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Brazilian Dental Journal

Print version ISSN 0103-6440On-line version ISSN 1806-4760

Braz. Dent. J. vol.29 no.6 Ribeirão Preto Nov./Dec. 2018

http://dx.doi.org/10.1590/0103-6440201802077 

Article

Toothache and Non-Clinical Individual and School Factors in Five-Year-Old Children: Multilevel Analysis

Monalisa Cesarino Gomes1 

Érick Tássio Neves1 

Matheus França Perazzo2 

Saul Martins Paiva2 

Fernanda Morais Ferreira2 

Ana Flávia Granville-Garcia1 

1Department of Dentistry, UEPB - Universidade Estadual da Paraíba, Campina Grande, Paraíba, Brazil

2Department of Pediatric Dentistry and Orthodontic, UFMG - Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil


Abstract

The objective of the present study was to evaluate the influence of individual and contextual factors on the occurrence of toothache in five-year-old children. A cross-sectional study was conducted with 756 five-year-old children from public and private preschools in a city in the countryside of the northeast of Brazil. The sample was determined through probabilistic sampling in two stages (preschools and children). The children included could not have systematic diseases, permanent tooth or orthodontic treatment. Parents/caregivers were required to spend at least 12 hours per day with their children. The history of toothache during the life of the child was reported by parents/guardians. Socioeconomic and psychological questionnaires were completed by parents/guardians. Variables related to social context were obtained from the preschools in which the children studied and the official publications of the municipal region. Unadjusted and adjusted multilevel Poisson regression models were used to investigate the association between individual and contextual characteristics and history of toothache. The history of toothache was found for 23.8% of the children. Among the individual determinants, gender of the child, order of birth, and schooling of parent/guardian were associated with toothache in children. The individual variables remained associated with the outcome after the addition of the contextual variables to the model. The type of preschool was the contextual determinant associated with toothache in the final model. Both individual (gender, order of birth and schooling of parents/guardians) and contextual (type of preschool) determinants were associated with history of toothache in five-year-old children.

Key Words: toothache; oral health; preschool children

Resumo

O objetivo do presente estudo foi avaliar a influência de fatores individuais e contextuais na ocorrência de dor de dente em crianças de cinco anos de idade. Um estudo transversal foi realizado com 756 crianças de cinco anos de idade de pré-escolas públicas e privadas em uma cidade no interior do Nordeste do Brasil. A seleção da amostra foi realizada por meio de amostragem probabilística em duas etapas (pré-escolas e crianças). As crianças incluídas não poderiam ter doenças sistêmicas, dentes permanentes ou tratamento ortodôntico. Foram incluídos apenas pais/responsáveis que passavam pelo menos 12 horas por dia com seus filhos. O histórico de dor de dente durante a vida da criança foi relatado pelos pais/responsáveis. Os questionários socioeconômicos e psicológicos foram preenchidos pelos pais/responsáveis. As variáveis relacionadas ao contexto social foram obtidas na pré-escola em que as crianças estudaram e nas publicações oficiais da região municipal. Os modelos de regressão de Poisson multinível não ajustados e ajustados foram utilizados para investigar a associação entre características individuais e contextuais e histórico de dor de dente. O histórico de dor de dente foi encontrado em 23,8% das crianças. Entre os determinantes individuais, gênero da criança, ordem de nascimento e escolaridade dos pais/responsáveis ​​foram associados com dor de dente em crianças. As variáveis ​​individuais permaneceram associadas ao resultado após a adição das variáveis ​​contextuais ao modelo. O tipo de pré-escola foi o determinante contextual associado ao histórico de dor de dente no modelo final. Tanto o indivíduo (gênero, ordem de nascimento e escolaridade dos pais/responsáveis) quanto os determinantes contextuais (tipo de pré-escolar) foram associados com o histórico de dor de dente em crianças de cinco anos de idade.

