Contextual and individual factors associated with dental pain in adolescents from Southeastern Brazil

Abstract

The aim of this study was to assess the factors associated with dental pain in adolescents from the state of Minas Gerais, Brazil. Individual data on adolescents aged 15 to 19 years were collected from the SB Minas survey secondary database. Dental pain over the past 6 months, assessed by a questionnaire, was used as the dependent variable. Sex, income, skin color, prevalence of untreated dental caries, periodontal health, dental treatment needs, and time of last dental appointment were analyzed as individual covariates. Allocation factor, Human Development Index (HDI), Gini coefficient, illiteracy rate, unemployment, 50% and 25% of the Brazilian monthly minimum wage, primary healthcare coverage, oral health team coverage, access to individual healthcare, and supervised toothbrushing average rate were the analyzed contextual variables. A multilevel analysis was conducted for the individual and contextual variables. Statistical analyses used hierarchical linear and nonlinear modeling to infer an association between the different levels. Male adolescents had a lower prevalence of dental pain (OR = 0.53; 95%CI = 0.37–0.75). There was an association between dental pain and low income (OR = 1.58; 95%CI = 1.07–2.33), prevalence of untreated dental caries (OR = 1.25; 95%CI = 1.11–1.40), periodontal health (OR = 1.80; 95%CI = 1.04–3.09), and dental treatment needs (OR = 6.93; 95%CI = 3.96–12.14). Sociodemographic and clinical factors at the individual level were associated with the outcome but not with contextual variables. These findings reinforce the need to address these factors for effective community health actions.

Adolescent; Social Determinants of Health; Multilevel Analysis

Introduction

The physical, social, and psychological impacts of dental pain can exert a negative influence on quality of life.¹ The etiology of dental pain is commonly related to dental caries, periodontal disease, and traumatic tooth injury.¹,² Dental pain is a public health problem.¹,³,⁴ In Brazil, caries experience increases from 43.5% to 76.1% during adolescence, affecting 99% of Brazilians aged 35 to 44 years,⁵ and dental caries is strongly associated with dental pain. Moreover, dental pain has been associated with loss of work productivity, school absenteeism, difficulty sleeping, refusal to eat certain foods, and greater use of healthcare services,¹,²,³,⁶-⁹ which often result in mutilating treatment (extraction)⁷ and high treatment costs.¹

The literature reports that individual (behavioral) and contextual factors are associated with dental pain, especially with lower socioeconomic status.²,¹⁰,¹¹ This outcome is also more common in individuals with less access to primary healthcare and with a lower degree of social development measured by the Human Development Index (HDI).¹²

Adolescence is the period of development between the ages of 10 and 19 years,¹³ during which important biological and psychosocial changes occur.¹³,¹⁴,¹⁵ A high prevalence of dental caries, gingival bleeding, and tooth loss has been commonly found in adolescents.¹⁴,¹⁶ Despite the existence of public policies that benefit this group, such as a fluoridated water supply and universal healthcare, there are few specific programs directed at the oral health of adolescents. Moreover, the adoption of harmful behaviors, such as smoking, alcohol consumption, and inappropriate eating habits, increases the risk of dental caries in this group.⁹,¹⁷

Most studies with adolescents evaluate dental pain in terms of clinical aspects and/or socioeconomic issues at the individual level.²,⁷ These individual clinical and socioeconomic aspects have been well documented in the literature. Adolescents from a worse socioeconomic background at an individual level are more exposed to risk factors for oral health problems.²,¹⁰ However, this socioeconomic issue needs to be better addressed within a social context. Few studies have assessed a direct relationship between the context in which the individual is inserted and dental pain, mainly in adolescents.¹⁵,¹⁸ Adolescents and their families from areas with a low HDI had a higher prevalence of dental pain than those in more developed areas, regardless of individual characteristics.¹⁸ Therefore, it is fundamental to assess health outcomes using multilevel analysis. This strategy allows inferences at the contextual and individual levels¹¹ and it is essential to underpin public policies to tackle oral healthcare needs, mainly in adolescents. Health promotion actions and intersectoral policies focusing on social development through improvements and on the expansion of primary healthcare should be implemented to reduce social inequalities related to oral health disparities. In summary, the clarification of this issue could provide more precise actions for the planning of social and health policies.

Therefore, the aim of the present study was to investigate the factors associated with dental pain in adolescents from a state in Southeastern Brazil. The null hypothesis was that dental pain is associated with socioeconomic and clinical factors.

