European Journal of Orthodontics, 2021, 193–199

doi:10.1093/ejo/cjaa071
Advance Access publication 13 November 2020

Original article

Is wearing orthodontic appliances associated

with eating difficulties and sugar intake among
British adolescents? A cross-sectional study

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Ghaliah Albaqami1, Lucas Guimarães Abreu1,2 and Eduardo Bernabé1,
1
Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, UK 2Department of Child’s and Adoles-
cent’s Oral Health, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

Correspondence to: Eduardo Bernabé, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, Bes-
semer Road, London SE5 9RS, UK. E-mail: eduardo.bernabe@kcl.ac.uk

Summary
Aim: To determine whether wearing orthodontic appliances was associated with eating difficulty
and lower sugars intake among British adolescents.
Methods: This study analysed data from 4116 12- and 15-year-olds who participated in the 2013
Children’s Dental Health Survey in the UK. Information on eating difficulties in the past 3 months
and usual intake of six sugary items was collected through self-administered questionnaires.
The presence and type of orthodontic appliances (fixed or removable) were assessed during
clinical examinations. Logistic regression was used to evaluate the association between wearing
orthodontic appliances and eating difficulty whereas linear regression was used to evaluate the
association between wearing orthodontic appliances and sugars intake. Regression models were
adjusted for socio-demographic, behavioural, and clinical characteristics of adolescents.
Results: 12.9 per cent of the 4116 adolescents wore orthodontic appliances (10.1 per cent fixed
and 2.8 per cent removable), 21.0 per cent reported eating difficulties and the mean daily intake
of sugars was 5.3 times/day (SD: 3.7, range: 0–20). Adolescents with fixed appliances had 4.02
(95% CI: 3.03, 5.33) greater odds of reporting eating difficulty than those with no appliances,
but no differences were found between adolescents wearing removable and no appliances. No
association was found between wearing orthodontic appliances and daily sugars intake either
[coefficients of 0.20 (95% CI: –0.27, 0.66) and –0.30 (95% CI: –0.96 to 0.36) for adolescents wearing
fixed and removable appliances, respectively].
Conclusion: Wearing fixed orthodontic appliances were associated with greater odds of reporting
eating difficulty, but not with lower sugars intake among British adolescents.

Introduction Information on the eating pattern of adolescent orthodontic pa-

tients is scarce. Orthodontists often recommend patients to eat soft,
Orthodontic treatment aims to correct different types of malocclu-
non-sticky food to avoid pressure sensitivity, and minimize damage
sion, and in many cases, the treatment starts during adolescence
to the appliances (8, 9). There is evidence that wearing orthodontic
(1). Adolescence is a developmental period when the nutritional de-
appliances have several side effects, including discomfort and pain,
mands of the body increase significantly to support the rapid changes
gingival inflammation and bleeding, that might subsequently af-
associated with pubertal growth (2, 3). Dietary habits of adolescents
fect daily activities such as eating and speaking (10–12). Another
are often characterized by having irregular meals, frequent snacking,
common advice of orthodontists is to avoid sugar-containing foods
and consumption of sugar-sweetened beverages (4, 5), which may
to prevent enamel demineralization (13). However, few studies have
have negative repercussions on their oral health (6, 7).