Introduction

Toothache is a subjective indicator of oral health and can have an impact on oral health related quality of life (OHRQoL), causing functional and social impairment 1. In addition, having children with toothache results in greater absenteeism of parents from work 2, as well as increased financial expenses 3 and parental guilt 4. Due to the major impact that toothache can have on OHRQoL, one of the aims of the Global Goals for Oral Health 2020 is to reduce the prevalence of tooth pain and its consequences in the population 5. Thus, studies that evaluate the factors associated with the occurrence of toothache and help achieve this goal are required.

Literature describes the prevalence of toothache in five-year-old children as being between 9.4% and 25.0% 1,6,7,8,9,10. As cognitive ability is still developing in this age group, the evaluation of tooth pain is performed via the reports of parents 11. This data is highly reliable, as studies have shown that toothache is the most perceived symptom by parents in children at a young age 12. In terms of the psychological issues of parents, such as sense of coherence (SOC) and locus of control, previous studies have evaluated their relationship with oral health problems 13,14 but have not provided specific information about the history of toothache.

Most studies with young children evaluate toothache in terms of clinical aspects and/or socioeconomic issues addressed at the individual level 6,7,8,10. These individual clinical and socioeconomic factors have therefore already been well demonstrated in literature. Dental caries and dental trauma are the main clinical conditions presented by children in this age group, and are related to toothache 8,15. Individuals with worse socioeconomic conditions at an individual level are more exposed to risk factors for oral health problems 7. However, this socioeconomic issue needs to be better addressed within a social context. In studies with adolescents and adults a direct relationship between the context in which the individual is inserted and toothache has already been demonstrated 16,17,18. Adolescents from areas with a low Human Development Index (HDI) had a higher prevalence of toothache than those in more developed areas, regardless of individual characteristics 16. In pre-school children, there is only one study that assesses toothache through a multilevel approach 9. This study was based on data from the national oral health survey conducted in 2010 in Brazil, and identified an association between toothache and a low level of HDI and literacy in the city 9.

New studies of this topic will allow a better understanding of the relationship between the non-clinical individual and contextual determinants of children’s oral health conditions. Brazil is a country with considerable social disparities, and researchers have sought to determine factors that may explain differences in the oral health status of the population 19. Type of school can be considered a contextual determinant, since this variable is sensitive for the discrimination of different oral health conditions 20. Thus, understanding the role of the school environment in children’s health is important when planning preventive strategies 21,22. To date, there are no studies that evaluate toothache in preschool children based on the school context.

The aim of the present study was therefore to evaluate non-clinical individual and school factors relating to the occurrence of toothache in five-year-old children.

Material and Methods

This study received approval from the Human Research Ethics Committee of the State University of Paraíba (38937714.0.0000.5187) and was conducted in compliance with the guidelines stipulated in the Declaration of Helsinki. All the legal guardians signed a statement of informed consent prior to the data collection process. All the preschools received clarifications regarding the study protocol and agreed to participate.

Sample Characteristics and Study Design

A cross-sectional study was conducted in public and private preschools in Campina Grande, a city located in the eastern part of the northeast of Brazil. This city has about 400,000 inhabitants and an HDI of 0.72. The present study was carried out to evaluate the oral health of five-year-old children and was conducted between August and December 2015. All stages of this study were performed in accordance with guidelines for cross-sectional studies.

Sample selection was performed through probabilistic sampling in two stages. A total of 263 preschools (129 public and 134 private) are registered with the Ministry of Education. The city is divided into six administrative districts and the preschools were randomly selected according to the total number of such preschool in each district in the first stage. Twenty-eight public and 20 private preschools were selected. The second phase consisted of the selection of children for the sample using a simple randomization procedure. The ratio of the total population enrolled in private and public preschools in each administrative district of the city was maintained in the sample distribution.

The sample size was calculated based on a 5% margin of error, a 95% confidence level and a correction factor of 1.6 to compensate for the design effect. A prevalence rate of 50% for toothache was considered to increase the power and because this value gave the largest sample regardless of the actual prevalence. The required sample size was calculated to be 615 preschool children. This value was increased to compensate for possible dropouts estimated at 20% resulting in a sample of 769 five-year-old children.

