Assessment of early orthodontic treatment needs in children aged 4–6 using the baby-risk of malocclusion assessment (Baby-ROMA) index

1. Introduction

Malocclusion is a common condition that may have significant impacts on oral health, aesthetics and oral health-related quality of life [1]. In more severe cases, it can result in functional impairments [2]. Early diagnosis and interceptive orthodontic treatments can halt the progress of malocclusion and facilitate optimal occlusal development. Such treatments are effective and desirable since they are less expensive, less invasive and have a relatively short duration [3].

Determining the ideal timing for orthodontic therapy and accurately assessing orthodontic treatment need are important in order to achieve effective treatment outcomes in the shortest possible time and at the lowest cost [4]. Hence, several orthodontic treatment need indexes are used to assess and categorize the severity of malocclusion, guide orthodontic treatment planning and facilitate optimal patient care. These indexes are also needed for countrywide epidemiologic studies to help build appropriate health policies [5].

At present, various indexes, including the Index of Orthodontic Treatment Need (IOTN) [6], the Dental Aesthetic Index (DAI) [7], the Risk of Malocclusion Assessment Index (ROMA index) and the Occlusal Index (OI) [8] are used to determine the malocclusion and orthodontic treatment need. With the exception of the OI, these indexes are targeted on mixed or permanent dentition. Although the OI is based on primary dentition, it overlooks both skeletal and functional problems and it also presents challenges in terms of data collection [9]. Studies have shown that malocclusion in primary dentition can predict the orthodontic treatment need in mixed and/or permanent dentition [10, 11]. Therefore, children with an apparent malocclusion in primary dentition should be frequently monitored with a simple and reliable method. The Baby-ROMA Index was developed as an adaptation of the original ROMA index, which was introduced by Russo et al. [12] in 1998 to evaluate skeletal and functional aspects of malocclusion in children with mixed or permanent dentition. The ROMA index was subsequently validated and applied to large cohorts of Italian children aged 9–13 years [12]. Recognizing the need for an index tailored to the primary dentition (when numerous skeletal, dental, and functional factors may adversely affect occlusion and craniofacial development if left unmonitored) the authors later modified the original index to create the Baby-ROMA. The Baby-ROMA index is intended to support early diagnosis of malocclusion risk and guide timely preventive or interceptive orthodontic interventions during the earliest stages of development. It can also indicate preventive or interceptive orthodontic treatment need by using a scored scale [4].

In the literature, the prevalence of malocclusion varies from country to country. Grippaudo et al. [13] reported that the prevalence of malocclusion is 71% among the Italian children aged between 2–7 years. Another study in which Baby-ROMA index was used showed that 31.6% of Iranian children aged 4–6 years had one type of malocclusion [14]. Despite the presence of studies in the literature investigating the prevalence of malocclusion in pre-schoolers using Baby-ROMA index, studies about the association between factors such as dental caries, molar-canine relationship, and presence of primate spaces with orthodontic treatment needs are limited. Therefore, the present study aimed:

• To assess the prevalence of malocclusion and orthodontic treatment need using Baby-ROMA index in a group of Turkish children aged 4–6 years.

• To assess the association between the Baby-ROMA index scores and demographic and dental characteristics in a group of Turkish children aged 4–6 years.

The null hypothesis was that there are no statistically significant differences in the dental characteristics of children with different Baby-ROMA index scores.

2. Materials and methods

3. Results

A total of 203 children aged between 4–6 years participated in the study. The demographic variables and dental characteristics of study population are presented in Table 2. The mean age was 4.6 and 55.2% of the participants were female. The most prevalent molar and canine relationship on both sides was flush terminal plane (63.5% on the right and 68% on the left) and Class I relation (69% on the right and 71.9% on the left), respectively.

