Association between malocclusion severity and social anxiety, self-esteem in adolescents: A cross-sectional study

This study investigates the association between malocclusion severity and social anxiety and self-esteem levels in adolescents and explores factors associated with heterogeneity in these psychological outcomes. A cross-sectional study design was employed. A convenience sample of 190 adolescents aged 12 to 18 years, recruited from the orthodontic department of a hospital from June 2023 to December 2025, was enrolled. Malocclusion severity was assessed using the Index of Orthodontic Treatment Need-Dental Health Component (IOTN-DHC) and categorized into mild, moderate, and severe groups. Social anxiety and self-esteem levels were evaluated using the Liebowitz Social Anxiety Scale and the Rosenberg Self-Esteem Scale, respectively. Sociodemographic data, perceived social support, concern about dental appearance, and history of being teased were also collected. Statistical analyses included analysis of variance, chi-square tests, Spearman's correlation, multiple linear regression, and exploratory interaction analyses. The severe malocclusion group exhibited significantly higher total social anxiety scores (48.6 ± 15.8) compared with the moderate (33.7 ± 12.5) and mild (28.4 ± 10.2) groups (P < .001), with 64.9% scoring above the Liebowitz Social Anxiety Scale threshold used to indicate clinically significant social anxiety risk. Their total self-esteem scores (26.3 ± 6.2) were significantly lower than those in the other 2 groups (P < .001). Malocclusion severity was positively correlated with social anxiety (rs = 0.35, P < .001) and negatively correlated with self-esteem (rs = -0.31, P < .001). After adjustment for measured covariates, severe malocclusion remained independently associated with higher social anxiety (β = 0.52) and lower self-esteem (β = -0.41; both P < .001). Exploratory interaction analyses suggested that these associations may be stronger among adolescents who were female, had a history of being teased about their teeth, or reported high concern about dental appearance; these findings should be considered hypothesis-generating. Greater malocclusion severity was associated with higher social anxiety and lower self-esteem in this cross-sectional clinical sample. Severe malocclusion was an independent correlate of both psychological outcomes after adjustment for measured covariates. Because temporality cannot be established, causal interpretations are not warranted, and longitudinal studies are needed. Clinicians may consider psychological screening, particularly when severe malocclusion co-occurs with teasing experiences or marked appearance concern.