Eligibility Criteria

Five-year-old children with no systematic diseases (based on the reports of parents/caregivers) enrolled at public and private preschools were included in the sample. Parents/caregivers were required to spend at least 12 hours per day with their children. The exclusion criteria were the presence of one or more erupted permanent tooth and a history of orthodontic treatment.

Pilot Study

A pilot study was conducted to test the methodology. The participants in the pilot study (n=45) were not included in the main sample. As there were no misunderstandings regarding the questionnaires or the methodology, no changes to the data collection process were deemed necessary.

Data Collection

Data collection was performed in preschools that were selected following contact with the principals of each school to explain the purpose of the study. Parents/guardians were previously contacted to attend a meeting at the preschool and participate in an oral health promotion activity, during which they received clarification on the study and signed an informed consent form. At the same meeting, the parents/guardians were asked to provide information related to their child’s history of toothache and complete questionnaires addressing their psychological aspects and sociodemographic data. Additionally, data regarding variables related to the social context in which the children were inserted were collected. The parents/guardians who did not participate in the activity scheduled at the preschool were contacted by telephone by the researchers, who stressed the importance of the study and asked them to return the completed questionnaires.

History of toothache. This information was provided by parents/guardians and a history of toothache was recorded if this symptom was observed at some time in the child’s life. The answer choices were yes or no.

Individual sociodemographic variables. The following sociodemographic variables were collected to obtain an individual profile of the child/family: child’s gender, education of parents/guardians, monthly family income, order of birth and whether the child had siblings.

Psychological aspects of parents/guardians: To analyze the psychological aspects of parents/guardians, the SOC and locus of control were evaluated. The SOC of the parents/caregivers was measured using the Brazilian Sense of Coherence Scale (SOC-13), employing the version validated for use on parents of preschool children 23. This questionnaire has 13 items, each with five response options that assist in evaluating the components that compose SOC: comprehensibility, manageability and meaningfulness. The total ranges from 13 to 69 points, with higher scores indicative of a stronger SOC and greater capacity to cope with stress. For the purposes of statistical analysis, the score was dichotomized by the median, as performed in a previous study 13. Scores below the median were considered indicative of a weak SOC and scores above the median were indicative of a strong SOC.

The locus of control of the parents/caregivers was evaluated using the Multidimensional Health Locus of Control index 14, which has 18 items distributed among three subdivisions (internal/external/chance) for the evaluation of the respondent’s perception of who or what determines health/illness events: the individual himself/herself (internal) or other forces (external/chance). Each item has five response options (1= fully agree; 2=agree in part; 3=neither agree nor disagree; 4=disagree in part; 5=fully disagree). The scores of the items on each subscale are totaled and can range from 6 to 30 points, with higher scores on the subscale indicating a lower degree of each factor (internal and external/chance). An internal LOC is considered when the lowest score is on the subscale of internal factors and an external LOC is considered when the lowest score is on the subscale of external or chance factors.

Contextual variables. Five variables of the children preschools were investigated to assess the influence of contextual aspects on children’s toothache: type of preschool in which the child was enrolled, number of children in the preschool, average monthly income of the neighborhood in which the preschool was located and number of general and oral health teams in the administrative district where the school was located. Information on the average income of the city’s districts was obtained from the Brazilian Institute of Geography and Statistics and the number of general and oral health teams from the administrative districts was obtained from the city’s Department of Health. Data on pre-schools were recorded during the first visit to each preschool.

