REVISTA
PAULISTA
DE
PEDIATRIA
www.rpped.com.br
ORIGINAL
ARTICLE
Dental
pain
and
associated
factors
in
Brazilian
preschoolers
João
Gabriel
Silva
Souza
a,∗,
Andrea
Maria
Eleutério
de
Barros
Lima
Martins
baDepartamentodeCiênciasFisiológicas,FaculdadedeOdontologiadePiracicaba,UniversidadeEstadualdeCampinas,
Piracicaba,SP,Brazil
bDepartamentodeOdontologia,UniversidadeEstadualdeMontesClaros,MontesClaros,MG,Brazil
Received17August2015;accepted2December2015 Availableonline3June2016
KEYWORDS
Pain; Child; Toothdecay; Oralhealth
Abstract
Objective: TodescribetheprevalenceofdentalpaininBrazilianpreschoolers,aswellasits
associatedfactors,consideringarepresentativesampleofthatpopulationgroupinBrazil.
Methods: Cross-sectional studythat usedthe analyticaldata fromnational oral health
sur-vey(SBBrazil)carriedoutin2010.ArepresentativesampleofBrazilianpreschoolersaged5 yearswas considered.Interviewswerecarried out(answeredbyparents/tutors),aswellas clinicalexaminationsinchildren.Descriptive,bivariateandmutipleanalyzeswereperformed, describedinoddsratiosand95%confidenceinterval(OR/95%CI).
Results: 7280preschoolerswereincluded.Ofthese,1520(21.1%)haddentalpaininthelast6
months.Thechanceoftheoccurrenceofdentalpainwashigheramongthosewhouseddental services(1.51/1.02---2.23),withtoothdecay(3.08/2.08---4.56),thatself-perceveidtheneedfor dental treatment(3.96/2.48---6.34),whose parentsreporteddissatisfactionbychildren with theirteethandmouth(1.47/1.04---2.10)andthosewhoreportedimpactoforalproblemson qualityoflife(5.76/3.90---8.49).
Conclusions: TheprevalenceofdentalpainamongBrazilianpreschoolchildrenwasrelatively
high,beingassociatedwiththeuseofdentalservicesandthenormativeandsubjectiveoral healthstatus.
©2016SociedadedePediatriadeS˜aoPaulo.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Dor; Crianc¸a;
Cáriesdentárias; Saúdebucal
Dordentáriaefatoresassociadosempré-escolaresbrasileiros
Resumo
Objetivo: Descreveraprevalênciadadordentáriaem pré-escolaresbrasileiros,assim como
seusfatoresassociados,considerandoumaamostrarepresentativadessecontingente popula-cionalnoBrasil.
∗Correspondingauthor.
E-mail:[email protected](J.G.Souza).
http://dx.doi.org/10.1016/j.rppede.2016.03.002
Métodos: Estudotransversal,analítico,queusouosdadosdoInquéritoNacionaldeSaúdeBucal (SBBrasil)feitoem2010.Considerou-seumaamostrarepresentativadepré-escolarescom5 anos.Foramfeitasentrevistas(respondidaspelosresponsáveis)eexamesclínicosnascrianc¸as. Conduziram-seanálisesdescritivas,bivariadasemúltiplas,descritasemoddsratioeintervalo deconfianc¸ade95%(OR/IC95%).
Resultados: Foramincluídos7.280pré-escolares.Desses,1.520(21,1%)tiveramdordentária
nosúltimos6meses.Achancedaocorrênciadedordentáriafoimaiorentreaquelesqueusaram servic¸os odontológicos(1,51/1,02-2,23),comcárie dentária(3,08/2,08-4,56),perceberam a necessidadedetratamentoodontológico(3,96/2,48-6,34),osqueospaisrelatavaminsatisfac¸ão porpartedascrianc¸ascomseusdentesesuaboca(1,47/1,04-2,10)eosquerelataramimpacto dosproblemasbucaisnaqualidadedevida(5,76/3,90-8,49).
Conclusões: Aprevalênciadadordentáriaentrepré-escolaresbrasileirosfoirelativamentealta
eassociadaaousodeservic¸osodontológicoseàscondic¸õesnormativasesubjetivasdesaúde bucal.
©2016SociedadedePediatriadeS˜aoPaulo. PublicadoporElsevier EditoraLtda.Este ´eum artigoOpenAccesssobumalicenc¸aCCBY(http://creativecommons.org/licenses/by/4.0/).
