ORIGINAL Oliveira ARTICLE et al
Impact of Oral Health Status on the Oral Health-Related Quality of Life of Brazilian Male Incarcerated Adolescents Diego Canavese Oliveiraa/Fernanda Morais Ferreirab/Imara de Almeida Castro Morosinic/Cassius Carvalho Torres-Pereirad/ Saul Martins Paivae/Fabian Calixto Fraizf Purpose: To assess the impact of oral health status on the oral health-related quality of life (OHRQoL) of incarcerated Brazilian male adolescents. Materials and Methods: A cross-sectional survey with 102 male adolescents incarcerated at the São Francisco Juvenile Detention Facility, Piraquara, Brazil in 2010 was carried out. Dental caries, oral hygiene, periodontal status, malocclusion, dental fluorosis and dental trauma were analysed. The Oral Health Impact Profile (OHIP-14) was administered to measure OHRQoL, along with a questionnaire addressing sociodemographic variables, health-related aspects and dental experience. Descriptive statistical analysis and univariate and multiple Poisson regression with robust variance were performed. Results: The prevalence of adolescents who reported an impact on OHRQoL was 64% (95% CI: 54–73) and the mean OHIP-14 score was 6.69 (SD = 8.79; median = 3.00). In the multiple regression model, the prevalence of a negative impact on OHRQoL was significantly higher among individuals with untreated caries (PR = 1.74; 95% CI: 1.10–2.77), those who reported having discomfort in the teeth or mouth (PR = 1.33; 95% CI: 1.03–1.73), using tobacco prior to internment (PR = 1.53; 95% CI: 1.04–2.24) and maintaining a stable relationship (PR = 1.31; 95% CI: 1.01–1.70) in comparison to individuals who did not exhibit these conditions. Moreover, each month of internment represented an increase in the prevalence of an impact on OHRQoL (PR = 1.03; 95% CI: 1.01–1.06). Conclusion: Incarcerated male adolescents reported that oral health problems exerted an influence on quality of life, with untreated caries exhibiting the greatest impact. Key words: adolescent, institutionalised, oral health, quality of life Oral Health Prev Dent 2015;13:417-425 doi: 10.3290/j.ohpd.a33922
F
Submitted for publication: 21.05.13; accepted for publication: 15.10.13
actors that affect health, including the mouth and teeth, have the potential to compromise well-being and quality of life.5,9,27,29,30 While the studies cited have demonstrated the effect of oral health status on the quality of life of adolescents, no such studies have been carried out involving incarcerated adolescents.
Every teenager experiences adolescence in a different manner. The construction of identity is both personal and social, occurring in an interactive fashion through exchanges between the individual and his/her environment. Thus, perceptions regarding the impact of oral health status on quality of life occur in a particular manner and determining
a
Dentist, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Study concept and design, data collection and analysis, co-wrote manuscript, reviewed final draft.
e
b
Adjunct Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Study concept and design, data analysis, co-wrote manuscript, reviewed final draft.
Full Professor, Department of Paediatric Dentistry and Orthodontics, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. Study concept and design, data analysis, cowrote manuscript, critically revised and reviewed final draft.
f
Associate Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Data analysis, cowrote manuscript, critically revised and reviewed final draft.
c
Adjunct Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Data collection and analysis, co-wrote manuscript, critically revised and reviewed final draft.
d
Adjunct Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Data collection and analysis, contributed substantially to manuscript, reviewed final draft.
Vol 13, No 5, 2015
Correspondence: Dr. Fabian Calixto Fraiz, Rua Francisco de Paula Guimarães, 465/ 303, Curitiba, Paraná, Brazil 80540-040. Tel: +5541-9619-7610, Fax: +55 41 33604134. Email: [email protected]
417
Oliveira et al
this impact is multidimensional, involving biopsychosocial aspects.17 The particularity of incarcerated adolescents requires an interpretation that considers the sociocultural framework, the burden of past personal history and the environment in which such individuals live. There are more than 16,000 incarcerated adolescents in Brazil and approximately 960 in the state of Paraná.7 However, information is lacking on the oral health status of such individuals and no studies have described the impact of oral health on their quality of life. Studies carried out in the USA report that adolescents in juvenile detention centres have an unfavourable oral health status;1,6 moreover, dental care was among the most common reasons for healthcare visits among incarcerated adolescents in the state of Washington.1 Understanding the oral health status of incarcerated adolescents from a clinical standpoint as well as a multidimensional perspective will enable the planning, implementation and evaluation of oral health promotion programmes. Thus, the aim of the present study was to assess the impact of oral health status on the quality of life of incarcerated Brazilian male adolescents.
MATERIALS AND METHODS Ethical considerations The study received approval from the Human Research Ethics Committee of the Federal University of Parana (Brazil) and carried out according to the Declaration of Helsinki. The legal guardians and adolescents signed a statement of informed consent authorising participation in the study.
tal trauma was assessed using the criteria described by Andreasen and Andreasen.2
Calibration process The calibration process was performed in two phases. The theoretical phase involved a discussion on the diagnosis of the different dental disorders studied using projected photographic images and plaster casts. An expert (FMF) with extensive experience in clinical data collection in epidemiological studies (gold standard in the theoretical framework) coordinated this step, training a general dentist (DCO) on how to perform the examination. The second phase was conducted with different methodologies, as the conditions evaluated were very different. Twenty-five adolescents were clinically examined for caries, periodontal disease and oral hygiene status and re-examined after a 15-day interval with regard to the first two variables. It was not possible to determine intra-examiner agreement for the IHO-S (oral hygiene status). For dental trauma and dental fluorosis, 39 and 30 images, respectively, were analysed by the same examiner on two occasions and in a different order with a 15-day interval between analyses. For the DAI, 22 plaster casts of the adolescents’ dentition were analysed by the same examiner on two occasions with a 15day interval between analyses. Weighted Cohen’s Kappa values and intraclass correlation coefficients were > 0.80 for the DAI. For the other parameters, weighted Cohen’s Kappa values (Dean’s index, CPI, IHO-S) and Kappa values (DMFT, dental trauma) were ≥ 0.80 for inter-examiner agreement. For all conditions, intra-examiner agreement was ≥ 0.80.
Pilot study Study population and study design A cross-sectional census study was carried out with all incarcerated adolescents (N = 103) incarcerated for at least 30 days at the São Francisco Social Education Centre in the city of Piraquara, state of Paraná, southern Brazil, from January to June 2010. The following indices were assessed: caries using the Decayed, Missing and Filled Teeth (DMFT) index, periodontal status using the Community Periodontal Index (CPI), malocclusion using the Dental Aesthetic Index (DAI) and dental fluorosis using Dean’s Dental Fluorosis Index.32 Oral hygiene was assessed using the Simplified Oral Hygiene Index (IHO-S)13 and den-
418
A pilot study was first carried out, involving a convenience sample of 10 incarcerated male adolescents incarcerated in another social education centre in the state of Paraná to test the methods and understanding of the questionnaires. The results revealed no need to change the initially proposed methods.
Data collection and questionnaires Clinical exams were performed with the aid of a disposable mouth mirror (PRISMA; São Paulo, SP, Brazil) and standard periodontal probe (WHO-621,
Oral Health & Preventive Dentistry
Oliveira et al
Trinity; São Paulo, SP, Brazil) by a single examiner (DCO) with the subject seated in a dental chair under the artificial light of the reflector. The clinical exam followed a standardised order, with oral hygiene and periodontal status evaluated first, followed by the determination of dental trauma, fluorosis, caries and malocclusion. The average time spent on each adolescent was 30 min. The adolescents completed a questionnaire in interview format addressing sociodemographic factors, health-related aspects and dental experience, with items on marital status, formal schooling, employment prior to internment, living prior to internment with at least one parent, first internment, visit to dentist prior to internment, type of dental office, reported discomfort in teeth and mouth and use of tobacco prior to internment. On the same occasion, the short form of the Oral Health Impact Profile,28 cross-culturally adapted and validated for Brazilian Portuguese,24 was administered through interviews by a single trained researcher (DCO) to measure the impact on oral health related quality of life (OHRQoL). This assessment tool has been employed in a large number of dentistry studies and has a solid conceptual basis, with known psychometric properties and easy administration. The questionnaire has six subscales, each with two items: physical limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. The rating scale response options are scored as follows: never = 0; hardly ever = 1; occasionally = 2; fairly often = 3; very often = 4. The previous month of incarceration was the timeframe used. The sum of the points attributed to the responses given to each item (0 to 4) were totaled for the overall OHIP-14 score, which ranged from 0 to 56 points.
