How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index

Farah M. Babakurd; Khaled Omar; Mayssoon Dashash

doi:10.12688/f1000research.179073.1

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Research Article

How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index

[version 1; peer review: 1 not approved]

Farah M. Babakurd ¹, Khaled Omar², Mayssoon Dashash³

PUBLISHED 19 Apr 2026

Author details Author details

¹ Pediatric Dentistry Department, Faculty of Dentistry, Damascus University, Damascus, Syria
² Faculty of Informatics Engineering, Damascus University, Damascus, Syria
³ Pediatric Dentistry Department, Faculty of Dentistry, Damascus University, Damascus, Syria

Farah M. Babakurd
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Khaled Omar
Roles: Data Curation, Formal Analysis, Writing – Review & Editing

Mayssoon Dashash
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Writing – Review & Editing

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Abstract

Introduction

This study examined the prevalence of anterior crossbite in school-age children, investigated the frequency of appearance- related bullying, and determined whether crossbite severity correlates with bullying exposure among children aged 8–12 years.

Materials and Methods

A cross-sectional study involved 2,080 children from public schools in Damascus, using random cluster sampling.

Anterior crossbite and other occlusal issues were assessed using the ROMA Index. Dental appearance-related bullying was evaluated using a modified Olweus Bully/Victim Questionnaire; children reporting bullying two or more times monthly were classified as victims.

Bullying types—teasing, name-calling, social exclusion, and physical aggression—were documented along with occurrence settings. Severity scores were calculated by summing numerical codes for each bullying type. Relationships between occlusal characteristics and bullying were analyzed using Chi-square tests, Cramer’s V, and logistic regression, adjusting for age and gender.

Results

Of 2,080 children aged 8 to 12 years, 19.6% had anterior crossbite, and 34.4%reported dental appearance-related bullying. Children with anterior crossbite were significantly more likely to experience bullying (p < 0.001), with bullying intensity increasing proportionally to crossbite severity. Teasing and mocking were the most prevalent forms, primarily occurring in playground settings.

Conclusion

Anterior crossbite severity functions as a meaningful risk indicator for psychosocial bullying in children, extending beyond simple dental concerns. Incorporating crossbite severity screening into school-based prevention programs offers a practical strategy to improve both oral health and psychological well-being in childhood.

Keywords

Anterior crossbite, ROMA Index, dental appearance-related bullying, Olweus Bully/Victim Scale, Mixed dentition, Children.

Corresponding author: Farah M. Babakurd

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2026 M. Babakurd F et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: M. Babakurd F, Omar K and Dashash M. How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index [version 1; peer review: 1 not approved]. F1000Research 2026, 15:590 (https://doi.org/10.12688/f1000research.179073.1) First published: 19 Apr 2026, 15:590 (https://doi.org/10.12688/f1000research.179073.1) Latest published: 08 Jun 2026, 15:590 (https://doi.org/10.12688/f1000research.179073.2)

Introduction

Malocclusion is among the most prevalent oral health conditions globally, affecting approximately 56% of populations. Prevalence varies considerably across populations and diagnostic criteria.¹ Beyond functional consequences, malocclusion carries a significant psychosocial burden, particularly during childhood—a period of increased sensitivity to peer judgments and appearance-based evaluation.^2–4

A meta-analysis of 40 cross-sectional studies demonstrated significantly reduced oral health–related quality of life (OHRQoL) in children with malocclusion. Children with malocclusion were 1.74 times more likely to experience OHRQoL impairment than unaffected peers.⁵

Severity showed a dose-response relationship: Children with normal or mild malocclusion were 56% less likely to experience quality-of-life impairments than those with severe malocclusion.⁶

Despite robust evidence linking malocclusion to compromised quality of life, the association between malocclusion and school bullying remains contested. A recent systematic review found that 88% of studies reported a positive correlation between dentofacial anomalies and victimization.⁷

However, a subsequent meta-analysis yielded inconclusive results, reflecting heterogeneity across studies.⁸

Bullying, defined as recurrent aggressive behavior within a power- imbalanced relationship, carries serious psychological and academic consequences, including reduced self-esteem, academic decline, and heightened risk of anxiety and depression.⁹

Appearance- related bullying specifically affects 7% to 47.8% of children globally,^10,11 underscoring the social significance of visible dentofacial characteristics in school settings.¹²

The mixed dentition stage (8–12 years) represents a critical window during which peer awareness intensifies, magnifying psychosocial impacts of visible dentofacial anomalies such as anterior crossbite.³

This sagittal malocclusion occurs in approximately 11% of populations,¹ and can compromise facial profile perception, cause functional mandibular displacement and abnormal incisal wear, and worsen skeletal Class III patterns if untreated.¹³

Beyond functional consequences, anterior crossbite affects dental aesthetics during speech and smiling; its psychosocial effects correlate with severity.¹⁴ However, limited research examines the relationship between anterior crossbite severity and appearance-related bullying, especially in Middle Eastern populations. Understanding these psychosocial dimensions is important for timely orthodontic referral and early intervention.

The Risk of Malocclusion Assessment (ROMA) Index provides an objective and standardized, reproducible classification of occlusal disorders, including anterior crossbite.¹⁵ The modified Olweus Bully/Victim Questionnaire enables systematic evaluation of bullying exposure, appearance- related victimization, severity, patterns, and contexts.^16,17

Combining objective clinical severity assessment with validated psychosocial measurement minimizes subjective bias and strengthens methodological rigor.

This study addressed a significant knowledge gap: the lack of severity-based analyses of anterior crossbite and bullying, and the absence of data from Syrian populations. The study aimed to ascertain the prevalence of anterior crossbite in children aged 8–12 years using the ROMA Index, estimate the prevalence of appearance-related bullying using the modified Olweus questionnaire, analyze the association between anterior crossbite severity and bullying exposure while controlling for age and gender, and describe bullying patterns and contexts.

The findings are expected to deepen the understanding of the psychosocial dimensions of anterior crossbite during mixed dentition, inform early orthodontic intervention decisions integrating functional and psychological considerarions and support integration of orthodontic care into school-based bullying prevention programs.

Materials and methods

This cross-sectional analytical study received ethical approval from the Research Ethics Committee at the Faculty of Dentistry, University of Damascus (IRB No. UDDS 2614_28042025/SRC_2320) and authorization from the Ministry of Education (No. 4/443, 02/07/2025).

The study followed the Declaration of Helsinki (2013),¹⁸ and written informed consent was obtained from parents or legal guardians of all participating children.

Data collection occurred between July and December 2025, and the research complies with the STROBE guidelines for observational studies.¹⁹

Sampling and study population

A cluster random sampling design was employed across public schools in Damascus, with schools designated as clusters. Children were assessed in private rooms within each school under the teacher’s supervision to ensure privacy and accuracy.²⁰

According to the Directorate of Education, the first cycle included 56,772 boys and 53,761 girls, totaling 110,533 children. Sample size calculation for determining anterior crossbite prevalence (±5% precision, and of 95% confidence level) used the reported global prevalence of anterior crossbite (11%)¹ and the standard formula for cross-sectional studies²¹:

n = (Z^{2 *} P^{*} (1 - P)) / D^{2}

With a 95% confidence level (Z) and a 2% margin of error (D), this yielded an initial estimate of approximately 150 children.

