Abstract

This study aimed to analyze the association of socioeconomic factors with the prevalence of dental caries in adolescents from São Luís, Maranhão, Brazil, to answer whether social inequalities persist in distributing this disease. This is a cross-sectional study nested in a prospective cohort. We included 2,413 adolescents aged 18-19 years evaluated in the 2016 second follow-up. The outcome was teeth with untreated dental caries (yes or no) assessed by the DMFT index. Socioeconomic and demographic characteristics were the independent variables. Descriptive statistical and Poisson regression analyses were performed, calculating crude and adjusted prevalence ratios (PRs) (alpha=5%). Belonging to economic classes C (PR=1.23; 95% CI: 1.11-1.37) or D-E (PR=1.48; 95% CI: 1.32-1.65), being married/living with a partner (PR=1.22; 95% CI: 1.07-1.39), having separated parents (PR=1.11; 95% CI 1.03-1.19) and a greater number of people in the household (PR=1.05; 95% CI: 1.03-1.07) were associated with a higher prevalence of dental caries. Social inequalities in adolescent oral health persist despite the implementation of the National Oral Health Policy. The current health care model should seek to reorient health education strategies, targeting them at vulnerable populations.

Key words:
Dental caries; Socioeconomic factors; Adolescent

Introduction

Due to the high frequency, economic impacts, and effect on people’s quality of life¹1 Costacurta M, Epis M, Docimo R. Evaluation of DMFT in paediatric patients with social vulnerability conditions. Eur J Paediatr Dent 2020; 21(1):70-73.

2 Eid SA, Khattab NMA, Elheeny AAH. Untreated dental caries prevalence and impact on the quality of life among 11 to 14-year-old Egyptian schoolchildren: a cross-sectional study. BMC Oral Health 2020; 20(83):1-11.^-33 Kastenbom L, Falsen A, Larsson P, Sunnegårdh-Grönberg K, Davidson T. Costs and health-related quality of life in relation to caries. BMC Oral Health 2019; 19(187):1-8., dental caries is a significant public health problem in Brazil⁴4 Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. Lancet 2019; 394(10219):249-260.. It is a chronic disease resulting from the mineral dissolution of dental tissues from the production of bacterial acids when they metabolize carbohydrates, mainly sucrose, from the diet⁵5 Featherstone JDB. Dental caries: A dynamic disease process. Aust Dent J 2008; 53(3):286-291..

While the etiology of caries is well known, many aspects related to the role of socioeconomic factors have been gaining relevance. They have been addressed in several studies in association with the biological determinants interacting in the etiology of the disease⁶6 Folayan MO, Tantawi M El, Aly NM, Al-Batayneh OB, Schroth RJ, Castillo JL, Virtanen JI, Gaffar BO, Amalia R, Kemoli A, Vulkovic A, Feldens CA, the ECCAG. Association between early childhood caries and poverty in low and middle income countries. BMC Oral Health 2020; 20:8.

7 Mizuta A, Aida J, Nakamura M, Ojima T. Does the Association between Guardians' Sense of Coherence and their Children's Untreated Caries Differ According to Socioeconomic Status? Int J Environ Res Public Health 2020; 5(17):e1619.^-88 Fonseca EP, Frias AC, Mialhe FL, Pereira AC, Meneghim MC. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: A population-based study. PLoS One 2017; 12(8):e0183310.. However, some aspects related to the role of these factors are poorly explained.

The association between poverty and social inequalities with oral morbidities has been the subject of Brazilian⁹9 Neves ÉTB, Dutra LC, Gomes MC, Paiva SM, Abreu MHNG, Ferreira FM, Granville-Garcia AF. The impact of oral health literacy and family cohesion on dental caries in early adolescence. Community Dent Oral Epidemiol 2020; 48(3):232-239.