Introduction
Dentalpainhasbeenconsideredthemostcommonsymptom orconsequenceofthepresenceoforaldiseases,suchas den-talcariesandgumdisease.1---3TheInternationalAssociation
fortheStudyofPain(IASP)definespainasanunpleasant
sen-soryandemotional experiencecaused bytissuedamage.4
Among the types of orofacial pain, those of dental
ori-ginhavebeen reportedasthemostfrequent,5mayaffect
social interaction, daily activities,6 and may have a
neg-ative impactonquality of life.7,8 It shouldbe noted that
theperceptionofpainmaybeinfluencedbyknowledgeand
beliefsoftheindividuals,aswellasbytheculturalandsocial
environment in which theylive.9,10 Different factorshave
beenassociatedwiththepresenceandperceptionof
den-talpain,suchaslowsocioeconomicstatus,9dentalcaries,11
food-relateddifficulties,andsleepdisorders.6Moreover,its
occurrencehasbeen identifiedasoneofthemain reasons
forseekingdentalcare.2,9
The prevalenceofdentalpainvaries widelyamong
dif-ferent studies and age groups. International studies have
addressed the prevalence of episodes of dental pain and
observedresults rangingfrom9%in Japan12 (11---15years)
to40%indistrictsofManchester,England(upto12years).13
InBrazil,theprevalenceisalsovariable,withratesbetween
11% and 39% (subjects aged 5---60 years).1,5,11,14---16 Among
thepopulationgroupsinvestigatedregardingthisissueare
children,especiallythoseatpre-schoolage.8,15
In Brazil,theoral health statusofpreschoolers is
wor-risome. Despitethe modestimprovement observed in the
lasttwoepidemiologicalpopulation surveys,conductedin
2002/200317 and 2010,18 such as the approximately 6%
increase in the number of children under 5 years freeof
caries, this population group is still affected by a high
prevalence of oral diseases, such as dental caries and
malocclusion.18 Thismayresultinhighprevalenceof
den-talpainand,consequently,anegativeimpactontheirdaily
life.
However, population-based studies with a
representa-tivesampleofBrazilianpreschoolersaddressingdentalpain
are scarce. Therefore, this study aimed to describe the
prevalenceofdentalpaininBrazilian preschoolersandits
associatedfactors.
Method
Thiswasacross-sectionalstudythatusedthedatabaseof theNational SurveyonOral HealthConditions (SBBrasil), conducted by the Brazilian Ministry of Health in 2010.18
FollowingthecriteriaproposedbytheWorldHealth
Organi-zationin1997,19arepresentativesampleofthepopulation
intheindexage rangeswasinterviewedandexamined at
theirhomesregardingtheiroral health,demographic,and
socioeconomicdata,aswellasuse ofdentalservicesand
subjectiveissuesoforal health.Thisstudy consideredthe
sampleof preschoolchildren, which inthe SBBrazil 2010
includedonlychildrenaged5years.
Residentsof 177cities were interviewedandassessed,
includingthe 27 capitals of the five geographical regions
(North,Northeast, Mid-West, Southeast,and South).
Sub-jects were selected by multi-stage probability cluster
sampling,withprobabilityproportionaltosizeand
consid-eringadesigneffect(deff)equalto2.The30municipalities
ineachregionandthe30censussectorsforcapitalsandthe
FederalDistrictweredrawnbythetechniqueofprobability
proportionaltosize.20
The testsandinterviewswereperformed bypreviously
traineddentistsandcalibratedbytheconsensustechnique;
the minimum acceptable kappa value for each examiner,
agegroup,andstudiedinjurywas0.65.Interviewswere
con-ductedwiththeaidofahandheldcomputer(PersonalDigital
Assistant).20
Inthepresentstudy,adatabaseslicewasused;the
anal-ysisincluded thepreschoolerswhoanswered thequestion
aboutthepresenceofdentalpain.
The dependent variable--- dental pain --- was assessed
by the question: ‘‘in the last six months, did you have
toothache?’’(No/Yes).Sincethiswasasampleof5-year-old
Therefore,thepresenceofdentalpaininpreschoolerswas
characterizedbytheanswer‘‘yes’’.