To assess the association between anterior crossbite and dental appearance-related bullying, global prevalence rates range from 7% to 47.8%.^10,11 However, no published data exist for children with anterior crossbite in Asia or Syria. Conservative estimates were therefore adopted (P1 ≈ 30% for affected children, P2 ≈ 15% for unaffected) for binary outcome analysis using Chi-square or Odds Ratio methods, maintaining 80% power and 95% confidence level.²² This calculation provided an initial estimate of approximately 236 children. Accounting for a potential 10–15% non-response rate of,²³ the sample size was adjusted to approximately 270 children.

Given that the study aimed to estimate the prevalence of anterior crossbite, and the prevalence of bullying, analyze associations within subgroups (such as age, gender, and crossbite severity), and perform logistic regression analyses, the final sample was expanded to 2,080 children to ensure adequate statistical power.²⁴

Clinical assessment of malocclusion and other occlusal features

A single certified examiner (FB) supported by two school health department staff members performed all clinical examinations. To evaluate intra-examiner reliability, 10% of participants underwent repeat examinations, spaced by 20 to 30-minutes.²⁵ Cohen’s kappa values ranged from 0.85 to 0.95, indicating excellent agreement.²⁶

Occlusion characteristics were classified using the ROMA Index, a standardized grading system that categorizes malocclusions by severity and orthodontic treatment need. The index defines three grades¹⁵:

Grade 2 N: Mild malocclusion requiring routine monitoring.

Grade 3 N: Moderate malocclusion with clear need for orthodontic treatment.

Grade 4 N: Severe malocclusion requiring urgent or immediate orthodontic intervention.

Four key occlusal traits were evaluated and graded according to clinical severity and treatment urgency:

• Anterior crossbite: one or more maxillary teeth occluding lingually to the corresponding mandibular teeth in centric occlusion.
• Anterior open bite: Absence of vertical overlap between opposing anterior teeth.
• Deep bite: Excessive vertical overlap of anterior teeth.
• Increased overjet: Horizontal protrusion of maxillary incisors.

All examinations followed standardized clinical protocols. When precise measurements were required to support.¹⁵

A calibrated Williams periodontal probe (1–10 mm increments) was used to ensure consistent and reproducible measurements.²⁷

Assessment of dental appearance-related bullying

Researchers adapted the Olweus Bully/Victim Questionnaire to measure bullying related to dental appearance.^16,17

The modified instrument evaluated the frequency and types of bullying incidents over a two-month reference period. Children were classified as victims if they experienced two or more bullying incidents per month, consistent with prior research.²⁸

The questionnaire assessed multiple forms of dental appearance-related bullying: teasing, name-calling, social exclusion, and physical aggression. Each response was coded numerically (Yes = 1, No = 2) to generate a bullying severity score ranging from 4 to 8 for each participant, with lower scores indicating greater bullying exposure. Researchers also recorded where bullying occurred (classroom, schoolyard, street, or multiple locations).

Before the main study with 2,080 children, a pilot study with 100 randomly selected participants tested the validity and reliability of the questionnaire, approximately 5% of the main sample. The pilot phase evaluated item clarity, validity, and reliability of the modified instrument.²⁹

Results demonstrated robust psychometric properties. Face validity was confirmed by 90% of expert reviewers. The Content Validity Index (CVI) was 0.92,³⁰ internal consistency (Cronbach’s alpha) was 0.85,³¹ and test-retest reliability measured at two weeks yielded an Intraclass Correlation Coefficient (ICC) of 0.88.^32,33 These findings confirmed the questionnaire’s reliability and stability of use in the main study. Refinements were made to items as needed ensuring the modified instrument³⁴ is aligned with international research standards.

Inclusion and exclusion criteria

Children aged 8 to 12 years enrolled in public schools were eligible for participation if they could complete both the questionnaire and clinical examination and had obtained parental consent.

The study excluded individuals with chronic medical conditions or disabilities, prior orthodontic treatment, prolonged school absences, or learning difficulties that could affect their ability to respond reliably to the questionnaire.

Statistical analysis

Data analysis was performed using SPSS software. Descriptive statistics summarized demographic characteristics, the prevalence of anterior crossbite, and the frequency of dental appearance-related bullying. Categorical variables were reported as frequencies and percentages, while continuous variables were presented as means and standard deviations.

Chi-square tests were examined associations between occlusal status and bullying, with Cramer’s V utilized to measure the strength of these associations. Post hoc pairwise comparisons identified specific differences between groups. Ordinal logistic regression assessed how anterior crossbite severity influenced bullying severity, while binary logistic regression determined the odds of bullying victimization across different occlusal groups after adjusting for age and gender. The locations and patterns of bullying incidents were analyzed descriptively using Chi-square and Cramer’s V comparisons. All statistical tests were two-tailed with a significance level of p < 0.05.

Results

A total of 2,080 children aged 8–12 years were included.

Among the participants, 408 children (19.6%) presented with an anterior crossbite. Of these cases, 15% required immediate intervention, 2.6% showed signs of malocclusion that could persist or worsen, and2% required routine occlusal monitoring. Findings are presented in Table 1.

Table 1. Prevalence of anterior crossbite among children aged 8–12 years, categorized by severity and required intervention according to the ROMA Index.

Anterior Crossbite	N(%)	ROMA Grade	N(%)
Present	408 (19.6%)	4n: Crossbite > 2 mm	312 (15.0%)
		3n: Crossbite > 1 mm	55 (2.6%)
		2n: Crossbite < 1 mm	41 (2.0%)
Absent	167 (80.4%)
Total	208 (100.0%)

The modified Olweus Bully/Victim Questionnaire identified 34.4% of the children as victims of dental appearance- related bullying. Victimization was defined in accordance with established Olweus criteria, whereby children who reported experiencing bullying two or more times per month were classified as victims. In contrast, those who reported no instances of bullying or only occasional occurrences were categorized as non-victims (see Table 2).

Table 2. Prevalence of dental appearance-related school bullying among children aged 8 to 12 years with mixed dentition.

Modified Olweus Bully/Victim Questionnaire	N(%)
Victims	715 (34.4%)
Non-victims	1365 (65.6%)
Total	2080 (100.0%)

A significant association was observed between occlusal status and dental appearance–related bullying (χ² = 694.38, df = 3, p < 0.001), with Cramer’s V = 0.578 (p < 0.001).

Children with anterior crossbite, particularly those with concomitant malocclusion, exhibited the highest prevalence of bullying compared to those with malocclusion alone or normal occlusion ( Table 3).

Table 3. Relationship between occlusal status and dental appearance-related bullying.

		Dental appearance–related bullying
		Non-victims N (%)	Victims N (%)	Total N (%)
Occlusal status	Normal occlusion	702 (99.9%)	1 (0.1%)	703 (100.0%)
	Malocclusion and anterior crossbite	4 (12.9%)	27 (87.1%)	31 (100.0%)
	Other malocclusion only	562 (58.0%)	407 (42.0%)	969 (100.0%)
	Anterior crossbite only	97 (25.7%)	280 (74.3%)	377 (100.0%)
	Total	1365 (65.6%)	715 (34.4%)	2080 (100.0%)
Chi-Square tests	Pearson Chi-Square	p- Value	694.380
		Degrees of Freedom(Df)	3
		Asymptotic significance (2-sided)	< 0.001*
Symmetric measures	Phi	p- Value	0.578
	Phi	Approximate significance	< 0.001*
	Cramer’s V	p- Value	0.578
	Cramer’s V	Approximate significance	< 0.001*

* Significant coefficient; no expected count less than 5.

