Abstract

Objective:

to analyze factors associated with the need for dental treatment in adults due to dental caries and tooth loss.

Methods:

this was a cross-sectional study with a random sample of adults attending Fluminense Federal University School of Dentistry outpatient clinics, in Niterói, RJ, between July and December 2013; we used data collected from clinical records; a questionnaire was administered in interviews; logistic regression analysis was performed to obtain crude and adjusted odds ratios (OR).

Results:

212 individuals participated, 71.7% were women; the prevalence of need for dental treatment was 56.1% (95%CI 49.4;62.7); need for treatment was lower in individuals with higher family income (OR=0.53 - 95%CI 0.28;0.98), and higher in women (OR=2.28 - 95%CI 1.21;4.32).

Conclusion:

prevalence of need for treatment in adults was high, especially in women and people with lower family income.

Keywords:
Dental Caries; Socioeconomic Factors; Cross-Sectional Studies; Tooth Loss; Dental Care.

Introduction

Dental caries and tooth loss are among the most prevalent oral diseases in Latin America.¹1. Kassebaum NJ, Smith AGC, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990-2015: a systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res. 2017 Apr; 96(4):380-7. doi: 10.1177/0022034517693566.
https://doi.org/10.1177/0022034517693566... Tooth loss occurs mainly in the population with lower income and less schooling, whereby most tooth extractions are attributed to caries and, on a smaller scale, to periodontopathies. In addition to poor living conditions, the main risk factors for these diseases are related to unhealthy lifestyles, such as bad eating habits, malnutrition and lack of oral hygiene, continuous use of tobacco and alcohol, as well as the unavailability or limited accessibility of oral health services.²2. Goulart MA, Vettore MV. Is the relative increase in income inequality related to tooth loss in middle‐aged adults? J Public Health Dent. 2016 Winter;76(1):65-75. doi: 10.1111/jphd.12113.
https://doi.org/10.1111/jphd.12113... ^,33. Barbato PR, Peres KG. Contextual socioeconomic determinants of tooth loss in adults and elderly: a systematic review. Rev Bras Epidemiol. 2015 Apr-Jun;18(2):357-71. doi: 10.1590/1980-5497201500020006.
https://doi.org/10.1590/1980-54972015000...

Oral health has a strong relationship with socioeconomic and demographic factors, especially in the case of individuals in lower income brackets.⁴4. Gupta N, Vujicic M, Yarbrough C, Harrison B. Disparities in untreated caries among children and adults in the U.S., 2011-2014. BMC Oral Health. 2018 Mar;18(1):30. doi: 10.1186/s12903-018-0493-7.
https://doi.org/10.1186/s12903-018-0493-... ^,55. Assari S. Socioeconomic status and self-rated oral health; diminished return among hispanic whites. Dent J. 2018 Apr;6(2). doi: 10.3390/dj6020011.
https://doi.org/10.3390/dj6020011... The association between social determinants and oral health influences access to and utilization of health care services.⁶6. Herkrath FJ, Vettore MV, Werneck GL. Contextual and individual factors associated with dental services utilisation by Brazilian adults: a multilevel analysis. PloS One. 2018 Feb;13(2):e0192771. doi: 10.1371/journal.pone.0192771.
https://doi.org/10.1371/journal.pone.019... ^,77. Bordin D, Fadel CB, Santos CBD, Garbin CAS, Moimaz SAS, Saliba NA. Determinants of oral self-care in the Brazilian adult population: a national cross-sectional study. Braz Oral Res. 2017 Dec;31:e115. doi: 10.1590/1807-3107bor-2017.vol31.0115.
https://doi.org/10.1590/1807-3107bor-201...