10 Aguiar VR, Pattussi MP, Celeste RK. The role of municipal public policies in oral health socioeconomic inequalities in Brazil: A multilevel study. Community Dent Oral Epidemiol 2017; 46(3):245-250.^-1111 Lins LSS, Bezerra NVF, Freire AR, Almeida LFD, Lucena EHG, Cavalcanti YW. Socio-demographic characteristics are related to the advanced clinical stage of oral cancer. Med Oral Patol Oral y Cir Bucal 2019; 24(6):759-763. and international studies⁶6 Folayan MO, Tantawi M El, Aly NM, Al-Batayneh OB, Schroth RJ, Castillo JL, Virtanen JI, Gaffar BO, Amalia R, Kemoli A, Vulkovic A, Feldens CA, the ECCAG. Association between early childhood caries and poverty in low and middle income countries. BMC Oral Health 2020; 20:8.^,1212 Kramer A-CA, Petzold M, Hakeberg M, Östberg AL. Multiple socioeconomic factors and dental caries in swedish children and adolescents. Caries Res 2018; 52(1-2):42-50.^,1313 Skeie MS, Klock KS. Dental caries prevention strategies among children and adolescents with immigrant-or low socioeconomic backgrounds-do they work? A systematic review. BMC Oral Health 2018; 18(1):20., and different theoretical explanations for social causation are raised, such as the social quality¹1 Costacurta M, Epis M, Docimo R. Evaluation of DMFT in paediatric patients with social vulnerability conditions. Eur J Paediatr Dent 2020; 21(1):70-73.^,22 Eid SA, Khattab NMA, Elheeny AAH. Untreated dental caries prevalence and impact on the quality of life among 11 to 14-year-old Egyptian schoolchildren: a cross-sectional study. BMC Oral Health 2020; 20(83):1-11., life course¹⁴14 MacEntee MI, Wong ST, Chi I, Lo ECM, Minichiello V, Soheilipour S, Mariño R. Developmental regulation of lifelong dental experiences and beliefs in Guangzhou and Hong Kong. Gerodontology 2019; 36(1):18-29., stress¹⁵15 Barauskas I, Barauskienė K, Janužis G. Dental anxiety and self-perceived stress in Lithuanian University of Health sciences hospital patients. A cross-sectional study. Stomatologija 2019; 21(2):42-46., and social support¹⁶16 Vettore M V, Ahmad SFH, Machuca C, Fontanini H. Socio-economic status, social support, social network, dental status, and oral health reported outcomes in adolescents. Eur J Oral Sci 2019; 127(2):139-146. theories. Several studies’ thesis is that socioeconomic disadvantage is associated with a higher incidence and prevalence of caries, justified by bad behavioral habits, greater vulnerability to risk factors for the disease, and less access to treatment¹1 Costacurta M, Epis M, Docimo R. Evaluation of DMFT in paediatric patients with social vulnerability conditions. Eur J Paediatr Dent 2020; 21(1):70-73.^,66 Folayan MO, Tantawi M El, Aly NM, Al-Batayneh OB, Schroth RJ, Castillo JL, Virtanen JI, Gaffar BO, Amalia R, Kemoli A, Vulkovic A, Feldens CA, the ECCAG. Association between early childhood caries and poverty in low and middle income countries. BMC Oral Health 2020; 20:8.^,1717 Watt RG, Mathur MR, Aida J, Bönecker M, Venturelli R, Gansky SA. Oral Health Disparities in Children: A Canary in the Coalmine? Pediatr Clin North Am 2018; 65(5):965-979..

However, population-based studies with adequate control of confounding factors designed for this purpose are rare, and there is no consensus on exactly which socioeconomic factors have a more relevant role in the disease. Furthermore, declining social inequalities were expected¹⁸18 Guimarães RM. A teoria da equidade reversa se aplica na atenção primária à saúde? Evidências de 5.564 municípios brasileiros. Rev Panam Salud Publica 2018; 42:128.^,1919 Nickel DA, Lima FG, Silva BB. Modelos assistenciais em saúde bucal no Brasil. Cad Saude Publica 2008; 24(2):241-246. with the expanded coverage of PHC for health promotion, disease prevention, and treatment of the most prevalent conditions, changes in care models, and growth of oral health care in the public network.

This study aimed to identify the prevalence of dental caries in adolescents from São Luís, followed up at the RPS cohort (Ribeirão Preto, Pelotas, and São Luís Brazilian Cohort) and evaluate their relationship with different socioeconomic factors, considering whether social inequalities persist in the distribution of dental caries to contribute to the quality of oral health policies.

Methods

This is a cross-sectional study nested in a prospective cohort of live births conducted in São Luís, Maranhão, Brazil. The original cohort is called RPS (since it was developed in Ribeirão Preto, Pelotas, and São Luís). The study was held from March 1997 to February 1998 (at the children’s birth), the baseline. The children were reevaluated in 2005 (school age: between 7-9 years), which was the first follow-up; and again in 2016, when they were in their teens (18-19 years), which was the second follow-up²⁰20 Cardoso V, Barbieri M, Bettiol H, Goldani M, Silva A, Alves M. Profile of three Brazilian birth cohort studies in Ribeirão Preto, SP and São Luís, MA. Braz J Med Biol Res 2007; 40(9):1165-1176..

The baseline of the birth cohort included live newborns in hospital delivery from mothers living in the municipality of São Luís, from March 1997 to February 1998. It was conducted in ten public and private hospitals. Systematic sampling was used with stratification proportional to the number of births in each hospital. Thus, one in seven deliveries per hospital was recruited. A total of 2,542 live births participated in this stage. After excluding stillbirths, the sample arrived at 2,443 births²⁰20 Cardoso V, Barbieri M, Bettiol H, Goldani M, Silva A, Alves M. Profile of three Brazilian birth cohort studies in Ribeirão Preto, SP and São Luís, MA. Braz J Med Biol Res 2007; 40(9):1165-1176..

In the first follow-up, based on a school census, all parents or guardians of children located who had been born with low or high weight and one-third of the others were invited for a reassessment, totaling 1,108 eligible participants.

The participants in this cohort underwent a new evaluation at 18 and 19, from January to December 2016, the second follow-up. We looked for enrollment in schools and universities, addresses and contacts on social networks, and military enrollment records (for men) to locate them. In total, 654 adolescents were identified and accepted to participate in this stage. We included the participants with two methods due to the difficulty in locating individuals and expanding the sample size of the study: drawing lots from the database of the Live Births Information System (SINASC) (n=1,716), and including volunteers identified in schools, universities, and social networks born in maternity hospitals in São Luís in 1997 (n=145). These new participants were subjected to the same tests and questionnaires as the original cohort²¹21 Moreira ARO, Batista RFL, Ladeira LLC, Thomaz EBAF, Alves CMC, Saraiva MC, Silva AAM, Brondani MA, Ribeiro CCC. Higher sugar intake is associated with periodontal disease in adolescents. Clin Oral Investig 2021; 25(3):983-991..

Thus, this phase included the participation of 2,515 adolescents. However, 102 of these were excluded because they were using orthodontic appliances or refused to participate. In the end, 2,413 participants were considered for this study (Figure 1).

Trained health professionals performed data collection. Data on sociodemographic characteristics, lifestyle, and food consumption were obtained using standardized questionnaires. The information was recorded in the Research Electronic Data Capture²²22 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf 2009; 42(2):377-3381. online program.

This sample size has been estimated with 90% power to identify relative risks from 1.5, considering a 50% incidence of disease among those exposed, a 1:1 ratio between exposed and unexposed, a confidence level of 95%, and a design effect equal to 2.0.

The independent variables were adolescent age (in years); adolescent’s school situation (currently studying, yes or no); adolescent’s current work history (yes or no); adolescent’s marital status (single, married, or living with a partner); the number of people in the household; parents’ marital status (separated or not); household income; the Poverty Income Ratio (PIR)²³23 Capurro DA, Iafolla T, Kingman A, Chattopadhyay A, Garcia I. Trends in income-related inequality in untreated caries among children in the United States: Findings from NHANES I, NHANES III, and NHANES 1999-2004. Community Dent Oral Epidemiol 2015; 43(6):500-510. income indicator, which is the relationship between household income divided by the number of people in the household, divided by R$ 140.00 (value referring to the poverty criterion, according to the World Bank and the Federal Government, 2016); social benefits received (yes or no); what social benefits received (retirement pension, LOAS, Bolsa Família, pension for death or illness); and economic class according to the criteria of the Brazilian Association of Research Companies (ABEP)²⁴24 Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de Classificação Econômica do Brasil. São Paulo: ABEP; 2014.^,2525 Associação Brasileira de Empresas de Pesquisa (ABEP). Alterações na aplicação do Critério Brasil. São Paulo: ABEP; 2018., distributing them between classes A-B, C, and D-E.

The outcome was the occurrence of teeth with untreated caries (yes or no), according to the DMFT index modified by the World Health Organization²⁶26 World Health Organization (WHO). Oral health: Action plan for promotion and integrated disease prevention. In: WHO - Sixtieth World Health Assembly. Geneva: WHO; 2007.. This data was collected through clinical dental examination, in a mobile office, under artificial lighting, using a rounded tip millimeter probe N° 11.5 indicated by the World Health Organization²⁶26 World Health Organization (WHO). Oral health: Action plan for promotion and integrated disease prevention. In: WHO - Sixtieth World Health Assembly. Geneva: WHO; 2007., in the second follow-up.

Descriptive statistical analyses, bivariate tests, and Poisson regression analyses were performed, calculating crude and adjusted prevalence ratios (PRs). The software STATA version 14 (Stata Corp., College Station, TX, USA) was used, considering 5% alpha for H0 rejection.

The project was approved by the Research Ethics Committee (CEP) of HU-UFMA. The informed consent was granted in writing after receiving the information.

Results

Table 1 summarizes the socioeconomic characteristics of the adolescents included in the study, totaling 2,413 participants. Some indicators cause a stir, as follows: 30.42% (n=734) were not attending school; 48.45% (n=1,169) had separated parents. The mean household income was R$ 2,421.03 (±5,132.72); 42.24% (n=1,007) of the households received some type of social benefit, such as the Bolsa Família, retirement or pension due to death/illness. According to ABEP criteria²⁴24 Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de Classificação Econômica do Brasil. São Paulo: ABEP; 2014.^,2525 Associação Brasileira de Empresas de Pesquisa (ABEP). Alterações na aplicação do Critério Brasil. São Paulo: ABEP; 2018., 50.95% (n=1,229) of the adolescents were from class C; 24.96% (n=602) belonged to class D-E and, according to PIR²³23 Capurro DA, Iafolla T, Kingman A, Chattopadhyay A, Garcia I. Trends in income-related inequality in untreated caries among children in the United States: Findings from NHANES I, NHANES III, and NHANES 1999-2004. Community Dent Oral Epidemiol 2015; 43(6):500-510., 24.09% (n=581) belonged to class A-B. According to the indicator, 44.03% (n=1,062) were three times or more above the poverty line, thus having a high income; 17.08% (n=412) had a median income; 18.16% (n=438) were poor; and 19.82% (n=478) were below the poverty criterion.

Fifty-six percent (n=1,349) of the adolescents evaluated had at least one tooth decay injury; 55.57% (n=1,336) had at least one tooth restored, and 19.93% (n=479) had already lost one or more permanent teeth. Table 2 shows that the mean DMFT was 3.69 (±3.26), representing, on average, 13.27% (±11.68%) of the evaluated teeth.

In the unadjusted analysis, the highest prevalence of untreated caries was associated with adolescents who were married or living with a partner (PR=1.33; 95%CI: 1.17-1.51), resided in homes with a higher number of people (PR=1.06; 95%CI: 1.04-1.08), those whose parents were separated (PR=1.13; 95%CI: 1.05-1.21), who received some social benefit (PR=1.14; 95%CI: 1.06-1.22), belonged to economic classes C (PR=1.26; 95%CI: 1.13-1.40) or D-E (PR=1.56; 95%CI: 1.41-1.74). Untreated caries was less frequent in adolescents who were studying at the time of the research (PR=0.87; 95%CI: 0.81-0.94) and who belonged to households with per capita income three or more times above the poverty line (PR=0.81; 95%CI: 0.74-0.89).

After model adjustment, a higher prevalence of untreated caries remained associated with being married or living with a partner (PR=1.22; 95% CI: 1.07-1.39), a higher number of people in the household (PR=1.05; 95% CI: 1.03-1.07), with separated parents (PR=1.11; 95% CI: 1.03-1.19) and belonging to economic classes C (PR=1.23; 95% CI: 1.11-1.37) or D-E (PR=1.48; 95% CI: 1.32-1.65).

Discussion

Unfair inequalities were found in the distribution of caries among adolescents aged 18-19 years in São Luís concerning socioeconomic factors. Belonging to socioeconomic classes C, D-E, being married, the son of separated parents, and living in a household with a higher number of people were associated with a higher prevalence of dental caries. The greatest social vulnerability can influence the distribution of adverse oral conditions in adolescents, such as dental caries.

The prevalence of untreated caries among the adolescents in the survey was 56%, a result lower than that found in Brazil (76.1%) and in the Northeast Region (77.1%), according to the last National Oral Health Survey in 2010²⁷27 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Coordenação Nacional de Saúde Bucal. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal. Resultados Principais. Brasília: MS; 2012..

However, the prevalence of caries found in adolescents was higher when compared to Goiânia (54%)²⁸28 Oliveira LB, Moreira RS, Reis SCGB, Freire MDCM. Cárie dentária em escolares de 12 anos: Análise multinível dos fatores individuais e do ambiente escolar em Goiânia. Rev Bras Epidemiol 2015; 18(3):642-654. and Campina Grande (38.5%)⁹9 Neves ÉTB, Dutra LC, Gomes MC, Paiva SM, Abreu MHNG, Ferreira FM, Granville-Garcia AF. The impact of oral health literacy and family cohesion on dental caries in early adolescence. Community Dent Oral Epidemiol 2020; 48(3):232-239.. According to Silva et al.²⁹29 Silva JV, Machado FCA, Ferreira MAF. Social inequalities and the oral health in Brazilian capitals. Cien Saude Colet 2015; 20(8):2539-2548., the historical differences in the occupation process and the economic development of the Brazilian regions, and the unequal public health financing at the onset of the implantation of the Unified Health System (SUS) in Brazil, justify the social disadvantage of the North and Northeast Regions and, consequently, worse oral health indicators.

The moderate mean DMFT found (3.69)²⁶26 World Health Organization (WHO). Oral health: Action plan for promotion and integrated disease prevention. In: WHO - Sixtieth World Health Assembly. Geneva: WHO; 2007. was below the results of SB Brasil 2010 for São Luís, which was 4.60²⁷27 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Coordenação Nacional de Saúde Bucal. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal. Resultados Principais. Brasília: MS; 2012., and to the Northeast Region in SB Brasil 2003 (6.34)³⁰30 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Coordenação Nacional de Saúde Bucal. Projeto SB Brasil 2003: Condições de saúde bucal da população brasileira 2002-2003. Resultados Principais. Brasília: MS; 2004.. The “filled” component of the DMFT index was relevant (1.76) against the total DMFT (3.69), as it expresses a reality of greater access by the evaluated adolescents.

This best-recorded condition could be a consequence of national public oral health policies benefiting this group and other age groups in recent years³¹31 Bastos TF, Medina LPB, Sousa NFS, Lima MG, Malta DC, Barros MBA. Income inequalities in oral health and access to dental services in the Brazilian population: National health survey, 2013. Rev Bras Epidemiol 2019; 22(Supl. 2):e190015.

32 Castro RD, Rangel ML, Silva MAA, Lucena BTL, Cavalcanti AL, Bonan PRF, Oliveira JA. Accessibility to specialized public oral health services from the perspective of Brazilian users. Int J Environ Res Public Health 2016; 13:1026.^-3333 Hobdell M, Petersen PE, Clarkson J, Johnson N. Global goals for oral health 2020. Int Dent J 2003; 53(5):285-288.. The last major Brazilian survey of caries was held almost ten years ago, shortly after implementing the National Oral Health Policy (PNSB).

Our data collected, in 2016, point to reducing the disease in a population with significant socioeconomic vulnerability. However, a higher prevalence of caries has been identified in the less favored socioeconomic segments. Likely, access to health promotion, disease prevention, and treatment measures will also be unevenly distributed³⁴34 Krupnikov Y, Levine AS. Political Issues, Evidence, and Citizen Engagement: The Case of Unequal Access to Affordable Health Care. Int J Polit 2019; 81(2):385-398..

The efforts of the PNSB, with the creation of Dental Specialty Centers (CEO), the inclusion, albeit late, of the oral health team (acronym in Portuguese - eSB) in the Family Health Strategy (ESF) with a focus on longitudinal and family care, and the changes in the Dentistry course curricular guidelines, emphasizing training general practitioners³⁵35 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Coordenação Nacional de Saúde Bucal. Diretrizes da Política Nacional de Saúde Bucal. Brasília: MS; 2004.

36 Brasil. Ministério da Educação (MEC). Diretrizes Curriculares Nacionais do Curso de Graduação em Odontologia. Brasília: MEC; 2002.^-3737 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde Bucal. Brasília: MS; 2008., have not yet been sufficient to eliminate oral health inequalities among adolescents, which is evidenced in this study conducted in one of the poorest Brazilian states.

There is a need to reduce socio-organizational and geographical barriers to facilitate access to more homogeneous¹⁸18 Guimarães RM. A teoria da equidade reversa se aplica na atenção primária à saúde? Evidências de 5.564 municípios brasileiros. Rev Panam Salud Publica 2018; 42:128. health services. It is also ideal to invest in training for a professional qualification, as it has effectively increased the quality of the APS attributes³⁸38 Oliveira MPR, Menezes IHCF, Souza LM, Peixoto MRG. Formação e Qualificação de Profissionais de Saúde: Fatores associados à Qualidade da atenção Primária Training and Qualification of Health Professionals: Factors associated to the Quality of Primary Care. Rev Bras Educ Med 2016; 40(4):547-559.. Besides strengthening the National Policy for Continuing Education in Health (PNEPS), in the elaboration of strategies to qualify health care and management³⁹39 Brasil. Ministério da Saúde (MS). Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Programa para o Fortalecimento das Práticas de Educação Permanente em Saúde no SUS (PRO EPS-SUS). Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília: MS; 2018..

Pró-Saúde and GraduaCEO were initiatives established by the Ministries of Health and Education, which aimed to bring the theory and practice taught in educational institutions closer to the reality of SUS to modify health education⁴⁰40 Brasil. Ministério da Saúde (MS). Ministério da Educação (MEC). Portaria Interministerial nº 3.019, de 26 de novembro de 2007. Dispõe sobre o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação da área da saúde. Brasília; Diário Oficial da União 1990; 26 nov.^,4141 Brasil. Ministério da Saúde (MS). Portaria Interministerial nº 1.646, de 5 de agosto de 2014. Institui o componente GraduaCEO - BRASIL SORRIDENTE, no âmbito da Política Nacional de Saúde Bucal, que irá compor a Rede de Atenção à Saúde (RAS), e dá outras providências. Brasília; Diário Oficial da União 1990; 5 ago.. However, it is necessary to reflect on a new care model targeting training reorientation, in which commitment to care for the subject and social determinants and action focused on SUS should be demanded⁴²42 Vendruscolo C, Trindade LDL, Prado ML, Kleba ME. Rethinking the Health Care Model through the reorientation of training. Rev Bras Enferm 2018; 71(Supl. 4):1580-1588.. This can occur with the inclusion of trainees in internships within PHC, such as, for example, participants in the School Health Program (PSE), with the dissemination of lectures on tooth brushing and flossing, application of fluoride, and sealants to avoid reaching permanent restorations.

This study is probably one of the pioneers to find “being married or living with a partner” as a variable associated with a higher prevalence of caries in adolescents (22%), as no reports of such an association were found in the literature. An inverse relationship was found in a study carried out with adults, which states that adults involved in a relationship tend to have greater self-care and the existence of a spouse serves as an incentive agent for the partner to maintain health treatments¹¹11 Lins LSS, Bezerra NVF, Freire AR, Almeida LFD, Lucena EHG, Cavalcanti YW. Socio-demographic characteristics are related to the advanced clinical stage of oral cancer. Med Oral Patol Oral y Cir Bucal 2019; 24(6):759-763.. Thus, it is believed that adolescents are faced with the responsibilities of an adult and married life and neglect aspects related to their health. Chronic diseases such as caries should be addressed in adolescents as it is possible to reverse adverse conditions interfering negatively throughout the life cycle⁴³43 Bezerra MRE, Lyra MJ, Santos MAM dos, Menezes VA. Fatores de Risco Modificáveis para Doenças Crônicas não Transmissíveis em Adolescentes: Revisão Integrativa. Adolesc Saude 2018; 15(2):113-120..

The prevalence of caries was 11% higher among those who had separated parents than among adolescents with married parents. Similar data were found in the study by Ferrazano et al.⁴⁴44 Ferrazzano GF, Sangianantoni G, Cantile T, Ingenito A. Relationship Between Social and Behavioural Factors and Caries Experience in Schoolchildren in Italy. Oral Health Prev Dent 2016; 14(1):55-61. and Pinto et al.⁴⁵45 Pinto GDS, Hartwig AD, Elias R, Azevedo MS, Goettems ML, Correa MB, Demarco FF. Maternal care influence on children's caries prevalence in southern Brazil. Braz Oral Res 2016; 30(1):S1806-83242016000100262., in which the experience of caries among adolescents who did not live with both parents or only with the mothers was considerably more significant, which may be associated with emotional instability of parents who, involved in their problems, do not prioritize their children’s oral health.

In the face of emotional and family stress, adolescents themselves may end up changing habits, affecting their health. The stress theory helps to support this hypothesis. According to some authors⁶6 Folayan MO, Tantawi M El, Aly NM, Al-Batayneh OB, Schroth RJ, Castillo JL, Virtanen JI, Gaffar BO, Amalia R, Kemoli A, Vulkovic A, Feldens CA, the ECCAG. Association between early childhood caries and poverty in low and middle income countries. BMC Oral Health 2020; 20:8.^,1515 Barauskas I, Barauskienė K, Janužis G. Dental anxiety and self-perceived stress in Lithuanian University of Health sciences hospital patients. A cross-sectional study. Stomatologija 2019; 21(2):42-46.^,4646 Akinkugbe AA, Hood KB, Brickhouse TH. Exposure to Adverse Childhood Experiences and Oral Health Measures in Adulthood: Findings from the 2010 Behavioral Risk Factor Surveillance System. JDR Clin Trans Res 2019; 4(2):116-125., a stressor can harm the individual health and psychological well-being. The quality of health and satisfaction with life are associated with individuals’ social and economic characteristics and the environment in which they reside. Therefore, the more stressful the environment, the worse the quality of life.

In agreement with previous studies⁴⁷47 Cable N, Sacker A. Validating overcrowding measures using the UK Household Longitudinal Study. SSM Popul Health 2019; 8:100439.^,4848 Russell J, Grant CC, Morton SMB. Multimorbidity in Early Childhood and Socioeconomic Disadvantage: Findings From a Large New Zealand Child Cohort. Acad Pediatr 2020; 20(5):619-627., living in homes with a more significant number of people was also considered a factor significantly associated with a higher prevalence of dental caries. In this situation, home overcrowding points to lower socioeconomic status, which, in turn, is associated with worse health conditions.

