ORIGINAL ARTICLE

Orofacial dysfunction, nonnutritive

sucking habits, and dental caries
influence malocclusion in children aged
8-10 years

lica Lima Granja,a Veruska Medeiros Martins Bernardino,a Larissa Chaves Morais de Lima,a
Ge
^nia Serafim de Arau
Luiza Jorda ^a Lea

jo,a Maria Jacinta Are ~o Lopes Arau

jo Arruda,a Fernanda Morais Ferreira,b
Saul Martins Paiva,b and Ana Fla
via Granville-Garciaa
Campina Grande, Para
ıba, and Belo Horizonte, Minas Gerais, Brazil

Introduction: Malocclusion is one of the most prevalent oral health problems and can affect self-esteem, social
relations, and oral health–related quality of life. The present study aimed to evaluate associations between
malocclusion and orofacial dysfunction, nonnutritive sucking habits, cavitated carious lesions, and anxiety in
Brazilian children. Methods: An analytical cross-sectional study was conducted with a representative sample
of 739 children aged 8-10 years. Parents or guardians provided sociodemographic data and information on the
nonnutritive sucking habits of the children. The children answered the Revised Children’s Manifest Anxiety
Scale. Four trained examiners examined the children for the diagnosis of malocclusion (dental aesthetic index),
dental caries (International Caries Detection and Assessment System), and orofacial dysfunction (Nordic
Orofacial Test-Screening). The control variables were selected using a directed acyclic graph. Descriptive
statistics were performed, followed by unadjusted and adjusted robust logistic regression analysis (P \0.05).
Results: The following variables remained associated with the occurrence of malocclusion in the final model:
nonnutritive sucking habits (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.25-4.08), orofacial dysfunction
(OR, 1.56; 95% CI, 1.13-2.17), and cavitated carious lesion (OR, 1.39; 95% CI, 1.03-1.89). Conclusions: Nonnu-
tritive sucking habits, orofacial dysfunction, and cavitated carious lesions were associated with the presence of
malocclusion in children aged 8-10 years. (Am J Orthod Dentofacial Orthop 2022;162:502-9)