The burden of oral disease is particularly high for disadvantaged and poor population groups, both in developed and in developing countries.¹1. Kassebaum NJ, Smith AGC, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990-2015: a systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res. 2017 Apr; 96(4):380-7. doi: 10.1177/0022034517693566.
https://doi.org/10.1177/0022034517693566... Caries is the oral disease that most affects children; globally, it is considered one of the most important diseases in contemporary society, affecting 1.76 billion deciduous teeth among 1.93 billion children. In 2016, dental caries was among the most prevalent top ten causes among adults worldwide.⁸8. Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017 Sep; 390(10100):1211-59. doi: 10.1016/S0140-6736(17)32154-2.
https://doi.org/10.1016/S0140-6736(17)32... The substantial costs involved in its treatment, added to the existence and availability of preventive methods, confirm the importance of dental caries as a public health problem.⁹9. Peres MA, Latorre MRDO, Sheiham A, Peres KG, Barros FC, Hernandez PG, et al. Effects of social and biological factors on dental caries in 6-year-old children: a cross sectional study nested in a birth cohort in Southern Brazil. Rev Bras Epidemiol. 2003 Dec;6(4):293-306. doi: 10.1590/S1415-790X2003000400004.
https://doi.org/10.1590/S1415-790X200300... In addition, caries integrates the list of diseases that are closely dependent on social determinants, such as sedentary lifestyle, smoking, alcoholism and stress.⁸8. Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017 Sep; 390(10100):1211-59. doi: 10.1016/S0140-6736(17)32154-2.
https://doi.org/10.1016/S0140-6736(17)32...

In Brazil, despite the relevance of actions to prevent and control dental caries and despite oral health care actions provided by the Brazilian National Health System (SUS), shortcomings can be seen in access to and comprehensiveness of dental treatment.¹⁰10. Ferreira Antunes JL, Toporcov TN, Bastos JL, Frazão P, Capel Narvai P, Peres MA. A saúde bucal na agenda de prioridades em saúde pública. Rev Saúde Pública. 2016;50:1-9. doi:10.1590/S1518-8787.2016050007093.
https://doi.org/0.1590/S1518-8787.201605...

The objective of this study was to analyze prevalence and factors associated with the need for dental treatment for tooth decay and tooth loss in adults attending Fluminense Federal University School of Dentistry graduate clinics (FOUFF), in the period from July to December 2013.

Methods

A cross-sectional study was conducted with the purpose of analyzing the need for treatment for dental caries and tooth loss in the reference population, corresponding to approximately 3,000 adult patients aged 18 years old or over registered with ten FOUFF undergraduate course clinics, between July and December 2013. The clinics involved in the study were: Dentistry, Occlusion, Integrated Clinical Practice, Total Prosthesis, Oral Diagnosis, Removable Prosthesis, Endodontics, Periodontics, Fixed Prosthesis and Surgery.

The definition of the needs for treatment of dental caries and tooth loss followed the classification proposed by the most recent national survey on oral health, conducted in 2010 (SB 2010),¹¹11. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. SB Brasil 2010 - relatório final [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2016 ago 26]. 92 p. Disponível em: Disponível em: http://dab.saude.gov.br/CNSB/sbbrasil/arquivos/projeto_sb2010_relatorio_final.pdf
http://dab.saude.gov.br/CNSB/sbbrasil/ar... which includes:

Treatment needed for reconstitution using prostheses was classified as:

Eligible patients were those who registered of their own accord and were attending FOUFF clinics, aged 18 or over, from July to December 2013. To be treated at one of these clinics, SUS users must register by phone or e-mail addressed to the FOUFF Secretaries’ office, attend a welcome lecture and undergo diagnostic screening, and join the waiting list to be seen. Individuals who registered during the first half of 2013 and those still in treatment were selected by simple random sampling of dental records, using a table of numbers taken randomly from the list of patients registered as at 30 June 2013.