Binary logistic regression, adjusted for age and gender, confirmed these findings. Older age was significantly associated with increased bullying victimization (Exp(B) = 1.556; 95% CI: 1.240–1.953; p < 0.001), while gender was not significant (Exp(B) = 1.007; 95% CI: 0.805–1.261; p = 0.949).

Compared with children with normal occlusion, those with both malocclusion and anterior crossbite had substantially increased bullying exposure, (Exp(B) = 0.000; 95% CI: 0.000–0.003; p < 0.001).

Children with anterior crossbite alone also showed significantly higher victimization risk (Exp(B) = 0.231; 95% CI: 0.176–0.303; p < 0.001), whereas those with malocclusion only did not differ significantly from the reference group (Exp(B) = 2.162; 95% CI: 0.735–6.360; p = 0.161). Findings are presented in Table 4.

Table 4. Logistic regression assessing the relationship between occlusal status and dental bullying.

Variables in the Equation		B	S.E.	Wald	df	Sig.	Exp (B)	95% C.I. for EXP(B)
Variables in the Equation		B	S.E.	Wald	df	Sig.	Exp (B)	Lower	Upper
Age		0.442	0.116	14.591	1	< 0.001*	1.556	1.240	1.953
Gender		0.007	0.115	0.004	1	0.949	1.007	0.805	1.261
Occlusal status	Normal occlusion (reference)			168.270	3	< 0.001*
	Malocclusion and anterior crossbite	−7.686-	1.008	58.123	1	< 0.001*	0.000	0.000	0.003
	Other malocclusion only	0.771	0.550	1.963	1	0.161	2.162	0.735	6.360
	Anterior crossbite only	−1.465-	0.138	113.134	1	< 0.001*	0.231	0.176	0.303
Constant		−0.439-	0.442	0.989	1	0.320	0.644

1 *A significant coefficient.

2 B: regression coefficient; SE: standard error; Wald: Wald chi-square; df: degrees of freedom; Sig: significance; Exp(B): odds ratio; 95% CI: 95% confidence interval

These results indicate that anterior crossbite, whether alone or combined with malocclusion, significantly increases bullying risk, whereas malocclusion without crossbite does not significantly influence victimization.

Among children with anterior crossbite, ordinal logistic regression revealed a clear dose–response relationship between ROMA severity and bullying severity.

Children requiring immediate treatment exhibited the highest bullying scores (Estimate = −3.761, 95% Confidence Interval: −4.730 to −2.793; p < 0.001), followed by those requiring observation (Estimate = −3.364, 95% Confidence Interval: −4.954 to −1.774; p < 0.001).

Children under routine follow-up showed no significant difference from the reference category (Estimate = −0.621, 95% Confidence Interval: −2.024 to 0.782; p = 0.385). Age (Estimate = 0.076; p = 0.649) and gender (Estimate = −0.477; p = 0.069) were not significantly associated with bullying severity. These findings indicate that bullying likelihood and severity are positively correlated with anterior crossbite severity and are independent of the child’s age and gender (see Table 5).

Table 5. Ordinal logistic regression analysis examining the dose–response relationship between the severity of anterior crossbite, as classified by the ROMA index, and the intensity of bullying exposure.

Threshold location		Estimate	Std. error	Wald	Df	Sig.	95% confidence interval
Threshold location		Estimate	Std. error	Wald	Df	Sig.	Lower bound	Upper bound
Bullying severity	[score = 4.00]	−10.624-	1.295	67.335	1	< 0.001*	−13.161-	−8.086-
	[score = 5.00]	−8.415-	0.886	90.114	1	< 0.001*	−10.153-	−6.678-
	[score = 6.00]	−1.993-	0.795	6.289	1	0.012*	−3.550-	−0.435-
	[score = 7.00]	3.648	1.216	8.997	1	0.003*	1.264	6.031
Age		0.076	0.166	0.207	1	0.649	−0.250-	0.402
Gender		−0.477-	0.263	3.298	1	0.069	−0.991-	0.038
ROMA severity grade	4n	−3.761-	0.494	57.958	1	< 0.001*	−4.730-	−2.793-
	3n	−3.364-	0.811	17.202	1	< 0.001*	−4.954-	−1.774-
	2n	−0.621-	0.716	0.753	1	0.385	−2.024-	0.782

* A significant coefficient.

Teasing and mocking were the most common forms, reported by 97.2% of children with anterior crossbite only, 94.4% of those with both malocclusion and anterior crossbite, and 71.4% of those with malocclusion only. These differences were statistically significant (χ² = 50.79, df = 2, p < 0.001) with a moderate strength of association (Cramer’s V = 0.291).

Unpleasant nickname- calling showed a strong association with occlusal status (χ² = 96.38, df = 2, p < 0.001; Cramer’s V = 0.401), with prevalence varying significantly across groups. Social exclusion was less frequently reported, remained significantly correlated with occlusal status (χ² = 969.95, df = 2, p < 0.001; Cramer’s V = 0.342). Physical bullying occurred infrequently across all groups but still showed a statistically significant difference (χ² = 10.09, df = 2, p = 0.006; Cramer’s V = 0.130).

Bullying locations varied significantly among occlusal groups (χ² = 13.23, df = 6, p = 0.004; Cramer’s V = 0.133).

Children with both malocclusion and anterior crossbite most frequently experienced bullying on the playground (63.0%), followed by the classroom (25.9%) and the route to school (11.1%), with no reports from.

Those with malocclusion reported incidents only at the playground (42.9%), classroom (31.4%), route to school (14.3%), and multiple locations (11.4%). Children with anterior crossbite only experienced bullying predominantly on the playground (64.0%), in the classroom (14.6%), on the route to school (16.2%), and in multiple locations (5.1%).

Children with normal occlusion were excluded from the analysis, as dental appearance-related bullying was negligible in this group. Consequently, all descriptive and comparative analyses of bullying patterns focused exclusively on children with malocclusion and/or anterior crossbite ( Table 6).

Table 6. Patterns and locations of dental appearance-related bullying among children with varying occlusal characteristics.