The intra-examiner correlation was assessed using replicate examinations of 30 subjects at a 20-day interval. The kappa value for the Baby-ROMA index was 0.782, indicating a high level of reproducibility. In addition, the reliability for other clinical variables, including dmft scores, molar relationship and canine relationship was also tested, yielding a kappa value of 0.798, confirming consistent intra-examiner agreement across all assessments. The results showed that 80.8% of the participants exhibited conditions associated with an increased risk of developing malocclusion. 50.3% had score 2, 3.4% had score 3 and 27.1% had score 4 (Fig. 1). No participant had a Baby-ROMA index score of 5. On the basis of these results, it is important to emphasize that not all the participants within the 80.8% prevalence required immediate intervention. The Baby-ROMA index stratifies malocclusion severity and recommends treatment only for specific cases, depending on the risk level.

Fig. 1.Prevalence in percentage of the risk score in study population.

The most common risk factors for malocclusion were parafunctions such as bruxism or jaw clenching (2v) (27.6%), poor oral hygiene (2t) (27.1%), caries and early loss of deciduous teeth (4l) (25.1%) and oral breathing/OSAS (2x) (19.7%). The prevalence of inheritance of malocclusion and overbite greater than 5 mm (2e and 2r) were 7.9%. Also, class III malocclusion with negative overjet (4k) and cross-bite up to 2 mm (2n) were found in 6.9% and 6.4% of children, respectively. The remaining scores in the index had a prevalence of less than 5% (Fig. 2).

Fig. 2.Prevalence of the Baby-ROMA index values in the study population.

Percentages of parent-perceived orthodontic treatment need are presented in Table 3. Among the parents of children who have malocclusion risk, a substantial proportion (76.2%) reported that their children did not require orthodontic treatment.

Table 4 illustrates the association between Baby-ROMA index scores and gender and dental characteristics, as well as parent-perceived treatment need. The results indicate that there were statistically significant differences in the index scores based on age groups (p = 0.004), right molar relationship (p = 0.019), and dmft (p < 0.001).

According to the multinomial logistic regression analysis (Table 5), age and dmft score were identified as statistically significant predictors in differentiating between the reference group (index scores 2) and higher risk groups (score 3 and score 4). Specifically, for children with an index score of 4, both increasing age (Odds Ratio (OR) = 2.17, 95% Confidence Interval (CI) = 1.30–3.65, p = 0.003) and higher dmft scores (OR = 1.12, 95% CI = 1.12–1.32, p < 0.001) were significantly associated with greater risk. No statistically significant predictors were found for index score 3.

4. Discussion

In the present study, the Baby-ROMA index showed that there is a high prevalence of malocclusion risk and high need for orthodontic treatment within the Turkish paediatric population. Moreover, dmft and age seemed to have an impact on the Baby-ROMA treatment need scores. Therefore, the null hypothesis was rejected.

To the best of the authors’ knowledge, this is the first study to use Baby-ROMA index to explore the prevalence of potential risk factors for orthodontic disorders in children within the Turkish population. In the study, the most common risk factor for malocclusion was parafunctions (bruxism, jaw clenching) (2v) (27.6%). A systematic review reported that prevalence of bruxism varies from 5.9% to 49.6% among children aged between 0 and 12 years [16]. In another study, bruxism was identified in 20.7% of children between 0 and 6 years old [17]. Discrepancies in the prevalence of bruxism may stem from differences in participants’ socioeconomic statuses, cultural backgrounds and the diagnostic criteria for identifying bruxism. In the present study, the predominant risk factors after bruxism were identified as poor oral hygiene (2t) (27.1%) as well as caries and early loss of deciduous teeth (4l) (25.1%). In the literature, studies utilizing the Baby-ROMA index have demonstrated variations in the prevalence of caries and early loss of deciduous teeth. For instance, in Italian children, the prevalence of caries and early loss of deciduous teeth was observed to be 14.5% [4], whereas in a study conducted by Singh et al. [18] among Indian children, this rate was found to be 37.7%, and in a study by Jahanimoghadam et al. [14] among Iranian children, it was observed to be 7.5%. The mean dmft score in our sample was 8.6, which is considerably higher than the national averages reported for Turkish children aged 5 years, where mean scores typically range from 3.6 to 3.7 [19]. This suggests a substantial caries burden in our study population. Given that the children included in this study had already sought dental care at a paediatric dental clinic, it is plausible that the prevalence of poor oral hygiene, along with the associated rates of dental caries and early loss of primary teeth, may have been relatively elevated. Additionally, regional factors such as dietary habits, exposure to fluoride, and oral hygiene practices may have influenced the prevalence of caries. Premature loss of deciduous teeth can lead to space loss and crowding in mixed and permanent dentition and, if left untreated, these may require complex orthodontic treatments [20]. Moreover, proximal cavities in primary molars may also have an impact on the space loss in dental arches [21]. Therefore, it is crucial to prevent early primary molar loss and its associated consequences on arch length. Several strategies can be employed for this purpose, such as maintaining good oral hygiene, restoring interproximal cavities or utilizing space maintainers [22].

