Community Dent Oral Epidemiol 2014; 42; 323–332 All rights reserved
Ó 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Associations between perceived needs for dental treatment, oral health-related quality of life and oral diseases in school-aged Thai children
Sudaduang Krisdapong1, Piyada Prasertsom2, Khanit Rattanarangsima2 and Aubrey Sheiham3 1 Department of Community Dentistry, Chulalongkorn University Bangkok, Thailand, 2Dental Health Division, Department of Health, Ministry of Public Health Nontaburi, Thailand, 3Department of Epidemiology and Public Health, University College London, London, UK
Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Associations between perceived needs for dental treatment, oral health-related quality of life and oral diseases in school-aged Thai children. Community Dent Oral Epidemiol 2014; 42: 323–332. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Abstract – Objectives: To assess perceived needs for dental treatment (PNDT), oral health-related quality of life (OHRQoL) and oral diseases in a Thai schoolaged national representative sample. In addition, relationships between PNDT and various aspects of OHRQoL, different levels of oral diseases as well as sociodemographic characteristics were assessed. Methods: Study sample was a subsample of Sixth Thailand National Oral Health Survey. Data were collected on 1063 12-year-olds and 811 15-year-olds through oral examinations, interviews on PNDT and OHRQoL, using Child-Oral Impacts on Daily Performances (Child-OIDP) or Oral Impacts on Daily Performances (OIDP) indices and questionnaires containing questions on sociodemographic information. Results: Prevalence rates of PNDT were 60.4% in 12-year-olds and 67.6% in 15-year-olds. PNDT were highly associated with OHRQoL with significant odds ratios that increased incrementally by the intensity of oral impacts. Oral impacts on eating, emotional stability and smiling and those attributed specifically to dental caries, periodontal diseases, malocclusion and tooth discolouration were associated with PNDT. The chances of having PNDT increased by number of untreated decayed teeth. Periodontal disease was associated with PNDT only when occurring to a great extent. Boys and children in some regional rural areas were less likely than girls and those living in Bangkok to have PNDT. Conclusions: Perceived needs for dental treatment were common and highly associated with levels of oral impacts, specifically impacts on eating, emotional stability and smiling performances. PNDT were also related to number of untreated decayed teeth, a great extent of periodontal disease, sex and geographical region.
Assessing subjective perceptions of oral health is becoming an integral part in planning dental services as the scope of oral health services and clinical practices has expanded to include people or patients’ perceptions, rather than focusing only on the presence/absence of oral diseases (1). Subjecdoi: 10.1111/cdoe.12092
Key words: dental caries; normative need; perceived need; periodontal disease; quality of life Sudaduang Krisdapong, Department of Community Dentistry, Faculty of Dentistry, Chulalongkorn University, Henri Dunant Road, Patumwan, 10330 Bangkok, Thailand Tel.: +66 2 2188543-4 Fax: +66 2 2188545 e-mail: [email protected] Submitted 28 December 2012; accepted 7 December 2013
tive perceptions of oral health can be measured using oral health-related quality of life (OHRQOL) indices to systematically assess oral impacts that adversely affect OHRQoL, or using a single question to rate overall oral health status or perceived needs for dental treatment (PNDT) (2, 3). Subjec-
323
Krisdapong et al.
tive perceptions are much more complex than professionally defined oral health or normative needs for dental treatment. The former involves various aspects of oral conditions that relate to people’s daily functioning as well as personal circumstances (4). Links between self-perceived and normative oral health have been extensively investigated. However, most studies focused on OHRQoL attributed to overall oral conditions, not to specific oral diseases (5), whereas studies on normative versus perceived needs focused mainly on orthodontic treatment (6–9). Studies on associations between normative and perceived needs for general dental treatment are very uncommon, particularly among school-aged children. Moreover, PNDT and associated factors in school-aged populations have never been reported on national samples. We have previously investigated the links between OHRQoL, oral diseases and sociodemographic characteristics as well as between oral disease and PNDT (10–13). Oral diseases, such as untreated decay and extensive gingivitis, affected children’s OHRQoL and in particular their eating, cleaning teeth and emotional stability. There are significant but poor associations between oral diseases and PNDT (2, 3, 14–16). There are significant associations between PNDT and overall OHRQoL as well as perceived symptoms such as pain or problems with chewing (2, 15, 17, 18). However, there are no studies identifying specifically which aspects of OHRQoL and which degrees of specific oral diseases influence PNDT although PNDT are considered as consequences of OHRQoL, which are in turn affected by oral disorders (4). According to Wilson and Cleary’s model (19), health perceptions are also influenced by sociodemographic characteristics. Our previous studies showed that sociodemographic characteristics such as region and urbanization were associated with oral diseases and OHRQoL (11, 13). Studies from other countries also found differences in PNDT between regions and residential areas (7, 8, 15, 16, 20). However, multivariate analyses on associations of PNDT with OHRQoL, oral diseases and sociodemographic characteristics have never been reported. Therefore, the objectives of this study were first to assess perceived needs for dental treatment (PNDT), oral health-related quality of life (OHRQoL) and oral diseases in a school-aged national representative sample. Second, to assess the relationships between PNDT and various aspects of OHRQoL, different levels of oral diseases as well as sociodemographic characteristics.
324
Methods Sampling procedure This study was a part of the Sixth Thailand National Oral Health Survey. Due to the practicality and the fact that schoolchildren are the main target of Thailand oral health services, this study was conducted on 12- and 15-year-old age groups. Total sample size of the national survey was 2200 12-year-olds and 1742 15-year-olds. Sample size of this study was calculated (21). However, for practical reasons, we included a random selection of half of the national survey sample, 1100 12-yearolds and 871 15-year-olds, which considerably exceeds the calculated minimum sample size. The national survey applied a stratified multistage sampling method and calculated sample size for each province based on proportion of urban and rural populations, thus constituting an equal probability sample. Samples were randomly drawn from the register of citizens. Full details of the national sample procedures are described elsewhere (21). The study’s protocol was approved by the Ethics Committee of Chulalongkorn University.
Steps in data collection Oral examinations and distribution of questionnaires were conducted at schools by a national survey team consisting of eight trained and calibrated dentists. Ten percentage of children were re-examined to test intraexaminer reliability. The intraclass correlation coefficients (ICC) were 0.857 for 12year-olds and 0.926 for 15-year-olds. Interviews on OHRQoL and PNDT were performed at schools by ten trained and calibrated interviewers who are local dentists, two for each province. Interviews were intentionally carried out after the oral examinations to obtain calm conditions that were not possible during the oral examinations. ICC for 10% repeating interviews were 0.863 for 12-year-olds and 0.862 for 15-year-olds.
Variables Four types of data were collected: oral diseases, sociodemographic information, OHRQoL and PNDT. Oral examinations of Thailand National Oral Health Surveys used the WHO (22) criteria. Each tooth was scored for caries-related conditions and missing due to other reasons. Each of the six mouth sextants was assessed for periodontal conditions. The presence of bleeding on probing, calculus or periodontal pockets (only for 15-year-olds) was
Perceived needs for dental treatment in children
impacts were toothache, sensitive tooth, hole in tooth, broken filling), (ii) periodontal disease (perceived causes: inflamed gum, pain in gum, tartar, bad breath), (iii) oral lesions (perceived causes: recurrent aphthous stomatitis (RAS) or other oral lesions such as herpes, dry/cracked lips), (iv) malocclusion (perceived cause: position of tooth/ teeth), (v) discolouration (perceived cause: colour of tooth/teeth), (vi) traumatic dental injuries (perceived cause: fractured tooth), (vii) tooth space due to extracted permanent tooth and (viii) natural process (perceived causes: exfoliating primary tooth or erupting permanent tooth). Univariate analyses were performed to examine associations of sociodemographic variables, oral diseases and OHRQoL with PNDT using chisquare and Mann–Whitney U-tests. Multicollinearity of variables ‘region’ and ‘site’ existed because Bangkok was considered as municipal, while the other four regions consisted of municipal and rural areas. A combined ‘region-site’ variable was created (consisting of nine categories, e.g., Bangkok, Central-urban, Central-rural) and used because the best fit regression models, as indicated by goodness-of-fit using the log-likelihood and pseudo R2, contained this combined variable instead of separate ones. A framework conceptually based on Andersen’s behavioural model (26) was built to illustrate specific relationships between various predictors and PNDT that were investigated in this study (Fig. 1). Significant associations of sociodemographic characteristics with oral diseases and with OHRQoL, as well as associations of oral diseases with OHRQoL, were reported by previous studies on the same sample to this study (11–13). Multivariate analyses were performed using a hierarchical technique (27). Sociodemographic factors are distal determinants that can affect PNDT through oral diseases (i), OHRQoL (ii) and directly (iii). Oral diseases are distal factors that can affect proximal OHRQoL (iv) and directly PNDT (v). OHRQoL exerts its effect on PNDT (vi) (Fig. 1). Multiple logistic regressions for the presence/ absence of PNDT associated with various predictors
considered as periodontal disease. Sociodemographic information included sex, school type (private/public), site (municipal/rural), region (Bangkok/Central/North/South/Northeast), and whether they were receiving dental treatment in the current semester (yes/no) was collected using questionnaires. OHRQoL referred to data on the Child-Oral Impacts on Daily Performances (ChildOIDP) (23) and the Oral Impacts on Daily Performances (OIDP) (24) for 12- and 15-year-olds, respectively. The two indices are conceptually the same. However, the OIDP that had been validated in adolescents and older age groups had more informative scales that were too complicated for 12-year-olds. Consequently, the Child-OIDP with a simple format is recommended for children aged 10–12 years (23). Child-OIDP and OIDP indices assessed oral impacts during the past 3 and 6 months, respectively, in relation to eight daily performances: (i) eating, (ii) speaking, (iii) cleaning teeth, (iv) emotional stability, (v) relaxing, including sleeping, (vi) smiling without feeling embarrassment, (vii) studying and (viii) social contact. For any impact experienced, perceived dental causes were recorded. PNDT were the presence or absence (yes/no) of current perceived dental treatment needs.
