Abstract

INTRODUCTION

There have been significant changes in the epidemiological profile of oral health diseases in Brazilian children and adolescents in the last few decades, such as reduction in the prevalence and severity of dental caries. ¹²12 . Narvai PC, Frazão P, Roncalli AG, Antunes JLF. Cárie dentária no Brasil: declínio, polarização, iniqüidade e exclusão social. Rev Panam Salud Publica . 2006;19(6):385-93. DOI:10.1590/S1020-49892006000600004
https://doi.org/10.1590/S1020-4989200600... These changes have led to an increase in the development of research into other oral health outcomes such as malocclusion. ⁸8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10.... ^{, 15}15 . Peres KG, Barros AJD, Anselmi L, Peres MA, Barros FC. Does malocclusion influence the adolescent’s satisfaction with appearance? A cross-sectional study nested in a Brazilian birth cohort. Community Dent Oral Epidemiol . 2008;36(2):137-43. DOI:10.1111/j.1600-0528.2007.00382.x
https://doi.org/10.1111/j.1600-0528.2007... Malocclusion is not a single entity and can be defined as a set of disorders in the growth and development that affects muscles and facial bones during childhood and adolescence ²⁰20 . Simões WA. Prevenção de oclusopatias. Ortodontia. 1978;11:117-25. and may lead to functional, aesthetic, and psychosocial disturbances, with negative consequences for the individual’s quality of life. ¹⁵15 . Peres KG, Barros AJD, Anselmi L, Peres MA, Barros FC. Does malocclusion influence the adolescent’s satisfaction with appearance? A cross-sectional study nested in a Brazilian birth cohort. Community Dent Oral Epidemiol . 2008;36(2):137-43. DOI:10.1111/j.1600-0528.2007.00382.x
https://doi.org/10.1111/j.1600-0528.2007...

Malocclusion are generally considered the third most important oral disorders according to the World Health Organization, identified in international epidemiological investigations. ¹⁶16 . Peres KG, Tomita NE. Oclusopatias. In: Antunes JLF, Peres MA. In: Epidemiologia da saúde bucal. Rio de Janeiro: Guanabara Koogan; 2008. p.83-101. Oral health population-based surveys in Brazil have included investigation of occlusion disorders since the 2002-2003 SBBrasil National Survey. In that study, it was found that 8.2% of 12-year-olds had severe and 9.8% very severe malocclusion. Among 15-19-year-old individuals, 8.0% and 11.1% showed severe and very severe malocclusion, respectively. ¹⁶16 . Peres KG, Tomita NE. Oclusopatias. In: Antunes JLF, Peres MA. In: Epidemiologia da saúde bucal. Rio de Janeiro: Guanabara Koogan; 2008. p.83-101.

Malocclusions originate from the interaction between genetic and environmental factors. ⁶6 . Corruccini RS, Potter RHY. Genetic analysis of occlusal variation in twins. Am J Orthod. 1980;78(2):140-54. Research addressing the etiology and factors associated with malocclusion have produced quite diverse results. Although some studies have highlighted the link between malocclusion and being socioeconomically disadvantaged, ⁸8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10.... others have failed to identify such an association. ³3 . Bernabé E, Flores-Mir C. Orthodontic treatment need in Peruvian young adults evaluated through dental aesthetic index. Angle Orthod. 2006;6(3):417-21. DOI: 10.1043/0003-3219(2006)076[0417:OTNIPY]2.0.CO;2
https://doi.org/10.1043/0003-3219(2006)0... The same is observed for demographic aspects and the presence of other oral health problems, such as dental caries ⁸8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10.... ^{, 14}14 . Peres KG, Latorre MRDO, Sheiham A, Peres MA, Victora CG, Barros FC. Social and biological early life influences on the prevalence of open bite in Brazilian 6-year-olds. Int J Paediatr Dent. 2007;17(1):41-9. DOI:10.1111/j.1365-263X.2006.00793.x
https://doi.org/10.1111/j.1365-263X.2006... and tooth loss. ¹⁷17 . Robke FJ. Effects of nursing bottle misuse on oral health. Prevalence of caries, tooth malalignments and malocclusions in North-German preschool children. J Orofac Orthop . 2008;69(1):5-19. DOI:10.1007/s00056-008-0724-7
https://doi.org/10.1007/s00056-008-0724-... The presence of association between these aspects and occlusal disorders is not clear among several researches.