Statistical analysis The data were analysed using the Statistical Package for the Social Sciences (SPSS for Windows, version 16.0, SPSS; Chicago, IL, USA). Descriptive and Poisson’s univariate regression analysis were performed to test associations between oral health conditions and the co-variables as well as self-reported impact on quality of life. Variables with p < 0.20 in the univariate analyses were incorporated into the Poisson multiple regression model with robust variance. For the analysis of associations, OHIP-14 scores were dichotomised as the presence of impact on quality of life (at least one ‘occasionally’, ‘fairly often’ or ‘very
Vol 13, No 5, 2015
often’ response) or absence of impact (only ‘never’ and ‘hardly ever’ responses on all items). The reports of rare events (response options of ‘never’ and ‘hardly ever’) were ignored, as they may not represent a significant impact on quality of life.28 The clinical variables were also dichotomised: oral hygiene: ‘satisfactory’ (OHI-S < 1) and ‘unsatisfactory’ (OHI-S ≥ 1); untreated caries: ‘presence’ (D component of DMFT index ≥ 1) and ‘absence’ (D component of DMFT index = 0); malocclusion: ‘presence’ (DAI > 25) and ‘absence’ (DAI ≤ 25); dental fluorosis: ‘presence’ (Dean’s Index > 1) and ‘absence’ (Dean’s index ≤ 1); periodontal status: ‘healthy’ (CPI < 1) and ‘unhealthy’ (CPI ≥ 1); dental trauma: ‘presence’ (clinical signs of dental trauma, from enamel fracture to avulsion) and ‘absence’ (no clinical signs of dental trauma). The sociodemographic, health-related aspects and dental experience variables were dichotomised as follows: marital status (single/stable relationship); schooling (> 8 years/≤ 8 years); employed prior to internment (yes/no); lived with at least one parent (yes/no); first internment (yes/no); visit to dentist prior to internment (yes/no); type of dental office (private office, public office); discomfort in teeth and mouth (yes/ no); user of tobacco prior to internment (no = never, rarely / yes = sometimes, constantly, always).
RESULTS One hundred three incarcerated adolescents met the inclusion criteria. One loss occurred due to incomplete answers. Thus, one hundred two adolescents between 15 and 19 years of age participated in the present study (response rate = 99%). These adolescents had a mean age of 16.8 (standard deviation [SD] = 0.94) years. Mean time of incarceration was 6.2 (SD = 4.1) months. Prior to internment, most of the participants lived with at least one parent (72.5%) and 52.9% worked. Only 7.8% had completed more than eight years of formal schooling and 36% were repeat offenders. The prevalence of oral health-related impact on quality of life was 64% (95% CI: 54–73) and the mean OHIP-14 score was 6.7 (SD = 8.8; median = 3; range: 0 to 38) (Table 1). ‘Felt pain in mouth or teeth’ (item 3) and ‘worried about problems with mouth or teeth’ (Item 5) were the aspects of quality of life most affected by oral health status (Table 2). A total of 36.3% of the participants reported feeling discomfort in their teeth or mouth at the moment of the interview. A statistically significant association was detected between this condition and
419
Oliveira et al
Table 1 Prevalence of impact on OHRQoL and OHIP-14 scores among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Scores OHIP-14 subscales
Mean ± SD
Min
Max
Median
Frequency (%) of impact on OHRQoL
Functional limitation
0.4 ± 1.2
0
8
0
14 (13.7)
Physical pain
1.8 ± 2.1
0
8
1
47 (46.1)
Psychological discomfort
1.8 ± 2.3
0
8
1
43 (42.2)
Physical disability
1.0 ± 1.8
0
8
0
26 (25.5)
Psychological disability
0.8 ± 1.4
0
6
0
26 (25.5)
Social disability
0.5 ± 1.2
0
6
0
15 (14.7)
Handicap
0.4 ± 1.0
0
4
0
12 (11.8)
Total OHIP
6.7 ± 8.8
0
38
3
65 (63.7)
SD = standard deviation; OHRQoL = oral health-related quality of life.
Table 2 Frequency of reported impact on each item of OHIP-14 among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Absence of impact OHIP-14 subscales
Presence of impact
N
(%)
N
(%)
Item 1
95
(93.1)
7
(6.9)
Item 2
93
(91.2)
9
(8.8)
Item 3
63
(61.8)
39
(38.2)
Item 4
73
(71.6)
29
(28.4)
Item 5
63
(61.8)
39
(38.2)
Item 6
82
(80.4)
20
(19.6)
Physical disability
Item 7
79
(77.5)
23
(22.5)
Item 8
88
(86.3)
14
(13.7)
Psychological disability
Item 9
85
(83.3)
17
(16.7)
Item 10
87
(85.3)
15
(14.7)
Item 11
89
(87.3)
13
(12.7)
Item 12
96
(94.1)
6
(5.9)
Item 13
90
(88.2)
12
(11.8)
Item 14
101
(99.0)
1
(1.0)
Functional limitation
Physical pain
Psychological discomfort
Social disability
Handicap Absence of impact = never or hardly ever; presence of impact = occasionally, fairly often or very often.
the report of an oral health-related impact on quality of life (prevalence ratio [PR] = 1.51; 95% CI: 1.14–1.98). The prevalence of impact on OHRQoL was significantly higher in adolescents who maintained a stable relationship (PR = 1.37; 95% CI: 1.05–1.81) (Table 3). The Poisson univariate analysis revealed a statistically significant association
420
between the use of tobacco prior to internment and OHRQoL (PR = 1.66; 95% CI: 1.12–2.46) (Table 3). Caries was found in 93% (95% CI: 88–98) of the participants. The mean DMFT index was 5.9 (SD = 4.5). The ‘decayed’ component contributed most to this index (mean = 2.8; SD = 3.3) and the ‘missing’ component contributed the least
Oral Health & Preventive Dentistry
Oliveira et al
Table 3 Frequency distribution of sociodemographic variables, report of discomfort in teeth and mouth, tobacco use and impact on OHRQoL among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Impact on OHRQoL
Univariate analysis
Without impact N (%)
With impact N (%)
Total N (%)
32 (41.6)
45 (58.4)
77 (75.5)
Stable relationship
5 (20.0)
20 (80.0)
25 (24.5)
> 8 years (ref.)
5 (62.5)
3 (37.5)
8 (7.8)
Variables Single (ref.) Marital status
Schooling ≤ 8 years
32 (34.0)
62 (66.0)
94 (92.2)
Employed prior to internment
Yes (ref.)
22 (40.7)
32 (59.3)
54 (52.9)
No
15 (31.2)
33 (68.8)
48 (47.1)
Lived with at least one parent
Yes (ref.)
26 (35.1)
48 (64.9)
74 (72.5)
No
11 (39.3)
17 (60.7)
28 (27.5)
First internment
Yes (ref.)
26 (40)
39 (60.0)
65 (63.7)
No
11 (29.7)
26 (70.3)
37 (36.3)
Been to dentist prior to internment
Yes (ref.)
33 (37.9)
54 (62.1)
87 (85.3)
Type of dental office
Public service (ref.)
Discomfort in teeth and mouth
No (ref.)
No
4 (26.7)
11 (73.3)
15 (14.7)
25 (37.9)
41 (62.1)
66 (75.9)
8 (38.1)
13 (61.9)
21 (24.1)
30 (46.2)
35 (53.8)
65 (63.7)
7 (18.9)
30 (81.1)
37 (36.3)
Non-User (ref.)
20 (55.6)
16 (44.4)
36 (35.6)
User
17 (26.2)
48 (73.8)
65 (64.4)
Private office
Yes
Tobacco
p*
Unadjusted PR [95% CI]
0.024
1.37 [1.05–1.81]
0.222
1.78 [0.71–4.34]
0.320
1.16 [0.86–1.56]
0.705
0.94 [0.66–1.33]
0.283
1.17 [0.87–1.56]
0.346
1.19 [0.84–1.69]
0.986
0.99 [0.68–1.47]
0.003
1.51 [1.14–1.98]
0.011
1.66 [1.12–2.46]
* p-value referring to Poisson univariate regression analysis; results significant at 5%(p < 0.05) level. OHRQoL = oral health-related quality of life; PR = prevalence ratio; CI = confidence interval. Ref: reference.
(mean = 0.5; SD = 0.9). The mean number of teeth among the participants was 28.5 (SD = 1.5), 22.4 (SD = 4.4) of which were sound teeth. High prevalence rates were found for periodontal problems (82.3%) (95% CI: 75–90) and malocclusion (60.8%) (95% CI: 51–70). Thirty-three participants (32.4%) (95% CI: 23–42) exhibited some type of dental trauma – from enamel fracture to avulsion. Fluorosis was detected in 15 individuals (15.6%) (95% CI: 7–22), ranging from very mild to severe. Univariate analysis was used to test associations between all clinical indicators and OHRQoL. A statistically significant association was found between untreated caries and OHRQoL (PR = 1.81; 95% CI: 1.07– 3.08). Oral hygiene also had an impact on OHRQoL (PR = 1.47; 95% CI: 1.13–1.87). No statistically significant associations were detected between the other clinical conditions and OHRQoL (Table 4).