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Orthodontic Society.
193
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194
looked at sugar intake among patients under orthodontic treatment.
A cross-sectional study in Australia showed no differences in carbo-
hydrates intake between adolescents under orthodontic treatment
and control individuals, who were matched by sex and age (14).
A 3-month longitudinal study of patients starting fixed orthodontic
treatment in England found no impact on dietary intake, includ-
ing carbohydrates (8). Finally, a cross-sectional study in Germany
showed no differences in consumption of sweets, candy, and choc-
olates between adolescents wearing fixed orthodontic appliances
and a control group of individuals at the same age who had not
undergone any orthodontic treatment (15).
Awareness of the common side effects of orthodontic treatment
on adolescents can help to improve the quality of orthodontic care
(12). A better understanding of the impact of orthodontic appli-
ances on eating and dietary behaviour would facilitate tailored and
patient-centred approaches for eating advice during orthodontic
consultations (16, 17). Therefore, the aim of this study was to deter-
mine whether wearing orthodontic appliances were associated with
difficulties in eating and lower sugars intake among British adoles-
cents. The hypothesis of this study is that adolescents wearing ortho-
dontic appliances would report more difficulties in eating and lower
sugars intake.
Subjects and methods
Data source
Data were taken from the 2013 Children’s Dental Health Survey,
which is the fifth in a series of cross-sectional national surveys that
have been carried out every 10 years since 1973. The 2013 survey
included comprehensive clinical assessments of the oral health of
schoolchildren aged 5, 8, 12, and 15 years in England, Northern
Ireland, and Wales. Participants were selected using stratified cluster
random sampling in England and Wales and simple random sam-
pling in Northern Ireland. Data were collected through parental and
child questionnaires as well as child clinical oral examinations. The
survey protocol was ethically approved by the Ethics Committee at
University College London (Project ID 2000/003). Parents provided
written informed consent and children positive verbal consent before
participation (18).
For this cross-sectional study, data from 12- and 15-year-olds
were analysed. A total of 3038 and 3281 children aged 12 and
15 years were eligible. Of them, 2532 (83 per cent) and 2418 (74
per cent) were clinically examined. The response rate for the pupil
questionnaire was over 99 per cent for both ages and for the parent
questionnaire was 39 per cent for 12 year-olds and 34 per cent for
15 year-olds (18).
Measures
Eating difficulty and sugars intake were the two outcome measures
for this study. For eating difficulty, adolescents were asked ‘In the
last three months, have you had difficulty eating because of prob-
lems with your teeth and mouth?’ with four possible response op-
tions (not at all, a little, a fair amount, and a lot). This question was
part of the Child version of the Oral Impacts on Daily Performances
(Child-OIDP) questionnaire (19) that has been validated for use
among British children (20). For analysis, responses were recoded
into no eating difficulty versus any eating difficulty because very few
participants reported a fair amount and a lot of difficulties in eating
(n = 94 and 28 respectively). For sugars intake, adolescents reported
European Journal of Orthodontics, 2021, Vol. 43, No. 2
their usual intake of 5 sugary items (cake or biscuits; sweets, candy,
or chocolate; coke or other soft drinks or squash that contain sugars;
energy or sports drinks; and fruit juices and smoothies). All answers
were collected using six response options: four or more times a day,
three times a day, twice a day, once a day, less than once a day, and
rarely or never. Weighted scores were used to estimate adolescents’
daily frequency of sugars intake as described elsewhere (21). A score
of 0 was assigned to responses ‘rarely or never’ and ‘less than once a
day’, a score of 1 to response ‘once a day’, a score of 2 to response
‘twice a day’, a score of 3 to response ‘three times a day’ and a score
of 4 to response ‘four or more times per day’. Weighted responses
for food items were added to produce separate scores for the two
solid sugary items (ranging from 0 to 8 times/day) and the three
liquid sugary items (ranging from 0 to 12 times/day). The sum of
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both scores yielded the total sugar intake, which ranged from 0 to
20 times/day.
Wearing orthodontic appliances is the exposure of interest,
which was assessed during clinical examination. The presence and
type of appliance worn (fixed or removable) were recorded for each
jaw. Participants were classified as individuals wearing fixed, remov-
able, or no appliances.
Several factors were also included in the analysis as potential
confounders. They were demographic factors (age, sex, ethnicity,
and country of residence), family socioeconomic status (area de-
privation), behaviours (dental attendance pattern and toothbrushing
frequency), and orthodontic treatment need, which were collected
as part of the pupil questionnaire. Information on ethnicity (White,
Mixed, Asian, Black, or Other) and household postcodes were ex-
tracted from schools’ records. Postcodes were used to retrieve the
Index of Multiple Deprivation (IMD) quintiles, which, based on ad-
ministrative data at the local level, classifies areas from the most
deprived to the least deprived. Adolescents also reported their dental
attendance pattern (regularly for check-up, only when in trouble or
never) and toothbrushing frequency (brushing their teeth three or
more times per day, three times, twice, once, less than once per day,
or never). Orthodontic treatment need was assessed using the Dental
Health Component of the Index of Orthodontic Treatment Need
(IOTN), which has 5 grades: Grades 1 to 2 indicate no treatment
need, grade 3 indicates borderline treatment need, and grades 4 and
5 indicate definite treatment need (22).
Data analysis
All analyses were run with Stata IC 16 (StataCorp., College Station,
TX). Weights were used to account for the unequal probability of se-
lection and non-response. The survey design (stratification and clus-
tering) was accounted for to produce corrected standard errors (18).
We first compared the socio-demographic, behavioural, and clin-
ical characteristics of adolescents included and those excluded from
the analysis because of missing data on relevant variables using the
χ 2 test. We, then, compared adolescents wearing fixed, removable
and no appliances in terms of sociodemographic, behavioural, and
clinical characteristics using the χ 2 test.
The crude and adjusted association between wearing orthodontic
appliances and difficulty eating was tested in logistic regression mod-
els as the outcome measure was a dichotomous variable. Odds ratios
(ORs) were the measure of association in this set of models. The
adjusted model controlled for all confounders (age, sex, ethnicity,
country of residence, area deprivation, IOTN, dental attendance pat-
tern, and toothbrushing frequency). The crude and adjusted associ-
ations of wearing orthodontic appliances with total sugar intake,
solid sugary items intake, and liquid sugary items intake were tested
G. Albaqami et al. 195

