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Periodontal condition of adolescents and associated factors

Condição periodontal de adolescentes e fatores associados

ABSTRACT

Objective:

This study aimed to describe the periodontal condition of adolescents and identify its potential determinants.

Methods:

This is a cross-sectional population-based study (n=763) conducted in a city in Northern Minas Gerais. Multistage probability cluster sampling method was used. Trained and calibrated professionals carried out the intraoral examinations and the interviews at the participants’ homes. Logistic regression model was used to identify the factors associated with the periodontal condition.

Results:

It was found that around 30% of the adolescents presented periodontal changes, being gingival bleeding (14.1%) and dental calculus (14.0%) the most prevalent impairments. Periodontal changes were associated in adolescents who did not attend school (OR=1,9; p=0.031), attended public schools (OR=2,0; p=0.005), never went to the dentist (OR=1,7; p=0,047), used public/philanthropic services (OR=1,7; p=0,002), smoked (OR=1,6; p=0,003), consumed alcohol (OR=1,6; p=0,016) and self-perceived their oral health as too bad/bad (OR=2,4; p=0,032) and regular (OR=1,5; p=0,023).

Conclusion:

About one-third of adolescents have periodontal changes, which were associated with the type of school and type of dental service they attend, smoking, alcohol consumption and self-perception of oral health.

Indexing terms
Adolescent; Adolescent health; Oral health; Periodontal diseases; Public health; Social determinants of health

RESUMO

Objetivo:

Objetivou-se descrever a condição periodontal entre adolescentes e identificar seus potenciais determinantes.

Métodos:

Trata-se de um estudo transversal de base populacional (n=763) realizado em município da região norte de Minas Gerais. Adotou-se amostragem probabilística por conglomerado em múltiplos estágios. Profissionais treinados e calibrados realizaram os exames intrabu-cais e entrevistas nos domicílios. Foi utilizado modelo de regressão logística para identificar os fatores associados à condição periodon-tal.

Resultados:

Verificou-se que 29,5% dos adolescentes apresentaram alterações periodontais, sendo que o sangramento gengival (14,1%) e o cálculo dentário (14,0%) foram os agravos mais prevalentes. As alterações periodontais foram associadas em adolescentes que não estudavam (OR=1,9; p=0.031), que estudavam em escolas públicas (OR=2,0; p=0.005), que nunca foram ao dentista (OR=1,7; p=0,047) utilizaram os serviços públicos/filantrópicos (OR=1,7; p=0,002), que fumavam (OR=1,6; p=0,003), que consumiam bebida alcoólica (OR=1,6; p=0,016) e que autoperceberam auto perceberam sua saúde bucal como péssima/ruim (OR=2,4; p=0,032) e regular (OR=1,5; p=0,023).

Conclusão:

Cerca de um terço dos adolescentes possui alterações periodontais, que foram associadas ao tipo de escola e ao tipo de serviço odontológico que frequentam, tabagismo, consumo de bebida alcoólica e autopercepção da saúde bucal.

Termos de indexação
Adolescentes; Saúde do adolescente; Saúde bucal; Doenças periodontais; Determinantes sociais da saúde; Saúde pública

INTRODUCTION

Oral health in adolescence represents a good individual health indicator and it is crucial to understand it at this age in order to subsidize health promotion actions [11 Saintrain MVL, Correa CRS, Saintrain SV, Nuto SAS, Vieira-Meyer APGF. Brazilian adolescents’ oral health trends since 1986: an epidemiological observational study. BMC Res Notes. 2015; 8: 554. http://dx.doi.org/10.1186/s13104-015-1538-5
https://doi.org/10.1186/s13104-015-1538-...
]. However, oral health problems are highly prevalent in this population [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
].

Periodontal disease can begin in childhood and adolescence and progress slowly throughout life, showing significant prevalence in this age group [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...

3 Souza CHC, Dantas-Neta NB, Laurentino JB, Antos DLN, Júnior RRP, Mendes RF. Fatores de risco relacionados à condição de saúde periodontal em universitários. Rev Odontol UNESP. 2013;42(3):152-9. http://dx.doi.org/10.1590/S1807-25772013000300002
https://doi.org/10.1590/S1807-2577201300...
-44 Al-Ghutaimel H, Riba H, Al-Kahtani S, Al-Duhaimi S. Common periodontal diseases of children and adolescents. Int J Dent. 2014;2014:850674. http://dx.doi.org/10.1155/2014/850674
https://doi.org/10.1155/2014/850674...
]. It is a major oral health problem, considered one of the leading causes of tooth loss at its more advanced stages, which could result in serious functional and aesthetic impairment for the patient [55 Rodrigues TQ, Silva RVC, Ribeiro FS, Pontes AEF. Conhecimento sobre saúde periodontal dos pacientes submetidos à triagem nos postos de saúde de Barretos. Periodontia. 2014; 24(2):19-23.

