Is Bad Tooth Position Associated with Bullying among Schoolchildren?ABSTRACT
Objective: To determine the prevalence of bullying and investigate the association between malocclusion and bullying victimization.
Material and Methods: A cross-sectional epidemiological study was conducted with students from the public school network in the city of Campina Grande, Brazil. The sample was probabilistic by cluster, resulting in 381 students of both sexes aged 12-15 years. The victim version of the Olweus Bullying Questionnaire was used to assess bullying victimization, the DAI for occlusion, and a socioeconomic questionnaire was directed to parents. Descriptive statistics were used for categorical variables and the Pearson’s Chi-square test was used to identify associations between victimization and independent variables. Variables with p-value <0.20 were included in the Poisson Regression analysis and the measure of association was demonstrated as PR and confidence intervals (95%).
Results: The prevalence of malocclusion was 67.7%, with more cases of normal malocclusion/or minor problems (32.3%). Maxillary overjet > 4 mm was the most frequent DAI component, followed by dental crowding and half-cusp molar relationship. The prevalence of bullying victimization was 41.2%, and of these, 42.9% were targets of dental bullying. Associations were identified between bullying victimization and self-perception of poorly positioned teeth (p<0.00l) and dental bullying (p<0.00l). Bullying victimization was higher among adolescents who used public services and among those who were victims of dental bullying.
Conclusion: High malocclusion and bullying rates were observed in the school population, both general and dental. High perception of poorly positioned teeth and use of public health services are associated with bullying victimization.
Keywords:
Bullying; Malocclusion; School Violence
Introduction
Bullying is a form of aggressive, violent and repetitive behavior, especially in the school context[1]. It consists of constant and intentional acts of oppression, humiliation, discrimination, cruelty and domination, thus creating a context of power imbalance. Its forms can include direct physical or verbal abuse, or indirect bullying that occurs through social exclusion and the spread of rumors or gossip, in addition to cyberbullying[1, 2].
Its prevalence can vary due to cultural, social, and economic differences between different populations, reaching values between 5.9%[3] and 56.5%[4], with this type of aggression being associated with the development of health problems, negative impacts on emotional well-being, social relationships, academic performance, and self-esteem, and can lead to stress, anxiety, depression and, in extreme cases, suicide[1, 5, 6].
Facial and body appearance are elements commonly cited in the practice of bullying, among which oral disorders end up by exposing the individual, especially school-age children, to embarrassing situations and verbal bullying[7]. Regarding dental conditions, the association between malocclusion and peer victimization has been related to consequences on quality of life[8, 9]. Characteristics such as severe malocclusion, major maxillary misalignment[7], extreme maxillary overjet, extreme deep overbite[10,] and space between anterior teeth, prominent teeth or missing teeth[6, 11] have already been associated with bullying victimization and negative impacts on quality of life[9].
Although previous studies have already brought this approach between malocclusion aspects and bullying victimization[6, 7, 10, 11], malocclusion should be further investigated because there are still gaps regarding the relationship between the social and family profile of victimized students, the bullying typology, and its influence on dental bullying.
Oral health and dentofacial aesthetics are part of the individual’s general perception of body image and self-esteem[3]. Aesthetic standards are significant in society, being observed both in childhood and adolescence, periods in which they are more intense, considering the need for insertion and acceptance in a social group[12]. Thus, in the adolescent population, there is a certain significant judgment of physical aspects, in which occlusal conditions can trigger bullying situations[4], which require information that can support the study and greater understanding of the impact of bullying victimization and its relationship with occlusal conditions.
The hypothesis adopted in this research is that adolescents with malocclusion are victims of dental bullying when compared to individuals who do not have poor dental positioning. Therefore, the present study aimed to determine the prevalence of bullying and investigate the association between malocclusion and bullying victimization.
Material and Methods
This study was conducted following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines[13].
