Is Wearing Orthodontic Appliances Associated With Eating Difficulties and Sugar Intake Among British Adolescents A Cross-Sectional Study
Is Wearing Orthodontic Appliances Associated With Eating Difficulties and Sugar Intake Among British Adolescents A Cross-Sectional Study
Is Wearing Orthodontic Appliances Associated With Eating Difficulties and Sugar Intake Among British Adolescents A Cross-Sectional Study
doi:10.1093/ejo/cjaa071
Advance Access publication 13 November 2020
Original article
Correspondence to: Eduardo Bernabé, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, Bes-
semer Road, London SE5 9RS, UK. E-mail: eduardo.bernabe@kcl.ac.uk
Summary
Aim: To determine whether wearing orthodontic appliances was associated with eating difficulty
and lower sugars intake among British adolescents.
Methods: This study analysed data from 4116 12- and 15-year-olds who participated in the 2013
Children’s Dental Health Survey in the UK. Information on eating difficulties in the past 3 months
and usual intake of six sugary items was collected through self-administered questionnaires.
The presence and type of orthodontic appliances (fixed or removable) were assessed during
clinical examinations. Logistic regression was used to evaluate the association between wearing
orthodontic appliances and eating difficulty whereas linear regression was used to evaluate the
association between wearing orthodontic appliances and sugars intake. Regression models were
adjusted for socio-demographic, behavioural, and clinical characteristics of adolescents.
Results: 12.9 per cent of the 4116 adolescents wore orthodontic appliances (10.1 per cent fixed
and 2.8 per cent removable), 21.0 per cent reported eating difficulties and the mean daily intake
of sugars was 5.3 times/day (SD: 3.7, range: 0–20). Adolescents with fixed appliances had 4.02
(95% CI: 3.03, 5.33) greater odds of reporting eating difficulty than those with no appliances,
but no differences were found between adolescents wearing removable and no appliances. No
association was found between wearing orthodontic appliances and daily sugars intake either
[coefficients of 0.20 (95% CI: –0.27, 0.66) and –0.30 (95% CI: –0.96 to 0.36) for adolescents wearing
fixed and removable appliances, respectively].
Conclusion: Wearing fixed orthodontic appliances were associated with greater odds of reporting
eating difficulty, but not with lower sugars intake among British adolescents.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Orthodontic Society.
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194 European Journal of Orthodontics, 2021, Vol. 43, No. 2
looked at sugar intake among patients under orthodontic treatment. their usual intake of 5 sugary items (cake or biscuits; sweets, candy,
A cross-sectional study in Australia showed no differences in carbo- or chocolate; coke or other soft drinks or squash that contain sugars;
hydrates intake between adolescents under orthodontic treatment energy or sports drinks; and fruit juices and smoothies). All answers
and control individuals, who were matched by sex and age (14). were collected using six response options: four or more times a day,
A 3-month longitudinal study of patients starting fixed orthodontic three times a day, twice a day, once a day, less than once a day, and
treatment in England found no impact on dietary intake, includ- rarely or never. Weighted scores were used to estimate adolescents’
ing carbohydrates (8). Finally, a cross-sectional study in Germany daily frequency of sugars intake as described elsewhere (21). A score
showed no differences in consumption of sweets, candy, and choc- of 0 was assigned to responses ‘rarely or never’ and ‘less than once a
olates between adolescents wearing fixed orthodontic appliances day’, a score of 1 to response ‘once a day’, a score of 2 to response
and a control group of individuals at the same age who had not ‘twice a day’, a score of 3 to response ‘three times a day’ and a score
undergone any orthodontic treatment (15). of 4 to response ‘four or more times per day’. Weighted responses
Awareness of the common side effects of orthodontic treatment for food items were added to produce separate scores for the two
on adolescents can help to improve the quality of orthodontic care solid sugary items (ranging from 0 to 8 times/day) and the three
(12). A better understanding of the impact of orthodontic appli- liquid sugary items (ranging from 0 to 12 times/day). The sum of
in linear regression models as the three outcome measures were nu- removable, and no appliances. Differences among groups were
merical variables with normal distribution. The regression coefficient identified in terms of demographic characteristics and behaviours.
