Artigos

INTRODUCTION
Bullying has been widely discussed 1,2,3 and is presented as a specific form of behavior, in which the student is repeatedly exposed to negative situations by one or more peers, with one of its main characteristics being the imbalance of power between the victim and the aggressor 4. With the increasing popularity of social networks, a new form of bullying has emerged in the virtual environment, called cyberbullying 5,6. Cyberbullying occurs through electronic communication channels, such as emails, mobile messages, chat rooms, personal websites, and social networks, and is used as a means for individuals or groups to adopt deliberate, repeated, and hostile behaviors aimed at harming others within an unequal power relationship. Compared to traditional bullying, cyberbullying is further aggravated by factors such as the anonymity of the aggressor and the reach and visibility of the aggression 5,7.
The prevalence of bullying worldwide is high (30.5%; 95% CI: 30.2-31%), being lowest in Europe (8.4%; 95% CI: 8-9%) and more prevalent in middle- and low-income countries (40.4%; 95% CI: 40-41.1%) 8. In Brazil, the prevalence was 12% (95% CI: 22.4-23.6%) and 13.2% (95% CI: 12.8-13.7%) in 2019 9,10. The prevalence of bullying and cyberbullying is heterogeneous, primarily due to variations in classifications, cut-off points, and the age groups studied 5.
Several factors are associated with the occurrence of bullying and cyberbullying among teenagers. For cyberbullying, risk factors include “age, gender, online behavior, race, health condition, past experience of victimization, and impulsiveness” 11. For traditional bullying, studies emphasize conduct, social, economic, and school problems 12-14, as well as race, religion, sexual orientation, and body, facial, and dental appearance 9,15.
Among adolescents, facial and dental appearance influences social and psychological aspects. Thus, a dental appearance that deviates from the norm, such as malocclusion, can affect various aspects of adolescents' lives, particularly peer sociability, self-esteem, self-confidence, and overall quality of life 16-18. Impaired peer interactions are especially significant during adolescence, as peer relationships play a central role in the development of social identity. Such impairments may serve as predictors for psychosocial adjustment difficulties and can also be linked to exposure to school violence 19,20. Malocclusions, such as significant maxillary misalignment 21, extreme maxillary overjet, gaps between anterior teeth, extreme deep overbite 22, Class II malocclusion, increased overbite, and increased overjet 23, were associated with bullying episodes among children and adolescents.
In addition, when suffering some victimization, adolescents' perception of satisfaction with life can worsen 24,25. Bullying has been associated with low self-esteem, psychosocial problems such as loneliness, anxiety, low school performance, and even violent or suicidal behavior 4,26-29.
Several studies have reported on the problem of bullying among schoolchildren. However, few have specifically analyzed the association between bullying and malocclusion, particularly concerning cyberbullying, where no articles evaluating this association have been found 22. Despite both bullying and malocclusion being recognized as public health issues with high prevalence 8,30,31, oral health policies in Brazil, such as Brasil Sorridente, focus primarily on essential care and conditions that directly impact health and functionality, such as tooth decay and periodontal disease. Other needs, such as orthodontic treatment, have been offered in a limited capacity. On the other hand, this kind of treatment goes beyond functionality; it has a social impact, especially for adolescents, which can reflect mental health, making it necessary to discuss the improvement of those policies.
In this context, this study aimed to explore the potential association between malocclusion, bullying, and cyberbullying among Brazilian teenagers. We hypothesize that self-reported bullying and cyberbullying are higher in adolescents with malocclusions, regardless of the demographic and economic variables assessed.
MATERIALS AND METHODS
This research was approved by the University of Pernambuco Ethics Committee. Parents/guardians and participants signed the informed consent form (ICF) before data collection.
This cross-sectional study is part of the "Care for Adolescent Health in Public Services of Olinda" and was conducted from February to June and August to October 2018 in Olinda, a Brazilian municipality located in the Metropolitan Region of Recife, PE, with a land area of 41.3 km² and an estimated population of 349,976 inhabitants. Among this population, 62,025 are adolescents aged 10 to 19 years, representing approximately 17% of the total estimated population 32.