Study Design and Location
A cross-sectional epidemiological study was conducted in the city of Campina Grande, Paraíba, located in Northeastern Brazil. The municipality has a Human Development Index (HDI) of 0.72 and a Gini Index of 0.58, a population of 419,000 inhabitants, a school enrollment rate of 6 to 14 year-olds of 97.6%, and a total of 288 elementary schools[14].
Population and Sample Size Calculation
A total of 53,114 students were enrolled in all elementary schools. Of these, students of both sexes aged 12-15 years who were regularly enrolled in the elementary school network were considered eligible. The sample was calculated considering a prevalence of 48.2%[15] and a confidence level of 5%, resulting in a final sample of 381 participants. Students who had difficulty understanding the questions on data collection instruments, even after assistance from the researchers, were not included in the sample.
Study Variables
A pre-structured questionnaire was prepared to characterize the individual, socioeconomic and family context of students, containing the following variables: sex (male, female), age group (12-13 years, 14-15 years), self-reported skin color (white, non-white), maternal schooling (≤ 8 years of study, > 8 years of study), monthly income (up to 1 Brazilian minimum wage, more than 1 Brazilian minimum wage), social benefits (yes, no) and type of housing (own, rented, loaned).
The Olweus Bullying Questionnaire (OBQ) – victim version[16] was used to characterize bullying victimization, considering that students who marked the option “several times a week” in at least one of the 23 questions in the questionnaire were classified as victims[17]. According to responses recorded, students were subdivided into three groups, which reflect the types of occurrence of the bullying phenomenon: G1) Direct physical bullying (9 OBQ items - 1, 2, 4, 5, 6, 14, 15, 16, 22), G2) Direct verbal bullying (8 OBQ items - 3, 7, 8, 9, 10, 11, 12, 13) and G3) Indirect bullying (6 OBQ items - 17, 18, 19, 20, 21, 23)[18]. Questions about dental bullying (yes, no) and the reason for its occurrence (subjective question) were also included.
The Dental Aesthetic Index (DAI) is an index of the need for orthodontic treatment, which evaluates the occlusion characteristics. Malocclusion was dichotomized into normal/or minor problems (DAI ≤ 25) and present malocclusion (DAI > 25). Regarding DAI components, the number of missing teeth was dichotomized into “none” and “one or more”, the median diastema into “no” and “yes”, the anterior misalignment (upper and lower) into “< 2 mm” and “≥ 2 mm”, overjet (maxillary and mandibular) into “< 4 mm” and “≥ 4 mm” and anterior open bite into “< 2 mm” and “≥ 2 mm”[19].
Training and Pilot Study
The team that performed the exams was composed of two researchers and four undergraduate students. A pilot study was previously conducted with the aim of testing the proposed methodology and calibrating the researchers, and participants included in this stage were not part of the final sample. In order to calculate inter-and intra-examiner agreements, researchers were trained in two stages: the first, theoretical, consisted of presenting the clinical criteria for diagnosing malocclusion, and the second, practical, consisted of examining 10 students, who were re-evaluated after one week. The inter- and intra-examiner Kappa values were 0.96 and 0.97, respectively.
Data Collection
Data collection occurred in different stages, with pre-structured questionnaires sent to the student’s parents and/or caregivers, while the bullying questionnaire was administered to students themselves within the school facilities to those who returned the socioeconomic questionnaire duly completed. Clinical examinations were individually performed in well-lit spaces in school facilities.
Statistical Analysis
Data were analyzed using the IBM SPSS software, version 22.0 for Windows (IBM Corp., Armonk, NY, USA). Considering bullying victimization as the dependent variable and the other variables (sociodemographic and malocclusion) as independent variables.
The descriptive statistical analysis consisted of calculating absolute and relative frequencies for categorical variables. Pearson’s chi-square test was used to identify possible associations between the prevalence of bullying victimization and independent variables. Variables with p-value <0.20 were included in the Poisson Regression analysis. The measure of association was demonstrated as PR (Prevalence Ratio) and confidence intervals (95%). The significance level adopted was 5%.