Part of this divergence may be due to the occlusal characteristics captured using different measurements instruments. Whereas some studies have investigated factors associated with specific occlusal deviations (anterior open bite, overjet), in others the outcome was malocclusion defined as a whole, shown as a score indicating whether the condition is mild, moderate or severe. For specific occlusal disorders, it is possible to identify proximal and distal associated factors. For moderate and severe malocclusions, it is only possible to evaluate the role played by distal factors as the results combine specific distortions of different etiological origin. ⁸8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10....

The possibility of identifying inequalities in the distribution of this oral health disorder according to different social and demographic aspects may contribute to provision of orthodontic treatment for the population through specialist orthodontic centers, an oral health care policy of the Brazilian health care system. ^aaMinistério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Coordenação Geral de Saúde Bucal. Brasil Sorridente. Brasília (DF); 2003 [cited 2010 Jun 24]. Available from: http://dtr2004.saude.gov.br/dab/cnsb/brasil_sorridente.php Knowing the pattern of malocclusion distribution, from a public health view, seeks to achieve two main aims: evaluating the need and priority for treatment of population groups, as well as obtaining data in order to allocate resources appropriately in the provision of oral health care to the population. The aim of this study was to describe the profile of very severe malocclusion in adolescents and to identify associated factors.

METHODS

Data from the National Oral Health Survey (SBBrasil 2010), carried out by the Brazilian Ministry of Health, was used. This study includes a sample of 12-year-olds and 15- 19-year-old adolescents. The sampling plan considered each of the state capitals and the Federal district and a sample of 30 interior municipalities in each macro-region (North, Northeast, Central-West, Southeast, and South) as domains, giving a total of 32 domains. A two-stage sampling scheme was adopted for the 26 state capitals and the Federal District and a three-stage sampling scheme for the municipalities in the interior of the five Brazilian macro regions. The primary sample units were: (a) municipality, for the interior, and (b) census tract for the state capitals. Data collection was performed at all participants’ homes. In this study, the sample size was 7,328 (12-year-olds) and 5,445 (15- to 19-year-olds). Detailed information on the sampling procedure is available in another publication. ¹⁸18 . Roncalli AG, Moyses SJ, Marques R, Pinto RS, Goes PSA, Figueiredo N, et al. Aspectos metodológicos do projeto SB Brasil 2010 de interesse para inquéritos nacionais de saúde. Cad Saude Publica. 2012;28(Suppl):s40-57. DOI:10.1590/S0102-311X2012001300006
https://doi.org/10.1590/S0102-311X201200...

Dental examinations and interviews through standardized and pre-coded questionnaires were carried out. Malocclusion was diagnosed using the Dental Aesthetic Index (DAI). ⁵5 . Cons NC, Jenny J, Kohout FJ. DAI: the dental aesthetic index. Iowa City: College of Dentistry, University of Iowa; 1986. The DAI is composed of ten measures: (a) number of incisors, canines, and premolars lost; (b) crowding and (c) spacing in the incisor region; (d) diastema; (e) irregularity anterior maxillary and (e) mandible; (f) anterior maxillary and (g) mandible overjet; (h) anterior open bite; and (i) molar ratio. Each measure receives a specific weighing, yielding a final score, which is categorized into four situations: (a) without malocclusion, score up to 25; (b) defined malocclusion, scores between 26 and 30; (c) severe malocclusion, score between 31 and 35; and (d) very severe malocclusion, scores greater than or equal to 36. In this study, the outcome adopted was the need for immediate treatment (yes/no) or, in other words, the prevalence of very severe malocclusion.

