ABSTRACT

OBJECTIVE

To evaluate the factors associated with tooth loss in adults from the position and number of teeth lost in the dental arches.

METHODS

This is a cross-sectional, population-based study with adults participating in the epidemiological survey of oral health of São Paulo in 2015. The outcome of the study was tooth loss, assessed by the proposed classification, namely: I) lost up to 12 back teeth; II) lost up to 12 teeth (including front teeth); and III) lost more than 12 teeth. A four-block analysis was conducted, supported by a conceptual theoretical model adapted for tooth loss. For the multinomial logistic regression, “individuals who did not lose teeth due to caries or periodontal disease” was used as reference (p < 0.05).

RESULTS

Of 6,051 adults evaluated, 25.3% (n = 1,530) were classified in category I, 32.7% (n = 1,977) in II, 9.4% (n = 568) in III, and 1.9% (n = 117) were edentulous. Lower income and schooling, the perception of need for treatment and the last appointment motivated by routine, pain or extraction were associated with tooth loss, regardless of the classification. The negative evaluation of the dental service was associated with individuals who lost up to 12 teeth, both front and back. The presence of women and periodontal pocket were associated with tooth loss of up to 12 teeth, including front, and more than 12 teeth. Caries were associated with adults who lost up to 12 teeth, including front teeth.

CONCLUSION

The proposed classification allowed the identification of differences between the associated factors. Thus, the need to consider such classification in future studies is evident.

Adult; Tooth Loss, epidemiology; Risk Factors; Oral Health Surveys

INTRODUCTION

In 2010, oral problems affected 3.9 billion people worldwide, with tooth loss being one of the 100 conditions that most affected the health of the world’s population in the last two decades. Tooth loss is the 36th most prevalent condition in the world, also being a public health problem¹1. Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, et al. Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res. 2013;92(7):592-7. https://doi.org/10.1177/0022034513490168
https://doi.org/10.1177/0022034513490168... .

Given this context, tooth loss is an important marker of oral health due to representing the lack of care in the dental field, resulting from the increase in the severity level of the disease, the model of oral health care adopted, and the way individuals understand the disease²2. Roncalli AG, Barbato PR, Resende CMBM. Perdas dentárias. In: Antunes JLF, Peres MA, organizadores. Epidemiologia da saúde bucal. 2. ed. São Paulo: Editora Santos; 2013. p 335-53.; thus, this condition tends to accumulate in the age range of adults³3. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJL, Marcenes W. Global burden of severe tooth loss: a systematic review and meta-analysis. J Dent Res. 2014;93 (7 Suppl):20S-28S. https://doi.org/10.1177/0022034514537828
https://doi.org/10.1177/0022034514537828... .

National surveys conducted in Brazil in 1986, 2003 and 2010 showed that the index of decayed, missing and filled teeth (DMFT) in adults was 22.5, 20.1 and 16.3, respectively, while the missing component was responsible for 65.4%, 65.7 % and 43.8% of occurrences⁴4. Nascimento S, Frazão P, Bousquat A, Antunes JLF. Condições dentárias entre adultos brasileiros de 1986 a 2010. Rev Saude Publica. 2013;47 Supl 3:69-77. https://doi.org/10.1590/S0034-8910.2013047004288
https://doi.org/10.1590/S0034-8910.20130... . The reduction of tooth loss in Brazilian adults in the last decade possibly indicates a combination of the reduction in the cohort effect of oral diseases⁵5. Silva-Junior MF, Batista MJ, Sousa MLR. Risk factors for tooth loss in adults: A population-based prospective cohort study. Plos One. 2019; 14(7): e0219240. https://doi.org/10.1371/journal.pone.0219240
https://doi.org/10.1371/journal.pone.021... and the improvement in socioeconomic conditions – especially education – and in the health system, such as exposure to fluoridation of water and use of fluoride dentifrices⁴4. Nascimento S, Frazão P, Bousquat A, Antunes JLF. Condições dentárias entre adultos brasileiros de 1986 a 2010. Rev Saude Publica. 2013;47 Supl 3:69-77. https://doi.org/10.1590/S0034-8910.2013047004288
https://doi.org/10.1590/S0034-8910.20130... ,⁶6. Peres MA, Barbato PR, Reis SCGB, Freitas CHSM, Antunes JLF. Tooth loss in Brazil: analysis of the 2010 Brazilian Oral Health Survey. Rev Saude Publica. 2013;47(3):78-89. https://doi.org/10.1590/S0034-8910.2013047004226
https://doi.org/10.1590/S0034-8910.20130... , and the impact of the Brazilian Oral Health Policy, mainly due to the growth in the access to health services offered in the country.

