Bullying: Nothing to Smile About

According to the National Center for Educational Statistics (2015), approximately one out of every five students (22%) ages 12-18 has reported being bullied at school. Although most bullying occurs in grades 6, 7 and 8, it can begin much earlier. One study, for example, demonstrated that a staggering quarter of children ages 6-8 designated their peers as playing the role of aggressor and a fifth the role of victim. As a matter of fact, sixty seven percent of parents of three to seven year olds surveyed nationwide worried that their children were being bullied (NY Times, 2010).

Why do kids get bullied? A survey of a nationally representative sample of 3450 students aged 13-18, showed that 39% of surveyed teens reported being harassed because of their physical appearance (Gay, Lesbian and Straight Education Network, 2005). Psychologists long ago have established that facial attractiveness plays an important role in many social settings, including school, work and personal relationships (Cunningham, 1999). Individuals who display good dental esthetics are assumed to be better at making friends, dating and career advancement, while those with poor dental appearance, often are perceived to have low esteem (Seehra, Newton, & DiBiase, 2011).

Certain dental features appear to elicit more teasing, including dental crowding, increased overjet and a deep overbite (Seehra, Fleming, Newton, & DiBiase, 2011). These dental anomalies are significantly linked to a negative emotional and social impact that affects overall oral health-related quality of life. Personal feelings towards the dentofacial region has been shown to be strongly related to self-esteem and self-concept (Philips & Beal, 2009).

Dental decay is another reason that children may be bullied. Fernandes et al. (2013) have shown that dental decay in schoolchildren aged 8-14 years was significantly associated with emotional and social well being. Children without decay evaluate their own smiles more positively, smile more frequently and receive more positive evaluation from their parents than children with decay (Low, Tan, & Schwartz, 1998; Patel et al., 2007). Smiling is an important social behavior that denotes self confidence and is an important factor in the way that a child interacts with their environment.

The dental profession is commonly called upon to help children who have been victims of bullying (Cunningham & Hunt, 2001). Several studies have investigated the impact that dental treatment has on psychosocial health. Schefell et al. (2014) reported three case studies where young children claimed to no longer be victims of verbal abuse and to experience higher self-esteem and socialization following dental treatment. Agou et al. (2011) demonstrated that 11 to 14 year old children with poor psychological well-being experienced worse oral health-related quality of life when they did not receive orthodontic treatment, as compared to those who did receive treatment. Birkeland, Boe and Wisth (2000) showed that satisfaction with own dental appearance increased significantly for children between the ages of 11 and 15 following treatment. Interestingly, a twenty year longitudinal study showed that a lack of orthodontic treatment did not lead to psychological disorders like depression and anxiety later in life. The study did however show that those who received treatment for severe malocclusion reported greater satisfaction with their dental and general appearance and an increased overall quality of life, as compared to those who did not undergo treatment but had significant dental needs.

There is no doubt that dentistry plays a crucial role in mitigating the effects of bullying in children and adolescents. According to Seehra et al. (2011), there is no clear guidance for dental practitioners to help identify children at risk for bullying. While some affirm the clinician’s role in identifying at-risk children (Lyznicki, McCaffree, & Robinowitz, 2004), Seehra et al. (2011), caution that identification of at-risk children can lead to stereotyping. The authors urge for anti-bullying interventions to be focused primarily on the school environment, involving parents, teachers and school nurses.

School nurses, who are experts in pediatric health, play a key role in promoting and enhancing student safety, wellness, engagement and learning (National Association of School Nurses, 2014), can therefore play a significant role in identifying incidents of bullying, liaising with the school’s administrative bodies to develop anti-bullying policies, providing counseling to families and restoring self-esteem. For those children that experience taunting due to dental decay, nurses can also be an important partner in oral disease prevention, providing oral health hygiene recommendations, nutritional advice, and referral for dental restoration, including operative procedures.

While orthodontic treatment can alleviate bullying, treatment can be so expensive that many families forego it, even if they have dental insurance. Luckily, there exist organizations such as Smiles Change Lives, a national network of 750 orthodontists who help children from families who cannot afford orthodontic treatment and whose self-esteem has been impacted by having crooked teeth! Dental schools too offer braces at reduced rates, where the residents-in-training provide orthodontic treatment supervised by more experienced orthodontists.