Data analysis Stata/SE 10.0 (Stata Corp., College Station, TX., USA) was used for data analysis. Although the Child-OIDP and OIDP indices differ in terms of scales as mentioned above, their outcomes are computed and presented in the same format, that is percentage score ranging from 0 to 100 and intensity classified into six levels of intensity: no impact, very little, little, moderate, severe and very severe (21). In this study, ‘intensity’ was used for classifying overall impacts, because it was shown to better reflect severity of oral impacts rather than total impact scores (25). In addition to overall oral impacts, condition-specific impacts (CS-impacts) attributed to eight types of oral diseases were calculated: (i) dental caries (perceived causes of oral
e a
Sociodemographic characteristics
Oral diseases
d
Oral HealthRelated Quality of Life
f
Perceived needs
b c
Fig. 1. Conceptual hierarchical framework for perceived needs for dental treatment.
325
Krisdapong et al.
were performed in two steps. Partially adjusted models controlled for sociodemographic variables and oral diseases. Fully adjusted models were further controlled for OHRQoL. Three different aspects of OHRQoL– intensity levels of overall impacts, impacts on eight daily performances and CS-impacts–were entered separately in fully adjusted models. Robust standard errors were obtained. Statistical significance was indicated when P-value was 0) Range; mean SD 0–17; 1.6 Untreated decay 445 (41.9) Range; mean SD 0–17; 0.9 Missing teeth for 63 (5.9) any reason Range; mean SD 0–4; 0.1 Periodontal disease 843 (79.3) Range in sextant; 0–6; 2.7 Mean SD OHRQoL Intensity of overall impacts Very little 158 (14.8) Little 374 (35.2) Moderate 203 (19.1) Severe 138 (13.0) Very severe 32 (3.0) Daily performances Eating 683 (64.3) Speaking 135 (12.7) Cleaning teeth 548 (51.6) Relaxing, sleeping 134 (12.6) Emotion 521 (49.0) Smiling 305 (28.7) Study 58 (5.5) Social contact 130 (12.2) Condition-specific impacts Dental caries 507 (47.7) Periodontal 276 (26.0) conditions Oral lesions 274 (25.8) Malocclusion 125 (11.8) Discolouration 87 (8.2) Traumatic dental 16 (1.5) injuries Tooth space 4 (0.4) Natural process 108 (10.2)
15-year-olds N (%) 548 (67.6) 556 (68.6)
2.1 1.6 0.3 2.1
0–16; 2.4 2.7 393 (48.5) 0–16; 1.2 1.9 96 (11.8) 0–4; 0.2 0.5 661 (81.5) 0–6; 2.9 2.1
159 (19.6) 200 (24.6) 250 (30.8) 41 (5.1) 25 (3.1) 520 (64.1) 123 (15.2) 450 (55.5) 70 (8.6) 429 (52.9) 208 (25.6) 48 (5.9) 93 (11.5) 330 (40.7) 240 (29.6) 295 (36.4) 104 (12.8) 64 (7.9) 8 (1.0) 3 (0.4) 17 (2.1)
impacts attributed to natural process, such as exfoliating primary tooth, were also relatively common in 12-year-olds. Univariate analyses revealed that children with PNDT had significantly more untreated decayed teeth, more sextants with periodontal diseases, more severe overall oral impacts and more severe CS-impacts they attributed to dental caries, periodontal diseases, malocclusion and tooth discolouration. There were nonstatistically significant associations between PNDT with CS-impacts attributed to oral lesions and those to natural processes (Table 3).
Multivariate analyses showed that for both age groups, girls were two times more likely than boys to have PNDT (P < 0.001) (Table 4). Children in rural areas in the South and Northeast were significantly less likely to have PNDT compared with children in Bangkok. The chances of having PNDT increased by number of untreated decayed teeth. Overall, children with untreated decay were 2–3 times significantly more likely to have PNDT, compared with those with no untreated decay. Odds ratios (ORs) for three or more untreated decayed teeth were attenuated in the adjusted2 models that included OHRQoL, suggesting a mediating role of OHRQoL on an association of extensive untreated decay with PNDT. The influence of periodontal diseases on PNDT was weaker than that of dental caries. In the adjusted1 models, only the extensive form of periodontal disease, namely, disease occurring in 3–6 sextants, was significantly associated with PNDT with ORs of 1.5–2. Nevertheless, when OHRQoL was entered into the models (adjusted2), the association remained significant only for the 15-year-olds. In 12-year-olds, extensive periodontal disease affected PNDT through OHRQoL. Oral health-related quality of life was highly associated with PNDT with significant ORs that increased by the intensity of oral impacts. For example, 12-year-olds with overall oral impacts at very little, little, moderate, severe or very severe levels were 3.5, 4.2, 8.5 and 15.6 times, respectively, more likely to have PNDT. PNDT were significantly associated only with impacts on three performances, namely, eating, emotional stability and smiling. Associations of four CS-impacts with PNDT remained statistically significant in the adjusted analyses, that is, CS-impacts attributed to dental caries, periodontal diseases, malocclusion and tooth discolouration.
Discussion This is the first study to report the perceived needs for dental treatment (PNDT) in a school-aged national representative sample. Even in this low dental diseases population, PNDT were common and higher than that of Tanzanian school-aged children (17); their lower PNDT might relate to lower level of oral diseases and oral impacts. Even though examinations for malocclusion, fluorosis and traumatic dental injuries were not included in Thailand national oral health survey, the preva-
327
Krisdapong et al. Table 3. Comparisons of mean ranks for specific oral diseases and oral impacts between children with and without perceived needs for dental treatment 12-year-olds (n = 1063)
Independent variables Untreated decay teeth Missing teeth for any reason Periodontal disease sextants Overall oral impacts (intensity) Daily performances (score) Eating Speaking Cleaning teeth Relaxing, sleeping Emotion Smiling Study Social contact Condition-specific impacts (intensity) Dental caries Periodontal conditions Oral lesions Malocclusion Discolouration Traumatic dental injuries Tooth space Natural process
15-year-olds (n = 811)
Presence of perceived needs (mean rank)
Absence of perceived needs (mean rank)
Presence of perceived needs (mean rank)
Absence of perceived needs (mean rank)
466.9 523.3 488.9 407.0
574.7a 537.7 560.3a 614.0a
341.2 401.0 370.7 314.4
437.1a 408.4 422.9b 449.9a
456.8 519.7 478.3 511.1 451.3 466.0 513.1 504.1
581.4a 540.1 567.2a 545.7b 585.0a 575.3a 544.4a 550.3a
337.3 386.9 364.5 394.2 330.6 350.0 395.8 392.3
439.0a 415.2c 425.9a 411.7c 442.2a 432.9a 410.9c 412.6c
444.9 495.3 535.5 507.9 509.4 527.8 532.5 521.1
589.1a 556.1a 529.7 547.8a 546.8a 534.8 531.7 539.2
338.3 366.7 392.9 382.9 386.1 403.6 406.0 405.2
438.5a 424.9a 412.3 417.1b 415.6a 407.2 406.0 406.4
P < 0.001, bP < 0.01, cP < 0.05 (Mann–Whitney U-tests).
a
lence of PNDT was much lower than normative needs (2, 15, 16). Nearly half of the children with normative needs did not have PNDT as found by this study was consistent with the literature in that early stages of oral diseases are considered by professionals as needs for treatment while people might perceive their needs when diseases progress and cause symptoms or interrupt life functioning or emotional or social well-being (2). Indeed, OHRQoL was the strongest predictor of PNDT (2, 15, 17), even after controlling for oral diseases and sociodemographic characteristics. Moreover, the influence of OHRQoL on PNDT related to the type of performance affected. Only impacts on eating, emotional stability and smiling performances independently significantly associated with PNDT. This was consistent with previous studies on adults and elderly people, namely those problems with eating and appearance were the significant predictors of overall perceived needs (15, 28, 29). Studies on need for orthodontics found that ability to chew and appearance were the main reasons for perceived orthodontic treatment needs (30). The strongest predictors of perceived orthodontic treatment
328
needs related to emotional dimension and satisfaction with appearance, while problems with social aspects were the weakest predictor (7, 9). Although clinical data on oral lesions, such as RAS, and natural processes, such as exfoliating primary teeth, were not available, CS-impacts attributed to these two conditions, even when relatively high, were not associated with PNDT. This finding was consistent with a study on older adults reporting that the gap between normative and perceived needs was higher for oral and pharyngeal mucosal lesions compared with dental caries and periodontal diseases (2). In addition, as most of oral lesions were RAS (31), the short period when RAS is present might not provoke PNDT. This study’s findings regarding the four types of CS-impacts, namely, those attributed to dental caries, periodontal conditions, malocclusion and discolouration, that were associated with PNDT agreed with findings of studies on adults and elderly people in the USA, reporting that PNDT were associated with perceived symptoms relating to toothache, cavities, broken filling, loose tooth, stained tooth and appearance, but not with broken tooth and denture (2, 15).