6 Whelton H, Crowley E, O’Mullane D. Oral health of irish adults 2000-2002. Dublin: Department of Health and Children; 2007.
-77 Vieira TR, Péret ACA, Péret Filho LA. Alterações periodontais associadas às doenças sistêmicas em crianças e adolescentes. Rev Paul Pediatr. 2010;28(2):237-43. http://dx.doi.org/10.1590/S0103-05822010000200017
https://doi.org/10.1590/S0103-0582201000...
]. Gingivitis, less severe and most common form of periodontal disease, currently affects 33.8% of adolescents in Brazil and periodontitis, 10.5% [88 Brasil. Ministério da Saúde. Secretaria de atenção à saúde. Secretaria de vigilância em saúde. Departamento de atenção básica. Coordenação geral de saúde bucal. SB Brasil 2010 - Pesquisa nacional de saúde bucal: resultados principais. Brasília: Ministério da Saúde; 2011 [citado 2017 Nov 10]. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf>.
http://bvsms.saude.gov.br/bvs/publicacoe...
].

Clinical signs such as gingival bleeding, supragingival calculus, probing depth and loss of insertion are indicators of periodontal disease that isolated or in association with other parameters, provide data to diagnose the presence or absence of periodontal inflammation [99 Segundo Takeshi K, Ferreira EF, Costa JE. A doença periodontal na comunidade negra dos Arturo’s, Contagem, Minas Gerais, Brasil. Cad Saúde Pública. 2004;20(2):596-603. http://dx.doi.org/10.1590/S0102-311X2004000200029
https://doi.org/10.1590/S0102-311X200400...
]. Most epidemiological studies [33 Souza CHC, Dantas-Neta NB, Laurentino JB, Antos DLN, Júnior RRP, Mendes RF. Fatores de risco relacionados à condição de saúde periodontal em universitários. Rev Odontol UNESP. 2013;42(3):152-9. http://dx.doi.org/10.1590/S1807-25772013000300002
https://doi.org/10.1590/S1807-2577201300...
] follow the parameters recommended by the World Health Organization, and use periodontal disease indicators systematized in indices such as the periodontal community index (CPI) - gingival bleeding, calculus presence and bag depth. It has as advantage simplicity, reproducibility and international uniformity [1010 Chalub LLF, Péret ACA. Desempenho do índice Periodontal Comunitário (CPI) na determinação da condição periodontal: enfoque no exame parcial. Arqu Bras Odontol. 2010;6(3):155-62.].

Several potential risk factors for periodontal disease have been reported in oral health epidemiological surveys, namely being male, of black origin, low socioeconomic status and low educational level, smoking, alcoholism, poor oral hygiene, biological factors, genetic factors, psychosocial conditions such as stress and depression and diabetes [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
,33 Souza CHC, Dantas-Neta NB, Laurentino JB, Antos DLN, Júnior RRP, Mendes RF. Fatores de risco relacionados à condição de saúde periodontal em universitários. Rev Odontol UNESP. 2013;42(3):152-9. http://dx.doi.org/10.1590/S1807-25772013000300002
https://doi.org/10.1590/S1807-2577201300...
,1111 Antunes JLF, Peres MA, Frias AC, Crosato EM, Biazeviz MGH. Saúde gengival de adolescentes e a utilização de serviços odontológicos, Estado de São Paulo. Rev Saúde Pública. 2008;42(2):191-9. http://dx.doi.org/10.1590/S0034-89102008000200002
https://doi.org/10.1590/S0034-8910200800...

12 Xavier ACV, Silva IN, Costa FO, Corrêa DS. Condição periodontal de crianças e adolescentes com diabetes melito tipo 1. Arq Bras Endocrinol Metab. 2009;53(3):348-54. http://dx.doi.org/10.1590/S0004-27302009000300009
https://doi.org/10.1590/S0004-2730200900...

13 Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health. 2015;15(Suppl 1):S6. http://dx.doi.org/10.1186/1472-6831-15-S1-S6
https://doi.org/10.1186/1472-6831-15-S1-...

14 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...

