Eur Arch Paediatr Dent DOI 10.1007/s40368-014-0124-1
ORIGINAL SCIENTIFIC ARTICLE
Prevalence of dental pain and its relationship to caries experience in school children of Udupi district Y. S. Kumar • S. Acharya • K. C. Pentapati
Received: 9 December 2013 / Accepted: 18 February 2014 Ó European Academy of Paediatric Dentistry 2014
Abstract Purpose To evaluate the prevalence of dental pain and its relationship to caries experience in 10–15-year-old school children of Udupi district of India. Methods A cross-sectional survey was conducted in Udupi district among 10–15-year-old school children. A self-administered questionnaire was used to collect information on age, gender, type of school, location and socioeconomic status followed by Child Dental Pain Questionnaire. This was followed by clinical examination for dental caries. Results A total of 306 children participated in the study; of whom, 56.5 % were B12 years old, 58.8 % were males, 50.7 % attended a government school and 54.9 % were from urban areas. The prevalence of dental pain was 35 %. Only gender showed significant association with presence of tooth pain (p = 0.027). A total of 14.3 % reported mild pain, 8.8 % reported moderate pain and 11.7 % reported severe pain. Almost half of the study participants (45.1 %) had experienced dental caries. The mean scores of each subscale and total scale scores were significantly higher among caries-experienced than among caries-free children (p = 0.017, 0.043, 0.022 and 0.02, respectively). There was significant weak positive correlation of global single item question with prevalence (r = 0.115, p = 0.045), severity (r = 0.146, p = 0.010) impact subscales (r = 0.117, p = 0.040) and total scale (r = 0.144, p = 0.012).
Y. S. Kumar S. Acharya K. C. Pentapati (&) Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka 576104, India e-mail: [email protected]
Conclusion The substantial effect that dental pain has on adolescents indicates an urgent need for public health strategies. Keywords
Caries Children Dental Pain Self-report
Introduction Oral health is an integral component of general health which has great impact on quality of life. Despite major improvements in oral health care in recent decades, many children in developing countries are still affected by common oral diseases such as dental caries (Petersen 2003). Pain is a commonly reported symptom of dental diseases and previous studies have shown specific and direct relationship (Goes et al. 2008). Pain is defined as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’’ (International Association for the Study of Pain 1979). Pain is perceived as a result of a neurophysiological process, which in turn is influenced by various sociodemographic, cultural and psychological factors related to an individual. Dental pain has marked effect on the psychosocial wellbeing of children. Of the many aspects of toothache caused by untreated decayed teeth, the most serious are the ones that affect quality of life. The common causes of oral pain other than dental caries in children are dento-alveolar trauma, erupting teeth, exfoliating primary teeth, and ulcers in oral mucosa (Shepherd et al. 1999). Pain in children is not always recognised and the objective assessment of children’s pain constitutes a challenge to health care professionals (Frank et al. 2000). Variations in children’s cognitive abilities affect how they
123
Eur Arch Paediatr Dent
perceive, understand, remember and report pain. Pain is a subjective phenomenon that must be measured by selfreported questions, which represent the ‘‘gold standard’’ for assessing children’s perceptual or psychological experience of pain. Relatively few studies have been reported to determine the prevalence of oral pain and its effect on oral health-related quality of life in children (Shepherd et al. 1999; Naidoo et al. 2001). Since adults and children have different perceptions about health problems on quality of life, there is a need for valid and objective tools for assessment of dental pain. There is a paucity of instruments which are specific and validated for the assessment of self-reported dental pain and quality of life among children. Instruments designed for children of specific ages allow accurate measurement of the effect of dental pain on daily activities and quality of life (Tesch et al. 2007). One such measure is the child dental pain questionnaire (childDPQ) (Barreˆtto et al. 2011). The child-DPQ was based on a questionnaire developed by Shepherd et al. (1999). The validity and reliability of this questionnaire among 8- and 9-year-old children was evaluated by Barreˆtto et al. (2011). Studies related to dental pain severity in children are scarce in developing countries such as India. The aim of this study was to evaluate the prevalence of dental pain and its relationship to caries experience in 10–15-year-old school children of Udupi district.
