Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 2 - Apr/Jun - 2018

Original Article Imprimir 

Páginas 81 a 91


Life style and oral health of Brazilian adolescents from rural settlements

Estilo de vida y salud oral de adolescentes brasileños residentes en asentamientos rurales

Estilo de vida e saúde oral de adolescentes brasileiros residentes em assentamentos rurais

Autores: Suzely Adas Saliba Moimaz1; Milene Moreira Leão2; Luis Felipe Pupim dos Santos3; Nemre Adas Saliba4; Tânia Adas Saliba5

1. Doctor in Preventive and Social Odontology by the Júlio de Mesquita Filho Paulista State University (UNESP), at the Odontology College of Araçatuba. Head Professor of the Odontology College of Araçatuba – Child and Social Department of Odontology, Araçatuba, SP, Brazil
2. Doctor in Preventive and Social Odontology by the Júlio de Mesquita Filho Paulista State University (UNESP), at the Odontology College of Araçatuba. Professor of the Cuiabá University (UNIC Educacional) – Odontology Department, Rondonópolis, MT, Brazil
3. Doctoral fellow of the Post-graduation Program in Preventive and Social Odontology at the Júlio de Mesquita Filho Paulista State University, Odontology College of Araçatuba, Araçatuba, SP, Brazil
4. Doctor in Preventive and Social Odontology by the Júlio de Mesquita Filho Paulista State University (UNESP), at the Odontology College of Araçatuba. Head Professor of the Odontology College of Araçatuba - Child and Social Department of Odontology. Araçatuba, SP, Brazil
5. Doctor in Legal Odontology and Deontology by Unicamp – Campinas State UNiversity. Assistant Professor of the Odonology College of Araçatuba - Child and Social Department of Odontology. Araçatuba, SP, Brazil

Tânia Adas Saliba
Faculdade de Odontologia de Araçatuba - UNESP - Departamento de Odontologia Infantil e Social
Rua José Bonifácio, n° 1193
Araçatuba, SP, Brasil. CEP: 16015-050
(taniasaliba@foa.unesp.br)

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Keywords: Adolescent behavior, oral health, public health, rural population.
Palabra Clave: Comportamiento del adolescente, salud bucal, salud pública, población rural.
Descritores: Comportamento do adolescente, saúde bucal, saúde pública, população rural.

Abstract:
OBJECTIVE: Verify the behavior, habits and the oral health of Brazilian adolescents from rural settlements considering the access inequity to odontological services.
METHODS: In this cross-sectional epidemiological study, 179 adolescents were interviewed using the Global School-based Student Health Survey instrument. Data were collected on caries index, periodontal health, dental services accessibility, diet and hygiene habits, and body mass index.
RESULTS: 53.3% of the respondents had consulted a dentist in the last year. High-caloric food consumption (p = .0465) and toothbrushing only once a day (p = .0172) were associated with gingival bleeding, which was related to unsatisfactory oral health (p = .0082). The presence of caries was associated with insufficient toothbrushing (p = .0001), which was related to chewing difficulty (p = .0098) and being embarrassed to smile (p < .0001).
CONCLUSION: Inequity of access to odontological services resulted in high caries index and gingivitis. Obesity and low-frequency toothbrushing increased the risks of these diseases. The difficulty in access culminated in the aggravation of the dental affections, damaging the chew and the social life of the adolescents.  Public Health Policies to prioritize socially excluded populations area a necessity, as well as Health Promotion strategies to cope oral problems.

