Article Type : Review Article
Authors : Talaat MA
Keywords : Dentofacial features; Malocclusion; Crowding; Orthodontics
Bullying is an aggressive behavior and a serious issue
that should be addressed by everyone and should be avoided at all costs. It is
is very common among adolescents and schoolchildren and the effects can be
devastating and long lasting. Most common causes of bullying among students are:
physical appearance, race, gender, disability, ethnicity, religion, and sexual
orientation. Appearance-targeted bullying is a form of bullying that targets
one’s physical appearance, which includes facial and dental features. Deviation
from accepted dentofacial aesthetics can lead to elevated cases of bullying in
schoolchildren. The aim of this review article is to assess the prevalence of
bullying due to dentofacial features, and evaluate the importance of
dentofacial appearance on the perceived social attractiveness, based on
multiple studies.
Bullying is described as an aggressive behavior in
which someone purposely and repeatedly causes harm or discomfort to another
individual [1]. Bullying exists in various shapes and different forms, which
includes physical or verbal assault, social bullying, engaging in insidious practices
and cyber bullying [2,3]. Bullying can also be categorized into: overt such as
hitting, threatening, or calling names, and covert such as spreading rumours,
manipulation of relationships, excluding and isolating [4]. In the U.S, 1 in 5
(20%) schoolchildren ages 12-18 experienced bulling throughout the school year,
and 41% of students who reported being bullied at school stated that they
believe the incidence would occur again [5] while 70% of school workers have
witnessed acts of bullying [6]. About 16% of secondary school students are
victims of bullying in Russia [7]. And a recent UNESCO report stated that
greater than 30% of schoolchildren around the world have experienced acts of
bullying [8]. It has been estimated that around 42% of students who have been
bullied during their school years indicated that it was associated with at
least one of the following: physical appearance (30%), race (10%), gender (8%),
disability (7%), ethnicity (7%), religion (5%), and sexual orientation (4%)
[9]. Victims of such an act are mainly children who are viewed as physically
unattractive and those who cannot fit society’s standards [10]. According to
the United Nations educational and cultural agency, bullies like to target
their victims based on their physical appearance, ethnicity, gender or sexual
orientation [11]. Appearance-targeted bullying is a form of bullying that
targets one aspect or more of a person's appearance [12]. YMCA England and
Wales’s In Your Face report, published in 2018, mentions that greater than half
(55%) of young people have experienced bullying targeted by their appearance,
60% of which admitted they tried to change the way they look after being
bullied. Around 53% of those who got bullied due to their appearance said they
suffered from anxiety as a result and 29% had experienced more depression. One
in 10 said they had experienced suicidal thoughts and 9% said they self-harmed
as a result [13]. The physical characteristics usually associated with bullying
are weight, height, and facial features moreover, children with better dental
appearance are perceived by society as more attractive and desirable as
friends, more intelligent, and less likely to be aggressive [14,15]. Children
ages 14 and 15 with higher clinical need for orthodontic treatment had less
self-perception and lower self-esteem when compared to others [16].
A wide search was preformed, with no time, location or
language restriction, using electronic databases, including: PubMed, PubMed
Central, National Library of Medicine and ResearchGate. Medical Subject
Headings (MeSH) terms such as “Malocclusion”, “Appearance-targeted bullying”,
“Dento-facial features” and their related entry terms were used. The included
studies’ reference lists were also searched. A comprehensive search of the
literature using a predefined search strategy found a total of 2,637 studies.
After de-duplication and eliminating irrelevant publications, the review
included a total of eight studies. Eligibility criteria included all scientific
articles concerning the incidence of bullying mainly targeted by the victims’
teeth and dento-facial features, six studies were conducted on schoolchildren
and adolescents, one study on orthodontic patients and one study on online
users as victims of dento-facial targeted bullying.
A study published in the American Journal of
Orthodontics & Dentofacial Orthopedics, aimed to look into the incidence of
bullying in a representative sample of Jordanian schoolchildren in Amman, and
to assess its consequences and effects on school performance, and the
contribution of general physical appearance and dentofacial features. The
prevalence of bullying turned out to be 47%, and teeth were the number 1
physical feature targeted by bullies. The three most commonly reported
dentofacial features targeted by bullies were spacing between the teeth or
missing teeth, shape and color of the teeth, and prominent upper anterior teeth
[17].