was the measure of association in this set of models. The adjusted In terms of demographic characteristics, there were significantly
model controlled for all confounders listed above. higher proportions of female adolescents, 15-year-olds and those
from Northern Ireland in the group wearing fixed appliances than in
the other two groups. As for behaviours, there were higher propor-
Results tions of adolescents who visited the dentist for check-ups and who
Of the 4950 12- and 15-year-old adolescents who participated in brushed their teeth 3 or more times a day in the group with fixed
the survey, 834 were excluded because of missing information on appliances than in the other two groups.
relevant variables. Thus, data from 4116 adolescents were analysed. Wearing orthodontic appliances was associated with difficulty
There were no differences between adolescents in the study sample eating in both crude and adjusted models (Table 3). In the ad-
and those excluded in terms of the type of orthodontic appliance justed model, adolescents with fixed appliance had 4.02 (95% CI:
worn, difficulty eating, total sugar intake, or confounders. The char- 3.03, 5.33) greater odds of reporting eating difficulty in the past
acteristics of the study sample are shown in Table 1. In the study 3 months than those wearing no appliances. However, no differ-
Table 1. Comparison between participants included and excluded from the analysis.
n % n % P*
Sex 0.903
Male 1973 50.7 404 50.1
Female 2143 49.3 430 49.9
Age 0.625
12 years 2070 48.2 462 50.1
15 years 2046 51.8 372 49.9
Ethnicity 0.699
White 3421 79.7 402 79.5
Asian 382 10.2 44 11.9
Black 155 4.8 21 4.2
Other 158 5.3 17 4.4
Area deprivation 0.092
Q1 (most deprived) 1519 32.7 233 30.8
Q2 887 19.9 161 31.3
Q3 655 14.3 78 14.6
Q4 617 18.3 93 14.7
Q5 (least deprived) 438 14.8 46 8.6
Country of residence 0.893
England 2324 91 423 92
Wales 932 5.4 236 4.6
Northern Ireland 860 3.6 175 3.4
IOTN 0.976
No/borderline need 2526 63 478 63
Definite need 1040 24.2 229 24.6
Under treatment 550 12.9 105 12.4
Dental attendance pattern 0.943
Check-up 3391 81.8 620 81.7
When trouble 624 15.6 117 15.4
Never 101 2.6 18 2.8
Toothbrushing frequency 0.707
3+ times a day 447 8.1 77 9.8
Twice a day 2743 70.7 493 68.7
Once a day 809 18.1 147 19.1
Less often 117 3.1 31 2.5
Table 2. Comparison of sociodemographic and behavioural factors between adolescents wearing no, fixed and removable orthodontic
appliances.
n % n % n % P*
Sex 0.002
Male 1777 52.5 158 36.6 38 46.9
Female 1789 47.5 295 63.4 59 53.1
Age <0.001
12 years 1864 50.2 161 32.4 45 40.9
15 years 1702 49.8 292 67.6 52 59.1
Ethnicity 0.249
White 2957 79.5 378 79.3 86 88.4
Asian 327 9.9 50 13.3 5 6.4
0.66) than those wearing no appliances. Adolescents with remov- robust to adjustments for well-known determinants of oral health
able orthodontic appliances had a lower, albeit not significant, among adolescents.
intake of sugars (regression coefficient: –0.30; 95% CI: –0.96 to Wearing fixed, but not removable, appliances was associated
0.36) than those with no appliances. Similar non-significant esti- with eating difficulty, which agrees with previous studies (10–12).
mates were found when analysis was stratified by solid or liquid The magnitude of the association was such that adolescents with
sugary items. For solid sugary items, the adjusted coefficients for fixed orthodontic appliances were four times more likely to report
adolescents wearing fixed and removable appliances were, re- eating difficulties than those not wearing appliances. Evidence from
spectively, 0.16 (95% CI: –0.11, 0.43) and 0.00 (95% CI: –0.32, qualitative studies suggests that adolescents wearing orthodontic
0.31) compared with adolescents with no appliances. For liquid appliances experience a restriction of food choices (i.e. moving to
sugary items, the adjusted coefficients for adolescents wearing a softer diet) due to pain, tooth mobility, and fear associated with
fixed and removable appliances were, respectively, 0.04 (95% CI: breaking the appliance (16, 17, 23). They also face issues during
–0.26, 0.34) and –0.29 (95% CI: –0.76, 0.17) compared with ado- the eating process, such as taking longer to eat, eating less, being
lescents with no appliances. messy while eating, and having chewing/biting problems and alter-
ation of taste (16, 17). These side effects should be openly discussed
with adolescents and their parents prior to treatment and balanced
Discussion against the potential long-term positive impacts of orthodontic
The findings showed that wearing orthodontic appliances, particu- treatment on quality of life (24). During treatment, inconveniences
larly fixed appliances, was associated with eating difficulty in the may be well interpreted as normal outcomes if the adolescent is con-
past 3 months, but not with intake of sugars. These findings were stantly reminded that he/she is paving the way for good occlusion
G. Albaqami et al. 197
Table 3. Regression models for the association of wearing orthodontic appliances with eating difficulty and sugars intake among British
adolescents (n = 4116).