Ethical Clearance
The study was approved by the Research Ethics Committee of the State University of Paraíba (Opinion no. 4.974.026). Parents and guardians were asked to sign the Informed Consent Form, while students were presented with the Informed Assent Form for their consent.
Results
Regarding the sociodemographic profile of students, the majority were male (50.7%), aged 12-13 years (69.3%). Most students were non-white (76.4%) and lived in non-nuclear family arrangements (59.5%). Regarding parents/guardians, 58.2% of mothers had more than eight years of schooling, monthly family income of up to one Brazilian minimum wage (62.2%), a little over half (53.2%) received social benefits, and 57.7% lived in their own home (Table 1).
Regarding previous dental history, 76.6% of students had already visited the dentist at some point in their lives, with the last visit having occurred more than 6 months ago for 75.0% of them. The most frequently reported place of care was the public service (51.7%). Regarding dental malposition, 16.8% of students reported the presence of this condition (Table 1).
Maxillary overjet equal to or greater than 4 mm was the most frequent DAI component among adolescents (67.5%), followed by dental crowding (64.8%) and half-cusp molar relationship (57.0%). Spacing in the anterior segment was identified in 40.7% of adolescents, while upper anterior misalignment equal to or greater than 2 mm was observed in 24.1%, and median diastema was present in 22.8% of the sample. The prevalence of malocclusion was 67.7%, with the majority of participants presenting normal malocclusion/or minor problems (32.3%) (Table 2).
Distribution of students according to DAI components, presence and severity of malocclusion.
The prevalence of bullying victimization was 41.2%. Among these cases, in the “Physical bullying” category, situations involving hair pulling and scratching stood out (6.3%). Regarding “Verbal bullying”, name-calling was prevalent, representing 16.8% of cases. As for “Indirect bullying”, actions such as “They said mean things about me or my family” and “They made or tried to make others dislike me”, each with 10.8%, were commonly reported (Table 3).
Among students who were victims of bullying, it was observed that 42.9% (n=67) were targets of harassment due to dental issues. In the bivariate analysis, statistically significant associations were identified between bullying victimization and self-perception of poorly positioned teeth (p<0.001) and dental bullying (p<0.001) (Table 4).
A multiple regression model was used to assess associations between variables (Table 5). In the adjusted analysis, association was found between bullying victimization and type of dental health service and dental bullying. Bullying victimization was 37.8% higher among adolescents who used the public service (PR=1.378; CI95%=1.046-1.817; p=0.023) and 97.8% higher among those who suffered bullying due to dental problems (PR=1.978; CI95%=1.375-2.845; p<0.001).
Discussion
In this study, the hypothesis of an association between bullying victimization and self-perception of poorly positioned teeth was confirmed. The malocclusion assessment resulted in high prevalence, with a predominance of cases of normal malocclusion and/or minor problems. The literature presents findings for the prevalence of this condition varying from 78.7%[20] to 32.6%[21] and reports of a higher number of children with severe cases of malocclusion[10]. Furthermore, in the present study, maxillary overjet ≥ 4 mm was the most frequent component, followed by dental crowding and half-cusp molar relationship. Occlusal characteristics will be diverse depending on the population under study, as well as genetic issues and previous orthodontic treatments, which may interfere with the most prevalent occlusal conditions.
In a study conducted in Mongolia, the most common type of malocclusion was dental crowding, followed by anterior and posterior crossbite[21], while in Saudi Arabia, the main characteristics were anterior crowding or greater spacing in the maxilla and diastema ≥ 2 mm[22] and in Brazil, diastema was found to be the most common condition, followed by maxillary overjet and anterior crowding[4].
The prevalence of bullying in school-age children varies, depending on several factors such as gender, age and cultural differences of victims and aggressors. The results of this research show the prevalence of bullying victimization of 41.2%, with similar values being found, 47%[6] and 48.2%[15], as well as significantly higher percentages, 78%[23] and 78.7%[24]. The study design, the time period used to determine the bullying frequency, and the different criteria used to differentiate between victims and non-victims are factors that may interfere with identifying the prevalence of this type of behavior[25].