1 0.8 (0.5, 1.1) 1.5 (1.0, 2.1)c
1 0.8 (0.5, 1.1) 1.5 (1.1, 2.0)c
1.2 (1.1, 1.3)a 0.8 (0.6, 1.0) 1.1 (1.0, 1.2) 1.0 (0.8, 1.2) 1.3 (1.1, 1.5)a 1.3 (1.2, 1.5)a 1.5 (1.0, 2.4)
1 1.7 (1.2, 2.4)b 2.5 (1.6, 4.0)a 3.0 (1.9, 4.9)a
1 1.7 (1.2, 2.3)b 2.5 (1.6, 3.8)a 3.1 (2.0, 4.9)a 1 0.7 (0.5, 1.0) 1.3 (0.9, 1.8)
1 1.7 (1.2, 2.4)b 2.4 (1.5, 3.8)b 2.5 (1.5, 4.2)a
1 0.7 (0.4, 1.4) 0.5 (0.4, 1.3) 1.0 (0.5, 1.9) 0.7 (0.4, 1.2) 1.1 (0.5, 2.2) 0.5 (0.3, 0.9)c 0.9 (0.5, 1.5) 0.5 (0.3, 0.8)b
1.3 (1.2, 1.5)a 1.2 (1.0, 1.5)c 1.3 (1.2, 1.4)a 1.3 (1.1, 1.6)b 1.5 (1.3, 1.6)a 1.4 (1.3, 1.6)a 2.0 (1.4, 3.1)b
1 0.9 (0.5, 1.6) 0.8 (0.5, 1.2) 1.9 (1.0, 3.6) 1.0 (0.6, 1.6) 1.8 (0.9, 3.6) 0.7 (0.4, 1.3) 1.3 (0.8, 2.3) 0.7 (0.5, 1.2)
1 1.0 (0.6, 1.8) 0.8 (0.5, 1.2) 2.1 (1.1, 4.0)c 1.1 (0.7, 1.8) 1.8 (0.9, 3.5) 1.0 (0.6, 1.7) 1.5 (0.9, 2.5) 0.8 (0.5, 1.3)
Daily performance scores* Eating Speaking Cleaning teeth Relaxing, sleeping Emotion Smiling Study
1 1.9 (1.4, 2.4)a
1 1.8 (1.4, 2.3)a
1 2.1 (1.6, 2.8)a
Adjusted2 OR (95% CI)
1 3.5 (2.1, 5.8)a 4.2 (2.6, 6.6)a 8.5 (5.0, 14.4)a 15.6 (8.6, 28.2)a Pseudo R2 = 0.16
Adjusted1 OR (95% CI)
1 3.1 (1.9, 4.9)a 3.6 (2.4, 5.4)a 7.3 (4.6, 11.7)a 15.0 (8.7, 26.0)a
Unadjusted OR (95% CI)
Sex Boy Girl Region-site Bangkok Central-municipal Central-rural North-municipal North-rural South-municipal South-rural Northeast-municipal Northeast-rural Untreated decay 0 1 tooth 2 teeth 3/more teeth Periodontal disease 0 1–2 sextants 3–6 sextants Overall oral impacts* None Very little Little Moderate Severe/very severe
Independent variables
12-year-olds (n = 1063)
1.1 (1.1, 1.2)a 1.2 (1.0, 1.3)b 1.1 (1.0, 1.1)b 1.1 (0.9, 1.3) 1.2 (1.2, 1.3)a 1.2 (1.1, 1.4)b 1.3 (1.0, 1.6)c
1 3.0 (1.8, 4.8)a 3.5 (2.2, 5.5)a 5.8 (3.7, 9.2)a 8.8 (4.1, 18.7)a
1 1.1 (0.7, 1.7) 1.8 (1.2, 2.6)b
1 2.1 (1.4, 3.1)a 2.3 (1.4, 4.0)b 3.0 (1.9, 4.8)a
1 0.7 (0.3, 1.4) 0.9 (0.5, 1.6) 1.7 (0.8, 3.7) 1.1 (0.6, 1.9) 1.0 (0.5, 2.2) 0.7 (0.4, 1.2) 0.7 (0.4, 1.2) 0.8 (0.5, 1.4)
1 2.3 (1.7, 3.1)a
Unadjusted OR (95% CI)
15-year-olds (n = 811)
1 1.2 (0.8, 1.9) 2.1 (1.3, 3.2)b
1 1.9 (1.3, 2.9)b 2.4 (1.4, 4.2)b 3.0 (1.8, 4.9)a
1 0.5 (0.2, 1.1) 0.8 (0.4, 1.4) 1.2 (0.5, 2.7) 0.9 (0.5, 1.6) 0.9 (0.4, 2.0) 0.4 (0.2, 0.7)b 0.5 (0.3, 1.0) 0.6 (0.3, 1.1)
1 2.3 (1.7, 3.1)a
Adjusted1 OR (95% CI)
1.1 (1.0, 1.1)c 1.0 (0.9, 1.1) 1.0 (1.0, 1.1) 0.9 (0.7, 1.0) 1.2 (1.1, 1.3)b 1.1 (1.0, 1.2)c 1.1 (0.8, 1.4)
1 3.4 (2.0, 5.7)a 3.8 (2.3, 6.3)a 6.0 (3.6, 10.0)a 9.6 (4.3, 21.7)a Pseudo R2 = 0.15
1 1.1 (0.7, 1.8) 2.0 (1.3, 3.1)b
1 2.0 (1.3, 3.1)b 2.7 (1.6, 4.7)a 2.8 (1.7, 4.6)a
1 0.4 (0.2, 1.1) 0.6 (0.3, 1.2) 0.7 (0.3, 1.6) 0.7 (0.4, 1.3) 0.5 (0.2, 1.2) 0.3 (0.1, 0.5)a 0.4 (0.2, 1.0) 0.6 (0.3, 0.9)b
1 2.1 (1.5, 2.9)a
Adjusted2 OR (95% CI)
Table 4. Logistic regression models for the associations of sociodemographic characteristics, oral diseases and OHRQoL with the presence/absence of perceived needs for dental treatment in Thai children
Perceived needs for dental treatment in children
329
330
1.6 (1.4, 1.8)a 1.4 (1.2, 1.6)a 1.4 (1.1, 1.7)b 1.9 (1.3, 2.8)b 1.5 (1.4, 1.7)a 1.3 (1.1, 1.5)b 1.6 (1.3, 1.9)a 1.8 (1.3, 2.4)a Pseudo R2 = 0.14
P < 0.001, bP < 0.01, cP < 0.05. Adjusted1: adjusted for sociodemographic characteristics and oral diseases; adjusted2: further adjusted for OHRQoL. *Adjusted analyses for overall oral impacts, daily performances and condition-specific impacts were on three separate models, which obtained the same significant levels for sociodemographic and oral disease variables.
Social contact
Condition-specific impacts (intensity)* Dental caries 1.5 (1.4, 1.7)a Periodontal conditions 1.3 (1.2, 1.5)a Malocclusion 1.4 (1.2, 1.6)a Discolouration 1.8 (1.4, 2.3)a
1.6 (1.3, 2.0)a
Independent variables
a
1.5 (1.3, 1.7)a 1.4 (1.2, 1.6)a 1.4 (1.1, 1.7)b 1.6 (1.1, 2.5)c Pseudo R2 = 0.14
1.0 (0.8, 1.1) Pseudo R2 = 0.14 1.2 (0.9, 1.4) 1.1 (0.9, 1.4) Pseudo R2 = 0.14
Unadjusted OR (95% CI) Unadjusted OR (95% CI)
Table 4 Continued
12-year-olds (n = 1063)
1
Adjusted OR (95% CI)
2
Adjusted OR (95% CI)
15-year-olds (n = 811)
Adjusted1 OR (95% CI)
Adjusted2 OR (95% CI)
Krisdapong et al.
