Need for orthodontic treatment among children in Foča

Methods. The study involved 81 students of two primary schools in the municipality of Foča, aged 11-13 years. The subjects underwent clinical examinations, the dental impressions were taken, study models were made and analyzed, and digital photographs of anterior dentition were taken too. Index of Complexity, Outcome and Need (ICON) was used to assess the need for orthodontic treatment. The number of orthodontists, which would be sufficient to meet the needs of this population of children, was estimated.


Introduction
Assessment of orthodontic treatment need is important for population trends monitoring and health service planning that includes the planning of orthodontic specialists and support staff.Moreover, funding planning is important as well, and is considered as an important addition to available resources management.
In many countries, mainly Scandinavian, malocclusion and craniofacial malformations are considered as national health problems and orthodontic services are financed by the state.In other countries, health insurance plans created limited fees for orthodontic treatment.This situation and the fact that demand for orthodontic treatment cannot always be met due to lack of staff, have created an urgent need for the establishment of health services planning organization [1].
Epidemiological indices are used to assess orthodontic treatment need with normative and clinical point of view.They are used for objective assessment of orthodontic treatment need and their use contributes to decision making on priorities in patients who need the orthodontic treatment.Indices have been in use for many years in countries where dental health care is financed by the state, unlike the countries where dental health care is not funded by the state and indices utilization is limited.Several indices have been used for the assessment of the need for orthodontic treatment: Index of Orthodontic Treatment Need (IOTN), Dental Aesthetic Index (DAI), Index of Complexity, Outcome and Need (ICON) [2].ICON index was developed in order to determine the complexity and results of treatment as well as the orthodontic treatment need.It is an internationally accepted index, easy to use, fast and valid.
Improvement of oral health, dental esthetics, occlusal function and psychosocial aspects of oral health justify the assessment of orthodontic treatment need.Orthodontic anomalies are related to psychosocial diseases [3,4], periodontal diseases [5], poor masticatory function [6] and represent a significant health problem.Assessment of the malocclu-sion severity and the need for treatment is not always easy and is dependent on many factors: age, gender, dentition, knowledge and experience of the orthodontist as well as financial status of patients.Esthetics is one of the most important factors for patients seeking orthodontic treatment.The importance of esthetics is emphasized by the esthetic component of the occlusal indices: IOTN index and ICON index.Patient's observation of own malocclusion is often contrary to the objective character of malocclusion.Orthodontics is a discipline that provides an opportunity for children to have a safe smile and functional occlusion that improves their quality of life.
The aim of the study was to determine the need for orthodontic treatment, as well as a sufficient number of orthodontic specialists.

Methods
This epidemiological study involved 81 students, aged 11-13 years, from the elementary schools in the municipality of Foča, who did not have a history of orthodontic treatment.Dental examinations were performed under daylight, using dental mirror and probe in school health centers.Students' teeth were fingerprinted in order to create study models and anterior dentition photographs were taken.Study casts were analyzed according to the protocol ICON index.ICON index was used to assess the need for orthodontic treatment.It is composed of five components: dental esthetics, space in the upper jaw (crowding and spacing), crossbite, deep/open bite and occlusion according to Angle.The need for orthodontic treatment was defined as having an ICON score of 43 and greater.
The study was approved by the Institutional Ethics Committee (N0: 01-8/61 issued on 24 December 2009) and was conducted in accordance with the Helsinki Declaration of 1975, as revised 1983.The written consent of the Director of the school and parental consent for participation in the study were obtained.
The number of specialists in orthodontics, sufficient for the treatment needs of the population studied, was estimated.Considering that each specialist can provide 1400 hours of treatment per year, the number of orthodontists was calculated as the quotient of the total need for specialized treatment in the hours and the total number of hours of treatment per year.The total demand for specialist treatment in hours was calculated as the product of secondary treatment time per patient per year and the total number of children who need specialist treatment.An average patient treatment per year was 3.5 hours [1].
Statistical analysis was performed in SPSS 11.5.The results were presented as frequencies and significance of the differences between analyzed groups was determined by χ2 test.
Results of the study showed that 56.8% of students need orthodontic treatment.There was no statistical significance in the need for orthodontic treatment between students of different age and gender (Table 1).
According to the results obtained one orthodontist is enough for the treatment of this study population group.However, considering other age groups of patients as well as new generations, only one specialist in the field of orthodontics is not enough for the treatment needs of the whole population of elementary school students.

