UNIVERSIDADEESTADUALDECAMPINAS
FACULDADEDEODONTOLOGIADEPIRACICABA
EVELY SARTORTI DA SILVA MORGAN
IMPACTO DO SENSO DE COERÊNCIA NA QUALIDADE DE
VIDA RELACIONADA A SAÚDE BUCAL EM ADULTOS
BRASILEIROS
SENSE OF COHERENCE IMPACT´S ON ORAL HEALTH
RELATED QUALITY OF LIFE AMONG BRAZILIAN
ADULTS
Piracicaba 2016
EVELY SARTORTI DA SILVA MORGAN
IMPACTO DO SENSO DE COERÊNCIA NA QUALIDADE DE VIDA
RELACIONADA A SAÚDE BUCAL EM ADULTOS BRASILEIROS
SENSE OF COHERENCE IMPACT´S ON ORAL HEALTH RELATED
QUALITY OF LIFE AMONG BRAZILIAN ADULTS
Dissertação de Mestrado Profissional apresentada a Faculdade de Odontologia de Piracicaba da Universidade Estadual de Campinas como parte dos requisitos exigidos para a obtenção do título de Mestra em Odontologia em Saúde Coletiva.
Dissertation of Professional Master presented to the Piracicaba Dental School of the University of Campinas in partial fulfillment of the requirements for the degree of Master in Community Health Dentistry.
Orientadora: Profa. Dra. Lívia Maria Andaló Tenuta Coorientadora: Profa. Dra. Rosana de Fátima Possobon
ESTE EXEMPLAR CORRESPONDE À VERSÃO FINAL DA DISSERTAÇÃO DEFENDIDA PELA ALUNA EVELY
SARTORTI DA SILVA MORGAN, E ORIENTADA PELA PROFA. DRA. LÍVIA MARIA ANDALÓ
TENUTA.
Piracicaba 2016
DEDICATÓRIA
Dedico este trabalho a todos os profissionais que, em qualquer área de
atuação, se esmeram no cuidado do ser humano em sua totalidade. Àqueles que
procuram compreender que, mais que um cliente, paciente ou objeto de trabalho
e estudo, o ser humano é um igual, mesmo que ele pense, sinta, creia ou reaja aos
estímulos de forma diferente. Porque muito além de sua formação biológica,
social, psicológica, cultural ou econômica, ele é fruto das mãos de um Criador que
o dotou com a liberdade de escolha.
AGRADECIMENTOS
Ao reitor desta universidade, Prof. Dr. José Tadeu Jorge, pela condução desta instituição que forma profissionais da mais alta qualidade.
À Faculdade de Odontologia de Piracicaba, na pessoa do seu Diretor, Prof. Dr. Guilherme Elias Pessanha Henriques, que me concederam a oportunidade de aprender e participar da produção do conhecimento em uma tão honrada instituição
À Coordenadora do programa de pós-graduação em Odontologia da Faculdade de Odontologia de Piracicaba, Profa. Profa. Dra. Cínthia Pereira Machado Tabchoury, pela oportunidade de cursar o mestrado profissionalizante neste programa.
À Coordenadora do programa de Mestrado Profissional em Odontologia em Saúde coletiva, Profa. Dra. Luciane Miranda Guerra, pela dedicação em oferecer aos alunos um conhecimento atualizado e prático da Saúde Coletiva.
Às queridas Profas. Dras. Lívia Tenuta e Rosana Possobon que aceitaram o desafio de me orientar na execução deste trabalho. Pelas dicas, pela cobrança que faz o trabalho ter ritmo, pela energia incansável e principalmente por dividir um pouco do seu saber.
Aos professores que participaram de alguma forma do meu crescimento profissional e desta jornada até aqui, seja com seu ensino, correções, orientações e estímulo.
À amiga e professora Dra. Marília Batista, juntamente com as, igualmente queridas, Profas. Dras. Débora Dias, Maria Paula Meireles, e Maria da Luz Souza, não só pelo apoio técnico, mas pelas palavras de ânimo, de correção e de conforto.
Aos queridos coordenadores, profissionais e amigos da Prefeitura Municipal de Jundiaí, Drs. Jane Tonetti, Luiz Carlos Miyashiro, Clóvis Tomazzoni, Magda Ykeda e muitos outros que confiaram na importância deste trabalho e na competência desta equipe.
À minha equipe de trabalho, que se tornou minha família: Maria Cristina Sciamarelli, Carla Marsi, Marcela Di Moura, Célia Ferragut, Rita Amaral, Andréia Souza, Sônia Saka, Bento Rodrigues, Thalita Alves, Renata Moraes, Michele Matos e Priscila Santos. Nada disso seria possível sem a incansável energia e afinidade desta equipe maravilhosa!
Aos voluntários jundiaienses, que se doaram por alguns instantes para o crescimento do conhecimento científico, com a convicção de que através de sua atitude, muitos outros podem ser beneficiados.
Ao meu esposo Levi Morgan, que sempre confiou em mim, e dividiu comigo sua força quando a minha estava para terminar. Aos seus filhos, Aline e Vitor, que sem saber, com sua vontade de vencer, me ensinam a ser melhor.
Aos meu pais, Lucas e Ruth Silva, que nunca desistiram de mim, mesmo quando tudo parecia desabar. Sua confiança em Deus me fez lutar pela vida e pela felicidade.
Aos meus amados familiares pela confiança, incentivo, risadas e demonstrações de carinho que sempre estiveram presentes no nosso relacionamento.
E principalmente à Deus, pela oportunidade de viver mais esta etapa que me trouxe amadurecimento pessoal e profissional, e me fez encontrar novos caminhos trilhados por pessoas em busca do conhecimento que enriquece a experiência.
Finalmente à todos aqueles que se envolveram de alguma forma neste trabalho, seja formal ou informalmente, que torceram, que lutaram, que oraram, meu muito obrigada!
“... e aprendi que se depende sempre de tanta, muita, diferente gente toda pessoa sempre é as marcas das lições diárias de outras tantas pessoas e é tão bonito quando a gente entende que a gente é tanta gente onde quer que a gente vá e é tão bonito quando a gente sente que nunca está sozinho por mais que pense estar...” (Gonzaguinha)
RESUMO
OBJETIVO: A qualidade de vida relacionada à saúde bucal (OHRQoL) autorreferida, pode sofrer influência do alto ou baixo senso de coerência (SOC). Porém, não existem estudos epidemiológicos que investigam esta associação em adultos brasileiros. O objetivo deste estudo foi estudar a relação entre a OHRQoL e o SOC entre os adultos de uma cidade brasileira de médio porte.
MATERIAL E MÉTODO: A amostragem probabilística consistiu em 342 adultos de 35 a 44 anos de idade, que foram examinados em seus domicílios para cárie (CPOD) e doença periodontal (CPI), segundo critérios da OMS. O questionário aplicado incluiu informações sobre fatores demográficos, socioeconômicos, de utilização de serviços, comportamentais, Senso de Coerência e o Oral Health Impact Profile (OHIP). O desfecho, OHIP (prevalência de impactos severos), foi analisado por regressão logística binária com abordagem hierárquica, utilizando modelo conceitual e significância 5%.
RESULTADOS: 67,9 % dos entrevistados tiveram um ou mais impactos severos na OHRQoL e 54,4 % apresentaram alto SOC. A presença de impactos na OHRQoL foi mais prevalente nos adultos que tinham ocupação manual, RP=2,47 (IC 95% 1,24 - 4,93), nos que percebem a necessidade de tratamento odontológico, RP=2,93 (1,67 - 5,14), e que apresentam cárie não tratada, RP=1,93 (1,07 - 3,47). Os indivíduos que apresentaram baixo SOC, tiveram uma prevalência duas vezes maior de impactos na OHRQoL , RP=2,19 (1,29 - 3,71). .
CONCLUSÃO: Um baixo Senso de Coerência foi associado à maior prevalência de impactos na OHRQoL de adultos brasileiros, mesmo após ajuste por fatores socioeconômicos, comportamentais e clínicos. Sugere-se que futuros estudos considerem o SOC na determinação do impacto da saúde bucal sobre a qualidade de vida.
