Occlusal Features and their Association with Oral Habits and Dental Caries among Children Aged 3 to 6 Years in Prishtina, KosovoABSTRACT
Objective: To evaluate the occlusal characteristics of the primary dentition and their association with dental caries and oral habits in children aged 3 - 6 years in Prishtina, Kosovo, aiming to provide epidemiological data to support early intervention and preventive strategies for malocclusion.
Material and Methods: This cross-sectional study included 655 children with complete primary dentition and no history of previous orthodontic treatment, recruited from both public and private kindergartens in Prishtina. Occlusal parameters were clinically assessed across three spatial planes, evaluating the terminal plane relationship of the second deciduous molars, the primary canine relationship, overjet, overbite, crossbites, and the presence of spacing or crowding. Dental caries was recorded using the defs index (decayed, extracted, and filled surfaces) according to the WHO Child Oral Health Assessment form, by tooth surface. In addition, parents completed structured questionnaires regarding their children’s oral habits and hygiene practices, followed by intraoral clinical examinations.
Results: The flush terminal plane (FTP) was observed in 57.7% of children, the distal step (DS) in 27.8%, and the mesial step (MS) in 2.0%. Regarding primary canine relationships, Class I was the most prevalent (62.9%), followed by Class II (30.7%) and Class III (2.1%). Most children (84.7%) exhibited a normal overjet, while 35.7% presented with a deep bite. Common oral habits included object or toy sucking (13.3%), nail biting (12.2%), and pacifier use (12.1%), with significant correlations identified between certain oral habits and occlusal characteristics. The defs index was significantly associated with pacifier use (p = 0.031) and mouth breathing (p = 0.014). No significant association was observed between dental caries and malocclusion.
Conclusion: Most preschool children in Prishtina exhibited favorable occlusal patterns. However, parafunctional oral habits, such as pacifier use and mouth breathing, were associated with occlusal anomalies and an increased risk of dental caries, while inadequate oral hygiene habits correlated with higher defs index scores. These findings highlight the need for early screening to promote healthy occlusion and minimize future orthodontic needs.
Keywords:
Malocclusion; Dental Caries; Oral Health.
Introduction
Malocclusion is a developmental anomaly of teeth or dental arches that can affect aesthetics in mild cases and lead to functional impairments in severe cases [1]. As a multifactorial condition influenced by both genetic and environmental factors, malocclusion results from abnormalities in the growth and development of the jaw bones and muscles during childhood and adolescence [2].
A recent systematic review estimates the global prevalence of malocclusion in children and adolescents to be around 56%, with no significant difference between the primary and permanent dentition [3]. However, there is still debate about the causes of malocclusion in the primary dentition and whether these predict malocclusion in the permanent dentition [4,5]. While numerous epidemiologic studies have examined caries and malocclusion separately, there are only a few that have comprehensively evaluated both dental and occlusal findings in a well-defined sample - and even fewer that have examined possible interactions between the two. Some researchers suggest that caries and premature loss of primary teeth may contribute to occlusal and spacing anomalies in mixed dentition and permanent dentition [6]. Furthermore Feldenes et al. [7] reported that severe malocclusion, maxillary irregularity, and abnormal molar relationships were significantly associated with both the occurrence and severity of dental caries. Similarly, a study conducted in Nigeria [8] demonstrated that dental crowding and buccal crossbite were strongly related to caries prevalence, while increased overjet and anterior open bite were more closely linked to gingivitis. These findings illustrate that malocclusion and dental caries are not independent conditions but rather share a bidirectional relationship. Occlusal anomalies may predispose to caries by creating plaque-retentive sites, while caries and premature tooth loss may further aggravate occlusal disturbances. However, a definitive causal relationship between malocclusion and caries has still not been proven [9].