POPULATION AND SAMPLING
At the time of the research, the municipality had 8,902 students enrolled in state high schools 33. The schools offer three types of programs: regular, with classes in a single shift five days a week; semi-integral, in which students attend school for eight shifts per week; and integral, where students remain at school for ten shifts, five days a week.
This study was conducted only in public schools because monitoring health behaviors among adolescents in public schools is a way to reduce inequity by assessing local needs and enhancing collaboration between education and health sectors. Given that access to healthcare is often limited, national monitoring initiatives like PeNSE are effective strategies for macro-level interventions.
ELIGIBILITY CRITERIA
Adolescents of both sexes, properly enrolled in the state school system of Olinda, PE, and aged between 14 and 19 years, were selected. Students with any physical or cognitive disorders that would prevent them from self-reporting the questionnaire were excluded, as reported by the teacher or school administrator. Students who did not complete the questions related to the variables of this study were excluded from the analysis.
Only adolescents attending during daytime hours (morning and afternoon) participated in the study. Evening students were not included in the sample due to accessibility challenges and to ensure the safety of the researchers.
SAMPLE CALCULATION
Olinda had 39 public state schools in 2018. Twelve of these were excluded during the selection process: six did not offer high school, two only had evening shifts, and in four schools, the management was not collaborative with the project, leaving 27 eligible schools for random selection. These included one small school (less than 200 students), one medium-sized school (200 to 499 students), and 25 large schools (more than 500 students) 33.
The sample selection was performed through a two-phase cluster sampling process. The first phase involved the random selection of schools, and the second phase involved the random selection of classes, according to the 10 political-administrative regions. The sample randomization was carried out using the Randomizer website, available at: https://www.randomizer.org/. All students in each class were invited to participate.
For the larger project, sample size estimation was based on the following parameters: a 95% confidence level, 80% power, an odds ratio of 1.4, a design effect correction of 1.2, and a 20% addition to account for potential losses. The minimum estimated sample size was 2206 adolescents. For this study, a post-hoc sample size calculation was conducted using the following criteria: a frequency of 24.9% ± 5% of adolescents who experienced bullying, based on a pilot study; a 95.0% confidence level; a design effect of 1.2; and an additional 20.0% to account for potential loss. Based on these parameters, a minimum sample size of 402 individuals would be sufficient to assess the "Bullying" variable.
DATA COLLECTION AND STUDY VARIABLES
The self-reported questionnaire was applied on the day of data collection, in a school setting, in a room designated by the school—usually the classroom itself—but without the presence of the teacher, and with all students present who agreed to participate in the study. The objectives of the research were explained beforehand, clarifying to students that the information provided would remain confidential.
The students' sociodemographic status was evaluated based on age, gender, Mother's and father's education, with whom the adolescent resides, and family income according to questions from the National School Health Survey (PeNSE). The data were categorized following the general sample distribution. Bullying and cyberbullying were evaluated by the Youth Risk Behavior Survey (YRBS) 34,35.
Sociodemographic variables: Household income was reported in Brazilian currency (BRL) and categorized into three levels based on the Brazilian Minimum Wage (BMW): ?1 BMW, >1 to <2 BMW, and ?2 BMW, approximately equivalent to USD 261,64 at the time of the study. Age range was categorized as 14–16 years and 17–19 years. Maternal education was classified by years of schooling as follows: ?8 years, indicating illiteracy or incomplete primary education; 9–11 years, corresponding to completion of basic education; and ?12 years, indicating completion of high school with some level of higher education either in progress or completed.
For father’s education, the same categorization was applied. The variable regarding living arrangements initially included six categories: living with both mother and father; with mother/father and other relatives; with other relatives; with only mother or father; in a foster care institution; or with a non-relative family. Since no participants lived in a foster care institution, this variable was reclassified into two categories: living with mother and/or father; and living with mother and/or father along with other relatives.
Bullying and cyberbullying victimization was determined by at least one affirmative response to the following three questions: (1. During the past 12 months, have you ever been bullied on school property? - answer choices: 1 “yes” 2 “no”. During the past 12 months, have you ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, WhatsApp, or other social media.) – answer choices: 1 “yes” 2 “no” 35.
