ORIGINAL ARTICLE

 

Impact of untreated dental caries on oral health of adolescents from cities in the countryside of Rio Grande do Sul

 

 

Paola Tibolla^I; Lilian Rigo^II

^IAcadêmica do curso de Odontologia da Faculdade Meridional/IMED de Passo Fundo (RS), Brasil
^IIProfessora Doutora do curso de Odontologia da Faculdade Meridional/IMED de Passo Fundo (RS), Brasil

Correspondence

 

 

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ABSTRACT

INTRODUCTION: Dental caries is a major public health problem around the world, because it can cause pain and suffering to individuals. Even with a decline in childhood disease in recent years, it is observed in many countries
OBJECTIVE: The objective of this research is to analyze the mean of dental caries and the prevalence of untreated caries and associated factors in students from the southern region of Brazil
METHODS: The approach of this study is quantitative, with a cross-sectional design. The research sample was composed of 77 adolescents from the state schools of the urban area of the municipalities of Ciríaco and David Canabarro, Rio Grande do Sul, Brazil. For the data collection, clinical exams were performed, using the DMFT index, and the application of two semistructured questionnaires to adolescents and their parents. The data were analyzed by descriptive statistics and inferential statistics to the Pearson chi-square test and ANOVA at a significance level of 5%
RESULTS: The prevalence of untreated dental caries in the final sample was 40.3% and the DMFT index (decayed, missing and filled teeth) 2.32, there was no statistical difference between cities. There was a statistically significant relationship between the variable toothache in the last six months and the outcome of untreated caries (p = 0.012) with 76% of those who had pain. There was also an association between the variable perception of the treatment at the last visit and untreated caries (p = 0.021), with 84.6% of adolescents considering poor / regular treatment
CONCLUSION: Although the average dental caries has been low, many adolescents have decayed and untreated teeth, with toothache and lack of quality in dental treatment being the factors that most impacted

Keywords: dental caries, toothache, dmf index, dental care.

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INTRODUCTION

Caries and periodontal disease are the most prevalent oral diseases from the point of view of public health, thus causing a great impact on the quality of life of the individuals affected by them. For this reason, such diseases are addressed in several epidemiological studies, and their results are important for the development of preventive and oral health promotion measures¹.

In particular, dental caries is a major public health problem worldwide, as it can cause pain and suffering to individuals. Even with a decline of the disease in children in recent years, it is observed in many countries, prevalence still remains high, with records from several countries having a prevalence greater than 50% in children 12 years of age².

Dental pain, which can be caused by untreated dental caries, is also a public health problem in many countries, including Brazil³. Due to its high prevalence, this pain is one of the main causes of suffering and with social, psychological and economic consequences in the affected individuals, resulting in a compromise of quality of life and bringing impacts to society. In addition, dental pain has been pointed out by individuals, including children, as the main reason for seeking dental care⁴. It is relatively common for school-age children to present high prevalence of dental pain, which is mainly caused by untreated dental caries and related to poor oral health conditions⁵.

Dental caries can be influenced by environmental factors, lifestyle and socioeconomic conditions. However, there are limitations and difficulties to its control, and in most of the world it remains untreated, particularly in the socioeconomically disadvantaged populations, affecting children and adolescents to a large extent⁶.

In recent years, the social condition has been highlighted in the evaluation of dental caries, being considered as a factor of relevance for the risk of caries². Low income, represented by the difficulty of accessing dental services and hygiene products, together with the lack of information and knowledge about oral hygiene habits, is associated with the prevalence and severity of dental caries^7-9. Many epidemiological studies describe the association between social status and poor oral health status^7-10. There is evidence that the distribution of caries in populations is unequal and commonly associated with socioeconomic status. Thus, studies on the factors that determine oral diseases have gained more importance and usually include socioeconomic factors, such as schooling, individual or family income, and occupation of individuals².

In this context, it is extremely important to carry out an epidemiological survey in municipalities that have not yet been carried out, such as the one developed in the present study, which intends to serve as a basis for assessing the current situation and for monitoring these indicators. In addition, it will be possible to assess the impact of possible changes, which must be achieved through the development of preventive, educational and oral health promotion measures in the population.