Most studies on associations between oral diseases and PNDT did not grade the extent of oral diseases. That might be a reason for the frequently reported weak associations (2, 3, 14–16). The present study clearly showed that probability of having PNDT increased according to the extent of both dental caries and periodontal disease. Similarly, perceived needs for orthodontic treatment were generally strongly associated with severe but not with slight malocclusions (6, 7). This study adds to existing knowledge by showing that that the greater the extent of oral diseases, the more likely that the influence of oral diseases on PNDT is mediated through OHRQoL. That supports findings from previous studies on the same sample that having few untreated decayed teeth or few sextants with periodontal disease did not lead to significant impacts on quality of life (11, 12). This study’s finding confirmed that the presence of dental caries was at all times significantly a predictor of PNDT in various age groups, while findings regarding bleeding gums or poor oral hygiene were equivocal (15, 29, 32). Nonsignificant association of missing teeth with PNDT, found in this study, might be explained by the low numbers of missing teeth at these young ages. In older age groups, missing teeth were associated with PNDT (29). Even when oral diseases and OHRQoL were taken into account, certain sociodemographic characteristics were still significantly associated with PNDT. PNDT were higher in females than males, as reported in various age groups (16, 32). This implies that females in general are possibly more concerned about their own health than males are. Studies on older age groups also found that people who visited dentists more often were more likely to have PNDT (16, 28), while this was not the case in this study. That is probably due to the fact that most of Thai children received free school dental services. There were differences in PNDT between urban and rural populations and also between regions. Urban residents with higher standards of livings tended to perceive dental care needs more than did rural people (15, 16, 20). Regional differences in PNDT were reported by Maharani (20), Josefsson et al. (7) and Li et al. (8), which might reflect cultural differences between regions. Differences in social characteristics might affect children’s perceptions about healthcare needs (19). That might also be the case for Thailand as data from the National Statistical Office Thailand (33) show that there are regional differences in socio-
Perceived needs for dental treatment in children
economic and cultural characteristics such as religion, education attainment and occupation in Thailand. Those factors might explain the difference in PNDT found in this study. Further studies on investigating localized social characteristics that influence health perceptions are recommended. This study has some drawbacks, particularly in relation to steps in data collection. The fact that the children were interviewed after the clinical examination might overestimate prevalence of PNDT, because children might have become more aware of their oral health. Their responses might have been influenced by what the dentists had reported to recorders about their oral status. This methodological drawback might, at least partially, affect the study’s conclusions. Moreover, the Thailand National Oral Health Survey used 15-year-olds as age for the adolescent group due to the ease in approaching such children at schools. However, findings could not be compared to those from other countries where different ages were used. The use of WHO criteria would make findings internationally comparable although there are some limitations. For example, severity of gingivitis/calculus at each site was not recorded. Validation of data on history of receiving dental treatment might be weakened by children’s recall ability. Number of data collectors and fact that they were allocated separately to different geographical areas made interexaminer reliability tests impossible. However, all data collectors were trained and well calibrated before fieldwork, and reliability was ensured through intraexaminer tests. In conclusion, perceived needs for dental treatment (PNDT) in school-aged Thai children were common. PNDT were primarily influenced by level of oral impacts on quality of life, specifically impacts on eating, emotional stability and smiling performances. CS-impacts attributed to oral lesions, such as RAS, and conditions relating natural process, even though frequently experienced, were not associated with PNDT. PNDT were also related to number of untreated decayed teeth and a great extent of periodontal disease. Boys and children in some regional rural areas were less likely than girls and those living in Bangkok to have PNDT.
References 1. Sischo L, Broder HL. Oral health-related quality of life: what, why, how, and future implications. J Dent Res 2011;90:1264–70.
2. Gilbert GH, Heft MW, Duncan RP, Ringelberg ML. Perceived need for dental care in dentate older adults. Int Dent J 1994;44:145–52. 3. Locker D, Jokovic A. Using subjective oral health status indicators to screen for dental care needs in older adults. Community Dent Oral Epidemiol 1996;24:398–402. 4. Locker D. Measuring oral health: a conceptual framework. Community Dent Health 1988;5:3–18. 5. Barbosa TS, Gavi~ ao MB. Oral health-related quality of life in children: part II. Effects of clinical oral health status. A systematic review. Int J Dent Hyg 2008;6:100–7. 6. Kerosuo H, Al Enezi S, Kerosuo E, Abdulkarim E. Association between normative and self-perceived orthodontic treatment need among Arab high school students. Am J Orthod Dentofacial Orthop 2004;125:373–8. 7. Josefsson E, Bjerklin K, Lindsten R. Factors determining perceived orthodontic treatment need in adolescents of Swedish and immigrant background. Eur J Orthod 2009;31:95–102. 8. Li XT, Tang Y, Huang XL, Wan H, Chen YX. Factors influencing subjective orthodontic treatment need and culture-related differences among Chinese natives and foreign inhabitants. Int J Oral Sci 2010;2:149–57. 9. Spalj S, Slaj M, Varga S, Strujic M, Slaj M. Perception of orthodontic treatment need in children and adolescents. Eur J Orthod 2010;32:387–94. 10. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Relationships between oral diseases and impacts on Thai schoolchildren’s quality of life: evidence from a Thai national oral health survey of 12and 15-year-olds. Community Dent Oral Epidemiol 2012;40:550–9. 11. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A, Tsakos G. The impacts of gingivitis and calculus on Thai children’s quality of life. J Clin Periodontol 2012;39:834–43. 12. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Impacts on quality of life related to dental caries in a national representative sample of Thai 12- and 15-year-olds. Caries Res 2012;47:9–17. 13. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Sociodemographic differences in oral health-related quality of life related to dental caries in Thai school children. Community Dent Health 2013;30:112–18. 14. Hancock PA, Blinkhorn AS. A comparison of the perceived and normative needs for dental care in 12year-old children in the northwest of England. Community Dent Health 1996;13:81–5. 15. Heft MW, Gilbert GH, Shelton BJ, Duncan RP. Relationship of dental status, sociodemographic status, and oral symptoms to perceived need for dental care. Community Dent Oral Epidemiol 2003;31:351–60. 16. Colussi CF, De Freitas SF, Calvo MC. The prosthetic need WHO index: a comparison between self-perception and professional assessment in an elderly population. Gerodontology 2009;263:187–92. 17. Mashoto KO, Astrøm AN, David J, Masalu JR. Dental pain, oral impacts and perceived need for dental treatment in Tanzanian school students: a cross-sectional study. Health Qual Life Outcomes 2009;7:73.
331
Krisdapong et al. 18. Seirawan H, Sundaresan S, Mulligan R. Oral healthrelated quality of life and perceived dental needs in the United States. J Public Health Dent 2011;71:194–201. 19. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life: conceptual model of patient outcomes. J Am Med Assoc 1995;273:59–65. 20. Maharani DA. Perceived need for and utilization of dental care in Indonesia in 2006 and 2007: a secondary analysis. J Oral Sci 2009;51(545–5):50. 21. Krisdapong S, Sheiham A, Tsakos G. Oral healthrelated quality of life of 12- and 15-year-old Thai children: findings from a national survey. Community Dent Oral Epidemiol 2009;37:509–17. 22. World Health Organization. Oral health surveys. Basic methods. Geneva: World Health Organization, 1997. 23. Gherunpong S, Tsakos G, Sheiham A. Developing and evaluating an oral health-related quality of life index for children: the Child-OIDP. Community Dent Health 2004;21:161–9. 24. Adulyanon S, Sheiham A. Oral impacts on daily performances. In. Slade GD, editor. Measuring oral health and quality of life. Chapel Hill: University of North Carolina, 1997; 151–60. 25. Krisdapong S, Sheiham A. Which aspects of an oral health-related quality of life measure are mainly associated with global ratings of oral health in children? Community Dent Oral Epidemiol 2013; doi: 10.1111/cdoe.12061 [Epub ahead of print].
332
26. Andersen R. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995;36:1–10. 27. Victora CG, Huttly SR, Fuchs S, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997;26:224–7. 28. Tickle M, Worthington HV. Factors influencing perceived treatment need and the dental attendance patterns of older adults. Br Dent J 1997;182:96–100. 29. Seremidi K, Koletsi-Kounari H, Kandilorou H. Selfreported and clinically-diagnosed dental needs: determining the factors that affect subjective assessment. Oral Health Prev Dent 2009;7:183–90. 30. Tuominen ML, Tuominen RJ. Factors associated with subjective need for orthodontic treatment among Finnish university applicants. Acta Odontol Scand 1994;52:106–10. 31. Krisdapong S, Sheiham A, Tsakos G. Impacts of recurrent aphthous stomatitis on quality of life of 12- and 15-year-old Thai children. Qual Life Res 2012;21:71–6. 32. Mosha HJ, Scheutz F. Perceived need and use of oral health services among adolescents and adults in Tanzania. Community Dent Oral Epidemiol 1993; 21:129–32. 33. National Statistical Office Thailand. The population and housing census 2010. Bangkok: NSO, 2011.