PALAVRAS-CHAVE: Senso de Coerência, Qualidade de Vida, Saúde Bucal, Epidemiologia, Adultos.
ABSTRACT
OBJECTIVE: Since the oral health-related quality of life (OHRQoL) may be affected by the Sense of Coherence (SOC), but there are no epidemiological studies investigating this association in Brazilian adults, this study was conducted among adults of a mid-sized Brazilian city.
METHODS: The probability sampling consisted of 342, 35-44 years-old adults from a mid-sized Brazilian city, who were examined in their homes for caries (DMFT) and periodontal disease (CPI), according to WHO criteria. The applied questionnaire included demographic factors, socioeconomic information, use of dental services, behaviour, SOC and the Oral Health Impact Profile (OHIP). The outcome OHIP, measured by the prevalence of impact, was analyzed by binary logistic regression with hierarchical approach, using a conceptual model and significance of 5%.
RESULTS: 67.9 % of the respondents had one or more impacts on OHRQoL and 54.4% showed a high SOC. The presence of impact on OHRQoL was more prevalent on adults who have manual occupation (PR=2.47, CI 95% 1.24-4.93), on those who perceive the need for dental treatment (PR=2.93, 1.67-5.14), and those who had untreated caries (PR=1.93, 1.07-3.47). Those who presented low SOC had a 2 times higher prevalence of impacts on OHRQoL(PR=2.19, 1.29-3.71).
CONCLUSION: A low SOC was associated with the presence of impact on OHRQoL of brazilian adults, even after adjustment by socioeconomic, behavioural and clinical factors.It is suggested that future studies consider the SOC for determination of oral health impact on quality of life.
LISTA DE ILUSTRAÇÕES
LISTA DE TABELAS
Tabela 1. Demographic, socioeconomic, psychosocial and clinical characteristics of adults residents in Jundiai, Brazil, 2014. ...26
Tabela 2. Bivariate analyzes and p value for presence and absence of impact in adults of Jundiaí, Brazil, 2014 (it continues). ...28
Tabela 3. Associated factors of the presence of impact on OHRQoL in adults of Jundiaí, Brazil , 2014. ...31
LISTA DE ABREVIATURAS E SIGLAS
CI - Confidence Index
IC - Índice de Confiança
CPI - Community Periodontal Index
(Índice Periodontal Comunitário)
CPOD - Índice de Dentes Cariados, Perdidos e Obturados IBGE - Instituto Brasileiro de Geografia e Estatística
MW - Minimum Wage
(Salário Mínimo)
OHIP - Oral Health Impact Profile
(Perfil de Impacto da Saúde Bucal) OHRQoL - Oral Health Related Quality of Life
(Saúde Bucal Relacionada à Qualidade de Vida) OMS - Organização Mundial da Saúde
WHO - World Health Organization
PR - Prevalence Ratio
RP - Razão de prevalência
SOC - Sense of Coherence
SUMÁRIO
1 INTRODUÇÃO 15
2 ARTIGO: Impact of the Sense of Coherence on Oral Health Related Quality of Life
among Brazilian Adults 19
3 CONCLUSÃO 36
REFERÊNCIAS 37
ANEXOS 44
Anexo 1. Comprovante de submissão do artigo 44
Anexo 2. Certificado de aprovação no Comitê de Ética em Pesquisa 45
Anexo 3. Termo de Consentimento Livre e Esclarecido 46
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1 INTRODUÇÃO
Segundo o Global Burden of Disease (GBD) 2010 Study, o impacto causado pelas doenças bucais sobre a população mundial está classificado entre os 100 primeiros de uma lista de 291 doenças (Marcenes et al., 2013). A OMS afirma que, até 2012, quase 100% dos adultos de todo o mundo tiveram lesões de cárie e 15 a 20% apresentam doença periodontal severa. Juntas, estas são as doenças bucais que mais causam perdas dentais. Ainda neste relatório, a OMS afirma que os principais fatores de risco para estas doenças bucais incluem uma dieta inadequada, uso de tabaco e bebidas alcoólicas, uma pobre higiene bucal e determinantes sociais negativos (World Health Organization, 2012). A privação de fatores socioeconômicos afeta tanto a manifestação das doenças bucais, como a interpretação do impacto causado por elas (Watt and Sheiham, 2012). Entretando, a presença de doenças bucais e fatores socioeconômicos deficientes ainda não têm sido suficientes para explicar o impacto multidimensional e multifatorial causado pela saúde bucal sobre a qualidade de vida (OHRQoL).
Locker em 1988, propôs um modelo teórico que afirma que a saúde bucal pode ter uma importante influência na percepção da qualidade de vida. Esta proposição foi tomada como base para a elaboração de instrumentos que mensuram esta influência, como o “Oral Health Impact Profile”(OHIP). Criado originalmente na língua inglesa, com 49 questões, foi reduzido pelo próprio autor para 14 questões (Slade, 1997), sendo traduzido e validado no Brasil (Oliveira and Nadanovsky, 2005). Através da autopercepção individual, o instrumento avalia as consequências biopsicossociais dos problemas bucais em sete dimensões: limitação funcional, dor física, desconforto psicológico, incapacidade física, incapacidade psicológica, incapacidade social e deficiência(Slade, 1997).
O OHIP tem sido um instrumento muito útil para enriquecer a avaliação das condições bucais, estabelecer prioridades para o cuidado em saúde bucal, avaliar a influência do tipo de tratamento adotado e rastrear grupos prioritários para acesso aos serviços (Almeida et al., 2004; Ferreira et al., 2004). A partir de 1998, ele foi introduzido em levantamentos de saúde bucal em vários países do mundo, como Reino Unido, País de Gales, Irlanda do Norte, Inglaterra, Noruega, Austrália, Nova Zelândia, Canadá, Estados Unidos e Brasil (Slade et al.,
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2005; Locker and Quiñonez, 2009, 2011; Sanders et al., 2009; Dahl et al., 2011; Thomson et al., 2012; Batista et al., 2014; Guarnizo-Herreno et al., 2014; Brennan and Teusner, 2015).
Em 2013, Gabardo et al. observaram em revisão sistemática da literatura, associação do OHIP-14 com fatores como renda, idade, escolaridade, gênero, etnia, condições de saúde bucal, como perdas dentais, necessidade de reabilitação protética, periodontopatias, lesões de cárie, condições de saúde geral, comportamentos nocivos à saúde bucal e percepção da necessidade de tratamento odontológico. Chama a atenção sua associação com variáveis comportamentais e psicossociais, como o Senso de Coerência (Sense of Coherence – SOC). Os trabalhos sugerem que um alto SOC está relacionado à percepção de menor impacto da saúde bucal sobre a qualidade de vida, (Savolainen et al., 2005a; Johansson et al., 2010; Boman et al., 2012; Gabardo et al., 2013; Gupta et al., 2015).
O Senso de Coerência é um conceito criado pelo sociologista médico Aaron Antonovsky em 1987, à luz de sua teoria salutogênica. Seus pressupostos afirmam que os fatores promotores de saúde diferem daqueles que modificam o risco para doenças específicas. Ele considera a saúde como resultado da capacidade adaptativa do ser humano ao estresse, procurando razões sobre como e porque as pessoas permanecem bem, ou satisfeitas com sua qualidade de vida, mesmo sob situações desfavoráveis e estressantes (Antonovsky, 1993; Lindström and Eriksson, 2005). Estes fatores promotores de saúde estariam relacionados à forma como os indivíduos dão sentido ao mundo (compreensão), reconhecem e usam recursos disponíveis para responder a uma demanda (manejo) e sentem que essas respostas fazem sentido emocionalmente (significado) (Antonovsky, 1987; Bonanato et al., 2009).