Methodology

In 2012, the Minas Gerais Oral Health Study was performed to evaluate the oral health status of residents of the state of Minas Gerais, which is located in Southeastern Brazil.¹⁹ Minas Gerais is the second most populated state in Brazil, with 21,168,791 inhabitants, and the third wealthiest state based on gross domestic product data.²⁰ The state has 853 municipalities. It ranks ninth among the 27 Brazilian states in terms of HDI and eighth in active formal employment among residents aged 16 years or older.²¹ The municipalities included in the study (n = 61) were grouped into three broad domains: Capital, Inland I, and Inland II, based on the “city allocation factor” used to distribute the state tax revenue for healthcare.²²,²³ The Inland I group included more autonomous/less vulnerable municipalities, whereas the Inland II group comprised less autonomous/more vulnerable municipalities. Thirty municipalities chosen through careful randomization methods were included in each of these two groups.¹⁹

With the objective of maintaining the same methodology, the process used was the same as that employed for the SB Brazil 2010 survey. Sample size was also based on the severity of dental caries, estimated by the DMFT (decayed, missing, and filled teeth) index according to SB Brazil 2010 data for the southeastern region. For each age group and each domain, the prevalence of dental caries and the DMFT average were used as reference for sample size calculation in association with a predefined margin of error. The proposed design allowed estimating the number of dental caries in each domain for the state of Minas Gerais, considering each age group. For other healthcare problems, the degree of representativeness varied according to the estimated prevalence and severity. A representative sample for the state of Minas Gerais was estimated and a 95% confidence interval and an 80% statistical power were obtained for the variables used in this study.¹⁹

Oral examinations were performed by teams that consisted of one dentist and one assistant. All examiners and assistants had undergone training and calibration exercises. Inter-examiner agreement (Cohen’s Kappa) was > 0.65. The examinations were performed in a well-lit room with the aid of mouth mirrors and probes and followed the World Health Organization recommendations.²⁴ In addition, oral health indices (DMFT index and the Community Periodontal Index (CPI)), were used by the same calibrated teams for demographic and socioeconomic status, use of dental services, and dental treatment needs.

For this study, the data on adolescents aged 15 to 19 years were extracted from the Minas Gerais Oral Health Study database. The dependent variable consisted of dental pain experience, which was determined by the answers to the following question: “Have you had a toothache in the past six months?” The independent variables considered two levels: individual variables (Level 1) and contextual variables (Level 2). Level 1 included sex, family income, skin color, prevalence of untreated dental caries, periodontal health, dental treatment needs, and time of the last dental appointment, all of them extracted from the Minas Gerais Oral Health Study database¹⁹ Level 2 comprised the HDI, which was extracted from the Brazilian section of the United Nations Development Programme;²⁵ Gini coefficient,²⁵ illiteracy rate, unemployment, earnings on the order of 50% of the Brazilian monthly minimum wage (BMMW), and earnings on the order of 25% of the BMMW, extracted from the Brazilian Institute of Geography and Statistics,²⁶ Primary Healthcare Coverage, Oral Health Team Coverage, records on the access to individual dental care, and from the supervised toothbrushing score.¹³Table 1 shows a description of the exposure variables for Levels 1 and 2.

Table 1
Description of independent variables according to the level of analysis involving adolescents, SB Minas Gerais, Brazil, 2012.

Variables	Description
Level 1 – Individual
Sex	Male – Female
Family Income	Up to $830 – More than U$830
Skin Color	Self-reported skin color; a dichotomous variable was created from five original categories (white or non-white)
Prevalence of dental caries*	Dichotomous: presence or absence
Periodontal health	Absence of disease
	Gingivitis/Dental calculus
	Probing depth greater than 3 mm
	Less than two functional teeth in at least one sextant
Treatment needs	No need (healthy crown and root)
	One surface restoration
	Two or more surface restorations
	Prosthetic crown needed for any reason
	Dental facet
	Pulp treatment and restoration
	Tooth extraction
	White spot treatment
	Sealant
Last dental appointment	Less than 1 year
	More than 1 year
	Never
Level 2 – Municipal
HDI	Human Development Index
Domain	Capital, Inland I, Inland II
Gini coefficient	Income or wealth distribution
Illiteracy	Percentage (%) of individuals who cannot read or write and have no language proficiency in the total resident population in the minimum age range in a geographic space within the considered year
Unemployment	Percentage (%) of economically active unemployed individuals during the reference week in a geographic space within the considered year
50% BMMW	Percentage (%) of residents with monthly family income per capita up to 50% of the Brazilian monthly minimum wage in a geographic space within the considered year
25% BMMW	Percentage (%) of residents with monthly family income per capita up to 25% of the Brazilian monthly minimum wage in a geographic space within the considered year
Oral health team coverage	Percentage (%) of the population covered by Oral Health Teams
Primary health care coverage	Percentage (%) of the population covered by Primary Health Care teams
Access to individual dental care (registered with scheduled treatment program)	Percentage (%) of residents who receive a scheduled primary dental consultation with the aim of diagnosing and drafting a preventive/therapeutic plan to address the detected needs, calculated as a percentage of the population
Supervised tooth brushing average	Percentage (%) of collective actions of supervised toothbrushing

• HDI: Human Development Index; *decayed component.