The need for deeper studies on tooth loss becomes evident, not only considering the number⁷7. Khazaei S, Keshteli AH, Feizi A, Savabi O, Adibi P. Epidemiology and risk factors of tooth loss among Iranian adults: findings from a large community-based study. Biomed Res Int. 2013;2013:786462. https://doi.org/10.1155/2013/786462
https://doi.org/10.1155/2013/786462... but also the position that lost teeth occupy in the dental arch⁸8. Batista MJ, Lawrence HP, Sousa MLR. Classificação das perdas dentárias: fatores associados a uma nova medida em uma população de adultos. Cienc Saude Coletiva. 2015;20(9):2825-35. https://doi.org/10.1590/1413-81232015209.17322014
https://doi.org/10.1590/1413-81232015209... . Individual social, economic and demographic characteristics are consistently associated with tooth loss in the literature⁶6. Peres MA, Barbato PR, Reis SCGB, Freitas CHSM, Antunes JLF. Tooth loss in Brazil: analysis of the 2010 Brazilian Oral Health Survey. Rev Saude Publica. 2013;47(3):78-89. https://doi.org/10.1590/S0034-8910.2013047004226
https://doi.org/10.1590/S0034-8910.20130... . According to Batista et al.⁸8. Batista MJ, Lawrence HP, Sousa MLR. Classificação das perdas dentárias: fatores associados a uma nova medida em uma população de adultos. Cienc Saude Coletiva. 2015;20(9):2825-35. https://doi.org/10.1590/1413-81232015209.17322014
https://doi.org/10.1590/1413-81232015209... , older age and low social class were factors related to tooth loss; however, the use of categories of the new classification – which considers the position and number of lost teeth – allowed the identification of clinical conditions and behavioral factors such as the use of dental service and periodontal disease.

Such an understanding gains important projections when considering that the production of this information should guide the organization of health services and identify the factors that generate demands. This study, based on a new classification for tooth loss, aims to evaluate such losses considering the position and number of teeth lost in the dental arches and its associated factors in the adult population of the state of São Paulo.

METHODS

Study Design

This is a population-based and cross-sectional study with representativeness for six regions of the state of São Paulo (capital, metropolitan region and regional health departments II to XVII). Data for this study were taken from the 2015 epidemiological survey of oral health of the state of São Paulo (SBSP 2015)⁹9. Pereira AC, Vieira V. Pesquisa estadual de saúde bucal 2015: relatório final. Águas de São Pedro, SP: Livronovo; 2016..

Ethical Aspects

This study was approved by the Research Ethics Committee of the School of Dentistry at Piracicaba from Universidade Estadual de Campinas (CEP-FOP/Unicamp), under no. 094/2015.

Sample

The design of the sampling plan was prepared by conglomerate in two stages of drawing with probability proportional to population size (PPS), considering the sample weight and the design effect (deff) in each drawing stage. In the first stage, the state of São Paulo was stratified in six macroregions, the domains. For each domain, 33 municipalities were drawn and named primary sampling units; except for macroregion 1 (metropolitan region of the capital), for which 12 municipalities were drawn, in addition to the capital. In the second stage, two census tracts (census sampling unit) were drawn in each drawn municipality, also respecting the PPS on the tracts.

The sample size was defined based on frequency estimation, the variability to be investigated, and the acceptable margin of error. All these estimates come from the results of the Pesquisa Nacional de Saúde Bucal de 2010 (SB Brasil 2010 – 2010 Brazilian Oral Health Survey)¹⁰10. Ministério da Saúde, Secretaria de Atenção à Saúde, Secretaria de Vigilância em Saúde. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal. Brasília, DF; 2012. for the city of São Paulo (macroregion 1 – capital and metropolitan region) and countryside of the Southeast region (macroregions 2 to 6).

Considering the differences in oral health conditions in different age groups, the sample size was estimated for adults between 35 and 44 years old. The deff adopted was 2.0, with 8% margin of error and 95% confidence interval. The sample size for the age group between 35 and 44 years was 6,051.

