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Association Between Untreated Dental Caries
Association Between Untreated Dental Caries
00022015 573
Abstract The aim of the present study was to Resumo O objetivo deste estudo foi avaliar a as-
assess the association between untreated den- sociação entre cárie dentária não tratada (CDNT)
tal caries (UDC) and household food insecurity e insegurança alimentar (IA) em escolares de dife-
(HFI) among schoolchildren in different income rentes estratos de renda. Foi realizado um estudo
strata. A population-based study was carried out de base populacional com uma amostra de 584 es-
with a sample of 584 12-y-old schoolchildren. colares de 12 anos de idade. Exames clínicos bucais
Oral examinations were performed and HFI was foram realizados e IA foi determinada por meio
determined using a validated scale. Other inde- de uma escala validada. Outras variáveis foram
pendent variables were analyzed for being of in- analisadas por serem de interesse para a estratifi-
terest to the stratification of the results (per capita cação dos resultados (renda domiciliar per capita)
household income) or for acting as potential con- ou como variáveis de confusão. A prevalência de
founding variables. The prevalence of UDC and CDNT e IA foi de 45% e 39%, respectivamente.
HFI was 45% and 39%, respectively. The multi- Os modelos multivariados demonstraram que
variate models demonstrated that the UDC was a CDNT foi significativamente mais prevalente
significantly more prevalent among children in entre as crianças com IA alimentar e renda per
food-insecure households with per capita income capita de até US$ 70,71 do que entre aqueles no
of up to US$ 70.71 than among those in the same mesmo estrato de renda que estavam livres de IA
income stratum that were free of HFI [PR = 1.52 [RP = 1,52 (IC 95% = 1,01 -2,29)]. A IA foi as-
(95%CI = 1.01-2.29)]. HFI was associated with sociada com uma maior frequência de CDNT em
1
Departamento de a greater frequency of UDC among low-income escolares de baixa renda, porém não teve impacto
Estomatologia, Universidade
Federal do Paraná. Av. schoolchildren, but had no significant impact on significativo sobre esta variável entre crianças de
Lothário Meissner 632, this variable among children from other income diferentes estratos de renda. Diante disso, garan-
Jardim Botânico. 80210- strata. Thus, ensuring access to quality food may tir o acesso a uma alimentação de qualidade pode
170 Curitiba PR Brazil.
[email protected] be a good strategy for minimizing inequities in representar uma boa estratégia para minimizar as
2
Departamento de oral health and reducing dental caries experience iniquidades em saúde bucal e reduzir a experiên-
Odontologia Preventiva e among schoolchildren from low-income families. cia de cárie dentária em escolares de baixa renda.
Social, Universidade Federal
de Minas Gerais (UFMG). Key words Food insecurity, Dental caries, Child, Palavras-chave Segurança alimentar e nutricio-
Belo Horizonte MG Brasil. Income nal, Cárie dentária, Criança, Renda
3
Departamento de
Odontopediatria e
Ortodontia, UFMG. Belo
Horizonte MG Brasil.
574
Santin GC et al.
mother’s schooling (nine categories ranging children were instructed to chew 2 cm2 of par-
from ‘did not study’ to ‘complete university ed- affin (Parafilm M™, Laboratory Film, Chicago,
ucation’), mother’s marital status (‘married/ USA), swallowing the saliva produced in the first
stable union’, ‘single’, ‘widowed’ and ‘separated/ minute and expectorating the saliva produced in
divorced’), number of children, number of res- the second and third minutes into a disposable
idents in home and monthly household income. plastic recipient. One aliquot of saliva was imme-
Income was analyzed based on the Brazilian diately used for inoculation of culture media on
minimum wage (BMW, equal to US$ 284.00 at the surfaces of the slides of the Dentalcult I and
the time of the study conduction) divided by the II kits. A disk of bacitracin was then deposited on
number of residents in the home for the calcula- the surface of the culture medium of the Den-
tion of per capita household income. The ques- talcult II kit and a CO2 pellet was placed at the
tionnaire also contained a question on access bottom of the flask. The flasks were incubated in
to dental care ‘Did your child ever need dental a microbiological culture incubator at 37° C for
treatment and not received it because of your im- 48 hours (Dentalcult II) or 72 hours (Dentalcult
possibility of affording it or getting an appoint- I). The number of colony-forming units (CFU)
ment for he/she at a public dental service?’ (‘yes’, of MS and LB per mL of saliva in each sample
‘no’) and a question on the time elapsed since was determined by similarities with the bacterial
the child’s last dental visit (‘less than 1 year’, ‘1 levels illustrated in the manufacturer’s manual.