In the current study, the prevalence of oral breathing/OSAS (2x) was determined to be 19.7%, consistent with the 22.8% reported in Grippaudo et al.’s [13] study. Mouth breathing is an important issue and has been found to be strongly associated with an increased or reduced overjet, anterior or posterior crossbite, open bite and displacement of contact points [23]. If left untreated, children with chronic mouth breathing may develop several morphological disorders, including maxillary constriction [24]. Therefore, early detection and management of mouth breathing play a vital role in ensuring the healthy development of dentofacial structures and functions.

The prevalence of inherited malocclusion (2e) and overbite greater than 5 mm (2r) was 7.9%. Using the Baby-Roma index, Jahanimoghadam et al. [14] reported an inherited malocclusion prevalence of 8%, aligning with our findings, while Grippaudo C. et al. [4] found a prevalence of 0%. Regarding increased overbite, both studies reported lower prevalence rates of less than 5%, specifically 1.9% and 3%, respectively. These differences may be attributed to variations in the participants’ ethnic and cultural backgrounds.

Class III malocclusion with negative overjet (4k) and crossbite up to 2 mm (4n) were observed in 6.9% and 6.4% of the children, respectively. While, Italian children exhibited a higher prevalence, with 24.5% for crossbite up to 2 mm and 12% for class III malocclusion with negative overjet [4], Jahanimoghadam et al. [14] reported a prevalence of 1.7% for both conditions. This difference may be attributed to the participants in Grippaudo et al.’s [4] study, who were patients referred by paediatricians for orthodontic assessment.

In the present study, none of the participants had a Baby-ROMA score of 5. This may be attributed to the rarity of the conditions classified under index score 5, such as maxillofacial trauma with condylar fracture (5a), congenital syndromes or malformations (5b), and outcomes of trauma or surgery involving the craniofacial region (5j). These conditions are relatively uncommon in the general paediatric population. For instance, Grippaudo et al. [13] reported that index score 5 was poorly represented, with only 0.3% of 1405 children falling into this category.

It is crucial to interpret certain occlusal features observed in the primary dentition with caution, as some may reflect normal developmental stages rather than true malocclusion. For instance, the flush terminal plane was the most frequently observed molar relationship in our study, consistent with previous findings among Turkish preschool children [25]. Although this occlusal pattern is commonly classified within malocclusion indices, it often represents a transitional stage. Longitudinal studies have shown that more than half of children with a flush terminal plane in the primary dentition develop a Class I molar relationship in the permanent dentition, while the remainder may shift toward Class II [26]. Similarly, minor spacing or crowding and slight anterior open bite are also frequently encountered in early childhood and may resolve spontaneously with growth and dental eruption [27, 28]. Therefore, while the Baby-ROMA index appropriately flags these conditions as potential risk factors for future malocclusion, clinicians must exercise judgment in interpreting their clinical significance. Overemphasis on transient conditions can lead to unnecessary concern or overtreatment. A nuanced understanding of normal occlusal development is essential to distinguish between cases requiring early intervention and those that merely warrant observation over time.

