Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ
NESA Publicação oficial
ISSN: 2177-5281 (Online)
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Páginas 25 a 32
Autores: Tássia Silvana Borges1; Cézane Priscila Reuter2; Natalí Lippert Schwanke3; Léo Kraeter Neto4; Gladis Benjamina Grazziotin5; Miria Suzana Burgos6
1. Doctoral student, Luterana do Brasil University (ULBRA) Canoas, Rio Grande do Sul State, Brazil. Master's Degree in Health Promotion, Santa Cruz do Sul University (UNISC). Santa Cruz do Sul, Rio Grande do Sul State, Brazil
Miria Suzana Burgos
How to cite this article
Keywords: Dental caries, obesity, students, epidemiology.
The prevalence of overweight and obesity has risen alarmingly in many of the developed and developing countries, becoming a world-wide public health problem1. This issue is even more concern among children and adolescents, due to countless complications that they may encounter during adulthood, as most obese children become obese adults2,3.
In Brazil, several studies indicate high levels of overweight and obesity among children and adolescents4, associated with nutritional status, parent and child eating habits, parental education levels, family incomes, place of residence, school location and genetic and environmental factors, among other characteristics 5,6. Overconsumption of carbohydrates7, carbonated soft drinks and sugars8 is common among overweight and obese children and adolescents. Moreover, eating these foods is related to the risk of developing tooth decay9.
Despite dropping decay rates in several countries, caries is still rated as a public health problem. According to a nationwide survey conducted in Brazil, only 0.2% of people between 65 and 74 years old are caries-free. For five-year-olds, this figure reaches 46.6% of deciduous teeth, dropping to 43.5% for permanent teeth at 12 years of age 10.
Some studies have thus attempted to link obesity to tooth decay, 11-13 finding both positive and negative associations. Although these studies may demonstrate overweight associated with the prevalence of caries, there are few studies addressing this association among children and adolescents.
In order to bridge this gap, this study attempts to identify the factors associated with the appearance of tooth decay compared to anthropometric indicators among schoolchildren in the Santa Cruz do Sul Municipality, in Southern Brazil.
Study subjects and design
This cross-sectional study consists of a random sample encompassing 623 adolescent boys and girls between 12 and 17 years old. The reference population base for this study was around 12,000 schoolchildren enrolled in government and private schools in this municipality, according to the Education Coordination Office. Sample size calculations were drawn up with a 95% confidence interval and 80% sample power, resulting in 373 youngsters taken as representative of this municipality. However, making allowance for possible losses and refusals while collecting the data, this sample was increased to 623 schoolchildren. The study was conducted between April and December 2012.
In order to assess the oral health of schoolchildren, the examination tool was calibrated, with a Kappa test concordance of K=0.90. The oral health assessments were performed at the University Research Laboratory by a pre-trained researcher, using the SB Brazil Project protocol (2010)14. During the oral examination, the pupil and the researcher sat in ordinary classroom chairs in from of a window, in order to obtain as much natural light as possible. Each dental examination lasted an average of ten minutes, using a WHO periodontal probe (ball point) and a flat Nº 5 mouth mirror used for epidemiological surveys,15 all wrapped in surgical paper and autoclaved. No type of radiography was used, with teeth not brushed prior to the examination, with no prophylaxis or drying the teeth. All the codes and criteria were noted on individual datasheets for each pupil. The Decayed, Missing and Filled Teeth (DMFT) Index was used for permanent teeth.
Gender was self-declared by these schoolchildren as male or female on self-completed questionnaires, together with their places of residence, self-defined as living in either rural or urban zones in this municipality. Oral hygiene was also assessed through a questionnaire with questions on brushing frequency, with these replies subsequently categorized as: 1 - 3 times a day; 4 - 5 times a day and 1 - 3 times a week.
Social and economic status was assessed through a questionnaire adapted to the criteria established by the Brazilian Market Research Companies Association (ABEP) 16 with three items scored: family assets, education levels of heads of families, and access to government services. Subsequently, they were classified by social and economic strata aligned with mean household incomes. After these classifications, we worked with Classes A, B, C and D and E in this study.
The Body Mass Index (BMI) was assessed by total body weight (kg)/height (m), 2 subsequently classified by gender and age through the Conde and Monteiro protocol (2006)17 as underweight (
In order to assess the sum of the skin folds and fat percentages, the tricipital and subscapular skin fold measurements were used, obtained through measurements with a Lange caliper. In order to calculate the Fat Percentage (%F) the equation drawn up by Slaughter et al (1988) was used, 18 mentioned by Heyward and Stolarczyk (2000)19, subsequently being classified by the Lonman data (1987)20 apud Heyward and Stolarczyk (2000)19 into six categories: very low, low, excellent, moderately high, high and very high. Subsequently, these categories were classified into three classes: 1) very low and low; 2) excellent and 3) moderately high, high and very high.
Waist circumference was measured by a non-stretch tape at the narrowest part of the body between the ribs and the iliac crest and the hip at the level of the greater trochanter, and then classified under the criteria established by Fernández et al (2004)21, as normal (percentile ≤ 75) and obese (percentile> 75), by gender and age.
