ORIGINAL
RESEARCH
Malocclusions
and social determinants of health in patients at the Eloy Alfaro Lay University
of Manabí
Maloclusiones
y determinantes sociales de la salud en pacientes de la Universidad Laica Eloy
Alfaro de Manabí
Ámbar Párraga Molina1. Iván Macías Alava2.
Alba Mendoza
Castro3
1 Undergraduate student in Dentistry. Eloy Alfaro Lay
University of Manabí. https://orcid.org/0009-0002-4507-2043
2 Undergraduate student in Dentistry. Eloy Alfaro Lay University of
Manabí. https://orcid.org/0009-0003-6862-4960
3 Specialist in Orthodontics. Faculty member, Eloy Alfaro Lay
University of Manabí. https://orcid.org/0000-0002-5720-3795
ABSTRACT
Malocclusions are among the
most common disorders in dentistry and are commonly classified according to
Angle's criteria into Classes I, II, and III. Although their origin is
multifactorial, social determinants of health (SDH) can influence their onset
and the timeliness of care. Objective: To analyze the relationship between
malocclusions and social determinants of health in the Orthodontic Clinic of
the Dentistry Degree at ULEAM during the academic period 2025-1. Materials and
methods: A descriptive, correlational, observational, cross-sectional study
with a quantitative approach was conducted. The sample consisted of 90 patients
selected using non-probability convenience sampling. Sociodemographic,
clinical, and social determinants data were collected from medical records and
administered surveys. Statistical analysis included frequencies, percentages,
and the chi-square test to establish associations between variables. Results:
Class I malocclusion was the most prevalent (71.1%), followed by Class II
(25.6%) and Class III (3.3%). No statistically significant associations were
found between Angle classification and gender (p = 0.567) or age (p = 0.090).
Regarding SSD, conditions of vulnerability were identified, including food
insecurity (45.6%), economic hardship (72.2%), and limited access to health
services (45.6%). Conclusions: Although no significant associations were found
between SSD and Angle class, the results show the presence of social factors
that may indirectly influence oral health.
Keywords: Malocclusions.
Social determinants of health. Angle classification.
Orthodontics.
RESUMEN
Las maloclusiones son de
las alteraciones más frecuentes en odontología y se clasifican comúnmente
mediante los criterios de Angle en Clases I, II y III. Aunque su origen es
multifactorial, los determinantes sociales de la salud (DSS) pueden influir en
su aparición y en la oportunidad de atención. Objetivo: Analizar la relación
entre las maloclusiones y determinantes sociales de la salud en la Clínica de
Ortodoncia de la Carrera de Odontología en la ULEAM durante el período
académico 2025-1. Materiales y métodos: Se realizó un estudio descriptivo
correlacional, observacional, transversal con enfoque cuantitativo. La muestra
fue de 90 pacientes seleccionados mediante muestreo no probabilístico por
conveniencia. Se recopilaron datos sociodemográficos, clínicos y de
determinantes sociales a partir de las historias clínicas y encuestas
aplicadas. El análisis estadístico incluyó frecuencias, porcentajes y la prueba
de Chi cuadrado para establecer asociaciones entre variables. Resultados: La
maloclusión Clase I fue la más prevalente (71,1%), seguida de la Clase II
(25,6%) y la Clase III (3,3%). No se encontraron asociaciones estadísticamente
significativas entre la clasificación de Angle y el género (p = 0,567) ni con
la edad (p = 0,090). Respecto a los DSS, se identificaron condiciones de
vulnerabilidad, destacando inseguridad alimentaria (45,6%), dificultades
económicas (72,2%) y limitaciones para el acceso a servicios de salud (45,6%).
Conclusiones: Aunque no se hallaron asociaciones significativas entre los DSS y
la clase de Angle, los resultados evidencian la presencia de factores sociales
que pueden influir indirectamente en la salud bucal.
Palabras clave:
Maloclusión. Determinantes sociales de la salud. Clasificación de Angle. Ortodoncia.