Vol 13, No 5, 2015
In the multiple regression model, untreated caries, discomfort in teeth or mouth, use of tobacco and marital status were significantly associated with OHRQoL (p < 0.05). The prevalence of an oral health-related impact on quality of life was higher among individuals with untreated caries (PR = 1.74; 95% CI: 1.10–2.77), those who reported discomfort in the teeth or mouth (PR = 1.33; 95% CI: 1.03–1.73), those who reported using tobacco prior to internment (PR = 1.53; 95% CI: 1.04–2.24) and those who maintained a stable relationship (PR = 1.31; 95% CI: 1.01–1.70) in comparison to individuals who did not exhibit these conditions. Moreover, each month of internment represented an increase in the prevalence of an oral health-related impact on quality of life (PR = 1.03; 95% CI: 1.01–1.06) (Table 5).
421
Oliveira et al
Table 4 Frequency distribution of clinical conditions and impact on OHRQoL among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Impact on OHRQoL Without impact N (%)
With impact N (%)
Absent (ref.)
14 (60.9)
9 (39.1)
23 (22.5)
Present
23 (29.1)
56 (70.9)
79 (77.5)
Satisfactory (ref.)
32 (37.6)
53 (62.4)
85 (85.5)
Variables Untreated dental caries
Univariate analysis Total N (%)
Oral hygiene Unsatisfactory
1 (9.1)
10 (90.9)
11 (11.5)
Healthy (ref.)
7 (41.2)
10 (58.8)
17 (17.7)
Unhealthy
26 (32.9)
53 (67.1)
79 (82.3)
Absent (ref.)
17 (42.5)
23 (57.5)
40 (39.2)
Periodontal status
Malocclusion Present
20 (32.3)
42 (67.7)
62 (60.8)
Absent (ref.)
26 (32.1)
55 (67.9)
81 (84.4)
Present
7 (46.7)
8 (53.3)
15 (15.6)
Absent (ref.)
23 (33.3)
46 (66.7)
69 (67.6)
Present
14 (42.4)
19 (57.6)
33 (32.4)
Dental fluorosis
Dental trauma
p*
Unadjusted PR [95% CI]
0.028
1.81 [1.07–3.08]
0.003
1.47 [1.13–1.87]
0.546
1.14 [0.75–1.75]
0.311
1.18 [0.86–1.62]
0.340
0.79 [0.48–1.29]
0.394
0.86 [0.62–1.21]
* p-value referring to Poisson univariate regression analysis; results significant at 5% (p < 0.05) level. OHRQOL = oral health-related quality of life; PR = prevalence ratio; CI = confidence interval.
DISCUSSION In the present study, the majority of participants reported that oral health problems exerted an influence on OHRQoL. However, the average OHIP-14 score was low, suggesting little impact on OHRQoL. Similar findings have been reported in studies conducted with Brazilian adolescents who were not incarcerated/institutionalised.5,10 ‘Worried about problems with the mouth or teeth’ (item 5) was reported with high frequency and achieved the greatest number of ‘very often’ responses. Items related to psychological discomfort and psychological disability had a considerable impact on the OHIP score, accounting for 39% of the overall score. As reported for non-incarcerated adolescents in Brazil,5,10 psychological discomfort was among the domains that most affected the daily activities of the adolescents, the score of which was only surpassed by the physical pain subscale. On items related to psychological aspects, the present findings are similar to those described for non-incarcerated Brazilian adolescents regarding the mean value10 and frequency of impact.5 This may be a characteristic of adolescence itself and therefore also present in those deprived of freedom.
422
Items related to social interaction had little impact on OHRQoL in this study. Among the sociodemographic variables, only marital status was associated with reports of an impact. Most of the participants were single and a statistically significant association was found between those in a stable relationship and OHRQoL, which remained significant even after controlling for confounding variables. Although studies indicate that marital status affects health-related quality of life31 and OHRQoL,16 more research is needed to understand this relationship and its consequences. The fact that the adolescents received weekly visits from family members and girlfriends may mean that concerns regarding the mouth and teeth, especially those related to aesthetics, have major importance to individuals in love relationships. Incarceration time was related to OHRQoL. It is therefore suggested that adolescents with a longer internment time tend to experience a diminishment in self-esteem and worsening with regard to issues related to self-perception. Thus, oral health conditions that may affect bio-psychosocial aspects tend to take on more importance to such individuals, thereby causing a greater impact on quality of life. Although the majority of the adolescents had used some type of drug prior to internment, only the use of
Oral Health & Preventive Dentistry
Oliveira et al
Table 5 Poisson multiple regression model for impact of oral health status on quality of life among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Variables
p-value
Adjusted PR
95% CI
0.019
1.74
1.10–2.77
0.031
1.33
1.03–1.73
0.030
1.53
1.04–2.24
0.048
1.31
1.01–1.70
0.022
1.03
1.01-1.06
No (ref.) Untreated dental caries Yes Discomfort in teeth or mouth
No (ref.) Yes Non-User (ref.)
Tobacco User Single (ref.) Marital status Stable relationship Time of incarceration (in months)
p-value refers to Poisson multivariate regression; PR= prevalence ratio; CI = confidence interval. Ref: reference.
tobacco prior to internment was significantly associated with OHRQoL, even after adjusting for the other co-variables in the multiple regression model. An association has been demonstrated between smoking and poor oral health status, especially oral cancer12 and periodontal disease,15 and that smoking may negatively affect dental health perceptions.22 In a cohort of Spanish university graduates, smokers reported a greater impact on quality of life than nonsmokers on the subscales of a generic health measure (SF-36), such as physical function, social well-being, emotional well-being and mental health.14 Moreover, smokers were found to have worse OHRQoL in all dimensions in a national cohort in Thailand.33 In this study, the adolescents reported that ‘pain in mouth or teeth’ (OHIP-14, item 3) had the greatest effect on OHRQoL. Although no adolescents reported feeling acute pain at the time of the interview, 36.3% reported some degree of discomfort in the mouth or teeth at the time of the interview and 38.2% reported impact on daily activities due to pain in the mouth or teeth in the previous 30 days (OHIP-14, item 3). Moreover, physical pain has also been found to be an important OHIP-14 item among adolescents who are not incarcerated.3,5 A statistically significant association was found between the report of discomfort in the teeth or mouth and OHRQoL in both the univariate and multivariate analyses. This association was expected; it confirms the negative repercussions of factors that affect the mouth and teeth in the daily lives of adolescents and demonstrates the consistency of the method used to assess the impact of oral health on the quality of life of adolescents (OHIP-14).