15 Shereef M, Sanara PP, Karuppanan S, Noorudeen AM, Joseph K. The effect of cigarette smoking on the severity of periodontal diseases among adults of Kothamangalam Town, Kerala. J Pharm Bioallied Sci. 2015;7(Suppl 2):S648-51. http://dx.doi.org/10.4103/0975-7406.163588
https://doi.org/10.4103/0975-7406.163588...
-1616 Susin C, Wagner MC, Haas AN, Oppermann RV, Albandar JM. The association between alcohol consumption and periodontitis in southern Brazilian adults. J Periodontal Res. 2015;50(5):622-8. http://dx.doi.org/10.1111/jre.12242
https://doi.org/10.1111/jre.12242...
]. Measures like oral hygiene education, patient empowerment for self-care, dental care and intersectoral and interdisciplinary actions and the establishment of public policies are critical to the prevention and treatment of this disease [11 Saintrain MVL, Correa CRS, Saintrain SV, Nuto SAS, Vieira-Meyer APGF. Brazilian adolescents’ oral health trends since 1986: an epidemiological observational study. BMC Res Notes. 2015; 8: 554. http://dx.doi.org/10.1186/s13104-015-1538-5
https://doi.org/10.1186/s13104-015-1538-...
,55 Rodrigues TQ, Silva RVC, Ribeiro FS, Pontes AEF. Conhecimento sobre saúde periodontal dos pacientes submetidos à triagem nos postos de saúde de Barretos. Periodontia. 2014; 24(2):19-23.,77 Vieira TR, Péret ACA, Péret Filho LA. Alterações periodontais associadas às doenças sistêmicas em crianças e adolescentes. Rev Paul Pediatr. 2010;28(2):237-43. http://dx.doi.org/10.1590/S0103-05822010000200017
https://doi.org/10.1590/S0103-0582201000...
,1313 Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health. 2015;15(Suppl 1):S6. http://dx.doi.org/10.1186/1472-6831-15-S1-S6
https://doi.org/10.1186/1472-6831-15-S1-...
,1414 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...
].

In view of the scarcity of information on periodontal condition among adolescents in Brazil and the assumption that factors such as sociodemographic, behavioral, use of dental services and self-perception of oral health could be determinants of the periodontal conditions among adolescents, the aim of this study was to describe the periodontal condition and identify its potential determinants among a population of adolescents in Northern Minas Gerais, Brazil.

METHODS

Ethical aspects

The present study was approved by the Ethics Committee in Research – approval number 318/08. All individuals participating in the study signed the Informed Consent Form.

Study design

It is a cross-sectional population-based study conducted in Montes Claros, a city located in Northern Minas Gerais, in the São Francisco River Basin, with approximately 360,000 inhabitants. In this study, the population of interest consisted of adolescents aged between 15 and 19 years living in the urban and rural areas of the municipality.

Sample size

The sample size was calculated in order to estimate population parameters with a prevalence of 0.50, 95% confidence level and 5.0% margin of error. Correction for the design effect was used (deff = 2), with a 20% increase to compensate for possible losses. The result was a sample of at least 761 individuals.

The two-stage cluster sampling was the method used. In the first stage, 52 of the 276 urban census sectors existing in the municipality were randomly selected through simple random sampling (SRS). In the second stage, a sample fraction was selected through SRS from the blocks in each of the 52 sectors randomly selected, resulting in an average of seven blocks per sector. All households in the selected blocks were sequentially visited and the residents within the age range studied were invited to participate in the study. In the rural area, the single-stage cluster sampling was the method used. Two of the eleven rural areas identified were randomly selected, and all households located at a distance of up to 500 meters from a reference institution (school) were selected and their residents aged between 15 and 19 years were invited to participate in the survey.

In order to incorporate the complex sampling design structure into the data analysis, each respondent was associated with a weight w, corresponding to the inverse of his/her inclusion probability in the sample (f) [1717 Szwarcwald CL, Damacena GN. Amostras complexas em inquéritos populacionais: planejamento e implicações na análise estatística dos dados. Rev Bras Epidemiol. 11(Suppl1):38-45. http://dx.doi.org/10.1590/S1415-790X2008000500004
https://doi.org/10.1590/S1415-790X200800...
]. In the urban area, the inclusion probability was obtained by the product of the inclusion probability in each of the two stages (f = f1 x f2), being f1 = inclusion probability in the first stage (number of sectors randomly selected /total number of sectors) and f2= inclusion probability in the second stage (number of blocks randomly selected /total number of blocks of the sector). Moreover, the possibility of refusal to participate in the study was also taken into account, which would result in different inclusion probabilities. Thus, the response rate (rr) in each sector was incorporated and the final inclusion probability of each individual was obtained by the expression f= f1 x f2 x rr. In the rural area, the selection of individuals consisted of only one stage, so the inclusion probability was calculated by the expression f= f1 x rr, considering f1= inclusion probability in the first stage (number of rural areas randomly selected /total number rural areas). Finally, each respondent’s weight was obtained by the inverse of the inclusion probability (w=1/f).