Statistical analyses were carried out using the Statistical Package for the Social Sciences (SPSS for Windows, version 16.0) and the hierarchical linear and nonlinear modeling (HLM 6.08 statistical package).²⁵ Multilevel analyses were used to determine associations between the absence or presence of dental pain in the past 6 months and the exposure (contextual and individual) variables.

All analyses were made using the complex samples module to account for the complex sampling design of the Minas Gerais Oral Health Study. The multilevel analyses included 1,200 individuals from 57 municipalities. To achieve that, nonlinear logit link function analyses were conducted with fixed or random effects models. The parameters were estimated using a restricted maximum likelihood method (predictive quasi-likelihood). A multilevel logistic regression model was used. In the first stage, a null model estimated the basic partition of the data variability between the two levels before the individual and contextual characteristics were taken into account.

Level 1 variables were first incorporated into the model one by one before being tested together (p < 0.05). Next, the contextual variables (Level 2) were incorporated one by one and associations were tested using the Student’s t-test (p < 0.05). The multilevel model was created using all variables with a p-value < 0.25. Odds ratios (OR) and the respective 95% confidence intervals (CI) were estimated in each analysis. The reliability estimate was used to determine the adequacy of the final multilevel model, which included only variables with a p-value < 0.05.

Results

The prevalence of self-reported dental pain in the past 6 months was 23.1%. Most participants were female (55.3%) and non-white (59.6%) and had a monthly family income of up to R$ 1,500 (57.7%), which was equivalent to approximately US$ 830. A total of 34.6% of the participants had gingivitis or dental calculus, 46.6% needed dental treatment, 51.6% had their last dental appointment in the previous year, and 60.2% did not have untreated dental caries (Table 2).

Table 2
Descriptive analysis of individual variables for the sample of adolescents (n = 1,200), Minas Gerais Oral Health Study, Brazil, 2012.

Variables*	N	% (95%CI)†
Dependent
Dental pain in previous 6 months*
No	925	76.9 (73.7–79.8)
Yes	275	23.1 (20.2–26.3)
Independent (individual level)
Sex
Male	533	44.7 (41.2–48.3)
Female	669	55.3 (51.7–58.8)
Family Income*
Up to U$830	742	57.7 (52.2–63.0)
More than U$830	402	42.3 (37.0–47.8)
Skin color
White	469	40.4 (35.9–45.0)
Non-white	733	59.6 (55.0–64.1)
Dental caries*,**
Absent	694	60.2 (56.0–64.2)
Present	506	39.8 (35.8–44.0)
Periodontal health*
Absence of disease	663	52.6 (47.6–57.5)
Gingivitis/Dental calculus	392	34.6 (30.3–39.3)
Probing depth greater than 3 mm	81	8.2 (5.2–12.8)
Less than two teeth	50	4.6 (2.9–7.0)
Treatment needs
None	619	53.4 (49.3–57.5)
Needs	583	46.6 (42.5–50.7)
Last dental appointment*
Less than 1 year	618	51.6 (48.0–55.1)
More than 1 year	432	37.3 (34.3–40.5)
Never	146	11.1 (8.5–14.3)

• ^*Missing values for some variables; ^**sampling design taken into account + decayed component

The null model indicated differences in dental pain experience among the 57 municipalities evaluated in the present study (p < 0.001). Among the 61 municipalities that had been originally selected (Inland I, n = 30; Inland II, n = 30; Capital, n = 1), three withdrew from the study (Table 3).

Table 3
Final estimation of variance components in the multilevel analysis – “null model”.

Random effect	Standard deviation	Variance component	df	Chi-square	p-value
Intercept, U0	0.91109	0.83009	55	178.61	< 0.001

• df: degrees of freedom

The results of the unadjusted or crude analyses (Model 1) showed that, at the individual level, dental pain was associated with sex (male), skin color (non-white), family income (< $830), presence of dental caries, probing depth > 3 mm, and dental treatment needs. After adjusting for potential confounders, the final adjusted multilevel analysis (Model 2) showed that male adolescents were less likely to have dental pain compared to females (OR = 0.53; 95%CI: 0.37 to 0.75). Moreover, individuals with a monthly family income of less than < $830 were more likely to have dental pain compared to those who earned more than < $830 (OR = 1.58; 95%CI: 1.07 to 2.33). The presence of untreated dental caries increased the likelihood of dental pain (OR = 1.25; 95%CI: 1.11 to 1.40) (Table 4). In addition, adolescents with probing depth greater than 3 mm were more likely to have dental pain compared to those whose probing depth was within the normal range (OR = 1.80; 95%CI: 1.04 to 3.09). The risk for dental pain was 6.93% higher in individuals with dental treatment needs (95%CI: 3.96 to 12.14) (Table 4). No associations were observed for the contextual variables.