For clinical data collection, researchers underwent prior training consisting of a theoretical phase and a practical phase, including examinations on adolescents. The theoretical phase involved a presentation of methodological procedures divided into two four-hour sessions. The first session introduced the entire project and suggested references for reading, while the second session was dedicated to discussion and clarification of questions.
The practical phase was conducted during the activities of the "Comprehensive Clinical Care II – Adolescent Care" course in the Dentistry program at UFPE, held at the University Campus in Recife. This clinic serves approximately 120 patients aged 10 to 19 each semester, who participated in the training phase of this study. The data collection on adolescents' oral health status was conducted by four previously trained and calibrated dentist-researchers (inter-examiner Kappa = 0.82-0.91), where one of them was the gold standard. To assist with the examination, conducted in a school setting, wooden spatulas and a head loupe with artificial light were used.
The Dental occlusion was classified as "normal occlusion" or "malocclusion," according to Moyers 36. It was considered normal occlusion: Angle Class I (normal anteroposterior relationship between maxilla and mandible) when the Mesiobuccal cusps of the first permanent maxillary molars (right and left) occlude in the Mesiobuccal groove of the first permanent mandibular molars (right and left), bilateral Class I canine; and/or absence of anterior crossbite; and/or lack of anterior open bite or top bite; and/or posterior crossbite.
The presence of malocclusion was categorized as "no" (Class I and no other malocclusion - right posterior crossbite, left posterior crossbite, bilateral posterior crossbite, anterior open bite) and "yes" (Class II or Class III and/or anterior open bite; bilateral posterior crossbite, anterior open bite or Class II or Class III and/or right posterior crossbite and/or left posterior crossbite and/or bilateral posterior crossbite and/or anterior open bite or even Class I and right posterior crossbite or left posterior crossbite and/or bilateral posterior crossbite and/or anterior open bite).
Bullying and cyberbullying are public health issues with multiple associated aspects, and the aim of this study is not to investigate all possible factors related to bullying. The conceptual model considered in this study suggests that bullying may be associated with demographic factors such as sex and age, economic factors including household composition and income, as well as different types of malocclusion.
The analysis was guided by this model, aiming to identify which factors or variables influence the occurrence of each dependent variable, bullying at school and cyberbullying. A logistic regression model was adjusted for each dependent variable, including only those variables that showed a significant association (p-value ?0.20) in the bivariate analysis. Through the backward stepwise selection process, variables with a p-value ?0.10 were retained. The model estimated the odds ratios (OR) with corresponding confidence intervals, the significance values (p-values) of the variables, and each category in relation to the reference category. The data was adjusted to the model using the Hosmer-Lemeshow test, and the percentage of correctly classified cases. A 5% margin of error was used to decide the statistical tests. The data were analyzed using IBM SPSS® version 25 statistical software.
The University of Pernambuco Ethics Committee approved this research. Parents/guardians and participants signed the informed consent form (ICF).
RESULTS
The age of the 801 adolescents analyzed ranged from 14 to 19 years (mean age 16.45 [±1.25] years); just over half were between 14 and 16 years old (51.2%); the majority were female (57.6%); more than half of the mothers (52.9%) and fathers (53.3%) of the participants had between 9 and 11 years of schooling; and the majority lived with their mother/father and other relatives (64.4%), with a family income of up to USD 261,64 (value converted to USD and the minimum wage in the year of the study - 2018) (52.4%).
Around 1/5 of the students said they had been bullied at school (19.4%), around one in 10 students reported cyberbullying (10.6%); of those who had malocclusion (42.5%) the majority were classified as having a class II malocclusion (16.7%), and 3.7% had an anterior open bite; the presence of malocclusion in general was found in almost half of the participants (42.5%).
Table 1 shows a significant association between the occurrence of bullying at school and sociodemographic variables. The percentage of students who had been bullied at school was higher in the 14-16 age group than in the 17-19 age group. A significant association was found between bullying at school and anterior open bite malocclusion (OR: 2.9; CI: 1.4-6.2).