M
alocclusion is a common oral disorder defined
as an incorrect relationship between the teeth
and causes an imbalance in the masticatory
system.1 This oral problem is highly prevalent2,3 and
can affect chewing function, self-esteem, social rela-
tions, and oral health–related quality of life.3-5
a
Department of Dentistry, State University of Paraiba, Campina Grande, Para
ıba,
Brazil.
b
Department of Paediatric Dentistry and Orthodontic, Federal University of
Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
This work was supported by the State University of Para
ıba, the Brazilian Coor-
dination of Higher Education, the Ministry of Education, and the National Coun-
cil for Scientific and Technological Development, Brazil.
Address correspondence to: Ana Fl
avia Granville-Garcia, Department of
Dentistry, State University of Paraiba, Rua Bara
una, 531, Bairro Universit
ario,
Campina Grande, Para
ıba, Brasil; e-mail, anaflaviagg@gmail.com.
Submitted, September 2020; revised and accepted, May 2021.
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2021.05.012
502
The prevalence in studies conducted in Brazil and
other parts of the world ranges from 16.52% to
82.1%.2,3,6,7 This variation is likely because of differ-
ences in diagnostic methods and the characteristics of
each population. Moreover, a systematic review found
that the overall prevalence and type of malocclusion
vary according to skin color.8
The mixed dentition phase is an important period of
dentoskeletal changes,3 during which children often prac-
tice harmful oral habits.9 Thus, investigating factors asso-
ciated with malocclusion in the mixed dentition phase
enables the interception of inadequate oral habits and
can help prevent functional and psychological harm.4
Nonnutritive sucking habits, such as thumb or finger
sucking and pacifier use, are considered etiologic factors
for developing malocclusion.10 However, the impact of
these habits on the stomatognathic system and occlu-
sion depends on the frequency, intensity, and duration.6
Moreover, psychosocial factors, such as anxiety, can lead
to the practice of harmful oral habits in children11 and
may influence the development of malocclusion.
Granja et al
Harmful oral habits can affect the neuromuscular or-
ofacial balance and contribute to the development of or-
ofacial disorders,12,13 which compromise functions such
as breathing, chewing, and speech.7,14 Population-
based studies report that orofacial disorders are com-
mon, affecting up to 87% of children aged between 8
and 10 years.7,15 The consequences of orofacial disor-
ders can affect orofacial growth and development and
induce malocclusion.16
Despite the relevance of this issue, few studies have
investigated the association between orofacial dysfunc-
tion and malocclusion in children.7,12,15 Moreover, the
studies cited either did not have representative samples
or did not evaluate the effects of orofacial dysfunction
on the occurrence of malocclusion.
Therefore, the present study aimed to evaluate asso-
ciations between malocclusion and nonnutritive sucking
habits, anxiety, and orofacial dysfunction in Brazilian
children aged 8-10 years.
MATERIAL AND METHODS
This study was conducted in accordance with the
guidelines stipulated in the Declaration of Helsinki and
received approval from the Human Research Ethics Com-
mittee of the State University of Para
ıba (certificate no.
10514619.2.0000.5187). All parents or guardians
received clarifications regarding the objectives of the
study and signed a statement of informed consent autho-
rizing the participation of the children. The children also
signed a statement of consent agreeing to participate.
This study was conducted following the Strength-
ening the Reporting of Observational Studies in Epidemi-
ology (STROBE) statement.17 A descriptive, analytical,
cross-sectional study was conducted with a representative
sample of children aged 8-10 years at public and private
schools in Campina Grande, Brazil.
The sample size was calculated for analytical studies
by comparing 2 independent proportions using the G*Po-
wer software (version 3.1; Franz Faul, Universitat Kiel,
Germany), adopting a 95% significance level and 80%
study power. The proportion of malocclusion in children
with and without nonnutritive sucking habits in the pilot
study was 60% and 45.9%, respectively. The use of this
variable provided the largest sample for the evaluation
of associations in this study. Thus, the minimum sample
was determined to be 396, to which a design effect of
1.6 was applied, leading to a sample of 634. Twenty
percent was added to compensate for possible dropouts,
leading to a final sample of 793 children.
The city is divided into 6 geographic regions (adminis-
trative districts) with 131 schools (73 public and 58 private
schools). The students were selected using probabilistic
American Journal of Orthodontics and Dentofacial Orthopedics
503
cluster sampling performed in 2 stages (schools and stu-
dents) stratified by administrative district. In the first
stage, 23 schools were randomly selected, ensuring the
representativeness of the sample with the aid of Microsoft
Excel (Microsoft Office 365, Microsoft, Redmond, Wash).
In the second stage, students aged 8-10 years were
selected from each school through simple random sam-
pling until obtaining the number of students necessary
to reach the desired sample size within each administrative
district (proportional to the number of students enrolled in
each district).
Male and female children aged 8-10 years enrolled at
public or private schools were included in the study.