Table 4
Multilevel models (1-crude and 2-adjusted) for individual and contextual variables associated with dental pain in adolescents. Minas Gerais. Brazil. 2012.

Models	OR1	(95%CI)	p-value	RE	OR2	(95%CI)	p-value	RE
Individual level
Sex
Female	1.00				1.00
Male	0.52	(0.37–0.74)	< 0.001	0.633	0.53	(0.37–0.75)	0.001
Family income
≥ U$830	1.00				1.00
< U$830	1.64	(1.12–2.40)	0.012	0.632	1.58	(1.07–2.33)	0.021
Skin color
White	1.00
Non–white	1.51	(1.06–2.16)	0.024	0.632
Dental caries*
Absence	1.00				1.00
Presence	1.39	(1.26–1.53)	< 0.001	0.657	1.25	(1.11–1.40)	< 0.001
Periodontal health
Absence of disease	1.00				1.00
Gingivitis/Dental calculus	1.39	(0.73–2.64)	0.316		1.22	(0.63–2.35)	0.553
Probing depth > 3 mm	2.35	(1.48–3.75)	< 0.001	0.633	1.80	(1.04–3.09)	0.034
≤ 2 teeth	2.33	(0.97–5.60)	0.059		2.08	(0.85–5.05)	0.108
Treatment needs
None	1.00				1.00			0.696
Needs	9.45	(5.73–15.56)	< 0.001	0.672	6.93	(3.96–12.14)	< 0.001
Last dental appointment
≤ 1 year	1.00
> 1 year	1.96	(0.82–4.70)	0.129	0.631
Never	1.27	(0.85–1.91)	0.245
Contextual level
Allocation factor	1.01	(0.20–4.95)	0.989	0.634
HDI	0.43	(0.00–67.41)	0.742	0.634
Gini coefficient	0.39	(0.00–1786.4)	0.823	0.634
Illiteracy	1.00	(0.97–1.05)	0.726	0.634
Unemployment	1.13	(1.01–1.27)	0.025	0.608
50% BMMW	1.01	(0.99–1.03)	0.172	0.631
25%BMMW	1.01	(0.99–1.04)	0.197	0.631
Oral Health Team Coverage	1.00	(0.99–1.01)	0.480	0.634
Primary Healthcare Coverage	0.99	(0.99–1.01)	0.944	0.634
Access to individual dental care	0.98	(0.94–1.02)	0.283	0.626
Supervised toothbrushing average	0.98	(0.87–1.11)	0.808	0.634

• RE: reliable estimation; SD: standard deviation; BMMW: Brazilian monthly minimum wage; OR: odds ratio HDI: Human Development Index.

The descriptive analysis of the contextual variables is shown in Table 5.

Table 5
Descriptive analysis of contextual variables. Minas Gerais. Brazil. 2012.

Variable	Mean	SD	P25	P50	P75
Allocation factor	1.416	0.203	1.237	1.402	1.594
HDI	0.693	0.061	0.639	0.697	0.751
Gini coefficient	0.499	0.046	0.473	0.495	0.524
Illiteracy	11.674	7.890	5.250	9.100	16.850
Unemployment	38.922	17.459	21.985	35.780	55.210
50%BMMW	15.613	10.625	6.050	12.540	22.900
25%BMMW	66.620	33.349	35.900	73.370	100.000
Oral Health Team Coverage	50.259	39.312	12.825	46.890	94.925
Primary Healthcare Coverage	10.803	9.401	4.070	7.190	16.425
Access to individual dental care	3.536	3.829	0.660	1.820	5.830
Supervised tooth brushing average	11.674	7.890	5.250	9.100	16.850

In the final model, 20.1% of the variance in dental pain was explained by the contextual variables.

Discussion

The present study provides a panorama of the individual and contextual factors of an important oral health problem: dental pain. Nearly 25% of the adolescents reported at least one episode of dental pain and this problem was more frequent in adolescents with at least one caries-affected tooth, in those with periodontal disease, in those with dental treatment needs, and in those from low-income families.