Ó 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Associations between perceived needs for dental treatment, oral health-related quality of life and oral diseases in school-aged Thai children
Sudaduang Krisdapong1, Piyada Prasertsom2, Khanit Rattanarangsima2 and Aubrey Sheiham3 1 Department of Community Dentistry, Chulalongkorn University Bangkok, Thailand, 2Dental Health Division, Department of Health, Ministry of Public Health Nontaburi, Thailand, 3Department of Epidemiology and Public Health, University College London, London, UK
Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Associations between perceived needs for dental treatment, oral health-related quality of life and oral diseases in school-aged Thai children. Community Dent Oral Epidemiol 2014; 42: 323–332. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Abstract – Objectives: To assess perceived needs for dental treatment (PNDT), oral health-related quality of life (OHRQoL) and oral diseases in a Thai schoolaged national representative sample. In addition, relationships between PNDT and various aspects of OHRQoL, different levels of oral diseases as well as sociodemographic characteristics were assessed. Methods: Study sample was a subsample of Sixth Thailand National Oral Health Survey. Data were collected on 1063 12-year-olds and 811 15-year-olds through oral examinations, interviews on PNDT and OHRQoL, using Child-Oral Impacts on Daily Performances (Child-OIDP) or Oral Impacts on Daily Performances (OIDP) indices and questionnaires containing questions on sociodemographic information. Results: Prevalence rates of PNDT were 60.4% in 12-year-olds and 67.6% in 15-year-olds. PNDT were highly associated with OHRQoL with significant odds ratios that increased incrementally by the intensity of oral impacts. Oral impacts on eating, emotional stability and smiling and those attributed specifically to dental caries, periodontal diseases, malocclusion and tooth discolouration were associated with PNDT. The chances of having PNDT increased by number of untreated decayed teeth. Periodontal disease was associated with PNDT only when occurring to a great extent. Boys and children in some regional rural areas were less likely than girls and those living in Bangkok to have PNDT. Conclusions: Perceived needs for dental treatment were common and highly associated with levels of oral impacts, specifically impacts on eating, emotional stability and smiling performances. PNDT were also related to number of untreated decayed teeth, a great extent of periodontal disease, sex and geographical region.
Assessing subjective perceptions of oral health is becoming an integral part in planning dental services as the scope of oral health services and clinical practices has expanded to include people or patients’ perceptions, rather than focusing only on the presence/absence of oral diseases (1). Subjecdoi: 10.1111/cdoe.12092
Key words: dental caries; normative need; perceived need; periodontal disease; quality of life Sudaduang Krisdapong, Department of Community Dentistry, Faculty of Dentistry, Chulalongkorn University, Henri Dunant Road, Patumwan, 10330 Bangkok, Thailand Tel.: +66 2 2188543-4 Fax: +66 2 2188545 e-mail: [email protected] Submitted 28 December 2012; accepted 7 December 2013
tive perceptions of oral health can be measured using oral health-related quality of life (OHRQOL) indices to systematically assess oral impacts that adversely affect OHRQoL, or using a single question to rate overall oral health status or perceived needs for dental treatment (PNDT) (2, 3). Subjec-
323
Krisdapong et al.
tive perceptions are much more complex than professionally defined oral health or normative needs for dental treatment. The former involves various aspects of oral conditions that relate to people’s daily functioning as well as personal circumstances (4). Links between self-perceived and normative oral health have been extensively investigated. However, most studies focused on OHRQoL attributed to overall oral conditions, not to specific oral diseases (5), whereas studies on normative versus perceived needs focused mainly on orthodontic treatment (6–9). Studies on associations between normative and perceived needs for general dental treatment are very uncommon, particularly among school-aged children. Moreover, PNDT and associated factors in school-aged populations have never been reported on national samples. We have previously investigated the links between OHRQoL, oral diseases and sociodemographic characteristics as well as between oral disease and PNDT (10–13). Oral diseases, such as untreated decay and extensive gingivitis, affected children’s OHRQoL and in particular their eating, cleaning teeth and emotional stability. There are significant but poor associations between oral diseases and PNDT (2, 3, 14–16). There are significant associations between PNDT and overall OHRQoL as well as perceived symptoms such as pain or problems with chewing (2, 15, 17, 18). However, there are no studies identifying specifically which aspects of OHRQoL and which degrees of specific oral diseases influence PNDT although PNDT are considered as consequences of OHRQoL, which are in turn affected by oral disorders (4). According to Wilson and Cleary’s model (19), health perceptions are also influenced by sociodemographic characteristics. Our previous studies showed that sociodemographic characteristics such as region and urbanization were associated with oral diseases and OHRQoL (11, 13). Studies from other countries also found differences in PNDT between regions and residential areas (7, 8, 15, 16, 20). However, multivariate analyses on associations of PNDT with OHRQoL, oral diseases and sociodemographic characteristics have never been reported. Therefore, the objectives of this study were first to assess perceived needs for dental treatment (PNDT), oral health-related quality of life (OHRQoL) and oral diseases in a school-aged national representative sample. Second, to assess the relationships between PNDT and various aspects of OHRQoL, different levels of oral diseases as well as sociodemographic characteristics.
324
Methods Sampling procedure This study was a part of the Sixth Thailand National Oral Health Survey. Due to the practicality and the fact that schoolchildren are the main target of Thailand oral health services, this study was conducted on 12- and 15-year-old age groups. Total sample size of the national survey was 2200 12-year-olds and 1742 15-year-olds. Sample size of this study was calculated (21). However, for practical reasons, we included a random selection of half of the national survey sample, 1100 12-yearolds and 871 15-year-olds, which considerably exceeds the calculated minimum sample size. The national survey applied a stratified multistage sampling method and calculated sample size for each province based on proportion of urban and rural populations, thus constituting an equal probability sample. Samples were randomly drawn from the register of citizens. Full details of the national sample procedures are described elsewhere (21). The study’s protocol was approved by the Ethics Committee of Chulalongkorn University.
Steps in data collection Oral examinations and distribution of questionnaires were conducted at schools by a national survey team consisting of eight trained and calibrated dentists. Ten percentage of children were re-examined to test intraexaminer reliability. The intraclass correlation coefficients (ICC) were 0.857 for 12year-olds and 0.926 for 15-year-olds. Interviews on OHRQoL and PNDT were performed at schools by ten trained and calibrated interviewers who are local dentists, two for each province. Interviews were intentionally carried out after the oral examinations to obtain calm conditions that were not possible during the oral examinations. ICC for 10% repeating interviews were 0.863 for 12-year-olds and 0.862 for 15-year-olds.
Variables Four types of data were collected: oral diseases, sociodemographic information, OHRQoL and PNDT. Oral examinations of Thailand National Oral Health Surveys used the WHO (22) criteria. Each tooth was scored for caries-related conditions and missing due to other reasons. Each of the six mouth sextants was assessed for periodontal conditions. The presence of bleeding on probing, calculus or periodontal pockets (only for 15-year-olds) was
Perceived needs for dental treatment in children
impacts were toothache, sensitive tooth, hole in tooth, broken filling), (ii) periodontal disease (perceived causes: inflamed gum, pain in gum, tartar, bad breath), (iii) oral lesions (perceived causes: recurrent aphthous stomatitis (RAS) or other oral lesions such as herpes, dry/cracked lips), (iv) malocclusion (perceived cause: position of tooth/ teeth), (v) discolouration (perceived cause: colour of tooth/teeth), (vi) traumatic dental injuries (perceived cause: fractured tooth), (vii) tooth space due to extracted permanent tooth and (viii) natural process (perceived causes: exfoliating primary tooth or erupting permanent tooth). Univariate analyses were performed to examine associations of sociodemographic variables, oral diseases and OHRQoL with PNDT using chisquare and Mann–Whitney U-tests. Multicollinearity of variables ‘region’ and ‘site’ existed because Bangkok was considered as municipal, while the other four regions consisted of municipal and rural areas. A combined ‘region-site’ variable was created (consisting of nine categories, e.g., Bangkok, Central-urban, Central-rural) and used because the best fit regression models, as indicated by goodness-of-fit using the log-likelihood and pseudo R2, contained this combined variable instead of separate ones. A framework conceptually based on Andersen’s behavioural model (26) was built to illustrate specific relationships between various predictors and PNDT that were investigated in this study (Fig. 1). Significant associations of sociodemographic characteristics with oral diseases and with OHRQoL, as well as associations of oral diseases with OHRQoL, were reported by previous studies on the same sample to this study (11–13). Multivariate analyses were performed using a hierarchical technique (27). Sociodemographic factors are distal determinants that can affect PNDT through oral diseases (i), OHRQoL (ii) and directly (iii). Oral diseases are distal factors that can affect proximal OHRQoL (iv) and directly PNDT (v). OHRQoL exerts its effect on PNDT (vi) (Fig. 1). Multiple logistic regressions for the presence/ absence of PNDT associated with various predictors
considered as periodontal disease. Sociodemographic information included sex, school type (private/public), site (municipal/rural), region (Bangkok/Central/North/South/Northeast), and whether they were receiving dental treatment in the current semester (yes/no) was collected using questionnaires. OHRQoL referred to data on the Child-Oral Impacts on Daily Performances (ChildOIDP) (23) and the Oral Impacts on Daily Performances (OIDP) (24) for 12- and 15-year-olds, respectively. The two indices are conceptually the same. However, the OIDP that had been validated in adolescents and older age groups had more informative scales that were too complicated for 12-year-olds. Consequently, the Child-OIDP with a simple format is recommended for children aged 10–12 years (23). Child-OIDP and OIDP indices assessed oral impacts during the past 3 and 6 months, respectively, in relation to eight daily performances: (i) eating, (ii) speaking, (iii) cleaning teeth, (iv) emotional stability, (v) relaxing, including sleeping, (vi) smiling without feeling embarrassment, (vii) studying and (viii) social contact. For any impact experienced, perceived dental causes were recorded. PNDT were the presence or absence (yes/no) of current perceived dental treatment needs.