Statistical Analysis

The STATA 12.0 program (Stata Corporation, College Station, TX, USA) was used for data analysis. Descriptive statistics were used for the characterization of the sample. Unadjusted and adjusted multilevel Poisson regression models were created to describe the associations between the outcomes and predictors. Multilevel Poisson regression analysis involved a fixed effects model with random intercepts to evaluate associations between the history of toothache of the children (primary outcome) and both individual and contextual covariates. This strategy enabled the estimation of prevalence ratio (PR) between comparison groups and respective 95% confidence intervals (CI). In the first step, an unconditional (null) model was used to estimate variability in the data before the individual and contextual characteristics were taken into account. The individual covariates were incorporated into model 2 and both the individual and contextual covariates were incorporated into model 3. Individual variables that achieved a p-value<0.20 in the univariate multilevel Poisson regression analysis were incorporated into model 2 and those with a p-value<0.05 in the adjusted analysis remained in the model. Next, contextual variables that achieved a p-value<0.20 in the univariate multilevel Poisson regression analysis were incorporated into model 3 and those with a p-value<0.05 in the adjusted analysis remained in the final model. The goodness-of-fit of the models was calculated based on deviance values (-2 log likelihood).

Results

A total of 756 pairs of children/parents were included in the present study, representing a response rate of 98.3%. Thirteen children were considered losses due to incomplete questionnaires. Table 1 shows the main characteristics of the sample. A history of toothache during the child’s lifetime was reported in 23.8% of cases, and the majority of children were male (52.2%), had parents/guardians with more than eight years of schooling (70.1%), and attended private preschools (61.4%).

In bivariate analysis of multilevel Poisson regression, the history of toothache was significantly associated with parents’/guardians’ schooling, monthly family income, presence of siblings, order of birth, number of children, locus of control and type of pre- school (p<0.05) (Table 2).

Table 1 Individual and contextual level characteristics of the sample 

Variable n(%)/ Mean (SD)
Individual Level
Gender
Female 361(47.8)
Male 395(52.2)
Parent’s/caregiver’s schooling
≤ 8 years of study 225(29.9)
> 8 years of study 528(70.1)
Monthly household income
< US$ 80.00 361(50.0)
≥ US$ 80.00 361(50.0)
Only child
Yes 258(34.4)
No 492(65.6)
Birth order
Only child 258(34.5)
Youngest child 277(37.0)
Oldest child 125(16.7)
Middle child 88(11.8)
Number of children 2.10(1.17)
Sense of coherence
Weak 317(41.9)
Strong 439(58.1)
Locus of control
Internal 513(68.3)
External 238(31.7)
History of toothache
No 576(76.2)
Yes 180(23.8)
Contextual-level variables
Type of preschool
Public 292(38.6)
Private 464(61.4)
Number of children in preschool 107.88(99.71)
Mean monthly income of neighborhood 1091.85(253.83)
Number of general health teams 17.50(4.60)
Number of oral health teams 8.94(2.13)

Table 2 Unadjusted assessment of the association of history of toothache among preschool children with individual and contextual-level variables 

Variable N History of toothache
n% p value PR(95%CI)
Individual-level variable
Gender
Female 361 97(26.9) 0,098 1.29(0.95-1.73)
Male 395 83(21.0) 1.00
Parent’s/caregiver’s schooling
≤ 8 years of study 225 92(40.9) p<0.001 2.45(1.83-3.29)
> 8 years of study 528 88(16.7) 1.00
Monthly household income
< US$ 280.00 361 115(31.9) p<0.001 1.92(1.40-2.62)
≥ US$ 280.00 361 60(16.6) 1.00
Only child
Yes 258 41(15.9) 0.007 0.61(0.43-0.88)
No 492 135(27.4) 1.00
Order of birth
Only child 258 41(15.9) 1.00
Youngest child 277 68(24.5) 0.055 1,47(0,99-2,19)
Oldest child 125 33(26.4) 0.040 1.62(1.02-2.58)
Middle child 88 35(39.8) 0.001 2.25(1.41-3.61)
Number of children - - 0.013 1.15(1.03-1,29)
Sense of coherence
Weak 317 91(28.7) 1.00
Strong 439 89(20.3) 0.072 0.76(0.56-1.03)
Locus of control
Internal 513 106(20.7) 0.031 0.71(0.53-0.97)
External 238 73(30.7) 1.00
Contextual-level variables
Type of preschool
Public 292 108(37.0) p<0.001 2.38(1.77-3.21)
Private 464 72(15.5) 1.00
Number of children in preschool - - 0.025 0.99(0.99-1.00)
Mean monthly income of neighborhood - - 0.220 0,99(0,99-1.00)
Number of general health teams - - 0.535 0.95(0.87-1.04)
Number of oral health teams - - 0.288 0.99(0.95-1.03)