The independent variables were socioeconomic variables as well as the use of dental services related to the interviewee or the family and it was included in the questionnaire. Figure 1 shows the independent variables of the study and the respective adaptations. The fieldwork teams were composed of an examiner (dentist) and an interviewer. Teams undertook 40 hours of training in regional workshop. The consensus technique was used to train and calibrate the team. ⁹9 . Frias AC, Antunes JLF, Narvai PC. Precisão e validade de levantamentos epidemiológicos em saúde bucal: cárie dentária na cidade de São Paulo, 2002. Rev Bras Epidemiol. 2004;7(2):144-54. DOI:10.1590/S1415-790X2004000200004
https://doi.org/10.1590/S1415-790X200400... Inter-observer reliability was obtained through the weighted kappa coefficient. The kappa equal to 0.65 was considered the minimum acceptable value for all conditions under study. ¹⁸18 . Roncalli AG, Moyses SJ, Marques R, Pinto RS, Goes PSA, Figueiredo N, et al. Aspectos metodológicos do projeto SB Brasil 2010 de interesse para inquéritos nacionais de saúde. Cad Saude Publica. 2012;28(Suppl):s40-57. DOI:10.1590/S0102-311X2012001300006
https://doi.org/10.1590/S0102-311X201200...

Data analysis considered the complex sampling cluster design. The primary sampling units were the municipality (when the domain was the interior of the region) and the census tract (when the domain was the state capital). ¹⁸18 . Roncalli AG, Moyses SJ, Marques R, Pinto RS, Goes PSA, Figueiredo N, et al. Aspectos metodológicos do projeto SB Brasil 2010 de interesse para inquéritos nacionais de saúde. Cad Saude Publica. 2012;28(Suppl):s40-57. DOI:10.1590/S0102-311X2012001300006
https://doi.org/10.1590/S0102-311X201200... In the regression analysis, estimates of the unadjusted and adjusted odds ratios (OR) and the respective 95%CI were considered for each independent variable. This analysis was carried out based on a theoretical model with a hierarchical approach. ²⁴24 . Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol . 1997;26(1):224-7. DOI:10.1093/ije/26.1.224
https://doi.org/10.1093/ije/26.1.224... The independent variables were introduced into the modeling from the most distal to the most proximal according to the model of analysis adopted ( Table 1 ). The first level of the model included demographic variables, sex, and skin color (using the skin color of the father and/or mother as proxy). The second level included socioeconomic variables (monthly household income, number of consumer goods, and cluster), and the third level was oral health conditions and use of orthodontic services ( Figure 2 ). This type of analysis provides the fit between the variables on the same level and those in previous levels ( Figure 2 ). Variables with “p” value equal to or lower than 0.20 in the bivariate analysis were included in the multiple analysis. Only those variables with p ≤ 0.20 were included in the final model, and variables with p < 0.05 after adjusting for variables at the same level and above were considered to be statistically significant. The variable “sex” was kept in the final model regardless of its statistical significance.

The SBBrasil 2010 Project followed the standards set by the Declaration of Helsinki and was approved by the National Council for Research Ethics, record no. 15,498, 7th January 2010.

RESULTS

A total of 7,328 adolescents aged 12 years and 5,445 adolescents aged 15 to 19 years old took part in the sample. The prevalence of very severe malocclusion in Brazil was 6.5% (95%CI 5.0;8.5) in the subjects aged 12 years and 9.1% (95%CI 7.5;10.9) in those aged 15 to 19 years old. According to the 32 domains investigated, the prevalence of very severe malocclusion in those aged 12 varied from 2.2% in Cuiabá (95%CI 0.6;7.6) to 15.3% (95%CI 8.8;25.3) in Porto Velho, with an estimate for the country as a whole of 6.5% (95%CI 5.0;8.5). In the 15- 19-year-old age group, the overall prevalence was 9.1% (95%CI 7.5;10.9), with the lowest value being 2.0 (95%CI 0.6;6.8) in São Luiz and the highest being 16.8% (95%CI 9.4;28.1) in João Pessoa ( Figure 3 ).