Data analysis Stata/SE 10.0 (Stata Corp., College Station, TX., USA) was used for data analysis. Although the Child-OIDP and OIDP indices differ in terms of scales as mentioned above, their outcomes are computed and presented in the same format, that is percentage score ranging from 0 to 100 and intensity classified into six levels of intensity: no impact, very little, little, moderate, severe and very severe (21). In this study, ‘intensity’ was used for classifying overall impacts, because it was shown to better reflect severity of oral impacts rather than total impact scores (25). In addition to overall oral impacts, condition-specific impacts (CS-impacts) attributed to eight types of oral diseases were calculated: (i) dental caries (perceived causes of oral
e a
Sociodemographic characteristics
Oral diseases
d
Oral HealthRelated Quality of Life
f
Perceived needs
b c
Fig. 1. Conceptual hierarchical framework for perceived needs for dental treatment.
325
Krisdapong et al.
were performed in two steps. Partially adjusted models controlled for sociodemographic variables and oral diseases. Fully adjusted models were further controlled for OHRQoL. Three different aspects of OHRQoL– intensity levels of overall impacts, impacts on eight daily performances and CS-impacts–were entered separately in fully adjusted models. Robust standard errors were obtained. Statistical significance was indicated when P-value was 0) Range; mean SD 0–17; 1.6 Untreated decay 445 (41.9) Range; mean SD 0–17; 0.9 Missing teeth for 63 (5.9) any reason Range; mean SD 0–4; 0.1 Periodontal disease 843 (79.3) Range in sextant; 0–6; 2.7 Mean SD OHRQoL Intensity of overall impacts Very little 158 (14.8) Little 374 (35.2) Moderate 203 (19.1) Severe 138 (13.0) Very severe 32 (3.0) Daily performances Eating 683 (64.3) Speaking 135 (12.7) Cleaning teeth 548 (51.6) Relaxing, sleeping 134 (12.6) Emotion 521 (49.0) Smiling 305 (28.7) Study 58 (5.5) Social contact 130 (12.2) Condition-specific impacts Dental caries 507 (47.7) Periodontal 276 (26.0) conditions Oral lesions 274 (25.8) Malocclusion 125 (11.8) Discolouration 87 (8.2) Traumatic dental 16 (1.5) injuries Tooth space 4 (0.4) Natural process 108 (10.2)
15-year-olds N (%) 548 (67.6) 556 (68.6)
2.1 1.6 0.3 2.1
0–16; 2.4 2.7 393 (48.5) 0–16; 1.2 1.9 96 (11.8) 0–4; 0.2 0.5 661 (81.5) 0–6; 2.9 2.1
159 (19.6) 200 (24.6) 250 (30.8) 41 (5.1) 25 (3.1) 520 (64.1) 123 (15.2) 450 (55.5) 70 (8.6) 429 (52.9) 208 (25.6) 48 (5.9) 93 (11.5) 330 (40.7) 240 (29.6) 295 (36.4) 104 (12.8) 64 (7.9) 8 (1.0) 3 (0.4) 17 (2.1)
impacts attributed to natural process, such as exfoliating primary tooth, were also relatively common in 12-year-olds. Univariate analyses revealed that children with PNDT had significantly more untreated decayed teeth, more sextants with periodontal diseases, more severe overall oral impacts and more severe CS-impacts they attributed to dental caries, periodontal diseases, malocclusion and tooth discolouration. There were nonstatistically significant associations between PNDT with CS-impacts attributed to oral lesions and those to natural processes (Table 3).
Multivariate analyses showed that for both age groups, girls were two times more likely than boys to have PNDT (P < 0.001) (Table 4). Children in rural areas in the South and Northeast were significantly less likely to have PNDT compared with children in Bangkok. The chances of having PNDT increased by number of untreated decayed teeth. Overall, children with untreated decay were 2–3 times significantly more likely to have PNDT, compared with those with no untreated decay. Odds ratios (ORs) for three or more untreated decayed teeth were attenuated in the adjusted2 models that included OHRQoL, suggesting a mediating role of OHRQoL on an association of extensive untreated decay with PNDT. The influence of periodontal diseases on PNDT was weaker than that of dental caries. In the adjusted1 models, only the extensive form of periodontal disease, namely, disease occurring in 3–6 sextants, was significantly associated with PNDT with ORs of 1.5–2. Nevertheless, when OHRQoL was entered into the models (adjusted2), the association remained significant only for the 15-year-olds. In 12-year-olds, extensive periodontal disease affected PNDT through OHRQoL. Oral health-related quality of life was highly associated with PNDT with significant ORs that increased by the intensity of oral impacts. For example, 12-year-olds with overall oral impacts at very little, little, moderate, severe or very severe levels were 3.5, 4.2, 8.5 and 15.6 times, respectively, more likely to have PNDT. PNDT were significantly associated only with impacts on three performances, namely, eating, emotional stability and smiling. Associations of four CS-impacts with PNDT remained statistically significant in the adjusted analyses, that is, CS-impacts attributed to dental caries, periodontal diseases, malocclusion and tooth discolouration.
Discussion This is the first study to report the perceived needs for dental treatment (PNDT) in a school-aged national representative sample. Even in this low dental diseases population, PNDT were common and higher than that of Tanzanian school-aged children (17); their lower PNDT might relate to lower level of oral diseases and oral impacts. Even though examinations for malocclusion, fluorosis and traumatic dental injuries were not included in Thailand national oral health survey, the preva-
327
Krisdapong et al. Table 3. Comparisons of mean ranks for specific oral diseases and oral impacts between children with and without perceived needs for dental treatment 12-year-olds (n = 1063)
Independent variables Untreated decay teeth Missing teeth for any reason Periodontal disease sextants Overall oral impacts (intensity) Daily performances (score) Eating Speaking Cleaning teeth Relaxing, sleeping Emotion Smiling Study Social contact Condition-specific impacts (intensity) Dental caries Periodontal conditions Oral lesions Malocclusion Discolouration Traumatic dental injuries Tooth space Natural process
15-year-olds (n = 811)
Presence of perceived needs (mean rank)
Absence of perceived needs (mean rank)
Presence of perceived needs (mean rank)
Absence of perceived needs (mean rank)
466.9 523.3 488.9 407.0
574.7a 537.7 560.3a 614.0a
341.2 401.0 370.7 314.4
437.1a 408.4 422.9b 449.9a
456.8 519.7 478.3 511.1 451.3 466.0 513.1 504.1
581.4a 540.1 567.2a 545.7b 585.0a 575.3a 544.4a 550.3a
337.3 386.9 364.5 394.2 330.6 350.0 395.8 392.3
439.0a 415.2c 425.9a 411.7c 442.2a 432.9a 410.9c 412.6c
444.9 495.3 535.5 507.9 509.4 527.8 532.5 521.1
589.1a 556.1a 529.7 547.8a 546.8a 534.8 531.7 539.2
338.3 366.7 392.9 382.9 386.1 403.6 406.0 405.2
438.5a 424.9a 412.3 417.1b 415.6a 407.2 406.0 406.4
P < 0.001, bP < 0.01, cP < 0.05 (Mann–Whitney U-tests).
a
lence of PNDT was much lower than normative needs (2, 15, 16). Nearly half of the children with normative needs did not have PNDT as found by this study was consistent with the literature in that early stages of oral diseases are considered by professionals as needs for treatment while people might perceive their needs when diseases progress and cause symptoms or interrupt life functioning or emotional or social well-being (2). Indeed, OHRQoL was the strongest predictor of PNDT (2, 15, 17), even after controlling for oral diseases and sociodemographic characteristics. Moreover, the influence of OHRQoL on PNDT related to the type of performance affected. Only impacts on eating, emotional stability and smiling performances independently significantly associated with PNDT. This was consistent with previous studies on adults and elderly people, namely those problems with eating and appearance were the significant predictors of overall perceived needs (15, 28, 29). Studies on need for orthodontics found that ability to chew and appearance were the main reasons for perceived orthodontic treatment needs (30). The strongest predictors of perceived orthodontic treatment
328
needs related to emotional dimension and satisfaction with appearance, while problems with social aspects were the weakest predictor (7, 9). Although clinical data on oral lesions, such as RAS, and natural processes, such as exfoliating primary teeth, were not available, CS-impacts attributed to these two conditions, even when relatively high, were not associated with PNDT. This finding was consistent with a study on older adults reporting that the gap between normative and perceived needs was higher for oral and pharyngeal mucosal lesions compared with dental caries and periodontal diseases (2). In addition, as most of oral lesions were RAS (31), the short period when RAS is present might not provoke PNDT. This study’s findings regarding the four types of CS-impacts, namely, those attributed to dental caries, periodontal conditions, malocclusion and discolouration, that were associated with PNDT agreed with findings of studies on adults and elderly people in the USA, reporting that PNDT were associated with perceived symptoms relating to toothache, cavities, broken filling, loose tooth, stained tooth and appearance, but not with broken tooth and denture (2, 15).