Vol 13, No 5, 2015
In the present study, individuals with untreated caries had a 1.81-fold greater prevalence of impact on OHRQoL than those without this condition and the association remained significant even after controlling for confounding variables (adjusted PR = 1.74). This finding may be explained by the fact that caries is a cumulative disease that can cause pain, functional limitations, aesthetic impairment and concern or disappointment with regard to the mouth and teeth, especially untreated carious lesions, thereby affecting various aspects of quality of life. The most affected OHIP subscales were those that can be influenced by the consequences of untreated caries. Among non-incarcerated adolescents in Brazil, an association between caries and OHRQoL has been demonstrated in previous studies.3,5 However, the literature is inconclusive with regard to this association. The age group analysed, the prevalence of caries and the method of analysing this variable may account for the divergence in the findings. In the present study, caries was dichotomised based on the ‘decayed’ component of the DMFT index. Previous studies involving Brazilian schoolchildren have also found that untreated caries exerted an influence on OHRQoL.19,26 While Paula et al25 found no such association, the authors report that the low prevalence rate of caries in their sample may have contributed to the absence of statistical significance in the multivariate analysis between this clinical condition and OHRQoL. Individuals with unsatisfactory oral hygiene had a 1.47-fold greater prevalence of impact than those with satisfactory oral hygiene. A greater frequency
423
Oliveira et al
of oral hygiene measures performed is reported to be associated with a lower prevalence of impact on the quality of life of Australian young adults8 and Tanzanian adolescents.20 Most individuals did not exhibit severe periodontal problems and no impact from these conditions on OHRQoL was reported. This result is similar to findings described in a previous Brazilian study with adolescents5 that also used the CPI, which defines periodontal disease based on the presence of bleeding upon probing. However, an association between periodontal disease and quality of life among Chilean adolescents was found when more serious aspects were analysed, such as attachment loss and necrotising ulcerative gingival lesions.18 Despite the large number of adolescents with malocclusion, these conditions were not significantly associated with an impact on OHRQoL. Brazilian studies demonstrated an association between quality of life (as assessed with the Oral Impacts on Daily Performances Index) and malocclusion among adolescents, as aesthetic aspects have the greatest impact on the quality of life.4,30 This is likely explained by the high prevalence of malocclusion relevant to aesthetic issues, which influences appearance, self-esteem and interpersonal relationships. However, adolescents deprived of freedom most often have restricted social interactions and such issues may lose their importance in this context. In Brazilian adolescents, when the OHRQoL was assessed by the OHIP-14, no association was found with DAI,10 similar to this study. This could be explained by the fact that OHIP-14 was not developed specifically to measure the impact of orthodontic problems on OHRQoL and some of the items may not be relevant to patients with malocclusion.10 Furthermore, the DAI allows categorising the presence or absence of malocclusion from clinical measurements, but it fails to analyse self-perception of aesthetics. As in previous cross-sectional studies carried out in Brazil,5,21 no association was found between dental fluorosis and quality of life in adolescents, which may be explained by the low prevalence and low degree of severity of the condition, as the majority of cases were questionable or very mild. Brazilian adolescents who experienced adverse psychosocial environments throughout life had more traumatic dental injuries.23 A great number of individuals with fractured teeth was observed, as expected since the population studied was made up of young males with a history of violence and
424
juvenile delinquency, and perhaps the great frequency of dental trauma reduces their impact on social relationships. Unlike findings reported in case-control studies involving 12- to 14-year-old Brazilian9 and Canadian11 adolescents, no significant association was found between dental trauma and quality of life. An analysis of the OHIP-14 items reveals that issues related to aesthetics and social relations are not overly important to these incarcerated adolescents, likely due to their lack of freedom and consequently restricted social interactions. This group of male adolescents lives under special conditions with strict rules, isolated from a large part of social life. Thus, caution should be exercised when making comparisons and inferences, as generalisations are not possible. One of the limitations of the present study was the possibility that the adolescents may have exaggerated their reports of a negative impact on OHRQoL in an attempt to obtain priority with regard to dental treatment. Moreover, the sample was composed only of male adolescents, whereas the discussion addressed studies involving both males and females.
CONCLUSION Understanding the oral health status of incarcerated adolescents from a multidimensional perspective will allow healthcare professionals to develop better oral health programmes for this particular group. Most individuals reported an impact on quality of life stemming from oral health problems. Sociodemographic aspects were found to exert a substantial impact on OHRQoL of the adolescents. Some conditions that are important from the clinical standpoint did not present a great impact on ORHQoL, such as malocclusion and dental trauma. However, untreated caries was the most important clinical aspect influencing the OHRQoL in this group. Therefore, for these adolescents, efforts must be made to prioritise caries treatment and to prevent tooth decay. There is urgent need for further studies for comparison and discussion purposes.
ACKNOWLEDGEMENTS This study was supported by the Fundação Araucária, support for scientific and technological development do Paraná and by the Brazilian Coordination for Higher Education (CAPES), Ministry of Education, Brazil.
Oral Health & Preventive Dentistry
Oliveira et al
REFERENCES 1. Anderson B, Farrow JA. Incarcerated adolescents in Washington State. Health services and utilization. J Adolesc Health 1998;22:363–367. 2. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, ed 4. Copenhagen: Munskgaard, 2007. 3. Bastos RS, Carvalho ES, Xavier A, Caldana ML, Bastos JRM, Lauris JRP. Dental caries related to quality of life in two Brazilian adolescent groups: a cross-sectional randomised study. Int Dent J 2012;62:137–143. 4. Bernabé E, Tsakos G, Oliveira CM, Sheiham A. Impacts on daily performances attributed to malocclusions using the conditions-specific feature of the oral impacts on daily performances Index. Angle Orthod 2008;78:241–247. 5. Biazevic MGH, Rissoto RR, Crosato EM, Mendes LA, Mendes MOA. Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res 2008;22:36–42. 6. Bolin K, Jones D. Oral health needs of adolescents in a juvenile detention facility. J Adolesc Health 2006;38:755– 757. 7. Brasil. Levantamento nacional da atenção em saúde mental aos adolescentes privados de liberdade e sua articulação com as Unidades Socioeducativas. Brasília: Ministério da Saúde/Secretaria de Direitos Humanos, 2008. 8. Brennan DS, Spencer AJ. Life events and oral health related quality of life among young adults. Qual Life Res 2009;18:557–565. 9. Cortes MIS, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12-14 year old children. Community Dent Oral Epidemiol 2002;30:193–198. 10. de Paula Junior DF, Santos NCM, Silva ET, Nunes MF, Leles CR. Psychosocial impact of dental esthetics on quality of life in adolescents: association with malocclusion, self-Image, and oral health–related issues. Angle Orthod 2009;79:1188–1193. 11. Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Impact of treated and untreated dental injuries on the quality of life of Ontario school children. Dent Traumatol 2008;24:309–313. 12. Gandini S, Botteri E, Iodice S, Boniol M, Lowenfels AB, Maisonneuve P, Boyle P. Tobacco smoking and cancer: a meta-analysis. Int J Cancer 2008;122:155–164. 13. Greene JC, Vermillion JR. The simplified oral hygiene index. JADA 1964;68:7–13. 14. Guitérrez- Bedmar MG, Gómez MS, Gracia EG, Rastrollo MB, González MAM. Smoking status, changes in smoking status and health-related quality of life: findings from the SUN (‘Seguimiento Universidad de Navarra’) cohort. Int J Environ Res Public Health 2009;6:310–320. 15. Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Periodontol 2004;75:196–209. 16. Kriz P, Seydlova M, Dostalova T, Valenta Z, Chleborad K, Zvarova J, Feberova J, Hippmann R. Dental implants and improvement of oral health-related quality of life. Community Dent Oral Epidemiol 2012;40(suppl 1):65–70.
Vol 13, No 5, 2015
17. Locker D. Oral health and quality of life. Oral Health Prev Dent 2004;2(suppl 1):247–53. 18. López R, Baelum V. Oral health impact of periodontal diseases in adolescents. J Dent Res 2007;86:1105–1109. 19. Martins-Júnior PA, Oliveira M, Marques LS, Ramos-Jorge ML. Untreated dental caries: impact on quality of life of children of low socioeconomic status. Pediatr Dent 2012;34:49–52. 20. Mbawalla HS, Masalu JR, Åstrøm AN. Socio-demographic and behavioral correlates of oral hygiene status and oral health related quality of life, the Limpopo – Arusha school health project (LASH): A cross-sectional study. BMC Pediatr 2010;10:87. 21. Michel-Crosato E, Biazevic MGH, Crosato E. Relationship between dental fluorosis and quality of life: a population based study. Braz Oral Res 2005;19:150–155. 22. Morin NM, Dye BA, Hooper TI. Influence of cigarette smoking on the overall perception of dental health among adults aged 20–79 years, United States, 1988–1994. Public Health Rep 2005;120:124–132. 23. Nicolau B, Marcenes W, Sheiham A. The relationship between traumatic dental injuries and adolescents‘ development along the life course. Community Dent Oral Epidemiol 2003;31:306–313. 24. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol 2005;33:307–314. 25. Paula JS, Leite IC, Almeida AB, Ambrosano GM, Pereira AC, Mialhe FL. The influence of oral health conditions, socioeconomic status and home environment factors on schoolchildren‘s self-perception of quality of life. Health Qual Life Outcomes 2012;10:6. 26. Peres KG, Peres MA, Araujo CL, Menezes AM, Hallal PC.Social and dental status along the life course and oral health impacts in adolescents: a population-based birth cohort. Health Qual Life Outcomes 2009;7:95. 27. Ramos-Jorge ML, Bosco VL, Peres MA, Nunes ACGP. The impact of treatment of dental trauma on the quality of life of adolescents –a case-control study in southern Brazil. Dent Traumatol 2007;23:114–119. 28. Slade G. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284–290. 29. Thelen DS, Trovik TA, Bardsen. A Impact of traumatic dental injuries with unmet treatment need on daily life among Albanian adolescents: a case-control study. Dent Traumatol 2011;27:88–94. 30. Traebert ESA, Peres MA. Do malocclusions affect the individual’s oral health-related quality of life? Oral Health Prev Dent 2007;5:3–12. 31. Wang T, Chou C, Shu Y Assessing the effects of oral health-related variables on quality of life in Taiwanese adults. Qual Life Res 2013;22:811–825. 32. World Health Organization: Oral health surveys. Basic Methods, ed 4. Geneva: World Health Organization, 1997. 33. Yiengprugsawan V, Somkotra T, Seubsman S, Sleigh AC. Oral health-related quality of life among a large national cohort of 87,134 Thai adults. Health Qual Life Outcomes 2011;9:42.
