The role of health literacy as a factor associated with tooth loss

Tenani, Carla Fabiana; Silva Junior, Manoelito Ferreira; Lino, Carolina Matteussi; Sousa, Maria da Luz Rosário de; Batista, Marília Jesus

doi:10.11606/s1518-8787.2021055003506

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Original Article • Rev. Saúde Pública 55 • 2021 • https://doi.org/10.11606/s1518-8787.2021055003506 copy

The role of health literacy as a factor associated with tooth loss

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

The objective was to analyze the role of health literacy (HL) as a factor associated with tooth loss among users of the Brazilian Health System with chronic non-communicable diseases.

METHODS

The cross-sectional analytical study was conducted with adult and elderly users chosen at ten Family Health Clinics in a draw in the town of Piracicaba, São Paulo State, Brazil. A questionnaire was applied with sociodemographic data (sex, age, skin color and education), behavioral data (brushing and flossing), determinants in health (type of dental health services and how often) and clinical data (pain). Mouth conditions were collected by intraoral examination of visible dental biofilm and community Pediodontal Index. The systemic clinical conditions (blood glucose, glycated hemoglobin and blood pressure) were extracted from the medical records. The explanatory variable was HL (low, medium and high), measured with the Health Literacy Scale (HLS-14).

RESULTS

The outcome was tooth loss measured by the index of decayed, missing and filled teeth. Logistic regression was performed using a conceptual model for HL (p < 0.05). For the 238 subjects, the mean age was 62.7 years (± 10.55). Tooth loss was associated with HL in regression models adjusted by type of dental service, dental frequency, and dental floss. In the final model, the factors associated with tooth loss are older age (OR = 1,12; 95%CI: 1,07–1,17), a lower education (OR = 3,43; 95%CI: 1,17–10,10), irregular use of dental floss (OR = 4,58; 95%CI: 1.75 in–7,31), irregular use of dental services (n = 2,60; 95% 1,32–5,12), periodontal pocket (> 4 mm) (n = 0,31; 95%CI: 0,01–0,08), having visible dental biofilm (OR = 7,23; 95%CI: 3,19–16,41) and a higher level of blood sugar (glucose) (n = 1,98; 95%CI: 1.00–3,92).

CONCLUSIONS

tooth loss was associated with HL when adjusted by health behaviors; when sociodemographic variables and clinical conditions were included, it was less significant. In the final model, behaviors, determinants in health and clinical conditions were risk indicators of tooth loss, showing the multifactorial nature of this phenomenon.

Oral Health; DMF Index; Health Knowledge, Attitudes, Practice; Health Education, Dental

Classification of variables		Classification of Health Literacy (HL^a)

		Total	Low HL	Medium HL	High HL	p

		n (%)	n (%)	n (%)	n (%)
Exogenous variables
Mean age in years (SD)	62.7 (± 10.55)	238 (100)	66.1 (± 8.66)	62.8 (± 9.78)	58.2 (± 12.00)	< 0.001
Sex	Female	165 (69.3)	62 (37.6)	56 (33.9)	47 (28.5)	0.518
Sex	Male	73 (30.7)	22 (30.1)	29 (39.8)	22 (30.1)	0.518
Skin color	White	168 (80.0)	59 (35.1)	57 (33.9)	52 (31.0)	0.322
Skin color	Other	42 (20.0)	14 (33.3)	19 (45.2)	9 (21.4)	0.322

Primary determinants in health
Personal income	Above 1 MS^b	165 (69.3)	57 (34.5)	56 (33.9)	52 (31.5)	0.419
Personal income	Up to 1 MS^b	73 (30.7)	27 (37.0)	29 (39.7)	17 (23.3)	0.419
Education	Less than 4 years	86 (36.1)	38 (44.2)	31 (36.0)	17 (19.8)	< 0.001
	Up to 4 full years	101(42.4)	38 (37.6)	40 (39.6)	23 (22.8)
	5 years or more	51(21.4)	08 (15.7)	14 (27.5)	29 (56.9)

Intermediate determinants of health

Access to health services
Type of medical service	Public	212 (89.5)	80 (37.7)	75 (35.4)	57 (26.9)	0.067
Type of medical service	Private	25 (10.5)	04 (16.0)	10 (40.0)	11 (44.0)	0.067
Type of dental service	Public	115(48.7)	32 (27.8)	52 (45.2)	31 (27.0)	0.010
Type of dental service	Private	121(51.3)	52 (43.0)	33 (27.3)	36 (29.8)	0.010
Reason for dental appointment	Routine	145 (61.2)	52 (35.9)	54 (37.2)	39 (26.9)	0.728
Reason for dental appointment	Pain or need	92 (38.8)	32 (34.8)	31 (33.7)	29 (31.5)	0.728
Time since last medical appointment	Up to 1 year	218 (91.6)	80 (36.7)	75 (34.4)	63 (28.9)	0.259
Time since last medical appointment	More than 1 year	20 (8.4)	04 (20.0)	10 (50.0)	06 (30.0)	0.259

Health behaviors
Tooth brushing	Up to 2 times/day	103 (43.3)	47 (45.6)	29 (28.2)	27 (26.2)	0.012
Tooth brushing	3 or more times/day	135 (56.7)	37 (27.4)	56 (41.5)	42 (31.1)	0.012
Dental floss	Uses daily	76 (31.9)	11 (14.5)	32 (42.1)	33 (43.4)	< 0.001
Dental floss	Does not use daily	162 (68.1)	73 (45.1)	53 (32.7)	36 (22.2)	< 0.001
Frequency/use of medical services	1 time/year or more (regular use)	181 (76.1)	70 (38.7)	66 (36.5)	45 (24.9)	0.030
Frequency/use of medical services	- 1 time/year (irregular use)	57 (23.9)	14 (24.6)	19 (33.3)	24 (42.1)	0.030
Frequency/use of dental services	+ 1 time/year or more (regular use)	58 (25.2)	08 (13.8)	24 (41.4)	26 (44.8)	< 0.001
Frequency/use of dental services	1 time/year (irregular use)	172 (74.8)	75 (46.3)	59 (34.3)	38 (22.1)	< 0.001

