Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2010  |  Volume : 28  |  Issue : 1  |  Page : 13--17

Dental aesthetic index: Applicability in Indian population: A retrospective study

KS Poonacha1, SD Deshpande2, Anand L Shigli3,  
1 K.M Shah Dental College and Hospital, Waghodia Road, Vadodara, Gujarat, India
2 YMTA Research Centre Dental College and Hospital, Kharghar, Navi Mumbai-410 210, Maharashtra, India
3 Modern Dental College and Hospital, Indore, Madhya Pradesh, India

Correspondence Address:
K S Poonacha
K.M Shah Dental College and Hospital, Pipariya, Waghodia Road, Vadodara Dist, Gujarat


A variety of indices have been developed to assist professionals in categorizing malocclusion according to treatment needs. Dental aesthetic index (DAI) is one such index. DAI quantifies the normal variations usually seen and the dentofacial anomalies. A retrospective study on hundred available and treated cases was carried out on the casts. This survey was mainly carried out to determine the role of pedodontist in early identification of dental anomalies using DAI and sound referral of the patient to the orthodontist for better comprehensive care during the growth period in children. The materials used to collect data included periodontal probe with millimeter markings, ruler, calipers, pencil, and eraser. The results showed that when grouped according to various malocclusion severity levels by DAI, 3% had no or minor malocclusion indicating no or slight need of treatment, 15% had definite malocclusion and the treatment needed was elective, 27% had severe malocclusion and treatment was highly desirable, and remaining 55% of the casts had very severe or handicapping malocclusion and the treatment was mandatory. This study shows that DAI can be effectively used to evaluate and recognize the orthodontic needs of Indian children with permanent dentition and treated at an early stage so that the treatment is more effective.

How to cite this article:
Poonacha K S, Deshpande S D, Shigli AL. Dental aesthetic index: Applicability in Indian population: A retrospective study.J Indian Soc Pedod Prev Dent 2010;28:13-17

How to cite this URL:
Poonacha K S, Deshpande S D, Shigli AL. Dental aesthetic index: Applicability in Indian population: A retrospective study. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2021 Oct 27 ];28:13-17
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Full Text


Pedodontist is the person who directly comes in contact with the oral status of children; therefore, it becomes his responsibility to guide the child in the right direction towards optimal oral health, which includes occlusal harmony and good dental aesthetics. Dental aesthetic Index (DAI) is one such tool which he can make use of in identifying the orthodontic treatment need of the child based on severity.

Over the years, a variety of indices have been developed to assist professionals in categorizing malocclusion according to the level of treatment need. DAI is one such index developed in the United States. It identifies defiant occlusal traits and mathematically derives a single score. The DAI has been used in epidemiological studies of orthodontic treatment need, and it was integrated into the items of the international collaborative study of oral health outcome by the World Health Organization. [1]

The orthodontic need and demand assessment is of interest for dental public health programs, clinical treatment, screening for treatment priority, resource planning, and third-party funding. Several studies have investigated the severity and malocclusion for specific ethnic groups, age distribution, and country-specific populations. However fewer reports specially address the need and demand issues of the orthodontic treatment of children. [2] The main benefit of orthodontic treatment to the patient is in improved dental aesthetics and psychological well-being, DAI specifically measures dental aesthetics. By considering societally defined norms for dental appearance, it was purported to recognize conditions that are potentially psychosocially handicapping. It consists of ten intraoral measurements of occlusal traits each of which is multiplied by its regression coefficient; the products are added and summed with a constant to give the DAI score. The score is then placed along a continuum of dental appearance to determine the point at which the score falls between 0 (the most socially acceptable) and 100 (the least socially acceptable). The DAI score of 36 serves as the cutoff point to differentiate handicapping from nonhandicapping malocclusion. [3] The DAI table was developed in Iowa, USA in 1986. [4] The components and weights of the DAI are shown in [Table 1]. The emphasis in dental aesthetics in predicting need for orthodontic treatment is supported by the extremely high correlation that has been reported between dental aesthetics, need for treatment, and severity of malocclusion in clinical assessments of need for orthodontic treatment. To demonstrate the usefulness of an orthodontic index in predicting decisions of orthodontists, it must be shown that cases judged as handicapping by orthodontists would also be judged same by the index. [4] The decision points on the DAI scale are further divided to identify malocclusion severity levels less severe than handicapping. [5]

It is apparent that the number of children seeking orthodontic treatment has dramatically increased over the past few decades; therefore, the purpose of this retrospective study on the casts was to know whether the patients who reported for orthodontic treatment in the age group of 12-14 years had real orthodontic problems when measured using the DAI. The results of this study would give pediatric dentists a much needed preliminary guidelines to the general distribution, severity, and treatment need in case of patients with malocclusion.

 Materials and Methods

One hundred pretreatment casts of the age group between 12-14 years were randomly selected from the department of orthodontics along with their case sheets. This age group was chosen because it is recommended that this index be used on age groups in which there are no longer primary teeth.

The general information gained from the case records included name, age, sex, occupation, and geographic location, which was further coded into two groups: urban and rural. The obtained data were entered in a separate format for each cast [Appendix]. All data were collected by a single examiner using periodontal probe with millimeter markings, millimeter ruler, calipers, pencil, and eraser. Each cast was examined and scored for the ten components of DAI [Table 1]. Each component was then multiplied by its corresponding regression coefficient using the rounded weights. The products were then added and summed with the regression constant to give the DAI score. Each subject's DAI score was then placed along the dental aesthetic continuum to determine the percentile score [Table 2]. The result was then grouped according to various malocclusion severity levels [Table 3].