Children with a past or current history of orthodontic
treatment and those with syndromes, developmental
disorders, or cognitive deficiency reported by the teach-
ers and guardians were excluded from the study.
Training for the diagnosis of malocclusion and dental
caries was conducted in 2 steps, as suggested by Peres
et al.18 In the theory step, an examiner with expertise
trained 4 dentists for the diagnosis of malocclusion using
the dental aesthetic index (DAI).19 The criteria for the diag-
nosis were studied using photographs, plaster models, a
clinical chart, the calculation of the index, and the proper
sequence to follow during the clinical examination. In the
practical step, the examiners diagnosed oral problems in
40 children: 20 from a public school and 20 from a private
school selected by convenience. Training for diagnosing
dental caries was conducted by a specialist in pediatric
dentistry and involved the use of the International Caries
Detection and Assessment System (ICDAS).20 In the theory
step, the diagnostic criteria were studied using photo-
graphs, a clinical chart, and the sequence to be followed
during the clinical examination. In the practical step, the
examiners performed the diagnosis of dental caries on
the same 40 children. The calibration exercises involved
determining intraexaminer and interexaminer agreement
using the kappa statistic. The following were the respec-
tive intraexaminer and interexaminer kappa coefficients
for DAI: examiner 1 (G.L.G.), 0.95 and 0.90; examiner 2
(V.M.M.B.), 0.92 and 0.92; examiner 3 (L.C.M.L.), 0.94
and 0.91; and examiner 4, 0.92 and 0.92. Kappa coeffi-
cients for ICDAS: examiner 1, 0.96 and 0.88; examiner
2, 0.95 and 0.81; examiner 3, 0.95 and 0.82; and examiner
4, 0.96 and 0.82. Kappa coefficients for Nordic Orofacial
Test-Screening (NOT-S): examiner 1, 0.82 and 0.88;
examiner 2, 0.87 and 0.83; examiner 3, 0.81 and 0.89;
and examiner 4, 0.86 and 0.91.
A pilot study was conducted with 40 children from 2
schools (1 public and 1 private school). These students
were selected by convenience and were not included in
the main sample. The results of the pilot study revealed
no need to change the methods.
October 2022
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504
Questionnaires were sent to the parents/guardians to
collect the nonclinical data. The questionnaire on socio-
demographic characteristics addressed the child’s age,
skin color, and sex; mother’s schooling; monthly family
income; and the number of residents in the home.
Another questionnaire was used for the parents/guard-
ians to report the practice and frequency of harmful
oral habits, such as thumb/finger sucking, pacifier suck-
ing, and bottle feeding.
To avoid recall bias, the respondent was asked
whether the child was currently practicing the sucking
habit.
The children answered the Revised Children’s Mani-
fest Anxiety Scale,21 which is a psychometric instrument
for assessing anxiety in children aged 8-13 years,
composed of 37 items divided into 2 subscales: 1 for
the assessment of anxiety and 1 denominated The Lie
Scale. The score ranges from 0 to 37, with higher scores
denoting a strong anxiety trait. For this study, we only
used the items addressing anxiety (items 1-28). The anx-
iety score was categorized in terciles and classified as
high, medium, or low.
The dentists gave instructions on proper oral hygiene
and supervised tooth brushing by the children. The par-
ticipants were examined separately in a reserved room
available at the school. The examinations were conduct-
ed with the child sitting in front of the examiner, who
used personal protective equipment, a light-emitting
diode headlamp (Petzl Zoom; Petzl America, Clearfield,
Utah), sterilized mouth mirror (PRISMA, S~ao Paulo,
Brazil), sterilized Williams probe (WHO-621; Trindade,
Campo Mour~ao, Brazil), and gauze to dry the teeth,
following the methods indicated by the World Health Or-
ganization.22
The diagnosis of malocclusion was performed using
the DAI, which is a quantitative index proposed by
Cons et al19 and recommended by the World Health Or-
ganization23 for the assessment of the psychosocial
impact of occlusal problems on the basis of the following
characteristics: missing teeth, anterior crowding, ante-
rior spacing, midline diastema, greater anterior
misalignment in the maxilla, greater anterior misalign-
ment in the mandible, maxillary horizontal overjet,
negative horizontal overjet, anterior open bite, and an-
teroposterior molar relationship.19 Using this index, the
severity of malocclusion and the need for orthodontic
treatment are classified as DAI of (1) #25: normal occlu-
sion, no treatment need; 26-30: definite malocclusion,
treatment elective; 31-35: severe malocclusion, treat-
ment highly recommended; and $36: very severe
malocclusion, treatment mandatory.19,23
The ICDAS was used for the diagnosis of dental
caries.20 This index has the following scoring system
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Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Granja et al
based on the extent of the carious lesion: 0, sound; 1,
visible alteration after drying; 2, visible alteration without
drying; 3, breakdown of enamel; 4, dark shadow on un-
derlying dentin; 5, cavity with dentin exposed at the
base; 6, extensive cavity with cavity exposed at the base
and on walls. Because of the epidemiologic nature of
this study and the impossibility of drying with compressed
air, codes 1 and 2 were pooled (denominated code 2). The
ICDAS also enables the classification of caries as active or