Materials and methods A cross-sectional survey was conducted in Udupi district among 10–15-year-old school children. Only subjects who were willing to participate were included. Prior consent from parents, and appropriate permission from school authorities, were obtained. Ethical clearance from Kasturba Hospital Ethics Committee, Manipal (IEC 108/2013) was obtained. This district had a total of 220 high schools of which 92 were privately run. This information was obtained from the district administration. As the distribution of the government and private schools was roughly the same in urban and rural areas, two government (one urban and one rural) and two private (one urban and one rural) were selected randomly using lottery method from the list of schools. All students of 10–15 years of age who were present on the day of the survey and who gave consent for the study were included, constituting a total sample of 306. Children with chronic health problems, systemic illnesses, under long-term medications and those undergoing orthodontic treatment were excluded from the study.
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Questionnaire The self-administered questionnaire consisted of demographic information such as age, gender, type of school (government or private), location of school (urban or rural), parents’ education, occupation and income which were assigned values using modified Kuppuswamy scale to compile the socioeconomic status of children into upper, middle and lower classes (Neeta et al. 2012). The child-DPQ had three subscales: (1) prevalence, (2) severity, and (3) impact of toothache on children’s quality of life. It had six questions, with two items in each subscale. The final score could either be 0 or range from 6 to 15, with lower scores indicating better oral health status. The first item of the questionnaire evaluated whether ‘‘child ever had toothache’’. If the child answered ‘‘no’’ on the first item, all other items were considered ‘‘not applicable’’ (score = 0). If the child answered ‘‘yes’’ on the first item, the subsequent items were then answered, with a minimum score of 1 on each item (Barreˆtto et al. 2011). Global single item self-reported pain question was used to establish validity of the child-DPQ. All the items in the questionnaire were initially prepared in English followed by linguistic translation of questionnaire as described by Acquadro et al. (2004). In the first step, the questions were independently translated into Kannada, by two qualified English-to-Kannada translators. After a group discussion with the translators and one author (SA), the first consensus Kannada questionnaire was backward translated to English, and then compared with the original questionnaire and the first consensus Kannada questionnaire. After finalising the questionnaire, 50 children completed it during the pilot study to evaluate face and content validity. These subjects were not included in the main survey. The questionnaire was distributed to children who were asked to complete it without discussing with each other, in 10 min. It was followed by full mouth clinical examination for dental caries. All children who needed dental treatment were referred to Manipal College of Dental Sciences, Manipal. Clinical examination All the children were examined according to the WHO Basic Oral Health Survey Guidelines for dental caries (1997). Decayed, missing and filled teeth were recorded by a single trained examiner (YSK) with mouth mirror and CPI probes in adequate natural light within the school premises. The DMFT index was computed by adding decayed, missing and filled teeth. DMFT was dichotomised into caries-free (DMFT = 0) and caries-experienced
Eur Arch Paediatr Dent
(DMFT C 1). Cohen’s j coefficient for the assessment of dental caries was 0.88, indicating good intra-examiner agreement in the pilot study. Statistical analysis All the analysis was carried out using the Statistical Package for Social Sciences (SPSS version 16.0). A p value of B0.05 was considered statistically significant. Chi square test was used for comparison of prevalence of pain between different groups based on age, gender, type of school, location, and socioeconomic status (SES). Spearman’s rank test was done to obtain correlations between global self-reported item for pain and Child-DPQ. Internal reliability was tested using the Cronbach a coefficient. The mean subscales and total Child-DPQ were compared between caries-free and caries-experienced children using Mann–Whitney U test.