Adolescence is a period of gradual transition from childhood to adulthood, and it is characterized by physiological, psychological, and social changes.¹³-¹⁵ This period is critical for health, including oral health, because adolescents are more vulnerable to socioeconomic risk factors and, consequently, more likely to engage in unhealthy behaviors, including smoking, alcohol consumption, and unhealthy oral hygiene practices.²⁹ Dental pain is the most common symptom of oral diseases and it is strongly associated with treatment needs.¹⁷ In this study, almost 25% of the adolescents had this outcome. The prevalence of dental pain is variable. In Brazil, the prevalence ranges from 21.2% to 36.4%.²,⁷,¹⁷ Generally, there are differences in methodology and in the periods during which the outcome was measured.² Indeed, a longer period of investigation increases the likelihood of forgetfulness and underestimation of pain.² Furthermore, access to and use of oral health care may differ.¹⁵

In the present study, male adolescents were less prone to have dental pain than were girls. There is no consensus in the literature yet. Some investigations have shown that female adolescents/women report more dental pain, whereas men are less likely to complain given the stereotype of men as strong.¹⁴,¹⁷,²⁹ In addition, another possible explanation is that the difference between sexes may be related to the hormone cycle, which exerts an influence on the pain threshold. It is important to bear in mind that dental pain may be influenced by biological, cultural, and psychological factors as well as expectations about social roles.⁹

Adolescents from low-income families were more prone to develop dental pain than those from a better socioeconomic background. The association between the greater occurrence of dental pain and unfavorable socioeconomic status is a common finding.⁶,⁹,¹⁰,¹²,¹⁶,¹⁷ Individuals from poor families tend to be at a higher risk for a wide variety of stressors and for some physical exposures that can influence psychosocial, physiological, and behavioral aspects during their lifetime.³⁰ Moreover, family income can lead to inequalities in oral healthcare as a result of differences in the availability of economic resources, which interferes with the frequency of visits to the dentist.³¹ All these aspects can contribute to or compromise their overall health, including oral health.

Untreated dental caries may predispose to dental pain. This finding is similar to those described in the literature.⁶,¹⁰,³² More advanced stages of dental caries require more invasive treatment and involve greater pain experience, thereby restricting the daily activities of affected children and adolescents.³³ Untreated caries on permanent teeth is the most prevalent condition, affecting 2.5 billion people around the world.³⁴ One of the most serious consequences of untreated caries is dental pain and/or tooth loss. This reflects the oral health history of individuals and their access to health services, including oral health.³⁵ In addition, this finding suggests that more appropriate approaches and interventions are necessary to reduce and/or control dental caries.⁶

Periodontal diseases (probing depth greater than 3 mm) were associated with the outcome. This finding may be related to gingival bleeding and dental plaque, important factors that exert a negative impact on the quality of life of adolescents, with psychosocial consequences such as embarrassment when smiling and difficulty brushing one’s teeth because of the fear of gingival bleeding.¹⁴ A study conducted in Brazil has shown that periodontal health status, such as probing depth greater than 3 mm, was associated with dental pain in adults.¹¹ This condition may perpetuate unhealthy oral habits that cause dental pain.

In this study, adolescents with dental treatment needs were more likely to have dental pain. Dental treatment needs are important for the effective planning and implementation of oral healthcare services.³² In addition, dental pain may be related to the use of dental services.⁴ According to data from the Brazilian Ministry of Health,⁵ dental pain was one of the main reasons for dental visits in Brazil in different age groups. Concerning municipal variables, we assessed the access to oral health services and oral health coverage. Despite the lack of association between them, it is important to increase access to oral health and oral health coverage in municipalities¹¹ to reduce inequalities.

As for the contextual variables in this study, no association was found for dental pain in adolescents. The literature has shown that adolescents from areas with a high HDI had a lower dental pain prevalence than those from areas with a low HDI.¹⁷ The literature reports that HDI can have an impact on the prevalence of dental caries,³⁶ which is the main factor for dental pain. Some authors suggest that residents of poorer municipalities are at greater risk of disease due to poorer eating patterns, inadequate oral hygiene, lower level of education, and less access to and use of healthcare services.²,⁸ However, pain is a complex phenomenon influenced by biological, cultural, and psychosocial factors.² One explanation for this negative association was the homogeneity of the sample.

Among the implications of the present findings for oral health policies and programs, the association of family income (at the individual level) with oral health outcome underscores the need to understand the underlying effects of oral health inequalities on dental pain so that enable effective actions can be taken to tackle this important public health problem.

Regarding the implications for administrators, health services, and dentists, primary, secondary, and tertiary health prevention/promotion protocols should consider the high prevalence of dental pain among adolescents, and include some strategies such as reducing sugar consumption, increasing access to fluoride, and focusing on appropriate approaches for those adolescents with dental pain.¹⁵

The literature points out that oral health problems can be exacerbated in adolescence, especially as a result of socioeconomic and demographic (sex) factors, among other determinants.¹⁶ To optimize the general well-being of adolescents, it is necessary to plan comprehensive oral health actions to promote treatments that meet their needs.³⁷,³⁸

The present study has limitations that should be considered. The use of a cross-sectional study to test associations does not allow determining the cause-and-effect relationship between the variables. Longitudinal studies are thus needed to analyze clinical, social, and economic factors in the longer term to establish causal relations. There is also the possibility of recall bias, since the outcome source data relied on adolescents’ memories. However, the main methodological strengths of this study are the use of a large representative population-based sample, providing better external validity. In addition, dental examiners were regarded as highly reliable, wielding sufficient power for the detection of important associations and multilevel analyses, which may contribute to a broader understanding of dental pain among adolescents.