With regard to dental bullying, 42.9% of schoolchildren were targets of some type of harassment due to dental characteristics, a value that can be considered high when compared to other studies whose findings were 14.3%[23] and 15.5%[5]. However, dental aspects have already been recorded as resources used in the dissemination of nicknames, harassment, and teasing among school-age children[25]. In addition, this type of bullying has been associated with self-esteem, well-being, and learning problems[26], and may lead to poor academic performance[5, 27].
Significant associations were identified between bullying victimization and self-perception of poorly positioned teeth and dental bullying, similar to results reported in another study[23]. Oral health and self-perception of the need for treatment are strongly associated with acceptance in groups and, consequently, with the occurrence of bullying episodes. In addition, aesthetic concerns and self-perception of the need for treatment end up being the main reasons for seeking orthodontic treatment[11].
The context of low family education and economic disadvantage have a direct and indirect impact on the occurrence of general bullying episodes and dental bullying[23]. In this study, the association between bullying victimization and the type of dental health service was observed so that students who use public services were more likely to be victims of bullying. This association can be understood due to the high costs of orthodontic services offered by professionals in the private sector, in addition to the difficult access by the most economically vulnerable classes, since public health services in Brazil do not provide orthodontic treatment to the population, especially when it is considered elective.
The relationship between malocclusion and bullying victimization was not significant in this study, as well as in other studies[10, 23]. This finding possibly reflects the greater prevalence of cases of normal occlusion/or minor problems that do not end up causing major aesthetic changes that can be used for several types of violence, unlike severe cases of malocclusion that may be associated with a greater chance of bullying exposure[7].
Orthodontic intervention in mixed dentition allows the prevention of malocclusions, contributing to the harmonious growth of the basal bones and normal occlusion development, reducing the chances of serious disorders in the permanent dentition[20]. Children with normal dental aesthetics are considered more beautiful, intelligent and friendly, while those with dental alterations are more prone to teasing and harassment[28]. Thus, the importance of orthodontics in preventing bullying is clear, and public investment in the access to orthodontic services is necessary since these are expensive in the private sector.
Although it is not possible to affirm that treating malocclusion will consolidate the end of bullying and improve self-esteem and social interactions[29], the search for and expectations of orthodontic treatment are related to emotional well-being[30, 31] and the feeling of no longer being bullied, contributing to improving appearance and self-confidence[11]. Thus, the dentist plays a prominent role in the diagnosis, prevention and treatment of occlusal problems, not only as a way to prevent bullying, but also as a way to improve the quality of life of children and adolescents.
Parents of schoolchildren who are bullying victims should be counseled and informed about the severity and possible consequences of this form of violence. They should be encouraged to maintain contact with the school and talk to teachers and principals about the situation, in addition to requesting measures to be taken, whether educational, acting to combat and raise awareness of school violence, or administrative, providing support for victims and identifying students involved in the bullying process with their families[25].
The cross-sectional design and the inclusion of students only from municipal public schools are among the study limitations. However, there are potentialities, such as the sample calculation, using trained examiners and applying valid instruments, such as the DAI and the Olweus Bullying Questionnaire (QBO). Additionally, this study contains important data for understanding this topic, in addition to presenting information that can be used by school administrators to interpret bullying scenarios in the population under study and also for developing public programs and actions for prevention and education against school violence.
Regarding the findings of this study, further investigations should be developed with different methodologies and qualitative designs, and considering the high bullying rates and the perception of malocclusion among schoolchildren, there is a need for studies including new populations and variables such as satisfaction with quality of life. Finally, considering the long-term repercussions, it is important to develop public policies, including actions to prevent bullying in the school environment and to implement free public services aimed at treating children and adolescents with severe and very severe occlusal problems, thus helping to reduce the occurrence of dental bullying.
