Abstract
This study aimed to assess the association between underlying dentin shadows (UDS) and oral health-related quality of life (OHRQoL) among 15-19-year-old adolescents from southern Brazil. This population-based cross-sectional study included a representative sample of 1,197 15–19-year-old adolescents attending 31 public and private schools from Santa Maria, Brazil. The Oral Health Impact Profile-14 (OHIP-14) was used to evaluate the OHRQoL, and clinical examinations were performed by two calibrated examiners (intra/interexaminer kappa values for caries examination ≥ 0.80) to diagnose UDS (ICDAS code 4 caries lesions). Sociodemographic information and clinical characteristics (overall caries experience, traumatic dental injury, malocclusion, and gingivitis) were also collected as adjusting variables. Multilevel Poisson regression models were used to assess the association between UDS and OHRQoL. Rate ratios (RR) and 95% confidence intervals (CI) were estimated. The UDS prevalence was 8.8% (n = 106 adolescents). In the adjusted models, adolescents with UDS had poorer OHRQoL than those without UDS, and the strength of the association was dependent on the number of lesions per individual. Individuals with 1-2 UDS had a mean OHIP-14 score 8% higher (RR = 1.08; 95%CI: 1.01–1.17) than adolescents without UDS, while those with 3-4 UDS had a mean score 35% higher (RR = 1.35; 95%CI: 1.12–1.63). This negative association was related to physical disability, psychological disability, social disability, and handicap domains. This study showed that UDS was associated negatively with OHRQoL among 15–19-year-old adolescents from southern Brazil. The negative effect of UDS on OHRQoL emphasizes the importance of addressing issues regarding OHRQoL even in the posterior teeth of adolescents.
Dental Caries; Adolescent; Quality of Life; Cross-Sectional Study; Epidemiology
Introduction
The concept of health includes biopsychosocial models in which physical, emotional, and social well-being is interconnected.11. Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2(6):576-82. https://doi.org/10.1370/afm.245
https://doi.org/10.1370/afm.245...
Oral health strongly influences this process, given its bearing on the ability to speak, eat, and socialize.22. Petersen PE, Kjøller M, Christensen LB, Krustrup U. Changing dentate status of adults, use of dental health services, and achievement of national dental health goals in Denmark by the year 2000. J Public Health Dent. 2004;64(3):127-35. https://doi.org/10.1111/j.1752-7325.2004.tb02742.x
https://doi.org/10.1111/j.1752-7325.2004...
Poor oral health directly affects one’s oral health-related quality of life (OHRQoL), defined as a multidimensional construct that describes an individual’s subjective perspective, based on his/her oral symptoms and experiences.33. Sischo L, Broder HL. Oral health-related quality of life: what, why, how, and future implications. J Dent Res. 2011 Nov;90(11):1264-70. https://doi.org/10.1177/0022034511399918
https://doi.org/10.1177/0022034511399918...
Major challenges during adolescence involve achieving good oral health and improving the OHRQoL, since this stage of life represents a period of constant changes, adaptations to new environmental and psychological structures, and the construction of the adolescents’ identity.44. Xiang B, Wong HM, Perfecto AP, McGrath CP. The association of socio-economic status, dental anxiety, and behavioral and clinical variables with adolescents' oral health-related quality of life. Qual Life Res. 2020 Sep;29(9):2455-64. https://doi.org/10.1007/s11136-020-02504-7
https://doi.org/10.1007/s11136-020-02504...
Poor oral health behaviors in this age group make adolescence a high-risk period for the development of caries lesions.55. Warren JJ, Van Buren JM, Levy SM, Marshall TA, Cavanaugh JE, Curtis AM, et al. Dental caries clusters among adolescents. Community Dent Oral Epidemiol. 2017 Dec;45(6):538-44. https://doi.org/10.1111/cdoe.12317
https://doi.org/10.1111/cdoe.12317...
An estimated 2.3 billion people worldwide suffer from tooth decay in the permanent dentition.66. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 [published correction appears in Lancet. 2019 Jun 22;393(10190):e44]. Lancet. 2018 Nov;392(10159):1789-858. https://doi.org/10.1016/S0140-6736 (18)32279-7
https://doi.org/10.1016/S0140-6736 (18)3...
According to Brazil’s last national oral health survey, 35.8% of adolescents aged 15–19 years had decayed teeth.77. Ministério da Saúde (BR). Projeto SB Brasil 2010. Pesquisa Nacional de Saúde Bucal. Resultados Principais. Brasília, DF: Ministério da Saúde; 2012. Epidemiological studies have consistently found that caries is negatively associated with OHRQoL in adolescents.88. Bastos RS, Carvalho ES, Xavier A, Caldana ML, Bastos JR, Lauris JR. Dental caries related to quality of life in two Brazilian adolescent groups: a cross-sectional randomised study. Int Dent J. 2012 Jun;62(3):137-43. https://doi.org/10.1111/j.1875-595X.2011.00105.x
https://doi.org/10.1111/j.1875-595X.2011...
9. Pulache J, Abanto J, Oliveira LB, Bönecker M, Porras JC. Exploring the association between oral health problems and oral health-related quality of life in Peruvian 11- to 14-year-old children. Int J Paediatr Dent. 2016 Mar;26(2):81-90. https://doi.org/10.1111/ipd.12160
https://doi.org/10.1111/ipd.12160...
10. Aimée NR, van Wijk AJ, Maltz M, Varjão MM, Mestrinho HD, Carvalho JC. Dental caries, fluorosis, oral health determinants, and quality of life in adolescents. Clin Oral Investig. 2017 Jun;21(5):1811-20. https://doi.org/10.1007/s00784-016-1964-3
https://doi.org/10.1007/s00784-016-1964-...
11. Maia CV, Mendes FM, Normando D. The impact of oral health on quality of life of urban and riverine populations of the Amazon: A multilevel analysis. PLoS One. 2018 Nov;13(11):e0208096. https://doi.org/10.1371/journal.pone.0208096
https://doi.org/10.1371/journal.pone.020...
12. 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...
13. Cadenas de Llano-Pérula M, Ricse E, Fieuws S, Willems G, Orellana-Valvekens MF. Malocclusion, dental caries and oral health-related quality of life: a comparison between adolescent school children in urban and rural regions in Peru. Int J Environ Res Public Health. 2020 Mar;17(6):2038. https://doi.org/10.3390/ijerph17062038
https://doi.org/10.3390/ijerph17062038...
14. Paula JS, Zina LG, Jamieson L, Mialhe FL. The effect of caries increment on oral health-related quality of life among adolescents in Brazil: a 3-year longitudinal study. Braz Oral Res. 2020;34:e107. https://doi.org/10.1590/1807-3107bor-2020.vol34.0107
https://doi.org/10.1590/1807-3107bor-202...
-1515. Karki S, Horváth J, