Abstract

Teeth with developmental defects of enamel (DDE) have porous and/or uneven enamel, making them more susceptible to the build-up of oral biofilm and development of caries and periodontal diseases. The aim of this cross-sectional study was to determine the prevalence of DDE and associated factors among children and adolescents living in a Quilombola community in the Northeast of Brazil. The study population was census-based and comprised individuals aged three to 14 years. The children’s parents/guardians answered a questionnaire devised to collect information on socioeconomic and demographic characteristics, health problems during pregnancy and illnesses during early childhood. DDE was diagnosed using the modified DDE index. The data were analyzed using descriptive statistics and Poisson regression with robust standard errors (p<0.05). A total of 406 individuals were examined. DDE prevalence was 80.5%: 42.2% in deciduous teeth and 61.1% in permanent teeth. There was an association between presence of DDE and age (PR=1.09, 95% CI=1.01-1.17), use of antibiotics during pregnancy (PR=1.14, 95% CI=1.07-1.22) and reported malnutrition during early childhood (PR=1.12; 95% CI=1.03-1.22). The findings reveal high prevalence of DDE among children and adolescents living in the Quilombola community. Associated factors were older age, use of antibiotics during pregnancy and malnutrition during early childhood.

Key words:
Dental enamel; Dental enamel hypoplasia; Risk groups; Cross-sectional studies

Introduction

Based on the criteria of self-attribution and common history and territory, Quilombolas are an ethnic-racial group with African ancestry characterized by resistance and oppression. Despite social inclusion policies, studies investigating the oral health of these populations are scarce¹1 Silva EKPD, Medeiros DS, Martins PC, Sousa LA, Lima GP, Rêgo MAS, Silva TOD, Freire AS, Silva FM. Insegurança alimentar em comunidades rurais no Nordeste brasileiro: faz diferença ser quilombola? Cad Saude Publica 2017; 33(4):e00005716.^,22 Souza MCA, Flório FM. Avaliação da história da cárie e fatores associados entre os quilombolas no Sudeste do Brasil. Braz J Ora Sci 2014; 13(3):175-181.^,33 Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MB, Bairros FS, Hilgert JB. Oral health self-perception in quilombola communities in Rio Grande do Sul: a cross-sectional exploratory study. Rev Bras Epidemiol 2017; 20(1):91-101.. Individuals living in Quilombola communities have restricted access to goods and services and consequently experience food insecurity¹1 Silva EKPD, Medeiros DS, Martins PC, Sousa LA, Lima GP, Rêgo MAS, Silva TOD, Freire AS, Silva FM. Insegurança alimentar em comunidades rurais no Nordeste brasileiro: faz diferença ser quilombola? Cad Saude Publica 2017; 33(4):e00005716.^,44 Marques AS, Freitas DA, Leão CD, Oliveira SK, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.^,55 Gubert MB, Spaniol AM, Bortolini GA, Pérez-Escamilla R. Household food insecurity nutritional status and morbidity in Brazilian children. Public Health Nutr 2016; 19(12):2240-2245..

Socially vulnerable people generally suffer from nutritional deficiency, which has been shown to be a factor associated with Developmental Defects of Enamel (DDE)⁶6 Robles MJ, Ruiz M, Bravo-Perez M, González E, Peñalver MA. Prevalence of enamel defects in primary and permanent teeth in a group of schoolchildren from Granada. Med Oral Patol Oral Cir Bucal 2013;18(2):187-193.

7 Yadav PK. Prevalence and Association of Developmental Defects of Enamel with, Dental-Caries and Nutritional Status in Pre-School Children, Lucknow. J Clin Diagn Res 2015; 9(10):71-74.

8 Ford D, Seow WK, Kazoullis S, Holcome T, Newman B. A controlled study of risk factors for enamel hypoplasia in the permanent dentition. Pediatr Dent 2009; 31(5):382-388.

9 Massoni AC, Chaves AM, Sampaio FC, Rosenblatt A; Oliveira AF. Prevalence of enamel defects related to pre-, peri- and postnatal factors in a Brazilian population. Community Dent Health 2009; 26(3):143-149.

10 Basha S, Mohamed RN, Swamy HS. Prevalence and associated factors to developmental defects of enamel in primary and permanent dentition. Oral Health Dent Manag 2014; 13(3):588-594.^-1111 Masterson EE, Fitzpatrick AL, Enquobahrie DA, Mancl LA, Conde E, Hujoel PP. Malnutrition-related early chidhood exposures and enamel defects in the permanente dentition: a longitudinal study from the Bolivian Amazon. Am J Phys Anthropol 2017; 164(2):416-423. These alterations are manifested as opacities or hypoplasias¹²12 Jacobsen PE, Haubek D, Henriksen TM, Østergaard JR, Poulsen S. Developmental defects of enamel in children born preterm: a systematic review. Eur J Oral Sci 2014; 122(1):7-14.

13 Mermarpour M, Golkari A, Ahmadian R. Association of characteristics of delivery and medical conditions during the first month of life with developmental defects of enamel. BMC Oral Health 2014; 14:122.^-1414 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444.. Teeth with DDE have porous and/or uneven enamel, making them more susceptible to the build-up of oral biofilm and, consequently, the development of caries and periodontal diseases⁷7 Yadav PK. Prevalence and Association of Developmental Defects of Enamel with, Dental-Caries and Nutritional Status in Pre-School Children, Lucknow. J Clin Diagn Res 2015; 9(10):71-74.^,1414 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444.

15 Vargas-Ferreira F, Ardenghi TM. Developmental enamel defects and their impact on child oral health-related quality of life. Braz Oral Res 2011; 25(6):531-537.

16 Salas MM, Nascimento GG, Tarquinio SB, Faggion CM Jr, Peres MA, Thomson WM, Demarco FF. Association between developmental defects of enamel and dental caries: A systematic review and meta-analysis. J Dent 2015; 43(6):619-628.^-1717 Costa FS, Silveira ER, Pinto GS, Nascimento GG, Thomson WM, Demarco F. Developmental defects of enamel and dental caries in the primary dentition: a systematic review and meta-analysis. J Dent 2017; 60:1-7..

The etiology of DDE is multifactorial, being associated with both systemic or environmental conditions during amelogenesis⁶6 Robles MJ, Ruiz M, Bravo-Perez M, González E, Peñalver MA. Prevalence of enamel defects in primary and permanent teeth in a group of schoolchildren from Granada. Med Oral Patol Oral Cir Bucal 2013;18(2):187-193.^,1414 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444.^,1515 Vargas-Ferreira F, Ardenghi TM. Developmental enamel defects and their impact on child oral health-related quality of life. Braz Oral Res 2011; 25(6):531-537.. Epidemiological studies investigating the prevalence of and factors associated with DDE in socially vulnerable populations such as Quilombolas are important for informing the formulation of health policies and implementation of health promotion programs directed at pregnant women and preschoolers, given that these defects are related to alterations during pregnancy and early childhood and to inadequate nutrition. This is the first population-based study that aims to assess the prevalence of DDE and associated factors in Quilombola communities.

Methods

We conducted a cross-sectional study in a rural Quilombola community called Lagoas, located 36 km from São Raimundo Nonato in the south of the State of Piauí. The community consists of 12 centers with a total of 1,498 families and 5,128 individuals distributed across an area of 62,366 hectares. This study was conducted in accordance with the guidelines of the STROBE Statement.

According to the National Institute for Colonization and Agrarian Reform (INCRA)¹⁸18 Instituto Nacional de Colonização e Reforma Agrária (INCRA). Relatório Antropológico do Território Quilombola de Lagoas. Brasília: INCRA; 2010., the community had 420 children and adolescents in 2010. The study population was census-based and consisted of children and adolescents of both sexes aged between three and 14 years. Individuals with amelogenesis imperfecta, carious lesions affecting more than two-thirds of the enamel, using a fixed orthodontic appliance and showing conditions that hindered the diagnosis of DDE were excluded.

School-age study participants were recruited from the community’s schools (N = 4). With regard to preschoolers, we performed an active search with the help of community leaders and asked parents/guardians to take their children to the school on the day the examinations were scheduled for the schoolchildren.

Before undertaking the study, three examiners were calibrated in two stages. The first stage consisted of the projection of images of teeth with different types of enamel defects¹⁹19 Brasil. Ministério da Saúde (MS). Coordenação Nacional de Saúde Bucal. Projeto SBBrasil 2010 - Pesquisa Nacional de Saúde Bucal: manual da Equipe de Campo. Brasília: MS; 2009.. To remain in the study, examiners had to correctly diagnose at least 80% of the cases. The second stage of the calibration was undertaken with 45 non-participating schoolchildren with all the conditions likely to be observed in the study. After 15 days, the preschoolers were re-evaluated and intra- and inter-examiner agreement (kappa) was greater than 0.80¹⁹19 Brasil. Ministério da Saúde (MS). Coordenação Nacional de Saúde Bucal. Projeto SBBrasil 2010 - Pesquisa Nacional de Saúde Bucal: manual da Equipe de Campo. Brasília: MS; 2009..

We conducted a pilot study with 45 children and adolescents enrolled in a public rural school in São Raimundo Nonato who did not participate in the study. No changes needed to be made to the proposed methodology.

Data was collected in two stages: 1) A questionnaire administered to parents/guardians devised to collect information on demographic and socioeconomic characteristics (sex, age, household income, parental education, sanitary conditions and eating habits) and other factors potentially associated with DDE cited by previous studies⁸8 Ford D, Seow WK, Kazoullis S, Holcome T, Newman B. A controlled study of risk factors for enamel hypoplasia in the permanent dentition. Pediatr Dent 2009; 31(5):382-388.^,1313 Mermarpour M, Golkari A, Ahmadian R. Association of characteristics of delivery and medical conditions during the first month of life with developmental defects of enamel. BMC Oral Health 2014; 14:122.^,2020 Ravindran R, Saji AM. Prevalence of the developmental defects of the enamel in children aged 12-15 years in Kollam district. J Int Soc Prev Community Dent 2016; 6 (1):28-33. (type of childbirth, health problems during pregnancy, and illnesses during early childhood); and 2) Dental examination of the children and adolescents. The questionnaires were administered individually to the parents/guardians by the researchers so that any questions arising while filling out the instrument could be answered.

The dental examinations were performed under artificial fluorescent ceiling lighting with the study participants sat on a chair or stool with their head resting on the examiner’s lap. The examination was carried out using a flat mouth mirror, dental explorer probe number 5 (SSWhite, Rio de Janeiro, Brazil) and gauze pads to remove excess saliva.

The data were recorded on a form prepared for the study. DDE was diagnosed using the modified DDE index²¹21 Federation Dental International. A review of the developmental defects of enamel index (DDE Index). Commission on Oral Health, Research & Epidemiology. Report of an FDI Working Group. Int Dent J 1992; 42(6):411-412., which assess the presence, location and extent of defects and combinations of defects. Opacities, defined as qualitative defects involving an alteration in the translucency of enamel, were classified as demarcated (opacities with a clearly defined border with the adjacent normal enamel) and diffuse (opacities with a poorly defined boundary with the adjacent normal enamel). Hypoplasias were defined as quantitative defects associated with a localized reduced thickness of the enamel. Location was classified as incisal one-half, gingival one-half, occlusal one-half and cuspal. Extent was classified as less than one-third, between at least one-third and two-thirds, and at least two-thirds of the surface²¹21 Federation Dental International. A review of the developmental defects of enamel index (DDE Index). Commission on Oral Health, Research & Epidemiology. Report of an FDI Working Group. Int Dent J 1992; 42(6):411-412..

Teeth with crown fractures, carious lesions and/or extensive restorations (covering more than two-thirds of the surface of the tooth), and extracted or exfoliated deciduous teeth were not included in the study. Single defects measuring less than 1mm in diameter and questionable cases were not recorded²¹21 Federation Dental International. A review of the developmental defects of enamel index (DDE Index). Commission on Oral Health, Research & Epidemiology. Report of an FDI Working Group. Int Dent J 1992; 42(6):411-412..

The data were analyzed using SPSS® for Windows version 21.0 (Armonk, NY, USA: IBM Corp). The dependent variable was dichotomized into presence or absence of DDE. The following independent variables were used: sex; age; self-declared skin color; socioeconomic characteristics (such as household income and maternal education); sanitary conditions; health problems during pregnancy (fever or infection, high blood pressure, urinary tract infection, use of antibiotics, bleeding, placental abruption and pre-eclampsia); and health problems during early childhood (diarrhea, chickenpox, pneumonia, asthma, bronchitis, sinusitis, allergic rhinitis, fever, malnutrition, otitis and use of antibiotics)^{1,4-7, 20}.

The data were analyzed using descriptive statistics. Poisson regression with robust standard errors was used to determine the association between the presence or absence of DDE and the independent variables. Strength of association was measured using crude and adjusted prevalence ratios (PR), confidence intervals (95% CI) and p-values. Variables that obtained a p-value of ≤0.20 in the bivariate analysis were included in the adjusted model. Only variables with a p-value of <0.05 were included in the final model.

The study was approved by Piauí Federal University’s research ethics committee and was conducted in accordance with in accordance with ethical, legal and regulatory norms and standards for research involving human subjects set out in the Declaration of Helsinki and National Health Council Resolution 466/12.

Results

We examined 406 (96.9%) children and adolescents who met the inclusion criteria. There were no refusals to participate in the study. There were 14 losses: five adolescents using fixed orthodontic appliances, four with amelogenesis imperfecta and five with carious lesions covering more than two-thirds of the surface of the tooth.

Mean age was 8.74 (±3.17) years (ranging from three to 14 years), 52.0% of the sample were male and 35.7% were black. Most of the families (82.5%) had an income of less than or equal to R$500.00. The minimum wage at the time of the study was R$880.00 (US$1.00 = R$3.2403). With regard to parental education, 49.5% of the mothers had less than eight years of formal schooling. The main source of water was water-storage cisterns supplied by water trucks (78.6%) and the main type of water treatment was effervescent chlorine tablets (41.1%) (Table 1).

The prevalence of DDE was 80.5% (Table 1): 42.2% in deciduous teeth and 61.1% in permanent teeth. The most common type of defect in both teeth was demarcated opacities. The most commonly affected areas of the teeth were the incisal one-half and cuspal. Most of the children and adolescents had enamel defects in less than one-third of the tooth surface (Table 2).

DDE prevalence was 9.0% higher in the 11-to-14-year age group than in the 3-to-5-year age group (PR = 1.09; 95%CI = 1.01 - 1.17). With regard to health problems during pregnancy, use of antibiotics (PR = 1.14; 95%CI = 1.07-1.22) was associated with the presence of DDE. Malnutrition during early childhood (PR = 1.12; 95%CI = 1.03-1.22) was also associated with the presence of DDE (Table 3).

Discussion

The findings show that most of the individuals had DDE, which is consistent with the results of previous studies with low-income populations¹⁰10 Basha S, Mohamed RN, Swamy HS. Prevalence and associated factors to developmental defects of enamel in primary and permanent dentition. Oral Health Dent Manag 2014; 13(3):588-594.^,1414 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444.^,1515 Vargas-Ferreira F, Ardenghi TM. Developmental enamel defects and their impact on child oral health-related quality of life. Braz Oral Res 2011; 25(6):531-537.. The early diagnosis of alterations in dental enamel is clinically important because DDE increases susceptibility to build-up of oral biofilm, which is associated with tooth sensitivity, hampers brushing and negatively affects quality of life¹³13 Mermarpour M, Golkari A, Ahmadian R. Association of characteristics of delivery and medical conditions during the first month of life with developmental defects of enamel. BMC Oral Health 2014; 14:122.^,1717 Costa FS, Silveira ER, Pinto GS, Nascimento GG, Thomson WM, Demarco F. Developmental defects of enamel and dental caries in the primary dentition: a systematic review and meta-analysis. J Dent 2017; 60:1-7..

Report of malnutrition was one of the factors associated with DDE, which explains the high prevalence of this condition among socially vulnerable groups such as Quilombolas¹1 Silva EKPD, Medeiros DS, Martins PC, Sousa LA, Lima GP, Rêgo MAS, Silva TOD, Freire AS, Silva FM. Insegurança alimentar em comunidades rurais no Nordeste brasileiro: faz diferença ser quilombola? Cad Saude Publica 2017; 33(4):e00005716.^,44 Marques AS, Freitas DA, Leão CD, Oliveira SK, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.^,55 Gubert MB, Spaniol AM, Bortolini GA, Pérez-Escamilla R. Household food insecurity nutritional status and morbidity in Brazilian children. Public Health Nutr 2016; 19(12):2240-2245., whose average household income is less than the minimum wage. Calcium ions in the diet regulate cell activities, such as cellular communication, signal transduction and the activation of enzymes that are essential to the activity of the proteins involved in amelogenesis²²22 Simmer JP, Hu JC. Expression, structure, and function of enamel proteinases. Connect Tissue Res 2002; 43(2-3):441-449.. Reduced serum phosphorus and calcium levels during pregnancy associated with other complications in this period may also result in defective enamel crystal and mineral formation²³23 Merheb R, Arumugam C, Lee W, Collin M, Nguyen C, Groh-Wargo S, Nelson S. Neonatal serum phosphorus levels and enamel defects in very-low-birth-weight infants. JPEN J Parenter Enteral Nutr 2016; 40(6):835-841.. In this regard, one of the limitations of the present study was that we did not evaluate malnutrition using a validated assessment instrument.

It is important to emphasize that lack of antenatal and early childhood care can lead to increased likelihood of DDE⁹9 Massoni AC, Chaves AM, Sampaio FC, Rosenblatt A; Oliveira AF. Prevalence of enamel defects related to pre-, peri- and postnatal factors in a Brazilian population. Community Dent Health 2009; 26(3):143-149.^,1010 Basha S, Mohamed RN, Swamy HS. Prevalence and associated factors to developmental defects of enamel in primary and permanent dentition. Oral Health Dent Manag 2014; 13(3):588-594.^,1414 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444.^,1515 Vargas-Ferreira F, Ardenghi TM. Developmental enamel defects and their impact on child oral health-related quality of life. Braz Oral Res 2011; 25(6):531-537., given that ameloblasts are sensitive to physical, chemical and biological attacks, which can lead to irreversible damage to the enamel of forming teeth²²22 Simmer JP, Hu JC. Expression, structure, and function of enamel proteinases. Connect Tissue Res 2002; 43(2-3):441-449.^,2424 Brook AH. Multilevel complex interactions between genetic, epigenetic and enviromental factors in the aetiology of anomalies of dental development. Arch Oral Biol 2009; 54(1):S3-17..

Prevalence of DDE was lower in deciduous teeth than in permanent teeth, corroborating the findings in the literature¹²12 Jacobsen PE, Haubek D, Henriksen TM, Østergaard JR, Poulsen S. Developmental defects of enamel in children born preterm: a systematic review. Eur J Oral Sci 2014; 122(1):7-14.^,1010 Basha S, Mohamed RN, Swamy HS. Prevalence and associated factors to developmental defects of enamel in primary and permanent dentition. Oral Health Dent Manag 2014; 13(3):588-594.^,1515 Vargas-Ferreira F, Ardenghi TM. Developmental enamel defects and their impact on child oral health-related quality of life. Braz Oral Res 2011; 25(6):531-537.. However, this result may be masked by difficulties in diagnosing DDE in deciduous teeth due to the presence of white spots, leading to a potential underestimation of structural defects²⁵25 Masumo R, Bardsen A, Astrøm AN. Developmental defects of enamel in primary teeth and association with early life course events: a study of 6-36 month old children in Manyara, Tanzania. BMC Oral Health 2013; 13:21.. Another explanation for the lower prevalence of DDE in deciduous teeth is the smaller window of exposure to environmental factors, as in the majority of deciduous teeth calcification occurs in intrauterine life, during which there is placental protection¹⁰10 Basha S, Mohamed RN, Swamy HS. Prevalence and associated factors to developmental defects of enamel in primary and permanent dentition. Oral Health Dent Manag 2014; 13(3):588-594.^,1414 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444.^,1515 Vargas-Ferreira F, Ardenghi TM. Developmental enamel defects and their impact on child oral health-related quality of life. Braz Oral Res 2011; 25(6):531-537..

The areas most affected by DDE in both teeth were the incisal one-half and cuspal, which is similar to the findings of previous studies²⁶26 Wagner Y. Developmental defects of enamel in primary teeth - findings of a regional German birth cohort study. BMC Oral Health 2016; 17(1):10.. The location of defects depends on the stage of tooth development in which the insults occurred. In this regard, amelogenesis begins at the cusp tip or incisal edge and progresses towards the cervical third of the tooth²⁷27 Velló MA, Martínez-Costa C, Catalá M, Fons J, Brines J, Guiiarro-Martínez R. Prenatal and neonatal risk factors for the development of enamel defects in low birth weight children. Oral Dis 2010; 16(3):257-262.. In most of the individuals, in both teeth the enamel defects covered less than one-third of the tooth surface, confirming the results reported by Wagner²⁶26 Wagner Y. Developmental defects of enamel in primary teeth - findings of a regional German birth cohort study. BMC Oral Health 2016; 17(1):10. (2016), but contrasting with those of Masterson¹¹ (2017), which showed that in most individuals the defects covered between one-third and two-third of the surface.

The most common type of defect was demarcated opacities, which is consistent with the findings of previous studies¹²12 Jacobsen PE, Haubek D, Henriksen TM, Østergaard JR, Poulsen S. Developmental defects of enamel in children born preterm: a systematic review. Eur J Oral Sci 2014; 122(1):7-14.^,1414 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444.^,2626 Wagner Y. Developmental defects of enamel in primary teeth - findings of a regional German birth cohort study. BMC Oral Health 2016; 17(1):10.^,2828 Correa-Faria P, Martins-Junior PA, Vieira-Andrade RG, Marques LS, Ramos-Jorge ML. Perinatal factors associated with developmental defects of enamel in primary teeth: a case-control study. Braz Oral Res 2013; 27(4):363-368.. Diffuse opacities such as very mild and mild fluorosis were more common than hypoplasias. This may be due to the intake of fluoride toothpaste during amelogenesis²⁹29 Goodarzi F, Mahvi AH, Hosseini M, Nedjat S, Nabizadeh Nodehi R, Kharazifard MJ, Parvizishad M, Cheraghi Z. The prevalence of dental fluorosis and exposure to fluoride in drinking water: A systematic review. J Dent Res Dent Clin Prospects 2016; 10(3):127-135., as the region’s water supply is not fluoridated and the children and adolescents have lived in the communities since they were born²⁹29 Goodarzi F, Mahvi AH, Hosseini M, Nedjat S, Nabizadeh Nodehi R, Kharazifard MJ, Parvizishad M, Cheraghi Z. The prevalence of dental fluorosis and exposure to fluoride in drinking water: A systematic review. J Dent Res Dent Clin Prospects 2016; 10(3):127-135.. Fluorosis was diagnosed using the modified DDE index²¹21 Federation Dental International. A review of the developmental defects of enamel index (DDE Index). Commission on Oral Health, Research & Epidemiology. Report of an FDI Working Group. Int Dent J 1992; 42(6):411-412.. Previous studies have shown that the frequency of dental fluorosis in permanent teeth is lower in children whose parents receive guidance on the quantity of fluoride toothpaste that should be used during early childhood³⁰30 Moura MS, Carvalho MM, Silva MC, Lima MDM, Moura LFAD, Simplício AHM.The impact of a dental program for maternal and infant health on the prevalence of dental fluorosis. Pediatr Dent 2013; 35(7):519-522..

The high prevalence of fluorosis in permanent teeth found in the current study may be due to the intake of fluoride toothpaste during the period of calcification of the crowns, given that the study participants have lived in the communities since they were born and have never left the community for periods longer than 30 days.

Our findings show that DDE prevalence was higher in the 6-10-year age group than in the 11-to14-year group. Amelogenesis is a long process that begins during intrauterine life and extends through early childhood, meaning that perturbations during this process may be a factor that triggers DDE in both deciduous and permanent teeth, depending on the moment in which the insults occurr⁸8 Ford D, Seow WK, Kazoullis S, Holcome T, Newman B. A controlled study of risk factors for enamel hypoplasia in the permanent dentition. Pediatr Dent 2009; 31(5):382-388.. In the majority of permanent teeth, calcification occurs in early childhood, when the chances of developing systemic diseases that cause high fever and are associated with DDE are greater¹⁴14 Hoffmann RHS, Sousa MDLR, Cypriano S. Prevalência de defeitos de esmalte e sua relação com cárie dentária nas dentições decídua e permanente, Indaiatuba, São Paulo, Brasil. Cad Saude Publica 2007; 23(2):435-444..

Health problems during pregnancy²⁷27 Velló MA, Martínez-Costa C, Catalá M, Fons J, Brines J, Guiiarro-Martínez R. Prenatal and neonatal risk factors for the development of enamel defects in low birth weight children. Oral Dis 2010; 16(3):257-262., adverse conditions at birth²⁸28 Correa-Faria P, Martins-Junior PA, Vieira-Andrade RG, Marques LS, Ramos-Jorge ML. Perinatal factors associated with developmental defects of enamel in primary teeth: a case-control study. Braz Oral Res 2013; 27(4):363-368., nutritional deficiency⁷7 Yadav PK. Prevalence and Association of Developmental Defects of Enamel with, Dental-Caries and Nutritional Status in Pre-School Children, Lucknow. J Clin Diagn Res 2015; 9(10):71-74. and early childhood illnesses have been associated with DDE. The findings of the current study show that use of medication during pregnancy was associated with presence of DDE, with antibiotics being the most commonly reported medicines by the mothers. These findings are consistent with those of other studies²⁰20 Ravindran R, Saji AM. Prevalence of the developmental defects of the enamel in children aged 12-15 years in Kollam district. J Int Soc Prev Community Dent 2016; 6 (1):28-33.. However, it is important to bear in mind that one of the limitations of cross-sectional studies is recall bias. In this regard, researchers received prior training to ensure they used accessible language when administering the interview to facilitate the study participants’ understanding of the questionnaire and technical terms.

This study encompasses a priority group for health research in Brazil. Our findings draw attention to the association between DDE and social factors and oral diseases, thus contributing to the effective planning of health promotion and disease prevention strategies.

In conclusion, the findings of the current study reveal high prevalence of DDE among children and adolescents in the Quilombola community. Associated factors were older age, use of antibiotics during pregnancy and malnutrition in early childhood.

References

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