Segundo a teoria salutogênica, o SOC seria desenvolvido pelo indivíduo desde seu nascimento, a partir das experiências vividas, alternadas entre presença e ausência de bem-estar, em aspectos históricos e culturais, individuais ou coletivos, estando relativamente estável após os trinta anos de idade (Antonovsky, 1987, 1993). A influência do senso de coerência sobre a saúde do indivíduo se daria, sobre a reação dos sistemas orgânicos e fisiológicos, a partir da sensibilização do raciocínio, podendo determinar a situação como perigosa, segura ou prazerosa, o que levaria a uma alteração da resposta cardiovascular e imunológica, por exemplo; e determinando as escolhas saudáveis em relação ao estilo de vida, como dieta, higiene, exercícios físicos, exames preventivos, entre outros (Dantas, 2007). Nas ciências médicas, um alto SOC tem sido relacionado à melhor sobrevida de pacientes com câncer, doenças renais, diabetes, artrites, osteoporose, doenças psiquiátricas e cardiovasculares, dentre outras (Motzer
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and Stewart, 1996; Eriksson and Lindström, 2005; Lindström and Eriksson, 2005; Dantas, 2007; Ahola et al., 2012)
A partir de 1997, a Organização Mundial de Saúde introduziu, na Europa, o Senso de Coerência no âmbito da promoção de saúde mental, com o objetivo de orientar a melhora dos locais de moradia, estudo, trabalho e diversão, fortalecendo o desenvolvimento do senso de coerência (WHO, 1998). Desde então, a mensuração do SOC também tem sido inserida no planejamento e execução de levantamentos nacionais de saúde bucal dos países europeus, com o objetivo de entender a influência dele sobre fatores clínicos, comportamentais e de impacto da saúde bucal sobre a qualidade de vida (Savolainen et al., 2005a; Bernabé et al., 2010; Jordan et al., 2014; Holde et al., 2016).
Nos estudos com indivíduos adultos, foram identificados fatores que se associam a um alto Senso de Coerência, destacando-se o estado civil de união estável, um maior suporte social, fatores socioeconômicos favoráveis, gênero masculino, maior idade e utilização de serviços privados de saúde bucal (Bernabé et al., 2009b; Emami et al., 2010; Johansson et al., 2010; Lindmark et al., 2010; Gupta et al., 2015). Em relação ao tratamento dentário, o alto Senso de Coerência foi relacionado a um menor nível de estresse, ansiedade e medo (Lindmark et al., 2011a; Boman et al., 2012; Gupta et al., 2015). Um alto SOC também mostrou-se favorável à adoção de comportamentos saudáveis como uma maior frequência de escovação dental, visitas regulares ao dentista, menor consumo de açúcar e abstenção do fumo (Savolainen et al., 2004, 2005b, 2009; Bernabé et al., 2009a; b, 2012a; b; Lindmark et al., 2011a; Gupta et al., 2015), além de melhorar a interpretação subjetiva da importância da saúde bucal (Savolainen et al., 2009; Bernabé et al., 2010; Lindmark et al., 2011a; Gupta et al., 2015).
Para os desfechos clínicos, o alto SOC foi relacionado com menor índice de biofilme bacteriano, menor quantidade de lesões de cárie não tratadas, menos sextantes com cálculo e bolsas periodontais, menor perda dentária e maior permanência dos dentes (Savolainen et al., 2005b; Bernabé et al., 2010, 2012a; Lindmark et al., 2011b; Wennström et al., 2013). No Brasil, foram publicados três estudos que avaliaram a relação entre o Senso de Coerência e os resultados clínicos em saúde bucal de adultos. O primeiro deles estudou uma população de mães de escolares, com baixo estatus socioeconômico, sugerindo que o SOC mediou o efeito das lesões de cárie sobre a dor de origem dental nesta amostra (da Silva and Vettore, 2016). No segundo estudo, com adultos de 50 a 59 anos, a conclusão foi que a maior presença de dentes e a menor necessidade de próteses dentárias foram relacionadas a um alto SOC (Davoglio et al., 2016). Já o estudo de Cyrino et al. (2016) não encontrou associação do
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SOC com variáveis clínicas relacionadas à doença periodontal em trabalhadores de 18 a 60 anos de idade, porém encontrou esta associação com variáveis autopercebidas em relação à saúde periodontal. (Cyrino et al., 2016)
A influência do SOC sobre o impacto da OHRQoL foi estudada por Savolainen et al. (2005) em uma amostra representativa da população finlandesa, encontrando associação do Senso de Coerência (SOC) com todas as dimensões do OHIP, em especial com o desconforto psicológico, incapacidade psicológica e deficiência, sugerindo que um baixo SOC seria determinante de um alto impacto na OHRQoL, independente das condições de saúde bucal, comportamentos saudáveis e fatores socioeconômicos. Johansson et al. (2010), também incluíram o SOC ao estudar o OHRQoL em adultos usuários de sistemas pagos e não pagos de saúde bucal da Suécia, encontrando a mesma associação entre eles. Boman et al. (2012) encontraram relação inversa entre o SOC, associado ao estresse dental, e o OHIP, em mulheres suécas. Baseado nestes achados, Gupta et al. (2015) propuseram um modelo que explicaria o papel dos fatores psicossociais como mediadores da relação entre fatores socioeconômicos e a OHRQoL, em um estudo longitudinal com homens trabalhadores de uma empresa na Índia. Ele conclui que um alto SOC no início do estudo foi preditor de um baixo OHRQoL, via baixos níveis de estresse ao término.
O conhecimento dos fatores que podem ter influência sobre o manejo, tanto dos desfechos de saúde como do impacto da qualidade de vida relacionado à saúde bucal de adultos é importante para a elaboração de estratégias de promoção de saúde bucal para esta idade. Considerando a influência de fatores socioeconômicos e culturais sobre a formação do SOC e sobre a interpretação da qualidade de vida relacionada à saúde bucal, faz-se necessário o estudo desta associação em diferentes contextos. No Brasil, entretando, não foram encontrados estudos que investiguem a associação entre o SOC e o OHRQoL. Desta forma, o objetivo deste trabalho foi verificar a associação entre o Senso de Coerência (SOC) e o impacto da saúde bucal na qualidade de vida (OHIP) ajustada pelas condições de saúde bucal, comportamentos relativos à saúde bucal e fatores socioeconômicos em adultos entre 35 e 44 anos de idade de um município brasileiro de médio porte.
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2 ARTIGO: Impact of the Sense of Coherence on Oral Health Related Quality of Life among Brazilian Adults
Running head: Sense of coherence and quality of life
Evely Sartorti da Silva Morgan1, Marcela Di Moura Barbosa2, Marília Jesus Batista1, Rosana de Fátima Possobon1, Livia Maria Andaló Tenuta3
1Department of Community Dentistry, Piracicaba Dental School, University of Campinas
-UNICAMP, Piracicaba, SP, Brazil.
2 Department of Prosthodontics and Periodontics, Piracicaba Dental School, University of
Campinas - UNICAMP, Piracicaba, SP, Brazil.
3Department of Physiological Sciences, Piracicaba Dental School, UNICAMP - University of
Campinas - UNICAMP, Piracicaba, SP, Brazil
Corresponding author: Livia M A Tenuta
Piracicaba Dental School, University of Campinas. Av. Limeira 901. CEP 13414-903. Piracicaba, SP, Brazil.
Article submitted for publication in the journal Community Health and Oral Epidemiology on July 15, 2016. Proof of submission attached on page 45 (Anexo 1).
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Abstract
Objective: Since the oral health-related quality of life (OHRQoL) may be affected by the Sense of Coherence (SOC), but there are no epidemiological studies investigating this association in Brazilian adults, this study was conducted among adults of a mid-sized Brazilian city.
Methods: The probability sampling consisted of 342, 35-44 years-old adults from a mid-sized Brazilian city, who were examined in their homes for caries (DMFT) and periodontal disease (CPI), according to WHO criteria. The applied questionnaire included demographic factors, socioeconomic information, use of dental services, behaviour, SOC and the Oral Health Impact Profile (OHIP). The outcome OHIP, measured by the prevalence of impact, was analyzed by binary logistic regression with hierarchical approach, using a conceptual model and significance of 5%.
Results: 67.9 % of the respondents had one or more impacts on OHRQoL and 54.4% showed a high SOC. The presence of impact on OHRQoL was more prevalent on adults who have manual occupation (PR=2.47, CI 95% 1.24-4.93), on those who perceive the need for dental treatment (PR=2.93, 1.67-5.14), and those who had untreated caries (PR=1.93, 1.07-3.47). Those who presented low SOC had a 2 times higher prevalence of impacts on OHRQoL (PR=2.19, 1.29-3.71). Even after adjustment by socioeconomic, behavioural and clinical factors, the presence of impact on OHRQoL was associated to a low SOC.