INTRODUCTION
People’s living conditions,
as well as how they learn, work, engage in leisure activities, and practice
their religion, can affect health and generate disparities. Therefore, despite
improvements in health care and disease prevention, health inequalities are
real and difficult to counteract¹˒². Likewise, the social determinants of
health are reflected in the way people live, that is, whether they have access
to medical care, economic stability, food security, and a safe climate. The
social environment, as well as the educational and work environments, also have
an impact. All these daily circumstances play a crucial role in patients’
overall health. Consequently, health professionals must be trained to
understand that they play a role in the detection, assessment, and management
of these determinants in their clinical practice².
In this regard, there are
social determinants that negatively impact health and well-being, such as
poverty; lack of access to quality education or employment; substandard
housing; unfavorable working and neighborhood conditions; and the concentration
of disadvantages among specific population groups and in specific locations³.
Similarly, social
determinants act as risk factors for collective oral health. This translates
into populations facing socioeconomic difficulties, belonging to less
advantaged social strata, with low income and limited formal education,
presenting a higher prevalence of oral diseases⁴˒⁵.
On the other hand, dental
occlusion involves the dynamic relationship among the teeth (upper and lower),
the maxilla, the mandible, the temporomandibular joint (TMJ), and the muscles.
Ideally, a dynamic balance should exist to ensure the functional state of the
stomatognathic system⁶. Malocclusions, by contrast, refer to misalignment or
imbalance between the upper and lower teeth, as well as between the jaws,
leading to unfavorable consequences for the patient from an anatomical,
physiological, and aesthetic standpoint⁷.
According to a scoping
review conducted by Cenzato et al.⁸, among the three
Angle classes, Class I was the most frequent, followed by Class II, with Class
III being the least frequent. Specifically, the prevalence of Class I ranged
from 34.9% to 93.6%, while the average prevalence of Class II was 20.2%. In
turn, Alhammadi et al.⁹ reported that the global
distribution of malocclusion according to Angle’s classification was 74.7% for
Class I, 19.56% for Class II, and 5.93% for Class III.
Orthodontics is commonly
understood exclusively from its clinical dimension¹⁰. However, incorporating
the analysis of the role of social determinants of health may allow for a more
comprehensive approach that includes preventive strategies, considering
patients within their social context, which is consistent with public health
principles. Furthermore, since social determinants influence oral health from
an early age¹¹, studying this relationship may reveal inequalities in the
occurrence and treatment of malocclusions, which is crucial for improving
health equity.
At the Orthodontics Clinic
of the Dentistry Program at ULEAM, patients with different types of
malocclusions are treated. This research aims to identify the types of malocclusions
according to Angle’s classification present in this population, while also
exploring possible connections between malocclusions and the social
determinants of health. Therefore, the objective of this study is to analyze
the relationship between malocclusions and social determinants of health at the
Orthodontics Clinic of the Dentistry Program at ULEAM during the academic
period 2025-1.
MATERIALS AND METHODS
This was a descriptive
study with a retrospective, observational, and cross-sectional design. The
population consisted of the clinical records of patients who attended the
Orthodontics Clinic of the Dentistry Program at ULEAM during the 2025-1 period,
as well as oral health–related quality of life questionnaires completed by the
patients with the support of their parents or legal guardians, and social
determinants questionnaires completed by the guardians. A non-probabilistic
convenience sampling method was used, resulting in a sample of 90 clinical
records with their corresponding surveys.
Data were obtained through
a database developed from the transcription of dental clinical records (Form
033) of the Ministry of Public Health¹² and from the application of the survey
on social determinants of health and risk factors for oral health¹³.
Ethical considerations
Prior to the execution of
the research, the protocol was submitted to the Ethics Committee for Research
Involving Human Beings of the Universidad Laica “Eloy
Alfaro” de Manabí (CEISH–ULEAM) and was approved under code CEISH-ULEAM_0346.
Before data collection, the parents and/or legal guardians of the participants
signed an informed consent form. The right to anonymity and confidentiality was
guaranteed, and ethical and responsible data management was ensured. The
information contained in the clinical records was transcribed into a database,
to which only the researchers had access.
Data analysis
Once the database was
obtained in Excel (Microsoft Office 365), it was imported into the statistical
software SPSS, version 27 (IBM), for data processing. Descriptive and
inferential statistical measures were obtained. Data were presented in
frequency distribution tables and cross-tabulation tables.