Occlusal status			Bullying Patterns				Bullying location
Occlusal status			Teasing and mocking N (%)	Unpleasant nicknames N (%)	Social exclusion N (%)	Physical bullying N (%)	ClassroomN(%)	Playground N (%)	Route to school N (%)	Multiple locations N (%)
	Malocclusion and anterior crossbite		51 (94.4%)	51 (94.4%)	9(16.7%)	1 (1.9%)	7 (25.9%)	17 (63.0%)	3(11.1%)	0(0.0%)
	Other Malocclusion only		25 (71.4%)	13 (37.1%)	2 (5.7%)	0 (0.0%)	11 (31.4%)	15 (42.9%)	5(14.3%)	4(11.4%)
	Anterior crossbite only		495(97.2%)	465(91.4%)	1 (0.2%)	0 (0.0%)	46 (14.6%)	201(64.0%)	51(16.2%)	16(5.1%)
	Total		571 (95.5%)	529 (88.5%)	1 (2.0%)	1 (0.2%)	64 (17.0%)	233(62.0%)	59(15.7%)	20(5.3%)
Chi-Square Tests		p- Value	50.794	96.376	69.947	10.091	13.230
		Degrees of Freedom(Df)	2	2	2	2	6
		Asymptotic Significance (2-sided)	< 0.001*	< 0.001*	< 0.001*	0.006*	0.040*
Symmetric Measures	Phi	p- Value	0.291	0.401	0.342	0.130	0.188
		Approximate Significance	< 0.001*	< 0.001*	< 0.001*	0.006*	0.040*
	Cramer’s V	p- Value	0.291	0.401	0.342	0.130	0.188
	Cramer’s V	Approximate Significance	< 0.001*	< 0.001*	< 0.001*	0.006*	0.040*

* Significant coefficient

Discussion

The study demonstrated that anterior crossbite extends beyond functional and aesthetic concerns to significantly impact children’s well-being in school settings. The prevalence of 19.6% in this study substantially exceeds global estimates off approximately 11% for mixed dentition, which are approximately 11%, placing this population in a higher-risk category and underscoring the urgency for early intervention.¹

Regional prevalence varies considerably, ranging from (5.5%) in Iraq to 14% in Palestine, with Egypt and Jordan reporting 10.1% and (6.8%) respectively^35,36 Jordan.^37,38

Notably, most existing studies examined older children than the current sample (ages 8–12 years), a critical developmental period characterized by ongoing dental and craniofacial changes.³⁹

During this stage, mild cases may spontaneously resolve or benefit from early treatment, making this age group essential for accurately assessing the overall disease burden.⁴⁰

The current study fills an important gap by providing both prevalence and severity estimates using the standardized ROMA index data previously lacking in early mixed dentition populations. These findings are vital for designing school-based screening initiatives and facilitating timely orthodontic referrals.

Dental appearance-related bullying affected 34.4% of the sample, highlighting a significant public health concern. Chronic childhood bullying exposure is well-documented to increase the risk of anxiety, depression, low self-esteem, and academic underperformance.⁴¹

Longitudinal evidence demonstrates that bullying victims face substantially elevated odds of developing psychological disorders extending into adolescence and adulthood (Odds Ratio = 1.60; 95% Confidence Interval: 1.42–1.81).⁴²

By linking a clinically diagnosable occlusal condition to a prevalent psychosocial stressor, this study reframes anterior crossbite as more than a localized dental issue. It is a broader health determinant affecting mental well-being and academic success.

Statistical analyses revealed a robust association between malocclusion and bullying, Cramer’s V = 0.578, representing a substantial effect size with both clinical and epidemiological relevance. This finding aligns with prior research indicating that children with prominent anterior dental characteristics experience higher bullying rates than their peers without such features.⁴³ These results underscore the essential role of anterior facial appearance in social perception during a formative development period for identity formation and self-esteem,⁴⁴ supporting the integration of malocclusion as a psychosocial risk marker in school health programs.

The graded association between anterior crossbite severity and bullying corresponds with Bradford Hill’s criteria for establishing causality, particularly, the epidemiological dose–response principle.⁴⁵

Ordinal logistic regression analysis indicated that higher severity scores, particularly those necessitating immediate intervention, experienced significantly greater bullying exposure (p < 0.001). This dose- response pattern reinforces the causal inference and strengthens the importance of integrating severity assessments into school-based screening and early prevention strategies. Such targeted interventions could reduce both the clinical burden.

Age emerged as a significant predictor of bullying risk, while gender did not demonstrate a significant effect. This finding is consistent with existing studies indicating showing that bullying exposure typically increases during late primary and early adolescence.⁴⁶

While gender differences in bullying do occur, they generally reflect variations in bullying type rather than severity.⁴⁷ The age-related increase likely reflects a heightened sensitivity to social evaluation and physical appearance during this development stage, emphasizing the critical need for preventive interventions targeting older primary school children.

Verbal bullying, including teasing, derogatory comments, and name-calling, was substantially more prevalent than physical aggression, consistent with evidence that verbal and social forms of bullying dominate among children within this age group.⁴⁸

Although physical bullying occurred less frequently, the data suggest that appearance-based verbal harassment can escalate into more severe forms of aggression without early intervention. This finding underscores the importance of comprehensive, multifaceted prevention strategies within schools. Schools emerged as the primary bullying setting, underscoring the critical role of both environmental and organizational factors on aggressive behaviors. Meta-analytic evidence demonstrates that increased school supervision and anti-bullying initiatives significantly reduce bullying rates.⁴⁹

These findings support an integrated approach combining early orthodontic screening with school-based bullying prevention initiatives- a dual approach with substantial potential to improve both oral and psychosocial health outcomes.

These findings should be interpreted within the context of the study’s cross-sectional design, which limits causal inference. Additionally, unmeasured variables such as self-esteem and familial support factors may mediate the observed associations. Therefore, longitudinal, multicenter studies are needed to assess the long-term psychosocial benefits of early orthodontic intervention and to evaluate the cost-effectiveness of incorporating malocclusion screening into routine school health programs.

Anterior crossbite severity represents a clinically significant indicator with considerable social consequences. Future interventions should operate within a comprehensive public health framework that integrates oral health, psychological well-being, and educational environments.

A multi-level intervention combining early orthodontic care, school-based anti-bullying programs, and community education could significantly reduce the psychosocial burden associated with malocclusion during childhood and promote holistic child health and development.

Conclusion

An anterior crossbite extends beyond dental aesthetics and function. It represents a significant psychosocial stressor in school environments, with effects that intensify as severity increases. This study establishes a clear dose–response relationship between anterior crossbite severity and bullying victimization, demonstrating clinical and social relevance.

Early identification of anterior crossbite severity during mixed dentition enables timely recognition of children at increased risk for psychosocial harm. Integrating orthodontic severity assessments into school health screening programs coupled with comprehensive anti-bullying initiatives offers a dual -intervention approach to safeguard children’s mental health and academic success.

Corresponding author

Correspondence to Farah M. Babakurd

Ethics declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Research Ethics Committee of the Faculty of Dentistry at Damascus University, Syria (IRB No. UDDS 2614_28042025/SRC_2320). Additionally, written consent was granted by the Ministry of Education (No. 4/443, 02/07/2025). The research adhered to the ethical principles of the Declaration of Helsinki (2013). Before participation, written informed consent was obtained from the parents or legal guardians of all children. The study’s reporting follows the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.

Consent for publication

All the parents or legal guardians of all children provided written informed consent for publication of anonymized data and findings.

Data availability statement

Underlying and extended data supporting the results of this study are deposited in the Open Science Framework (OSF) repository and can be accessed via the following DOI:

https://doi.org/10.17605/OSF.IO/HW8KM.⁵⁰

Note: If the hyperlink does not activate directly in your document, please copy and paste the DOI into your web browser to access the dataset.

This project contains the following underlying data:

De-identified Excel Dataset (Child IDs).xlsx – Contains coded participant data without personal identifiers.

Dataset Code Explanation.docx – Explains the coding system used in the Excel dataset.

Extended data

Parental Informed Consent Form.docx – Contains the consent form provided to participants.

Participant Information Sheet.docx – Contains participant information details.

Modified Dental Appearance-Related Bullying Questionnaire.docx – Contains the questionnaire used in the study.

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Universal).

Note: The DOI link provides access to all underlying and extended files. No personal identifiers are included in any of the datasets to ensure participant confidentiality.