The data were collected from the dental records already used in clinics and through interviews with the patients themselves, carried out between July and December 2013. All dental records were standardized and the information generated was the responsibility of the dental professional who treated the patients. This information was validated by the university teacher in charge of the sector. The dental records contained data on patients’ age, sex, address, dental elements examined, diagnosis and respective treatment. The questionnaire was based on the form used by the Brazilian Ministry of Health in a national oral health survey.¹²12. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. SB Brasil 2010: pesquisa nacional de saúde bucal, resultados principais [Internet]. Brasília: Ministério da Saúde; 2012 [citado 2018 out 29]. 116 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

The dependent variable was the need for treatment of dental caries or tooth loss, dichotomized as follows: zero (no need) or 1 (any category of classification for treatment of dental caries or tooth loss).

The independent variables were: family income (≤2 minimum wages; >2 minimum wages), household density (≤3 persons; ≥4 persons), number of domestic appliances (≤6 appliances; >6 appliances), healthcare plan (private; SUS only), reason for appointment (free of charge; specialized treatment), education level (≤ 11 years of study; >11 years of study), sex (male; female) and age group (in years: 18-40; 41-59; 60 and over).

A pilot study was conducted to test the data collection instrument with a sample of 20 individuals who were not included in the main study, although data collection during the field work itself was done by the same interviewer used in the pilot study. The purpose of the pilot study was to verify the applicability of the questionnaire: to test whether interviewees understood the questions and to assess average time spent on answering it.

The Epi Info Statcalc application was used to calculate the sample size.¹³13. Centers for Disease Control and Prevention. Division of Health Informatics & Surveillance (DHIS). Epi InfoTM | CDC [Internet]. 2016 [cited 2018 Oct 29]. Available in: Available in: https://www.cdc.gov/epiinfo/index.html
https://www.cdc.gov/epiinfo/index.html... The exposure hypotheses used were that individuals with 'lower family income' were considered to be exposed, while individuals with 'higher family income' were considered to be non-exposed. The proportion of non-exposed cases (9.1) and exposed cases (24.5) was established using the values found in a similar study carried out at the same institution.¹⁴14. Gonçalves R. Socioeconomic profile of patients attended in the clinics of the specialization courses of the odontology faculty of the federal fluminense university - fouff. Int J Sci Dent. 2012;1(37). The sample size calculated for each group was 104, based on a 5% significance level and test power of 80%. We therefore planned to examine 208 individuals plus a further 10.

The data were analyzed using the Statistic Package for Social Science (SPSS for Windows, version 21.0). Associations between the independent variables and the dichotomic 'need for treatment' outcome were verified using the chi-square test. The independent variables were clustered according to a three-level hierarchical model¹⁵15. Dahlgren G, Whitehead M. European strategies for tackling social inequities in health: levelling up Part 2 [Internet]. Copenhagen: World Health Organization; 2007 [cited 2018 Oct 29]. 137 p. Available in: Available in: http://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf
http://www.euro.who.int/__data/assets/pd... and were analyzed sequentially, starting with the most distal layer (contextual factors) and ending with the proximal layer (service access/use and demographic factors), according to the determinants involved on each level (Figure 1). For each stage of the hierarchical structure, logistic regression analysis was performed using a backward stepwise procedure, selecting the best predictors with a significance level of p<0.25 in the bivariate analysis. When defining the final model, the variables with greater statistical significance on each horizontal level were added in ascending order. Thus, the bivariate analysis variables were included on their hierarchical level in the multivariate models. Only 'income' and 'sex ' were significant in their respective blocks, whereby the covariate adjusted odds ratios (OR) were obtained taking the hierarchical levels (individual and contextual) into consideration. Second-order iterations were tested at each stage of the analysis. The significance level established in the analysis of the final model was 5%.

The study project was approved by the FOUFF Research Ethics Committee: Report No. 146803/2012. The participants signed a Free and Informed Consent form before answering the questionnaire.