The demographic characteristics of the study population aged 12 and 15- 19-years old were similar. In both groups, a higher proportion of women, participants with brown and black skin compared with those with white skin, those whose household income was below R$1,500.00, and those who had visited a dentist for treatment within the last year were observed. With regard to oral health conditions, the most favorable situation was observed in those aged 12, with only 5.0% having lost one or more first permanent molars, in contrast with 15.8% for those aged 15-19. On the other hand, having at least one tooth with dental caries was observed in 41.8% and 50.4% of those aged 12 and 15 to 19 years old, respectively ( Table 1 ).

In the 12-year-olds group, significantly higher levels of very severe malocclusion were identified among those with brown or black skin and those who had lost at least one first molar due to dental caries. In the 15- to 19-year-olds, having household income of R$1,500.00 or less, having lost at least one first molar due to dental caries, having one or more untreated dental caries, and having seen a dentist for reasons other than a check-up were factors associated with higher prevalence of very severe malocclusion.

In the unadjusted analysis for the 12-year-olds, individuals with brown or black skin (p = 0.019) and having lost one or more first permanent molar (p = 0.030) are more likely to present very severe malocclusion than those in the reference categories. Both variables remained in the final model after adjusted analysis, with a small increase (nearly 10%) observed in the magnitude of the association of the variable having lost one or more first molars and the outcome ( Table 2 ).

Regarding the 15- 19 years-old group, having monthly household income up to R$1,500.00 (p < 0.001), having lost one or more first permanent molars (p = 0.006), and to have the last dental visit for treatment (p = 0.001) were associated with the presence of very severe malocclusion in the unadjusted analysis ( Table 2 ). After adjustment, it was verified that an income of R$ 1,500.00 or lower remained associated with the outcome, although the magnitude of that association declined. Having one or more teeth with untreated dental caries lost statistical significance after adjustment for the variables skin color and income, whereas having received dental treatment remained significantly associated with the outcome after adjusting for the variables skin color, income, and having one or more untreated dental caries ( Table 2 ).

DISCUSSION

There was no significant variation in the distribution pattern of very severe malocclusion in Brazilian adolescents according to the state capitals and the interior of the different regions. Moreover, lower levels of income, brown or black skin people, loss of first permanent molar, and the presence of dental treatment were associated with very severe malocclusion after adjusting for potential confounders. Despite being a population-based study and adopting standardized methodology the SBBrasil 2010 is a cross-sectional study which limits the ability to make causal inference.

The prevalence of very severe malocclusion found in this study was similar to findings from studies carried out in Iran (10.9%) ⁴4 . Borzabadi-Farahani A, Eslamipour F, Asgari I. Association between orthodontic treatment need and caries experience. Acta Odontol Scand. 2011;69(1):2-11. DOI:10.3109/00016357.2010.516732
https://doi.org/10.3109/00016357.2010.51... and in Tanzania (6.9%), ¹⁹19 . Rwakatema DS, Ng’ang’a PM, Kemoli AM. Orthodontic treatment needs among 12-15 year-olds in Moshi, Tanzania. East Afr Med J. 2007;84(5):226-32. and to those performed in Brazil, such as the study carried out in the state of São Paulo (8.2% in 12-year-olds and 6.5% in 18-year-olds), ⁸8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10.... in Recife (5.8% in 13- to 15-year-olds), ¹⁰10 . Marques CR, Couto GB, Orestes Cardoso S. Assessment of orthodontic treatment needs in Brazilian schoolchildren according to the Dental Aesthetic Index (DAI). Community Dent Health . 2007;24(3):145-8. and in Belo Horizonte (13.2% in 10- to 14-year-olds). ¹¹11 . Marques LS, Barbosa CC, Ramos-Jorge ML, Pordeus IA, Paiva SM. Prevalência da maloclusão e necessidade de tratamento ortodôntico em escolares de 10 a 14 anos de idade em Belo Horizonte, Minas Gerais, Brasil: enfoque psicossocial. Cad Saude Publica . 2005;21(4):1099-106. DOI:10.1590/S0102-311X2005000400012
https://doi.org/10.1590/S0102-311X200500... On the other hand, a study in India (1.8%) ²¹21 . Singh A, Purohit B, Sequeira P, Acharya S, Bhat M. Malocclusion and orthodontic treatment need measured by the dental aesthetic index and its association with dental caries in Indian schoolchildren. Community Dent Health . 2011;28(4):313-6. identified a lower prevalence, whereas a study in Nigeria found a higher one (17.0% for 12- to 16-year-olds). ¹1 . Anosike AN, Sanu OO, Costa OO. Malocclusion and its impact on quality of life of school children in Nigeria. West Afr J Med . 2010;29(6):417-24. The difference in the studied age groups and the chance of accessing orthodontic treatment may vary between countries, which limits direct comparisons. ⁷7 . Foster Page LA, Thomson WM, Quick AN. Changes in malocclusion over time in New Zealand adolescents. Aust Orthod J. 2011;27(2):169-75.