Results A total of 306 children participated in the study; of them, 56.5 % were B12 years old, 58.8 % were males, 50.7 % were in government school and 54.9 % were from urban areas. Prevalence of dental pain was 35 %. Among the pain group, 61.7 % were B12 years, 67.3 % were males, 54.2 % were in private schools and 57.9 % were from urban areas. Only gender showed significant association with presence of tooth pain (p = 0.027). A total of 14.3 % Table 1 Comparison of tooth pain with sociodemographic characteristics of participants Tooth pain
p value
No N (%)
Yes N (%)
B12 (173)
107 (53.8)
66 (61.7)
[12 (133)
92 (46.2)
41 (38.3)
Male (180)
108 (54.3)
72 (67.3)
Female (126) School
91 (45.7)
35 (32.7)
reported mild pain, 8.8 % reported moderate pain and 11.7 % reported severe pain (Table 1). No significant difference was found in the distribution of caries experience between B12 years old (n = 78) and [12 years old (n = 60) (p value = 0.996). Almost half of the study participants (45.1 %) had experienced dental caries. The mean scores of each subscale and total scale scores were significantly higher among caries-experienced than among caries-free children (p = 0.017, 0.043, 0.022 and 0.02, respectively) (Table 2). The mean (SD) DMFT in children with pain (1.36 ± 1.54) was significantly higher than in those children who did not have pain (0.96 ± 1.37) (p = 0.024). All the participants completed the questionnaire. Internal consistency reliability (standardised item alpha) was 0.975. The inter-item correlations ranged from 0.853 (When was your last tooth pain?) to 0.956 (Have you ever had a toothache?). The corrected item total correlation (i.e. the correlation between each item and the total score omitted for that item) ranged from 0.905 (Were you awakened at night by pain?) to 0.96 (How was it when the pain was at its worst?), which was above the minimum level of 0.20 for including an item into a scale. Cronbach’s a decreased when any one item was deleted from the scale (Table 3). Table 2 Comparison of mean subscale and total scale scores between caries-free and experienced groups Subscale
Caries free (n = 168) Mean ± SD
Caries experienced (n = 138) Mean ± SD
p value
Prevalence
0.77 ± 1.25
1.07 ± 1.36
0.017
Severity
1.22 ± 2.06
1.81 ± 2.36
0.043
Impact
0.76 ± 1.23
1.13 ± 1.43
0.022
Total
2.76 ± 4.40
4.01 ± 4.98
0.02
Age 0.183
Cronbach’s a = 0.975
Gender
Government (155)
106 (53.3)
49 (45.8)
93 (46.7)
58 (54.2)
Rural (138)
93 (46.7)
45 (42.1)
Urban (168)
106 (53.3)
62 (57.9)
Lower (132)
84 (42.2)
48 (44.9)
Middle (174)
115 (57.8)
59 (55.1)
Private (151)
Table 3 Internal consistency of individual items of Child-DPQ using Cronbach’s a
0.027
0.213
Location 0.433
SES 0.656
Corrected itemtotal correlation
Cronbach’s a if item deleted
Have you ever had a toothache?
0.956
0.920
When was your last tooth pain?
0.853
0.910
Did you cry at the worst movement of a toothache?
0.925
0.910
How was it when the pain was at its worst? (intensity)
0.905
0.960
Were you awakened at night by pain?
0.943
0.905
Were you unable to do your normal tasks because of tooth pain?
0.888
0.913
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There was significant weak positive correlation of global single item question with prevalence (r = 0.115, p = 0.045), severity (r = 0.146, p = 0.010) impact subscales (r = 0.117, p = 0.040) and total scale (r = 0.144, p = 0.012).