References

1. Stomatologic, S: Worldwide prevalence of malocclusion in the different stages of dentition: A systematic review and meta-analysis. Eur. J. Paediatr. Dent. 2020; 21: 115–122.
2. Sun L, Wong HM, McGrath CP, et al.: Association between the severity of malocclusion, assessed by occlusal indices, and oral health related quality of life: a systematic review and meta-analysis. Oral Health Prev. Dent. 2018; 16.
3. Laursen B, Veenstra R: Toward understanding the functions of peer influence: A summary and synthesis of recent empirical research. J. Res. Adolesc. 2021; 31: 889–907. PubMed Abstract | Publisher Full Text | Free Full Text
4. Babakurd F, al Shammary NH, Azrak L, et al.: Assessment of Dentists' Knowledge of Space Maintainer Indications After Primary First Molar Extraction: A Cross-Sectional Study. Cureus. 2024; 16. Publisher Full Text
5. Kragt L, Dhamo B, Wolvius EB, et al.: The impact of malocclusions on oral health-related quality of life in children—a systematic review and meta-analysis. Clin. Oral Investig. 2016; 20: 1881–1894. PubMed Abstract | Publisher Full Text | Free Full Text
6. Dutra SR, Pretti H, Martins MT, et al.: Impact of malocclusion on the quality of life of children aged 8 to 10 years. Dental Press J. Orthod. 2018; 23: 46–53. PubMed Abstract | Publisher Full Text | Free Full Text
7. Broutin A, Blanchet I, Canceill T, et al.: Association between dentofacial features and bullying from childhood to adulthood: a systematic review. Children. 2023; 10: 934. Publisher Full Text
8. e Paulo DM, et al.: Impact of malocclusion on bullying in school children and adolescents: A systematic review and meta-analysis. Child Youth Serv. Rev. 2022; 142: 106636.
9. Andrews NC, Cillessen AH, Craig W, et al.: Bullying and the Abuse of Power. Int. J. Bullying Prev. 2023; 5: 261–270. PubMed Abstract | Publisher Full Text | Free Full Text
10. Shaw W, Meek S, Jones D: Nicknames, teasing, harassment and the salience of dental features among school children. Br. J. Orthod. 1980; 7: 75–80.
11. Baram D, Yang Y, Ren C, et al.: Orthodontic Treatment Need and the Psychosocial Impact of Malocclusion in 12-Year-Old Hong Kong Children. Sci. World J. 2019; 2019: 1–9. Publisher Full Text
12. Terada ASSD, Oliveira MB, Silva LM, et al.: Malocclusion and bullying experience among school-aged children and adolescents: a systematic review. Caderno Pedagógico. 2025; 22: e20526–e20526. Publisher Full Text
13. Sunil M, Zareena M, Ratheesh MS, et al.: Early orthodontic interception of anterior crossbite in mixed dentition. Journal of International Oral Health. 2017; 9: 88–90. Publisher Full Text
14. Lo Giudice A, Polizzi A: Pediatric treatment of anterior-upper-single dental crossbite using a versatile sagittal screw system: a case series. Pediatric Reports. 2025; 17: 11. PubMed Abstract | Publisher Full Text | Free Full Text
15. Grippaudo C, Paolantonio E, Deli R, et al.: Orthodontic treatment need in the Italian child population. Eur. J. Paediatr. Dent. 2008; 9: 71.
16. Olweus D: Revised Olweus bully/victim questionnaire. J. Psychopathol. Behav. Assess. 1996.
17. Gaete J, Valenzuela D, Godoy MI, et al.: Validation of the revised Olweus bully/victim questionnaire (OBVQ-R) among adolescents in Chile. Front. Psychol. 2021; 12: 578661. PubMed Abstract | Publisher Full Text | Free Full Text
18. Crespo JE, Rodríguez ICR, de Jesús F , et al.: The Declaration of Helsinki and the Evolution of Ethics in Medical Research. International Journal of Sustainable Science and Technology. 2025; 3.
19. Ghaferi AA, Schwartz TA, Pawlik TM: STROBE reporting guidelines for observational studies. JAMA Surg. 2021; 156: 577–578. Publisher Full Text
20. Iqbal Jeelani M, Danish F, Gul M: A review on the recent development on the cluster sampling. Biostat Biom Open Access J. 2018; 5: 146–150.
21. Pourhoseingholi MA, Vahedi M, Rahimzadeh M: Sample size calculation in medical studies. Gastroenterology and Hepatology from bed to bench. 2013; 6: 14–17. PubMed Abstract
22. Manual, A. P: Geneva.1991.
23. Naing L, Winn T, Rusli B: Practical issues in calculating the sample size for prevalence studies. Arch. Orofac. Sci. 2006; 1: 9–14.
24. Bujang MA, Sa’at N, Bakar TMITA, et al.: Sample size guidelines for logistic regression from observational studies with large population: emphasis on the accuracy between statistics and parameters based on real life clinical data. Malays J Med Sci. 2018; 25: 122.
25. Saulicz E, Saulicz O, Koterba J, et al.: Inter-and intra-examiner reliability study of two-point discrimination test (TPD) and two-point estimation task (TPE) in the sacral area of pain-free individuals. Diagnostics (Basel). 2023; 13: 3438. Publisher Full Text
26. Madadizadeh F, Ghafari H, Bahariniya S: Kappa statistics: A method of measuring agreement in dental examinations. Open Public Health J. 2023; 16.
27. Ramachandra SS, Mehta DS, Nagarajappa Sandesh M, et al.: Periodontal probing systems: a review of available equipment. Periodontics. 2009; 3: 16.
28. Solberg ME, Olweus D: Prevalence estimation of school bullying with the Olweus Bully/Victim Questionnaire. Aggressive Behavior: Official Journal of the International Society for Research on Aggression. 2003; 29: 239–268.
29. Hertzog MA: Considerations in determining sample size for pilot studies. Res. Nurs. Health. 2008; 31: 180–191. Publisher Full Text
30. Polit DF, Beck CT: The content validity index: are you sure you know what's being reported? Critique and recommendations. Res. Nurs. Health. 2006; 29: 489–497. PubMed Abstract | Publisher Full Text
31. Kumar RV: Cronbach’s alpha: Genesis, issues and alternatives. Management (Andover, Mass). 2024; 1: 17.
32. Koo TK, Li MY: A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J. Chiropr. Med. 2016; 15: 155–163. PubMed Abstract | Publisher Full Text | Free Full Text
33. de Arruda GT , Terwee CB, Elsman EBM, et al.: Explanation & Elaboration document of the COSMIN Reporting Guideline 2.0 for studies on measurement properties of patient-reported outcome measures. Qual. Life Res. 2025; 34: 1891–1899. Publisher Full Text
34. Yousufi S, et al.: BULLYING IN ORTHODONTIC PATIENTS AND ITS ASSOCIATION TO MALOCCLUSION, MENTAL AND ORAL HEALTH RELATED QUALITY OF LIFE. JOURNAL OF KHYBER COLLEGE OF DENTISTRY JKCD. 2021; 11: 17–22.
35. Khalil R, Khalil S: Prevalence of malocclusion among schoolchildren in Beni-Suef, Egypt. Egypt. Dent. J. 2022; 68: 1277–1289.
36. Amro H, Najjar S, Owda M, et al.: A comprehensive national survey on malocclusion prevalence among Palestinian children. BMC Oral Health. 2024; 24: 664. PubMed Abstract | Publisher Full Text | Free Full Text
37. Alhaija E, Al-Khateeb SN, Al-Nimri KS: Prevalence of malocclusion in 13-15 year-old North Jordanian school children. Community Dent. Health. 2005; 22: 266.
38. Al Huwaizi AF, Al-Alousi WS, Al-Mulla AA: A National Iraqi Survey on Anterior Cross Bite. Iraqi Orthod J. 2005; 1: 1–3.
39. Vucic S, Dhamo B, Jaddoe VW, et al.: Dental development and craniofacial morphology in school-age children. Am. J. Orthod. Dentofacial Orthop. 2019; 156: 229–237. e224. Publisher Full Text
40. Alami S, Aghoutan H, El Quars F, et al.: Early Treatment of Anterior Crossbite Relating to. Emerging Trends in Oral Health Sciences and Dentistry. 2015; 341.
41. Balluerka N, Aliri J, Goñi-Balentziaga O, et al.: Association between bullying victimization, anxiety and depression in childhood and adolescence: The mediating effect of self-esteem. Revista de Psicodidáctica (English ed.). 2023; 28: 26–34. Publisher Full Text
42. Moore SE, Norman RE, Suetani S, et al.: Consequences of bullying victimization in childhood and adolescence: A systematic review and meta-analysis. World journal of psychiatry. 2017; 7: 60–76. PubMed Abstract | Publisher Full Text | Free Full Text
43. Martins Maia PR, Fialho T, Salvatore Freitas KM, et al.: Relationship between dentofacial features and bullying in school children. Pediatr. Dent. 2024; 46: 99–107. PubMed Abstract
44. Sicari F, Merlo EM, Gentile G, et al.: Body image and psychological impact of dental appearance in adolescents with malocclusion: a preliminary exploratory study. Children. 2023; 10: 1691. PubMed Abstract | Publisher Full Text | Free Full Text
45. Shimonovich M, Pearce A, Thomson H, et al.: Assessing causality in epidemiology: revisiting Bradford Hill to incorporate developments in causal thinking. Eur. J. Epidemiol. 2021; 36: 873–887. PubMed Abstract | Publisher Full Text | Free Full Text
46. López-Castro L, Smith PK, Robinson S, et al.: Age differences in bullying victimisation and perpetration: Evidence from cross-cultural surveys. Aggress. Violent Behav. 2023; 73: 101888. Publisher Full Text
47. Perazzini M, Bontempo D, Giancola M, et al.: Adolescents’ Self and Bullying Victimisation: The Key Role of Gender. Children. 2025; 12: 217. PubMed Abstract | Publisher Full Text | Free Full Text
48. Jansen PW, Verlinden M, Berkel ADV, et al.: Prevalence of bullying and victimization among children in early elementary school: Do family and school neighbourhood socioeconomic status matter?. BMC Public Health. 2012; 12: 494. PubMed Abstract | Publisher Full Text | Free Full Text
49. Gaffney H, Ttofi MM, Farrington DP: Effectiveness of school-based programs to reduce bullying perpetration and victimization: An updated systematic review and meta-analysis. Campbell Syst. Rev. 2021; 17: e1143. PubMed Abstract | Publisher Full Text | Free Full Text
50. Babakurd FM: Anterior crossbite and appearance-related bullying dataset. OSF. 2026. Reference Source