425
Impact of Oral Health Status on the Oral Health-Related Quality of Life of Brazilian Male Incarcerated Adolescents Diego Canavese Oliveiraa/Fernanda Morais Ferreirab/Imara de Almeida Castro Morosinic/Cassius Carvalho Torres-Pereirad/ Saul Martins Paivae/Fabian Calixto Fraizf Purpose: To assess the impact of oral health status on the oral health-related quality of life (OHRQoL) of incarcerated Brazilian male adolescents. Materials and Methods: A cross-sectional survey with 102 male adolescents incarcerated at the São Francisco Juvenile Detention Facility, Piraquara, Brazil in 2010 was carried out. Dental caries, oral hygiene, periodontal status, malocclusion, dental fluorosis and dental trauma were analysed. The Oral Health Impact Profile (OHIP-14) was administered to measure OHRQoL, along with a questionnaire addressing sociodemographic variables, health-related aspects and dental experience. Descriptive statistical analysis and univariate and multiple Poisson regression with robust variance were performed. Results: The prevalence of adolescents who reported an impact on OHRQoL was 64% (95% CI: 54–73) and the mean OHIP-14 score was 6.69 (SD = 8.79; median = 3.00). In the multiple regression model, the prevalence of a negative impact on OHRQoL was significantly higher among individuals with untreated caries (PR = 1.74; 95% CI: 1.10–2.77), those who reported having discomfort in the teeth or mouth (PR = 1.33; 95% CI: 1.03–1.73), using tobacco prior to internment (PR = 1.53; 95% CI: 1.04–2.24) and maintaining a stable relationship (PR = 1.31; 95% CI: 1.01–1.70) in comparison to individuals who did not exhibit these conditions. Moreover, each month of internment represented an increase in the prevalence of an impact on OHRQoL (PR = 1.03; 95% CI: 1.01–1.06). Conclusion: Incarcerated male adolescents reported that oral health problems exerted an influence on quality of life, with untreated caries exhibiting the greatest impact. Key words: adolescent, institutionalised, oral health, quality of life Oral Health Prev Dent 2015;13:417-425 doi: 10.3290/j.ohpd.a33922
F
Submitted for publication: 21.05.13; accepted for publication: 15.10.13
actors that affect health, including the mouth and teeth, have the potential to compromise well-being and quality of life.5,9,27,29,30 While the studies cited have demonstrated the effect of oral health status on the quality of life of adolescents, no such studies have been carried out involving incarcerated adolescents.
Every teenager experiences adolescence in a different manner. The construction of identity is both personal and social, occurring in an interactive fashion through exchanges between the individual and his/her environment. Thus, perceptions regarding the impact of oral health status on quality of life occur in a particular manner and determining
a
Dentist, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Study concept and design, data collection and analysis, co-wrote manuscript, reviewed final draft.
e
b
Adjunct Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Study concept and design, data analysis, co-wrote manuscript, reviewed final draft.
Full Professor, Department of Paediatric Dentistry and Orthodontics, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. Study concept and design, data analysis, cowrote manuscript, critically revised and reviewed final draft.
f
Associate Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Data analysis, cowrote manuscript, critically revised and reviewed final draft.
c
Adjunct Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Data collection and analysis, co-wrote manuscript, critically revised and reviewed final draft.
d
Adjunct Professor, Department of Stomatology, Universidade Federal do Paraná, Curitiba, Paraná, Brazil. Data collection and analysis, contributed substantially to manuscript, reviewed final draft.
Vol 13, No 5, 2015
Correspondence: Dr. Fabian Calixto Fraiz, Rua Francisco de Paula Guimarães, 465/ 303, Curitiba, Paraná, Brazil 80540-040. Tel: +5541-9619-7610, Fax: +55 41 33604134. Email: [email protected]
417
Oliveira et al
this impact is multidimensional, involving biopsychosocial aspects.17 The particularity of incarcerated adolescents requires an interpretation that considers the sociocultural framework, the burden of past personal history and the environment in which such individuals live. There are more than 16,000 incarcerated adolescents in Brazil and approximately 960 in the state of Paraná.7 However, information is lacking on the oral health status of such individuals and no studies have described the impact of oral health on their quality of life. Studies carried out in the USA report that adolescents in juvenile detention centres have an unfavourable oral health status;1,6 moreover, dental care was among the most common reasons for healthcare visits among incarcerated adolescents in the state of Washington.1 Understanding the oral health status of incarcerated adolescents from a clinical standpoint as well as a multidimensional perspective will enable the planning, implementation and evaluation of oral health promotion programmes. Thus, the aim of the present study was to assess the impact of oral health status on the quality of life of incarcerated Brazilian male adolescents.
MATERIALS AND METHODS Ethical considerations The study received approval from the Human Research Ethics Committee of the Federal University of Parana (Brazil) and carried out according to the Declaration of Helsinki. The legal guardians and adolescents signed a statement of informed consent authorising participation in the study.
tal trauma was assessed using the criteria described by Andreasen and Andreasen.2
Calibration process The calibration process was performed in two phases. The theoretical phase involved a discussion on the diagnosis of the different dental disorders studied using projected photographic images and plaster casts. An expert (FMF) with extensive experience in clinical data collection in epidemiological studies (gold standard in the theoretical framework) coordinated this step, training a general dentist (DCO) on how to perform the examination. The second phase was conducted with different methodologies, as the conditions evaluated were very different. Twenty-five adolescents were clinically examined for caries, periodontal disease and oral hygiene status and re-examined after a 15-day interval with regard to the first two variables. It was not possible to determine intra-examiner agreement for the IHO-S (oral hygiene status). For dental trauma and dental fluorosis, 39 and 30 images, respectively, were analysed by the same examiner on two occasions and in a different order with a 15-day interval between analyses. For the DAI, 22 plaster casts of the adolescents’ dentition were analysed by the same examiner on two occasions with a 15day interval between analyses. Weighted Cohen’s Kappa values and intraclass correlation coefficients were > 0.80 for the DAI. For the other parameters, weighted Cohen’s Kappa values (Dean’s index, CPI, IHO-S) and Kappa values (DMFT, dental trauma) were ≥ 0.80 for inter-examiner agreement. For all conditions, intra-examiner agreement was ≥ 0.80.
Pilot study Study population and study design A cross-sectional census study was carried out with all incarcerated adolescents (N = 103) incarcerated for at least 30 days at the São Francisco Social Education Centre in the city of Piraquara, state of Paraná, southern Brazil, from January to June 2010. The following indices were assessed: caries using the Decayed, Missing and Filled Teeth (DMFT) index, periodontal status using the Community Periodontal Index (CPI), malocclusion using the Dental Aesthetic Index (DAI) and dental fluorosis using Dean’s Dental Fluorosis Index.32 Oral hygiene was assessed using the Simplified Oral Hygiene Index (IHO-S)13 and den-
418
A pilot study was first carried out, involving a convenience sample of 10 incarcerated male adolescents incarcerated in another social education centre in the state of Paraná to test the methods and understanding of the questionnaires. The results revealed no need to change the initially proposed methods.
Data collection and questionnaires Clinical exams were performed with the aid of a disposable mouth mirror (PRISMA; São Paulo, SP, Brazil) and standard periodontal probe (WHO-621,
Oral Health & Preventive Dentistry
Oliveira et al
Trinity; São Paulo, SP, Brazil) by a single examiner (DCO) with the subject seated in a dental chair under the artificial light of the reflector. The clinical exam followed a standardised order, with oral hygiene and periodontal status evaluated first, followed by the determination of dental trauma, fluorosis, caries and malocclusion. The average time spent on each adolescent was 30 min. The adolescents completed a questionnaire in interview format addressing sociodemographic factors, health-related aspects and dental experience, with items on marital status, formal schooling, employment prior to internment, living prior to internment with at least one parent, first internment, visit to dentist prior to internment, type of dental office, reported discomfort in teeth and mouth and use of tobacco prior to internment. On the same occasion, the short form of the Oral Health Impact Profile,28 cross-culturally adapted and validated for Brazilian Portuguese,24 was administered through interviews by a single trained researcher (DCO) to measure the impact on oral health related quality of life (OHRQoL). This assessment tool has been employed in a large number of dentistry studies and has a solid conceptual basis, with known psychometric properties and easy administration. The questionnaire has six subscales, each with two items: physical limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. The rating scale response options are scored as follows: never = 0; hardly ever = 1; occasionally = 2; fairly often = 3; very often = 4. The previous month of incarceration was the timeframe used. The sum of the points attributed to the responses given to each item (0 to 4) were totaled for the overall OHIP-14 score, which ranged from 0 to 56 points.