Discussion This study aimed to evaluate the prevalence of dental pain in 10–15-year-old school children and its relationship with dental caries experience. Oral and dental pain are different parameters in that the former indicates pain within mouth whereas later is described as ‘pain that originates from innervated tissues within tooth or immediately adjacent to it’ (Ratnayake and Ekanayake 2005). The prevalence rate of dental pain (35 %) in this study was lower than that of other studies by Shepherd et al. (1999) (47.5 %), Ratnayake and Ekanayake (2005) (49 %), Dandi et al. 2011 (71.4 %), but similar to studies conducted by Mashoto et al. (2009) (36.4 %), Nomura et al. (2004) (33.7 %) and Pau et al. (2008) (30.4 %). These variations could be due to differences in cultural or behavioural perceptions of pain and pain measurement issues, recall bias in children and variations in disease patterns (Slade 2001). Our study showed significantly higher prevalence of toothache in boys than in girls which was in contrast to the studies conducted by Levine and De Simone (1991), Josimari et al. (2013). In this study, there was a significantly higher mean DMFT in children who reported to have toothache. Dental caries can be regarded as one of the important dental pain-triggering factors. Studies by Pau et al. (2008) and Traebert et al. (2005) pointed out dental caries as a strong predictor for dental pain in school children and adolescents. Children with decayed teeth clearly experience toothache more often than do children without decayed teeth. Our study was in agreement with the literature which reports positive association between dental pain (prevalence, severity and impact) and caries experience in children. The difference in the prevalence of pain between boys and girls could be due to the selection bias which has occurred due to the inclusion of a whole class for selecting children. This study did not show any association with socioeconomic status, location of school, and type of school with the prevalence of toothache among children. However, previous studies by Dandi et al. (2011) and Ratnayake and Ekanayake (2005) showed an association with SES and location. These differences could be due to small sample size and differences in assessment of SE status.
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Ignoring the recall interval period in which dental pain prevalence was estimated previously (1 month to 1 year), existing data suggest that dental pain affects significant proportions of adolescents worldwide. These proportions may well be underestimated because the collection of selfreported health data necessarily depends on the recall ability of the respondents (van den Brink et al. 2001). Limitations of this study were the lack of assessment of caries severity and other conditions causing dental pain viz., erupting teeth, exfoliating primary teeth, and dentoalveolar trauma. Further studies are needed in this study area to evaluate the above factors in this target group. The use of this questionnaire can help screen large numbers of children in order to allocate valuable resources and manpower to those who are in need. One of the reasons for dental pain is that dental care is not universally available, and thus those with perceived need might not be able to access care because of high costs of treatment or lack of dental services. Furthermore, care may not be easily available, especially in the rural parts of a developing country. The substantial impact that dental pain has on adolescents indicates an urgent need for public health strategies for caries prevention and treatment using appropriate technologies such as affordable fluoridated toothpaste, atraumatic restorative techniques and increased manpower (dental auxiliary workers) to prevent cariesrelated dental pain.
References Acquadro C, Conway K, Giroudet C, Mear I. Linguistic validation manual for patient-reported outcomes (PRO) instruments. Lyon: Mapi Research Institute; 2004. Barreˆtto ER, Paiva SM, Pordeus IA, Ferreira e Ferreira E. Validation of a child dental pain questionnaire instrument for the selfreporting of toothache in Children. Pediatr Dent. 2011;33: 228–32. Dandi KK, Rao EV, Margabandhu S. Dental pain as a determinant of expressed need for dental care among 12-year-old school children in India. Indian J Dent Res. 2011;22:611. Frank LS, Greenberg CS, Stevens A. Pain assessment in infants and children. Pediatr Clin N Am. 2000;47:487–512. Goes PS, Watt RG, Hardy R, Sheiham A. Impacts of dental pain on daily activities of adolescents aged 14 to 15 years and their families. Acta Odontol Scand. 2008;66:7–12. International Association for the Study of Pain. Sub-committee on taxonomy. Pain terms: a list with definitions and notes on usage. Pain. 1979;6:249–52. Josimari T, De Lacerda, Pereira MDB, Traebert E. Dental pain in Brazilian schoolchildren: a cross-sectional study. Int J Paediatr Dent. 2013;23:131–7. Levine FM, De Simone LL. The effects of experimenter gender on pain report in male and female subjects. Pain. 1991;44:69–72. Mashoto KO, Astrøm AN, David J, Masalu JR. Dental pain, oral impacts and perceived need for dental treatment in Tanzanian
Eur Arch Paediatr Dent school students: a cross-sectional study. Health Qual Life Outcomes. 2009;30(7):73. Naidoo S, Chikte UME, Sheiham A. Prevalence and impact of dental pain in 8- to 10-year-olds in the Western Cape. SADJ. 2001;56:521–3. Neeta K, Neeru G, Jugal K. Kuppaswamy’s socioeconomic scale: updating income ranges for the year 2012. Indian J Pub Health. 2012;56:103–4. Nomura LH, Bastos JL, Peres MA. Dental pain prevalence and association with dental caries and socioeconomic status in schoolchildren, Southern Brazil, 2002. Braz Oral Res. 2004;18:134–40. Pau A, Khan SS, Babar MG, Croucher R. Dental pain and careseeking in 11–14-yr-old adolescents in a low-income country. Eur J Oral Sci. 2008;116:451–7. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century: The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003;31:3–23.