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Author details Author details

¹ Pediatric Dentistry Department, Faculty of Dentistry, Damascus University, Damascus, Syria
² Faculty of Informatics Engineering, Damascus University, Damascus, Syria
³ Pediatric Dentistry Department, Faculty of Dentistry, Damascus University, Damascus, Syria

Farah M. Babakurd
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Khaled Omar
Roles: Data Curation, Formal Analysis, Writing – Review & Editing

Mayssoon Dashash
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

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The author(s) declared that no grants were involved in supporting this work.

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M. Babakurd F, Omar K and Dashash M. How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index [version 1; peer review: 1 not approved]. F1000Research 2026, 15:590 (https://doi.org/10.12688/f1000research.179073.1)

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Reviewer Report 26 May 2026

Tiago Fialho, Bauru Dental School, São Paulo University, São Paulo, Brazil

Not Approved

https://doi.org/10.5256/f1000research.197541.r485889

Thank you for the opportunity to review the manuscript entitled “How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index” (version 1; DOI: 10.12688/f1000research.179073.1). I have completed a thorough critical appraisal of this work. ... Continue reading

Thank you for the opportunity to review the manuscript entitled “How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index” (version 1; DOI: 10.12688/f1000research.179073.1). I have completed a thorough critical appraisal of this work. While the research question is clinically relevant and the authors have attempted to address an important gap in the literature concerning anterior crossbite severity and psychosocial outcomes in Syrian schoolchildren, I regret to conclude that the manuscript is not acceptable for indexing in its current form due to fundamental statistical errors that compromise the validity and interpretability of the main findings.
The most serious flaw concerns the binary logistic regression analysis presented in Table 4. The authors report odds ratios for bullying victimization comparing different occlusal status groups to the reference category of normal occlusion. According to the table, children with both malocclusion and anterior crossbite have an Exp(B) of 0.000 with a 95% confidence interval of 0.000 to 0.003, and children with anterior crossbite only have an Exp(B) of 0.231 with a 95% confidence interval of 0.176 to 0.303. Both odds ratios are substantially below 1, which mathematically indicates a strong protective effect, meaning these groups would have a much lower risk of bullying compared to children with normal occlusion. However, this directly contradicts the descriptive data presented earlier in Table 3, where 87.1% of children in the malocclusion and anterior crossbite group and 74.3% of those with anterior crossbite only were classified as bullying victims, whereas only 0.1% of children with normal occlusion were victims. The odds ratios as reported are therefore impossible to reconcile with the observed proportions, indicating a critical error in either the coding of the outcome variable, the specification of the reference category, the direction of the calculated odds ratios, or the interpretation of the regression output. Until this error is corrected and the analysis is rerun with proper verification, no reliable conclusions can be drawn from the multivariable analysis, and consequently the paper’s central claim that anterior crossbite increases bullying risk lacks valid statistical support.
Beyond this critical error, there are additional methodological concerns that require attention. The sample size justification is problematic. The authors initially calculate that approximately 150 children would be needed for prevalence estimation and approximately 236 children for the association between crossbite and bullying, yet they ultimately recruit 2,080 children without providing a clear, statistically grounded rationale for this tenfold expansion. While a larger sample is not inherently problematic, the absence of a priori justification based on expected effect sizes, design effects from cluster sampling, or required power for subgroup and ordinal regression analyses weakens the transparency of the study design. Furthermore, the manuscript claims a dose-response relationship between crossbite severity and bullying severity based on ordinal logistic regression (Table 5), which is conceptually sound, but this finding is undermined by the unresolved inconsistency in the binary regression results. Readers and reviewers cannot fully trust the ordinal model when the more basic binary model contains an uncorrected error.
Additionally, the authors invoke Bradford Hill criteria for causality, particularly the dose-response principle, yet the cross-sectional design of the study precludes any causal inference. The observed associations, even if correctly analyzed, could be explained by unmeasured confounders such as baseline self-esteem, pre-existing psychological vulnerability, family support structures, or socioeconomic status, none of which were included in the regression models. The language throughout the discussion, including phrases such as “causal inference” and “risk indicator” being interpreted as more than associative, overreaches the limitations of the study design. The authors should reframe their conclusions to reflect only associational findings.
There are also several reporting inconsistencies that detract from the manuscript’s clarity. On page 4, the text refers to “anterior cross-profile prevalence” and “anterior cross-site” instead of anterior crossbite, suggesting typographical errors that should be corrected. The description of the ROMA grading system indicates that higher grades represent greater severity, yet the interpretation of the ordinal regression coefficients requires careful attention to the coding of bullying severity scores, where lower scores paradoxically indicate greater bullying exposure. While the authors acknowledge this coding scheme, the presentation remains confusing for readers not intimately familiar with the modified Olweus scoring method. Finally, the exclusion of children with normal occlusion from the analysis of bullying patterns and locations (Table 6) is justified on the grounds that bullying was negligible in this group, but this decision removes an important comparative anchor and limits the interpretability of the location data.
On a positive note, the study has several strengths that should be acknowledged. The use of the ROMA Index provides a standardized and reproducible clinical assessment, and the pilot testing of the modified Olweus questionnaire demonstrated good psychometric properties with a content validity index of 0.92, Cronbach’s alpha of 0.85, and an intraclass correlation coefficient of 0.88. The sample size of 2,080 children is impressive and, if properly analyzed, could provide precise estimates. The authors should also be commended for making their data and materials available through the Open Science Framework, which aligns with F1000Research’s commitment to transparency and reproducibility. The study addresses a genuinely under-researched population, namely children in Syria, and the focus on severity-based analysis rather than simple presence or absence of malocclusion is conceptually valuable.
I believe the research question remains important and the dataset has potential value. Therefore, I encourage the authors to thoroughly revise the statistical analysis, specifically correcting the binary logistic regression error and ensuring consistency across all tables and interpretations. They should also provide a clearer and more justified sample size calculation, tone down causal language, and improve reporting consistency. Once these revisions are made, the manuscript could be resubmitted as a new version for further review. Given the severity of the statistical error, I cannot recommend acceptance at this stage, but I remain open to evaluating a corrected version in the future.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Orthodontics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Tiago Fialho, Bauru Dental School, São Paulo University, São Paulo, Brazil