Statistical analysis The data were analysed using the Statistical Package for the Social Sciences (SPSS for Windows, version 16.0, SPSS; Chicago, IL, USA). Descriptive and Poisson’s univariate regression analysis were performed to test associations between oral health conditions and the co-variables as well as self-reported impact on quality of life. Variables with p < 0.20 in the univariate analyses were incorporated into the Poisson multiple regression model with robust variance. For the analysis of associations, OHIP-14 scores were dichotomised as the presence of impact on quality of life (at least one ‘occasionally’, ‘fairly often’ or ‘very
Vol 13, No 5, 2015
often’ response) or absence of impact (only ‘never’ and ‘hardly ever’ responses on all items). The reports of rare events (response options of ‘never’ and ‘hardly ever’) were ignored, as they may not represent a significant impact on quality of life.28 The clinical variables were also dichotomised: oral hygiene: ‘satisfactory’ (OHI-S < 1) and ‘unsatisfactory’ (OHI-S ≥ 1); untreated caries: ‘presence’ (D component of DMFT index ≥ 1) and ‘absence’ (D component of DMFT index = 0); malocclusion: ‘presence’ (DAI > 25) and ‘absence’ (DAI ≤ 25); dental fluorosis: ‘presence’ (Dean’s Index > 1) and ‘absence’ (Dean’s index ≤ 1); periodontal status: ‘healthy’ (CPI < 1) and ‘unhealthy’ (CPI ≥ 1); dental trauma: ‘presence’ (clinical signs of dental trauma, from enamel fracture to avulsion) and ‘absence’ (no clinical signs of dental trauma). The sociodemographic, health-related aspects and dental experience variables were dichotomised as follows: marital status (single/stable relationship); schooling (> 8 years/≤ 8 years); employed prior to internment (yes/no); lived with at least one parent (yes/no); first internment (yes/no); visit to dentist prior to internment (yes/no); type of dental office (private office, public office); discomfort in teeth and mouth (yes/ no); user of tobacco prior to internment (no = never, rarely / yes = sometimes, constantly, always).
RESULTS One hundred three incarcerated adolescents met the inclusion criteria. One loss occurred due to incomplete answers. Thus, one hundred two adolescents between 15 and 19 years of age participated in the present study (response rate = 99%). These adolescents had a mean age of 16.8 (standard deviation [SD] = 0.94) years. Mean time of incarceration was 6.2 (SD = 4.1) months. Prior to internment, most of the participants lived with at least one parent (72.5%) and 52.9% worked. Only 7.8% had completed more than eight years of formal schooling and 36% were repeat offenders. The prevalence of oral health-related impact on quality of life was 64% (95% CI: 54–73) and the mean OHIP-14 score was 6.7 (SD = 8.8; median = 3; range: 0 to 38) (Table 1). ‘Felt pain in mouth or teeth’ (item 3) and ‘worried about problems with mouth or teeth’ (Item 5) were the aspects of quality of life most affected by oral health status (Table 2). A total of 36.3% of the participants reported feeling discomfort in their teeth or mouth at the moment of the interview. A statistically significant association was detected between this condition and
419
Oliveira et al
Table 1 Prevalence of impact on OHRQoL and OHIP-14 scores among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Scores OHIP-14 subscales
Mean ± SD
Min
Max
Median
Frequency (%) of impact on OHRQoL
Functional limitation
0.4 ± 1.2
0
8
0
14 (13.7)
Physical pain
1.8 ± 2.1
0
8
1
47 (46.1)
Psychological discomfort
1.8 ± 2.3
0
8
1
43 (42.2)
Physical disability
1.0 ± 1.8
0
8
0
26 (25.5)
Psychological disability
0.8 ± 1.4
0
6
0
26 (25.5)
Social disability
0.5 ± 1.2
0
6
0
15 (14.7)
Handicap
0.4 ± 1.0
0
4
0
12 (11.8)
Total OHIP
6.7 ± 8.8
0
38
3
65 (63.7)
SD = standard deviation; OHRQoL = oral health-related quality of life.
Table 2 Frequency of reported impact on each item of OHIP-14 among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Absence of impact OHIP-14 subscales
Presence of impact
N
(%)
N
(%)
Item 1
95
(93.1)
7
(6.9)
Item 2
93
(91.2)
9
(8.8)
Item 3
63
(61.8)
39
(38.2)
Item 4
73
(71.6)
29
(28.4)
Item 5
63
(61.8)
39
(38.2)
Item 6
82
(80.4)
20
(19.6)
Physical disability
Item 7
79
(77.5)
23
(22.5)
Item 8
88
(86.3)
14
(13.7)
Psychological disability
Item 9
85
(83.3)
17
(16.7)
Item 10
87
(85.3)
15
(14.7)
Item 11
89
(87.3)
13
(12.7)
Item 12
96
(94.1)
6
(5.9)
Item 13
90
(88.2)
12
(11.8)
Item 14
101
(99.0)
1
(1.0)
Functional limitation
Physical pain
Psychological discomfort
Social disability
Handicap Absence of impact = never or hardly ever; presence of impact = occasionally, fairly often or very often.
the report of an oral health-related impact on quality of life (prevalence ratio [PR] = 1.51; 95% CI: 1.14–1.98). The prevalence of impact on OHRQoL was significantly higher in adolescents who maintained a stable relationship (PR = 1.37; 95% CI: 1.05–1.81) (Table 3). The Poisson univariate analysis revealed a statistically significant association
420
between the use of tobacco prior to internment and OHRQoL (PR = 1.66; 95% CI: 1.12–2.46) (Table 3). Caries was found in 93% (95% CI: 88–98) of the participants. The mean DMFT index was 5.9 (SD = 4.5). The ‘decayed’ component contributed most to this index (mean = 2.8; SD = 3.3) and the ‘missing’ component contributed the least
Oral Health & Preventive Dentistry
Oliveira et al
Table 3 Frequency distribution of sociodemographic variables, report of discomfort in teeth and mouth, tobacco use and impact on OHRQoL among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Impact on OHRQoL
Univariate analysis
Without impact N (%)
With impact N (%)
Total N (%)
32 (41.6)
45 (58.4)
77 (75.5)
Stable relationship
5 (20.0)
20 (80.0)
25 (24.5)
> 8 years (ref.)
5 (62.5)
3 (37.5)
8 (7.8)
Variables Single (ref.) Marital status
Schooling ≤ 8 years
32 (34.0)
62 (66.0)
94 (92.2)
Employed prior to internment
Yes (ref.)
22 (40.7)
32 (59.3)
54 (52.9)
No
15 (31.2)
33 (68.8)
48 (47.1)
Lived with at least one parent
Yes (ref.)
26 (35.1)
48 (64.9)
74 (72.5)
No
11 (39.3)
17 (60.7)
28 (27.5)
First internment
Yes (ref.)
26 (40)
39 (60.0)
65 (63.7)
No
11 (29.7)
26 (70.3)
37 (36.3)
Been to dentist prior to internment
Yes (ref.)
33 (37.9)
54 (62.1)
87 (85.3)
Type of dental office
Public service (ref.)
Discomfort in teeth and mouth
No (ref.)
No
4 (26.7)
11 (73.3)
15 (14.7)
25 (37.9)
41 (62.1)
66 (75.9)
8 (38.1)
13 (61.9)
21 (24.1)
30 (46.2)
35 (53.8)
65 (63.7)
7 (18.9)
30 (81.1)
37 (36.3)
Non-User (ref.)
20 (55.6)
16 (44.4)
36 (35.6)
User
17 (26.2)
48 (73.8)
65 (64.4)
Private office
Yes
Tobacco
p*
Unadjusted PR [95% CI]
0.024
1.37 [1.05–1.81]
0.222
1.78 [0.71–4.34]
0.320
1.16 [0.86–1.56]
0.705
0.94 [0.66–1.33]
0.283
1.17 [0.87–1.56]
0.346
1.19 [0.84–1.69]
0.986
0.99 [0.68–1.47]
0.003
1.51 [1.14–1.98]
0.011
1.66 [1.12–2.46]
* p-value referring to Poisson univariate regression analysis; results significant at 5%(p < 0.05) level. OHRQoL = oral health-related quality of life; PR = prevalence ratio; CI = confidence interval. Ref: reference.
(mean = 0.5; SD = 0.9). The mean number of teeth among the participants was 28.5 (SD = 1.5), 22.4 (SD = 4.4) of which were sound teeth. High prevalence rates were found for periodontal problems (82.3%) (95% CI: 75–90) and malocclusion (60.8%) (95% CI: 51–70). Thirty-three participants (32.4%) (95% CI: 23–42) exhibited some type of dental trauma – from enamel fracture to avulsion. Fluorosis was detected in 15 individuals (15.6%) (95% CI: 7–22), ranging from very mild to severe. Univariate analysis was used to test associations between all clinical indicators and OHRQoL. A statistically significant association was found between untreated caries and OHRQoL (PR = 1.81; 95% CI: 1.07– 3.08). Oral hygiene also had an impact on OHRQoL (PR = 1.47; 95% CI: 1.13–1.87). No statistically significant associations were detected between the other clinical conditions and OHRQoL (Table 4).