Resumen:
OBJETIVO: Verificar el comportamiento, hábitos y condición de salud bucal de los adolescentes brasileños de asentamientos rurales, frente a la desigualdad de acceso a los servicios odontológicos.
MÉTODOS: En este estudio epidemiológico, transversal, fueron entrevistados y examinados 179 adolescentes empleando el instrumento Global School-based Student Health Survey. Se recolectaron datos sobre índice de caries, salud bucal, acceso a los servicios odontológicos, hábitos alimenticios y de higiene, Índice de Masa Corporal (IMC), con foco en el Índice CPOD (dientes cariados, perdidos y obturados) y en el Índice Periodontal Comunitario (IPC ). IMC, con foco en el CPOD e IPC.
RESULTADOS: El 53.3% de los entrevistados consultó a un dentista en el último año. Hubo asociación entre dolor y alto predominio de caries (p = 0.0011). La ingesta de alimentos calóricos y cepillados dentales realizados una vez al día estuvieron asociados al sangrado gingival (p = 0.0465; p = 0.0172, respectivamente), resultando en insatisfacción con la salud bucal (p = 0.0082). Se observó asociación entre caries y falta de cepillado (p = 0.0001), causando dificultad para masticar (p = 0.0098) y vergüenza al sonreír (p = .0098).
CONCLUSIÓN: La desigualdad de acceso a los servicios odontológicos resultó en un alto índice de caries y gingivitis. La obesidad y el cepillado de baja frecuencia aumentaron los riesgos de estas enfermedades. La dificultad en el acceso culminó en el agravamiento de las afecciones dentales, perjudicando la masticación y la vida social de los adolescentes. Hay necesidad de políticas públicas de salud que prioricen esa población socialmente excluida así como el perfeccionamiento de estrategias de promoción de la salud para ayudar a lidiar con los problemas orales.

Resumo:
OBJETIVO: Verificar o comportamento, hábitos e condição de saúde bucal de adolescentes brasileiros de assentamentos rurais frente à inequidade de acesso aos serviços odontológicos.
MÉTODOS: Neste estudo epidemiológico, transversal, foram entrevistados e examinados 179 adolescentes empregando o instrumento Global School-based Student Health Survey. Foram coletados dados sobre índice de cáries, saúde bucal, acesso aos serviços odontológicos, hábitos alimentares e de higiene, Índice de Massa Corpórea (IMC), com foco no Índice CPOD (dentes cariados, perdidos e obturados) e no Índice Peridontal Comunitário (IPC). IMC, com foco no CPOD e IPC.
RESULTADOS: 53.3% dos entrevistados consultou um dentista no último ano. Houve associação entre dor e alta prevalência de cárie (p=0.0011). A ingestão de comidas calóricas e escovação dentária realizada uma vez/dia estiveram associadas ao sangramento gengival (p =0.0465; p=0.0172, respectivamente), resultando em insatisfação com a saúde bucal (p=0.0082). Houve associação entre cárie e falta de escovação (p=0.0001), causando dificuldade para mastigar (p=0.0098) e vergonha ao sorrir (p=.0098).
CONCLUSÃO: A inequidade de acesso aos serviços odontológicos resultou em alto índice de cárie e gengivite. A obesidade e a escovação dentária em baixa frequência aumentaram os riscos destas doenças. A dificuldade no acesso culminou no agravamento das afecções dentárias, prejudicando a mastigação e a vida social dos adolescentes. Há necessidade de políticas públicas de saúde que priorizem essa população socialmente excluída assim como o aprimoramento de estratégias de promoção da saúde para ajudar a lidar com os problemas orais.

INTRODUCTION

Social disparities in access to health services have gained prominence in public health research, aiming to acquire subsidies for new policies that sustain the provision of services in a universal and equitable way.1

When it comes to socially excluded populations, such as those in rural and remote areas, difficulties in access are evident in view of the scarcity of health facilities in rural areas, the lack of infrastructure in health promotion sites, and the demotivation of professionals to work in distant areas, aggravated by the lack of affinity and commitment to the public service1.

Rural settlements originate in the search for agrarian reform. Unproductive lands are invaded by landless families, where they camp without any sanitary conditions. After granting and dividing the land, families move from camps to settlements, with the formation of a rural settlement2.

In Brazil, residents of rural settlements are assisted by doctors, dentists and nurses who work in health centers in the rural area, since the government has guaranteed investments that support the establishment of these centers in order to prevent harmful habits, health and chronic diseases2.