Ratnayake N, Ekanayake L. Prevalence and impact of oral pain in 8-year-old children in Sri Lanka. Int J Pediatr Dent. 2005;15:105–12. Shepherd MA, Nadanovsky P, Sheiham A. The prevalence and impact of dental pain in 8-year-old school children in Harrow, England. Br Dent J. 1999;187:38–41. Slade GD. Epidemiology of dental pain and dental caries among children and adolescents. Community Dent Health. 2001;18:219–27. Tesch FC, Oliveira BH, Leao A. Measuring the impact of oral health problems on children’s quality of life: conceptual and methodological issues. Cad Saude Publica. 2007;23:2555–64. Traebert J, Lacerda JT, Jinbo Y, Fischer TK. Dental caries and orofacial pain trends in 12-year-old school children between 1997 and 2003. Oral Health Prev Dent. 2005;3:243–8. van den Brink M, Bandell-Hoekstra EN, Abu-Saad HH. The occurrence of recall bias in pediatric headache: a comparison of questionnaire and diary data. Headache. 2001;41:11–20. World Health Organization. Oral health surveys—basic methods. 4th ed. Geneva: World Health Organization; 1997.
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ORIGINAL SCIENTIFIC ARTICLE
Prevalence of dental pain and its relationship to caries experience in school children of Udupi district Y. S. Kumar • S. Acharya • K. C. Pentapati
Received: 9 December 2013 / Accepted: 18 February 2014 Ó European Academy of Paediatric Dentistry 2014
Abstract Purpose To evaluate the prevalence of dental pain and its relationship to caries experience in 10–15-year-old school children of Udupi district of India. Methods A cross-sectional survey was conducted in Udupi district among 10–15-year-old school children. A self-administered questionnaire was used to collect information on age, gender, type of school, location and socioeconomic status followed by Child Dental Pain Questionnaire. This was followed by clinical examination for dental caries. Results A total of 306 children participated in the study; of whom, 56.5 % were B12 years old, 58.8 % were males, 50.7 % attended a government school and 54.9 % were from urban areas. The prevalence of dental pain was 35 %. Only gender showed significant association with presence of tooth pain (p = 0.027). A total of 14.3 % reported mild pain, 8.8 % reported moderate pain and 11.7 % reported severe pain. Almost half of the study participants (45.1 %) had experienced dental caries. The mean scores of each subscale and total scale scores were significantly higher among caries-experienced than among caries-free children (p = 0.017, 0.043, 0.022 and 0.02, respectively). There was significant weak positive correlation of global single item question with prevalence (r = 0.115, p = 0.045), severity (r = 0.146, p = 0.010) impact subscales (r = 0.117, p = 0.040) and total scale (r = 0.144, p = 0.012).