Table 3 shows the results of the multivariate Poisson regression model. In model 2, with the inclusion of individual determinants, the variables associated with the history of toothache were lower levels of schooling of parents/guardians (PR= 2.24; CI95%: 1.64-3.06), being a middle child (PR= 1.87; CI95%: 1.17-2.99) and the female gender (PR= 1.36; CI95%: 1.01-1.82). Following adjustment for the contextual determinants, the individual variables remained associated with the result (Model 3). Attending private preschools was a protective factor in relation to the history of toothache at some time in the child’s life (PR=0.61; CI95%: 0.42-0.88).

Table 3 Multilevel Adjusted Assessment of cavitation of toothache among preschool children associating individual and contextual variables 

Fixed effects Model 1 (“null”) Model 2 Model 3
PR (CI 95%) PR (CI 95%)
Intercept 0.24(0.21-0.27) 0.11(0.08-0.17) 0.18(0.11-0.27)
Individual level
Parent’s/caregiver’s chooling
≤ 8 years of study 2.24(1.64-3.06) 1.65(1.14-2.39)
> 8 years of study 1.00 1.00
Order of birth
Only child 1.00 1.00
Youngest child 1.19(0.79-1.77) 1.16(0.78-1.74)
Oldest child 1.50(0.95-2.38) 1.50(0.95-2.38)
Middle child 1.87(1.17-2.99) 1.73(1.08-2.77)
Gender
Male 1.00 1.00
Female 1.36(1.01-1.82) 1.37(1.02-1.85)
Contextual level: Preschool
Type of preschool
Public 1.00
Private 0.58(0.40-0.84)
Random effects
Deviance (-2loglikelihood) 870.0276 817.2961 809.1280

Model 1 (“null”): represents the unconditional model; Model 2: represents individual covariates; Model 3: represents subject and contextual-level covariates.

Discussion

A history of toothache was more prevalent among children living in an unfavorable social context. The schooling of parents/guardians and the type of preschool can be used as a means of intervention to improve the oral health of children and consequently decrease the prevalence of toothache. The results of the present study are therefore valid for the support of oral health policies.

According to parents/guardians, 23.8% of children had a history of toothache. This prevalence agrees with other studies conducted in the same age group 6,9. However, other reports of toothache in preschool children have found a lower prevalence 1,7,8,10. Caution should be exercised when performing comparisons with these studies, as they are based on different methodologies, especially in relation to the time considered for the reporting of toothache 7 and feature age groups, involving children under 5 years of age 1,8,10. These factors may result in a less frequent reporting of toothache.

Toothache was reported more frequently among female children. Possible, parents may tend to be more careful with their daughters, and thus, they are more attentive to the reported pain of female children. In addition to the child’s gender, birth order also influenced this problem. Middle children were associated with a more prevalent history of toothache. An earlier study with pre-school children revealed that being a middle child led to an approximately ten times greater chance of suffering an impact on OHRQoL 1. Based on this, it is possible to assume that the prevalence of oral health problems, including toothache, tends to be greater among such children. One possible explanation for this relationship is the fact that when there are more than 2 children, parents tend to pay more attention to their older and younger children, while the middle children are less remembered.

A lower level of schooling of parents/guardians was an individual socioeconomic predictor that influenced the history of toothache in five-year-old children. However, the psychological aspects of the parents/guardians evaluated (SOC and control locus) were not associated with a history of toothache. This result confirms the significant influence of social inequality on the oral health of the Brazilian population. Parents/guardians with a lower educational level may have lower oral health knowledge and reduced financial conditions 24. Moreover, parents with lowest education only take their children to the dentist when problems arise 25. These factors can result in poorer oral health conditions for children. It is worth mentioning that this individual determinant remained associated with a history of toothache even after adjustment with the contextual variables. There is therefore a need for public health programs that educate parents to seek preventive oral health care on an ongoing basis, rather than in response to oral problems.