With regard to dental care, inequality in access among rural populations can lead to aggravation of oral diseases resulting in irreversible losses and damages and impairments in quality of life3. Among oral problems, caries and periodontitis are notable for reaching predominantly rural populations, generating social damages to individuals. Habits and lifestyle may interfere with oral health, increasing the chances of development of these diseases4.

The CPO-D index (decayed, missing and filled teeth) is around three among Brazilian adolescents between 11 and 14 years of age, and almost six among young people between 15 and 19 years of age and residents of the rural zone5. When flossing isn´t a common practice, gingivitis and periodontitis are more likely to occur, jeopardizing the fixation of the teeth in the jaws6. The lack of care for the population with this dental condition tends to result in a population with young edentulous adults, and in the respective losses and damages to general health5.

In view of the disparities in access to oral health services, the challenge is to follow a non-cariogenic diet, dental brushing and daily flossing, and distancing from harmful habits such as alcohol and tobacco consumption, in order to avoid the acquisition of oral affections6. In this aspect, the objective of this research was to verify the behavior, habits and oral health condition of Brazilian adolescents from rural settlements in face of the inequality of access to dental services.


METHODOLOGY

A cross - sectional epidemiological study with exploratory, descriptive and analytical surveys was carried out in which all adolescents from a rural settlement (Caiuá, São Paulo, Brazil) were invited to be part of the research. In the settlement there are two small villages with a Family Health Unit in each of them, offering medical, dental, and nursing care. In one of these villages is the school that serves all the rural adolescent residents of the municipality.

For the World Health Organization (WHO), adolescence comprises the age group between 10 and 19 years. As in Brazil, regular primary and secondary education comprises young people between the ages of six and seventeen, the study was conducted in the school itself, in which 349 adolescents are enrolled. Because they belong to low-income families, they receive financial assistance from the Federal Government (Bolsa Família) and for the maintenance of the same, young people can´t miss school, thus facilitating the approach with the study population. Data collection was performed during class period, in a place reserved for them not to cause embarrassment and/or coercion. The research was approved by the Committee of Ethics in Research with Human Beings of the Paulista State University - Odontology College of Araçatuba, and the ethical rigors were followed in conducting the research.

Among all the adolescents interviewed and examined, only those whose parents / guardians authorized participation in the survey, those who agreed, and those who allowed the oral exam were included in the sample. Students who were absent on the days scheduled for oral examination and / or interviews were not included in the sample and were not found after three consecutive attempts.

The GSHS-WHO (Global School-based Student Health Survey), developed in 2003 by the WHO to evaluate health risk behaviors among adolescents, was used as the script for the interviews. It was explored the parts of the original instrument that dealt with eating habits and BMI (Body Mass Index) (33 questions), oral hygiene habits and access to dental services (27 questions); alcohol consumption (24 questions) and tobacco (6 questions)7.

To evaluate the dental and periodontal condition, the adolescents underwent oral examination by a single calibrated researcher whose intra-examiner Kappa test was 0.88, obtained in a pilot study previously performed with other adolescents from other rural areas of the region, in order to adapt the methodology . The examinations followed WHO guidelines for epidemiological studies.

During the oral examination, the caries CPOD index was evaluated, which measures the number of decayed and missing teeth and the CPI (Periodontal Community Index), which evaluates the periodontal/gingival condition of the maxilla and mandible, according to sextants, classifying them (IPC = 1), dental calculus (CPI=2), periodontal pocket between 4 and 5mm deep (CPI=3) and periodontal pocket with 6mm or more (CPI=4) ). A descriptive data analysis was performed to characterize the sample; then the bivariate analyzes were performed, the Chi-square test or Fisher's Exact Test was applied with a 95% confidence interval for both. The software BioEstat 5.3 and SPSS 20.0 were used. The multivariate Logistic Regression analysis was applied to the variables that were statistically significant in the bivariate analyzes.


RESULTS

Among the 349 students who studied in the rural school, 15.2% moved from the settlement to other areas / cities during the duration of the research, 4.3% stopped studying, 0.6% died; 2.3% refused to participate in the survey or had no parent / guardian authorization, 26.4% didn´t respond to all interview questions or didn´t allow oral examination. The final sample consisted of 179 adolescents.

