Bullying is an aggressive behavior and a serious issue that should be addressed by everyone and should be avoided at all costs. It is is very common among adolescents and schoolchildren and the effects can be devastating and long lasting. Most common causes of bullying among students are: physical appearance, race, gender, disability, ethnicity, religion, and sexual orientation. Appearance-targeted bullying is a form of bullying that targets one’s physical appearance, which includes facial and dental features. Deviation from accepted dentofacial aesthetics can lead to elevated cases of bullying in schoolchildren. The aim of this review article is to assess the prevalence of bullying due to dentofacial features, and evaluate the importance of dentofacial appearance on the perceived social attractiveness, based on multiple studies.

Bullying is described as an aggressive behavior in which someone purposely and repeatedly causes harm or discomfort to another individual [1]. Bullying exists in various shapes and different forms, which includes physical or verbal assault, social bullying, engaging in insidious practices and cyber bullying [2,3]. Bullying can also be categorized into: overt such as hitting, threatening, or calling names, and covert such as spreading rumours, manipulation of relationships, excluding and isolating [4]. In the U.S, 1 in 5 (20%) schoolchildren ages 12-18 experienced bulling throughout the school year, and 41% of students who reported being bullied at school stated that they believe the incidence would occur again [5] while 70% of school workers have witnessed acts of bullying [6]. About 16% of secondary school students are victims of bullying in Russia [7]. And a recent UNESCO report stated that greater than 30% of schoolchildren around the world have experienced acts of bullying [8]. It has been estimated that around 42% of students who have been bullied during their school years indicated that it was associated with at least one of the following: physical appearance (30%), race (10%), gender (8%), disability (7%), ethnicity (7%), religion (5%), and sexual orientation (4%) [9]. Victims of such an act are mainly children who are viewed as physically unattractive and those who cannot fit society’s standards [10]. According to the United Nations educational and cultural agency, bullies like to target their victims based on their physical appearance, ethnicity, gender or sexual orientation [11]. Appearance-targeted bullying is a form of bullying that targets one aspect or more of a person's appearance [12]. YMCA England and Wales’s In Your Face report, published in 2018, mentions that greater than half (55%) of young people have experienced bullying targeted by their appearance, 60% of which admitted they tried to change the way they look after being bullied. Around 53% of those who got bullied due to their appearance said they suffered from anxiety as a result and 29% had experienced more depression. One in 10 said they had experienced suicidal thoughts and 9% said they self-harmed as a result [13]. The physical characteristics usually associated with bullying are weight, height, and facial features moreover, children with better dental appearance are perceived by society as more attractive and desirable as friends, more intelligent, and less likely to be aggressive [14,15]. Children ages 14 and 15 with higher clinical need for orthodontic treatment had less self-perception and lower self-esteem when compared to others [16].

A wide search was preformed, with no time, location or language restriction, using electronic databases, including: PubMed, PubMed Central, National Library of Medicine and ResearchGate. Medical Subject Headings (MeSH) terms such as “Malocclusion”, “Appearance-targeted bullying”, “Dento-facial features” and their related entry terms were used. The included studies’ reference lists were also searched. A comprehensive search of the literature using a predefined search strategy found a total of 2,637 studies. After de-duplication and eliminating irrelevant publications, the review included a total of eight studies. Eligibility criteria included all scientific articles concerning the incidence of bullying mainly targeted by the victims’ teeth and dento-facial features, six studies were conducted on schoolchildren and adolescents, one study on orthodontic patients and one study on online users as victims of dento-facial targeted bullying.

A study published in the American Journal of Orthodontics & Dentofacial Orthopedics, aimed to look into the incidence of bullying in a representative sample of Jordanian schoolchildren in Amman, and to assess its consequences and effects on school performance, and the contribution of general physical appearance and dentofacial features. The prevalence of bullying turned out to be 47%, and teeth were the number 1 physical feature targeted by bullies. The three most commonly reported dentofacial features targeted by bullies were spacing between the teeth or missing teeth, shape and color of the teeth, and prominent upper anterior teeth [17].