Discussion
ICON is a relatively new index and its increasing use is imminent.Reliability and validity of the ICON index to assess the need for orthodontic treatment was confirmed by Firestone et al. [12].Đorđević et al. [13] confirmed the validity and reliability of the three occlusal indices need for orthodontic treatment in Serbia: Index of Orthodontic Treatment Need (IOTN), Peer Assessment Rating Index (PAR), and the Index of Complexity, Outcome and Need (ICON).This is the first epidemiological study of malocclusion based on ICON index in Bosnia and Herzegovina.The use of the index for assessment of the need for orthodontic treatment and diagnosis of malocclusion is of a great importance not only for revealing the prevalence of malocclusion but also for planning of preventive measures.Results of the present study showed that 57% of examined students needed orthodontic treatment.A high percentage of orthodontic problems is associated with poor oral hygiene, caries and premature loss of primary teeth.Results of the study conducted by Davidović et al. [14], who used Klein-Palmer DMFT system (D-Decayed, M-Missing, F-filled) to estimate the prevalence of dental caries in the group of children of 12 and 15 years of age in the municipality of Foča, Kalinovik and Čajniče, showed that the average DMF teeth index was 6.17 in all patients, while in the group of 12-year-olds it was 5.64.Džemidžić et al. [11] examined children aged 12 and 14 years using Dental Health Component of IOTN and reported that 53.5% of them needed orthodontic treatment, similarly to our results.They also found no statistically significant difference between the genders.Liepa A et al. [8] found that 35.3% of children in Latvia needed orthodontic treatment, which is less in comparison with the results of our study.They found no statistically significant difference between the genders, which is in concert with the results presented here.Baubinie and collaborators [15] showed that almost half of the children in Lithuania (49.6%), aged 10 and 11 years needed orthodontic treatment, while every third child, aged 14 and 15 years needed this treatment (34.1%), which is less compared with the results of our study.
Most of the studies assessed orthodontic treatment need using IOTN index.Souames et al. [7] found that 21.3% of children in France needed orthodontic treatment, 28.6% were borderline cases; and 50.1% of children did not need orthodontic treatment.There was no a statistically significant difference in relation to gender, which coincides with the results of this study.Similar results were obtained in Italy [9], Northern Ireland [16] and Spain [17].
Based on a sample of 1.050482 subjects aged 7 to 16 years, S Linder-Aronson [1] reported that the overall need for specialized treatment could be met by 488 specialists in orthodontics in Sweden.Rashed Al-Azemi and coworkers [18] assessed the need for orthodontic treatment in Kuwait and reported that 30% of adolescents needed treatment, but 50-60 specialists in orthodontics could meet the needs for treatment of tested population.Also, orthodontic treatment need in Teheran was less as compared to most countries in Europe [19].Research in Albania [20] showed that 41.2% of respondents had the need for orthodontic treatment, which is more than in most European countries, and less in comparison with the results of our study.
In the municipality of Niš, Serbia, Janošević et al. [21] found that orthodontic treatment need was similar to those in most European countries, but less than that found in our study (27.4% of children had great, 41.0% moderate and 31.6%light or no treatment need according to DHC IOTN index).

Conclusion
A high percentage of children in Foča need orthodontic treatment, approximately every second child.One orthodontist is enough to meet the need for orthodontic treatment of the study population group.Considering other age groups of patients as well as new generations, one orthodontist will not be able to meet the needs of all groups of children and adults.
The authors declare no conflicts of interest.Autori izjavljuju da nemaju sukob interesa.

Table 1 .
The need for orthodontic treatment (ICON index) according to gender and age of subjects

Table 2 .
Frequency of orthodontic abnormalities