Given the increasing importance of early diagnosis and preventive orthodontics, further research is warranted to clarify these relationships [4]. The treatment of malocclusion is not only crucial for oral function, but also for psychosocial wellbeing, as it can significantly affect a child’s quality of life [1]. Oral habits, both functional (e.g., chewing, swallowing) and parafunctional (e.g., thumb sucking, pacifier use), which develop through repetitive actions, can interfere with normal jaw growth and occlusion [10,11]. The American Academy of Pediatric Dentistry (AAPD) emphasizes the need for early intervention, as persistent oral habits beyond preschool age are recognized as contributors to malocclusion [12]. Such habits are among the clearest examples of how environmental factors influence occlusal development [13,14]. Studies suggest that dietary trends (e.g., diets with soft foods that reduce masticatory forces), non-nutritive sucking and early weaning are important risk factors [15-17]. For example, anterior open bite, a common malocclusion in preschool children, has been strongly associated with thumb sucking [18]. Similarly, research in Brazilian children found a high prevalence of malocclusion associated with oral habits that negatively impact oral health-related quality of life [19]. Despite these findings, data on the prevalence of malocclusion and orthodontic treatment needs in southern European populations remain limited [20,21], especially in the Kosovo region [22]. To our knowledge, no previous study has investigated malocclusion in kindergarten-aged children in Kosovo. Given that ages 3 to 12 represent a critical window for the diagnosis and detection of maxillofacial and dental anomalies [23], early assessment can guide preventive measures and minimize long-term complications.
In light of the limited number of studies on malocclusion, oral habits and caries in the primary dentition, this study aims to: describe the occlusal characteristics of the primary dentition, investigate the prevalence and relationships between oral habits, dental caries and malocclusion, provide baseline data for kindergarten children (aged 3-6 years) in Eastern Kosovo. Clinical examinations of occlusion and extraoral facial assessments were combined with parent questionnaires to gain comprehensive insights.
Material and Methods
Study Design and Ethical Clearance
This cross-sectional study was conducted between July and December 2021 in Prishtina, Kosovo, in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the Kosovo Dental Chamber (Ref. No. 17/2021) and the Directorate of Education of the City of Prishtina (Ref. No. 03-610/01-56638/21). Written informed consent was obtained from parents/guardians, and only children whose parents/guardians provided consent were examined.
Study Population
A total of 655 children aged 3 to 6 years were selected from 11 kindergartens in Prishtina using a cluster sampling method. The following inclusion criteria were established: Children with only primary dentition; Fully erupted primary dentition; and No previous orthodontic treatment.
The following parameters were adopted as exclusion criteria: Presence of permanent teeth (e.g., first molars in six-year-olds); Hypodontia, craniofacial anomalies (e.g., clefts, deviated septum); Systemic diseases (e.g., neuromuscular, respiratory or congenital disorders); and Non-cooperative children or children undergoing orthodontic treatment.
Data Collection
Six dental students and two specialists (a pediatric dentist and an orthodontist) were trained to perform the examinations. Prior to data collection, the examiners were calibrated by jointly examining 20 children and reaching consensus on any discrepancies. Examiner calibration was statistically verified on a 10% random subsample of children re-examined on a separate day. Inter-examiner reliability across seven occlusal traits (overjet, overbite, crossbite, spacing, crowding, and primary molar and canine relationships) was assessed using Cronbach’s alpha, applied as a consistency index across categorical traits. Coefficients ranged from 0.623 to 0.733, with the highest value (α = 0.733) indicating acceptable agreement and confirming sufficient examiner calibration for the study.
Questionnaire
Parents/guardians completed a self-administered questionnaire during the scheduled parent-teacher conferences. The questionnaire contained the following questions: 1. Demographic data (child’s age, gender); 2. Oral habits (thumb sucking, mouth breathing, lip biting); and 3. Oral hygiene practices and dietary habits. Teachers received standardized training to help distribute and collect the data. Incomplete forms were excluded.
Clinical Examination
Examinations were conducted in kindergarten classrooms during daylight using sterile dental mirrors and probes. The WHO Child Oral Health Assessment Form (2013) served as a guide for caries detection, and the defs index (decayed, extracted, filled surfaces) was recorded for each tooth surface [24].
Occlusal assessments included:
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1. Molar relation (Baume’s classification was used to evaluate the distal surface relation of the primary second molars) [25]:
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Flush terminal plane (Class I): The distal surfaces of the upper/lower second molars are vertically aligned.
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Distal step (Class II): The lower second molar is distal to the upper one.
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Mesial step (Class III): Lower second molar mesial to the upper one.
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2. The canine relationship was evaluated based on the measurements of a previous study [26]:
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Class I: Maxillary canine cusp aligns with mandibular canine distal surface.
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Class II: Maxillary canine mesial to the canine of the mandible
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Class III: Maxillary canine distal to the canine of the mandible.
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3. Overjet/Overbite:
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Normal overjet: 1-3 mm; increased: >3 mm; edge to edge: <1 mm.
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Normal overbite :1-3 mm; deep bite: >3 mm; open bite: <1 mm.