Oral health is integral to providing children with a healthy smile, a key to preventing episodes of bullying and promoting healthy social interactions. Tomorrow’s SMILES is a wonderful oral health education program conducted in partnership between the National Association of School Nurses and the National Children’s Oral Health Foundation that matches dental practitioners with students who suffer from embarrassment and poor self-esteem as a result of poor dental esthetics (Ingber, 2011). In return for the restorative treatment, the teens in the program share important oral health tools with younger children in their communities that promote good oral hygiene and hopefully prevent any future dental-related bullying.

February is Children’s Oral Health Month. Let’s all work together to improve our children’s self-esteem and good oral health!


Agou, S., Locker, D., Streiner, D. L., & Tompson, B. (2008). Impact of self-esso teem on the oral-health-related quality of life of children with malocclusion.American Journal of Orthodontics and Dentofacial Orthopedics134(4), 484-489.

Birkeland, K., Bøe, O. E., & Wisth, P. J. (2000). Relationship between occlusion and satisfaction with dental appearance in orthodontically treated and untreated groups. A longitudinal study. The European Journal of Orthodontics22(5), 509-518.

Cunningham, S. J. (1999). The psychology of facial appearance. Dental update26(10), 438-443.

Cunningham, S. J., & Hunt, N. P. (2015). Quality of life and its importance in orthodontics. Journal of Orthodontics.

Fernandes, M. L. D. M. F., Moura, F. M. P., Gamaliel, K. S., & Correa-Farria, P. (2013). Dental Caries and Need of Orthodontic Treatment: Impact on the Quality of Life of Schoolchildren. Brazilian Research in Pediatric Dentistry and Integrated Clinic13(1), 37-43.

Gay, Lesbian and Straight Education Network. (2005). From teasing to torment: School climate in America. New York: Gay, lesbian, and straight education network.

Ingber, F. K. (2011). Tomorrow’s SMILES® Gives Hope to Teens With Extreme Dental Needs. NASN School Nurse26(1), 40-43.

Low, W., Tan, S., & Schwartz, S. (1998). The effect of severe caries on the quality of life in young children. Pediatric Dentistry21(6), 325-326.

Lyznicki, J. M., McCaffree, M. A., & Robinowitz, C. B. (2004). Childhood bullying: Implications for physicians. American family physician70, 1723-1730.

Monks, C. P., Smith, P. K., & Swettenham, J. (2005). Psychological correlates of peer victimisation in preschool: Social cognitive skills, executive function and attachment profiles. Aggressive Behavior31(6), 571-588.

National Association of School Nurses. (2014). Bullying Prevention in Schools. Position Statement. Retrieved from https://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/638/Bullying-Prevention-in-Schools-Adopted-January-2014

Patel, R. R., Tootla, R., & Inglehart, M. R. (2007). Does oral health affect self perceptions, parental ratings and video‐based assessments of children’s smiles?. Community dentistry and oral epidemiology35(1), 44-52.

Paul, P. (2010). The Playground Gets Tougher. New York Times. Retrieved from http://www.nytimes.com/2010/10/10/fashion/10Cultural.html?_r=1

Phillips, C., & Beal, K. N. E. (2009). Self-concept and the perception of facial appearance in children and adolescents seeking orthodontic treatment. The Angle orthodontist79(1), 12-16.

Scheffel, D. L. S., Jeremias, F., Fragelli, C. M. B., dos Santos-Pinto, L. A. M., Hebling, J., & de Oliveira Jr, O. B. (2014). Esthetic dental anomalies as motive for bullying in schoolchildren. European journal of dentistry8(1), 124.

Seehra, J., Fleming, P. S., Newton, T., & DiBiase, A. T. (2011). Bullying in orthodontic patients and its relationship to malocclusion, self-esteem and oral health-related quality of life. Journal of Orthodontics38(4), 247-256.

Seehra, J., Newton, J. T., & DiBiase, A. T. (2011). Bullying in schoolchildren–its relationship to dental appearance and psychosocial implications: an update for GDPs. British dental journal210(9), 411-415.

Shaw, W. C., Richmond, S., Kenealy, P. M., Kingdon, A., & Worthington, H. (2007). A 20-year cohort study of health gain from orthodontic treatment: psychological outcome. American Journal of Orthodontics and Dentofacial Orthopedics132(2), 146-157.

U.S. Department of Education, National Center for Education Statistics. (2015). Indicators of School Crime and Safety: 2014 (NCES 2015-072), Figure 11.1. Retrieved from https://nces.ed.gov/fastfacts/display.asp?id=719







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