Vol 13, No 5, 2015
In the multiple regression model, untreated caries, discomfort in teeth or mouth, use of tobacco and marital status were significantly associated with OHRQoL (p < 0.05). The prevalence of an oral health-related impact on quality of life was higher among individuals with untreated caries (PR = 1.74; 95% CI: 1.10–2.77), those who reported discomfort in the teeth or mouth (PR = 1.33; 95% CI: 1.03–1.73), those who reported using tobacco prior to internment (PR = 1.53; 95% CI: 1.04–2.24) and those who maintained a stable relationship (PR = 1.31; 95% CI: 1.01–1.70) in comparison to individuals who did not exhibit these conditions. Moreover, each month of internment represented an increase in the prevalence of an oral health-related impact on quality of life (PR = 1.03; 95% CI: 1.01–1.06) (Table 5).
421
Oliveira et al
Table 4 Frequency distribution of clinical conditions and impact on OHRQoL among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Impact on OHRQoL Without impact N (%)
With impact N (%)
Absent (ref.)
14 (60.9)
9 (39.1)
23 (22.5)
Present
23 (29.1)
56 (70.9)
79 (77.5)
Satisfactory (ref.)
32 (37.6)
53 (62.4)
85 (85.5)
Variables Untreated dental caries
Univariate analysis Total N (%)
Oral hygiene Unsatisfactory
1 (9.1)
10 (90.9)
11 (11.5)
Healthy (ref.)
7 (41.2)
10 (58.8)
17 (17.7)
Unhealthy
26 (32.9)
53 (67.1)
79 (82.3)
Absent (ref.)
17 (42.5)
23 (57.5)
40 (39.2)
Periodontal status
Malocclusion Present
20 (32.3)
42 (67.7)
62 (60.8)
Absent (ref.)
26 (32.1)
55 (67.9)
81 (84.4)
Present
7 (46.7)
8 (53.3)
15 (15.6)
Absent (ref.)
23 (33.3)
46 (66.7)
69 (67.6)
Present
14 (42.4)
19 (57.6)
33 (32.4)
Dental fluorosis
Dental trauma
p*
Unadjusted PR [95% CI]
0.028
1.81 [1.07–3.08]
0.003
1.47 [1.13–1.87]
0.546
1.14 [0.75–1.75]
0.311
1.18 [0.86–1.62]
0.340
0.79 [0.48–1.29]
0.394
0.86 [0.62–1.21]
* p-value referring to Poisson univariate regression analysis; results significant at 5% (p < 0.05) level. OHRQOL = oral health-related quality of life; PR = prevalence ratio; CI = confidence interval.
DISCUSSION In the present study, the majority of participants reported that oral health problems exerted an influence on OHRQoL. However, the average OHIP-14 score was low, suggesting little impact on OHRQoL. Similar findings have been reported in studies conducted with Brazilian adolescents who were not incarcerated/institutionalised.5,10 ‘Worried about problems with the mouth or teeth’ (item 5) was reported with high frequency and achieved the greatest number of ‘very often’ responses. Items related to psychological discomfort and psychological disability had a considerable impact on the OHIP score, accounting for 39% of the overall score. As reported for non-incarcerated adolescents in Brazil,5,10 psychological discomfort was among the domains that most affected the daily activities of the adolescents, the score of which was only surpassed by the physical pain subscale. On items related to psychological aspects, the present findings are similar to those described for non-incarcerated Brazilian adolescents regarding the mean value10 and frequency of impact.5 This may be a characteristic of adolescence itself and therefore also present in those deprived of freedom.
422
Items related to social interaction had little impact on OHRQoL in this study. Among the sociodemographic variables, only marital status was associated with reports of an impact. Most of the participants were single and a statistically significant association was found between those in a stable relationship and OHRQoL, which remained significant even after controlling for confounding variables. Although studies indicate that marital status affects health-related quality of life31 and OHRQoL,16 more research is needed to understand this relationship and its consequences. The fact that the adolescents received weekly visits from family members and girlfriends may mean that concerns regarding the mouth and teeth, especially those related to aesthetics, have major importance to individuals in love relationships. Incarceration time was related to OHRQoL. It is therefore suggested that adolescents with a longer internment time tend to experience a diminishment in self-esteem and worsening with regard to issues related to self-perception. Thus, oral health conditions that may affect bio-psychosocial aspects tend to take on more importance to such individuals, thereby causing a greater impact on quality of life. Although the majority of the adolescents had used some type of drug prior to internment, only the use of
Oral Health & Preventive Dentistry
Oliveira et al
Table 5 Poisson multiple regression model for impact of oral health status on quality of life among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010 Variables
p-value
Adjusted PR
95% CI
0.019
1.74
1.10–2.77
0.031
1.33
1.03–1.73
0.030
1.53
1.04–2.24
0.048
1.31
1.01–1.70
0.022
1.03
1.01-1.06
No (ref.) Untreated dental caries Yes Discomfort in teeth or mouth
No (ref.) Yes Non-User (ref.)
Tobacco User Single (ref.) Marital status Stable relationship Time of incarceration (in months)
p-value refers to Poisson multivariate regression; PR= prevalence ratio; CI = confidence interval. Ref: reference.
tobacco prior to internment was significantly associated with OHRQoL, even after adjusting for the other co-variables in the multiple regression model. An association has been demonstrated between smoking and poor oral health status, especially oral cancer12 and periodontal disease,15 and that smoking may negatively affect dental health perceptions.22 In a cohort of Spanish university graduates, smokers reported a greater impact on quality of life than nonsmokers on the subscales of a generic health measure (SF-36), such as physical function, social well-being, emotional well-being and mental health.14 Moreover, smokers were found to have worse OHRQoL in all dimensions in a national cohort in Thailand.33 In this study, the adolescents reported that ‘pain in mouth or teeth’ (OHIP-14, item 3) had the greatest effect on OHRQoL. Although no adolescents reported feeling acute pain at the time of the interview, 36.3% reported some degree of discomfort in the mouth or teeth at the time of the interview and 38.2% reported impact on daily activities due to pain in the mouth or teeth in the previous 30 days (OHIP-14, item 3). Moreover, physical pain has also been found to be an important OHIP-14 item among adolescents who are not incarcerated.3,5 A statistically significant association was found between the report of discomfort in the teeth or mouth and OHRQoL in both the univariate and multivariate analyses. This association was expected; it confirms the negative repercussions of factors that affect the mouth and teeth in the daily lives of adolescents and demonstrates the consistency of the method used to assess the impact of oral health on the quality of life of adolescents (OHIP-14).