Another recent study aimed to investigate bullying's prevalence owing to malocclusions and how it affects people's desire for orthodontic treatment in a sample of German orthodontic patients, the final sample involved 1020 patients (females = 547, males =473), 23.7% reported that they had been bullied at least 2 or 3 times a month in the past 2 months, teeth and weight were pointed out to be the main features targeted by bullies, the three highly reported dentofacial features targeted for bullying were: crooked teeth, prominent teeth and gaps between the teeth. The subjects were separated into three categories based on the occurrence and cause of bullying: subjects bullied due to dentofacial features, subjects bullied due to general physical features, and subjects who didn’t experience bullying (control group). Subjects from the dentofacial features group (6.3%) initiated orthodontic treatment themselves significantly more often when compared to subjects from the other 2 groups, and the dentofacial features group stated that ‘ugly teeth’ were their main reason to seek orthodontic treatment (40.4%), in addition, significantly higher mean scores for the expectation ‘keep me from being bullied’ were obtained from this group in comparison to subjects from other groups [18]. One study was held among Saudi schoolchildren to determine bullying's prevalence and consequences and the associated sociodemographic, physical, and dentofacial features, the final sample included 1028 parents of schoolchildren aged 8-18 years old who were asked to fill questionnaires for their children. The study revealed that (89.2%) of schoolchildren experienced bullying. Teeth were the number one targeted physical feature for bullying, followed by the shape of the lips and strength. The three most commonly reported dentofacial features targeted by bullies were tooth shape and color, followed by anterior open bite and protruded anterior teeth [19]. A cross-sectional study was conducted to assess the severity and frequency of bullying reported by adolescents referred for orthodontic treatment at three UK hospitals and to investigate the relation between levels of self-reported bullying, malocclusion and requirement for orthodontic therapy, Three hundred and thirty-six subjects aged between 10 and 14 years participated and questionnaires were used to calculate the self-reported frequency and severity of bullying, self-esteem and OHRQoL (Oral Health-Related Quality of Life). Orthodontic treatment need was assessed using IOTN (Index of Orthodontic Treatment Needed). The results revealed that (12.8%) of the subjects experienced bullying, and the most commonly reported dentofacial features targeted by bullies were class II Division 1 incisor relationship, increased overbite and increased overjet. A higher need for orthodontic treatment assessed using the AC of IOTN (P50.014) was also targeted by bullies. The study reported the presence of a significant relation between bullying and certain occlusal traits, self-esteem and OHRQoL [20]. An investigation into the frequency of self-harm among a sample of eighth-grade children aged 13-14 years was conducted in a cross-sectional study, it aimed to evaluate the contribution of dentofacial appearance and being bullied because of dentofacial appearance to self-harm, the subjects were requested to fill out anonymous questionnaires, and the final sample included 699 children with the mean age being 13.3 years. The results of this study stated that the prevalence of self-harm was 26.9%, and 47.9% of all subjects who admitted to self-harm did so because of their dentofacial characteristics. 41 subjects reported self-harm because of bullying targeted at dentofacial features, The three most commonly reported dentofacial features contributing to self-harm and bullying-related self-harm were: tooth color and shape, spacing between the teeth or missing teeth, and prominent maxillary anterior teeth [21]. One study looked at the relationship between bullying and malocclusion in high school students from Olinda, Pernambuco public schools. The sample included 236 subjects aged between 14 to 19 years, and data was collected through a questionnaire with questions regarding PeNSE-based sociodemographic characterization and bullying. The results indicated that (24.9%) of adolescents reported being bullied, and (42.5%) of those who reported being bullied had malocclusion, mostly Class II malocclusion was the prevalent. However, according to this study, bullying of any kind did not statistically correlate with malocclusion, and malocclusion did not correlate with bullying as a practice [22]. Another recent study sought to qualitatively evaluate Twitter posts for common themes concerning dentofacial features, orthodontic appliances and bullying. Keywords related to bullying, teeth and orthodontics were used to search Twitter’s database from 2010 to 2014. 321 posts were incorporated into the final sample, and 4 main categories relevant to ‘dental-related bullying’ were recognized: (i) morphological features, (ii) psychological and psychosocial impact, (iii) coping mechanisms, (iv) role of family. Subjects that experienced bullying reported a diverse range of psychological impacts and coping mechanisms, in addition, family members were discovered to play a contributing as well as a mediating role in bullying. Twitter users reported that ‘morphological features of teeth or malocclusion’ were targeted by bullies, and victims of bullying reported that bullies used adjectives such as ‘messed up’, ‘ugly’, ‘horrible’ or ‘shitty’ to describe their teeth, other users included words such as ‘bunny’, ‘goofy’, ‘horse’, ‘monster’, ‘vampire’, ‘rabbit’, ‘crooked’, ‘missing’ or ‘gap’ to describe their teeth [23]. A study was held to compare the crowding of anterior teeth in children who had experienced bullying and those who had not, the sample included 218 subjects aged between 11 and 16 years, little's irregularity index was used to assess dental crowding. A questionnaire was completed to diagnose bullying. The U-Mann Whitney statistical test was used to compare crowding in patients who had experienced bullying and those who had not. According to the findings, there was considerably more dental crowding in schoolchildren who had experienced bullying than in those with no bullying. The average crowding for the group subjected to bullying was 11.6 +/- 9.4 mm and in the group without bullying was 9.1 +/- 7.9 mm [24].

Bullying due to dentofacial features is very common among adolescents and schoolchildren, and in some cases it can lead to suicidal thoughts and self-harm. The likelihood of malocclusion, low self-esteem, and being bullied are all significantly correlated. Bullies frequently use the following dentofacial features as their targets: spacing between the teeth or missing teeth, shape and color of the teeth, prominent teeth, crooked teeth, class II malocclusion, anterior open bite, increased overbite and increased overjet. Malocclusion-related bullying may alter attitude toward orthodontic treatment.

Funding Statement

The author did not receive support from any organization for the submitted work.

Conflict of Interest

The author declares no conflict of interest.

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