1 0.8 (0.5, 1.1) 1.5 (1.0, 2.1)c
1 0.8 (0.5, 1.1) 1.5 (1.1, 2.0)c
1.2 (1.1, 1.3)a 0.8 (0.6, 1.0) 1.1 (1.0, 1.2) 1.0 (0.8, 1.2) 1.3 (1.1, 1.5)a 1.3 (1.2, 1.5)a 1.5 (1.0, 2.4)
1 1.7 (1.2, 2.4)b 2.5 (1.6, 4.0)a 3.0 (1.9, 4.9)a
1 1.7 (1.2, 2.3)b 2.5 (1.6, 3.8)a 3.1 (2.0, 4.9)a 1 0.7 (0.5, 1.0) 1.3 (0.9, 1.8)
1 1.7 (1.2, 2.4)b 2.4 (1.5, 3.8)b 2.5 (1.5, 4.2)a
1 0.7 (0.4, 1.4) 0.5 (0.4, 1.3) 1.0 (0.5, 1.9) 0.7 (0.4, 1.2) 1.1 (0.5, 2.2) 0.5 (0.3, 0.9)c 0.9 (0.5, 1.5) 0.5 (0.3, 0.8)b
1.3 (1.2, 1.5)a 1.2 (1.0, 1.5)c 1.3 (1.2, 1.4)a 1.3 (1.1, 1.6)b 1.5 (1.3, 1.6)a 1.4 (1.3, 1.6)a 2.0 (1.4, 3.1)b
1 0.9 (0.5, 1.6) 0.8 (0.5, 1.2) 1.9 (1.0, 3.6) 1.0 (0.6, 1.6) 1.8 (0.9, 3.6) 0.7 (0.4, 1.3) 1.3 (0.8, 2.3) 0.7 (0.5, 1.2)
1 1.0 (0.6, 1.8) 0.8 (0.5, 1.2) 2.1 (1.1, 4.0)c 1.1 (0.7, 1.8) 1.8 (0.9, 3.5) 1.0 (0.6, 1.7) 1.5 (0.9, 2.5) 0.8 (0.5, 1.3)
Daily performance scores* Eating Speaking Cleaning teeth Relaxing, sleeping Emotion Smiling Study
1 1.9 (1.4, 2.4)a
1 1.8 (1.4, 2.3)a
1 2.1 (1.6, 2.8)a
Adjusted2 OR (95% CI)
1 3.5 (2.1, 5.8)a 4.2 (2.6, 6.6)a 8.5 (5.0, 14.4)a 15.6 (8.6, 28.2)a Pseudo R2 = 0.16
Adjusted1 OR (95% CI)
1 3.1 (1.9, 4.9)a 3.6 (2.4, 5.4)a 7.3 (4.6, 11.7)a 15.0 (8.7, 26.0)a
Unadjusted OR (95% CI)
Sex Boy Girl Region-site Bangkok Central-municipal Central-rural North-municipal North-rural South-municipal South-rural Northeast-municipal Northeast-rural Untreated decay 0 1 tooth 2 teeth 3/more teeth Periodontal disease 0 1–2 sextants 3–6 sextants Overall oral impacts* None Very little Little Moderate Severe/very severe
Independent variables
12-year-olds (n = 1063)
1.1 (1.1, 1.2)a 1.2 (1.0, 1.3)b 1.1 (1.0, 1.1)b 1.1 (0.9, 1.3) 1.2 (1.2, 1.3)a 1.2 (1.1, 1.4)b 1.3 (1.0, 1.6)c
1 3.0 (1.8, 4.8)a 3.5 (2.2, 5.5)a 5.8 (3.7, 9.2)a 8.8 (4.1, 18.7)a
1 1.1 (0.7, 1.7) 1.8 (1.2, 2.6)b
1 2.1 (1.4, 3.1)a 2.3 (1.4, 4.0)b 3.0 (1.9, 4.8)a
1 0.7 (0.3, 1.4) 0.9 (0.5, 1.6) 1.7 (0.8, 3.7) 1.1 (0.6, 1.9) 1.0 (0.5, 2.2) 0.7 (0.4, 1.2) 0.7 (0.4, 1.2) 0.8 (0.5, 1.4)
1 2.3 (1.7, 3.1)a
Unadjusted OR (95% CI)
15-year-olds (n = 811)
1 1.2 (0.8, 1.9) 2.1 (1.3, 3.2)b
1 1.9 (1.3, 2.9)b 2.4 (1.4, 4.2)b 3.0 (1.8, 4.9)a
1 0.5 (0.2, 1.1) 0.8 (0.4, 1.4) 1.2 (0.5, 2.7) 0.9 (0.5, 1.6) 0.9 (0.4, 2.0) 0.4 (0.2, 0.7)b 0.5 (0.3, 1.0) 0.6 (0.3, 1.1)
1 2.3 (1.7, 3.1)a
Adjusted1 OR (95% CI)
1.1 (1.0, 1.1)c 1.0 (0.9, 1.1) 1.0 (1.0, 1.1) 0.9 (0.7, 1.0) 1.2 (1.1, 1.3)b 1.1 (1.0, 1.2)c 1.1 (0.8, 1.4)
1 3.4 (2.0, 5.7)a 3.8 (2.3, 6.3)a 6.0 (3.6, 10.0)a 9.6 (4.3, 21.7)a Pseudo R2 = 0.15
1 1.1 (0.7, 1.8) 2.0 (1.3, 3.1)b
1 2.0 (1.3, 3.1)b 2.7 (1.6, 4.7)a 2.8 (1.7, 4.6)a
1 0.4 (0.2, 1.1) 0.6 (0.3, 1.2) 0.7 (0.3, 1.6) 0.7 (0.4, 1.3) 0.5 (0.2, 1.2) 0.3 (0.1, 0.5)a 0.4 (0.2, 1.0) 0.6 (0.3, 0.9)b
1 2.1 (1.5, 2.9)a
Adjusted2 OR (95% CI)
Table 4. Logistic regression models for the associations of sociodemographic characteristics, oral diseases and OHRQoL with the presence/absence of perceived needs for dental treatment in Thai children
Perceived needs for dental treatment in children
329
330
1.6 (1.4, 1.8)a 1.4 (1.2, 1.6)a 1.4 (1.1, 1.7)b 1.9 (1.3, 2.8)b 1.5 (1.4, 1.7)a 1.3 (1.1, 1.5)b 1.6 (1.3, 1.9)a 1.8 (1.3, 2.4)a Pseudo R2 = 0.14
P < 0.001, bP < 0.01, cP < 0.05. Adjusted1: adjusted for sociodemographic characteristics and oral diseases; adjusted2: further adjusted for OHRQoL. *Adjusted analyses for overall oral impacts, daily performances and condition-specific impacts were on three separate models, which obtained the same significant levels for sociodemographic and oral disease variables.
Social contact
Condition-specific impacts (intensity)* Dental caries 1.5 (1.4, 1.7)a Periodontal conditions 1.3 (1.2, 1.5)a Malocclusion 1.4 (1.2, 1.6)a Discolouration 1.8 (1.4, 2.3)a
1.6 (1.3, 2.0)a
Independent variables
a
1.5 (1.3, 1.7)a 1.4 (1.2, 1.6)a 1.4 (1.1, 1.7)b 1.6 (1.1, 2.5)c Pseudo R2 = 0.14
1.0 (0.8, 1.1) Pseudo R2 = 0.14 1.2 (0.9, 1.4) 1.1 (0.9, 1.4) Pseudo R2 = 0.14
Unadjusted OR (95% CI) Unadjusted OR (95% CI)
Table 4 Continued
12-year-olds (n = 1063)
1
Adjusted OR (95% CI)
2
Adjusted OR (95% CI)
15-year-olds (n = 811)
Adjusted1 OR (95% CI)
Adjusted2 OR (95% CI)
Krisdapong et al.