After adjustment, the model revealed that belonging to classes C and D-E, according to ABEP²⁴24 Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de Classificação Econômica do Brasil. São Paulo: ABEP; 2014.^,2525 Associação Brasileira de Empresas de Pesquisa (ABEP). Alterações na aplicação do Critério Brasil. São Paulo: ABEP; 2018., is closely related to the higher prevalence of caries, and is 23% and 48% higher, respectively, than the prevalence found in class A-B adolescents. However, in Table 1, the results point to a divergence between the economic classification and the income indicator PIR²³23 Capurro DA, Iafolla T, Kingman A, Chattopadhyay A, Garcia I. Trends in income-related inequality in untreated caries among children in the United States: Findings from NHANES I, NHANES III, and NHANES 1999-2004. Community Dent Oral Epidemiol 2015; 43(6):500-510.. Although most of the sample belongs to class C (50.95%), the predominant income was high (PIR≥3.0) among 44.03% of adolescents. In the adjusted analysis (Table 3), only the economic class was associated with caries, which reveals that the variable “economic class” was more sensitive to variations in the outcome, which can be explained by the fact that having an above-average household income does not necessarily imply socioeconomic improvements or a higher quality of life⁴⁹49 Browne-Yung K, Ziersch A, Baum F. "Faking til you make it": Social capital accumulation of individuals on low incomes living in contrasting socio-economic neighbourhoods and its implications for health and wellbeing. Soc Sci Med 2013; 85:9-17..

Much of the income came from social benefits, which can be interrupted with each change of government. As a result of this financial instability, income may not be a good indicator of household assets⁵⁰50 Calvasina P, O'Campo P, Pontes MM, Oliveira JB, Vieira-Meyer APGF. The association of the Bolsa Familia Program with children's oral health in Brazil. BMC Public Health 2018; 18(1186):1-10.. The mother-child binomial relates to maternal education and the prediction of caries in the child. Therefore, it would be interesting to consider education a more meaningful indicator than income in future studies⁵¹51 Silva MGB, Catão MHCV, Andrade FJP, Alencar CRB. Cárie precoce da infância: fatores de risco associados. Arch Health Investig 2017; 6(12):574-579..

Different mechanisms have been proposed to describe the possible effects of the socioeconomic status on health outcomes. A possible explanation is that the weak bonds of social cohesion, caused by social inequalities, result in scarce access to information and knowledge of fundamental aspects to promote good health conditions, including oral health⁵²52 Barata RB. O que queremos dizer com desigualdades sociais em saúde? In: Rita BB, organizadora. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Fiocruz; 2009. p. 11-22..

Some limitations of this study refer to the collection of different indicators of socioeconomic conditions throughout the life cycle of the participants, which hindered analyzing social mobility precisely, which would help us understand its role in the prevalence of dental caries. Although the study used data from a follow-up of the RPS cohort, it was the first time that clinical dental examinations were performed on the participants, hampering the analysis of the incidence of the disease and leaving out only its prevalence.

This study is relevant because it has allowed confirming the persisting social inequalities, even in the face of numerous actions implemented decades ago, and identifying individual and collective risk factors for dental caries, represented by social, economic, and cultural conditions. This corroborates the need to qualify oral health care and implement public health promotion and disease prevention policies structured by contemporary theories and appropriate for more effective actions to curb inequalities.

Social capital elements such as norms of harmony or solidarity, mutual trust, and civic engagement coupled with the growth of social epidemiology, addressing collective health, are themes that may bring new perspectives to the field of public health and health promotion. It is not only for proposing a healthier life for the populations based on behavioral changes but also for the possible reduction of social inequalities and a fundamental role in stimulating the participation of the community in formulating public policies and assuring their control⁵³53 Campbell C. Social capital, social movements and global public health: Fighting for health-enabling contexts in marginalised settings. Soc Sci Med 2019; 257:112153.^,5454 Wind TR, Villalonga-Olives E. Social capital interventions in public health: Moving towards why social capital matters for health. J Epidemiol Community Health 2019; 73(9):793-795..

Conclusion

The prevalence of dental caries in adolescents in São Luís, Maranhão, is associated with socioeconomic disadvantages, especially the number of people in the residence, social class, the marital status of their parents, and that of the teenager himself. Social inequalities in oral health persist even after significant investments.

The knowledge of risk factors for dental caries, represented by social, economic, and cultural conditions, helps understand the health-disease process in social groups and quickly identify groups at higher risk to receive preferential care in health programs.

Thus, we recommend investing in the qualification of oral health care in socially vulnerable populations and reflecting on a change in the care model to one that is directed towards the reorientation of training.

References

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