Fieldwork

The fieldwork was conducted by 24 teams composed of an examiner and a note taker, all previously trained and calibrated. The data were collected using a handheld computer with a program created specifically for that purpose, enabling simultaneous and automatic database building [1818 Martins AMEBL, Rodrigues CAQ, Haikal DS, Silveira MF, Mendes DC, Oliveira MP, et al. Desenvolvimento de um programa de computador para levantamentos epidemiológicos sobre condições de saúde bucal. Rev Unimontes Científ. 2012;14(1):30-42.]. Interviews and intraoral examinations were carried out in a wide environment under natural light with a mouth mirror and CPI probe (WHO) previously sterilized [1919 World Health Organization. Oral health surveys: basic methods. 4 ed. Geneva: World Health Organization; 1997.]. The data stored on the handheld computer were transferred to a central computer, and then exported to the Statistical Package SPSS version 17.0 to be checked, reviewed and corrected.

The dependent variable “periodontal status” was assessed using the Community Periodontal Index (CPI). Dentition was divided into six sextants and the most serious situation found in the sextant examined was recorded. The scores adopted for the CPI evaluation were: 0= healthy periodontium; 1= presence of bleeding on probing; 2= presence of calculus; 3= 4-5 mm pocket; 4= 6 mm pocket or over19. Adolescents presenting CPI>0 were considered as having periodontal changes and those with CPI=0 were classified as having no periodontal changes.

The other independent variables investigated were arranged into four groups: demographic characteristics and socioeconomic status, use of dental services, health-related behavior, and subjective oral health status (Table 1).

Table 1
Independent variables and their categories. Montes Claros (MG), 2008/2009.

Data analysis

The variables were described by means of their frequency distributions, with correction for the design effect (deff). A 95% interval was estimated for the prevalence of periodontal changes, set up from the CPI categorization.

The logistic regression model was used in the analysis of the factors associated with periodontal changes. Initially, bivariate analyses were performed and the variables showing descriptive level p<0.20 at this stage were selected for the multivariate analysis. In order to build the multiple regression model, the step forward procedure was adopted. The variables significantly associated with the outcome at the level of 0.05 remained in the final model. Crude and adjusted odds ratios were estimated with their respective 95% confidence intervals. Hosmer & Lemeshow test was used to evaluate the goodness of fit of the logistic model. All analyses were performed with the Statistical Package SPSS version 17.0, using the Complex Sample module to analyze data from complex samples, in order to adjust the variability estimates in the cluster sampling.

RESULTS

The study comprised 763 subjects (99.6% from the urban area), with a response rate of 91.5%. Subjects not found after three home visits were excluded from the study, being that the main reason for the losses.

The mean age of the adolescents was 17.1 years, most of them were female (52.7%), single (94.7%), self-declared brown skin color (52.8%), attending education institutions (73.9%), had already attended over eight years of regular education (77.2%), did not work (75.5%), and held a monthly per capita income equal to or below R$ 200,00 (58.7%). Over 80.0% of adolescents lived in own homes. On average, their homes had 6.3 rooms housing 4.8 people, with a person-to-room ratio of less than or equal to one in 81.5% of the cases interviewed.

Most of the population studied (93.9%) had used dental services at least once in life, 46.4% of whom used dental services over a year prior to the beginning of the study. More than half of the adolescents who had access to dental treatment (55.6%) had the treatment done in public services, and 40.3% reported dental treatment as the reason for their last visit to the dentist. Only 26.2% of the adolescents reported visiting the dentist periodically.

It was noticed that 28.9% of the adolescents did oral hygiene less than three times a day, 58.8% did not use dental floss, 58.8% had never used topical fluoride, 41.2% reported one or more deleterious oral habits and 79.0% had never done oral self-examination. A significant percentage (31.8%) of the adolescents reported not or rarely practicing physical activity; smoking and drinking habits were reported by 5.1% and 18.8% of the respondents, respectively.

As for the subjective aspects of oral health, the following percentages of negative self-perception (fair/poor or very poor) were found: self-perception of oral health (34.4%), chewing (22%), appearance (35.4%), speech due to the teeth and gingivae (14.0%). Self-perception of toothache and/or gingival pain in the last six months was reported by 32.8% of the respondents.

Periodontal change (CPI>0) was found in 246 (29.5%) adolescents being gingival bleeding (14.1%) and dental calculus (14.0%) the most prevalent damages in this population. The presence of shallow or deep periodontal pockets was observed in only 1.3% of the subjects and 2.9% of the population studied (n=27) presented the six sextants affected (Table 2).

Table 2
Distribution of adolescents according to periodontal condition and the frequency of healthy sextants, with gingival bleeding, calculus and periodontal pockets assessed by the Community Periodontal Index (CPI). Montes Claros (MG), 2008/2009.