The independent variables were combined into three
groups: sociodemographicconditions,healthcareservices,
andhealthoutcomes(normativeandsubjective conditions
oforal health).The assessedsociodemographic conditions
weresex,self-reportedethnicity,familyincome,and
Brazil-ianregion.Regardinghealthcareservices,theuseofdental
careservicesthroughout life wasconsidered. Itshouldbe
notedthatsuchuse,whichwasdefinedashavingusedthe
service atleast onceduring thelifetime,is not
necessar-ilyrelatedtohealthoutcomesortheoccurrenceofdental
pain.Regardinghealthoutcomes,thenormativeoralhealth
conditionassessedwasthepresenceofcaries.This
assess-ment wasbased on thedecayed component of the DMFT
index,whichcounts thenumberof decayed,missing,and
filledteeth.18,19Regardingthesubjectiveconditionsoforal
health,theself-perceivedneedfortreatment,satisfaction
withteeth and mouth, and the impact of oral health on
qualityof lifewere assessed.Due tothe ageof patients,
thesedatawereansweredbytheir parents/guardian.This
impactwas measured by the instrument Oral Impacts on
DailyPerformance(OIDP),whichassessestheimpactoforal
conditionsontheindividual’sabilitytoperformtheirdaily
activities.21,22 The present study considered as impacted
thosepreschoolers forwhominvolvementwasreportedin
atleastoneofthenineitemsthatcomposetheinstrument.
Therefore,thedichotomizedOIDPscore(Yes/No)wasused.
For data analysis, SPSS Statistics 18.0 software (SPSS,
IBM Company, Hong Kong, China)was used. As the study
involvedcomplexclustersampling,thecorrectionwasmade
bythesampledesigneffect,takingintoaccountthecluster
effectsandassigningweightstothesampledelements.For
categoricalvariables,thedescriptiveanalysisincludedthe
distributionofthesample,correctedrelativefrequency(%),
andstandarderror(SE).Toevaluatethefactorsassociated
withtheoutcome(dentalpain),bivariateandmutiple
anal-yseswereperformed.Inthebivariateanalysis,therawodds
ratios (ORraw) and 95% confidence intervals (95%CI) were
estimated,withthecorrectionfortheeffectofthesample
design.Independentvariablesthatpresentedadescriptive
levellowerthanorequalto20%(p≤0.20)atthisstageofthe
analysiswereselectedformultipleanalysis.Inthemultiple
analysisofthefactorsassociatedwiththeoutcome,based
onlogisticregression(ORadjusted/95%CI),asignificancelevel
of5%(˛=5%)wasadopted.
Thisepidemiologicalsurveywasconductedbasedonthe
ethicalprinciplesofResolutionoftheNationalHealth
Coun-cilNo·196/96 andwasapproved byandregistered atthe
NationalInstitutional ReviewBoard(Comissão Nacionalde
ÉticaemPesquisa[CONEP])underNo.15498/2010.
Results
Thisstudy included 7280 childrenaged5 years.Of these, 1520 (21.1%) had episodes of dental pain in the six monthspriortodatacollection. Mostchildrenweremale, had already used dental services, and were caries-free (Table1).
The bivariate analysis indicated that variables in all
categories(sociodemographic, useof services,and health
Table 1 Descriptiveanalysis of dental pain, sociodemo-graphic characteristics, healthcare services, and health outcomesamongBrazilianpreschoolersin2010(n=7280).
n % SE
Dentalpaininthelast6months
No 5760 78.9
Yes 1520 21.1 1.7
Sex
Male 3643 51.9 Female 3637 48.1 1.4
Ethnicity
White 3259 48.5 Asian/Black/Mixed-race/Indigenous 4021 51.5 2.1
Familyincome
OverR$500 5434 78.1 UptoR$500 1526 21.9 1.8
Brazilianregion
Mid-West 1141 8.1 1.1 South 917 13.3 2.1 Southeast 1283 50.3 4.3 Northeast 2145 17.2 2.0 North 1794 11.1 1.4
Useofdentalservices
No 3416 46.7
Yes 3800 53.3 1.6
Toothdecay
0 3624 52.6
1ormore 3535 47.4 1.8
Self-perceivedneedfortreatment
No 3027 45.8
Yes 3962 54.2 2.0
Satisfactionwiththeteethandmouth
Satisfied 4788 71.5 Unsatisfied 2066 28.5 1.9
ImpactoforalproblemsinQOL
No 5510 74.8
Yes 1770 25.2 2.2
n,numberofsubjects;SE,standarderror;QOL,qualityoflife.
outcomes)remainedassociatedwithdentalpain(p≤0.20)
andwereconsideredinthemultipleanalysis(Table2).