This research project was approved by the Research Ethics Committee at the Santa Cruz do Sul University under Protocol Nº 3044/11, compliant with the Declaration of Helsinki. All the participant schoolchildren presented Deeds of Informed Consent duly signed by their parents or guardians.
Experiencing tooth decay was defined by the percentage of schoolchildren presenting at least one decayed, missing or filled tooth (DMFT> 1). The profile of each variable was defined through descriptive statistics, with absolute values and relative percentages. The chi-squared test was used to explore the association between independent variables and the prevalence of caries, with the Poisson regression used for the inferential analyses, using a 5% significance level, run on the SPSS 20.0 for Windows (IBM, USA) software.
Among the 623 schoolchildren assessed, 57.9% were girls, 50.1% lived in urban areas of the municipality and 3.4% belonged to the D and E economic classes. With regard to BMI, overweight reached a prevalence of 15.6%, with obesity at 9.3% of the sample. Waist circumference was rated as large for 15.7% of the sample, with the fat percentage classified as moderately high, high or very high for 45.2% of the schoolchildren. The prevalence of caries reached 63.6% for schoolchildren living in rural areas (p<0001) in the B and C economic classes (p=0.007) (Table 1).
No association was found between tooth decay and overweight (PR: 1.01; CI: 0.8-1.1), obesity (PR: 0.91; CI: 0.7-1.1), large waist circumference (PR: 0.99; CI: 0.8-1.1) and moderately high, high, very high fat percentage (PR: 0.99; CI: 0.7-1.3), as shown in Table 2.
This study of overweight and tooth decay is based on the concept that the consuming sugary foods and beverages,8 together with excess carbohydrates,7 is related to the development of both pathologies. In our study, no association was found between tooth decay and overweight / obesity, waist circumference and fat percentage.
Other research projects have attempted to explore this association. In Rio Grande do Sul State, a survey of 1,528 schoolchildren living in Porto Alegre found no association between BMI and tooth decay22, similar to the study of 1,000 schoolchildren in Hamedan, Iran, by Mojarad and Maybodi (2011)12, which also found no association between tooth decay and obesity. In these studies, the small number of obese children may have influenced the findings towards a negative association between these pathologies, which presumably also occurred in our study.
However, the study of 2,071 schoolchildren between 6 and 10 years old conducted by Willerhausen et al. (2007)23 in Mainz, Germany, noted a positive association between obesity and tooth decay. Through these findings, the authors demonstrated that preventive programs must be implemented, in order to work on nutritional aspects while also encouraging physical activities, as they reported that a lack of physical activity was one of the main reasons for the rising number of overweight and obese children.
Along the same lines, the survey of 2,303 ten-year-old schoolchildren in Sweden conducted by Gerdin et al (2008)11 found a positive association between these variables. Although this association was weak, the authors recommended that dental services and medical and nutritional programs for children should work together, in order to respond to future demands from this public.
Social and economic status presented significant differences for the prevalence of caries in our study. It is known that belonging to less-privilege social classes is a risk factor for tooth decay. These results corroborate the findings of studies by Chu et al. (2012)24 in Hong Kong, China and Lopes et al. (2013)25 in São Paulo, Brazil, in which social and economic status were also associated with greater experience of tooth decay.
Consequently, family incomes directly influence oral health. The lower the income, the poorer the conditions for accessing some treatments and services, in addition to insufficient information on health, thus resulting in social inequalities25. Good oral hygiene habits are rooted in cultural and educational processes that are assimilated by youngsters. However, despite being endowed with sufficient information, some people are not in the habit of performing these tasks, or lack the environmental and residential conditions to do so.
In our study, no association was noted between oral hygiene and tooth decay. Although we found no association between these variables, several studies related poor oral hygiene to the presence of tooth decay 26-29. Regular oral hygiene and healthy eating habits are the main allies for adequate oral health 29. Consequently, we stress that careful assessment of these findings is of the utmost importance, emphasizing that this complex information is extremely hard to evaluate, as it is based on self-reported hygiene habits, which may have influenced the replies of these schoolchildren. The visible plaque rate was not measured for this study.
In a systematic review conducted by Hayden et al. (2013)30 in which they attempted to explain some issues related to obesity and tooth decay, it was found that all the studies presented some constraints, mainly in terms of sample size and BMI assessment characteristics. In our study, we tempted to add other anthropometric factors that could modify the listings found so far in the literature. However, we found no differences after the inclusion of these variables, in terms of the prevalence of caries.
In conclusion, the findings of our study indicated no associations between BMI, waist circumference, fat percentage and tooth decay among schoolchildren in Southern Brazil, although we noted that medium and low social and economic status and rural domiciles were associated with tooth decay among schoolchildren in the Santa Cruz do Sul municipality. This underscores the importance of implementing preventive and alternative activities for promoting oral health. Alternative activities could easily be slotted into extension activities involving undergraduate students in interdisciplinary areas, in addition to actions specifically addressing rural zones in small towns. It is of the utmost importance that health education reaches out to all sectors in these municipalities, steadily pursuing their target populations.
NOTE OF THANKS
We offer our thanks for financial support from the University Level Staff Higher Education Coordination Office (CAPES) through funding for the Private Education Institutions Graduate Studies Support Program (PROSUP). The funding entities were not involved in the study design, the data collection and analysis, the decision to publish or the preparation of the manuscript.
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