Conclusions

Individual factors such as sex, family income, clinical oral conditions, and dental treatment needs were associated with dental pain in 15- to 19-year-old adolescents. In addition, in this study, there was no association between contextual variables and the outcome. Thus, the data of this study contribute to the identification and planning of interventions focused on the prevention and reduction of dental pain.

Acknowledgments

We thank the Research Provost’s Office of Universidade Federal de Minas Gerais (PRPq/UFMG) for the financial support.

References

• ¹
  Carvalho JC, Rebelo MA, Vettore MV. [Dental pain in the previous 3 months in adolescents and Family Health Strategy: the comparison between two areas with different to oralhealth care approaches]. Cienc Saúde Colet. 2011 Oct; 16(10): 4107-4114. Portuguese. https://doi.org/10.1590/S1413-81232011001100016
  » https://doi.org/10.1590/S1413-81232011001100016
• ²
  Borges CM, Cascaes AM, Fischer TK, Boing AF, Peres MA, Peres KG. [Dental and gingival pain and associated factors among Brazilian adolescents: an analysis of the Brazilian Oral Health Survey 2002-2003]. Cad Saude Publica. 2008 Aug;24(8):1825-34. Portuguese. https://doi.org/10.1590/S0102-311X2008000800011
  » https://doi.org/10.1590/S0102-311X2008000800011
• ³
  Escoffié-Ramirez M, Ávila-Burgos L, Baena-Santillan ES, Aguilar-Ayala F, Lara-Carrillo E, Minaya-Sánchez M, et al. Factors associated with dental pain in Mexican xchoolchildren Aged 6 to 12 Years. BioMed Res Int. 2017;2017:7431301. https://doi.org/10.1155/2017/7431301
  » https://doi.org/10.1155/2017/7431301
• ⁴
  Pau A, Khan SS, Babar MG, Croucher R. Dental pain and care-seeking in 11-14-yr-old adolescents in a low-income country. Eur J Oral Sci. 2008 Oct;116(5):451-7. https://doi.org/10.1111/j.1600-0722.2008.00563.x
  » https://doi.org/10.1111/j.1600-0722.2008.00563.x
• ⁵
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal: resultados principais. ância em Saúde. Brasília, DF: Ministério da Saúde; 2012.
• ⁶
  Bastos JL, Nomura LH, Peres MA. Dental pain, socioeconomic status, and dental caries in young male adults from southern Brazil. Cad Saude Publica. 2005 Sep-Oct;21(5):1416-23. https://doi.org/10.1590/S0102-311X2005000500014
  » https://doi.org/10.1590/S0102-311X2005000500014
• ⁷
  Noro LR, Roncalli AG, Mendes Júnior FI, Lima KC, Teixeira AK. Toothache and social and economic conditions among adolescents in Northeastern Brazil. Cien Saude Colet. 2014 Jan;19(1):105-13. https://doi.org/10.1590/1413-81232014191.2110
  » https://doi.org/10.1590/1413-81232014191.2110
• ⁸
  Ghorbani Z, Peres MA, Liu P, Mejia GC, Armfield JM, Peres KG. Does early-life family income influence later dental pain experience? A prospective 14-year study. Aust Dent J. 2017 Dec;62(4):493-9. https://doi.org/10.1111/adj.12531
  » https://doi.org/10.1111/adj.12531
• ⁹
  Bulgareli JV, Faria ET, Cortellazzi KL, Guerra LM, Meneghim MC, Ambrosano GM, et al. Factors influencing the impact of oral health on the daily activities of adolescents, adults and older adults. Rev Saude Publica. 2018;52:44. https://doi.org/10.11606/S1518-8787.2018052000042
  » https://doi.org/10.11606/S1518-8787.2018052000042
• ¹⁰
  Ferreira LL, Brandão GA, Garcia G, Costa LS, Ambrosano GM, Possobon RF. Dental pain associated with socioeconomic status, psychosocial factors and oral health. Rev Dor. 2012 Dec;13(4):343-9. https://doi.org/10.1590/S1806-00132012000400007
  » https://doi.org/10.1590/S1806-00132012000400007
• ¹¹
  Aranha RL, Pinto RS, Abreu MH, Martins RC. Factors associated with toothache among Brazilian adults: a multilevel analysis. Braz Oral Res. 2020 Apr;34:e036. https://doi.org/10.1590/1807-3107bor-2020.vol34.0036
  » https://doi.org/10.1590/1807-3107bor-2020.vol34.0036
• ¹²
  Ardila CM, Agudelo-Suárez AA. Social context and dental pain in adults of colombian ethnic minority groups: a multilevel cross-sectional study. J Oral Facial Pain Headache. 2016 winter;30(1):21-6. https://doi.org/10.11607/ofph.1524