to 3 years ago’, ‘3 to 5 years ago’, ‘over 5 years ago’, The children also answered a question on the
‘never’). frequency with which they brushed their teeth
The Food Frequency Questionnaire was used (‘does not brush’, ‘once a day’, ‘twice a day’, ‘three
for the determination of sugar intake. This ques- or more times a day’).
tionnaire was made up with the 20 foods (solids
and liquids) which contained sugar in its com- Data analysis
position most often reported to be consumed in
the 24-hour logs by the participants in the pilot Data analysis involved the description of the
study (n = 61)35. The participants in the main absolute and relative frequencies of the variables
study were instructed to choose an option (‘nev- according to the response variable ‘UDC’, which
er’, ‘less than once a month’, ‘1 to 3 times a month’, was dichotomized as ‘present’ (D component of
‘once a week’, ‘2 to 4 times a week’, ‘once a day’ DMFT index ≥ 1) or ‘absent’ (D component of
and ‘2 or more times a day’) that came closest DMFT index = 0). Univariate Poisson regression
to their consumption of each of the foods listed analyses were performed to determine associ-
on the questionnaire. Every different food, solid ations between the response variable and inde-
or liquid, that was answered to be consumed at pendent variables. ‘Brushing frequency’, ‘salivary
least once a day was computed and added to as- levels of MS and LB’, ‘marital status’, ‘mother’s
sess the total number of sugary foods consumed schooling’ and ‘time since last dental visit’ were
daily by each child. dichotomized based on theoretic references.
The sweet taste preference was assessed using ‘Number of children’ and ‘number of residents in
a modified version of the Sweet Preference Inven- home’ were dichotomized by the median value.
tory36, having the tea (Mate Leão™, Curitiba, PR, Sugar intake was categorized as ‘0 to 3’, ‘4 to 6’
Brazil) as the vehicle, with the following concen- and ‘ ≥ 7’ sugary foods consumed daily and sweet
trations of sucrose: 0.075 mol/L, 0.15 mol/L, 0.3 preference was categorized as ‘low’, ‘medium’ and
mol/L, 0.6 mol/L and 0.9 mol/L. It was also added ‘high’ concentrations of sugar. Household in-
one sugar free option (0.0 mol/L). The partici- come was categorized based on the Brazilian pov-
pants tasted one solution (30 mL) at a time in erty line, which considers families below fourth
an increasing order of sugar concentration, alter- BMW per capita as in extreme poverty37. Thus, it
nating the ingestion of the solution with saltine was divided into the following strata: ‘per capita
crackers to desensitize the taste buds. At the end income ≤ ¼ BMW’, ‘¼ BMW < per capita income
of the test, the participant chose the solution that ≤ ½ BMW’, ‘½ BMW < per capita income ≤ 1
most pleased him/her. BMW’, per capita income > 1 BMW’. HFI (main
Samples of stimulated saliva were collected explanatory variable) was dichotomized as ‘pres-
for the assessment of lactobacilli (LB) and mu- ent’ (FIS-B score ≥ 1) or ‘absent’ (FIS-B score =
tans streptococci (MS) using the Dentalcult I and 0). Multivariate Poisson regression models with
Dentalcult II laboratory kits (Laborclin™, Pinhais, robust variance were constructed to investigate
PR, Brazil), respectively. In the school setting, the the association between UDC and HFI in each
577
Table 1. FIS-B responses of parent/guardian of 12-year-olds, according to the last three months. Araucária city,
Brazil (n = 538).