Conclusion: It is suggested that future studies consider the SOC for determination of oral health impact on quality of life.
Key words: Behavioral science, Dental health perceptions, Oral health, Psychosocial aspects of oral health, Quality of life
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Introduction
According to the Global Burden of Disease (GBD) 2010 Study, the impact of oral diseases (untreated caries, severe periodontal disease and dental loss) on the world’s population is ranked among the top 100 of a list with 291 diseases (1). It is well known that socioeconomic deprivation affects the occurrence of oral diseases as well as the interpretation of the impact caused by them (2). However, the presence of oral diseases and unfavourable socioeconomic factors are not sufficient to explain the multidimensional and multifactorial oral health impact on quality of life, usually referred to as the oral health-related quality of life (OHRQoL).
In epidemiological studies with adults measuring the OHRQoL, assessed by the “Oral Health Impact Profile” (OHIP) (3), associations with socioeconomic factors such as income, age, education, gender andethnicity; and oral health conditions, such as dental loss, need for prosthetic rehabilitation, periodontitis and caries lesions were found (4). Also the OHIP was associated with general health conditions, oral health behaviours, perception of the need for dental treatment and psychosocial factors li ke the Sense of Coherence (4).
The Sense of Coherence (SOC) is an instrument created by Antonovsky (1987), based on his salutogenic theory, which evaluates how individuals give meaning to the world (understanding), recognize and use available resources to respond to a demand (management) and feel that these answers make sense emotionally (meaning) (5). A high SOC would determine the adaptive capacity of human beings to stress, making people stay well, or satisfied with their quality of life, even under adverse and stressful situations (5,6). Epidemiological studies with adults have identified clinical and socioeconomic factors associated to a high SOC, very similar to those found for a low OHIP (7,8). In fact, a high SOC is usually associated with the adoption of healthy behaviours related to oral health, which would change the clinical state and the subjective interpretation of the importance of oral health (9–11).
The influence of SOC on the impact of OHRQoL was studied by Savolainen et al. (2005) on a representative sample of the Finnish population, which found association of the SOC with all dimensions of OHIP, especially with psychological discomfort, psychological incapacity and handicap. They suggested that a low SOC would determine a high impact on OHRQoL, regardless of conditions of oral health, healthy behaviours and socioeconomic factors (12). Others also detected the same relationship between SOC and OHIP (7); in two of them, the ability to cope with stress caused by oral diseases mediated this association (8,10).
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Thus, the inclusion of the SOC in a study on the impact on OHRQoL can help understand the psychosocial aspects that would modify the interpretation of this impact.
In addition, it should be take into consideration that socioeconomic, demographic and even cultural differences between populations may alter the interpretation of both the OHRQoL and the SOC. Since in Brazil there are no studies that have investigated the association between SOC and OHRQoL, the objective of this work was to verify this association adjusted for conditions of oral health, oral health-related behaviors and socioeconomic factors in Brazilian adults.
Materials and Methods
Ethical issues
This study was conducted within the standards required by the Brazilian regulation (Resolution 466/2012) for research in humans and has been approved by the Research and Ethics Committee of the Piracicaba Dental School – UNICAMP.
Location of Study
The study was conducted in the municipality of Jundiaí, a mid-sized city in São Paulo State, Brazil. According to the last census of the Brazilian Institute of Geography and Statistics (IBGE), held in 2010, the number of inhabitants in Jundiaí was 370,126, and the human development index was 0.857, which is considered very high by IBGE, in comparison with other Brazilian cities. The planning steps and calibration of examiners occurred in 2013 and data collection in 2014.
Sample
The sample comprised adults, aged between 35 and 44 years, which is considered the default group for the evaluation of oral health conditions in adults, according to the World Health Organization (WHO) (13). This study was a part of a bigger project intitled “Epidemiological Surveys of Oral Health - Jundiaí/SP 2014”. The calculation of the sample size was carried out on the basis of data obtained from the national survey of oral health, SB-Brasil 2010, Southeast region, using the mean DMFT and the prevalence of periodontal disease (14). A 50% prevalence of high SOC also was considered in the sample calculation, and corresponded to the highest and final value. After adding a samples loss of 30%, considering the possibility of losses and refusals, the sample size was 342, of a total of 56,558 inhabitants
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in this age group, according to the IBGE. The criterion for inclusion was to be a resident in Jundiaí-SP, between 35 and 44 years-old, with cognitive capacity to answer the questionnaire and agree to participate in the study.
Participants were selected by probabilistic sampling of households. Initially, 30 census sectors and 2 substitute sectors, involving both urban and rural areas, were chosen by sampling interval. For the calculation of the households, it was considered that one adult would be found in every two households visited (15) Thus, 640 households were randomly selected for sample interval Residents of 330 households in the 32 sectors were examined, resulting in a 48.4% non-response rate. They were at home either at the time of the visit, or during a conveniently scheduled appointment. Considering that all adults within the age group found in the households were examined, there was no sample loss.
The clinical examinations were carried out at home, under natural lighting without prophylaxis or prior drying, with the aid of CPI probes and intraoral mirrors as recommended by the WHO (WHO, 1997). The examiners were 5 dentists and 3 auxiliaries, hired by the municipality. All were trained and calibrated in a 16 h theoretical and 64 h practical training. The percentage of agreement for the examination of dental caries ranged from 80.4% and 99.2% (kappa 0.72 a 0.98) and for periodontal disease, from 63% to 91% (kappa 0.63 to 0.76), being considered a substantial or higher agreement, according to Landis & Koch (16).
Variables
This was a cross-sectional, observational study. The outcome was the Oral Health Impact Profile (OHIP), measured by the instrument of 14 questions (OHIP-14), which was applied in the form of interviews. For each question, the responses ranged from 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often and 4 = very often (3,17). The evaluation of the questionnaires considered the absence or presence of impact, being absence when all responses were “0” and presence when there was at least one response “1 to 4” to any of the questions (18).
The main independent variable of interest was the SOC, which was investigated using its 13-question version (SOC-13), adapted transculturally by Bonanato et al. (2009). The questions include the 5 to 1 response on a Likert scale. The correction of the questionnaires was performed after the reversal of scores of questions 4, 5, 6, 7, 8, 9, 10, 11 and 12. The sum of the values of the SOC of the individual responses can range from 13 to 65, with the median being considered the cut-off between a low and a high SOC. In questionnaires in which less than three questions were blank, the average value of the other answers was used in the blank questions,
24
as described by Suominen et al. (2001). The higher the value found, the better the individual's adaptive capacity and the lower the value, the worse this capacity. Also, clinical, demographic and socioeconomic variables, as well as the use of dental services, were collected and used in a model as possible predictor, confounding or effect modifier variables.
Statistical model and analysis
The conceptual theoretical model organized the variables in hierarchical blocks adapted from the model of Andersen & Davison (1997) (Fig. 1). The location of the variable of interest (SOC) is justified based on the work of Suominen et al., (2001).
In the first block of the model are the exogenous variables gender (male or female), ethnicity (self-reported as white or not white (black, yellow, brown or indian) and age (35-39 and 40-49 years).
In the second block are the primary determinants of oral health: 1 – availability of services and information on oral health: type of service used (private, insurance or public) and preventive guidance on oral health (if ever received or not); 2 – Personal characteristics: marital state (living with a companion or without companion), family income (> 4 minimum wages (MW) (MW was approximately U$ 210.00 at the time of the study), 2 to 4 MW and < 2 MW), number of people living in the same house (≤4 or >5 people), level of education (high – university degree, middle – high school or vocational school or low - less than a high school), occupation of the respondent (not manual, manual, or with no activities, like pensioners or unemployed), and SOC (high or low); and 3 – Characteristics of the environment: treated and fluoridated water (received or not).