Conclusion
The prevalence of bullying victimization and dental bullying was high among students. Although no association was observed between the existence of bullying and the presence of malocclusion, it was related to the self-perception of poorly positioned teeth and the use of public dental services.
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Financial Support
This research received financial support from Research Support Foundation of the State of Paraíba (Notice No. 010/2021/ FAPESQ/PB -MCTIC/CNPq - Programa de Infraestrutura Para Jovens Pesquisadores / Programa Primeiros Projetos – PPP – Outorga 3188/2021), the Brazilian National Council for Scientific and Technological Development — CNPq (Grant No. 306774/2022-4) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
Acknowledgments
The authors would like to thank the PIBIC/CNPq/UEPB for the scientific initiation scholarship
References
-
1 Olweus E. School bullying: Development and some important challenges. Annu Rev Clin Psychol 2013; 9:751-780. https://doi.org/10.1146/annurev-clinpsy-050212-185516
» https://doi.org/10.1146/annurev-clinpsy-050212-185516 -
2 Olweus D. Bullying at school: basic facts and effects of a school based intervention program. J Child Psychol Psychiatry 1994; 35(7): 1171-1190. https://doi.org/10.1111/j.1469-7610.1994.tb01229.x
» https://doi.org/10.1111/j.1469-7610.1994.tb01229.x -
3 Al-Bitar ZB, Sonbol HN, Al-Omari IK, Badran SA, Naini FB, Al-Omiri MK, et al. Self-harm, dentofacial features, and bullying. Am J Orthod Dentofacial Orthop 2022; 162(1):80-92. https://doi.org/10.1016/j.ajodo.2021.02.025
» https://doi.org/10.1016/j.ajodo.2021.02.025 -
4 Ramos ITM, Nabarrette M, Vedovello-Filho M, de Menezes CC, de C Meneghim M, Vedovello SAS. Correlation between malocclusion and history of bullying in vulnerable adolescents. Angle Orthod 2022; 92(5):677-682. https://doi.org/10.2319/100721-749.1
» https://doi.org/10.2319/100721-749.1 -
5 Ortiz FR, Ardenghi TM, Paiva SM, Maroneze MC, Pordeus IA. Impact of oral conditions and subjective factors on academic performance. Pesqui Bras Odontopediatria Clin Integr 2021; 21:e0233. https://doi.org/https://doi.org/10.1590/pboci.2021.083
» https://doi.org/10.1590/pboci.2021.083 -
6 Al-Bitar ZB, Al-Omari IK, Sonbol HN, Al-Ahmad HT, Cunningham SJ. Bullying among Jordanian schoolchildren, its effects on school performance, and the contribution of general physical and dentofacial features. Am J Orthod Dentofacial Orthop 2013; 144(6):872-878. https://doi.org/10.1016/j.ajodo.2013.08.016
» https://doi.org/10.1016/j.ajodo.2013.08.016 -
7 Duarte-Rodrigues L, Ramos-Jorge ML, Alves-Duarte AC, Fonseca-Silva T, Flores-Mir C, Marques LS. Oral disorders associated with the experience of verbal bullying among Brazilian school-aged children: A case-control study. J Am Dent Assoc 2020; 151(6):399-406. https://doi.org/10.1016/j.adaj.2020.02.001
» https://doi.org/10.1016/j.adaj.2020.02.001 -
8 Broutin A, Blanchet I, Canceill T, Noirrit-Esclassan E. Association between dentofacial features and bullying from childhood to adulthood: A Systematic Review. Children 2023; 10(6):934. https://doi.org/10.3390/children10060934
» https://doi.org/10.3390/children10060934 -