Results

212 individuals undergoing treatment in FOUFF graduation clinics were included in the study, 71.7% of whom were women. Most of the participants were aged either between 18 and 40 years (46.2%) or between 41 and 49 years (42.5%). Tooth loss prevalence was 28.8% (95%CI 23.0;25.1); while dental caries prevalence was 71.2% (95%CI 64.9;77.0); and prevalence of need for dental treatment was 56.1% (95%CI 49.4;62.7).

Table 1 shows the distribution of individual and contextual characteristics according to prevalence of need for dental treatment. 43.3% of males had some need for treatment, while this percentage was 61.2% (p=0.02) among females. In the analysis of the remaining independent variables, no significant differences were found in the comparison of the groups.

In the multivariate analysis, the 'household density', 'number of appliances ', 'healthcare plan', 'reason for appointment' and 'education level' variables were removed because they had a significance level of p ≥ 0.25. Among the contextual and access to services variables, only 'family income' showed significant association (p<0.05) when model 1 was adjusted (Table 2). Following adjustment of the final multivariate logistic regression model, the 'family income' and 'sex' variables were included since the p-value was <0.05. The level 2 variables were not included as their p-value was >0.05. The need for dental treatment was lower (OR=0.53 95%CI 0.28;0.98) in individuals with higher family income and higher among women (OR=2.28 95%CI 1.21;4.32). None of the groups showed statistical significance (Table 2).

Discussion

More than half the adults attending the FOUFF clinics needed dental treatment for dental caries or tooth loss. Poorer individuals and women had the greatest need for dental treatment for these causes.

The main limitations of this study lie in the power of the sample. The sample size calculation was based on the proportion of individuals exposed and not exposed to health inequalities and not on the prevalence of the dependent variable: the need for dental treatment. Post hoc analysis of test power, based on the prevalence found in our study, found power of less than 65%, with minimum OR equal to 2.2, and OR to be detected with a power of 80%, based on the proportion found in a similar study which was equal to 3.2. Despite having a random sampling process, the sample studied does not allow extrapolation to other population groups, because it reflects only those who had access to FOUFF outpatient clinics. Over half of the sample analyzed (56.1%) needed treatment for dental caries or tooth loss; however, this prevalence reflects people who sought treatment on their own initiative and who had greater access, given that making an appointment depended upon prior registration. In Brazil, 44% of the population had consulted a dentist in the last 12 months, according to the 2013 National Health Survey.¹⁶16. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde, 2013: acesso e utilização dos serviços de saúde, acidentes e violências: Brasil, grandes regiões e unidades da Federação [Internet]. Rio de Janeiro: Fundação Instituto Brasileiro de Geografia e Estatística; 2015 [citado 2018 out 29]. 100 p. Disponível em: Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv94074.pdf
https://biblioteca.ibge.gov.br/visualiza... This increased demand for treatment in our study sample also influenced dental caries prevalence greater than 70% in the adults in our study, while in Brazil as a whole this prevalence is much lower among adults (9.5%) and the elderly (13.9%) Another limitation refers to the cross-sectional study design, which does not allow the identification of causal inferences, as well as possible information and memory biases on the part of patients interviewed.

Prevalence of tooth loss, as assessed by the need for some type of prosthesis, was lower than that found for Brazil as a whole in the most recent oral health survey, according to which the need for some type of prosthesis in adults aged 35 to 44 years occurred in 68.8% of cases.¹²12. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. SB Brasil 2010: pesquisa nacional de saúde bucal, resultados principais [Internet]. Brasília: Ministério da Saúde; 2012 [citado 2018 out 29]. 116 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... A possible explanation for the lower prevalence of tooth loss is related to the characteristics of the sample, restricted to people who already have access to a specialized public clinic, with a large part of the interviewees only seeking restorative treatment.