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Overjet was measured from the palatal surface of the mesial corner of the most prominent upper incisor to the labial surface of the corresponding lower incisor. Overbite was graded according to the coverage of the lower incisor by the most prominent, fully erupted upper incisor [27,28].
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4. Transversal anomalies:
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Posterior crossbite: maxillary molars occlude lingually to mandibular molars. Scissor bite: maxillary molars occlude buccally/lingually to the opposing teeth.
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Space analysis: Crowding/spacing: recorded if discrepancy was ≤2 mm. To record overjet, overbite and occlusion type, the child was asked to close his teeth in centric occlusion [29].
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Oral habits were confirmed by: Thumb sucking: proclined maxillary incisors; Mouth breathing: mirror mist test, incompetent lips, gingival inflammation; Lip biting: lower lip bite marks/inflammation; The diagnostic criteria for the malocclusion types followed the established literature [30]. After the examination, each child received a report on oral health.
Statistical Analysis
The collected data were entered into Microsoft Excel 2008 and imported into the Statistical Package for the Social Sciences (IBM SPSS, Armonk, NY, USA) 11.0 for statistical analysis. Data processing was carried out using the software package STATISTICA 64 Version 10 for Windows and the software package PASW Statistica 18. The data distribution was analyzed using the Kolmogorov-Smirnov test and subsequently described by frequencies and relative frequencies, i.e., parameters of central tendency and dispersion (range, arithmetic mean, standard deviation). Possible associations between nominal variables were tested using the χ2 test and correlations between ordinal variables were examined using Spearman rank and Kendall’s tau coefficients. Differences between continuous variables by nominal categories were tested using the Mann-Whitney test and the Kruskal-Wallis test. Binary logistic regression was used to predict the relationship between the occlusal characteristics’ variables and the Oral Habits questionnaire variables.
Results
The study included 655 children aged 3-6 years after excluding 45 older participants, with a normal age distribution (Kolmogorov-Smirnov Z = 1.173, p = 0.128) and balanced representation across all age groups (Figure 1).
The flush terminal plane (Class I) was the most common molar relationship (57.7%), followed by the distal step (Class II, 27.8%) and the mesial step (Class III, 2.0%). For canine relationships, Class I predominated (62.9%) while Class II (30.7%) and Class III (2.1%) were less frequent, with Class III markedly less common than Class II (Table 1). Sagittal malocclusions were relatively uncommon, with 84.7% of children having a normal overjet (1-3 mm), 11.3% an increased overjet (>3 mm), and 2.4% an overjet greater than 5 mm (Table 1). Vertical anomalies were more prevalent, with deep bite (>3 mm) observed in 35.7%, reduced bite (<1 mm) in 8.9%, and anterior open bite in 2.9% of the participants. Regarding crossbites, posterior crossbites were most prevalent, with unilateral and bilateral occurrences observed in 6.4% and 2.9% of children, respectively. Anterior crossbites were rare, affecting only 0.5% of the sample. 78.6% of children exhibited natural spacing between primary teeth, with crowding noted in 21.7% (Table 1). Tooth crowding was significantly associated with the defs index (p = 0.007) (Table 2).
Common oral habits included object/toy sucking (13.3%), nail biting (12.2%), pacifier use (12.1%), lip sucking (11.6%), and a history of bottle feeding in 51.6% of children (Table 3).
The defs index also varied significantly with pacifier use (p = 0.031) and mouth breathing (p = 0.014). Additionally, the frequency of dental visits was correlated with defs scores (p < 0.001) (Table 4).
Oral habits, dental visits, and their association with the defs index in children aged 3-6 years.
These oral habits were significantly associated with occlusal characteristics, and specific habit-occlusion relationships were identified using Kendall’s tau tests (Table 5).
Logistic regression analysis indicated that increased overjet was associated with prolonged pacifier use or thumb-sucking habits (Table 6), whereas deep bite was associated with lip biting habits (Table 7).
Correlation between oral habits and overjet variations in the primary dentition of children.
Discussion
This cross-sectional study provides the first epidemiological data on occlusal characteristics in preschool children in Prishtina, Kosovo. Our findings provide valuable insights for the development of preventive programs aimed at promoting proper occlusal development during this critical growth period. By combining clinical examinations with parent questionnaires, we were able to assess both biological and behavioral factors that influence early dental development.