Another recent study aimed to investigate bullying's
prevalence owing to malocclusions and how it affects people's desire for
orthodontic treatment in a sample of German orthodontic patients, the final
sample involved 1020 patients (females = 547, males =473), 23.7% reported that
they had been bullied at least 2 or 3 times a month in the past 2 months, teeth
and weight were pointed out to be the main features targeted by bullies, the
three highly reported dentofacial features targeted for bullying were: crooked
teeth, prominent teeth and gaps between the teeth. The subjects were separated
into three categories based on the occurrence and cause of bullying: subjects
bullied due to dentofacial features, subjects bullied due to general physical
features, and subjects who didn’t experience bullying (control group). Subjects
from the dentofacial features group (6.3%) initiated orthodontic treatment
themselves significantly more often when compared to subjects from the other 2
groups, and the dentofacial features group stated that ‘ugly teeth’ were their
main reason to seek orthodontic treatment (40.4%), in addition, significantly
higher mean scores for the expectation ‘keep me from being bullied’ were
obtained from this group in comparison to subjects from other groups [18]. One
study was held among Saudi schoolchildren to determine bullying's prevalence
and consequences and the associated sociodemographic, physical, and dentofacial
features, the final sample included 1028 parents of schoolchildren aged 8-18
years old who were asked to fill questionnaires for their children. The study
revealed that (89.2%) of schoolchildren experienced bullying. Teeth were the
number one targeted physical feature for bullying, followed by the shape of the
lips and strength. The three most commonly reported dentofacial features
targeted by bullies were tooth shape and color, followed by anterior open bite
and protruded anterior teeth [19]. A cross-sectional study was conducted to
assess the severity and frequency of bullying reported by adolescents referred
for orthodontic treatment at three UK hospitals and to investigate the relation
between levels of self-reported bullying, malocclusion and requirement for
orthodontic therapy, Three hundred and thirty-six subjects aged between 10 and
14 years participated and questionnaires were used to calculate the
self-reported frequency and severity of bullying, self-esteem and OHRQoL (Oral
Health-Related Quality of Life). Orthodontic treatment need was assessed using
IOTN (Index of Orthodontic Treatment Needed). The results revealed that (12.8%)
of the subjects experienced bullying, and the most commonly reported
dentofacial features targeted by bullies were class II Division 1 incisor
relationship, increased overbite and increased overjet. A higher need for
orthodontic treatment assessed using the AC of IOTN (P50.014) was also targeted
by bullies. The study reported the presence of a significant relation between
bullying and certain occlusal traits, self-esteem and OHRQoL [20]. An
investigation into the frequency of self-harm among a sample of eighth-grade
children aged 13-14 years was conducted in a cross-sectional study, it aimed to
evaluate the contribution of dentofacial appearance and being bullied because
of dentofacial appearance to self-harm, the subjects were requested to fill out
anonymous questionnaires, and the final sample included 699 children with the
mean age being 13.3 years. The results of this study stated that the prevalence
of self-harm was 26.9%, and 47.9% of all subjects who admitted to self-harm did
so because of their dentofacial characteristics. 41 subjects reported self-harm
because of bullying targeted at dentofacial features, The three most commonly
reported dentofacial features contributing to self-harm and bullying-related
self-harm were: tooth color and shape, spacing between the teeth or missing
teeth, and prominent maxillary anterior teeth [21]. One study looked at the
relationship between bullying and malocclusion in high school students from
Olinda, Pernambuco public schools. The sample included 236 subjects aged
between 14 to 19 years, and data was collected through a questionnaire with
questions regarding PeNSE-based sociodemographic characterization and bullying.
The results indicated that (24.9%) of adolescents reported being bullied, and
(42.5%) of those who reported being bullied had malocclusion, mostly Class II
malocclusion was the prevalent. However, according to this study, bullying of
any kind did not statistically correlate with malocclusion, and malocclusion
did not correlate with bullying as a practice [22]. Another recent study sought
to qualitatively evaluate Twitter posts for common themes concerning
dentofacial features, orthodontic appliances and bullying. Keywords related to
bullying, teeth and orthodontics were used to search Twitter’s database from
2010 to 2014. 321 posts were incorporated into the final sample, and 4 main
categories relevant to ‘dental-related bullying’ were recognized: (i)
morphological features, (ii) psychological and psychosocial impact, (iii)
coping mechanisms, (iv) role of family. Subjects that experienced bullying
reported a diverse range of psychological impacts and coping mechanisms, in
addition, family members were discovered to play a contributing as well as a
mediating role in bullying. Twitter users reported that ‘morphological features
of teeth or malocclusion’ were targeted by bullies, and victims of bullying
reported that bullies used adjectives such as ‘messed up’, ‘ugly’, ‘horrible’
or ‘shitty’ to describe their teeth, other users included words such as
‘bunny’, ‘goofy’, ‘horse’, ‘monster’, ‘vampire’, ‘rabbit’, ‘crooked’, ‘missing’
or ‘gap’ to describe their teeth [23]. A study was held to compare the crowding
of anterior teeth in children who had experienced bullying and those who had
not, the sample included 218 subjects aged between 11 and 16 years, little's
irregularity index was used to assess dental crowding. A questionnaire was
completed to diagnose bullying. The U-Mann Whitney statistical test was used to
compare crowding in patients who had experienced bullying and those who had
not. According to the findings, there was considerably more dental crowding in
schoolchildren who had experienced bullying than in those with no bullying. The
average crowding for the group subjected to bullying was 11.6 +/- 9.4 mm and in
the group without bullying was 9.1 +/- 7.9 mm [24].
Bullying due to dentofacial features is very common
among adolescents and schoolchildren, and in some cases it can lead to suicidal
thoughts and self-harm. The likelihood of malocclusion, low self-esteem, and
being bullied are all significantly correlated. Bullies frequently use the
following dentofacial features as their targets: spacing between the teeth or
missing teeth, shape and color of the teeth, prominent teeth, crooked teeth,
class II malocclusion, anterior open bite, increased overbite and increased
overjet. Malocclusion-related bullying may alter attitude toward orthodontic
treatment.
Funding Statement
The author did not receive support from any
organization for the submitted work.
Conflict of Interest
The author declares no conflict of interest.