Doesn’t know/
Questions Yes No Doesn’t want
n (%) n (%) to answer
n (%)
Were you concerned that the food ran out before the house could 150 (27.9) 327 (60.8) 61 (11.3)
afford to buy or received more?
Did the food run out before you had money to buy more? 88 (16.4) 386 (71.7) 64 (11.9)
Did you run out of money for a healthy, varied diet? 138 (25.7) 340 (63.2) 60 (11.2)
Did you to get by with only a few foods because the money ran out? 125 (23.2) 356 (66.2) 57 (10.6)
Were you unable to offer your children a healthy, varied meal 118 (21.9) 353 (65.6) 67 (12.5)
because you had no money?
Did the children not eat enough because there was no money to buy 54 (10.0) 416 (77.3) 68 (12.6)
more?
Did an adult at home any time decrease the amount of food or skip 58 (10.8) 414 (77.0) 66 (12.3)
meals because there was not enough money to buy more?
Did you ever eat less than felt you should because there was no 54 (10.0) 403 (74.9) 81 (15.1)
money to buy more?
Have you ever felt hungry but did not eat because they could not 38 (7.1) 411 (76.4) 89 (16.5)
afford enough food?
Did any adult at home lose weight because they do not have enough 24 (4.5) 426 (79.2) 88 (16.4)
money to buy food?
Did any adult ever spend a whole day without eating or just had a 31 (5.8) 419 (77.9) 88 (16.4)
meal because there was no money to buy more?
Have you ever reduced the amount of food children’s meals because 42 (7.8) 413 (76.8) 83 (15.4)
there was no money to buy more?
Have you ever had to skip a meal for children because there was no 36 (6.7) 415 (77.1) 87 (16.2)
money to buy food?
Were the children hungry, but you just could not afford more food? 25 (4.6) 429 (79.7) 84 (15.6)
Were the children without food for a whole day because there was 25 (4.6) 428 (79.6) 85 (15.8)
no money to buy more food?
ies was represented by outcomes such as ‘presence that dental caries constitute a multifactor con-
of toothache at night or in the previous month’, dition and confer credibility to both the method
‘denture use’ and ‘previous experience with res- employed and the results obtained regarding HFI.
torations and extractions’ in children between The use of a multivariate model involving ex-
five and 14 years of age in New Zealand24-26 and plicative variables on different levels for the eval-
low-income laborers between 18 and 64 years of uation of the association between HFI and den-
age in Canada27. tal caries is a strong point of the present study,
In the present state of knowledge regarding allowing the avoidance of the interference of
the etiology of dental caries, it is unacceptable confounding variables regarding the effect found
for studies addressing factors associated with this among the variables of interest and ensuring
outcome to disregard its classic determinants, greater accuracy in the findings. Moreover, the
such as demographic, socioeconomic, behavior inclusion of microbiological factors in this analy-
and biological factors. The present study corrob- sis fills a gap often found in field studies. Despite
orates associations reported in the literature be- the recognized importance of biological factors
tween dental caries and the number of children39, in the causal network of caries, it is difficult to
income40-42, number of residents in home43, type evaluate variables that require laboratory sup-
of school43, mother’s schooling41, sugar intake44, port when large samples are involved.
brushing frequency40,42,44 and salivary levels of MS One hypothesis that may explain the asso-
and LB45. These findings strengthen the notion ciation between UDC and HFI is that FI leads
579
PR, prevalence ratio; CI, confidence interval; BMW, Brazilian minimum wage (about US$ 284.00 at the time of the study
conduction).* Frequencies lower than 538 are due to missing data. † Univariate Poisson regression analysis. Results significant at 5%
level marked in bold.