Y. S. Kumar S. Acharya K. C. Pentapati (&) Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka 576104, India e-mail: [email protected]
Conclusion The substantial effect that dental pain has on adolescents indicates an urgent need for public health strategies. Keywords
Caries Children Dental Pain Self-report
Introduction Oral health is an integral component of general health which has great impact on quality of life. Despite major improvements in oral health care in recent decades, many children in developing countries are still affected by common oral diseases such as dental caries (Petersen 2003). Pain is a commonly reported symptom of dental diseases and previous studies have shown specific and direct relationship (Goes et al. 2008). Pain is defined as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’’ (International Association for the Study of Pain 1979). Pain is perceived as a result of a neurophysiological process, which in turn is influenced by various sociodemographic, cultural and psychological factors related to an individual. Dental pain has marked effect on the psychosocial wellbeing of children. Of the many aspects of toothache caused by untreated decayed teeth, the most serious are the ones that affect quality of life. The common causes of oral pain other than dental caries in children are dento-alveolar trauma, erupting teeth, exfoliating primary teeth, and ulcers in oral mucosa (Shepherd et al. 1999). Pain in children is not always recognised and the objective assessment of children’s pain constitutes a challenge to health care professionals (Frank et al. 2000). Variations in children’s cognitive abilities affect how they
123
Eur Arch Paediatr Dent
perceive, understand, remember and report pain. Pain is a subjective phenomenon that must be measured by selfreported questions, which represent the ‘‘gold standard’’ for assessing children’s perceptual or psychological experience of pain. Relatively few studies have been reported to determine the prevalence of oral pain and its effect on oral health-related quality of life in children (Shepherd et al. 1999; Naidoo et al. 2001). Since adults and children have different perceptions about health problems on quality of life, there is a need for valid and objective tools for assessment of dental pain. There is a paucity of instruments which are specific and validated for the assessment of self-reported dental pain and quality of life among children. Instruments designed for children of specific ages allow accurate measurement of the effect of dental pain on daily activities and quality of life (Tesch et al. 2007). One such measure is the child dental pain questionnaire (childDPQ) (Barreˆtto et al. 2011). The child-DPQ was based on a questionnaire developed by Shepherd et al. (1999). The validity and reliability of this questionnaire among 8- and 9-year-old children was evaluated by Barreˆtto et al. (2011). Studies related to dental pain severity in children are scarce in developing countries such as India. The aim of this study was to evaluate the prevalence of dental pain and its relationship to caries experience in 10–15-year-old school children of Udupi district.
Materials and methods A cross-sectional survey was conducted in Udupi district among 10–15-year-old school children. Only subjects who were willing to participate were included. Prior consent from parents, and appropriate permission from school authorities, were obtained. Ethical clearance from Kasturba Hospital Ethics Committee, Manipal (IEC 108/2013) was obtained. This district had a total of 220 high schools of which 92 were privately run. This information was obtained from the district administration. As the distribution of the government and private schools was roughly the same in urban and rural areas, two government (one urban and one rural) and two private (one urban and one rural) were selected randomly using lottery method from the list of schools. All students of 10–15 years of age who were present on the day of the survey and who gave consent for the study were included, constituting a total sample of 306. Children with chronic health problems, systemic illnesses, under long-term medications and those undergoing orthodontic treatment were excluded from the study.
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Questionnaire The self-administered questionnaire consisted of demographic information such as age, gender, type of school (government or private), location of school (urban or rural), parents’ education, occupation and income which were assigned values using modified Kuppuswamy scale to compile the socioeconomic status of children into upper, middle and lower classes (Neeta et al. 2012). The child-DPQ had three subscales: (1) prevalence, (2) severity, and (3) impact of toothache on children’s quality of life. It had six questions, with two items in each subscale. The final score could either be 0 or range from 6 to 15, with lower scores indicating better oral health status. The first item of the questionnaire evaluated whether ‘‘child ever had toothache’’. If the child answered ‘‘no’’ on the first item, all other items were considered ‘‘not applicable’’ (score = 0). If the child answered ‘‘yes’’ on the first item, the subsequent