The objective of this research is to analyze the mean of dental caries and the prevalence of untreated caries and associated factors in school children in the southern region of Brazil.

 

METHODS

For ethical questions, the project was submitted to the approval of the Research Ethics Committee of the Southern Faculdade Meridional/IMED and approved under number 2,014,434. School principals were also asked to consent to access to schoolchildren, from the Authorization Term of the site. Parents of adolescents were asked to sign a Free and Informed Consent Form in order to confirm their understanding and the release of their children's participation in the present study. Also, the adolescents were asked to sign the Term of Assent, confirming their participation in the accomplishment of this work.

Study Design and Sampling

The research has a quantitative approach, whose design is cross-sectional. The study population consisted of all 100 students enrolled in the month of July 2016 in the two state schools of the urban area of the municipalities of the interior of Rio Grande do Sul aged between 11 and 12 years. Of these, 60 adolescents were students of the school that belongs to the municipality of David Canabarro and 40 students of the school of the municipality of Ciríaco. Of the total, 54 and 23 students, respectively from the two municipalities, accepted to participate in the study, totaling a sample of 77 adolescents, which characterized a loss of 23%.

Location of the Study

The municipality of David Canabarro is located in the Northwest region of Rio Grande do Sul, Brazil. With a population of 4,683 inhabitants¹¹ and a total area of 174,939 km². The municipality of Ciríaco is located in the Northwest region of Rio Grande do Sul, Brazil. With a population of 4,922 inhabitants¹¹ and total area of 273,873 km².

Instruments and Procedures for Data Collection

To collect data, a self-administered questionnaire was used for the students and another one for the parents, with questions related to dental care, risk factors and knowledge about dental caries.

Afterwards, a clinical examination was performed to collect data on dental caries in all adolescents, using the DMFT index (index of decayed, missing and filled teeth). The DMFT index measures the dental caries attack on the permanent dentition. Their initials represent, respectively: decayed (D), missing (M), filled (F) teeth and the unit measure being the tooth (T). The lost are subdivided into extracted and indicated extraction, proposed by Palmer and Klein¹².

For inclusion criteria, students should be enrolled in the state schools of the urban area of David Canabarro and Ciríaco, accept to participate in the research, by signing the Terms of Consent, and be present at the date of data collection.

Firstly, it was requested the authorization of the place in the state schools of the municipalities, and later, to request the signature of the parents or guardians consenting to participate in the research besides signing the Term of Assentment by the adolescents.

A questionnaire was sent to parents of adolescents, containing questions related to socioeconomic conditions, access to dental services of their children, using as reference the "Form of socioeconomic evaluation, access to dental services, and self-perception of oral health adopted in SB Brazil 2010.¹³ Both questionnaires were adapted, adding some specific questions to the present study on knowledge about dental caries, methods of prevention and oral hygiene, ingestion of candies and candies and access to the dentist.

Subsequently, a semi-structured questionnaire was applied to students with information on diet, knowledge about dental caries, oral hygiene habits and self-perception of oral health. The questionnaires were delivered to the students in their respective classrooms to be answered. After 1 hour, the rooms were collected to collect the questionnaires, so that the influence of the researcher did not occur. Data collection was carried out in the schools in July 2016, in the morning and afternoon shifts, according to the availability of the schedules by the School Directors and the Teachers present in class, seeking not to interfere with the activities proposed by the schools and the teachers. Afterwards, the data were collected through intraoral clinical examinations, according to the DMFT index for dental caries. The students were called one at a time so that they could be examined properly. Groups composed of flat mouth mirror and sterilized exploratory catheter and tongue depressors were used, following biosafety norms of the Ministry of Health for epidemiological survey. All students were examined next to natural light (window) and with lighting and flashlight help in a room provided by the school heads.

Data were analyzed individually by descriptive statistics and by inferential statistics using the Pearson chi-square test and ANOVA at a significance level of 5%. Statistical Package for the Social Sciences (SPSS) 20.0 was used for this purpose.