9 Al-Omari IK, Al-Bitar ZB, Sonbol HN, Al-Ahmad HT, Cunningham SJ, Al-Omiri M. Impact of bullying due to dentofacial features on oral health-related quality of life. Am J Orthod Dentofacial Orthop 2014; 146(6):734-739. https://doi.org/10.1016/j.ajodo.2014.08.011
» https://doi.org/10.1016/j.ajodo.2014.08.011 -
10 Tristão SKPC, Ammari MM, Tavares MC, Pomarico L, Pintor AVB, Souza IPR. Relationship between malocclusion, bullying, and quality of life in students from low social development area: A cross-sectional study. Pesqui Bras Odontopediatria Clin Integr 2023; 23:e220051. https://doi.org/10.1590/pboci.2023.042
» https://doi.org/10.1590/pboci.2023.042 -
11 Bauss O, Vassis S. Prevalence of bullying in orthodontic patients and its impact on the desire for orthodontic therapy, treatment motivation, and expectations of treatment. J Orofac Orthop 2023; 84(2):69-78. https://doi.org/10.1007/s00056-021-00343-w
» https://doi.org/10.1007/s00056-021-00343-w -
12 Scheffel DLS, Jeremias F, Fragelli CMB, Dos Santos-Pinto LAM, Hebling J, de Oliveira OB Jr. Esthetic dental anomalies as motive for bullying in schoolchildren. Eur J Dent 2014; 8(1):124-128. https://doi.org/10.4103/1305-7456.126266
» https://doi.org/10.4103/1305-7456.126266 -
13 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Ann Intern Med 2007; 147(8):573-577. https://doi.org/10.7326/0003-4819-147-8-200710160-00010
» https://doi.org/10.7326/0003-4819-147-8-200710160-00010 -
14 Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades e Estados. Disponível em: https://cidades.ibge.gov.br/brasil/pb/campina-grande/panorama [Accessed on April 19, 2024].[In Portuguese].
» https://cidades.ibge.gov.br/brasil/pb/campina-grande/panorama -
15 Gatto RCJ, Garbin AJI, Corrente JE, Garbin CAS. The relationship between oral health-related quality of life, the need for orthodontic treatment and bullying, among Brazilian teenagers. Dental Press J Orthod. 2019; 24(2):73-80. https://doi.org/10.1590/2177-6709.24.2.073-080.oar
» https://doi.org/10.1590/2177-6709.24.2.073-080.oar - 16 Olweus D. The Revised Olweus Bully/Victim Questionnaire. Bergen: University of Bergen, 1996.
-
17 Alonso LS, Serra-Negra JM, Abreu LG, Martins IM, Tourino LFPG, Vale MP. Association between possible awake bruxism and bullying among 8- to 11-year-old children/adolescents. Int J Paediatr Dent 2022; 32(1):41-48. https://doi.org/10.1111/ipd.12789
» https://doi.org/10.1111/ipd.12789 -
18 Malta DC, do Prado RR, Dias AJ, Mello FC, Silva MA, da Costa MR, et al. Bullying and associated factors among Brazilian adolescents: analysis of the National Adolescent School-based Health Survey (PeNSE 2012). Rev Bras Epidemiol 2014; 17(Suppl 1):131-145. https://doi.org/10.1590/1809-4503201400050011
» https://doi.org/10.1590/1809-4503201400050011 -
19 Bauman JM, Souza JGS, Bauman CD, Flório FM. Socio-demographic aspects related to severity of malocclusion among 12-year-old Brazilian children. Cien Saude Coletiva 2018; 23(3):723-732. https://doi.org/10.1590/1413-81232018233.07702016
» https://doi.org/10.1590/1413-81232018233.07702016 -
20 Guimarães SPA, Jorge KO, Fontes MJF, Ramos-Jorge ML, Araújo CTP, Ferreira EF, et al. Impact of malocclusion on oral health-related quality of life among schoolchildren. Braz Oral Res 2018; 32:e95. https://doi.org/10.1590/1807-3107bor-2018.vol32.0095