Vol 13, No 5, 2015
In the present study, individuals with untreated caries had a 1.81-fold greater prevalence of impact on OHRQoL than those without this condition and the association remained significant even after controlling for confounding variables (adjusted PR = 1.74). This finding may be explained by the fact that caries is a cumulative disease that can cause pain, functional limitations, aesthetic impairment and concern or disappointment with regard to the mouth and teeth, especially untreated carious lesions, thereby affecting various aspects of quality of life. The most affected OHIP subscales were those that can be influenced by the consequences of untreated caries. Among non-incarcerated adolescents in Brazil, an association between caries and OHRQoL has been demonstrated in previous studies.3,5 However, the literature is inconclusive with regard to this association. The age group analysed, the prevalence of caries and the method of analysing this variable may account for the divergence in the findings. In the present study, caries was dichotomised based on the ‘decayed’ component of the DMFT index. Previous studies involving Brazilian schoolchildren have also found that untreated caries exerted an influence on OHRQoL.19,26 While Paula et al25 found no such association, the authors report that the low prevalence rate of caries in their sample may have contributed to the absence of statistical significance in the multivariate analysis between this clinical condition and OHRQoL. Individuals with unsatisfactory oral hygiene had a 1.47-fold greater prevalence of impact than those with satisfactory oral hygiene. A greater frequency
423
Oliveira et al
of oral hygiene measures performed is reported to be associated with a lower prevalence of impact on the quality of life of Australian young adults8 and Tanzanian adolescents.20 Most individuals did not exhibit severe periodontal problems and no impact from these conditions on OHRQoL was reported. This result is similar to findings described in a previous Brazilian study with adolescents5 that also used the CPI, which defines periodontal disease based on the presence of bleeding upon probing. However, an association between periodontal disease and quality of life among Chilean adolescents was found when more serious aspects were analysed, such as attachment loss and necrotising ulcerative gingival lesions.18 Despite the large number of adolescents with malocclusion, these conditions were not significantly associated with an impact on OHRQoL. Brazilian studies demonstrated an association between quality of life (as assessed with the Oral Impacts on Daily Performances Index) and malocclusion among adolescents, as aesthetic aspects have the greatest impact on the quality of life.4,30 This is likely explained by the high prevalence of malocclusion relevant to aesthetic issues, which influences appearance, self-esteem and interpersonal relationships. However, adolescents deprived of freedom most often have restricted social interactions and such issues may lose their importance in this context. In Brazilian adolescents, when the OHRQoL was assessed by the OHIP-14, no association was found with DAI,10 similar to this study. This could be explained by the fact that OHIP-14 was not developed specifically to measure the impact of orthodontic problems on OHRQoL and some of the items may not be relevant to patients with malocclusion.10 Furthermore, the DAI allows categorising the presence or absence of malocclusion from clinical measurements, but it fails to analyse self-perception of aesthetics. As in previous cross-sectional studies carried out in Brazil,5,21 no association was found between dental fluorosis and quality of life in adolescents, which may be explained by the low prevalence and low degree of severity of the condition, as the majority of cases were questionable or very mild. Brazilian adolescents who experienced adverse psychosocial environments throughout life had more traumatic dental injuries.23 A great number of individuals with fractured teeth was observed, as expected since the population studied was made up of young males with a history of violence and
424
juvenile delinquency, and perhaps the great frequency of dental trauma reduces their impact on social relationships. Unlike findings reported in case-control studies involving 12- to 14-year-old Brazilian9 and Canadian11 adolescents, no significant association was found between dental trauma and quality of life. An analysis of the OHIP-14 items reveals that issues related to aesthetics and social relations are not overly important to these incarcerated adolescents, likely due to their lack of freedom and consequently restricted social interactions. This group of male adolescents lives under special conditions with strict rules, isolated from a large part of social life. Thus, caution should be exercised when making comparisons and inferences, as generalisations are not possible. One of the limitations of the present study was the possibility that the adolescents may have exaggerated their reports of a negative impact on OHRQoL in an attempt to obtain priority with regard to dental treatment. Moreover, the sample was composed only of male adolescents, whereas the discussion addressed studies involving both males and females.
CONCLUSION Understanding the oral health status of incarcerated adolescents from a multidimensional perspective will allow healthcare professionals to develop better oral health programmes for this particular group. Most individuals reported an impact on quality of life stemming from oral health problems. Sociodemographic aspects were found to exert a substantial impact on OHRQoL of the adolescents. Some conditions that are important from the clinical standpoint did not present a great impact on ORHQoL, such as malocclusion and dental trauma. However, untreated caries was the most important clinical aspect influencing the OHRQoL in this group. Therefore, for these adolescents, efforts must be made to prioritise caries treatment and to prevent tooth decay. There is urgent need for further studies for comparison and discussion purposes.
ACKNOWLEDGEMENTS This study was supported by the Fundação Araucária, support for scientific and technological development do Paraná and by the Brazilian Coordination for Higher Education (CAPES), Ministry of Education, Brazil.
Oral Health & Preventive Dentistry
Oliveira et al
REFERENCES 1. Anderson B, Farrow JA. Incarcerated adolescents in Washington State. Health services and utilization. J Adolesc Health 1998;22:363–367. 2. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, ed 4. Copenhagen: Munskgaard, 2007. 3. Bastos RS, Carvalho ES, Xavier A, Caldana ML, Bastos JRM, Lauris JRP. Dental caries related to quality of life in two Brazilian adolescent groups: a cross-sectional randomised study. Int Dent J 2012;62:137–143. 4. Bernabé E, Tsakos G, Oliveira CM, Sheiham A. Impacts on daily performances attributed to malocclusions using the conditions-specific feature of the oral impacts on daily performances Index. Angle Orthod 2008;78:241–247. 5. Biazevic MGH, Rissoto RR, Crosato EM, Mendes LA, Mendes MOA. Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res 2008;22:36–42. 6. Bolin K, Jones D. Oral health needs of adolescents in a juvenile detention facility. J Adolesc Health 2006;38:755– 757. 7. Brasil. Levantamento nacional da atenção em saúde mental aos adolescentes privados de liberdade e sua articulação com as Unidades Socioeducativas. Brasília: Ministério da Saúde/Secretaria de Direitos Humanos, 2008. 8. Brennan DS, Spencer AJ. Life events and oral health related quality of life among young adults. Qual Life Res 2009;18:557–565. 9. Cortes MIS, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12-14 year old children. Community Dent Oral Epidemiol 2002;30:193–198. 10. de Paula Junior DF, Santos NCM, Silva ET, Nunes MF, Leles CR. Psychosocial impact of dental esthetics on quality of life in adolescents: association with malocclusion, self-Image, and oral health–related issues. Angle Orthod 2009;79:1188–1193. 11. Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Impact of treated and untreated dental injuries on the quality of life of Ontario school children. Dent Traumatol 2008;24:309–313. 12. Gandini S, Botteri E, Iodice S, Boniol M, Lowenfels AB, Maisonneuve P, Boyle P. Tobacco smoking and cancer: a meta-analysis. Int J Cancer 2008;122:155–164. 13. Greene JC, Vermillion JR. The simplified oral hygiene index. JADA 1964;68:7–13. 14. Guitérrez- Bedmar MG, Gómez MS, Gracia EG, Rastrollo MB, González MAM. Smoking status, changes in smoking status and health-related quality of life: findings from the SUN (‘Seguimiento Universidad de Navarra’) cohort. Int J Environ Res Public Health 2009;6:310–320. 15. Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Periodontol 2004;75:196–209. 16. Kriz P, Seydlova M, Dostalova T, Valenta Z, Chleborad K, Zvarova J, Feberova J, Hippmann R. Dental implants and improvement of oral health-related quality of life. Community Dent Oral Epidemiol 2012;40(suppl 1):65–70.
Vol 13, No 5, 2015
17. Locker D. Oral health and quality of life. Oral Health Prev Dent 2004;2(suppl 1):247–53. 18. López R, Baelum V. Oral health impact of periodontal diseases in adolescents. J Dent Res 2007;86:1105–1109. 19. Martins-Júnior PA, Oliveira M, Marques LS, Ramos-Jorge ML. Untreated dental caries: impact on quality of life of children of low socioeconomic status. Pediatr Dent 2012;34:49–52. 20. Mbawalla HS, Masalu JR, Åstrøm AN. Socio-demographic and behavioral correlates of oral hygiene status and oral health related quality of life, the Limpopo – Arusha school health project (LASH): A cross-sectional study. BMC Pediatr 2010;10:87. 21. Michel-Crosato E, Biazevic MGH, Crosato E. Relationship between dental fluorosis and quality of life: a population based study. Braz Oral Res 2005;19:150–155. 22. Morin NM, Dye BA, Hooper TI. Influence of cigarette smoking on the overall perception of dental health among adults aged 20–79 years, United States, 1988–1994. Public Health Rep 2005;120:124–132. 23. Nicolau B, Marcenes W, Sheiham A. The relationship between traumatic dental injuries and adolescents‘ development along the life course. Community Dent Oral Epidemiol 2003;31:306–313. 24. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol 2005;33:307–314. 25. Paula JS, Leite IC, Almeida AB, Ambrosano GM, Pereira AC, Mialhe FL. The influence of oral health conditions, socioeconomic status and home environment factors on schoolchildren‘s self-perception of quality of life. Health Qual Life Outcomes 2012;10:6. 26. Peres KG, Peres MA, Araujo CL, Menezes AM, Hallal PC.Social and dental status along the life course and oral health impacts in adolescents: a population-based birth cohort. Health Qual Life Outcomes 2009;7:95. 27. Ramos-Jorge ML, Bosco VL, Peres MA, Nunes ACGP. The impact of treatment of dental trauma on the quality of life of adolescents –a case-control study in southern Brazil. Dent Traumatol 2007;23:114–119. 28. Slade G. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284–290. 29. Thelen DS, Trovik TA, Bardsen. A Impact of traumatic dental injuries with unmet treatment need on daily life among Albanian adolescents: a case-control study. Dent Traumatol 2011;27:88–94. 30. Traebert ESA, Peres MA. Do malocclusions affect the individual’s oral health-related quality of life? Oral Health Prev Dent 2007;5:3–12. 31. Wang T, Chou C, Shu Y Assessing the effects of oral health-related variables on quality of life in Taiwanese adults. Qual Life Res 2013;22:811–825. 32. World Health Organization: Oral health surveys. Basic Methods, ed 4. Geneva: World Health Organization, 1997. 33. Yiengprugsawan V, Somkotra T, Seubsman S, Sleigh AC. Oral health-related quality of life among a large national cohort of 87,134 Thai adults. Health Qual Life Outcomes 2011;9:42.
425