No statistically significant relationship was found between the children’s index scores and the parents’ perception of the need for orthodontic treatment. This discrepancy may be attributed to several factors, including limited awareness of early orthodontic indicators, varying levels of parental education and socioeconomic status. In many cases, parents may not recognize subtle occlusal deviations as problematic or may prioritize treatment only in the presence of aesthetic concerns. To bridge this gap, strategies such as early orthodontic consultations, community-based educational campaigns, and the distribution of accessible printed or digital informational materials could be implemented to improve parental understanding and promote timely intervention when necessary [29, 30]. These resources should include caries prevention strategies, such as oral hygiene instruction and topical fluoride use, and provide guidance on habit-breaking appliances and space maintainers.

The findings of the multinomial logistic regression analysis highlight the critical roles of age (OR = 2.17; 95% CI = 1.29–3.64) and the dmft (OR = 1.12; 95% CI = 1.12–1.32) score as key determinants in differentiating between groups with lower and higher index scores. The OR of 2.17 for age suggests that with each additional year, the odds of being in a higher-risk group (score 4) increase by more than two-fold. This trend may reflect the cumulative impact of untreated oral health issues and prolonged exposure to risk factors such as parafunctional habits, poor oral hygiene or environmental influences. Similarly, the dmft score showed a significant association with higher Baby-ROMA scores. An OR of 1.12 indicates that for each unit increase in the dmft score, the likelihood of falling into the higher-risk group rises by 12%. This reinforces the critical link between caries experience and orthodontic treatment need. A high dmft may indicate poor oral health maintenance, premature loss of primary teeth and subsequent occlusal disturbances. Together, these findings suggest that dmft score and age can serve as early indicators of more severe malocclusion risk in primary dentition. These insights support the need for integrated preventive strategies focusing on oral hygiene and early dental visits, particularly as children approach the later years of primary dentition.

Unlike earlier studies conducted in Italy, Iran and India, this study also examined associations with specific dental characteristics such as dmft scores, molar and canine relationships, and parental perception of treatment need. These additions provide a more comprehensive understanding of risk factors in primary dentition and highlight areas for targeted early intervention. Although the present study provides valuable data regarding the orthodontic treatment needs of children with primary dentition, one of its limitations is that it was conducted exclusively on patients attending for routine check-ups at the paediatric dentistry clinic. Furthermore, data on participants’ socioeconomic background and geographic origin were not collected, limiting the generalizability of the findings. To obtain more representative and objective data, further studies involving more diverse populations are required. While the Baby-ROMA index is advantageous in terms of evaluating primary dentition, it has some limitations compared to established indices like the IOTN and DAI, which are considered the gold standards for assessing malocclusion. Unlike the Baby-ROMA, these indices also incorporate an aesthetic component. Further prospective studies are needed to evaluate the predictive validity of the Baby-ROMA index.

5. Conclusions

This study highlights the high prevalence (80.8%) of malocclusion risk and the significant orthodontic treatment needs among Turkish children aged 4–6 years, as assessed using the Baby-ROMA index. The primary risk factors included parafunctional habits, inadequate oral hygiene, dental caries, early loss of primary teeth and oral breathing/obstructive sleep apnea syndrome, all of which are manageable through appropriate interventions. Furthermore, the study underlines the need to raise parental awareness about orthodontic needs and the benefits of early detection and treatment. Within the limitations of this study, it can be concluded that the Baby-ROMA index demonstrated its practicality and ease of use in evaluating early orthodontic treatment needs.

Availability of data and materials

The data presented in this study are available on reasonable request from the corresponding author.

Author contributions

NY and ECT—designed the research study. ECT—performed the research. EGA and EGEA—analyzed the data. NY and EGEA—wrote the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study was approved the ethics committee of the Faculty of Dentistry at Ankara Yıldırım Beyazıt University (protocol number: 2023-140) and was performed in full accordance with Declaration of Helsinki, as revised in 2013. Each parent/guardian indicated their agreement to participate by signing a consent form, while the children provided their verbal consent.

Acknowledgment

The authors would like to thank all the participants for their invaluable contribution to the present study.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.