Table 3 shows the results of the crude analysis of the factors associated with periodontal changes. The variables that did not show statistically significant association (p-value>0.20) were not included in the table. Table 3 also shows the results of the adjusted analysis, whose variables associated with periodontal change (p-value ≤0.005) were: type of school, type of dental service, smoking, alcohol consumption and self-perception of oral health. It was found that the chances of periodontal changes among the subjects who did not attend school and among those who attended public schools were 1.9 times and 2.0 times, respectively, the chances observed among the subjects who attended private schools. In the groups of variables “use of dental services” and “health-related behavior” the chances of periodontal changes were higher among the subjects who never went to the dentist (OR=1.7), used public/philanthropic services (OR=1.7), smoked (OR=1.6) and consumed alcohol (OR=1.6). Among the subjective conditions of oral health, it was found that the adolescents who self-perceived their oral health as poor/very poor (OR=2.4) and fair (OR=1.5) presented higher chances of periodontal changes. The Hosmer-Lemeshow test showed goodness of fit of the final model (p=0.929).

Table 3
Association among demographic characteristics, socioeconomic status, health-related behaviors, use of dental services, Subjective conditions of oral health and periodontal change: crude and adjusted analysis. Montes Claros, MG, 2008/2009.

DISCUSSION

The occurrence of periodontal damages in its various forms has been a reality among adolescents and may impact their lives [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
,1414 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...
]. This study has identified a significant prevalence of adolescents with some periodontal change (CPI>0) in the city of Montes Claros - MG, however, lower than that found in Ireland, and other national scenarios such as in the town of Água Doce - SC, in the Vale do Jequitinhonha - MG and in all Brazilian regions as reported in the last national oral health survey [66 Whelton H, Crowley E, O’Mullane D. Oral health of irish adults 2000-2002. Dublin: Department of Health and Children; 2007.,88 Brasil. Ministério da Saúde. Secretaria de atenção à saúde. Secretaria de vigilância em saúde. Departamento de atenção básica. Coordenação geral de saúde bucal. SB Brasil 2010 - Pesquisa nacional de saúde bucal: resultados principais. Brasília: Ministério da Saúde; 2011 [citado 2017 Nov 10]. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf>.
http://bvsms.saude.gov.br/bvs/publicacoe...
,1414 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...
,2020 Biazevic MGH, Rissotto RR, Michel-Crosato E, Mendes LA, Mendes MOA. Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res 2008;22(1):36-42. http://dx.doi.org/10.1590/S1806-83242008000100007
https://doi.org/10.1590/S1806-8324200800...
].

Gingival bleeding and dental calculus were the most prevalent damages and shallow or deep periodontal pockets showed low prevalence (1.4%), which is in line with previous studies [1212 Xavier ACV, Silva IN, Costa FO, Corrêa DS. Condição periodontal de crianças e adolescentes com diabetes melito tipo 1. Arq Bras Endocrinol Metab. 2009;53(3):348-54. http://dx.doi.org/10.1590/S0004-27302009000300009
https://doi.org/10.1590/S0004-2730200900...
,1414 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...
,2020 Biazevic MGH, Rissotto RR, Michel-Crosato E, Mendes LA, Mendes MOA. Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res 2008;22(1):36-42. http://dx.doi.org/10.1590/S1806-83242008000100007
https://doi.org/10.1590/S1806-8324200800...
,2121 Idris FAI. Periodontal disease prevalence and some related factors among 15 years old school children in Khartoum State, Sudan. Sudanese J Public Health. 2010;5(4):187-92.]. The prevalence of gingival bleeding identified in this study was higher than those observed among adolescents in the Brazilian regions, ranging from 7.1% (North) to 11.7% (South) [88 Brasil. Ministério da Saúde. Secretaria de atenção à saúde. Secretaria de vigilância em saúde. Departamento de atenção básica. Coordenação geral de saúde bucal. SB Brasil 2010 - Pesquisa nacional de saúde bucal: resultados principais. Brasília: Ministério da Saúde; 2011 [citado 2017 Nov 10]. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf>.
http://bvsms.saude.gov.br/bvs/publicacoe...
] and lower among those living in the municipalities of the Vale do Jequitinhonha – MG [1414 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...
]. On the other hand, dental calculus was less prevalent when compared to adolescents in the Southeast and North regions of Brazil [88 Brasil. Ministério da Saúde. Secretaria de atenção à saúde. Secretaria de vigilância em saúde. Departamento de atenção básica. Coordenação geral de saúde bucal. SB Brasil 2010 - Pesquisa nacional de saúde bucal: resultados principais. Brasília: Ministério da Saúde; 2011 [citado 2017 Nov 10]. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf>.
http://bvsms.saude.gov.br/bvs/publicacoe...
] and more prevalent compared to the findings in a study conducted in the Vale do Jequitinhonha – MG [1414 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...
].