inactive. This study recorded the cavitated carious lesion
when codes 3, 5, and 6 were identified.
Orofacial dysfunctions were evaluated using the
NOT-S, validated and adapted for Brazilian Portu-
guese.24 The NOT-S has 12 domains divided between
items administered in an interview format (6 domains)
and a clinical examination (6 domains). The interview
addresses sensory function, breathing, habits, chewing
and swallowing, salivation, and dry mouth. The answers
were yes (1 point) or no (0 points). Domains with at least
1 affirmative answer received 1 point. The clinical exam-
ination section evaluates the face at rest, nasal breath-
ing, facial expression, masticatory muscles and
mandibular function, oral motor function, and speech.
The aspects are categorized as impaired (1 point) or
not impaired (0 points). Each domain is scored 1 point
if at least 1 action is classified as impaired. The total
NOT-S score ranges from 0 to 12. This study recorded or-
ofacial dysfunction when at least 5 domains had an
affirmative response or impaired function.7,24
A directed acyclic graph (DAG) was created on the ba-
sis of the previous literature and using the DAGitty soft-
ware (version 3.0; http://www.dagitty.net/) to select
covariables for the statistical adjustments and to assist
in the interpretation of the effect of the exposure vari-
ables on the occurrence of malocclusion.25 This study
hypothesized that orofacial dysfunction is associated
with malocclusion. The variables incorporated into the
DAG were selected from previous studies in the literature
reporting associations between malocclusion and socio-
demographic factors,6 a greater degree of anxiety,11 a
greater number of cavitated carious lesions,26 nonnutri-
tive sucking habits,27 and hereditary factors28 (uncol-
lected latent variable). The DAG indicated that the
following variables should be incorporated into the anal-
ysis for the statistical control: anxiety, cavitated carious
lesion, mother’s schooling, skin color, nonnutritive suck-
ing habits, family income, and sex. DAG is a useful tool
for research problems on causal associations between
exposure and outcome, enabling the projection of a
theoretical model of the study and the development of
an analytical plan for the variables.29 Possible causal fac-
tors are incorporated into a graph to identify confound-
ing factors for the statistical adjustment25 (Fig 1).
Granja et al
Fig 1. DAG used for the analysis of response variables and malocclusion. DAG, directed acyclic
graph.
Statistical analysis
SPSS software (version 25.0; IBM Inc, Armonk, NY)
was used to organize and analyze data. The DAI score
was the dependent variable and was treated as a dichot-
omous categorical variable (yes, DAI .25; no,
DAI #25).2 The independent variables were sociodemo-
graphic characteristics, nonnutritive sucking habits,
anxiety, orofacial dysfunction, and cavitated carious
lesion. For the data analysis, logistic regression for com-
plex samples was employed. Unadjusted robust logistic
regression analyses were performed, and variables with
a P value \0.20 were incorporated into the final model
using the Wald backward stepwise method adjusted by
the Hosmer-Lemeshow goodness-of-fit test. Indepen-
dent variables with a P value \0.05 in the adjusted
model were considered significantly associated with
the outcome and remained in the final model.
RESULTS
The final sample comprised 739 children aged 8-10
years, corresponding to a response rate of 93%. Missing
data occurred because of 3 consecutive absences of the
students and refusals to participate.
Table I displays the characteristics of the sample. The
prevalence of malocclusion was 49.1%. A high level of
anxiety was found in 34.2% of the children, and orofa-
cial dysfunction was found in 33.3%. The prevalence of
the individual NOT-S domains was as follows: sensory
function, 19.1%; breathing, 25.2%; habits, 61.2%;
chewing and swallowing, 52.1%; salivation, 9.9%; dry
American Journal of Orthodontics and Dentofacial Orthopedics
505
mouth, 29.1%; face at rest, 20.8%; nasal breathing,
5.3%; facial expression, 11.5%; masticatory muscles
and mandibular function, 8.0%; motor function,
18.4%; and speech, 17.6%. The majority had cavitated
carious lesions (52.8%), and 7.7% had nonnutritive
sucking habits.
Table II displays the associations between the inde-
pendent variables and malocclusion. In the final model,
the likelihood of malocclusion was 36% greater in chil-
dren with orofacial disorders (odds ratio [OR], 1.36; 95%
confidence interval [CI], 1.13-1.60), 20% greater among
those with nonnutritive sucking habits (OR, 1.20; 95%
CI, 1.01-1.37), and 63% greater among those with cavi-
tated carious lesions (OR, 1.63; 95% CI, 1.10-2.52).
DISCUSSION
In this study, the prevalence of malocclusion was
higher among children with nonnutritive sucking habits,
orofacial disorders, and cavitated carious lesions. Studies
of this nature are important, as the mixed dentition
phase is a transitory period characterized by important
changes in facial growth and development, changes in
the dental arches, and the persistence of inadequate
oral habits.3 Some malocclusions found at the onset of
the deciduous dentition undergo a process of self-
correction. Those that persist until the mixed dentition
phase are the malocclusions that require a therapeutic
approach.30 Children begin to develop a greater sense
of esthetics at this age, and malocclusions may exert a
negative influence on the self-perception of these
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506 Granja et al