Clinical conditions
Tooth loss	Has up to 20 teeth	75 (31.5)	15 (20.0)	24 (32.0)	36 (48.0)	< 0.001
	Has 1 to 19 teeth	86 (36.1)	33 (38.4)	32 (37.2)	21 (24.4)	< 0.001
	Edental	77 (32.4)	36 (46.8)	29 (37.7)	12 (15.6)
Pain (teeth/gums)	No pain	156 (66.5)	57 (36.5)	47 (30.1)	52 (33.3)	0.029
Pain (teeth/gums)	Some pain	82 (34.5)	27 (32.9)	38 (46.3)	17 (20.7)	0.029
Glucose	Up to 126 dmgl	113 (47.5)	41 (36.3)	37 (32.7)	35 (31.0)	0.693
Glucose	127 dmgl or more	125 (52.5)	43 (43.4)	48 (38.4)	34 (27.2)	0.693
Glycated hemoglobin (HbA1c)	Up to 7.0%	92 (38.7)	35 (38.0)	30 (32.6)	27 (29.3)	0.643
Glycated hemoglobin (HbA1c)	7.1% or more	146 (61.3)	49 (33.6)	55 (37.7)	42 (28.8)	0.643
Systolic blood pressure	Up to 139 mmhg	174 (73.1)	69 (39.7)	61 (35.1)	44 (25.3)	0.036
Systolic blood pressure	140 mmhg or more	64 (26.9)	15 (23.4)	24 (37.5)	25 (39.1)	0.036
Diastolic blood pressure	Up to 89 mmhg	210 (88.2)	77 (36.7)	70 (33.3)	63 (30.0)	0.110
Diastolic blood pressure	90 mmhg or more	28 (11.8)	07 (25.0)	15 (53.6)	06 (21.4)	0.110
Periodontal pocket (> 4mm)	Yes	137 (57.6)	57 (41.6)	39 (35.8)	31 (22.6)	0.017
Periodontal pocket (> 4mm)	No	101 (42.4)	27 (26.7)	36 (35.6)	38 (37.6)	0.017
Visible dental biofilm	Yes	81 (34.0)	20 (24.7)	30 (37.0)	31 (38.3)	0.021
Visible dental biofilm	No	155 (65.1)	63 (40.6)	55 (35.5)	37 (23.9)	0.021

VARIABLES		Model 1			Model 2			Model 3			Model 4			Model 5			Model 6

		OR	(95%CI)	p	OR	(95%CI)	p	OR	(95%Cl)	p	OR	(95%CI)	p	OR	(95%CI)	p	OR	(95%CI)	p
Age	Mean years (62.7)	1.12	(1.08–1.16)	0.000							1.11	(1.08–1.15)	0.000	1.10	(1.06–1.14)	0.000	1.12	(1.07–1.17)	0.000
Education	Less than 4 years	6.52	(2.85–14.91)	0.000							5.55	(2.37–12.97)	0.000	3.18	(1.27–7.93)	0.013	3.15	(1.01–9.74)	0.046
	Up to 4 full years	6.00	(2.80–12.85)	0.000							5.14	(2.35–11.25)	0.000	2.90	(1.22–6.93)	0.016	3.43	(1.17–10.10)	0.025
	5 years or more	1									1			1			1
HL	Lower				4.70	(2.50–8.82)	0.000				1.86	(0.92–3.77)	0.083	1.45	(0.68–3.08)	0.326	0.93	(0.37–2.36)	0.894
	Media				2.80	(1.50–5.20)	0.001				1.67	(0.83–3.35)	0.146	1.84	(0.88–3.85)	0.104	1.59	(0.65–3.88)	0.308
	High				1.00						1			1			1
Use of dental floss	Does not use daily													3.58	(1.75–7.31)	0.000	4.88	(1.99–11.95)	0.001
Use of dental floss	Uses daily													1			1
Frequency/use of dental services	regular use (up to 1 year)				1									1			1
Frequency/use of dental services	Irregular use (+1 year)				2.60	(1.32–5.12)	0.005							1.94	(0.93–4.03)	0.075	3.15	(1.25–7.95)	0.015
Type of dental service	Private				1
Type of dental service	Public				1.38	(0.84–2.25)	0.196
Periodontal pocket (>4mm)	No							1									1
Periodontal pocket (>4mm)	Yes							0.36	(0.01–0.07)	0.000							0.31	(0.01–0.08)	0.000
Oral pain	No pain							1
Oral pain	Some pain							0.54	(0.30–0.96)	0.036
Visible dental biofilm	No							1									1
Visible dental biofilm	Yes							3.84	(2.09–7.04)	0.000							7.23	(3.19–16.41)	0.000
Glucose	Up to 126 dgml							1									1
Glucose	127 dgml or more							1.50	(0.87–2.58)	0.138							1.98	(1.00–3.92)	0.049

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

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[1] Correspondence: Marília Jesus Batista Avenida Limeira, 901 13414-018 Piracicaba, SP, Brasil E-mail: mariliamota@g.fmj,br