Data Collection

Clinical oral examinations were performed in the households visited, as advocated by the World Health Organization (WHO), with buccal plane mirrors, CPI probes and natural lighting, without previous drying or any type of prophylaxis procedure¹¹11. World Health Organization. Basic methods. 4.ed. Geneva: WHO; 1997.. The minimum acceptable kappa value for each examiner, age group, and disease studied was 0.65¹²12. Ministério da Saúde. Cadastro e repasse de recursos para os Laboratórios Regionais de Prótese Dentária: Nota técnica. Brasília, DF: 2011.. The mean kappa value for periodontal disease was 0.76⁹9. Pereira AC, Vieira V. Pesquisa estadual de saúde bucal 2015: relatório final. Águas de São Pedro, SP: Livronovo; 2016., and for dental caries above 0.85.

Coronary dental caries, need for treatment, and periodontal condition were investigated as clinical conditions of oral health¹¹11. World Health Organization. Basic methods. 4.ed. Geneva: WHO; 1997.. DMFT was used to evaluate the caries experience, resulting from the sum of the teeth affected by caries, missing and filled. The community periodontal index (CPI) was used to measure the presence of periodontal pockets.

Each volunteer responded to a questionnaire on demographics, socioeconomic factors and use of dental services. The SBSP 2015 questionnaire was answered via an interview at the time of the home examination.

Variables

The dependent variable was classified into four categories based on the number of lost teeth and the position they occupied in the mouth, according to the classification of Batista et al.⁸8. Batista MJ, Lawrence HP, Sousa MLR. Classificação das perdas dentárias: fatores associados a uma nova medida em uma população de adultos. Cienc Saude Coletiva. 2015;20(9):2825-35. https://doi.org/10.1590/1413-81232015209.17322014
https://doi.org/10.1590/1413-81232015209... : no tooth lost due to caries or periodontal disease; lost up to 12 back teeth; lost up to 12 teeth (including front teeth); and lost more than 12 teeth.

The independent variables measured were related to baseline data and divided into four blocks (Figure 1). The first block comprised one exogenous variable, age in years. In the second block, the main determinants of oral health were the type of dental service (public, private or insurance), evaluation of the service (good or not good), sex (female or male), family income (< R$ 1,500.00, R$ 1,500, 00–2,500, 00 or >R$ 2,500.00) and educational level (≤ 4 years, 5–10 years or ≥ 11 years of schooling), number of people living in the same household (≤ 3 people or ≥ 4 people) and need for treatment (yes or no). In the third block, on oral health behaviors, the use of dental service was evaluated as the time since the last visit to the dentist (< 1 year, 1–2 years or ≥ 3 years), and the reason for seeking dental services (routine, necessity, extraction, or pain). In the fourth block, the following oral health results were measured: decayed teeth (yes or no), periodontal pocket (< 4 mm or ≥ 4 mm) and toothache (yes or no).

Data Analysis

The programs used to tabulate the data were the Statistical Package for the Social Sciences (SPSS), version 20.0, and Excel^® (Microsoft Office). Absolute and percentage distribution, mean and standard deviation (SD) of the variables were obtained by descriptive analysis, in which the conditions of tooth loss were categorized according to the position and number of lost teeth.

Initially, bivariate analysis was conducted between the outcome (tooth loss) and the independent variables. The variables with p < 0.20 were used in the analysis, divided into four blocks, following the theoretical conceptual model “Aging, Ethnicity and Oral Health Outcomes” proposed by Andersen & Davidson¹³13. Andersen RM, Davidson PL. Ethnicity, aging, and oral health outcomes: a conceptual framework. Adv Dent Res 1997;11(2):203-9. https://doi.org/10.1177/08959374970110020201
https://doi.org/10.1177/0895937497011002... and adapted for tooth loss by Batista et al.¹⁴14. Batista MJ, Lawrence HP, Sousa MLR, Impact of tooth loss related to number and position on oral health quality of life among adults. Health Qual Live Outcomes. 2014;12:165. https://doi.org/10.1186/s12955-014-0165-5
https://doi.org/10.1186/s12955-014-0165-... ,⁸8. Batista MJ, Lawrence HP, Sousa MLR. Classificação das perdas dentárias: fatores associados a uma nova medida em uma população de adultos. Cienc Saude Coletiva. 2015;20(9):2825-35. https://doi.org/10.1590/1413-81232015209.17322014
https://doi.org/10.1590/1413-81232015209... (Figure 1).

The variables were adjusted in each block, in which they were chosen to adjust the subsequent block (p < 0.20). The reference category of the analysis to perform the multinomial logistic regression (p < 0.05) were individuals who had not lost any teeth due to the presence of caries or periodontal disease.