items were then answered, with a minimum score of 1 on each item (Barreˆtto et al. 2011). Global single item self-reported pain question was used to establish validity of the child-DPQ. All the items in the questionnaire were initially prepared in English followed by linguistic translation of questionnaire as described by Acquadro et al. (2004). In the first step, the questions were independently translated into Kannada, by two qualified English-to-Kannada translators. After a group discussion with the translators and one author (SA), the first consensus Kannada questionnaire was backward translated to English, and then compared with the original questionnaire and the first consensus Kannada questionnaire. After finalising the questionnaire, 50 children completed it during the pilot study to evaluate face and content validity. These subjects were not included in the main survey. The questionnaire was distributed to children who were asked to complete it without discussing with each other, in 10 min. It was followed by full mouth clinical examination for dental caries. All children who needed dental treatment were referred to Manipal College of Dental Sciences, Manipal. Clinical examination All the children were examined according to the WHO Basic Oral Health Survey Guidelines for dental caries (1997). Decayed, missing and filled teeth were recorded by a single trained examiner (YSK) with mouth mirror and CPI probes in adequate natural light within the school premises. The DMFT index was computed by adding decayed, missing and filled teeth. DMFT was dichotomised into caries-free (DMFT = 0) and caries-experienced
Eur Arch Paediatr Dent
(DMFT C 1). Cohen’s j coefficient for the assessment of dental caries was 0.88, indicating good intra-examiner agreement in the pilot study. Statistical analysis All the analysis was carried out using the Statistical Package for Social Sciences (SPSS version 16.0). A p value of B0.05 was considered statistically significant. Chi square test was used for comparison of prevalence of pain between different groups based on age, gender, type of school, location, and socioeconomic status (SES). Spearman’s rank test was done to obtain correlations between global self-reported item for pain and Child-DPQ. Internal reliability was tested using the Cronbach a coefficient. The mean subscales and total Child-DPQ were compared between caries-free and caries-experienced children using Mann–Whitney U test.
Results A total of 306 children participated in the study; of them, 56.5 % were B12 years old, 58.8 % were males, 50.7 % were in government school and 54.9 % were from urban areas. Prevalence of dental pain was 35 %. Among the pain group, 61.7 % were B12 years, 67.3 % were males, 54.2 % were in private schools and 57.9 % were from urban areas. Only gender showed significant association with presence of tooth pain (p = 0.027). A total of 14.3 % Table 1 Comparison of tooth pain with sociodemographic characteristics of participants Tooth pain
p value
No N (%)
Yes N (%)
B12 (173)
107 (53.8)
66 (61.7)
[12 (133)
92 (46.2)
41 (38.3)
Male (180)
108 (54.3)
72 (67.3)
Female (126) School
91 (45.7)
35 (32.7)
reported mild pain, 8.8 % reported moderate pain and 11.7 % reported severe pain (Table 1). No significant difference was found in the distribution of caries experience between B12 years old (n = 78) and [12 years old (n = 60) (p value = 0.996). Almost half of the study participants (45.1 %) had experienced dental caries. The mean scores of each subscale and total scale scores were significantly higher among caries-experienced than among caries-free children (p = 0.017, 0.043, 0.022 and 0.02, respectively) (Table 2). The mean (SD) DMFT in children with pain (1.36 ± 1.54) was significantly higher than in those children who did not have pain (0.96 ± 1.37) (p = 0.024). All the participants completed the questionnaire. Internal consistency reliability (standardised item alpha) was 0.975. The inter-item correlations ranged from 0.853 (When was your last tooth pain?) to 0.956 (Have you ever had a toothache?). The corrected item total correlation (i.e. the correlation between each item and the total score omitted for that item) ranged from 0.905 (Were you awakened at night by pain?) to 0.96 (How was it when the pain was at its worst?), which was above the minimum level of 0.20 for including an item into a scale. Cronbach’s a decreased when any one item was deleted from the scale (Table 3). Table 2 Comparison of mean subscale and total scale scores between caries-free and experienced groups Subscale
Caries free (n = 168) Mean ± SD
Caries experienced (n = 138) Mean ± SD
p value
Prevalence
0.77 ± 1.25
1.07 ± 1.36
0.017
Severity
1.22 ± 2.06
1.81 ± 2.36
0.043
Impact
0.76 ± 1.23
1.13 ± 1.43
0.022
Total
2.76 ± 4.40
4.01 ± 4.98
0.02
Age 0.183
Cronbach’s a = 0.975
Gender
Government (155)
106 (53.3)
49 (45.8)
93 (46.7)
58 (54.2)
Rural (138)
93 (46.7)
45 (42.1)
Urban (168)
106 (53.3)
62 (57.9)
Lower (132)
84 (42.2)
48 (44.9)
Middle (174)
115 (57.8)
59 (55.1)
Private (151)
Table 3 Internal consistency of individual items of Child-DPQ using Cronbach’s a
0.027
0.213
Location 0.433
SES 0.656
Corrected itemtotal correlation
Cronbach’s a if item deleted
Have you ever had a toothache?