and adolescents aged between 4 and 14 years.6,11,13

Table I. Characterization of sample
Early interventions targeting these habits can minimize
Variables n (%) or even prevent dentoskeletal harm.13 Moreover, future
Sex studies should investigate the association between the
Male 367 (49.7) duration (in hours) of the practice of nonnutritive suck-
Female 372 (50.3)
ing habits and malocclusion.
Self-declared skin color
Non-White 483 (65.4) Orofacial disorders were associated with malocclu-
White 255 (34.6) sion in this study. It is likely that the imbalance in orofa-
Mother’s schooling cial structures (muscles, tongue, and lips) and functional
#8 years of study 310 (42.2) alterations, such as mouth breathing, contribute to the
.8 years of study 425 (57.8)
inadequate positioning of the teeth, thereby exerting
Mother’s age, y
#35 387 (53.1) an influence on the malocclusion. Indeed, the interposi-
.35 342 (46.9) tion of the tongue, lip-smacking, and the mouth breath-
No. of residents in home ing pattern have been associated with malocclusion in
$6 96 (13.2) children.6,27,28 A study conducted with preschoolers
#5 634 (86.8)
found that orofacial dysfunction was greater among
Monthly family income
#R$1000 327 (57.0) children in which the parents or guardians had less infor-
.R$1000 247 (43.0) mation on the oral health of children.13 These findings
Malocclusion underscore the importance of establishing preventive
Yes 363 (49.1) and educational practices to reduce the occurrence of
No 376 (50.9)
oral dysfunction in children and consequently assist in
Anxiety
High 253 (34.2) preventing malocclusion.
Medium 259 (35.0) Children with cavitated carious lesions were 63%
Low 227 (30.7) more likely to have malocclusion compared with children
Orofacial dysfunction without cavitated carious lesions. Previous studies in
Yes 246 (33.3)
Brazil and other countries report similar results in chil-
No 496 (66.7)
Nonnutritive sucking habits dren and adolescents aged between 6 and 15
Yes 57 (7.7) years.26,33-35 Researchers have found that dental caries
No 682 (92.3) are associated with anterior crowding and an abnormal
Cavitated carious lesion molar relation,26,35 likely because of the loss of contact
Yes 390 (52.8)
points, which contributes to dental mesialization. A
No 348 (47.2)
study conducted with Brazilian children aged 3-5 years
found an association between caries and deepbite.36
children.31 Moreover, it is common for orthodontic Extensive caries of the occlusal face can reduce the
treatment to begin in the mixed dentition phase.32 vertical dimension and contribute to deepbite. This asso-
Despite knowledge of the importance of malocclusion ciation was also found in a systematic review and meta-
and associated factors in this phase, it remains an analysis, in which the authors found that less caries
under-investigated age in the literature. At the time of severity was associated with a lower DAI in adoles-
the writing of this paper, no studies were found address- cents.37 Moreover, the prevalence of dental caries is
ing the association between orofacial disorders and higher among children with a lower degree of family
malocclusion in a representative sample of children in union,38 which can lead to the maintenance of harmful
the mixed dentition phase. oral habits, consequently exerting an influence on the
Nonnutritive sucking habits were associated with malocclusion.
malocclusion in the present sample, which is in agree- Although an association was found between dental
ment with data described in previous studies.6,11 caries and malocclusion, other studies have demon-
Although nonnutritive sucking behavior is acceptable strated a relation in the opposite direction.33,34 This
in infants and small children, the prolonged duration is a limitation of cross-sectional studies, which do
of such habits can have consequences for oral-facial not enable establishing the order of occurrence of
development.27 Nonnutritive sucking habits become the variables. However, the influence of dental caries
harmful when persisting throughout childhood or on the loss of adequate occlusal and proximal contacts
adolescence,6 as such habits can alter the position of was considered in the proposal for this study. A previ-
teeth and negatively affect the balance of the occlusion, ous study with a longitudinal design found that
as reported in previous studies conducted with children malocclusion was not a causal factor for dental caries,