Regarding access to dental services, 55.3% consulted a dental surgeon in the last 12 months, the rest consulted two or more years ago, or were never consulted. Among the 177 who visited a dental surgeon, the main reason for the last consultation was pain resulting from a problem in the teeth / gingiva (69.5%), followed by routine consultations (16.4%) and continued dental treatment (14.1% ).

Data on dietary habits and oral hygiene, social behavior regarding the oral health condition and the Mann-Whitney test result among the variables are presented in table 1.




Habits related to alcohol and tobacco consumption are presented in table 2. There was no association between alcohol consumption and tobacco with dental caries, or with gingivitis / periodontitis. Among those interviewed, 13.4% were overweight.




Table 3 shows the composition of the DMFT index by age, gender and components of the index. Among all treatment needs, restorative procedures were the most prevalent (97.3%). When questioned about the self-perception of the dental condition, 35.8% described it as "good", 58.7% as "regular" and 5.5% as bad.




The IPC index ranged from 0 to 3 and 68.2% of the total didn´t present periodontal changes. Analyzing the worst condition among all the sextants examined, it was observed that 24.6% of the interviewees had gingival bleeding (CPI=1), 6.7% dental calculus (CPI=2) and 0.5% with a periodontal pocket between 4 and 5mm depth (IPC =3). There was no sextant with a deep periodontal pocket (≥ 6mm deep). The needs for periodontal treatment focused on preventive actions with hygiene instructions (19.6%) followed by prophylaxis (2.7%). Regarding self-perception of gingival health, 62.6% of the total described it as "good", 33.0% as regular and 4.4% as poor.

In the bivariate analyzes, when adjusting the data according to the median DMFT index (median = 5), an association between high prevalence of caries (DMFT ≥ 5) and the following variables were observed: obesity (p=0.0435), reason for pain at the last visit (p=0.0011) and frequency of daily dental brushing less than three times (p=0.0048).

As for the periodontal condition, gingival bleeding was associated with the ingestion of caloric foods (p=0.046), dental brushing once a day (p=0.0172) and dissatisfaction with oral health (p=0.0082); (p=0.0386) and with the routine reason at the last visit (p=0.0500). In the logistic regression model, there was only association between dental calculus and the reason for the last visit as routine (p=0.0158).


DISCUSSION

Considering that the study population is assisted by two Family Health Units in the rural settlement, and still had worse oral health conditions than the national average, whose DMFT is 4.28, it is suggested that there is a problem of access to since a little more than half of the interviewees consulted frequently with the dental surgeon, and because the pain was the main reason for the consultation. It was also noted that, during the development of the research, analyzes of the fluoride contents present in the artesian wells that supplied the residents of the site were performed, and significant levels of the ion (below 0.15 mgF/L) were not observed. , therefore, another reason that may have contributed to the oral health condition found in the adolescents studied.

There are two ways of interpreting access inequality: first, as a gradient inversely proportional to income per capita and educational level; second, as a serious problem among marginalized parts of a given population, characterized by lack of resources, opportunity, vulnerability and contrasts with the rest of the population9. When inequity of access to health persists, regardless of its interpretive form, the tendency is to find a population with poor oral health status, pain, suffering and significant dental loss10.

Inequality of access to health services persists in many countries, regardless of the profile of each system. Although managers try to contain it with the implementation of new public policies seeking to expand population coverage and access to financing for new projects, the lack of specific legislation on accessibility and the long time provided for the implementation of new strategies become the main barriers11.

Given the disparity in access, the challenge is to maintain good habits and lifestyle in order to prevent the worsening of the oral health condition, highlighting mainly the eating habits. Youth in general have shown the same eating behavior all over the world, even if it comes from different cultures and countries, since it has already adhered to the inclusion of soft drinks, fruit juice, coffee and milk with added sugar in the diet daily12.