in linear regression models as the three outcome measures were nu-
merical variables with normal distribution. The regression coefficient
was the measure of association in this set of models. The adjusted
model controlled for all confounders listed above.
Results
Of the 4950 12- and 15-year-old adolescents who participated in
the survey, 834 were excluded because of missing information on
relevant variables. Thus, data from 4116 adolescents were analysed.
There were no differences between adolescents in the study sample
and those excluded in terms of the type of orthodontic appliance
worn, difficulty eating, total sugar intake, or confounders. The char-
acteristics of the study sample are shown in Table 1. In the study
removable, and no appliances. Differences among groups were
identified in terms of demographic characteristics and behaviours.
In terms of demographic characteristics, there were significantly
higher proportions of female adolescents, 15-year-olds and those
from Northern Ireland in the group wearing fixed appliances than in
the other two groups. As for behaviours, there were higher propor-
tions of adolescents who visited the dentist for check-ups and who
brushed their teeth 3 or more times a day in the group with fixed
appliances than in the other two groups.
Wearing orthodontic appliances was associated with difficulty
eating in both crude and adjusted models (Table 3). In the ad-
justed model, adolescents with fixed appliance had 4.02 (95% CI:
3.03, 5.33) greater odds of reporting eating difficulty in the past
3 months than those wearing no appliances. However, no differ-

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sample, 453 adolescents (10.1 per cent) worn fixed appliances and
97 (2.8 per cent) worn removable appliances. Furthermore, 21.0 per
cent had eating difficulties and the mean daily frequency of sugar
intake was 5.3 times/day (SD: 3.7, range: 0–20).
Table 2 shows the comparison of sociodemographic, behav-
ioural, and clinical characteristics among adolescents wearing fixed,
ences were found between adolescents wearing removable and no
appliances (OR: 0.64; 95% CI: 0.24, 1.69). In contrast, no asso-
ciation between wearing orthodontic appliances and total sugar
intake was identified (Table 3). In the adjusted model, those with
fixed orthodontic appliances had a higher, albeit not significant,
intake of sugars (regression coefficient: 0.20; 95% CI: –0.27 to

Table 1. Comparison between participants included and excluded from the analysis.