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Granja et al 507

Table II. Logistic regression for malocclusion associated with orofacial disorders, sociodemographic characteristics,
and clinical factors
Malocclusion Unadjusted Adjusted

Variable Yes, n (%) No, n (%) P value OR, 95% CI P value OR, 95% CI
Sex
Male 174 (47.4) 193 (52.6) 0.35 – – –
Female 189 (50.8) 183 (49.2) – –
Self-declared skin color
White 127 (49.8) 128 (50.2) 0.76 – – –
Non-White 235 (48.7) 248 (51.3) – –
Monthly family income
#R$1000 166 (50.8) 161 (49.2) 0.53 – – –
.R$1000 119 (48.2) 128 (51.8) – –
Mother’s age, y
#35 183 (47.3) 204 (52.7) 0.26 – – –
.35 176 (51.5) 166 (48.5) – –
Mother’s schooling,
#8 161 (51.9) 149 (48.1) 0.17y 1.10 (0.95-1.28) – –
.8 199 (46.8) 226 (53.2) 1.00 –
No. of residents in home
.5 51 (53.1) 45 (46.9) 0.40 – – –
#5 308 (48.6) 326 (51.4) – –
Anxiety
High 136 (53.8) 117 (46.2) 0.12y 1.09 (0.92-1.31) – –
Medium 116 (44.8) 143 (55.2) 0.91 (0.75-1.10) –
Low 111 (48.9) 116 (51.1) 1.00
Orofacial dysfunction
Yes 140 (56.9) 106 (43.1) 0.003y 1.25 (1.08-1.45) 0.01z 1.36 (1.13-1.60)
No 223 (45.2) 270 (54.8) 1.00 1.00
Nonnutritive sucking habits
Yes 39 (68.4) 18 (31.6) #0.01y 1.44 (1.18-1.74) 0.04z 1.20 (1.01-1.37)
No 324 (47.5) 358 (52.5) 1.00 1.00
Cavitated carious lesion
Yes 206 (52.8) 184 (47.2) 0.03y 1.17 (1.01-1.36) 0.02z 1.63 (1.10-2.52)
No 156 (44.8) 192 (55.2) 1.00 1.00

Note. Variables included in the final model: mother’s schooling, anxiety, orofacial dysfunction, nonnutritive sucking habits, and cavitated carious
lesion (P \0.20 in the unadjusted model). Variables in the final model: orofacial dysfunction, nonnutritive sucking habits, and cavitated carious
lesion (P \0.05 in the adjusted model).
y
Unadjusted logistic regression for independent variables and malocclusion.
z
Adjusted logistic regression for independent variables and malocclusion.