Table 3. Association between untreated dental caries and biological and behavior variables in 12-year-old
schoolchildren. Araucária city, Brazil (n = 538).
had been included in the multiple model, the greater severity of FI in this stratum. In a fami-
statistical significance of HFI was maintained. ly, children are only affected by more severe de-
So, there must be other aspects of FI beyond an grees of FI, whereas adults are the ones affected
increase in sugar intake influencing the dental and children are generally spared in situations of
caries experience. mild degrees of FI49. Moreover, HFI in higher in-
Another strong point of the present study come strata may represent unexpected economic
was the analysis of the association between den- changes in the family structure, with the emer-
tal caries and HFI for each income stratum. In- gence of factors that may temporarily compete
come has been described as the most important with the food budget21 and incapability of man-
variable in the determination of HFI in Brazil47. aging their finances50.
Households with a monthly income of less than In a case-control study comparing families
two times the BMW have an approximately 13- with an income above the poverty line in situa-
fold greater chance of being in a situation of tions of mild FI and those with food security, the
moderate to severe FI and a 2.9-fold chance of authors found that 37.5% of the former reported
being in a situation of mild FI48. As this finding the loss of a job, the gain of another household
was confirmed in the present study and, based member or the loss of food assistance50. Thus,
on the belief that, regardless the collinearity of HFI that affects higher income strata tends to be
these variables, income and FI comprise distinct of short duration, which may not be enough to
constructs, the decision was made to stratify the have an impact on oral health, as tooth decay is a
analyses by income. chronic condition that depends on the exposure
The stratified analyses demonstrated that the time to risk factors.
association between dental caries and HFI does The finding that the association between den-
not occur in the same fashion in the different tal caries and HFI occurs in the lowest income
income strata. The finding that dental caries in stratum suggests the need for food banks and/or
schoolchildren was influenced by HFI only in the assistance programs that can meet the needs of
lowest income stratum may be explained by the these families or income transference programs,
581
which may assist in reducing the prevalence of explained by the fact that low-income families
dental caries. Every 10 Reais (Brazilian curren- with FI cannot afford to pay for dental treatment
cy corresponding to US$ 5.57) in increased in- due to competing financial demands. However,
come in Brazilian families stemming from so- in the present study, 77% of the children report-
cial transference programs increases the odds of ed having visited the dentist in the previous year
food security by 8%, especially in low-income and UDC was not related to difficulties in access
households (per capita income up to ¼ BMW)49. to health services.
In the USA, a study demonstrated that access The present study has the limitations of all
to breakfast at schools reduces the risk of mild cross-sectional studies, especially the lack of
HFI7. Another study realized in the New Zealand temporality, which limits reliability in establish-
observed that offering supermarket vouchers to ing the direction of the associations. The study
family with food-insecurity resulted in an in- design and the assessment tool used for quanti-
crease in overall expenditure on food51. Thus, fying HFI do not allow identifying how long the
there is a need for changes in public policies and individuals surveyed have been in a situation of
health promotion actions. An approach directed FI. HFI represents the conditions of household
solely at the disease factor and its prevention has members as a group and not necessarily the con-
proven ineffective at times and there is a need for dition of any particular member, especially a
interventions that can reduce health inequalities child. Such information would be useful to a bet-
through changes in the determinants of health52. ter understanding of the role of FI as an episodic
As the FIS-B provides information on a recent or cyclic condition in the development of dental
period (previous three months), the decision was caries. As tooth decay has a chronic, cumulative
made to assess tooth decay based on the pres- nature, the effects of FI on oral health are expect-
ence of UDC and not the DMFT index, which ed to be greater when the situation persists for a
includes filled and missing teeth and therefore longer period of time. Thus, longitudinal studies
may reflect a situation prior to the HFI event. using instruments that provide individually ref-
Since untreated caries is also a measure of access erenced food security information for children
to dental care, it would be possible for the mod- are needed to allow a better understanding of the
erating effect of income on HFI to be partially association between dental caries and FI.
582
Santin GC et al.
Conclusions
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