Adolescents aged 12 years old who self-reported brown or black skin had a higher chance of having severe malocclusion than those with white skin. Research on the Brazilian population shows that brown and black skinned individuals, generally, have lower income than those with white skin, even taking other socioeconomic and demographic factors such as schooling, sex, and age into account. ²2 . Bastos JL, Peres MA, Peres KG, Dumith SC, Gigante DP. Socioeconomic differences between self-and interviewer-classification of color/race. Rev Saude Publica. 2008;42(2):324-34. DOI:10.1590/S0034-89102008005000005
https://doi.org/10.1590/S0034-8910200800... ^{, 22}22 . Telles EE, Lim N. Does it matter who answers the race question? Racial classification and income inequality in Brazil. Demography. 1998;35(4):465-74. In this study, the difference observed regarding skin color, may be an important indicator of socioeconomic inequalities because brown and black skinned individuals are still placed at the bottom of the social ladder in Brazil.

The influence of socioeconomic conditions on malocclusions has been addressed by few studies, and so far, the findings are inconclusive. In this study, the chance of adolescents aged 15 to 19 years old with lower levels of family income, having severe malocclusion was almost three times greater compared with those with higher income. Economic conditions seem to play an important role in oral health. Complex interrelations between these factors and other determinants, such as level of schooling; knowledge; certain behaviors; access to basic services and goods, healthy food consumption, access to hygiene products, and health-care services are observed. Some studies have also found an association between socioeconomic characteristics and malocclusion ⁸8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10.... ^{, 23}23 . Tickle M, Kay EJ, Bearn D. Socio-economic status and orthodontic treatment need. Community Dent Oral Epidemiol . 1999;27(6):413-8. and some have not. ³3 . Bernabé E, Flores-Mir C. Orthodontic treatment need in Peruvian young adults evaluated through dental aesthetic index. Angle Orthod. 2006;6(3):417-21. DOI: 10.1043/0003-3219(2006)076[0417:OTNIPY]2.0.CO;2
https://doi.org/10.1043/0003-3219(2006)0... ^{, 11}11 . Marques LS, Barbosa CC, Ramos-Jorge ML, Pordeus IA, Paiva SM. Prevalência da maloclusão e necessidade de tratamento ortodôntico em escolares de 10 a 14 anos de idade em Belo Horizonte, Minas Gerais, Brasil: enfoque psicossocial. Cad Saude Publica . 2005;21(4):1099-106. DOI:10.1590/S0102-311X2005000400012
https://doi.org/10.1590/S0102-311X200500...

Adolescents aged 12 years old who had lost a first molar due to dental caries had a nearly three times higher chance of having very severe malocclusion than those who were caries free. Some studies also identified an association between malocclusion and dental caries in the permanent teeth. ⁴4 . Borzabadi-Farahani A, Eslamipour F, Asgari I. Association between orthodontic treatment need and caries experience. Acta Odontol Scand. 2011;69(1):2-11. DOI:10.3109/00016357.2010.516732
https://doi.org/10.3109/00016357.2010.51... ^{, 8}8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10.... ^{, 21}21 . Singh A, Purohit B, Sequeira P, Acharya S, Bhat M. Malocclusion and orthodontic treatment need measured by the dental aesthetic index and its association with dental caries in Indian schoolchildren. Community Dent Health . 2011;28(4):313-6. Considering the decreasing rates of dental caries in Brazilian children, ⁸8 . Frazão P, Narvai PC. Socio-environmental factors associated with dental occlusion in adolescents. Am J Orthod Dentofacial Orthop. 2006;129(6):809-16. DOI:10.1016/j.ajodo.2004.10.016
https://doi.org/10.1016/j.ajodo.2004.10.... the loss of first permanent molar may be a marker of social exclusion, characterizing those adolescents living in households with substantially fewer life opportunities.