Worldwide, lower dental caries prevalence is found among people with higher purchasing power, compared to those with low income. In Brazil, the worst oral health conditions are related to poverty and a lower level of income.¹⁸18. Silva JV, Machado FCA, Ferreira MAF. Social inequalities and the oral health in Brazilian capitals. Ciênc Saúde Coletiva. 2015 Aug;20(8):2539-48. doi: 10.1590/1413-81232015208.12052014.
https://doi.org/10.1590/1413-81232015208... In this study, the majority of the sample was comprised of low-income people in need of restorative treatment, which may also have influenced the higher prevalence and associations found.

Other surveys that also used convenience samples found greater demand for oral health treatment by women on the SUS.¹⁹19. Gomes R, Nascimento EF, Araújo FC. Why do men use health services less than women? Explanations by men with low versus higher education. Cad Saúde Pública. 2007 Mar;23(3):565-74. doi: 10.1590/S0102-311X2007000300015.
https://doi.org/10.1590/S0102-311X200700... ^,2020. Figueiredo W. Assistance to the men health: a challenge for the services of primary attention. Ciênc Saúde Coletiva. 2005 Jan-Mar;10(1):105-9. doi: 10.1590/S1413-81232005000100017.
https://doi.org/10.1590/S1413-8123200500... Despite universal access, men do not feel encouraged to seek care, due to questions of health service organization and other barriers.¹⁹19. Gomes R, Nascimento EF, Araújo FC. Why do men use health services less than women? Explanations by men with low versus higher education. Cad Saúde Pública. 2007 Mar;23(3):565-74. doi: 10.1590/S0102-311X2007000300015.
https://doi.org/10.1590/S0102-311X200700... A survey conducted in 2008 in the city of Pelotas, in the state of Rio Grande do Sul, with a sample of 2,961 individuals, found increased demand and increased use of dental services by females, and association of this demand with greater schooling, prior guidance on prevention and greater income level, among other factors.²¹21. Camargo MBJ, Dumith SC, Barros AJD. Regular use of dental care services by adults: patterns of utilization and types of services. Cad Saúde Pública. 2009 Sep;25(9):1894-906. doi: 10.1590/S0102-311X2009000900004.
https://doi.org/10.1590/S0102-311X200900... These results may also explain higher treatment needs detected in the women in our study, to the extent that greater demand for treatment in this group would increase the probability of their selection in the sample.

The need for dental treatment was associated with socioeconomic inequalities. Another study, which was not limited to users of health care services but rather involved people with lower purchasing power, found that oral health conditions worsened when there was less access to prevention and care services.²²22. Jaccottet CMG, Barros AJD, Camargo MBJ, Cascaes AM. Assessment of dental treatment needs and productive capacity of primary dental care in the municipality of Pelotas, state of Rio Grande do Sul, Brazil, 2009. Epidemiol Serv Saúde. 2012 abr-jun;21(2):333-40. doi: 10.5123/S1679-49742012000200016.
https://doi.org/10.5123/S1679-4974201200... ^,2323. Peres MA, Peres KG, Thomson WM, Broadbent JM, Gigante DP, Horta BL. The Influence of family income trajectories from birth to adulthood on adult oral health: findings from the 1982 Pelotas birth cohort. Am J Public Health. 2011 Apr;101(4):730-6. doi: 10.2105/AJPH.2009.184044.
https://doi.org/10.2105/AJPH.2009.184044... These findings suggest the existence of oral health inequalities, possibly related to less access to prevention actions and to dental treatment services.

The importance of controlling and reducing inequalities in relation to the occurrence of dental caries and its treatment is based on the ethical imperative of avoiding these inequalities becoming health inequities, as they are avoidable, unfair and unnecessary.²⁴24. Whitehead M. A typology of actions to tackle social inequalities in health. J Epidemiol Community Health. 2007 Jun;61(6):473-8. doi: 10.1136/jech.2005.037242.
https://doi.org/10.1136/jech.2005.037242...

The need for dental treatment due to caries and tooth loss in patients attending Fluminense Federal University School of Dentistry outpatient clinics was high, especially in women and individuals with lower family income.

References

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