RESULTS

In total, 6,051 adults aged between 35 to 44 years were examined, representing the adult population living in the state of São Paulo. Table 1 shows the sample’s demographic and socioeconomic characteristics. Most of them were women, with family income lower than R$ 1,500.00, with nine or more years of schooling, and living with more than four people. The mean DMFT was 15.84 (SD = 16.29) teeth with caries experience, 1.53 (SD = 1.74) decayed teeth, 6.30 (SD = 6.79) missing teeth, and 7.46 (SD = 7.87) filled teeth.

The percentage of adults who had not lost any teeth due to oral diseases was 24.8% (1,500). Table 2 describes the frequency of tooth loss according to the proposed classification. A total of 5.9% (n = 359) of the adults examined presented loss of 1 to 4 first molars, 25.3% (n = 1,530) lost up to 12 back teeth, 32.7% (n = 1,977) lost up to 12 teeth, including one or more front teeth, 9.4% (n = 568) lost from 13 to 31 teeth, and 1.9% (n = 117) were edentulous.

Table 3 shows the results of the bivariate analyses and the crude odds ratio for the new classification of tooth loss. Table 4 presents the adjusted data according to the classification of tooth loss. The loss of up to 12 front teeth was associated with women (OR = 1.11; 95%CI 0.94–1.31), income lower than R$ 1,500.00 (OR = 1.39; 95%CI 1.13–1.71) and between R$ 1,500.00 and 2,500.00 (OR = 1.78; 95%CI 1.46–2.17), schooling between 5 and 9 years of study (OR = 1.39; 95%CI 1.14–1.70) and demand for service motivated by routine (OR = 1.30; 95%CI 1.08–1.56), pain (OR = 2.04; 95%CI 1.43–2.90) and for tooth extraction (OR = 1.37; 95%CI 1.07 – 1.75). For those who lost up to 12 teeth, including front ones, the associated factors were women (OR = 1.19; 95%CI 1.00–1.42), income lower than R$ 1,500.00 (OR = 1.65; 95%CI 1.33–2.05) and between R$ 1,500.00 and 2,500.00 (OR = 1.82; 95%CI 1.47–2.25), schooling less than 5 years (OR = 2.2; 95%CI 1.68–2.90) and between 5 and 9 years (OR = 2.01; 95%CI 1.65–2.45), and positive perception about the need for treatment (OR = 1.95; 95%CI 1.57–2.43), in addition to demand for service motivated by routine (OR = 1.83; 95%CI 1.50–2.24), pain (OR = 3.49; 95%CI 2.46–4.97) and for tooth extraction (OR = 1.97; 95%CI 1.53–2.55). For those who lost more than 12 teeth, women (OR = 1.42; 95%CI 1.09–1.86), income lower than R$ 1,500.00 (OR = 1.63; 95%CI 1.13–2.33) and between R$ 1,500.00 and 2,500.00 (OR = 1.97; 95%CI 1.37–2.83), schooling less than 5 years (OR = 7.19; 95%CI 5.02–10.32) and between 5 and 9 years (OR = 4.71; 95%CI 3.49–6.37) and demand for service motivated by routine (OR = 4.09; 95%CI 2.70–6.17), pain (OR = 11.79; 95%CI 7.02–19.80) and tooth extraction (OR = 3.60; 95%CI 2.25–5.77).

DISCUSSION

In this study, lower income and schooling, the perception of the need for treatment, and last appointment motivated by routine, pain or extraction were associated with tooth loss, regardless of the classification. The negative evaluation of the dental service was associated with individuals who lost up to 12 teeth, both front and back. The presence of women and periodontal pocket were associated with tooth loss of up to 12 teeth, including front, and of more than 12 teeth. Caries were associated only with individuals who lost up to 12 teeth, including front ones.