The predominance of flush terminal plane (57.7%) and Class I canine relationships (62.9%) is consistent with patterns observed in Huizhou, China [31]. However, the rates observed in this sample were 10% higher than those reported in Turkish and Greek populations [32,33]. In the present study, Class I canine relationships predominated (62.9%), with Class II (30.7%) and Class III (2.1%), less common confirming that Class III was much rarer than Class II. This is consistent with most reports in the literature, while some studies, such as Zhang et al. [34] reported a higher prevalence of Class III compared to Class II. This discrepancy could be due to differences in genetic predisposition or environmental factors in the different populations. It is noteworthy that the prevalence of increased overjet (11.3%) observed in this study falls within the global range (3-16%) [35,36], suggesting that children in Kosovo follow similar developmental trends. The high frequency of deep bite (35.7%), which is consistent with a previous study [37], deserves special attention. Although some self-correction may occur during eruption of permanent teeth [38,39], early detection allows for timely intervention if needed. Interestingly, the prevalence of tooth spacing (78.6%) exceeded previous reports [40], possibly indicating particular local growth patterns or nutritional influences.
The most common oral habits were found to be objects sucking (13.3%), nail biting (12.2%) and pacifier use (12.1%), with 51.6% of children being bottle-fed. These findings are particularly relevant given that previous studies have established a link between prolonged bottle feeding (>18 months) and Class II malocclusions [41]. Although the duration of habits was not recorded in our study, the demonstrated association between persistent habits and occlusal anomalies [42] emphasizes the need for early parental education and intervention. The prevalence of mouth breathing in this cross-sectional study was 8.1%, which lies at the lower end of the range reported in preschool populations. Previous studies have documented considerable variability, with prevalence rates ranging from 11% to 57% among Brazilian preschoolers, 23% in Italian children, and 17% in Indian school-aged populations [43-45]. These discrepancies may be attributed to differences in cultural practices, diagnostic criteria, or age groups examined across studies. Consistent with the previous studies reporting that the prevalence of sleep bruxism ranges from 3.5% to 40.6% in children and approximately 16.5% in adults [46], the present study found that 3.4% of children exhibited sleep bruxism. Compared to previous reports, the prevalence of sleep bruxism in our study is at the lower end of the range observed in children.
Our data showed no significant association between caries and malocclusion in the primary dentition, confirming the findings of Stahl and Grabowski [47]. However, we identified crowding as a notable exception, which is consistent with the work of Gowda and Das [48]. This distinction illustrates how specific occlusal features may interact differently with caries risk factors.
As the first comprehensive assessment of occlusion in primary dentition in Kosovo, this study offers several strengths. These encompass participation of all public kindergartens in Prishtina, the integration of clinical examinations with parent-reported questionnaires, and the creation of baseline data for future research.
Nonetheless, several limitations should be acknowledged. Due to a cross-sectional nature of the study, causal relationships between occlusal features, oral habits, and dental caries could not be established. Information on oral habits was obtained from parent-reported questionnaires, which introduces the possibility of recall bias, as parents may under or over-report certain behaviors. Data on the duration and intensity of oral habits were not collected. Children not attending kindergarten were excluded, although their number was minimal. In addition, the relationship between caries experience, oral habits, and malocclusion should be interpreted within the broader context of socioeconomic status and other background factors. Future longitudinal studies with objective measures of oral habits are needed to confirm these associations and further explore potential causal links.
These findings have important implications for Kosovo's oral health system, including: (i) emphasis on prevention - early screening programs should be implemented to identify children at risk for persistent malocclusion; (ii) parent education - efforts should be made to educate parents about the impact of oral habits on dental development; and (iii) future research directions - longitudinal studies should be prioritized to track the duration of oral habits and changes in occlusion over time.
Although our findings are not representative of all Kosovar children, they provide an important foundation for understanding occlusal development in this population. The interplay between oral habits, caries and occlusion patterns emphasizes a need for integrated preventive approach during this formative dental period.
Conclusion
This study provides new insights into occlusal patterns and their associations with oral habits and the defs index in Kosovar kindergarten children. While most children exhibited flush terminal plane of the second primary molars, Class I primary canine relationships, and normal overjet, with a tendency toward Class II canine relationships, as well as increased overjet and overbite. Caries experience did not appear to significantly influence malocclusion. These findings emphasize the importance of oral health education programs targeting both children and their caregivers, as well as the need for further studies to explore additional factors influencing dental development.
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Financial SupportNone.
Acknowledgements
The authors would like to thank all the institutions that granted ethical approval for this study. Many thanks also go to the kindergartens in Prishtina, Kosovo, for their cooperation at all times and to the children and their parents who were willing to cooperate.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Academic Editor: Catarina Ribeiro Barros de Alencar