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26 May 2026 | for Version 1

Tiago Fialho, Bauru Dental School, São Paulo University, São Paulo, Brazil

20 Views Cite this report Responses(0)

Not Approved

Thank you for the opportunity to review the manuscript entitled “How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index” (version 1; DOI: 10.12688/f1000research.179073.1). I have completed a thorough critical appraisal of this work. While the research question is clinically relevant and the authors have attempted to address an important gap in the literature concerning anterior crossbite severity and psychosocial outcomes in Syrian schoolchildren, I regret to conclude that the manuscript is not acceptable for indexing in its current form due to fundamental statistical errors that compromise the validity and interpretability of the main findings.
The most serious flaw concerns the binary logistic regression analysis presented in Table 4. The authors report odds ratios for bullying victimization comparing different occlusal status groups to the reference category of normal occlusion. According to the table, children with both malocclusion and anterior crossbite have an Exp(B) of 0.000 with a 95% confidence interval of 0.000 to 0.003, and children with anterior crossbite only have an Exp(B) of 0.231 with a 95% confidence interval of 0.176 to 0.303. Both odds ratios are substantially below 1, which mathematically indicates a strong protective effect, meaning these groups would have a much lower risk of bullying compared to children with normal occlusion. However, this directly contradicts the descriptive data presented earlier in Table 3, where 87.1% of children in the malocclusion and anterior crossbite group and 74.3% of those with anterior crossbite only were classified as bullying victims, whereas only 0.1% of children with normal occlusion were victims. The odds ratios as reported are therefore impossible to reconcile with the observed proportions, indicating a critical error in either the coding of the outcome variable, the specification of the reference category, the direction of the calculated odds ratios, or the interpretation of the regression output. Until this error is corrected and the analysis is rerun with proper verification, no reliable conclusions can be drawn from the multivariable analysis, and consequently the paper’s central claim that anterior crossbite increases bullying risk lacks valid statistical support.
Beyond this critical error, there are additional methodological concerns that require attention. The sample size justification is problematic. The authors initially calculate that approximately 150 children would be needed for prevalence estimation and approximately 236 children for the association between crossbite and bullying, yet they ultimately recruit 2,080 children without providing a clear, statistically grounded rationale for this tenfold expansion. While a larger sample is not inherently problematic, the absence of a priori justification based on expected effect sizes, design effects from cluster sampling, or required power for subgroup and ordinal regression analyses weakens the transparency of the study design. Furthermore, the manuscript claims a dose-response relationship between crossbite severity and bullying severity based on ordinal logistic regression (Table 5), which is conceptually sound, but this finding is undermined by the unresolved inconsistency in the binary regression results. Readers and reviewers cannot fully trust the ordinal model when the more basic binary model contains an uncorrected error.
Additionally, the authors invoke Bradford Hill criteria for causality, particularly the dose-response principle, yet the cross-sectional design of the study precludes any causal inference. The observed associations, even if correctly analyzed, could be explained by unmeasured confounders such as baseline self-esteem, pre-existing psychological vulnerability, family support structures, or socioeconomic status, none of which were included in the regression models. The language throughout the discussion, including phrases such as “causal inference” and “risk indicator” being interpreted as more than associative, overreaches the limitations of the study design. The authors should reframe their conclusions to reflect only associational findings.
There are also several reporting inconsistencies that detract from the manuscript’s clarity. On page 4, the text refers to “anterior cross-profile prevalence” and “anterior cross-site” instead of anterior crossbite, suggesting typographical errors that should be corrected. The description of the ROMA grading system indicates that higher grades represent greater severity, yet the interpretation of the ordinal regression coefficients requires careful attention to the coding of bullying severity scores, where lower scores paradoxically indicate greater bullying exposure. While the authors acknowledge this coding scheme, the presentation remains confusing for readers not intimately familiar with the modified Olweus scoring method. Finally, the exclusion of children with normal occlusion from the analysis of bullying patterns and locations (Table 6) is justified on the grounds that bullying was negligible in this group, but this decision removes an important comparative anchor and limits the interpretability of the location data.
On a positive note, the study has several strengths that should be acknowledged. The use of the ROMA Index provides a standardized and reproducible clinical assessment, and the pilot testing of the modified Olweus questionnaire demonstrated good psychometric properties with a content validity index of 0.92, Cronbach’s alpha of 0.85, and an intraclass correlation coefficient of 0.88. The sample size of 2,080 children is impressive and, if properly analyzed, could provide precise estimates. The authors should also be commended for making their data and materials available through the Open Science Framework, which aligns with F1000Research’s commitment to transparency and reproducibility. The study addresses a genuinely under-researched population, namely children in Syria, and the focus on severity-based analysis rather than simple presence or absence of malocclusion is conceptually valuable.
I believe the research question remains important and the dataset has potential value. Therefore, I encourage the authors to thoroughly revise the statistical analysis, specifically correcting the binary logistic regression error and ensuring consistency across all tables and interpretations. They should also provide a clearer and more justified sample size calculation, tone down causal language, and improve reporting consistency. Once these revisions are made, the manuscript could be resubmitted as a new version for further review. Given the severity of the statistical error, I cannot recommend acceptance at this stage, but I remain open to evaluating a corrected version in the future.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Orthodontics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Respond to this report

Responses (0)

[1] 1. Stomatologic, S: Worldwide prevalence of malocclusion in the different stages of dentition: A systematic review and meta-analysis. Eur. J. Paediatr. Dent. 2020; 21: 115–122.