Three of the variables analyzed in the bivariate study showed p<0.20 with the dependent variable bullying at school. The variables included were age group, gender, and anterior open bite. The variables age group and anterior open bite were significant at 5% anterior open bite. It is estimated that the percentage of adolescents being bullied at school is higher if they are between 14 and 16 years old than between 17 and 19 and if they have an anterior open bite (Table 2).
The malocclusion variable was not included because the anterior open bite is one of the malocclusions; therefore, the two variables were highly correlated. The model was accepted (p<0001) and proved to be well adjusted, according to the Hosmer and Lemeshow test (p=0.109), and correctly classified the cases in 80.8% of those surveyed.
Table 3 shows a significant association between cyberbullying and the variables age group and mother's years of study, being higher, percentage-wise, in the 17-19 age group and among students with mothers with 12 years or more of study. There were no significant associations (p>0.05) between the occurrence of cyberbullying and the types of malocclusions.
Four variables showed p<0.20 with the dependent variable cyberbullying (Table 4). The variables included in the model were age group, mother's schooling, occlusion class, and anterior open bite; age group and mother's education remained in the model, all two significant at 5%.
The model was accepted (p=0.041) and proved to be well adjusted, according to the Hosmer and Lemeshow test (p=0.708), correctly classifying the cases in 89.4% of those surveyed.
DISCUSSION
The presence of malocclusion, in general, was identified in almost half of the adolescents investigated in this study, aligning with national and international findings 37-40. A systematic review found high prevalences, ranging from 48 to 81%, with a lower prevalence in Asia and a higher prevalence in Africa 31. However, in a study in Brazil, the prevalence of severe and very severe malocclusion was 17.5% 41.
The prevalence of malocclusion is quite heterogeneous, especially concerning the diagnosis used to identify it and the degree of severity each author intends to investigate. In general, malocclusions are assessed using the Angle classification, Orthodontic Treatment Need Index (OTNI), and Dental Aesthetic Index (DAI) 42. Other variables, such as race and ethnicity, severity level, and treatment access, can also influence prevalence 31,43.
Of the adolescents who took part in the study, 23% reported having suffered some bullying, with bullying at school being the most prevalent, compared to cyberbullying. These results are in line with research carried out in Brazil 9,44 and in the world 25,45,46. Different results were found in a large-scale population-based study of Norwegian adolescents, in which the involvement of bullying was relatively low, with only 1.7% of adolescents reporting being victims 47. In the United States, the prevalence also differed from this study, with 7.6% for bullying and 4.4% for cyberbullying 48.
The lower prevalence in Norway as well as in the United States may be a result of the high awareness of school bullying at a societal level, as well as differences in national policy and implementation of prevention programs and interventions against bullying, which have proven to be effective 48.
Younger adolescents were almost twice as likely to report being victimized by bullying at school and cyberbullying. Some studies show that age plays an important role in exposure to violence 49,50. In the case of bullying, being younger puts the victim in an unequal power relationship, which is the main characteristic of this type of violence 1,9. Another point to consider is the maturity and emotional development of adolescents. Younger adolescents are still developing their social skills, whereas older adolescents may have developed more resilient coping mechanisms to handle indirect aggression, such as bullying 50.
Cyberbullying was the only form of victimization associated with a higher level of maternal schooling. Family relationships can be a risk or protective factor for cyberbullying 51,52. However, a study carried out with young adults showed that low maternal education is associated with cyberbullying and the perpetuation of this type of violence 51. Nevertheless, no articles were found showing the association between cyberbullying victimization and maternal schooling. However, a study conducted with Brazilian adolescents showed that a higher parental supervision is associated with a lower chance of suffering bullying 13. This question, such as the family relationship and parental style, still needs to be researched.
However, the fact that maternal schooling was an essential factor for cyberbullying but not for bullying at school may mean that the mother who has a high educational level concerning the sample studied can offer more outstanding technological support for educational purposes and, therefore, greater access to the internet and access devices; and/or clarify the meaning of what cyberbullying is increasing the reporting of this group. It can also be considered that mothers with lower levels of education can have a greater chance of their children becoming aggressors 51, so it is essential to understand how these factors can be associated with this type of violence and to include parents in coping strategies.