The literature presents studies that numerically assess tooth loss using the presence of 20 teeth or more as the cutoff base⁷7. Khazaei S, Keshteli AH, Feizi A, Savabi O, Adibi P. Epidemiology and risk factors of tooth loss among Iranian adults: findings from a large community-based study. Biomed Res Int. 2013;2013:786462. https://doi.org/10.1155/2013/786462
https://doi.org/10.1155/2013/786462... . We verified that the use of the classification of tooth loss proposed by Batista et al.⁸8. Batista MJ, Lawrence HP, Sousa MLR. Classificação das perdas dentárias: fatores associados a uma nova medida em uma população de adultos. Cienc Saude Coletiva. 2015;20(9):2825-35. https://doi.org/10.1590/1413-81232015209.17322014
https://doi.org/10.1590/1413-81232015209... was able to measure associated factors more specifically according to the number and position of teeth in the dental arch. This classification is based on the reduced dental arch theory, which considers as satisfactory the presence of ten pairs of occlusive teeth without aesthetic gaps¹⁵15. Armellini D, Fraunhofer JA. The shortened dental arch: a review of the literature. J Prosthetic Dent. 2002;92(6):531-5. https://doi.org/10.1016/j.prosdent.2004.08.013
https://doi.org/10.1016/j.prosdent.2004.... and considers losses due to dental caries and periodontal disease, excluding teeth deemed to be absent congenitally or due to orthodontic reasons, which was already a WHO criterion¹¹11. World Health Organization. Basic methods. 4.ed. Geneva: WHO; 1997.. Clinically, the incorporation of teeth lost due to periodontal disease by this new classification allows the identification of the aesthetic and functional issue, which are also important for the planning of the oral rehabilitation of patients. Moreover, a previous study identified that the position and number of lost teeth have different affects the quality of life of adults⁷7. Khazaei S, Keshteli AH, Feizi A, Savabi O, Adibi P. Epidemiology and risk factors of tooth loss among Iranian adults: findings from a large community-based study. Biomed Res Int. 2013;2013:786462. https://doi.org/10.1155/2013/786462
https://doi.org/10.1155/2013/786462... .

Several studies have associated tooth loss with lower income and schooling¹⁶16. Barbato PR, Nagano HCM, Zanchet FN, Boing AF, Peres MA. Perdas dentárias e fatores sociais, demográficos e de serviços associados em adultos brasileiros: uma análise dos dados do Estudo Epidemiológico Nacional (Projeto SB Brasil 2002-2003). Cad Saude Publica. 2007;23(8):1803-14. https://doi.org/10.1590/S0102-311X2007000800007
https://doi.org/10.1590/S0102-311X200700... ,¹⁷17. Barbato PR, Peres MA. Perdas dentárias em adolescentes brasileiros e fatores associados: estudo de base populacional. Rev Saude Publica. 2009;43(1):13-25. https://doi.org/10.1590/S0034-89102009000100003
https://doi.org/10.1590/S0034-8910200900... ,¹⁸18. Frazão P, Antunes JLF, Narvai PC. Perda dentária precoce em adultos de 35 a 44 anos de idade: estado de São Paulo, Brasil, 1998. Rev Bras Epidemiol. 2003;6(1):49-57. https://doi.org/10.1590/S1415-790X2003000100007
https://doi.org/10.1590/S1415-790X200300... ,⁶6. Peres MA, Barbato PR, Reis SCGB, Freitas CHSM, Antunes JLF. Tooth loss in Brazil: analysis of the 2010 Brazilian Oral Health Survey. Rev Saude Publica. 2013;47(3):78-89. https://doi.org/10.1590/S0034-8910.2013047004226
https://doi.org/10.1590/S0034-8910.20130... ,¹⁹19. Seerig LM, Nascimento GG, Peres MA, Horta BL, Demarco FF. Tooth loss in adults and income: systematic review and meta-analysis. J Dent. 2015;43(9):1051-9. https://doi.org/10.1016/j.jdent.2015.07.004
https://doi.org/10.1016/j.jdent.2015.07.... . This can be explained by the fact that poorer and less educated individuals live in places with lower coverage of fluoridation of water²⁰20. Peres MA, Antunes JLF, Peres KG. Is water fluoridation effective in reducing inequalities in dental caries distribution in developing countries? Recent findings from Brazil. Soz Preventivmed. 2006;51(5):302-10. https://doi.org/10.1007/s00038-006-5057-y
https://doi.org/10.1007/s00038-006-5057-... , have impaired access to dental services²¹21. Fernandes LS, Peres MA. Associação entre atenção básica em saúde bucal e indicadores socioeconômicos municipais. Rev Saude Publica. 2005;39(6):930-6. https://doi.org/10.1590/S0034-89102005000600010
https://doi.org/10.1590/S0034-8910200500... ,⁴4. Nascimento S, Frazão P, Bousquat A, Antunes JLF. Condições dentárias entre adultos brasileiros de 1986 a 2010. Rev Saude Publica. 2013;47 Supl 3:69-77. https://doi.org/10.1590/S0034-8910.2013047004288
https://doi.org/10.1590/S0034-8910.20130... and hygiene products⁴4. Nascimento S, Frazão P, Bousquat A, Antunes JLF. Condições dentárias entre adultos brasileiros de 1986 a 2010. Rev Saude Publica. 2013;47 Supl 3:69-77. https://doi.org/10.1590/S0034-8910.2013047004288
https://doi.org/10.1590/S0034-8910.20130... , and practice inappropriate habits such as consuming more sugar²²22. Hobdell MH, Myburgh NG, Kelman M, Hausen H. Setting global goals for oral health for the year 2010. Int Dent J. 2000;50(5): 245-9. https://doi.org/10.1111/j.1875-595X.2000.tb00560.x
https://doi.org/10.1111/j.1875-595X.2000... and brushing the teeth less frequently²³23. Abegg C. Hábitos de higiene bucal de adultos porto-alegrenses. Rev Saude Publica. 1997;31(6):586-93. https://doi.org/10.1590/S0034-89101997000700007
https://doi.org/10.1590/S0034-8910199700... .