The results of the present study showed that among those seeking orthodontic treatment between age group 12-14 years, 73% were females and 27% were males, and 58% belonged to urban population whereas 42% belonged to rural population.

When grouped according to various malocclusion severity levels by DAI, 3% had no or minor malocclusion indicating no or slight need of treatment, 15% had definite malocclusion and the treatment required was elective, whereas 27% had severe malocclusion and the treatment was highly desirable. Remaining, i.e., 55% of the casts had very severe or handicapping malocclusion and the treatment was mandatory.

When placed on the graph, the cumulative percentage of 100 was reached at the DAI score of 68 beginning from the minimum of 23.


The DAI is based on socially defined aesthetic standards. It bridges the gap between the aesthetic and clinical aspects of occlusal conditions by mathematically producing a single score. However, DAI has some limitations, it does not identify cases with deep overbite that impinge on gingival or palatal tissue. The DAI has been developed as a screening tool for permanent dentitions; it might be unsuitable during the mixed dentition stage accompanied with changes in future dental appearance. [6] However, it can easily be adapted for use in mixed dentition stage. [7]

The prevalence of orthodontic problems can be assessed in terms of the number of individuals who are believed to require treatment. For this reason, a malocclusion index has to distinguish subjects with the highest scores and priority for treatment, from those with lower scores and a less urgent need. Therefore, a meaningful cut-off point along the index must be established. A cut-off score can be established depending on the availability of resources. This score can serve as the lowest severity level at which orthodontic treatment will be offered. Using the established cut-off score of 36, the prevalence of various degrees of malocclusion in this study was measured. [3]

Perceptions of dental aesthetics by different ethnic groups have to be considered when applying the index in different population groups since DAI was developed to determine severity of malocclusion and relative need for publicly subsidized orthodontic treatment based on perceptions of dental aesthetics by US students; hence the cut-off score for different ethnic groups may have to be established. However, a study by Cons et al. has already confirmed statistically that there is no difference in perceptions of occlusal conditions that are socially acceptable and unacceptable between America, (former) East Germany, Australia, Thailand, and Japan. [6]

The importance of patients' perceptions regarding orthodontic treatment cannot be underestimated, as it is the patients who receive treatment and need to gain satisfaction from improved aesthetics and function. Although DAI appears to be easier to use, the lack of assessment of traits such as buccal crossbite, openbite, center line discrepancy, and deep overbite weakens the index, even though buccal crossbite and openbite may not be important from the aesthetic point of view, but they could affect the need for orthodontic treatment. In addition, DAI measurements are made using a millimeter gauge, and small errors in accuracy can have an exaggerated effect because of the index weightings. [1] The inability of the DAI to consider assessment in mixed dentition may limit its use in prioritizing treatment need. [8]

Knutson surmised that the temporary malocclusions are corrected with age because the child outgrows deforming habits and dental relationships are returned to normal. Profit, on the other hand, suggested that the morphological variations observed with age might not be related to chronological age but to the stages of dental development. Considering this concept of developmental changes and its relation to malocclusion, the validity of a malocclusion index must be tested to determine consistency of its measurements over a period of time. [3]

The DAI has been compared with other commonly used occlusal indices. When compared with one of the most commonly used index, the Index of Orthodontic Treatment Need (IOTN), which has the same goal as DAI in identification of children most in need of orthodontic treatment, DAI has the advantage that perceptions of aesthetics are linked with anatomical trait measurements to produce a single score, obviating the need for two separate instruments that cannot be combined as in the IOTN. IOTN uses only three grades and thus lacks the ability to rank order cases with greater or lesser need for treatment within grades. In contrast, DAI scores can be rank ordered on a continuous scale and can differentiate cases within severity levels. [7] When compared with the Standardized Continuum of Aesthetic Need Index (SCAN), DAI proved more reliable than SCAN. [8] Another study compared DAI with Handicapping Labio-Lingual Deviations Index with the California modification (HLD [CalMod]), and IOTN, and found all the three indexes to be valid measures of treatment need as perceived by orthodontists and did not find any significant difference between them. [9]

The main requirements for an index of occlusion are reliability, validity, and validity during time. [10] The results of the present study showed that among those seeking orthodontic treatment, only 4% had minor or no anomaly with little or no treatment needed; rest all needed definite orthodontic treatment as they had DAI score of more than 25. More number of females can be attributed to their earlier growth and development, and also consciousness compared to males. There are more number of urban patients may be due to increased awareness, nearness to the dental hospital, and affordability.

As this is a retrograde study, it can very well be assumed that the patients who came on their own for the treatment really had problems, which could be identified by this study. This shows that DAI can be effectively used by the pedodontists on a prospective basis to identify the need for orthodontic treatment quantitatively; also the other advantages include that it can be used directly in the patients' mouth, dental auxiliaries can be trained to use it to reduce cost and burden on dentists, and also finally to assess the treatment standards although it was not developed for such use. However, the treatment indications should serve only as a guide. The decision points used to determine treatment indications could then be modified according to local conditions and available resources.


The authors are grateful to Dr. Keluskar, Dr. Shivayogi Hugar, Dr. Ravindranath Reddy, Dr. Roshan NM, Dr. Santosh Sholapurmath and Dr. Varun Sardana for their help in conducting this study.


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