RESULTS
Demographic data showed a
predominance of male patients, with 51 individuals (56.7%), and of the age
group of nine years or older (51.1%). Regarding malocclusions, 71.1% were Class
I and 25.6% were Class II (Table 1).
Table 1.
Demographic characteristics and malocclusions in patients who attended the
Orthodontics Clinic of the Dentistry Program at ULEAM during the 2025-1 period.
|
Gender
|
n (90)
|
%
|
|
Male
|
51
|
56.7
|
|
Female
|
39
|
43.3
|
|
Age
group
|
n (90)
|
%
|
|
≤ 8
|
44
|
48.9
|
|
≤ 9
|
46
|
51.1
|
|
Malocclusions
|
n (90)
|
%
|
|
Class I
|
64
|
71.1
|
|
Class II
|
23
|
25.6
|
|
Class II
|
3
|
3.3
|
Source: Clinical
records – Orthodontics Clinic of the Dentistry Program at ULEAM, 2025-1.
In the analysis of
distribution by gender, it was concluded that in Class I, 53.1% were male and
46.9% were female. In Class II, 65.2% were male and 34.8% were female;
meanwhile, in Class III, males accounted for 66.7% and females for 33.3%. The
Chi-square test result (p = 0.567) showed no statistically significant
differences between gender and Angle classification (Table 2). Class I was more
frequent in the group aged 8 years or younger (56.3%) than in the group aged 9
years or older (43.7%).
On the other hand, Class II
was more frequent among patients aged 9 years or older (69.6%), while Angle
Class III was similarly distributed between the two age cohorts. The
relationship between age and Angle classification was not statistically
significant according to the Chi-square analysis (p = 0.090) (Table 2).
Table 2.
Prevalence of malocclusions according to Angle classification among patients of
the Orthodontics Clinic of the Dentistry Program at ULEAM during the 2025-1
period, by gender and age group.
|
Angle
Classification
|
Gender
|
Totals
|
|
Male
|
Female
|
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Class I
|
34
|
53.1
|
30
|
46.9
|
64
|
100
|
|
Class II
|
15
|
65.2
|
8
|
34.8
|
23
|
100
|
|
Class III
|
2
|
66.7
|
1
|
33.3
|
3
|
100
|
|
p = 0.567 (NS)
Chi-square test of independence.
S = Significant (p < 0.05); NS = Not significant (p ≥ 0.05)
|
|
Angle
Classification
|
Age
group
|
Gender
|
Totals
|
|
≤ 8
|
≥ 9
|
Male
|
Female
|
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Class I
|
36
|
56.3
|
28
|
43.7
|
64
|
100
|
|
Class II
|
7
|
30.4
|
16
|
69.6
|
23
|
100
|
|
Class III
|
1
|
33.3
|
2
|
66.7
|
3
|
100
|
|
Totales
|
44
|
48.9
|
46
|
51.1
|
90
|
100
|
|
p = 0.090 (NS)
Chi-square test of independence.
S = Significant (p < 0.05); NS = Not significant (p ≥ 0.05)
|
Source:
Clinical records – Orthodontics Clinic of the Dentistry Program at ULEAM,
2025-1.
Patients reported various
situations experienced due to dental or gingival problems. A total of 47.8% of
participants stated that they were not satisfied with the appearance of their
teeth, and 34.4% reported avoiding smiling because of their teeth (Figure 1).
Figure 1.
Situations experienced by patients of the Orthodontics Clinic of the Dentistry
Program at ULEAM during the 2025-1 period due to dental or gingival problems.
Source: Surveys
conducted – Orthodontics Clinic of the Dentistry Program at ULEAM, 2025-1.
Regarding the frequency of
dental visits, 31.1% of patients visited the dentist at least twice in recent
months, 16.7% more than four times, while 17.8% had not visited a dentist in
the past year and 1.1% had never received dental care (Table 3).
Table 3.