Young people who reported having had dental treatment showed a 2.5 times higher chance of suffering very severe malocclusion. This association remained significant even after adjusted for skin color and income. Although orthodontic normative needs are relevant at this age, orthodontic care in Brazil is still scarce and only accessible to those from the higher social strata. Consequently, the majority of dental treatment reported in this study may have happened due to general dental treatment. All of these aspects reflect the complex interrelation among socioeconomic and behavioral determinants as well as the access to basic services on malocclusion.

Comparing the prevalence of malocclusion with nation-wide findings from 2003, it can be seen that the magnitude of the problem remains the same, affecting up to one in ten adolescents. This group comprises young people with very severe malocclusion which could lead to psychosocial problems related to appearance and orofacial aesthetics; functional disorders, including muscle pain and temporomandibular, and difficulties with chewing, swallowing and with digestion and pronunciation; moreover this group has greater susceptibility to dental trauma, periodontal disease, and dental caries. ¹³13 . Narvai PC, Frazão P. Saúde bucal coletiva. In: Luiz RR, Costa AJL, Nadanovsky P. Epidemiologia e bioestatística em Odontologia. São Paulo: Atheneu; 2008. p21-48. ^{, 15}15 . Peres KG, Barros AJD, Anselmi L, Peres MA, Barros FC. Does malocclusion influence the adolescent’s satisfaction with appearance? A cross-sectional study nested in a Brazilian birth cohort. Community Dent Oral Epidemiol . 2008;36(2):137-43. DOI:10.1111/j.1600-0528.2007.00382.x
https://doi.org/10.1111/j.1600-0528.2007... The estimated population of Brazilian adolescents aged 12 to 19 years old, in 2010, accounts for nearly 2.7 million people, with higher prevalence among those on lower monthly incomes, those with brown and black skin and those who had lost at least one permanent molar.

Consequently, public health policy that provides free of charge specialized services specialists may improve adolescents’ quality of life. A significant implication is that, without a public health policy which provides public services with specialists and with suitable working conditions, these young people face difficulties in socializing, with serious consequences for their quality of life and their opportunities.

The provision of specialist services through the Brazilian public health-care system was structured in 2004, with the creation of specialist centers within the National Oral Health Care Policy. However, it was only from the end of 2010 (Brasil, 2010 – Portaria SAS 2010) that orthodontic treatment was included as a Sistema Único de Saúde (SUS, Brazilian Health System) procedure. ^bbMinistério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Coordenação Geral de Saúde Bucal. Nota Técnica: Portaria 718/SAS. Brasília (DF); 2010 [citado 2010 mai 12]. Disponível em: http://189.28.128.100/dab/docs/geral/nota_portaria718_sas4.pdf Up until February 2012, the SUS outpatients’ information system recorded 8,810 orthodontic appliances, 3,978 of these in the age group between 10 and 14 years old and 2,051 in the age group between 15 and 19 years old.

There is gap in the provision of specialized services along with regional inequalities. The North region has 8% of the Brazilian population and corresponds to nearly 2% of the procedures; the Northeast, with 27.8% of the population, had 1,527 procedures (17%) while 53% of all orthodontic procedures were carried out in the Southeast, where 42% of Brazilians live.

From a public health policy perspective, epidemiological data provided by this study may inform policy makers when allocating both distribution and provision of resources and in choosing priorities for orthodontic treatment aiming to achieve the principle of equity in oral health care.

References

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History