Regarding the demographic characteristics and socioeconomic status, only the variable “type of school” was associated with the outcome after adjusting for the other variables analyzed, showing higher chances of periodontal change among adolescents who did not attend school and who attended public schools when compared to those who attended private schools. The higher prevalence of periodontitis among individuals with low education level has been reported in Mangalore, India [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
]. Survey of Rio Janeiro adolescents found that those who were from private schools had better quality of life related to health in comparison to public schools [2222 Agathão BT, Reichenheim ME, Moraes CL. Qualidade de vida relacionada à saúde de adolescentes escolares. Ciênc Saúde Coletiva. 2018;23(2):659-68. http://dx.doi.org/10.1590/1413-81232018232.27572016
https://doi.org/10.1590/1413-81232018232...
].

It should be considered that the highest chance of periodontal diseases among public school students could be partly explained by the socioeconomic factor, which might be lower among these students. Previous studies have shown that the socioeconomic status influences the development and progression of periodontal disease in different age groups, including among adolescents, which could be related to oral hygiene habits and access to dental services, oral care products and appropriate treatment [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
,55 Rodrigues TQ, Silva RVC, Ribeiro FS, Pontes AEF. Conhecimento sobre saúde periodontal dos pacientes submetidos à triagem nos postos de saúde de Barretos. Periodontia. 2014; 24(2):19-23.,2121 Idris FAI. Periodontal disease prevalence and some related factors among 15 years old school children in Khartoum State, Sudan. Sudanese J Public Health. 2010;5(4):187-92.,2323 Ababneh KT, Hwaij ZMFA, Khader YS. Prevalence and risk indicators of gingivitis and periodontitis in a Multi-Centre study in North Jordan: a cross sectional study. BMS Oral Health. 2012;12(1). http://dx.doi.org/10.1186/1472-6831-12-1
https://doi.org/10.1186/1472-6831-12-1...
,2424 Davoglio RS, Aerts DRGC, Abegg C, Freddo Sl, Monteiro L. Fatores associados a hábitos de saúde bucal e utilização de serviços odontológicos entre adolescentes. Cad. Saúde Pública. 2009; 25(3): 655-67. http://dx.doi.org/10.1590/S0102-311X2009000300020
https://doi.org/10.1590/S0102-311X200900...
]. Low socioeconomic status over youth’s life is presented as a risk factor for lack of dental care in a prospective study in Sobral (CE) [2525 Teixeira AKM, Roncalli AG, Noro LRA. Iniquidades na assistência odontológica ao longo do curso de vida de jovens: um estudo de coorte. Ciênc Saúde Coletiva. 2018;23(1):249-258. http://dx.doi.org/10.1590/1413-81232018231.16012015
https://doi.org/10.1590/1413-81232018231...
].

In the group “use of dental services and health-related behaviors”, the chances of periodontal involvement were higher among adolescents who had never been to the dentist, which is in line with the findings of a study conducted in São Paulo [1111 Antunes JLF, Peres MA, Frias AC, Crosato EM, Biazeviz MGH. Saúde gengival de adolescentes e a utilização de serviços odontológicos, Estado de São Paulo. Rev Saúde Pública. 2008;42(2):191-9. http://dx.doi.org/10.1590/S0034-89102008000200002
https://doi.org/10.1590/S0034-8910200800...
]. The presence of mild periodontal disease among Cuban adolescents was related to lack of oral hygiene [2626 NavarroNapóles J. Enfermedad periodontal en adolescentes. Rev Med Electrón. 2017;39(1):15-23.]. Lower prevalence of gingivitis was observed among Indian adolescents who reported regular tooth brushing and visits to the dentist [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
]. It is possible that adolescents who have using dental services at least once in life are more likely to have access to maintenance, prevention and early treatment procedures. The effect of maintaining good oral hygiene on the periodontium has been well-documented [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
]. A previous study found that individuals who did not receive oral health information in adolescence and consulted the dentist for more than one year during the youth showed a higher number of teeth without dental care [2525 Teixeira AKM, Roncalli AG, Noro LRA. Iniquidades na assistência odontológica ao longo do curso de vida de jovens: um estudo de coorte. Ciênc Saúde Coletiva. 2018;23(1):249-258. http://dx.doi.org/10.1590/1413-81232018231.16012015
https://doi.org/10.1590/1413-81232018231...
].