However, although oral hygiene is performed, most adolescents are affected by dental caries (97%), due to the cariogenic action of sugar present in these foods and the delay in dental hygiene. Poor hygiene among young rural residents has prevented significant progress in reducing this disease6. Adolescents oriented to the proper brushing technique tend to improve oral hygiene and, consequently, dental and periodontal conditions13.

Inadequate dental hygiene results in biofilm accumulation and consequent gingival inflammation; when uncorrected, gingivitis progresses and affects the periodontium, that is, the supporting structures of the tooth in the alveolar bone4. The higher the educational level, the lower the probability of developing moderate and severe periodontitis4.

Beer consumption has also increased among young rural residents. Family environments, whose habits include the deliberate consumption of alcoholic beverages, stimulate the same customs in the children who live in these environments, adhering to it, since the beginning of adolescence14. In observing the data, it was noticed that the families of the young people interviewed raised their children in a hostile environment regarding the consumption of alcoholic beverages, making them more vulnerable to addiction and chemical addiction. Although the sale of alcoholic beverages is prohibited for minors under 18 years in Brazil, their consumption by young people would not be avoided, since the relatives themselves would not prevent such a habit, after all, just over 8% reported that the minority was not an impediment in the purchase of these beverages.

The population of this study has no leisure options and therefore considers the use of alcoholic beverage as a form of fun, whose habit is common for almost all members of the family. In another aspect, oral hygiene habits by consumers of alcoholic beverages are unsatisfactory and therefore result in halitosis and gingival alterations15.

In the same way smoking starts, which is also a contributing factor for the worsening of periodontitis and social damage; the frequent consumption of cigarettes can increase by almost three times the chances of an individual developing periodontal problems15.

Overweight is another significant indicator for chronic diseases as early as adolescence, especially with regard to periodontitis16. The association between overweight and dental caries is due to the ingestion of a cariogenic diet, rich in sugar and carbohydrates. Obesity should be carefully considered in preventive programs, including the intention to avoid dental caries, especially in relation to interproximal injuries, and should include several health professionals such as dentists and nutritionists in the team.17

The worsening of caries disease generates high rates of dental loss among young adults and, consequently, presents "exodontia" as the most common dental treatment procedure2. In developed countries, consultations with the dental surgeon are regular and preventive, since it is a multifactorial disease, which depends on the presence of specific bacteria, food remains, genetic predisposition, ph of saliva, among other factors. results in a low percentage of restorative and surgical procedures6.

Carious teeth, pain and dental trauma are conditions that impair the quality of life of young people, but can be triggering factors for the search for dental treatment among them, since in social life, good appearance is a criterion for inclusion in some groups of friends18.

The data regarding the social behavior of the young in relation to oral health transcribe the social damages that the lack of oral care brings to the individual, culminating in suffering and dental loss due to lack of care. It should be noted that almost 20% of the study population reported avoiding smiling in public because of their dental appearance, and that almost half of the young people reported satisfaction with the appearance of their own teeth.

At this point, it is justified the intervention of professionals using health education to guide the community about the importance of oral hygiene and the risks resulting from the lack of health care. Consequently, this conduct could be considered a habit of the population in question and / or lack of orientation in oral health. These works with rural youth in a school environment are of paramount importance for the maintenance of the health of this population, as they achieve improvements in oral hygiene habits1 and changes in eating habits19, especially when using methodologies with demonstration and participation of adolescents20.

In this oral health survey of adolescents living in a rural settlement, it was noted that access inequality, habits and behaviors may influence the oral health condition. It was concluded that the difficulty in access to dental services culminates in the deterioration of caries and periodontal disease, which impairs chewing and the social life of adolescents. The oral health condition depends on the lifestyle, habits, customs and behavior of young people, among other aspects. Obesity and low frequency dental brushing increase the risk of caries. Ingestion of caloric foods and insufficient brushing result in gingival bleeding. The persistent inequity in access to dental services by socially excluded populations needs to be addressed through public health policies that achieve the principles of fairness and universality, given the irreversible losses and damages to health, especially with regard to adolescents.


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