a
Eating difficulty was modelled using logistic regression and odds ratios (ORs) were reported. Intake of sugars was modelled using linear regression and re-
gression coefficients (Coef.) were reported. The adjusted model controlled for demographic (sex, age, ethnicity, and country of residence), behavioural (dental
attendance pattern and toothbrushing frequency) and clinical factors (IOTN).
*P < 0.05; ** P < 0.001.
and at the end of treatment, an improved smile will be achieved. home environment, peer pressure, and the commercial advertising
These discussions can help with managing expectations and increas- of profitable industries (27). In this regard, motivational interview-
ing satisfaction with treatment (25). The lack of differences be- ing, a person-centred counselling technique that elicits patients’ in-
tween adolescents wearing removable and no appliances could be trinsic motivations, enhances their commitment and explores their
explained by the ability to remove the appliance for eating. Indeed, own solutions towards change (30), was shown to be more effective
adolescents wearing removable appliances adapt to their appliances than traditional dental health education to reduce sugars intake and
by persevering and using strategies to manage physical impacts (26). prevent dental caries in adolescents (31). These findings are encour-
Contrary to our expectations, wearing orthodontic appliances aging for various reasons: first, parents must be involved in the
were not associated with consumption of sugars, either when ana- decision-making process for changes to be sustainable; second, caries
lysed as total intake or stratified by food consistency (solid and risk assessment can be a valuable resource in discussions prior to and
liquid items). Although those wearing fixed and removable had dif- during treatment; third, positive reinforcement during the appoint-
ferent intakes of sugars than those not wearing any appliances, such ments for appliance bonding and activation are needed to avoid re-
differences were not significant and, therefore, unlikely to be clin- lapse; and fourth the intervention was delivered by dental hygienists,
ically relevant given the high sugars intake observed among these thus providing a way to implementation in general dental practices.
adolescents. Our sugars intake questionnaire was brief and unlikely The present findings have some implications for practice and fur-
to capture all sources of sugars in the diet of participants. That said, ther research. Clinicians and patients should be aware of the side
our findings were consistent with those of previous studies (14, 15). effects of orthodontic treatment, particularly on eating, that could
However, these findings contradict qualitative evidence suggesting affect people’s daily lives. Given the high intake of sugars observed
that some adolescents restrict their food choices (i.e. sweets and among adolescents, especially sugared-sweetened beverages (4), and
fizzy drinks) following advice from the orthodontist to prevent de- growing evidence that wearing orthodontic appliances might in-
calcification (16, 17). These findings imply that adolescents are not crease caries risk (32), the lack of differences in sugars intake among
being informed adequately or they are simply not following their adolescents with and without orthodontic appliances is somewhat
orthodontist’s recommendations. Unassertive counselling from the worrisome. As for research, population-based longitudinal studies
orthodontist and failure of adolescents in following the practition- would be welcome in this research area, especially those accounting
er’s instructions may be associated with the challenges involved in for treatment duration and including multiple measures of sugars
changing an individual’s behaviour (27). Orthodontists should in- intake over time.
clude in their portfolio strategies aiming to modify behaviours that The study has a few limitations that ought to be addressed. First,
are incompatible with appliance wearing (28) and guide adolescents the cross-sectional design implies that we are only able to report as-
regarding the implications of other issues, such as the use of medica- sociations rather than causal relationship between variables. Second,
tions and dietary supplements for orthodontic treatment movement data collection of the Children’s Dental Health Survey took place
(29). Behaviour change in relation to dietary habits is a complex in 2013, which might be considered relatively old. However, this
task because an individual’s diet is shaped not only by his/her own is the latest oral health survey among children in the UK and al-
beliefs and values but more so by external influences such as the lowed testing our hypothesis at national level. Third, we excluded
198 European Journal of Orthodontics, 2021, Vol. 43, No. 2
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