The odds of periodontal changes were also higher among adolescents who used public or philanthropic services. It is also believed that private service users have greater purchasing power to buy oral hygiene products such as dental floss, which has been identified as a protective factor for periodontal conditions among young adults [55 Rodrigues TQ, Silva RVC, Ribeiro FS, Pontes AEF. Conhecimento sobre saúde periodontal dos pacientes submetidos à triagem nos postos de saúde de Barretos. Periodontia. 2014; 24(2):19-23.]. Adolescents from Ceará who used the private service throughout their life were more likely to receive immediate dental care [2525 Teixeira AKM, Roncalli AG, Noro LRA. Iniquidades na assistência odontológica ao longo do curso de vida de jovens: um estudo de coorte. Ciênc Saúde Coletiva. 2018;23(1):249-258. http://dx.doi.org/10.1590/1413-81232018231.16012015
https://doi.org/10.1590/1413-81232018231...
].

The negative effect of cigarette smoking on the periodontal condition has also been observed, as already evidenced in other studies with populations of different age groups [66 Whelton H, Crowley E, O’Mullane D. Oral health of irish adults 2000-2002. Dublin: Department of Health and Children; 2007.,1515 Shereef M, Sanara PP, Karuppanan S, Noorudeen AM, Joseph K. The effect of cigarette smoking on the severity of periodontal diseases among adults of Kothamangalam Town, Kerala. J Pharm Bioallied Sci. 2015;7(Suppl 2):S648-51. http://dx.doi.org/10.4103/0975-7406.163588
https://doi.org/10.4103/0975-7406.163588...
,2727 Franca MSM, Gomes RCB, Lins RDAU, Santos PAV, Lima FJ. A influência do fumo sobre a condição periodontal. Stomatos. 2010;16(31):23-36.]. Smoking has been considered as one of the main risk factors involved in the prevalence, extent and severity of periodontal diseases and quitting smoking as a factor to maintain periodontal health [1313 Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health. 2015;15(Suppl 1):S6. http://dx.doi.org/10.1186/1472-6831-15-S1-S6
https://doi.org/10.1186/1472-6831-15-S1-...
,1515 Shereef M, Sanara PP, Karuppanan S, Noorudeen AM, Joseph K. The effect of cigarette smoking on the severity of periodontal diseases among adults of Kothamangalam Town, Kerala. J Pharm Bioallied Sci. 2015;7(Suppl 2):S648-51. http://dx.doi.org/10.4103/0975-7406.163588
https://doi.org/10.4103/0975-7406.163588...
]. A study conducted in Japan has shown that both active and passive smoking can have harmful effects on men’s periodontal health, which demands that people be made aware of the negative effects of smoking, not only on their own health, but also on other individuals’ health [2828 Ueno M, Ohara S, Sawada N, Inoue M, Tsugane S, Kawaguchi Y. The association of active and secondhand smoking with oral health in adults: Japan public health center-based study. Tobacco Induced Diseases. 2015;13:19. http://dx.doi.org/10.1186/s12971-015-0047-6
https://doi.org/10.1186/s12971-015-0047-...
].

Similarly, a significant association between periodontal change and alcohol consumption has also been identified. A study carried out with adults in Southern Brazil has shown that individuals who consume more alcohol are more likely to have periodontitis. Furthermore, alcohol consumption affects men’s and women’s periodontal health differently [1616 Susin C, Wagner MC, Haas AN, Oppermann RV, Albandar JM. The association between alcohol consumption and periodontitis in southern Brazilian adults. J Periodontal Res. 2015;50(5):622-8. http://dx.doi.org/10.1111/jre.12242
https://doi.org/10.1111/jre.12242...
].

There was an association between periodontal condition and self-perception of oral health, being the prevalence of unfavorable periodontal condition (CPI>0) higher among those who evaluated their oral health negatively. This finding could be partly explained by the presence of signs and symptoms of periodontal changes such as halitosis and bleeding, which can cause discomfort with consequent negative impact on the individuals’ perception of their own oral health. This fact reinforces the idea that epidemiological surveys in oral health should include, in addition to the normative aspects, subjective questions of oral health in order to gain a comprehensive view of the individuals’ real needs, which has also been highlighted in a previous study [1313 Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health. 2015;15(Suppl 1):S6. http://dx.doi.org/10.1186/1472-6831-15-S1-S6
https://doi.org/10.1186/1472-6831-15-S1-...
].