The third block approaches the variables representing behaviours of oral health: 1 - Use of dental services (<1 year, 1 and 2 years or >3 years since last visit), and the reason/frequency to visit a dentist (routine, pain or does not go to the dentist); 2 – Personal habits: toothbrushing (3 or more times per day or up to 2 times per day), daily flossing (yes or no) and smoking (yes or no); and 3 – Psychosocial characteristic: perception of morbidity (feeling or not the need for dental treatment at the moment).
The fourth block grouped the independent clinically observed variables, which are the presence of dental biofilm on one or more sextants of the mouth or its absence in all sextants (21), the presence of caries (caries component of the DMF index), the presence of periodontal pockets over 4 mm-deep in at least 1 sextant (measured by the Community Periodontal Index
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(CPI), and missing teeth (between 0 and 4 or above 5, being dicothomyzed in the third quartile) (13).
The last block contains the outcome variable of impact on OHRQoL assessed by the OHIP, measured through prevalence of impact in at least one of the 14 questions.
Figure 1. Adapted conceptual framework for outcome Oral Health Impact Profile
Font: Aging, Ethnicity and Oral Health Outcomes: A conceptual Framework (20).
The data was organized in an Excel® datasheet. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 20.0. Simple descriptive statistics was used to describe the sample, with absolute and percentage distribution of the variables studied.
Bivariate analyses were made to the outcome presence of impact on OHRQoL, considering the prevalence of individuals with any impact on one or more questions or without impact, by single binary logistic regression. The main explanatory variable was SOC, dichotomized between high and low by the median. Then multivariate analyses were made using the hierarchical binary logistic regression, according to the theoretical model adapted.
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The variables that showed statistical significance of 5% were kept, adjusted by those which presented p < 0.20. Each block of variables set the subsequent, to obtain the final model.
Results
Table 1 describes the sampling characteristics. A higher prevalence of women (67.1%) and people living with a partner (69.3%) were found. The family income of 44.4% of the examined was ≥ 4 MW, and the number of people living in the same house was between 1 and 4 in 75.1% of cases. The middle level of schooling (38.9%) and non-manual occupation (56.7%) prevailed. Most of the respondents use private services (67%) and visited the dentist for the last time in the last year (53.5%), but many of the surveyed (74.9%) still believed to need dental treatment. Most of respondents claimed that they were brushing 3 times a day (73.4%), and flossing daily (60.2%) their teeth. However, 61.4% of them present dental biofilm in one or more sextants. Untreated caries and periodontal pockets of more than 4 mm were present in 36.5% and 24.3% of the sample, respectively. Among the adults 75% presented less than 5 lost teeth. The SOC score ranged from 37 to 62, with an average of 49.31 (SD=5.79), median of 50 and 54% prevalence of high SOC. The prevalence of any impact measured by the OHIP was 67.9%.
Table 2 presents the results of the bivariate analyses between the OHIP and independent variables of the model proposed. Significant association (p ≤ 0.05) were found with gender, ethnicity, family income, education, occupation, SOC, reason/frequency of visits to the dentist, tooth brushing, perception of morbidity, presence of bacterial biofilm and presence of caries. Variables with a p level ≤ 0.20 were also kept in the model.
The results of the multivariate analyses with hierarchical approach are shown in table 3. After the multivariate regression adjustments, the presence of impact on OHRQoL was more prevalent on adults who have manual occupation (Prevalence Ratio (PR)=2.47, Confidence Interval (CI) 95% 1.24-4.93), on those who perceive the need for dental treatment (PR=2.93, 1.67-5.14), and those who had untreated caries (PR=1.93, 1.07-3.47). Those who presented low SOC had a 2 times higher prevalence of impacts on OHRQoL (PR=2.19, 1.29-3.71). SOC was maintained in the three adjustment blocks of the model.
Tabela 1. Demographic, socioeconomic, psychosocial and clinical characteristics of adults
residents in Jundiai, Brazil, 2014.
Variables blocks n (%) Variables blocks n (%)
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Gender Water supply net
Male 111 (32.5) Treated and fluoridated 288 (84.2)
Female 231 (67.5) Not treated 54 (15.8)
Total 342 (100) Oral Health Behavior
Ethnicity 1. Use of dental services
White skin 241 (70.5) Time since the last appointment
Not white skin 100 (29.2) < 1 year 183 (53.5)
Age Between 1 and 2 years 96 (28.1)
35 to 39 years old 187 (54.7) >3 years 63 (18.4)
40 to 44 years old 155 (45.3) Reason/Frequency to visit a dentist
Primary determinants of Oral Health Routine 215 (62.9)
1. Availability of services and information on oral health
Pain 114 (33.3)
Does not go to the dentist 13 (3.8)
Type of service used 2. Personal habits
Private 229 (67) Frequency of tooth brushing
Insurance 65 (19) ≥ 3 times per day 251 (73.4)
Public 46 (13.5) <2 times per day 91 (26.6)
Preventive orientation on Oral Health Use of dental floss
not received 62 (18.1) No 136 (39.8)
Received 279 (81.6) Yes 206 (60.2)
2. Personal Characteristics Tobacco use
Marital status No 283 (82.7)
Partner 237 (69.3) Yes 58 (17)
No partner 101 (29.5) 3. Psychosocial characteristics
Family income Perception of morbidity
>4 minimum wages 152 (44.4) No 83 (24.3)
2 to 4 minimum wages 99 (28.9) Yes 256 (74.9)
<2 minimum wages 66 (19.3) Oral Health Outcomes
Number of people living in the same house Presence of bacterial biofilm
≤ 4 people 257 (75.1) Yes 210 (61.4)
> 5 people 83 (24.3) No 132 (38.6)
Education Presence of untreated caries
High 103 (30.1) Yes 125 (36,5)
Middle 133 (38.9) No 217 (63,5)
Low 94 (27.5) Presence of periodontal pockets
Occupation (over 4 mm depth)
Not manual 194 (56.7) Yes, at least 1 sextant 83 (24.3)
Manual 85 (24.9) No 259 (75.7))
With no activities 61 (17.8) Missing Teeth
Sense of Coherence (SOC) 5 to 32 lost teeth 141 (41.2)
High 185 (54.4) 0 to 4 lost teeth 200 (58.5)
Low 155 (45.6) Presence of Impacts on OHIP
No 109 (32.1)
Yes 231 (67.9)
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Tabela 2. Bivariate analyzes and p value for presence and absence of impact in adults of
Jundiaí, Brazil, 2014 (it continues).
Absence of Impacts Presence of Impacts
Variables blocks n (%) n (%) p Exogenous variables Gender Male 44 (39.6) 67 (60.4) 0.04 Female 66 (28.6) 165 (71.4) Ethnicity White skin 86 (35.7) 155 (64.3) 0.036
Not white skin 24 (24.0) 76 (76.0)
Age
35 to 39 years old 62 (33.2) 125 (66.8) 0.666
40 to 44 years old 48 (31.0) 107 (69.0)
Primary determinants of Oral Health
2. Personal Characteristics Marital Status Partner 83 (35.0) 154 (65.0) 0.095 No partner 26 (25.7) 75 (74.3) Family income >4 minimum wages 57 (37.5) 95 (62.5) 0.002 2 to 4 minimum wages 31 (31.3) 68 (68.7) < 2 minimum wages 9 (13.6) 57 (86.4)
Number of people living in the same house ≤ 4 people 80 (31.1) 177 (68.9) 0.657 > 5 people 28 (33.7) 55 (66.3) Education High 42 (40.8) 61 (59.2) 0.042 Middle 40 (30.1) 93 (69.9) Low 23 (24.5) 71 (75.5) Occupation Not manual 81 (41.8) 113 (58.2) <0.001 Manual 14 (16.5) 71 (83.5) With no activities 14 (23.0) 47 (77.0)
Sense of Coherence (SOC)
High 74 (40.0) 111 (60.0) 0.001
Low 35 (22.6) 120 (77.4)
Oral Health Behavior
1. Use of dental services
Time since the last appointment
< than 1 year 54 (29.5) 129 (70.5) 0.105
Between 1 and 2 years 39 (40.6) 57 (59.4)
> 3 years 17 (27.0) 46 (73.0)
Reason/Frequency to visit a dentist
Routine 81 (37.7) 134 (62.3) 0.018
Pain 26 (22.8) 88 (77.2)
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Table 2. Bivariate analyzes and p value for presence and absence of impact in adults of Jundiaí, Brazil, 2014 (conclusion).