The type of preschool was the only contextual variable that presented an association with the history of toothache in children. Children in private preschools had a lower prevalence of history of toothache than children in public preschools. In Brazil, the type of preschool reflects the socioeconomic condition, and thus may possibly reflect inequalities associated with oral conditions, such as dental caries and the use of the health service. Thus, public health policies should prioritize the incorporation of measures that encourage healthy habits and the creation of healthy environments in public schools to promote health among this population 20, because on that socioeconomic context, these children are more vulnerable to oral health problems. The other contextual variables analyzed in the present study did not exhibit an association with a history of toothache, perhaps because they did not reflect the contextual differences between the environments in which the children were inserted. The results of the present study suggest that, in Brazil, type of school better represents the socioeconomic environment in which children are inserted than monthly income of the neighborhood of the school that they attend, as children often live in a different neighborhood and the income of the neighborhood in which the school is located may not reflect their actual socioeconomic status. With regard to the number of health professionals, this information only referred to those at public services, which could be considered a limitation of the present study. Moreover, for the population of the study, socioeconomic status probably had greater importance than access to healthcare services with regard to the outcome of toothache in the children.

One limitation of this research is that it is a cross-sectional study that prevents causal inferences. However, it includes a representative sample of the population, followed the norms established for cross-sectional studies, and performs differentiated analyzes to evaluate the social context. Although the history of toothache was reported by proxy measure, this is a reliable alternative for the evaluation of this condition in young children. Further studies should aim to establish the influence of the school context, such as structure, methods of teaching children, as well as the existence of health promotion actions, on the child’s oral health conditions.

The results found in the present study can help to identify the individual and contextual characteristics that should be explored further, and support interventions to improve oral health. Some characteristics associated with the history of toothache are immutable factors such as gender and birth order. However, public health policies that address social inequalities can be elaborated. Especially, the present study warns of the importance of establishing healthy measures and changes in behavior in public preschools, as children in this context had a higher prevalence of toothache.

References

1 Clementino MA, Gomes MC, Pinto-Sarmento TC, Martins CC, Granville-Garcia AF, Paiva SM. Perceived impact of dental pain on the quality of life of preschool children and their families. Plos One2015;10:e0130602. [ Links ]

2 Ribeiro GL, Gomes MC, Lima KC, Martins CC, Paiva SM, Granville-Garcia AF. Work absenteeism by parents because of oral conditions in preschool children. Int Dent J 2015;65:331-337. [ Links ]

3 Ribeiro GL, Gomes MC, Lima KC, Martins CC, Paiva SM, Granville-Garcia AF. The potential financial impact of oral health problems in the families of preschool children. Cien Saude Colet 2016;21:1217-1226. [ Links ]

4 Gomes MC, Clementino MA, Pinto-Sarmento TC, Martins CC, Granville-Garcia AF, Paiva SM. Association between parental guilt and oral health problems in preschool children: a hierarchical approach. BMC Public Health 2014;14:854. [ Links ]

5 Hobdell M, Petersen PE, Clarkson J. Global goals for oral health 2020. Int Dent J 2003;53:285-288. [ Links ]

6 Moure-Leite FR, Ramos-Jorge J, Ramos-Jorge ML, Paiva SM, Vale MP, Pordeus IA. Impact of dental pain on daily living of five-year-old Brazilian preschool children: prevalence and associated factors. Eur Arch Paediatr Dent 2011;12:293-297. [ Links ]

7 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;46:488-495 [ Links ]

8 Ortiz FR, Tomazoni F, Oliveira MD, Piovesan C, Mendes F, Ardenghi TM. Toothache, associated factors, and its impact on oral health-related quality of life (OHRQoL) in preschool children. Braz Dent J 2014;25:546-553. [ Links ]