Frequency of dental visits among patients of the Orthodontics Clinic of the
Dentistry Program at ULEAM during the 2025-1 period.
|
Frequency
of dental visits in recent months
|
n (90)
|
%
|
|
Once
|
9
|
10.0
|
|
Twice
|
28
|
31.1
|
|
Three times
|
11
|
12.2
|
|
Four times
|
8
|
8.9
|
|
More than
four times
|
15
|
16.7
|
|
Did not visit
in the last 12 months
|
16
|
17.8
|
|
Never
received dental care or visited a dentist
|
1
|
1.1
|
|
Do not know /
do not remember
|
2
|
2.2
|
Source: Surveys
conducted – Orthodontics Clinic of the Dentistry Program at ULEAM, 2025-1.
With respect to other
social determinants of health, the following findings are highlighted:
regarding food access, 45.6% reported having experienced limitations in access
to sufficient food during the past 12 months; concerning transportation, 27.8%
stated that they had delayed or neglected medical appointments due to
transportation difficulties or distance; 47.8% of the population reported
having problems covering basic services such as water or electricity; 72.2%
reported having insufficient income at some point to pay their bills; and 45.6%
indicated that they needed medical care but were unable to attend due to lack
of resources for transportation (Table 4).
Table 4. Social
determinants of health among patients of the Orthodontics Clinic of the
Dentistry Program at ULEAM during the 2025-1 period.
|
Category
|
Item
|
Response
options
|
|
Yes
|
No
|
|
n
|
%
|
n
|
%
|
|
Housing and
shelter
|
Are you
concerned that in the coming months you may not have stable housing that you own,
rent, or belong to as part of your household?
|
37
|
41.1
|
53
|
58.9
|
|
Food
|
| In the past
12 months, did you ever eat less than you should because you were worried
that food would run out before you had money to buy more, or because the food
you bought did not last and you had no money to buy more?
|
41
|
45.6
|
49
|
54.4
|
|
Transportation
|
Do you
postpone or neglect going to the doctor due to distance or transportation
issues?
|
25
|
27.8
|
65
|
72.2
|
|
Utilities
|
In the past
12 months, have you had difficulty paying utility bills (electricity or
water)?
|
43
|
47.8
|
47
|
52.2
|
|
Family care
|
Do you have
difficulty finding or paying for childcare or care for dependent family
members?
|
14
|
15.6
|
76
|
84.4
|
|
If yes, do
these problems make it difficult for you to work or study?
|
12
|
13.3
|
78
|
86.7
|
|
Income
|
Have you ever
not had enough money to pay your bills?
|
65
|
72.2
|
25
|
27.8
|
|
Safety
|
Have you ever
felt unsafe, been threatened, physically harmed, insulted, belittled, or
shouted at in your home or neighborhood?
|
29
|
32.2
|
61
|
67.8
|
|
Health care
|
During the
past month, did poor physical or mental health prevent you from carrying out
your usual activities such as work, school, or hobbies?
|
28
|
31.1
|
62
|
68.9
|
|
In the past
year, was there a time when you needed to see a doctor but could not because
it was too expensive?
|
41
|
45.6
|
49
|
54.4
|
|
Assistance
|
Would you
like to receive help with any of these needs?
|
68
|
75.6
|
22
|
24.4
|
|
Is any of
your needs urgent?
|
39
|
43.3
|
51
|
56.7
|
|
Employment
|
Do you have a
job or another stable source of income?
|
59
|
65.6
|
31
|
34.4
|
|
Education
|
Do you have a
high school diploma?
|
79
|
87.8
|
11
|
12.2
|
|
Clothing and
household items
|
Do you have
enough household items, such as clothing, shoes, blankets, mattresses,
diapers, toothpaste, and shampoo?
|
79
|
87.8
|
11
|
12.2
|
Source: Surveys
conducted – Orthodontics Clinic of the Dentistry Program at ULEAM, 2025-1.
DISCUSSION
The results of the present
study allow for an analysis of the impact of the ULEAM Mobile Dental
Clinic on the oral health of children and adolescents in southern Manabí and
enable comparison with similar research conducted in rural settings and
vulnerable populations.