[2] 2. Sun L, Wong HM, McGrath CP, et al.: Association between the severity of malocclusion, assessed by occlusal indices, and oral health related quality of life: a systematic review and meta-analysis. Oral Health Prev. Dent. 2018; 16.

[3] 3. Laursen B, Veenstra R: Toward understanding the functions of peer influence: A summary and synthesis of recent empirical research. J. Res. Adolesc. 2021; 31: 889–907. PubMed Abstract | Publisher Full Text | Free Full Text

[4] 4. Babakurd F, al Shammary NH, Azrak L, et al.: Assessment of Dentists' Knowledge of Space Maintainer Indications After Primary First Molar Extraction: A Cross-Sectional Study. Cureus. 2024; 16. Publisher Full Text

[5] 5. Kragt L, Dhamo B, Wolvius EB, et al.: The impact of malocclusions on oral health-related quality of life in children—a systematic review and meta-analysis. Clin. Oral Investig. 2016; 20: 1881–1894. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Dutra SR, Pretti H, Martins MT, et al.: Impact of malocclusion on the quality of life of children aged 8 to 10 years. Dental Press J. Orthod. 2018; 23: 46–53. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. Broutin A, Blanchet I, Canceill T, et al.: Association between dentofacial features and bullying from childhood to adulthood: a systematic review. Children. 2023; 10: 934. Publisher Full Text

[8] 8. e Paulo DM, et al.: Impact of malocclusion on bullying in school children and adolescents: A systematic review and meta-analysis. Child Youth Serv. Rev. 2022; 142: 106636.

[9] 9. Andrews NC, Cillessen AH, Craig W, et al.: Bullying and the Abuse of Power. Int. J. Bullying Prev. 2023; 5: 261–270. PubMed Abstract | Publisher Full Text | Free Full Text

[10] 10. Shaw W, Meek S, Jones D: Nicknames, teasing, harassment and the salience of dental features among school children. Br. J. Orthod. 1980; 7: 75–80.

[11] 11. Baram D, Yang Y, Ren C, et al.: Orthodontic Treatment Need and the Psychosocial Impact of Malocclusion in 12-Year-Old Hong Kong Children. Sci. World J. 2019; 2019: 1–9. Publisher Full Text

[12] 12. Terada ASSD, Oliveira MB, Silva LM, et al.: Malocclusion and bullying experience among school-aged children and adolescents: a systematic review. Caderno Pedagógico. 2025; 22: e20526–e20526. Publisher Full Text

[13] 13. Sunil M, Zareena M, Ratheesh MS, et al.: Early orthodontic interception of anterior crossbite in mixed dentition. Journal of International Oral Health. 2017; 9: 88–90. Publisher Full Text

[14] 14. Lo Giudice A, Polizzi A: Pediatric treatment of anterior-upper-single dental crossbite using a versatile sagittal screw system: a case series. Pediatric Reports. 2025; 17: 11. PubMed Abstract | Publisher Full Text | Free Full Text

[15] 15. Grippaudo C, Paolantonio E, Deli R, et al.: Orthodontic treatment need in the Italian child population. Eur. J. Paediatr. Dent. 2008; 9: 71.

[16] 16. Olweus D: Revised Olweus bully/victim questionnaire. J. Psychopathol. Behav. Assess. 1996.

[17] 17. Gaete J, Valenzuela D, Godoy MI, et al.: Validation of the revised Olweus bully/victim questionnaire (OBVQ-R) among adolescents in Chile. Front. Psychol. 2021; 12: 578661. PubMed Abstract | Publisher Full Text | Free Full Text

[18] 18. Crespo JE, Rodríguez ICR, de Jesús F , et al.: The Declaration of Helsinki and the Evolution of Ethics in Medical Research. International Journal of Sustainable Science and Technology. 2025; 3.

[19] 19. Ghaferi AA, Schwartz TA, Pawlik TM: STROBE reporting guidelines for observational studies. JAMA Surg. 2021; 156: 577–578. Publisher Full Text

[20] 20. Iqbal Jeelani M, Danish F, Gul M: A review on the recent development on the cluster sampling. Biostat Biom Open Access J. 2018; 5: 146–150.

[21] 21. Pourhoseingholi MA, Vahedi M, Rahimzadeh M: Sample size calculation in medical studies. Gastroenterology and Hepatology from bed to bench. 2013; 6: 14–17. PubMed Abstract

[22] 22. Manual, A. P: Geneva.1991.

[23] 23. Naing L, Winn T, Rusli B: Practical issues in calculating the sample size for prevalence studies. Arch. Orofac. Sci. 2006; 1: 9–14.

[24] 24. Bujang MA, Sa’at N, Bakar TMITA, et al.: Sample size guidelines for logistic regression from observational studies with large population: emphasis on the accuracy between statistics and parameters based on real life clinical data. Malays J Med Sci. 2018; 25: 122.

[25] 25. Saulicz E, Saulicz O, Koterba J, et al.: Inter-and intra-examiner reliability study of two-point discrimination test (TPD) and two-point estimation task (TPE) in the sacral area of pain-free individuals. Diagnostics (Basel). 2023; 13: 3438. Publisher Full Text

[26] 26. Madadizadeh F, Ghafari H, Bahariniya S: Kappa statistics: A method of measuring agreement in dental examinations. Open Public Health J. 2023; 16.

[27] 27. Ramachandra SS, Mehta DS, Nagarajappa Sandesh M, et al.: Periodontal probing systems: a review of available equipment. Periodontics. 2009; 3: 16.

[28] 28. Solberg ME, Olweus D: Prevalence estimation of school bullying with the Olweus Bully/Victim Questionnaire. Aggressive Behavior: Official Journal of the International Society for Research on Aggression. 2003; 29: 239–268.

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How Anterior Crossbite Severity Relates to Appearance-Based Bullying in School-Age Children: Evidence from the ROMA Index

Abstract

Introduction

Materials and Methods

Results

Conclusion

Keywords

Introduction

Materials and methods

Sampling and study population

Clinical assessment of malocclusion and other occlusal features

Assessment of dental appearance-related bullying

Inclusion and exclusion criteria

Statistical analysis

Results

Table 1. Prevalence of anterior crossbite among children aged 8–12 years, categorized by severity and required intervention according to the ROMA Index.

Table 2. Prevalence of dental appearance-related school bullying among children aged 8 to 12 years with mixed dentition.

Table 3. Relationship between occlusal status and dental appearance-related bullying.

Table 4. Logistic regression assessing the relationship between occlusal status and dental bullying.

Table 5. Ordinal logistic regression analysis examining the dose–response relationship between the severity of anterior crossbite, as classified by the ROMA index, and the intensity of bullying exposure.

Table 6. Patterns and locations of dental appearance-related bullying among children with varying occlusal characteristics.

Discussion

Conclusion

Ethics declarations

Ethics approval and consent to participate

Consent for publication

Data availability statement

Extended data

References

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