Data from the National Household Sample Survey (PNAD) showed that individuals with higher schooling present higher frequency in dental appointments: 67.4% among those with complete higher education and 36.6% among individuals without any schooling or with incomplete elementary education²⁴24. Instituto Brasileiro de Geografia e Estatística. Síntese de Indicadores Sociais: uma análise das condições de vida da população brasileira 2010. Rio de janeiro: IBGE; 2014 [citado junho de 2018]. Available from: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/indicadoresminimos/sinteseindicsociais2010/
http://www.ibge.gov.br/home/estatistica/... . For Chrysanthakopoulos²⁵25. Chrysanthakopoulos NA. Risk factors for the progression of periodontal disease in a Greek adult population. J Investig Clin Dent. 2017;8(2):e12199. https://doi.org/10.1111/jicd.12199
https://doi.org/10.1111/jicd.12199... , schooling also has affected the self-perception of individuals about the state of their oral health condition and the assessment of the need for dental treatment. In this study, an association was found between higher schooling level and lower number of lost teeth; however, the perception of the need for treatment was also associated with tooth loss, regardless of the classification. The study by Santillo et al.²⁶26. Santillo PMH, Gusmão ES, Moura C, Soares RSC, Cimões R. Fatores associados às perdas dentárias entre adultos em áreas rurais do estado de Pernambuco, Brasil. Cienc Saude Coletiva. 2014;19(2):581-90. https://doi.org/10.1590/1413-81232014192.20752012
https://doi.org/10.1590/1413-81232014192... in a rural population of Pernambuco (PE) found a relationship between tooth loss and self-perceived negative oral health. These results indicate that the dentistry model still has a mutilation character and that the perception of the need for treatment occurs only in advanced stages of oral diseases, thus determining the late search for dental services²⁷27. Silva-Junior MF, Batista MJ, Sousa MLR. Incidence of tooth loss in adults: a 4-year population-based prospective cohort study. Int J Dent. 2017:2017:6074703. https://doi.org/10.1155/2017/6074703
https://doi.org/10.1155/2017/6074703... ,²⁸28. Silva-Junior MF, Souza ACC, Batista MJ, Sousa MLR. Oral health condition and reasons for tooth extraction among an adult population (20-64 years). Cienc Saude Coletiva. 2017;22(8):2693-702. https://doi.org/10.1590/1413-81232017228.22212015
https://doi.org/10.1590/1413-81232017228... .

This idea can be reinforced in this study, in which the last dental appointment motivated by routine, pain or extraction was associated with tooth loss, regardless of the classification. Although the literature relates the demand for dental services due to pain with the prevalence⁸8. Batista MJ, Lawrence HP, Sousa MLR. Classificação das perdas dentárias: fatores associados a uma nova medida em uma população de adultos. Cienc Saude Coletiva. 2015;20(9):2825-35. https://doi.org/10.1590/1413-81232015209.17322014
https://doi.org/10.1590/1413-81232015209... ,²⁹29. Silva DD, Rihs LB, Sousa MLR. Fatores associados à presença de dentes em adultos de São Paulo, Brasil. Cad Saude Publica. 2009;25(11):2407-18. https://doi.org/10.1590/S0102-311X2009001100011
https://doi.org/10.1590/S0102-311X200900... and incidence of tooth loss⁵5. Silva-Junior MF, Batista MJ, Sousa MLR. Risk factors for tooth loss in adults: A population-based prospective cohort study. Plos One. 2019; 14(7): e0219240. https://doi.org/10.1371/journal.pone.0219240
https://doi.org/10.1371/journal.pone.021... , this is probably the first study that also shows association with the search for the service motivated by tooth extraction and routine. This result can be explained by the history of Brazilian oral health care – especially among adults –, which is marked by the restriction of access and high demand⁴4. Nascimento S, Frazão P, Bousquat A, Antunes JLF. Condições dentárias entre adultos brasileiros de 1986 a 2010. Rev Saude Publica. 2013;47 Supl 3:69-77. https://doi.org/10.1590/S0034-8910.2013047004288
https://doi.org/10.1590/S0034-8910.20130... .