 

RESULTS

The analysis identified that of the 77 participants who answered the questionnaire, 54 (70.1%) lived in the municipality of David Canabarro and the others in Ciríaco and were 11 or 12 years old, 50.6% female and the other male. Of these, 59 (76.6%) reported not knowing how tooth decay occurs, but only 3.9% of them brush their teeth only once a day, unlike the others, who brush twice or more a day and only 33.8% use dental floss daily. The majority of them have ever been to the dentist, being 98.7% in the last year, the reasons for which were varied: 54.5% for review / checkup or prevention, 10.4% for toothache, and the others for some treatment. The majority had a good perception of the dental treatment performed in the last consultation (83.1%), but 28.6% believe that they currently require dental treatment.

When the students were questioned about the presence of toothache, 25 (32.5%) reported having suffered toothache in the last 6 months. Thus, 64 (83.1%) of the students had a good perception of the treatment in the last consultation being satisfied.

When questioned about the frequency of intake of candy or sweets, 23.4% stated that they ingest every day.

Regarding parents' schooling, 57.2% attended elementary school, 27% up to high school and 15.6% attended higher education. Regarding income, questioned about the amount received monthly, 55.9% receive from R$500 to R$1,500.00, and the other part (44.1%) receives from R$1,501.00 to R$4,500.00 monthly. According to the parents, 85.5% said that access to the dental surgeon is easy and fast, 67.5% attending public service and 32.5% attending private service.

The mean DMFT index found in all adolescents was 2.32 (sd 1.81). According to the municipalities, the average of the adolescents of David Canabarro was 2.43 (sd1.93) and that of Ciríaco 2.09 (sd 1.50). According to statistical analysis to verify difference between the groups, it was possible to observe that there was no statistically significant difference between the means of dental caries among the adolescents of the two municipalities, from the Analysis of Variance (ANOVA) test, with p = 0.45.

When the components of the DMFT index were analyzed separately, it was verified that the prevalence of untreated dental caries was 40.3%, observed by the sum of the components decayed and filled, but with caries present. In Figure 1, the frequencies of the DMFT components (decayed, missing and filled teeth) are represented (Figure 1).

 

 

For the construction of the dental caries untreated dependent variable, the components of the DMFT were categorized into two groups: 1. Yes - decayed and filled, but with caries; 2. No caries - all other components.

Bivariate relationships are presented in Tables 1 and 2, between dependent variable and independent variables (socio-demographic variables and variables of habits and oral perceptions). After statistical analysis, a statistically significant relationship was observed between the variable toothache in the last 6 months and untreated caries with a frequency of 76% of those who had toothache in the last 6 months and caries present (p=0.012). Also, there was an association between the variable perception of dental treatment at the last visit and untreated caries (p=0.021), with 84.6% of those who considered the treatment as poor and / or regular (Table 1 and Table 2).

The data found in the scientific publications with high evidences and that served for the discussion of the work are in Table 3.

 

DISCUSSION

According to the World Health Organization, index values correspond to the following degrees of severity: very low (0.0 to 1.1), low (1.2 to 2.6), moderate (2.7 to 4, 4), high (4.5 to 6.5) and very high (6.6 and more)¹⁴. It's observed that the values obtained in the present study classify the mean of dental caries as low in both municipalities investigated.

The total DMFT index found was 2.32, of which 2.43 in schoolchildren in the municipality of David Canabarro and 2.09 in the schoolchildren of Ciríaco. Similar results were found in the National Oral Health Survey, in which the DMFT was 2.06 in the Southern Region of the country at age^12,15 as well as in the study by Rihs et al.¹⁶ in the city of Indaiatuba, SP, in which the DMFT was 2.50. These indi corroborate the data presented in this research. The importance of these oral findings in schoolchildren is of extreme relevance for the Public Health of the municipalities, since the planning of strategies can be formulated from the results demonstrated here.

Differently from these results, some studies found moderate DMFT: in Rio Claro, SP, the authors obtained DMFT 2,71¹⁷; in João Pessoa, PB, 3.37 in public schools and 1.35 in private schools¹⁸; in Serro, MG, the mean was 2,73³, and in the municipality of Passo Fundo-RS the DMFT index at 12 years of age was 3,386. However, better results were still found by Geus et al.¹⁹, with a very low DMFT average of only 1.0 in Ponta Grossa, PR, as well as in the National Oral Health Survey, which obtained a mean of 1.49 in Porto Alegre¹⁵.