  » https://doi.org/10.11607/ofph.1524
• ¹³
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Proteger e cuidar da saúde de adolescentes na atenção básica. 2nd ed. Brasília, DF: Ministério da Saúde, 2018 [cited 2020 May 18]. Available from http://bvsms.saude.gov.br/bvs/publicacoes/proteger_cuidar_adolescentes_atencao_basica_2ed.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/proteger_cuidar_adolescentes_atencao_basica_2ed.pdf
• ¹⁴
  Fonseca RC, Antunes JL, Cascaes AM, Bomfim RA. Analysis of the combined risk of oral problems in the oral health-related quality of life of Brazilian adolescents: multilevel approach. Clin Oral Investig. 2020 Feb;24(2):857-66. https://doi.org/10.1007/s00784-019-02976-z
  » https://doi.org/10.1007/s00784-019-02976-z
• ¹⁵
  Freire MC, Nery NG, Jordão LM, Abreu MH. Individual and contextual determinants of dental pain in adolescents: evidence from a national survey. Oral Dis. 2019 Jul;25(5):1384-93. https://doi.org/10.1111/odi.13100
  » https://doi.org/10.1111/odi.13100
• ¹⁶
  Peres MA, Barbato PR, Reis SC, Freitas CH, Antunes JL. Tooth loss in Brazil: analysis of the 2010 Brazilian oral health survey. Rev Saude Publica. 2013 Dec;47 Suppl 3:78-89. https://doi.org/10.1590/S0034-8910.2013047004226
  » https://doi.org/10.1590/S0034-8910.2013047004226
• ¹⁷
  Vettore MV, Moysés SJ, Sardinha LM, Iser BP. [Socioeconomic status, toothbrushing frequency, and health-related behaviors in adolescents: an analysis using the PeNSE database]. Cad Saude Publica. 2012;28 Suppl:s101-13. Portuguese. https://doi.org/10.1590/S0102-311X2012001300011
  » https://doi.org/10.1590/S0102-311X2012001300011
• ¹⁸
  Peres MA, Peres KG, Frias AC, Antunes JL. Contextual and individual assessment of dental pain period prevalence in adolescents: a multilevel approach. BMC Oral Health. 2010 Aug;10(1):20. https://doi.org/10.1186/1472-6831-10-20
  » https://doi.org/10.1186/1472-6831-10-20
• ¹⁹
  Secretaria de Estado da Saúde (MG). Subsecretaria de Políticas e Ações de Saúde. Superintendência de Redes de Atenção à Saúde. SB Minas Gerais: pesquisa das condições de saúde bucal da população mineira: resultados principais. Belo Horizonte: Secretaria de Estado da Saúde; 2013 [cited 2020 May 18]. Available from: http://www.saude.mg.gov.br/sobre/publicacoes/estatistica-e-informacao-em-saude
  » http://www.saude.mg.gov.br/sobre/publicacoes/estatistica-e-informacao-em-saude
• ²⁰
  Instituto Brasileiro de Geografia e Estatística. População estimada de Minas Gerais, escolaridade e IDH. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019 [cited 2019 Oct 10]. Available from: https://cidades.ibge.gov.br/brasil/mg/panorama
  » https://cidades.ibge.gov.br/brasil/mg/panorama
• ²¹
  Associação Mineira de Municípios. FJP atualiza perfil dos 853 municípios mineiros na plataforma IMRS. Belo Horizonte (MG): Associação Mineira de Municípios; 2018 [cited 2018 Oct 3]. Available from: https://portalamm.org.br/fjp-atualiza-perfil-dos-853-municipios-mineiros-na-plataforma-imrs/
  » https://portalamm.org.br/fjp-atualiza-perfil-dos-853-municipios-mineiros-na-plataforma-imrs/
• ²²
  Machado EN, Fortes FB, Somarriba M. Efeitos da introdução do PAB sobre a distribuição de recursos e a prestação de serviços: o caso de Minas Gerais. Cien Saude Colet. 2004;9(1):99-111. https://doi.org/10.1590/S1413-81232004000100010
  » https://doi.org/10.1590/S1413-81232004000100010
• ²³
  Malachias I, Leles FA, Pinto MA. Plano diretor de regionalização da saúde de Minas Gerais. Belo Horizonte: Secretaria de Estado de Saúde de Minas Gerais; 2010.
• ²⁴
  World Health Organization. Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization; 1997 [cited 2018 Jun 16]. Available from: http://www.who.int/iris/handle/10665/41905
  » http://www.who.int/iris/handle/10665/41905
• ²⁵