9 Ferreira-Júnior OM, Freire MCM, Moreira RS, Costa LR. Contextual and individual determinants of dental pain in preschool children. Community Dent Oral Epidemiol 2015;43:349-356. [ Links ]

10 Lemes MG, Peixoto MR, Meneses IH, Freire MC. Dental pain and associated factors in 2 to 4-year-old children in Goiânia. Rev Bras Epidemiol 2015;18:630-641. [ Links ]

11 Slade GD. Epidemiology of dental pain and dental caries among children and adolescents. Community Dent Health 2001;18:219-227 [ Links ]

12 Gomes MC, Clementino MA, Pinto-Sarmento TC, Costa EM, Martins CC, Granville-Garcia AF, et al. Parental perceptions of oral health status in preschool children and associated factors. Braz Dent J 2015;26:428-434. [ Links ]

13 Bonanato K, Paiva SM, Pordeus IA, Ramos-Jorge ML, Barbadela D, Alisson PJ. Relationship between mothers’ sense of coherence and oral health status of preschool children. Caries Res 2009;43:103-109. [ Links ]

14 Nunes VH, Perosa GB. Dental decay in 5-year-old children: sociodemographic factors, locus of control and parental attitudes. Cien Saude Colet 2017;22:191-200. [ Links ]

15 Viegas CM, Paiva SM, Carvalho AC, Scarpelli AC, Ferreira FM, Pordeus IA. Influence of traumatic dental injury on quality of life of Brazilian preschool children and their families. Dent Traumatol 2014;30:338-347. [ Links ]

16 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;10:20. [ Links ]

17 Santiago BM, Valença AM, Vettore MV. Social capital and dental pain in Brazilian northeast: a multilevel cross-sectional study. BMC Oral Health 2013;13:2. [ Links ]

18 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;30:21-26. [ Links ]

19 Martins MT, Sardenberg F, Abreu MH, Vale MP, Paiva SM, Pordeus IA. Factors associated with dental caries in Brazilian children: a multilevel approach. Community Dent Oral Epidemiol 2014;42:289-299. [ Links ]

20 Piovesan C, Pádua MC, Ardenghi TM, Mendes FM, Bonini GC. Can type of school be used as an alternative indicator of socioeconomic status in dental caries studies? A cross-sectional study. BMC Med Res Methodol 2011;11:37. [ Links ]

21 Fernández MR, Goettems ML, Ardenghi TM, Demarco FF, Correa MB. The role of school social environment on dental caries experience in 8- to 12-year-old Brazilian children: a multilevel analysis. Caries Res 2015;49:548-556. [ Links ]

22 Sanders AE, Turrel G, Slade GD. Affluent neighborhoods reduce excess risk of tooth loss among the poor. J Dent Res 2008;87:969-973. [ Links ]

23 Bonanato K, Branco DBT, Mota JPT, Ramos-Jorge ML, Piava SM, Pordeus IA, et al. Trans-Cultural adaptation and psychometric properties of the ‘Sense of Coherence Scale’ in mothers of preschool children. R Interam Psicol 2009;43:144-153. [ Links ]

24 Feldens CA, Giugliani ER, Vigo A, Vitolo MR. Early feeding practices and severe early childhood caries in four-year-old children from southern Brazil: a birth cohort study. Caries Res 2010;44:445-452. [ Links ]

25 Van den Branden S, Van den Broucke S, Leroy R, Declerck D, Hoppenbrouwers K. Oral health and oral health-related behaviour in preschool children: evidence for a social gradient. Eur J Pediatr 2013;172:231-237. [ Links ]

Received: January 19, 2018; Accepted: July 16, 2018

Correspondence: Ana Flávia Granville-Garcia, 1325/410, Rua Capitão João Alves de Lira, 58428-800 Campina Grande, PB, Brasil. Tel: +55-83-3315-3326. e-mail:anaflaviagg@hotmail.com

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