Cyberbullying was not associated with any malocclusion, and no studies were found that investigated this association. This aspect requires further investigation, as any additional inference could exceed the scope of what this study can address. However, it is suggested that the ease with which images and videos can be manipulated to disguise imperfections and achieve facial appearance standards may have influenced this outcome.
Among the malocclusions investigated, anterior open bite proved to be statistically associated with bullying at school. This result differs from two studies in Brazil, in which malocclusion was not associated with bullying 15,53. However, other studies, including a review, also evaluated other occlusal characteristics, such as increased overjet, crowding, and overbite, and found significant relationships with bullying victimization 22,23.
In this study, the only malocclusion associated with face-to-face bullying was one with visible repercussions on the face, reinforcing the results found by Malta et al. 9 that one of the reasons for bullying, reported by the participants is the appearance of the face.
Dentofacial appearance has been reported as one of the reasons for making the target of bullying situations 54,55, as well as being associated with quality of life and self-esteem 17,56,57. Previous studies have shown that treatment to correct malocclusion was enough to stop the episodes of victimization by bullying, even though we know that the psychological consequences may persist and lead to outcomes such as increased self-injury and suicidal behavior 23,57.
In this study, we can conclude that malocclusions with visible facial repercussions are those associated with victimization by school bullying, which did not occur with cyberbullying, probably because the possibility of manipulating the image of the face or smile for the social network interfered with this result.
The study has limitations regarding external validity. Although it is a study with a representative sample of adolescents in public schools in a city in Northeast Brazil, it is important to highlight that cultural and socioeconomic differences may limit the extrapolation of the results to adolescents from other regions.
All participants in this study attended public schools, which may reduce data heterogeneity. Therefore, a design effect (deff) was applied to the sample size calculation. In categorizing demographic and social variables, this aspect was also considered, leading to categorization based on both statistical (frequency distribution) and plausible considerations. For instance, parental education level was classified into three categories: parents who had no access to or did not complete basic education (provided free of charge and universally accessible by the government), those who accessed basic education, and those who completed basic education and proceeded to higher education (also provided free but with limited access).
There are several questionnaires for monitoring the health of school-aged children and adolescents, such as the Youth Risk Behavior Surveillance (YRBS) applied in the United States, the Global School-Based Student Health Survey (GSHS), mostly applied in low- and middle-income countries, the Health Behaviour in School-Aged Children (HBSC), and the National Adolescent School-Based Health Survey (PeNSE) applied in Brazil. The YRBS was chosen because there is a Brazilian Portuguese translation and validation of the 2007 version. However, this version does not include questions about bullying, which were added from the 2015 version through a free translation. Bullying and cyberbullying are also investigated through specific instruments, such as those developed by Olweus 58. However, since this survey includes other health behaviors, it was decided not to include additional questions.
The instrument used to assess malocclusion had limitations in its focus on intraoral assessment, which may have led to an underestimation of our results. It's important to acknowledge that due to the study's cross-sectional nature, establishing cause-and-effect relationships is not feasible. Future studies must assess malocclusion and its impact on facial appearance since those restricted to the intraoral aspect do not usually deviate from the aesthetic standards imposed by society, so they probably will not be the target of bullying either.
As a clinical contribution, this study highlights the importance for dentists to consider not only malocclusion in adolescence but also the broader context in which adolescents live. Dentists should be able to identify risk situations and refer patients to an interdisciplinary team. Regarding public health, there is a significant lack of accessible orthodontic care for this population. Demonstrating this relationship is a crucial first step in encouraging further research on the topic and raising questions about the role of orthodontists in adolescent health and well-being. Given that the care provided by these professionals extends beyond aesthetic benefits, it is important to explore ways to make oral health policies more accessible to adolescents. Although bullying is a widespread issue with numerous associated factors, some of which are difficult to resolve, addressing one of these factors may offer an alternative for reducing its occurrence.
CONCLUSIONS
Anterior open bite malocclusion was associated with bullying. Cyberbullying was not associated with any malocclusion.
ACKNOWLEDGEMENTS
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001
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