  United Nations Development Programme/Brazil. Human Development Reports. Human developmente indicators: country profiles: Brazil. New York (NY): United Nations Development Programme / Brazil; 2018 [cited 2018 Oct 04]. Available from: http://hdr.undp.org/en/countries/profiles/BRA
  » http://hdr.undp.org/en/countries/profiles/BRA
• ²⁶
  Snidjers TA, Bosker RJ. Multilevel analyses: An introduction to basic and advanced multilevel modeling. 2nd ed. London: Sage; 2012.
• ²⁷
  Sanders AE, Slade GD, Turrell G, John Spencer A, Marcenes W. The shape of the socioeconomic-oral health gradient: implications for theoretical explanations. Community Dent Oral Epidemiol. 2006 Aug;34(4):310-9. https://doi.org/10.1111/j.1600-0528.2006.00286.x
  » https://doi.org/10.1111/j.1600-0528.2006.00286.x
• ²⁸
  Watt RG, Listl S, Peres M, Heilmann A. Social inequalities in oral health: from evidence to action. 1st ed. London: ICOHIRP; 2015.
• ²⁹
  Marmot M, Wilkinson RG. Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. BMJ. 2001 May;322(7296):1233-6. https://doi.org/10.1136/bmj.322.7296.1233
  » https://doi.org/10.1136/bmj.322.7296.1233
• ³⁰
  Sfreddo CS, Moreira CH, Nicolau B, Ortiz FR, Ardenghi TM. Socioeconomic inequalities in oral health-related quality of life in adolescents: a cohort study. Qual Life Res. 2019 Sep;28(9):2491-500. https://doi.org/10.1007/s11136-019-02229-2
  » https://doi.org/10.1007/s11136-019-02229-2
• ³¹
  Boeira GF, Correa MB, Peres KG, Peres MA, Santos IS, Matijasevich A, et al. Caries is the main cause for dental pain in childhood: findings from a birth cohort. Caries Res. 2012;46(5):488-95. https://doi.org/10.1159/000339491
  » https://doi.org/10.1159/000339491
• ³²
  Moor I, Spallek J, Richter M. Explaining socioeconomic inequalities in self-rated health: a systematic review of the relative contribution of material, psychosocial and behavioural factors. J Epidemiol Community Health. 2017 Jun;71(6):565-75. https://doi.org/10.1136/jech-2016-207589
  » https://doi.org/10.1136/jech-2016-207589
• ³³
  Mashoto KO, Astrøm AN, David J, Masalu JR. Dental pain, oral impacts and perceived need for dental treatment in Tanzanian school students: a cross-sectional study. Health Qual Life Outcomes. 2009 30; 7:73. https://doi.org/10.1186/1477-7525-7-73
  » https://doi.org/10.1186/1477-7525-7-73
• ³⁴
  Daher A, Abreu MH, Costa LR. Recognizing preschool children with primary teeth needing dental treatment because of caries-related toothache. Community Dent Oral Epidemiol. 2015 Aug;43(4):298-307. https://doi.org/10.1111/cdoe.12154
  » https://doi.org/10.1111/cdoe.12154
• ³⁵
  Kassebaum NJ, Smith AG, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990-2015: A systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res. 2017 Apr;96(4):380-7. https://doi.org/10.1177/0022034517693566
  » https://doi.org/10.1177/0022034517693566
• ³⁶
  Figueiredo DR, Bastos JL, Peres KG. Association of adverse oral health outcomes with socioeconomic inequalities and dental needs in Brazilian adolescents. Cad Saude Publica. 2017 Jun;33(5):e00165415. https://doi.org/10.1590/0102-311x00165415
  » https://doi.org/10.1590/0102-311x00165415
• ³⁷
  Brito AC, Bezerra IM, Cavalcante DF, Pereira AC, Vieira V, Montezuma MF, et al. Dental caries experience and associated factors in 12-year-old-children: a population based-study. Braz Oral Res. 2020 Feb;34:e010. https://doi.org/10.1590/1807-3107bor-2020.vol34.0010
  » https://doi.org/10.1590/1807-3107bor-2020.vol34.0010
• ³⁸
  Peres MA, Iser BP, Peres KG, Malta DC, Antunes JL. [Contextual and individual inequalities in dental pain prevalence among Brazilian adults and elders]. Cad Saude Publica. 2012;28 Suppl:s114-23. Portuguese. https://doi.org/10.1590/S0102-311X2012001300012
  » https://doi.org/10.1590/S0102-311X2012001300012

Publication Dates

• Publication in this collection
  19 Nov 2021
• Date of issue
  2021

History

• Received
  26 June 2020
• Accepted
  23 Feb 2021
• Reviewed
  19 Apr 2021