whereas other factors were, such as schooling, income,
brushing frequency, and frequency of visits to the
dentist.39
Regarding the absence of an association between a
mother’s schooling and malocclusion, there is no
consensus on this issue. Although some studies have re-
ported a lack of an association between sociodemo-
graphic factors and malocclusion,30,31,36,40 others have
found an association.3,41 However, methodologic differ-
ences are encountered among the studies regarding the
collection of malocclusion and sociodemographic vari-
ables, which may have influenced this association. More-
over, the social and cultural differences of each
population constitute another aspect that may have
contributed to these divergent results.40 Brazil is one
of the largest countries in the world, with social and cul-
tural differences among its regions reflected in the re-
sults of studies conducted in the country.
The lack of an association between anxiety and
malocclusion in the multivariate analysis likely occurred
because this variable has no direct association with
malocclusion. Studies have indicated an association be-
tween anxiety and harmful oral habits, possibly related
to malocclusion.11,42,43 However, a direct association
between anxiety and oral habits is not always found.44,45
Other factors could cause anxiety, such as school perfor-
mance, sibling rivalry, bullying at school for whatever
reason, home environment, attention deficit hyperactiv-
ity disorder, etc. Further studies with a longitudinal
design are needed to explore this possible association.

American Journal of Orthodontics and Dentofacial Orthopedics October 2022
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508
The major limitation of this study is the cross-
sectional design, which does not enable establishing a
cause-and-effect relationship among the factors stud-
ied. Nonetheless, cross-sectional studies contribute to
the formulation of hypotheses and help guide public
policies. Moreover, such studies avoid directing health
care strategies and public expenditures on aspects that
are not prioritized or do not suggest a significant clinical
impact. This study has strong points that should be
mentioned, such as using a DAG to select and control
confounding variables and assist in the causal interpre-
tation of the effect of the exposure on the outcome.
Other strong points regard the representative sample,
the use of validated instruments, and the use of a diag-
nostic index recommended by the World Health Organi-
zation.23 This instrument (DAI) analyzes occlusal
abnormalities that have a potential psychosocial impact.
A possible limitation of the DAI is the underestimation of
hypodontia. However, the prevalence of this anomaly is
low among children (0.29-0.60)46,47 and is not likely to
have affected the DAI scores.
Our findings can assist in directing priorities for pre-
venting and diagnosing possible factors associated with
malocclusion in the mixed dentition. The findings can
also assist in allocating public funds and planning oral
health promotion actions to raise awareness regarding
the importance of oral hygiene practices and the elimi-
nation of harmful oral habits. Moreover, it would be pru-
dent to include information on the diagnosis of orofacial
dysfunction in children on the dental evaluation chart,
as the early interception of such disorders would likely
contribute to preventing malocclusion.
Further studies are needed to understand the possible
influence of orofacial dysfunction on the occurrence of
malocclusion over time. Studies should also investigate
the influence of the individual domains of the NOT-S
to determine what orofacial disorders have repercussions
on dentoskeletal alterations.
CONCLUSIONS
Nonnutritive sucking habits, orofacial dysfunction,
and cavitated carious lesions were associated with the
presence of malocclusion in children aged 8-10 years.
AUTHOR CREDIT STATEMENT
G
elica Granja contributed to conceptualization,
methodology, investigation, and original manuscript
preparation; Veruska Bernardino contributed to investi-
gation and original manuscript preparation; Larissa
Lima contributed to methodology, investigation, formal
analysis, and original manuscript preparation; Luiza
Ara

ujo contributed to investigation and original
October 2022
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Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Granja et al
manuscript preparation; Maria Arruda contributed to
methodology and investigation. Fernanda Ferreira
contributed to methodology and manuscript review
and editing; Saul Paiva contributed to methodology
and manuscript review and editing; and Ana Granville-
Garcia contributed to conceptualization, methodology,
and manuscript review and editing.
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October 2022
Vol 162
Issue 4