0.956
0.920
When was your last tooth pain?
0.853
0.910
Did you cry at the worst movement of a toothache?
0.925
0.910
How was it when the pain was at its worst? (intensity)
0.905
0.960
Were you awakened at night by pain?
0.943
0.905
Were you unable to do your normal tasks because of tooth pain?
0.888
0.913
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Eur Arch Paediatr Dent
There was significant weak positive correlation of global single item question with prevalence (r = 0.115, p = 0.045), severity (r = 0.146, p = 0.010) impact subscales (r = 0.117, p = 0.040) and total scale (r = 0.144, p = 0.012).
Discussion This study aimed to evaluate the prevalence of dental pain in 10–15-year-old school children and its relationship with dental caries experience. Oral and dental pain are different parameters in that the former indicates pain within mouth whereas later is described as ‘pain that originates from innervated tissues within tooth or immediately adjacent to it’ (Ratnayake and Ekanayake 2005). The prevalence rate of dental pain (35 %) in this study was lower than that of other studies by Shepherd et al. (1999) (47.5 %), Ratnayake and Ekanayake (2005) (49 %), Dandi et al. 2011 (71.4 %), but similar to studies conducted by Mashoto et al. (2009) (36.4 %), Nomura et al. (2004) (33.7 %) and Pau et al. (2008) (30.4 %). These variations could be due to differences in cultural or behavioural perceptions of pain and pain measurement issues, recall bias in children and variations in disease patterns (Slade 2001). Our study showed significantly higher prevalence of toothache in boys than in girls which was in contrast to the studies conducted by Levine and De Simone (1991), Josimari et al. (2013). In this study, there was a significantly higher mean DMFT in children who reported to have toothache. Dental caries can be regarded as one of the important dental pain-triggering factors. Studies by Pau et al. (2008) and Traebert et al. (2005) pointed out dental caries as a strong predictor for dental pain in school children and adolescents. Children with decayed teeth clearly experience toothache more often than do children without decayed teeth. Our study was in agreement with the literature which reports positive association between dental pain (prevalence, severity and impact) and caries experience in children. The difference in the prevalence of pain between boys and girls could be due to the selection bias which has occurred due to the inclusion of a whole class for selecting children. This study did not show any association with socioeconomic status, location of school, and type of school with the prevalence of toothache among children. However, previous studies by Dandi et al. (2011) and Ratnayake and Ekanayake (2005) showed an association with SES and location. These differences could be due to small sample size and differences in assessment of SE status.
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Ignoring the recall interval period in which dental pain prevalence was estimated previously (1 month to 1 year), existing data suggest that dental pain affects significant proportions of adolescents worldwide. These proportions may well be underestimated because the collection of selfreported health data necessarily depends on the recall ability of the respondents (van den Brink et al. 2001). Limitations of this study were the lack of assessment of caries severity and other conditions causing dental pain viz., erupting teeth, exfoliating primary teeth, and dentoalveolar trauma. Further studies are needed in this study area to evaluate the above factors in this target group. The use of this questionnaire can help screen large numbers of children in order to allocate valuable resources and manpower to those who are in need. One of the reasons for dental pain is that dental care is not universally available, and thus those with perceived need might not be able to access care because of high costs of treatment or lack of dental services. Furthermore, care may not be easily available, especially in the rural parts of a developing country. The substantial impact that dental pain has on adolescents indicates an urgent need for public health strategies for caries prevention and treatment using appropriate technologies such as affordable fluoridated toothpaste, atraumatic restorative techniques and increased manpower (dental auxiliary workers) to prevent cariesrelated dental pain.
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