Study sample Excluded

(n = 4116) (n = 834)

n % n % P*

Sex 0.903
Male 1973 50.7 404 50.1
Female 2143 49.3 430 49.9
Age 0.625
12 years 2070 48.2 462 50.1
15 years 2046 51.8 372 49.9
Ethnicity 0.699
White 3421 79.7 402 79.5
Asian 382 10.2 44 11.9
Black 155 4.8 21 4.2
Other 158 5.3 17 4.4
Area deprivation 0.092
Q1 (most deprived) 1519 32.7 233 30.8
Q2 887 19.9 161 31.3
Q3 655 14.3 78 14.6
Q4 617 18.3 93 14.7
Q5 (least deprived) 438 14.8 46 8.6
Country of residence 0.893
England 2324 91 423 92
Wales 932 5.4 236 4.6
Northern Ireland 860 3.6 175 3.4
IOTN 0.976
No/borderline need 2526 63 478 63
Definite need 1040 24.2 229 24.6
Under treatment 550 12.9 105 12.4
Dental attendance pattern 0.943
Check-up 3391 81.8 620 81.7
When trouble 624 15.6 117 15.4
Never 101 2.6 18 2.8
Toothbrushing frequency 0.707
3+ times a day 447 8.1 77 9.8
Twice a day 2743 70.7 493 68.7
Once a day 809 18.1 147 19.1
Less often 117 3.1 31 2.5

IOTN, Index of Orthodontic Treatment Need.

* Chi-squared test was used for comparisons.
196 European Journal of Orthodontics, 2021, Vol. 43, No. 2

Table 2. Comparison of sociodemographic and behavioural factors between adolescents wearing no, fixed and removable orthodontic
appliances.

No appliances Fixed appliances Removable appli-

(n = 3566) (n = 453) ances (n = 97)

n % n % n % P*

Sex 0.002
Male 1777 52.5 158 36.6 38 46.9
Female 1789 47.5 295 63.4 59 53.1
Age <0.001
12 years 1864 50.2 161 32.4 45 40.9
15 years 1702 49.8 292 67.6 52 59.1
Ethnicity 0.249
White 2957 79.5 378 79.3 86 88.4
Asian 327 9.9 50 13.3 5 6.4

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Black 142 5.1 9 3.1 4 3.4
Other 140 5.5 16 4.2 2 1.8
Area deprivation 0.754
Q1 (most deprived) 1327 32.8 157 31.1 35 34
Q2 776 19.9 96 20.3 15 16.5
Q3 552 14.6 89 12.7 14 9.7
Q4 541 18.5 59 17.1 17 17.3
Q5 (least deprived) 370 14.1 52 18.8 16 22.4
Country of residence 0.034
England 2048 91 221 89.5 55 94.3
Wales 822 5.6 86 4.8 24 3.3
Northern Ireland 696 3.4 146 5.7 18 2.4
IOTN –
No/borderline need 2526 72.2
Definite need 1040 27.8
Under treatment 453 100 97 100
Dental attendance pattern 0.007
Check-up 2871 80.0 430 95.0 90 91.3
When trouble 595 17.1 22 4.6 7 8.7
Never 100 2.9 1 0.4 0 0.0
Toothbrushing frequency <0.001
3+ times a day 311 6.9 120 18.8 16 7.9
Twice a day 2383 70.1 287 72.2 73 82.1
Once a day 758 19.4 44 9.0 7 9.9
Less often 114 3.6 2 0.1 1 0.03

IOTN, Index of Orthodontic Treatment Need.

*Chi-squared test was used for comparisons.

0.66) than those wearing no appliances. Adolescents with remov-
able orthodontic appliances had a lower, albeit not significant,
intake of sugars (regression coefficient: –0.30; 95% CI: –0.96 to
0.36) than those with no appliances. Similar non-significant esti-
mates were found when analysis was stratified by solid or liquid
sugary items. For solid sugary items, the adjusted coefficients for
adolescents wearing fixed and removable appliances were, re-
spectively, 0.16 (95% CI: –0.11, 0.43) and 0.00 (95% CI: –0.32,
0.31) compared with adolescents with no appliances. For liquid
sugary items, the adjusted coefficients for adolescents wearing
fixed and removable appliances were, respectively, 0.04 (95% CI:
–0.26, 0.34) and –0.29 (95% CI: –0.76, 0.17) compared with ado-
lescents with no appliances.
Discussion
The findings showed that wearing orthodontic appliances, particu-
larly fixed appliances, was associated with eating difficulty in the
past 3 months, but not with intake of sugars. These findings were
robust to adjustments for well-known determinants of oral health
among adolescents.
Wearing fixed, but not removable, appliances was associated
with eating difficulty, which agrees with previous studies (10–12).
The magnitude of the association was such that adolescents with
fixed orthodontic appliances were four times more likely to report
eating difficulties than those not wearing appliances. Evidence from
qualitative studies suggests that adolescents wearing orthodontic
appliances experience a restriction of food choices (i.e. moving to
a softer diet) due to pain, tooth mobility, and fear associated with
breaking the appliance (16, 17, 23). They also face issues during
the eating process, such as taking longer to eat, eating less, being
messy while eating, and having chewing/biting problems and alter-
ation of taste (16, 17). These side effects should be openly discussed
with adolescents and their parents prior to treatment and balanced
against the potential long-term positive impacts of orthodontic
treatment on quality of life (24). During treatment, inconveniences
may be well interpreted as normal outcomes if the adolescent is con-
stantly reminded that he/she is paving the way for good occlusion
G. Albaqami et al. 197