Moreover, the late search for oral health services determines the progression of oral diseases, resulting in the need for mutilating procedures and techniques and especially tooth loss⁶6. Peres MA, Barbato PR, Reis SCGB, Freitas CHSM, Antunes JLF. Tooth loss in Brazil: analysis of the 2010 Brazilian Oral Health Survey. Rev Saude Publica. 2013;47(3):78-89. https://doi.org/10.1590/S0034-8910.2013047004226
https://doi.org/10.1590/S0034-8910.20130... ,²⁸28. Silva-Junior MF, Souza ACC, Batista MJ, Sousa MLR. Oral health condition and reasons for tooth extraction among an adult population (20-64 years). Cienc Saude Coletiva. 2017;22(8):2693-702. https://doi.org/10.1590/1413-81232017228.22212015
https://doi.org/10.1590/1413-81232017228... ,³⁰30. Baldani MH, Brito WH, Lawder JAC, Mendes YBE, Silva FFM, Antunes JLF. Determinantes individuais da utilização de serviços odontológicos por adultos e idosos de baixa renda. Rev Bras Epidemiol. 2010;13(1):150-62. https://doi.org/10.1590/S1415-790X2010000100014
https://doi.org/10.1590/S1415-790X201000... . Another relevant aspect is how to turn the search for dental services into a routine for an economically active population. The study by Silva-Junior et al.²⁸28. Silva-Junior MF, Souza ACC, Batista MJ, Sousa MLR. Oral health condition and reasons for tooth extraction among an adult population (20-64 years). Cienc Saude Coletiva. 2017;22(8):2693-702. https://doi.org/10.1590/1413-81232017228.22212015
https://doi.org/10.1590/1413-81232017228... found that the choice for extracting teeth rather than keeping them is mainly due to the absence of another treatment option at the time of appointment, and to the high cost of the procedures necessary to maintain teeth.

Another relevant aspect for our study was the association between the classification of tooth loss and the evaluation of dental services. The evaluation of health services by patients assists in the construction of indicators aiming at the implementation of health strategies of the service, guiding the actions of prevention and promotion³¹31. Gouveia GC, Souza WV, Luna CF, Souza-Junior PRB, Szwarcwald CL. Satisfação dos usuários do sistema de saúde brasileiro: fatores associados e diferenças regionais. Rev Bras Epidemiol. 2009;12(3):281-6. https://doi.org/10.1590/S1415-790X2009000300001
https://doi.org/10.1590/S1415-790X200900... . A study conducted in Bahia found inequality in the use of oral health services even among patients of the public service at different care levels. Those who had lower schooling and who were exposed to a worse service organization did not use the service as often³²32. Soares FF, Chaves SCL, Cangussu MCT. Governo local e serviços odontológicos: análise da desigualdade na utilização. Cad Saude Publica. 2015:31(3);586-96. https://doi.org/10.1590/0102-311x00077214
https://doi.org/10.1590/0102-311x0007721... .

When compared with private supplementary care, the public service presented a profile of vulnerability, although its disorganization does not favor its use. The results reinforce that coping with inequalities in the access and use of public health services is dependent on how the local government plans the project and its ability to reorganize dental care. Therefore, we must think about ways to promote the use and satisfaction with public health services, especially among adults. This economically active age group faces the restriction of the working hours of health units, hindering their access to health care and, consequently, to the management of the initial stages of the main oral diseases.

In this study, association was found between the clinical conditions of oral health, caries and periodontal disease, with tooth loss among individuals who have a greater number of back teeth. From this finding, we can infer that the presence of back teeth increases the occurrence of caries and periodontal disease, which would explain the maintenance of this association even in the final adjusted model. Back teeth are the most affected by oral diseases⁵5. Silva-Junior MF, Batista MJ, Sousa MLR. Risk factors for tooth loss in adults: A population-based prospective cohort study. Plos One. 2019; 14(7): e0219240. https://doi.org/10.1371/journal.pone.0219240
https://doi.org/10.1371/journal.pone.021... , mainly due to the lack of knowledge of the presence of permanent teeth still in childhood and for being in non-aesthetic areas, making it difficult to visualize the need for treatment in the absence of painful symptomatology and delaying the demand for dental service for treatment.

