLE 4.  Odds Ratios and Upper and Lower Boundaries of 95% Confidence Interval for Background (Independent) Variables to be on the Waiting List for Orthodontic Treatment (Dependent Variable) in a Logistic Regression Model. Age is Continuous Variable, whereas all the Others are Dichotomized. Non-Kuwaitis and Subjects With Present or Past History of Orthodontic Treatment are Excluded From the Analysis, N = 687^a

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TABLE 5.  Odds Ratios and Upper and Lower Boundaries of 95% confidence interval for Background (Independent) Variables to Receive Orthodontic Treatment (Dependent Variable) in a Logistic Regression Model. Age is a Continuous Variable, Whereas All the Others are Dichotomized. Only Kuwaitis are Included in the Analysis, N = 785^a

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DISCUSSION

Owing to the sampling method, the results of this study represent second-year high school students in the two districts studied. The majority of the questions addressed facts that students at that stage are likely to know and recall, and the questions on perception were based on a tried and proved format previously used in similar studies.29 Considering our efforts to avoid errors during completion of the questionnaire, the results may be considered valid. Second-year high school students were selected as the target group because the permanent dentition typically is established by that stage, so that under optimal circumstances, orthodontic treatment to those in need should have been identified and initiated.30

Our finding of a higher treatment rate of Kuwaitis in the urban Capital (11%) when compared with Kuwaitis in rural Jahra (5%) may be because of the more favorable specialist per capita ratio in the capital31 and supports the theory that availability of orthodontic services affects the uptake of treatment.17 Previous results regarding whether an association exists between social class and orthodontic treatment experience are contradictory in societies offering free-of-cost services.613–1532 Our findings support the notion that other variables may be more important.61532

The finding that treatment rate was five times higher for Kuwaiti than for non-Kuwaiti students is not likely to reflect differences in the need for treatment because all subjects in our sample were ethnic Arabs. Because subjective treatment need was similar in both Kuwaitis and non-Kuwaitis, the different uptake of treatment may rather be the consequence of differences in the access to treatment. In keeping with previous studies, this finding may highlight the significance of funding for treatment rate.11216 But the fact that nearly half of the non-Kuwaiti students belonged to the lowest social group as opposed to only one-quarter of the Kuwaitis may have contributed to that finding.1216

Our findings support the argument that girls are more likely to pursue orthodontic treatment than boys.4–6 Because no gender differences, excluding a few individual occlusal traits, have been observed in the total frequency of malocclusion,33–35 the likely explanation is that most societies consider attractive physical appearance to be more important for girls than for boys.1836 In line with previous results, the girls in our sample valued teeth as more important for facial appearance than boys did, reflecting the higher demand for treatment among girls than among boys.37

The age at treatment start was high in this sample, compared with previous studies from other countries providing public funding.8932 The age was also high with respect to recommendations for optimal timing of orthodontic treatments.38–40 By 13–15 years, most girls would have passed their growth peak and will therefore miss growth modification as a treatment option. The fact that hardly any treatments were started before 10 years of age may reflect that no mechanism was available to identify subjects in need of early treatment.

The subjective need for treatment was higher in urban Capital than in rural Jahra, confirming earlier findings that subjects in rural areas, characterized by low orthodontic treatment rates, are likely to demonstrate a greater degree of tolerance toward malocclusion.221 This explanation is also supported by the previous finding that peer groups have a greater influence on the uptake of orthodontic treatment than other variables such as social class or gender.15

The unavailability of orthodontic services for the non-Kuwaitis did not decrease their self-perceived treatment need as compared with their Kuwaiti peers. This may be attributable to the fact that the two groups lived in the same areas and went to the same schools. Therefore, other factors like peer group at school and treatment rate in the area of living may have had greater influence on perceived need for treatment than whether or not treatment was readily available.215

In this study, subjective need for treatment and dissatisfaction with dentofacial appearance were the only variables of significance for increasing the odds of being on the waiting list. This is in keeping with our finding that the initiative for treatment was typically made by the subjects themselves or by their parents and only rarely by a dentist. But it should be stressed that being on the waiting list does not necessarily imply that treatment will be actually rendered.

Depending on criteria and indices, approximately 25% to 35% of adolescents from various populations and ethnic groups have been considered to definitely need orthodontic treatment, and more than half present with some degree of treatment need.51241–43 The rather low treatment rate found in our study, compared with standard estimations of orthodontic treatment need as well as with the limited information on treatment need of other Arab populations in the Middle East,2843 suggest that the provision of orthodontic treatment in Kuwait may be insufficient to cover the need and demand for treatment. The higher proportion of subjects on the waiting list compared with the proportion that had completed treatment or was under active treatment, as well as the high age of the students on the waiting list, is likely to reflect the same lack of resources as well as an inadequate number of providers, resulting in slow unloading from the waiting list.

Our study suggests that access to free-of-cost orthodontic treatment is likely to be of major importance for frequency of treatment, whereas it does not seem to affect the self-perceived need for treatment. Gender and area of living may be significant for receiving orthodontic treatment. Our results also suggest that treatment rate in Kuwait may be considerably below the subjective desire for treatment. Our findings indicate that further information is needed for successful planning of orthodontic services in Kuwait.