Inthemultipleanalysis,dentalpaininthelastsixmonths
in children at 5years wasassociatedwithnouse of
den-tal services (p=0.037); tooth decay(p≤0.001); perception
byparents/guardiansoftheirchildren’sneedfortreatment
(p≤0.001); parents’/guardians’ report of their children’s
dissatisfactionwithteethandmouth(p=0.029);andimpact
of oral health on quality of life according to the applied
instrument(OIDIP---p≤0.001;Table3).
Regarding the distribution of dental pain among
preschoolers, according to the Brazilian states, a lower
prevalence of this findingwasobserved in thoseliving in
Table2 BivariateanalysisoffactorsassociatedwithdentalpaininBrazilianpreschoolersin2010. Presenceofdentalpain
% ORraw 95%CI p-value
Sex
Male 21.6 1.00
Female 20.7 0.94 0.72---1.23 0.694
Ethnicity
White 18.5 1.00
Asian/Black/Mixed-race/Indigenous 23.6 1.36 1.06---1.75 0.16
Familyincome
OverR$500 18.6 1.00
UptoR$500 30.0 1.87 1.39---2.51 0.000
Brazilianregion
Mid-West 23.4 1.00
South 17.4 0.68 0.44---1.06 0.94 Southeast 19.6 0.80 0.55---1.15 0.237 Northeast 24.4 1.5 0.80---1.37 0.688
Useofdentalservices
No 17.6 1.00
Yes 24.4 1.51 1.16---1.96 0.2
Toothdecay
0 7.8 1.00
1ormore 35.5 6.48 4.76---8.83 0.000
Self-perceivedneedfortreatment
No 5.2 1.00
Yes 35.3 10.2 6.36---15.76 0.000
Satisfactionwiththeteethandmouth
Satisfied 12.9 1.00
Unsatisfied 42.0 4.90 3.76---6.40 0.000
ImpactoforalproblemsonQoL
No 10 1.00
Yes 54.2 10.63 7.58---14.91 0.000
ORraw,rawoddsratio;95%CI,95%confidenceinterval;QOL,qualityoflife.
Table3 MultipleanalysisoffactorsassociatedwithdentalpainamongBrazilianpreschoolersin2010.
ORadjusted 95%CI p-value
Useofdentalservices
No 1.00
Yes 1.51 1.02---2.23 0.037
Toothdecay
0 1.00
1ormore 3.08 2.08---4.56 <0.001
Self-perceivedneedfortreatment
No 1.00
Yes 3.96 2.48---6.34 <0.001
Satisfactionwiththeteethandmouth
Satisfied 1.00
Unsatisfied 1.47 1.04---2.10 0.029
Impactoforalproblemsonqualityoflife
No 1.00
Yes 5.76 3.90---8.49 <0.001
0
Distrito Federal Rio Grande do Sul Santa Catarina Paraná Espírito Santo Rio de Janeiro São Paulo Minas Gerais Goiás Mato Grosso do Sul Mato Grosso Rio Grande de Norte Maranhão Piauí Ceará Paraíba Pemambuco Sergipe Bahia Alagoas Tocantins Roraima Rondônia Pará Amapá Acre Amazonas
North
Northeast
Mid- west
Southeast
South
%
5 10 15 20 25 30 35
Figure1 Distributionofthepresence(%)ofdentalpaininBrazilianpreschoolersperstate.
Discussion
A high prevalence of dental pain (21.1%) among chil-dren aged 5 years was observed. This prevalence was higherthan that identified in other studies in Brazil with preschoolers.15,23 Nevertheless, higher prevalences were
observed in national1,16 and international12,13 studies that
included older children (6---12 years), indicating a
possi-bilitythat advancing age can influence theoccurrence of
oral health problems and, consequently,pain perception.
The prevalenceof dentalpainamong Brazilian
preschool-erspossiblyderivesfromthehighprevalenceofsomeoral
problems amongthese individuals, such astooth decay.18
However,considering theprevalence oftheseproblems,a
higherprevalenceofdentalpainwasexpected,sincetooth
decayhasbeenidentifiedastheprimarycauseofdentalpain
inchildren.24 Itisworthnotingthatthereportofpainwas
madebythepreschoolers’parents/guardians,whomayhave
underestimatedtheoccurrenceofthisevent.Inadditionto
itsrates,it wasobservedthat dentalpain wasassociated
withvariablesrelatedtotheuseofdentalservicesand
out-comesinoralhealth (normativeandsubjective conditions
oforalhealth).