Most studies on associations between oral diseases and PNDT did not grade the extent of oral diseases. That might be a reason for the frequently reported weak associations (2, 3, 14–16). The present study clearly showed that probability of having PNDT increased according to the extent of both dental caries and periodontal disease. Similarly, perceived needs for orthodontic treatment were generally strongly associated with severe but not with slight malocclusions (6, 7). This study adds to existing knowledge by showing that that the greater the extent of oral diseases, the more likely that the influence of oral diseases on PNDT is mediated through OHRQoL. That supports findings from previous studies on the same sample that having few untreated decayed teeth or few sextants with periodontal disease did not lead to significant impacts on quality of life (11, 12). This study’s finding confirmed that the presence of dental caries was at all times significantly a predictor of PNDT in various age groups, while findings regarding bleeding gums or poor oral hygiene were equivocal (15, 29, 32). Nonsignificant association of missing teeth with PNDT, found in this study, might be explained by the low numbers of missing teeth at these young ages. In older age groups, missing teeth were associated with PNDT (29). Even when oral diseases and OHRQoL were taken into account, certain sociodemographic characteristics were still significantly associated with PNDT. PNDT were higher in females than males, as reported in various age groups (16, 32). This implies that females in general are possibly more concerned about their own health than males are. Studies on older age groups also found that people who visited dentists more often were more likely to have PNDT (16, 28), while this was not the case in this study. That is probably due to the fact that most of Thai children received free school dental services. There were differences in PNDT between urban and rural populations and also between regions. Urban residents with higher standards of livings tended to perceive dental care needs more than did rural people (15, 16, 20). Regional differences in PNDT were reported by Maharani (20), Josefsson et al. (7) and Li et al. (8), which might reflect cultural differences between regions. Differences in social characteristics might affect children’s perceptions about healthcare needs (19). That might also be the case for Thailand as data from the National Statistical Office Thailand (33) show that there are regional differences in socio-
Perceived needs for dental treatment in children
economic and cultural characteristics such as religion, education attainment and occupation in Thailand. Those factors might explain the difference in PNDT found in this study. Further studies on investigating localized social characteristics that influence health perceptions are recommended. This study has some drawbacks, particularly in relation to steps in data collection. The fact that the children were interviewed after the clinical examination might overestimate prevalence of PNDT, because children might have become more aware of their oral health. Their responses might have been influenced by what the dentists had reported to recorders about their oral status. This methodological drawback might, at least partially, affect the study’s conclusions. Moreover, the Thailand National Oral Health Survey used 15-year-olds as age for the adolescent group due to the ease in approaching such children at schools. However, findings could not be compared to those from other countries where different ages were used. The use of WHO criteria would make findings internationally comparable although there are some limitations. For example, severity of gingivitis/calculus at each site was not recorded. Validation of data on history of receiving dental treatment might be weakened by children’s recall ability. Number of data collectors and fact that they were allocated separately to different geographical areas made interexaminer reliability tests impossible. However, all data collectors were trained and well calibrated before fieldwork, and reliability was ensured through intraexaminer tests. In conclusion, perceived needs for dental treatment (PNDT) in school-aged Thai children were common. PNDT were primarily influenced by level of oral impacts on quality of life, specifically impacts on eating, emotional stability and smiling performances. CS-impacts attributed to oral lesions, such as RAS, and conditions relating natural process, even though frequently experienced, were not associated with PNDT. PNDT were also related to number of untreated decayed teeth and a great extent of periodontal disease. Boys and children in some regional rural areas were less likely than girls and those living in Bangkok to have PNDT.
References 1. Sischo L, Broder HL. Oral health-related quality of life: what, why, how, and future implications. J Dent Res 2011;90:1264–70.
2. Gilbert GH, Heft MW, Duncan RP, Ringelberg ML. Perceived need for dental care in dentate older adults. Int Dent J 1994;44:145–52. 3. Locker D, Jokovic A. Using subjective oral health status indicators to screen for dental care needs in older adults. Community Dent Oral Epidemiol 1996;24:398–402. 4. Locker D. Measuring oral health: a conceptual framework. Community Dent Health 1988;5:3–18. 5. Barbosa TS, Gavi~ ao MB. Oral health-related quality of life in children: part II. Effects of clinical oral health status. A systematic review. Int J Dent Hyg 2008;6:100–7. 6. Kerosuo H, Al Enezi S, Kerosuo E, Abdulkarim E. Association between normative and self-perceived orthodontic treatment need among Arab high school students. Am J Orthod Dentofacial Orthop 2004;125:373–8. 7. Josefsson E, Bjerklin K, Lindsten R. Factors determining perceived orthodontic treatment need in adolescents of Swedish and immigrant background. Eur J Orthod 2009;31:95–102. 8. Li XT, Tang Y, Huang XL, Wan H, Chen YX. Factors influencing subjective orthodontic treatment need and culture-related differences among Chinese natives and foreign inhabitants. Int J Oral Sci 2010;2:149–57. 9. Spalj S, Slaj M, Varga S, Strujic M, Slaj M. Perception of orthodontic treatment need in children and adolescents. Eur J Orthod 2010;32:387–94. 10. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Relationships between oral diseases and impacts on Thai schoolchildren’s quality of life: evidence from a Thai national oral health survey of 12and 15-year-olds. Community Dent Oral Epidemiol 2012;40:550–9. 11. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A, Tsakos G. The impacts of gingivitis and calculus on Thai children’s quality of life. J Clin Periodontol 2012;39:834–43. 12. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Impacts on quality of life related to dental caries in a national representative sample of Thai 12- and 15-year-olds. Caries Res 2012;47:9–17. 13. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham A. Sociodemographic differences in oral health-related quality of life related to dental caries in Thai school children. Community Dent Health 2013;30:112–18. 14. Hancock PA, Blinkhorn AS. A comparison of the perceived and normative needs for dental care in 12year-old children in the northwest of England. Community Dent Health 1996;13:81–5. 15. Heft MW, Gilbert GH, Shelton BJ, Duncan RP. Relationship of dental status, sociodemographic status, and oral symptoms to perceived need for dental care. Community Dent Oral Epidemiol 2003;31:351–60. 16. Colussi CF, De Freitas SF, Calvo MC. The prosthetic need WHO index: a comparison between self-perception and professional assessment in an elderly population. Gerodontology 2009;263:187–92. 17. Mashoto KO, Astrøm AN, David J, Masalu JR. Dental pain, oral impacts and perceived need for dental treatment in Tanzanian school students: a cross-sectional study. Health Qual Life Outcomes 2009;7:73.
331
Krisdapong et al. 18. Seirawan H, Sundaresan S, Mulligan R. Oral healthrelated quality of life and perceived dental needs in the United States. J Public Health Dent 2011;71:194–201. 19. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life: conceptual model of patient outcomes. J Am Med Assoc 1995;273:59–65. 20. Maharani DA. Perceived need for and utilization of dental care in Indonesia in 2006 and 2007: a secondary analysis. J Oral Sci 2009;51(545–5):50. 21. Krisdapong S, Sheiham A, Tsakos G. Oral healthrelated quality of life of 12- and 15-year-old Thai children: findings from a national survey. Community Dent Oral Epidemiol 2009;37:509–17. 22. World Health Organization. Oral health surveys. Basic methods. Geneva: World Health Organization, 1997. 23. Gherunpong S, Tsakos G, Sheiham A. Developing and evaluating an oral health-related quality of life index for children: the Child-OIDP. Community Dent Health 2004;21:161–9. 24. Adulyanon S, Sheiham A. Oral impacts on daily performances. In. Slade GD, editor. Measuring oral health and quality of life. Chapel Hill: University of North Carolina, 1997; 151–60. 25. Krisdapong S, Sheiham A. Which aspects of an oral health-related quality of life measure are mainly associated with global ratings of oral health in children? Community Dent Oral Epidemiol 2013; doi: 10.1111/cdoe.12061 [Epub ahead of print].
332
26. Andersen R. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995;36:1–10. 27. Victora CG, Huttly SR, Fuchs S, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997;26:224–7. 28. Tickle M, Worthington HV. Factors influencing perceived treatment need and the dental attendance patterns of older adults. Br Dent J 1997;182:96–100. 29. Seremidi K, Koletsi-Kounari H, Kandilorou H. Selfreported and clinically-diagnosed dental needs: determining the factors that affect subjective assessment. Oral Health Prev Dent 2009;7:183–90. 30. Tuominen ML, Tuominen RJ. Factors associated with subjective need for orthodontic treatment among Finnish university applicants. Acta Odontol Scand 1994;52:106–10. 31. Krisdapong S, Sheiham A, Tsakos G. Impacts of recurrent aphthous stomatitis on quality of life of 12- and 15-year-old Thai children. Qual Life Res 2012;21:71–6. 32. Mosha HJ, Scheutz F. Perceived need and use of oral health services among adolescents and adults in Tanzania. Community Dent Oral Epidemiol 1993; 21:129–32. 33. National Statistical Office Thailand. The population and housing census 2010. Bangkok: NSO, 2011.