The study also aimed to relate the socioeconomic conditions, such as the family income of the students, to the prevalence of dental caries, since findings in the literature showed associations between this variable and the high DMFT. One can cite in this regard the research of Galindo et al.⁸, which reinforce this statement, since the authors observed that the DMFT decreased significantly with the increase in family income. Other studies corroborating these findings are Freire et al.², who observed that the caries experience was significantly higher in families with lower income, and that of Skinner et al.²⁰, who showed that the experience of dental caries severity was related to several factors, including family income. However, in the present study, there was no statistical significance. This can be attributed to the higher socioeconomic level of the municipalities in which the research was carried out. These municipalities have Human Development Index (HDI) equal to 0.762 in David Canabarro and 0.719 in Ciríaco. This means that both are in the range of high Human Development Index between 0.700 and 0.799) and may suggest that there is effective access to health services and goods for their population. With regard to the dimensions that contribute most to the HDI of both municipalities are longevity, income and education²¹. The Gini index (which measures the degree of concentration of income and varies from 0 to 1, where 0 represents the situation of total equality, and the value 1 means complete inequality of income) of the municipalities is 0.44 in the municipality of David Canabarro and 0.45 in the municipality of Ciríaco²¹. Thus, the presented indicators are considered good to demonstrate social development in both municipalities. It should also be noted that socioeconomic conditions and the higher level of education and information may be related to lower rates of dental caries among schoolchildren in the municipalities, resulting in a greater demand for dental services.

The variables "last dental consultation", "access to dental services", "frequency of brushing and flossing" had no relation to dental caries not treated in the present study. Although no relation was observed with these variables, the percentage of adolescents who attended the dentist in the last year was 98.7%, and the main reasons for the professional's search were the review, prevention or checkup reported by the students. In addition, the vast majority found access to dental services easy, so much so that 94.8% of parents reported taking their child to the dentist. With regard to oral hygiene habits, most students reported brushing at least twice a day. According to authors, hygiene habits and access to dental services are important factors for the prevention of dental caries⁶. However, the study by Ferreira et al.²² showed different results to those found in the present study, since 33.44% reported that the reason for the last visit was pain of dental origin, related to the low frequency of daily brushing, to the longest period of time of the last dental visit and high experience of caries. In view of this, it can be inferred that the search for dental services for reviews and oral hygiene habits were frequent in schoolchildren in both municipalities. Results found in the study by Junqueira et al.²³ showed a positive relationship between higher rates of health need and the difficulty of access to services, and also lower health needs related to the higher prevalence of children free of dental caries.

The prevalence of untreated dental caries ascertained in this study was 40.3%, similar to the studies by Santin et al.²⁴ conducted in Araucária, PR, with 12-year-old adolescents, where the prevalence of caries with untreated clinical diagnosis was 45%. Similarly, a study by Skinner et al.²⁰ conducted in New South Wales, Australia, showed that 44.4% of adolescents had experience in caries in at least one tooth. However, it was slightly higher when compared to other studies, such as those by Ferreira et al.²² and Ferreira et al.²⁵, both conducted in Piracicaba, São Paulo, Brazil, which showed that 23.3% and 22.32% of the adolescents presented with untreated carious lesion, respectively. However, the prevalence was lower than the findings of the capital, Porto Alegre, where the experience of untreated dental caries was high, with 63.1%, and in the southern region of Brazil, which was 60.7%¹⁵. Thus, it can be observed that the students of the municipalities surveyed had better results than the studies carried out in the South of the Country.