This can be evidenced in our study since the variable of self-perception of the need for treatment was associated with the three tooth loss categories. Individuals who lost up to 12 teeth, including front ones, and thus still maintain back teeth, were associated with the presence of caries and periodontal pocket, and for losses of more than 12 teeth, only to periodontal pocket. The study by Batista et al.⁸8. Batista MJ, Lawrence HP, Sousa MLR. Classificação das perdas dentárias: fatores associados a uma nova medida em uma população de adultos. Cienc Saude Coletiva. 2015;20(9):2825-35. https://doi.org/10.1590/1413-81232015209.17322014
https://doi.org/10.1590/1413-81232015209... also found an association between individuals who lost 12 teeth, including front ones, with periodontal pocket. Therefore, studies that consider the position of the lost teeth can infer more reliably the association of variables for tooth loss.

Dannewitz et al.³³33. Dannewitz B, Zeidler A, Hüsing J, Saure D, Pfefferle T, Eickholz P, et al. Loss of molars in periodontally treated patients: results ten years and more after active periodontal therapy. J Clin Periodontol. 2016;43(1):53-62. https://doi.org/10.1111/jcpe.12488
https://doi.org/10.1111/jcpe.12488... showed that access to periodontal therapy results in a good prognosis of molars. According to the results shown in our study, the presence of periodontal pocket was not associated with participants who already lost back teeth. The scarcity of access to specialized services to perform periodontal treatment can contribute to the large number of tooth losses, mainly of the molars. Despite the launch, in 2004, of the current Brazilian Oral Health Policy and the consequent expansion of the supply of specialized dental services, the number of periodontal and endodontic procedures did not increase in all studied municipalities. Several possibilities and justifications can explain this, such as the availability of the workforce and their geographic distribution, the ease or not of access to dental services, the characteristics of the service administration, or the organization of the care network and of the work process³⁴34. Chaves SCL, Cruz DN, Barros SG, Figueiredo AL. Avaliação da oferta e utilização de especialidades odontológicas em serviços públicos de atenção secundária na Bahia, Brasil. Cad Saude Publica. 2011;27(1):143-54. https://doi.org/10.1590/S0102-311X2011000100015
https://doi.org/10.1590/S0102-311X201100... . We must stress that the policy is still recent, especially the secondary care actions.

In this study, the main component identified in the caries experience of adults was ‘restored teeth.’ This datum was also verified in the last national oral health survey for the south and southeast regions of the country, both of which present better socioeconomic conditions and may reflect in a better case management in the early stages of dental caries and incorporation of less invasive treatments⁴4. Nascimento S, Frazão P, Bousquat A, Antunes JLF. Condições dentárias entre adultos brasileiros de 1986 a 2010. Rev Saude Publica. 2013;47 Supl 3:69-77. https://doi.org/10.1590/S0034-8910.2013047004288
https://doi.org/10.1590/S0034-8910.20130... , as well as in the impact of the insertion and expansion of the Brazilian Oral Health Policy. The diagnosis of oral health conditions and of the population’s treatment needs, and the evaluation of the current health care model, is crucial as a first step towards the scheduling and planning in oral health, enabling the establishment of priorities for action and resource allocation to improve the health conditions of the population³⁵35. Jaccottet CMG, Barros AJD, Camargo MBJ, Cascaes AM. Avaliação das necessidades de tratamento odontológico e da capacidade produtiva da rede de atenção básica em saúde bucal no município de Pelotas, estado do Rio Grande do Sul, Brasil, 2009. Epidemiol Serv Saude. 2012;21(2);333-40. https://doi.org/10.5123/S1679-49742012000200016
https://doi.org/10.5123/S1679-4974201200... .

The limitations of the study are in its cross-sectional nature, with exposure and outcome evaluated at a single moment in time, and in the possibility of prevalence bias; the greater participation of women given that it was a household survey with adults is another limitation. Moreover, the questionnaire included past experiences of dental care, which depend on the individual’s memory for accuracy.

The categories of the new tooth loss classification, considering the position and number of lost teeth, allowed different associated factors to be identified. The results of our study indicate an evident need to consider a qualitative and quantitative assessment of tooth loss, so such an occurrence is not underestimated. This is a fundamental observation to be considered in future studies, including to subsidize decision making in the supply and organization of dental services.

REFERÊNCIAS

Publication Dates

History