2. Personal habits
Frequency of tooth brushing
≥3 times per day 93 (37.1) 158 (62.9) 0.001
<2 times per day 17 (18.7) 74 (81.3)
Use of dental floss
No 37 (27.2) 99 (72.8) 0.111 Yes 73 (35.4) 133 (646) Tobacco use No 96 (33.9) 187 (66.1) 0.087 Yes 13 (22.4) 45 (77.6) 3. Psychosocial characteristics Perception of morbidity No 47 (56.6) 36 (43.4) <0.001 Yes 62 (24.2) 194 (75.8)
Oral Health Outcomes
Presence of dental biofilm
Yes 59 (28.1) 151 (71.9) 0.042
No 51 (38.6) 81 (61.4)
Presence of untreated caries
Yes 24 (19.2) 101 (80.8) <0.001
No 86 (39.6) 131 (60.4)
Presence of periodontal pockets (over 4 mm depth)
Yes, at least 1 sextant 20 (24.1) 63 (75.9) 0.071
No 90 (34.7) 169 (65.3)
Missing Teeth
5 to 32 lost teeth 46 (32.6) 95 (67.4) 0.903
0 to 4 lost teeth 64 (32.0) 136 (68.0)
Discussion
The present study showed association between a low SOC and the presence of impact on OHRQoL. That is, between those who had more impacts on quality of life, there was a higher prevalence of low SOC. In addition to SOC, socioeconomic, behavioural and clinical variables were also associated to the impact on OHRQoL. This demonstrates the importance of a conceptual theoretical model for determination of outcomes like OHRQoL, which are multidimensional and depend on multiple contextual factors.
The absence of impact on OHRQoL was reported in the present study by 32.1% of respondents. Some of the participants had difficulties in classifying the answers between “hardly ever” and “occasionally”; therefore, the answer “never” really reported the absence of impact, as observed by Batista et al. (2014). Studies with European adults, reported a prevalence of approximately 60-70% of answer “not at all” and “very seldom”, considered as “no
30
problems” by these authors (8,12). Even considering methodological, socioeconomic, clinical, psychosocial and cultural differences, which could interfere with the self-perception of impact in these two studies and in the present, the SOC maintained an inverse relationship with the impacts on OHRQoL, emphasizing the validity of this kind of study for different socioeconomic and cultural contexts.
The association between impacts in OHRQoL and clinical variables, such as untreated caries, periodontal diseases and dental loss in adults, has been widely shown in the literature, mainly concerning pain and psychological incapacity directly caused by oral diseases (4,18). However, Bandeca et al. (2011) suggested that the presence of these conditions have little influence on the perception of the OHRQoL by Brazilian adults.Similar results were found in the present study, in which only the presence of untreated caries remained significantly associated with the OHIP. Other clinical conditions, not studied here, can also impact the OHRQoL (4, 12, 23), but they are not usually considered in epidemiological surveys.
Although not all clinical variables were associated with the OHRQoL, the perception of positive morbidity had a high influence on the impact. Other studies also showed that there are discrepancies between the real needs and those referred by the patient (24). This suggests that the interpretation of the impact of illness can be considered as subjective and not always be linked to clinical and epidemiological disease detection.
Concerning the socioeconomic factors, already established by the literature as determining for health, risk factors for development of diseases (2) and for a high impact on OHRQoL (4, 22), the present study also showed its association with the impact on OHRQoL. People who worked with manual occupations had a greater impact of oral health on the quality of life. The WHO considers the occupation as an intermediate determinant for health and it is directly connected to the income and education, so it can also determine access to the health services and other resources (25). The fact that those determinants do not reduce the influence of SOC on OHRQoL may confirm the salutogenic assumptions: socioeconomic determinants influence the development of an individual SOC, but in an adult, with an established SOC, such determinants would not change his or her individual perception of quality of life (5). Therefore, individuals with good oral health can perceive it negatively, due to a low SOC, independently of their socioeconomic status.
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Note: The reference category for the multinomial analysis was "presence of impact".
Tabela 3. Associated factors of the presence of impact on OHRQoL in adults of Jundiaí, Brazil , 2014.
Block 1 adjustment Block 1 by 2 adjustment
Blocks 1 and 2 by 3 adjustment
(OHIP-14) PR IC 95% P PR CI 95% p PR CI 95% p PR CI 95% p
Block 1: Primary determinants of Oral Health Family income < 2 minimum wages 2.42 1.04 - 5.63 0.04 2.42 1.04 – 5.61 0.04 1.84 0.73 – 4.64 0.196 2 to 4 minimum wages 1.12 0.64 – 1.98 0.69 1.1 0.62 – 1.95 0.74 0.82 0.45 – 1.51 0.530 >4 minimum wages 1 1 1 Occupation With no activities 1.73 0.84 – 3.57 0.14 1.75 0.84 – 3.61 0.13 1.65 0.81 – 3.35 0.17 1.51 0.73 – 3.1 0.27 Manual 3.07 1.54 – 6.11 <0.001 3.1 1.56 – 6.19 0.001 2.53 1.27 – 5.02 0.008 2.47 1.24 – 4.93 0.01 Not manual 1 1 1 1
Sense of Coherence (SOC)
Low 1.91 1.13 – 3.22 0.02 1.88 1.12 – 3.17 0.02 2.22 1.31 – 3.74 0,003 2.19 1.29 – 3.71 0.004
High 1 1 1 1
Block 2: Oral Health Behavior
Frequency of tooth brushing
<2 times per day 1.16 1.04 – 1.29 0.01 2.00 1.04 – 3.82 0.04 1.83 0.95 – 3.55 0.07
≥3 times per day 1 1 1
Perception of morbidity
Yes 1.35 1.20 – 1.51 <0.001 3.37 2 – 5.83 <0.001 2.93 1.67 – 5.14 <0.001
No 1 1 1
Block 3: Oral Health Outcomes
Presence of untreated caries
Yes 1.52 1.64 – 4.65 0.002 1.93 1.07 – 3.47 0.03
No 1 1
Missing Teeth
5 to 32 lost teeth 1.08 0.96 – 1.22 0.2
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Based on these results, it is possible to suggest changes in the oral health practices directed to adults. If they are only focused on the clinical outcomes and prevention of diseases risk factors, without considering the OHRQoL, the objectives of oral health promotion will not be achieved, changes in behaviors will be less substantial and last for shorter periods. Directing the oral health care to the understanding of the human being as a whole, considering his socioeconomic and cultural context may help humanize, bring close, reduce differences and promote long-lasting healthy oral behaviors (23,26). Within these strategies, the SOC can be used in order to "empower" individuals to identify appropriate resources to cope with stressors, and encourage reflection about the stressful situations, so as to render them comprehensible, manageable and meaningful (27).
One limitation of the present study is the proportion of male and female examined, which may not fully characterize the profile of the population. The higher number of women than men found in their homes is common in home sampling studies, emphasizing the representability of the present study sampling procedure. Also, considering the cross-sectional design of the study, analysis of this subject through qualitative and interventional studies is suggested.
Conclusion
In the present study there was a higher number of adults with low sense of coherence among those who showed a higher prevalence impacts on oral health related quality of life. Untreated caries, manual occupation and positive perception of morbidity were also associated to the impact on OHRQoL. The results suggest that the SOC should be considered in further qualitative and interventional studies assessing the impact of oral health on quality of life.
Acknowledgments
We thank Oral Health Coordination represented by Dr. Luiz Carlos Miyashiro and the Government and Management School of the municipality of Jundiaí for supporting this study. We also thank to the organizers Dr. Maria Cristina Sciamarelli and Dr. Jane R. C. Tonetti, and all participants of this study.
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Competing Financial Interests
The authors have no competing interests.
References
1. 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 Jul;92(7):592– 7.
2. Watt RG, Sheiham A. Integrating the common risk factor approach into a social determinants framework. Community Dent Oral Epidemiol. 2012 Aug;40(4):289–96.
3. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol. 1997 Aug;25(4):284–90.
4. Gabardo MCL, Moysés ST, Moysés SJ. Self-rating of oral health according to the Oral Health Impact Profile and associated factors: a systematic review. Rev Panam Salud Pública. 2013;33(6):439–45.
5. Antonovsky A. Unraveling the mystery of health: How people manage stress and stay well (Jossey Bass Social and Behavioral Science Series). 1st editio. San Francisco, CA, US: Jossey-Bass; 1987. 238 p.
6. Bonanato K, Ramos-jorge ML, Kaeppler KC, Pré-escolares MDC. Trans-Cultural Adaptation and Psychometric Properties of the “ Sense of Coherence Scale ” in Mothers of Preschool Children. Interam J Psychol. 2009;43(31):144–53.
7. Johansson V, Axtelius B, Söderfeldt B, Sampogna F, Paulander J, Sondell K. Multivariate analyses of patient financial systems and oral health-related quality of life. Community Dent Oral Epidemiol. 2010 Oct;38(5):436–44.
8. Boman UW, Wennström A, Stenman U, Hakeberg M. Oral health-related quality of life, sense of coherence and dental anxiety: an epidemiological cross-sectional study of middle-aged women. BMC Oral Health. 2012;12:14.
9. Bernabé E, Watt RG, Sheiham A, Suominen-Taipale AL, Nordblad A, Savolainen J, et al. The influence of sense of coherence on the relationship between childhood socioeconomic
34
status and adult oral health-related behaviours. Community Dent Oral Epidemiol. 2009 Aug;37(4):357–65.
10. Gupta E, Robinson PG, Marya CM, Baker SR. Oral Health Inequalities: Relationships between Environmental and Individual Factors. J Dent Res. 2015 Oct;94(10):1362–8.
11. Davoglio RS, Abegg C, Fontanive VN, Oliveira MMC de, Aerts DRG de C, Cavalheiro CH. Relationship between Sense of Coherence and oral health in adults and elderly Brazilians. Braz Oral Res. 2016;30(1):1–9.
12. Savolainen J, Suominen-Taipale A-L, Hausen H, Harju P, Uutela A, Martelin T, et al. Sense of coherence as a determinant of the oral health-related quality of life: a national study in Finnish adults. Eur J Oral Sci. 2005 Apr;113(2):121–7.
13. World Health Organization. Oral Health Surveys Basic Methods. 4th Editio. Geneva; 1997. 70 p.
14. Brasil. SB Brazil 2010: National Research on Oral Health: main results. Brasília: Livromapas, tab; 2014. 116 p.
15. Roncalli AG, Silva NN da, Nascimento AC, Freitas CHS de M, Casotti E, Peres KG, et al. Relevant methodological issues from the SBBrasil 2010 Project for national health surveys. Cad Saude Publica. 2012;28:s40–57.
16. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977 Mar;33(1):159–74.
17. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol. 2005;33(4):307–14. 18. Batista MJ, Perianes LBR, Hilgert JB, Hugo FN, Sousa MDLR De. The impacts of oral health on quality of life in working adults. Braz Oral Res. 2014;28(1):1–6.
19. Suominen S, Helenius H, Blomberg H, Uutela A, Koskenvuo M. Sense of coherence as a predictor of subjective state of health: results of 4 years of follow-up of adults. J Psychosom Res. 2001 Feb;50(2):77–86.
20. Andersen RM, Davidson PL. Ethnicity, Aging, and Oral Health Outcomes: A Conceptual Framework. Adv Dent Res. 1997 May 1;11(2):203–9.
35
21. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J. 1975 Dec;25(4):229–35.
22. Bandeca MC, Nadalin MR, Calixto LR, Saad JRC, da Silva SRC. Correlation between oral health perception and clinical factors in a Brazilian community. Community Dent Health. England; 2011 Mar;28(1):64–8.
23. Slade GD. Are dental health behaviors rational, after all? J Dent Res. 2013 Jan;92(1):5–6. 24. Lundegren N. Oral health and self-perceived oral treatment need of adults in Sweden. Swed Dent J Suppl. 2012;(223):10–76.
25. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. England; 2008 Nov;372(9650):1661–9.
26. Miettola J, Viljanen AM. A salutogenic approach to prevention of metabolic syndrome: A mixed methods population study. Scand J Prim Health Care. 2013;32(February):217–25. 27. Super S, Wagemakers MAE, Picavet HSJ, Verkooijen KT, Koelen MA. Strengthening sense of coherence: opportunities for theory building in health promotion. Health Promot Int. 2015 Jul 23;(1):dav071.
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3 CONCLUSÃO
No presente estudo houve maior prevalência de impactos na qualidade de vida relacionada a saúde bucal, entre adultos que apresentaram baixo senso de coerência. Também foram associados ao impacto na OHRQoL ter cárie não tratada, ter ocupação manual e percepção positiva de morbidade. Os resultados sugerem um aprofundamento do assunto através de estudos qualitativos e intervencionais e que o SOC seja considerado em estudos que abordam o impacto da saúde bucal na qualidade de vida.
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*De acordo com as normas da UNICAMP/FOP, baseadas na padronização do International Committee of Medical Journal Editors - Vancouver Group. Abreviatura dos periódicos em conformidade com o PubMed.
REFERÊNCIAS*
Ahola AJ, Mikkilä V, Saraheimo M, Wadén J, Mäkimattila S, Forsblom C, et al. Sense of coherence, food selection and leisure time physical activity in type 1 diabetes. Scand J Public Health. 2012 Nov;40(7):621–8.
Almeida AM, Loureiro CA, Araújo VE de. Um estudo transcultural de valores de saúde bucal utilizando o instrumento OHIP-14 (Oral Health Impact Profile) na forma simplificada. UFES Rev Odontol. 2004;6(1):6–15.
Antonovsky A. Unraveling the mystery of health: How people manage stress and stay well (Jossey Bass Social and Behavioral Science Series). 1st editio. San Francisco, CA, US: Jossey-Bass; 1987.
Antonovsky A. The structure and properties of the sense of coherence scale. Soc Sci Med. 1993 Mar;36(6):725–33.
Batista MJ, Lawrence HP, Rosário de Sousa M da L. Impact of tooth loss related to number and position on oral health quality of life among adults. Health Qual Life Outcomes. 2014 Dec 30;12(1):165.
Bernabé E, Kivimäki M, Tsakos G, Suominen-Taipale AL, Nordblad A, Savolainen J, et al. The relationship among sense of coherence, socio-economic status, and oral health-related behaviours among Finnish dentate adults. Eur J Oral Sci. 2009a Aug;117(4):413– 8.
Bernabé E, Newton JT, Uutela A, Aromaa A, Suominen AL. Sense of coherence and four-year caries incidence in Finnish adults. Caries Res. 2012a;46(6):523–9.
38
*De acordo com as normas da UNICAMP/FOP, baseadas na padronização do International Committee of Medical Journal Editors - Vancouver Group. Abreviatura dos periódicos em conformidade com o PubMed.
Bernabé E, Watt RG, Sheiham A, Suominen AL, Vehkalahti MM, Nordblad A, et al. Childhood socioeconomic position, adult sense of coherence and tooth retention. Community Dent Oral Epidemiol. 2012b Feb;40(1):46–52.
Bernabé E, Watt RG, Sheiham A, Suominen-Taipale AL, Nordblad A, Savolainen J, et al. The influence of sense of coherence on the relationship between childhood
socioeconomic status and adult oral health-related behaviours. Community Dent Oral Epidemiol. 2009b Aug;37(4):357–65.
Bernabé E, Watt RG, Sheiham A, Suominen-Taipale AL, Uutela A, Vehkalahti MM, et al. Sense of coherence and oral health in dentate adults: findings from the Finnish Health 2000 survey. J Clin Periodontol. 2010 Nov;37(11):981–7.
Boman UW, Wennström A, Stenman U, Hakeberg M. Oral health-related quality of life, sense of coherence and dental anxiety: an epidemiological cross-sectional study of middle-aged women. BMC Oral Health. 2012;12:14.