Table 3. Regression models for the association of wearing orthodontic appliances with eating difficulty and sugars intake among British
adolescents (n = 4116).

% difficulty Crude associations Adjusted associations

n % ORa [95% CI] ORa [95% CI]

None 714 18.8 1.00 [Reference] 1.00 [Reference]

Fixed 171 42.8 3.23 [2.36, 4.42]** 4.02 [3.03, 5.33]**
Removable 15 10.8 0.52 [0.21, 1.28] 0.64 [0.24, 1.69]

Sugar intake Crude associations Adjusted associations

Mean (SD) Coef.a [95% CI] Coef.a [95% CI]

Total sugar intake (times/day)
None 5.4 (3.8) 0.00 [Reference] 0.00 [Reference]

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Fixed 5.0 (3.8) –0.32 [–0.79, 0.14] 0.20 [–0.27, 0.66]
Removable 4.7 (3.1) –0.67 [–1.52, 0.18] –0.30 [–0.96, 0.36]
Intake of solid sugary items (times/day)
None 2.6 (2.1) 0.00 [Reference] 0.00 [Reference]
Fixed 2.6 (2.2) –0.04 [–0.30, 0.22] 0.16 [–0.11, 0.43]
Removable 2.5 (1.6) –0.14 [–0.51, 0.24] –0.00 [–0.32, 0.31]
Intake of liquid sugary items (times/day)
None 2.5 (2.2) 0.00 [Reference] 0.00 [Reference]
Fixed 3.4 (2.7) –0.28 [–0.56, –0.03]* 0.04 [–0.26, 0.34]
Removable 4.4 (3.2) –0.53 [–1.09, 0.04] –0.29 [–0.76, 0.17]

a
Eating difficulty was modelled using logistic regression and odds ratios (ORs) were reported. Intake of sugars was modelled using linear regression and re-
gression coefficients (Coef.) were reported. The adjusted model controlled for demographic (sex, age, ethnicity, and country of residence), behavioural (dental
attendance pattern and toothbrushing frequency) and clinical factors (IOTN).
*P < 0.05; ** P < 0.001.