» https://doi.org/10.1590/1807-3107bor-2018.vol32.0095 -
21 Badrakhkhuu N, Matsuyama Y, Araki MY, Yasuda YU, Ogawa T, Tumurkhuu T, et al. Association between malocclusion and academic performance among Mongolian adolescents. Front Dent Med 2021; 1:623768. https://doi.org/10.3389/fdmed.2020.623768
» https://doi.org/10.3389/fdmed.2020.623768 -
22 Qahtani AA, Ingle NA, Assery MK, AIshamrani SS. Prevalence of malocclusion among female schoolchildren aged 12-15 years: Saudi Arabia. J Int Oral Health 2019; 11(2):86-91. https://doi.org/10.4103/jioh.jioh_285_18
» https://doi.org/10.4103/jioh.jioh_285_18 -
23 Bolsson GB, Knorst JK, Menegazzo GR, Ardenghi TM. Pathways between oral health conditions and bullying on adolescents: A 10-year cohort study. Oral Dis 2024; 30(3):1716-1723. https://doi.org/10.1111/odi.14581
» https://doi.org/10.1111/odi.14581 -
24 Raji IA, Bashir SS, Stephen AA, Umeokonkwo CD, Sufiyan MB, Abubakar AU, et al. Predictors of bullying perpetration among adolescents attending secondary schools in Sokoto Metropolis, Nigeria, 2019. Pan Afr Med J 2021; 39:49. https://doi.org/10.11604/pamj.2021.39.49.22690
» https://doi.org/10.11604/pamj.2021.39.49.22690 -
25 Seehra J, Newton JT, DiBiase AT. Bullying in schoolchildren - its relationship to dental appearance and psychosocial implications: An update for GDPs. Br Dent J 2011; 210(9):411-415. https://doi.org/10.1038/sj.bdj.2011.339
» https://doi.org/10.1038/sj.bdj.2011.339 -
26 Figueirôa T, Raposo J, Soares L, Oliveira L, Menezes V, Colares V, et al. Association between bullying and both awake and sleep bruxism in school adolescents: A cross-sectional study. Pesqui Bras Odontopediatria Clin Integr 2024; 24:e230157. https://doi.org/10.1590/pboci.2024.081
» https://doi.org/10.1590/pboci.2024.081 -
27 Moraes RB, Knorst JK, Brondani B, Marques BB, Sousa MR, Henriqson D, et al. Relationship between gingival bleeding and associated factors with reports of verbal bullying in adolescents. J Periodontol 2021; 92(2):225-233. https://doi.org/10.1002/jper.19-0745
» https://doi.org/10.1002/jper.19-0745 -
28 Shaw WC. The influence of children’s dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981; 79(4):399-415. https://doi.org/10.1016/0002-9416(81)90382-1
» https://doi.org/10.1016/0002-9416(81)90382-1 -
29 Tristão SKPC, Magno MB, Pintor AVB, Christovam IFO, Ferreira DMTP, Maia LC, et al. Is there a relationship between malocclusion and bullying? A systematic review. Prog Orthod 2020; 21(1):26. https://doi.org/10.1186/s40510-020-00323-7
» https://doi.org/10.1186/s40510-020-00323-7 -
30 Muniz Júnior AB, Carneiro DPA, de Menezes CC, Degan VV, Vedovello SAS, Vedovello Filho M. A multivariate analysis of the psychosocial impact of malocclusion and self-esteem in adolescents. Pesqui Bras Odontopediatria Clin Integr 2022; 22:e200178. https://doi.org/10.1590/pboci.2022.081
» https://doi.org/10.1590/pboci.2022.081 -
31 Mendonza GNB, Zambrano TBS, Wied AL. Dental anxiety and self-esteem in pediatric patients undergoing maxillofacial orthopedics. Pesqui Bras Odontopediatria Clin Integr 2025; 25:e240022. https://doi.org/10.1590/pboci.2025.050
» https://doi.org/10.1590/pboci.2025.050
Edited by
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Academic Editor:
Wilton Wilney Nascimento Padilha