Bonanato K, Ramos-jorge ML, Kaeppler KC, Pré-escolares MDC. Trans-Cultural Adaptation and Psychometric Properties of the “ Sense of Coherence Scale ” in Mothers of
Preschool Children. Interam J Psychol. 2009;43(31):144–53.
Brennan DS, Teusner DN. Oral health impacts on self-rated general and oral health in a cross-sectional study of working age adults. Community Dent Oral Epidemiol. 2015
Jun;43(3):282–8.
Cyrino RM, Costa FO, Cortelli JR, Cortelli SC, Cota LOM. Sense of coherence and periodontal health outcomes. Acta Odontol Scand. 2016 Jul 3;74(5):368–73.
Dahl KE, Wang NJ, Skau I, Öhrn K. Oral health-related quality of life and associated factors in Norwegian adults. Acta Odontol Scand. 2011 Jul 19;69(4):208–14.
39
*De acordo com as normas da UNICAMP/FOP, baseadas na padronização do International Committee of Medical Journal Editors - Vancouver Group. Abreviatura dos periódicos em conformidade com o PubMed.
Dantas RAS. Adaptação cultural e validação do Questionário de Senso de Coerência de Antonovsky em uma amostra de pacientes cardíacos brasileiros. Universidade de São Paulo; 2007.
Davoglio RS, Abegg C, Fontanive VN, Oliveira MMC de, Aerts DRG de C, Cavalheiro CH. Relationship between Sense of Coherence and oral health in adults and elderly
Brazilians. Braz Oral Res. 2016;30(1):1–9.
Emami E, Allison PJ, de Grandmont P, Rompré PH, Feine JS. Better oral health related quality of life: type of prosthesis or psychological robustness? J Dent. 2010 Mar;38(3):232–6.
Eriksson M, Lindström B. Validity of Antonovsky’s sense of coherence scale: a systematic review. J Epidemiol Community Health. 2005 Jun;59(6):460–6.
Ferreira CA, Loureiro CA, Araújo VE. Propriedades psicométricas de indicador subjetivo aplicado em crianças. Rev Saude Publica. 2004 Jun;38(3):445–52.
Gabardo MCL, Moysés ST, Moysés SJ. Self-rating of oral health according to the Oral Health Impact Profile and associated factors: a systematic review. Rev Panam Salud Pública. 2013;33(6):439–45.
Guarnizo-Herreno CC, Watt RG, Fuller E, Steele JG, Shen J, Morris S, et al. Socioeconomic position and subjective oral health: findings for the adult population in England, Wales and Northern Ireland. BMC Public Health. 2014;14:1–9.
Gupta E, Robinson PG, Marya CM, Baker SR. Oral Health Inequalities: Relationships between Environmental and Individual Factors. J Dent Res. 2015 Oct;94(10):1362–8.
40
*De acordo com as normas da UNICAMP/FOP, baseadas na padronização do International Committee of Medical Journal Editors - Vancouver Group. Abreviatura dos periódicos em conformidade com o PubMed.
Holde GE, Oscarson N, Tillberg A, Marstrander P, Jönsson B. Methods and background characteristics of the TOHNN study: a population-based study of oral health conditions in northern Norway. Int J Circumpolar Health. 2016;75(2):30169.
Johansson V, Axtelius B, Söderfeldt B, Sampogna F, Paulander J, Sondell K. Multivariate analyses of patient financial systems and oral health-related quality of life. Community Dent Oral Epidemiol. 2010 Oct;38(5):436–44.
Jordan RA, Bodechtel C, Hertrampf K, Hoffmann T, Kocher T, Nitschke I, et al. The Fifth German Oral Health Study (Fünfte Deutsche Mundgesundheitsstudie, DMS V) - rationale, design, and methods. BMC Oral Health. 2014;14(1):161.
Lindmark U, Hakeberg M, Hugoson A. Sense of coherence and its relationship with oral health-related behaviour and knowledge of and attitudes towards oral health. Community Dent Oral Epidemiol. 2011a Dec;39(6):542–53.
Lindmark U, Hakeberg M, Hugoson A. Sense of coherence and oral health status in an adult Swedish population. Acta Odontol Scand. 2011b Jan;69(1):12–20.
Lindmark U, Stenström U, Gerdin EW, Hugoson A. The distribution of sense of coherence’' among Swedish adults: a quantitative cross-sectional population study. Scand J Public Health. 2010 Feb;38(1):1–8.
Lindström B, Eriksson M. Salutogenesis. J Epidemiol Community Health. 2005 Jun;59(6):440–2.
Locker D, Quiñonez C. Functional and psychosocial impacts of oral disorders in Canadian adults: a national population survey. J Can Dent Assoc. 2009 Sep;75(7):521.
41
*De acordo com as normas da UNICAMP/FOP, baseadas na padronização do International Committee of Medical Journal Editors - Vancouver Group. Abreviatura dos periódicos em conformidade com o PubMed.
Locker D, Quiñonez C. To what extent do oral disorders compromise the quality of life? Community Dent Oral Epidemiol. 2011 Feb;39(1):3–11.
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 Jul;92(7):592–7.
Motzer SU, Stewart BJ. Sense of coherence as a predictor of quality of life in persons with coronary heart disease surviving cardiac arrest. Res Nurs Health. 1996 Aug;19(4):287– 98.
Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol. 2005;33(4):307–14.
Quevedo J, Feier G, Agostinho FR, Martins MR, Roesler R. Consolidação da memória e estresse pós-traumático. Rev Bras Psiquiatr. 2003 Jun;25(SUPPL. 1):25–30.
Sanders AE, Slade GD, Lim S, Reisine ST. Impact of oral disease on quality of life in the US and Australian populations. Community Dent Oral Epidemiol. 2009 Apr;37(2):171–81.
Savolainen J, Knuuttila M, Suominen-Taipale L, Martelin T, Nordblad A, Niskanen M, et al. A strong sense of coherence promotes regular dental attendance in adults. Community Dent Health. 2004 Dec;21(4):271–6.
Savolainen J, Suominen-Taipale A, Uutela A, Aromaa A, Härkänen T, Knuuttila M. Sense of coherence associates with oral and general health behaviours. Community Dent Health. 2009 Dec;26(4):197–203.
42
*De acordo com as normas da UNICAMP/FOP, baseadas na padronização do International Committee of Medical Journal Editors - Vancouver Group. Abreviatura dos periódicos em conformidade com o PubMed.
of coherence as a determinant of the oral health-related quality of life: a national study in Finnish adults. Eur J Oral Sci. 2005a Apr;113(2):121–7.
Savolainen JJ, Suominen-Taipale A-L, Uutela AK, Martelin TP, Niskanen MC, Knuuttila MLE. Sense of coherence as a determinant of toothbrushing frequency and level of oral hygiene. J Periodontol. 2005b Jun;76(6):1006–12.
da Silva AN, Vettore M V. Sense of coherence modifies the association between untreated dental caries and dental pain in low-social status women. Community Dent Health. 2016 Mar;33(1):54–9.
Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol. 1997 Aug;25(4):284–90.
Slade GD, Nuttall N, Sanders a E, Steele JG, Allen PF, Lahti S. Impacts of oral disorders in the United Kingdom and Australia. Br Dent J. 2005 Apr 23;198(8):489–93; discussion 483.
Thomson WM, Mejia GC, Broadbent JM, Poulton R. Construct validity of Locker’s global oral health item. J Dent Res. 2012 Nov 1;91(11):1038–42.
Watt RG, Sheiham A. Integrating the common risk factor approach into a social determinants framework. Community Dent Oral Epidemiol. 2012 Aug;40(4):289–96.
WHO. Health21 - health for all in the 21 century. Frank Theakston, editor. World Heal. Organ. Eur. Heal. All Ser. Copenhagen, Denmark: WHO Library Cataloguing in Publication Data; 1998.
43
*De acordo com as normas da UNICAMP/FOP, baseadas na padronização do International Committee of Medical Journal Editors - Vancouver Group. Abreviatura dos periódicos em conformidade com o PubMed.
World Health Organization. Oral health [Internet]. Media Centre, Fact Sheet No318. 2012 [cited 2016 Jun 15]. p. 1–4. Available from:
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