It can be realized from this study that, the efforts towards prevention, detection and treatment of periodontal changes in adolescents, besides requiring an in-depth knowledge of periodontics, calls for a wider understanding of oral health taking into account the associated factors and the behavioral changes needed in this population [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
,1313 Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health. 2015;15(Suppl 1):S6. http://dx.doi.org/10.1186/1472-6831-15-S1-S6
https://doi.org/10.1186/1472-6831-15-S1-...
]. Therefore, it is crucial to invest in health promotion and prevention actions, considering the impact of periodontal disease on quality of life [2929 Lopes MWF, Gusmão ES, Alves RV, Cimões R. Impacto das doenças periodontais na qualidade de vida. RGO, Rev Gaúch Odontol. 2011;59(Suppl 1):39-44.], with emphasis on oral health education for adolescents, held mainly by schools as well as within the scope of the Primary Health Care, in view of their close proximity to this population, so as to empower them to play an active role in their own health care [22 Nanaiah KP, Nagarathna DV, Manjunath N. Prevalence of periodontitis among the adolescents aged 15-18 years in Mangalore City: An epidemiological and microbiological study. J Indian Soc Periodontol. 2013;17(6):784-9. http://dx.doi.org/10.4103/0972-124X.124507
https://doi.org/10.4103/0972-124X.124507...
,1313 Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health. 2015;15(Suppl 1):S6. http://dx.doi.org/10.1186/1472-6831-15-S1-S6
https://doi.org/10.1186/1472-6831-15-S1-...
,1414 Leite LO, Fonseca EP, Ferreira EF, Vargas AMD, Palmier AC, Abreu MHNG. Condição gengival de adolescentes residentes no Vale do Jequitinhonha, Minas Gerais. Arq Odontol. 2013;49(2):75-81. http://dx.doi.org/10.7308/aodontol/2013.49.2.04
https://doi.org/10.7308/aodontol/2013.49...
].

The use of the Community Periodontal Index (CPI) to assess the presence of periodontal changes should be considered as a limitation in the present study. The hierarchical record of periodontal conditions (bleeding, calculus and periodontal pocket) in populations with low prevalence of periodontal pockets may underestimate the prevalence of gingival bleeding, since the record of dental calculus (CPI=2) does not allow concurrent identification of bleeding (CPI=1) in the same sextant, a fact that raises questions as to the use of the CPI. Nevertheless, the CPI was adopted in this study because it is regarded as an international index used in several epidemiological studies in oral health, and recommended by the WHO to study and compare the periodontal condition in different populations [66 Whelton H, Crowley E, O’Mullane D. Oral health of irish adults 2000-2002. Dublin: Department of Health and Children; 2007.,88 Brasil. Ministério da Saúde. Secretaria de atenção à saúde. Secretaria de vigilância em saúde. Departamento de atenção básica. Coordenação geral de saúde bucal. SB Brasil 2010 - Pesquisa nacional de saúde bucal: resultados principais. Brasília: Ministério da Saúde; 2011 [citado 2017 Nov 10]. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf>.
http://bvsms.saude.gov.br/bvs/publicacoe...
,1111 Antunes JLF, Peres MA, Frias AC, Crosato EM, Biazeviz MGH. Saúde gengival de adolescentes e a utilização de serviços odontológicos, Estado de São Paulo. Rev Saúde Pública. 2008;42(2):191-9. http://dx.doi.org/10.1590/S0034-89102008000200002
https://doi.org/10.1590/S0034-8910200800...
,1919 World Health Organization. Oral health surveys: basic methods. 4 ed. Geneva: World Health Organization; 1997.,2121 Idris FAI. Periodontal disease prevalence and some related factors among 15 years old school children in Khartoum State, Sudan. Sudanese J Public Health. 2010;5(4):187-92.].

The periodontal condition of the adolescents in this study showed the need to implement actions related to the prevention, detection and control of these alterations by dental surgeons in order to avoid their repercussions on oral health and the life of this population. This fact is essential, considering this phase of the life cycle, considering that the health behaviors can last through the adult life. Social, economic and cultural situations among adolescents should be considered when planning intervention measures. Inequalities in access and lack of equity in relation to dental care need to be minimized.

The development of educational actions based on active learning methodologies is necessary in order to produce the public’s knowledge about this condition and to promote reflection and encouragement for the development of healthy habits, especially the appropriate oral hygiene practices and the prevention of alcohol and tobacco consumption, important variables related to periodontal diseases.

It is important to establish acceptable oral health parameters from a regional perspective, taking into account local characteristics and peculiarities. The findings described here may help gain a deeper insight into the periodontal condition of this age group living in northern Minas Gerais.

CONCLUSION

About one-third of adolescents have periodontal changes, which were associated with the type of school and type of dental service they attend, smoking, alcohol consumption and self-perception of oral health. It is suggested to carry out prospective studies that evaluate the interaction of multiple factors involved in the alterations of the periodontal conditions throughout the life course of the individual.

Acknowledgements

We thank the Fundação de Amparo a Pesquisa do Estado de Minas Gerais (FAPEMIG) for the funding of this research.

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Publication Dates

  • Publication in this collection
    25 Apr 2019
  • Date of issue
    2019

History

  • Received
    30 May 2018
  • Reviewed
    20 Aug 2018
  • Accepted
    20 Sept 2018
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