This studyobserveda higherprevalenceof dentalpain
amongthose whohad been to a dentist.This association
isworrisome,consideringthatadentalconsultationshould
stimulate greater care and treatment of dental issues,
resultinginpainrelief.Thus,itispossiblethatthedental
servicesuseddidnotresolvethe issues.Aprevious study,
conductedamongpreschoolchildreninMontes Claros(MG
-Brazil),identifiedalowerchanceofusingdentalservices
amongthosewhohadneverhaddentalcariesexperience,25
whichevidencesthepossibilitythatinjuriesorpaindidnot
occur,leadingtonon-useoftheservice.
Dentalcarieshavebeenidentifiedasthemaincauseof
tooth pain.24,26 The prevalence of dentalpain washigher
among preschoolers with one or more teeth with caries.
This association was to be expected, since pain is one
of the symptoms of tooth decay, and was also identified
among adolescents5 andadults.9 A previous cohort study,
withpreschoolchildrenaged5yearsinPelotas(RS-Brazil),
observedthatindividualswithcarieshadagreaterchance
(4.8 times) of having dental pain.26 Increased access to
dental services, as well as preventive and health
educa-tion measures, could have a positive impact on reducing
caries rates in this population and, consequently, dental
pain.
A greater chance of dental pain was observed in
preschoolers who were likely dissatisfied with their oral
health conditions and required dentaltreatment,
accord-ingtothereportbytheirparents/guardians.Thepresence
of dental pain is a result of the presence of dental
injuries1---3;these,inturn, canleadtodissatisfactionwith
oral health and to a perceived need for treatment. It
shouldbenotedthatthedataonsubjectiveissuesoforal
healthwerereportedbythoseresponsibleforthechildren.
Thus,theassessedperceptionmaynotfullyrepresenthow
preschoolersfeltaffectedbytheiroralproblems.However,
consideringthelowageofthesampleandthedifficultyof
assessingtheiroralconditions,theaccountofthosewholive
withthesechildren (parents/guardians)isa reliable
mea-sureofevaluation.Inthissense,dentalpainisanimportant
predictorforthesearchfordentalcare.
Consideringthefactthatdentalpainnegativelyimpacts
people’sdailylives6andimpairsqualityoflife,7,8thegreater
chance of dental pain among those whose oral health
impacted their quality of life identified in this study was
asoftheimpactsonqualityoflife,especiallyamong
chil-dren, isnoteworthy. Regarding theself-perceptionof oral
healthandtheneedfor dentaltreatment,theassessment
ofthe impactonqualityof lifewasansweredby the
par-ents/guardians, andmay differ fromhow thechild really
feltabouttheirdentalproblems.
Painisamultidimensionalphenomenon:itcanbe
influ-encedbydifferentfactors,anditsobjectiveevaluationin
preschoolers is a challenge for healthcare professionals.
Therefore, the identification of the prevalence of dental
painanditsassociatedfactorsmayallowforimprovements
andfortheimplementationofpublicpoliciesaimedat
fos-teringbetter oral health and dailylife conditions for this
population group.Among the limitations of thisstudy are
itstransversedesign,which doesnotallow forthe
identi-fication ofcauses and effects,and thefact thatthe data
wascollectedin 2010andthatchangesinthepainprofile
mayhaveoccurredovertheyears.Moreover,thereportof
pain,aswellasofothersubjectivemattersoforalhealth,
wasprovidedbytheparents/guardians,andisasubjective
anddynamicmeasurement.Nevertheless,thisstudyallowed
for the characterization of the occurrenceof dentalpain
amongBrazilianpreschoolers,consideringarepresentative
sampleofthisagegroup.Thischaracterizationalsoallowed
fortheidentification ofthedistributionof theoccurrence
ofatleastoneepisodeofdentalpaininpreschoolersamong
the Brazilian states and their capitals. The variability in
theprevalenceof painbetweencapital citiesof thesame
regionwasnoteworthy;ingeneral,alowerprevalencewas
observedintheSouthofthecountry.
Ofthepreschoolersincludedinthisstudy,21.1%had
den-talpaininthelastsixmonthspriortodatacollection.Itis
noteworthythatthisphenomenonremainedassociatedwith
the use of dental services, dentalcaries, need for
treat-ment,dissatisfactionwithteethandmouth,andimpactof
oralhealth onqualityoflife.Therefore,suchassociations
shouldbeconsideredinhealthplanningbyhealthcare
pro-fessionalsandmanagersinordertoreducetheoccurrence
ofdentalpainamongBrazilianpreschoolers.
Funding
Thisstudydidnotreceivefunding.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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