In addition, in the present study, 32.5% reported having suffered toothache in the last 6 months, similar time to results found by other authors, such as Schuch et al.⁴ in Pelotas, RS, where the prevalence of dental pain was of 35.7%, and Noro et al^.26, made in Sobral, CE, where the prevalence of toothache was 31.8% in the last 6 months. This prevalence should be considered high when compared to the following studies: Freire et al.²⁷ performed in 26 capitals of Brazilian states and in the Federal District, where the prevalence of toothache was 17.8%; Jaiswal et al.²⁸, in Kollipara Mandal, Guntur district, Andhra Pradesh, India, whose prevalence of toothache was 28.3%; Rosa et al.²⁹, performed in 36 municipalities with up to 50,000 inhabitants in Rio Grande do Sul, where 29.8% reported having toothache in the last 6 months. In turn, it is inferior to the results of the study carried out in Santa Maria, RS, where they found a prevalence of toothache in the last 6 months in 63.2% of students³⁰ and in Leh, Ladakh, India, which showed that the prevalence of pain in the last 6 months was 77%³¹. In the literature, different periods of time can be observed to investigate the experience of dental pain, some shorter, such as 4 weeks, which reduce bias risks. However, in longer periods, such as 6 months and 1 year, pain resulting from a chronic disease can be evaluated, as described by Schuch et al.⁴ in which, as in the present study, a period of 6 months. The prevalence of dental pain is a measure of quality of life and one of the indicators of oral health. Its reduction is one of the objectives of the 2020 global oral health goals³².

The untreated tooth decay experience had a statistically significant association with the toothache variables in the last 6 months, with 76% of those who had toothache in the last 6 months and caries present (p = 0.012). In the study by Rihs et al.³³ conducted in Paulínia, SP, students who reported dental pain had a higher DMFT index and, as a consequence, a greater need for treatment, saying that pain in recent months was related to schoolchildren with worse oral health conditions. Our results still corroborate with the findings of Lopes et al.¹⁰ carried out in São Paulo, SP, which observed an association between untreated dental caries in children who had pain in the last 6 months. caries not treated as being of African descent, from public schools, with income equal to or less than a minimum wage and living in housing with a high family density. The study by Rosa et al.²⁹ conducted in 36 municipalities with up to 50,000 inhabitants in Rio Grande do Sul, showed that adolescents with dental caries reported having up to twice as much toothache as those without dental caries. Authors describe that quality of life related to oral health and dental pain was associated with school absenteeism in 12-year-old adolescents. The authors describe that, in every 20 children, at least one report school absence due to toothache⁵. Therefore, the present study observed that school adolescents with untreated tooth decay presented dental pain in the last 6 months, which was similar to other regions of the State and the Country, which may cause oral health impacts of adolescents in society.

Noro et al.²⁶ described that the fear of dental surgeons and dental procedures are still experienced by a large part of the population. Because of this, adolescents are likely to seek fewer dental services because of their distrust of dentists and the high anxiety associated with fear of procedures. According to the authors, these elements explain the irregular pattern of dental care in adolescents. In the present study, another variable that was associated with untreated caries was the perception of the treatment in the last consultation, 84.6% of whom found the treatment to be poor or regular, and caries present (p = 0.021). It can be assumed that fear and anxiety cause adolescents to describe dental treatment as bad or regular, frequent less the dentist and, as a consequence, have more untreated tooth decay. Corroborating this statement, Schuch et al.⁴ described that patients with fear are more likely to postpone treatment, thus leading to more extensive dental problems.

The study has the design as a limitation, especially since it does not allow cause-effect inferences among dental caries factors, and because it does not allow follow-up of the examined ones, as in most cross-sectional studies^2,3,24,34,35. It suggests thus, the next studies are carried out with a different methodological approach, such as a cohort study that allows cause-effect inferences with the factors related to dental caries.

The research has a great social relevance, since it approached a sample of school adolescents of two interior municipalities of the northwest region of Rio Grande do Sul. The determination of the oral health status, through this survey, contributes and allows the public sector to take cognizance and develop strategies to prevent wider problems, and may reduce the pathologies investigated.

The contribution of this research to the field of public health of the municipalities is inediticidade in carrying out an epidemiological research with oral exams in the students, thus describing a prevalent oral complaint and its need for treatment.

 

CONCLUSION

From the obtained results, it was possible to conclude that:

• average dental caries is low in schoolchildren of both municipalities, however, with a high prevalence of untreated dental caries;

• there was an association between the presence of toothache in the last six months and the perception of dental treatment in the last consultation with the presence of untreated dental caries, being the toothache and the absence of quality in dental treatment the factors that most impacted.

 

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Correspondence:
lilia.nrigo@imed.edu.br

Manuscript received: May 2018
Manuscript accepted: October 2018
Version of record online: November 2018