The equitable distribution
of patients by gender is consistent with findings reported in previous studies,
which have identified no significant differences in access to mobile dental
services between boys and girls. This reinforces the inclusive nature of this
care model in vulnerable populations (6). This finding supports the
effectiveness of mobile clinics as a strategy to promote equity in child oral
healthcare.
Regarding age, the highest
concentration of care in the 5–7-year age group (47.5%) is consistent with
national and international research indicating that this age group presents
greater vulnerability to dental caries, particularly in primary dentition (7),
Due to inadequate oral hygiene habits and limited adult supervision. This
result demonstrates that the mobile clinic is reaching a priority group for the
early prevention of oral pathologies.
With respect to geographic
distribution, the predominance of the canton of Manta as the main recipient of
dental care aligns with studies reporting that mobile clinics tend to
concentrate their interventions in areas with higher population density or greater
logistical accessibility (8). However, this concentration also
reflects unequal coverage in cantons such as Portoviejo and Montecristi,
a situation previously described as one of the main barriers to equitable
access to oral health services in rural communities in Ecuador (9,10).
In terms of preventive
interventions, the high frequency of dental prophylaxis and fluoride
application in Manta and Jipijapa is consistent with
other studies highlighting these procedures as priorities in community programs
due to their low cost and high impact on plaque reduction and caries
prevention. Nevertheless, the low application of dental sealants observed in
this study differs from recommendations in the literature, which identify
sealants as one of the most effective strategies for preventing caries in
permanent molars in the pediatric population (11,12). This finding
suggests the need to strengthen this preventive component.
Finally, the limited
provision of restorative treatments in several cantons is consistent with World
Health Organization recommendations, which indicate that mobile programs tend
to prioritize health promotion and prevention over complex curative treatments.
However, the persistence of untreated caries, particularly in primary
dentition, highlights the need to reinforce follow-up actions and timely
referral mechanisms to achieve a sustained impact on child oral health (13).
Overall, the findings
confirm that the ULEAM Mobile Dental Clinic constitutes an effective strategy
for improving access to oral health services and strengthening preventive
education among children and adolescents, in line with reports in the
scientific literature. However, as in other similar contexts, challenges remain
related to territorial equity, continuity of care, and the intensification of
early preventive actions (14).
CONCLUSION
The evaluation of records
from children and adolescents treated by the ULEAM Mobile Dental Clinic during
the academic period 2024-1 made it possible to identify an oral health
condition that, while showing progress in terms of coverage and oral hygiene
education, still faces significant challenges in the prevention and effective
treatment of dental caries, particularly in primary dentition.
The concentration of care
in certain localities, the high proportion of untreated caries, and the
presence of plaque in a substantial segment of the pediatric population reveal
the need to strengthen health promotion and prevention strategies, prioritizing
intervention at the earliest stages of life. The study reaffirms the value of
the mobile clinic as a fundamental resource for delivering dental care to
communities with limited access and highlights the importance of maintaining
systematic monitoring of oral health indicators to guide future actions.
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AUTHOR CONTRIBUTION
STATEMENT
“Conceptualization and
design: Párraga Ámbar
and Macías Iván; Literature review: Párraga Ámbar and Macías Iván; Methodology and validation: Párraga Ámbar; Formal
analysis: Macías Iván; Research and data
collection: Párraga Ámbar
and Macías Iván; Resources: Not applicable; Data
analysis and interpretation: Párraga Ámbar and Macías Iván; Writing
– original draft preparation: Párraga Ámbar and Macías Iván; Writing
– review and editing: Párraga Ámbar,
Macías Iván, and Mendoza Alba; Supervision:
Mendoza Alba; Project administration: Not applicable; Funding
acquisition: Not applicable.”
CONFLICTS OF INTEREST
The authors declare that
there were no conflicts of interest during the conduct of this research. In
addition, the manuscript was submitted exclusively to the Revista
Científica “Especialidades Odontológicas UG” for review and publication.
FUNDING
The authors report that
personal funds were used to carry out this research.
HOW TO CITE:
Párraga,
A. Macías, I. Mendoza, A. Malocclusions
and social determinants of health in patients at the Eloy Alfaro Lay University
of Manabí. Revista Científica Especialidades Odontológicas
UG. 2026:9(1):1-7