and at the end of treatment, an improved smile will be achieved.
These discussions can help with managing expectations and increas-
ing satisfaction with treatment (25). The lack of differences be-
tween adolescents wearing removable and no appliances could be
explained by the ability to remove the appliance for eating. Indeed,
adolescents wearing removable appliances adapt to their appliances
by persevering and using strategies to manage physical impacts (26).
Contrary to our expectations, wearing orthodontic appliances
were not associated with consumption of sugars, either when ana-
lysed as total intake or stratified by food consistency (solid and
liquid items). Although those wearing fixed and removable had dif-
ferent intakes of sugars than those not wearing any appliances, such
differences were not significant and, therefore, unlikely to be clin-
ically relevant given the high sugars intake observed among these
adolescents. Our sugars intake questionnaire was brief and unlikely
to capture all sources of sugars in the diet of participants. That said,
our findings were consistent with those of previous studies (14, 15).
However, these findings contradict qualitative evidence suggesting
that some adolescents restrict their food choices (i.e. sweets and
fizzy drinks) following advice from the orthodontist to prevent de-
calcification (16, 17). These findings imply that adolescents are not
being informed adequately or they are simply not following their
orthodontist’s recommendations. Unassertive counselling from the
orthodontist and failure of adolescents in following the practition-
er’s instructions may be associated with the challenges involved in
changing an individual’s behaviour (27). Orthodontists should in-
clude in their portfolio strategies aiming to modify behaviours that
are incompatible with appliance wearing (28) and guide adolescents
regarding the implications of other issues, such as the use of medica-
tions and dietary supplements for orthodontic treatment movement
(29). Behaviour change in relation to dietary habits is a complex
task because an individual’s diet is shaped not only by his/her own
beliefs and values but more so by external influences such as the
home environment, peer pressure, and the commercial advertising
of profitable industries (27). In this regard, motivational interview-
ing, a person-centred counselling technique that elicits patients’ in-
trinsic motivations, enhances their commitment and explores their
own solutions towards change (30), was shown to be more effective
than traditional dental health education to reduce sugars intake and
prevent dental caries in adolescents (31). These findings are encour-
aging for various reasons: first, parents must be involved in the
decision-making process for changes to be sustainable; second, caries
risk assessment can be a valuable resource in discussions prior to and
during treatment; third, positive reinforcement during the appoint-
ments for appliance bonding and activation are needed to avoid re-
lapse; and fourth the intervention was delivered by dental hygienists,
thus providing a way to implementation in general dental practices.
The present findings have some implications for practice and fur-
ther research. Clinicians and patients should be aware of the side
effects of orthodontic treatment, particularly on eating, that could
affect people’s daily lives. Given the high intake of sugars observed
among adolescents, especially sugared-sweetened beverages (4), and
growing evidence that wearing orthodontic appliances might in-
crease caries risk (32), the lack of differences in sugars intake among
adolescents with and without orthodontic appliances is somewhat
worrisome. As for research, population-based longitudinal studies
would be welcome in this research area, especially those accounting
for treatment duration and including multiple measures of sugars
intake over time.
The study has a few limitations that ought to be addressed. First,
the cross-sectional design implies that we are only able to report as-
sociations rather than causal relationship between variables. Second,
data collection of the Children’s Dental Health Survey took place
in 2013, which might be considered relatively old. However, this
is the latest oral health survey among children in the UK and al-
lowed testing our hypothesis at national level. Third, we excluded
198
around 17 per cent of the participants because of missing values on
relevant variables. However, survey weights were used during the
analysis to account for non-response. Moreover, we found no dif-
ferences between participants included and excluded from the ana-
lysis. Therefore, the present findings might still be representative of
the adolescent population in England, Wales, and Northern Ireland.
Fourth, both outcomes (eating difficulty and sugars intake) were self-
reported and, as such, prone to measurement bias. However, self-
reports are the standard and most feasible way to measure these
variables in national surveys. In addition, they were taken from
validated measures (19, 13) that had been previously used among
British children (20, 34). Finally, although the presence and type of
orthodontic appliances were clinically determined, no information
on how long adolescents have had the appliances was collected as
part of the survey. As some participants might have already adapted
to their appliances, the estimates reported here are considered con-
servative. In addition, it is possible that orthodontic treatment might
have been completed among some 15-year-olds, which could have
altered their sugars intake, thus pulling the estimates towards the
null.
Conclusion
Using data from a national sample of 12- and 15-year-old adoles-
cents in England, Wales, and Northern Ireland, this study found
that wearing orthodontic appliances, especially fixed ones, was as-
sociated with greater odds of experiencing eating difficulty. In con-
trast, wearing orthodontic appliances was not associated with daily
sugar intake.
Acknowledgements
The period of Lucas Guimaraes Abreu as a visiting researcher at
King’s College London was financed in part by Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior—Brasil (CAPES)—
Códico de Financiamento 001. Support from Conselho Nacional de
Desenvolvimento Científico e Tecnológico (CNPq) (404710/2018-2
and 310797/2019-5) is also recognized.
Funding
This study received no funding to conduct this study.
Conflict of interest
The authors declare no conflict of interest in relation to this work.
Data availability
Data from the Children’s Dental Health Survey are publicly
available from the UK data archive (http://doi.org/10.5255/
UKDA-SN-7774-1).
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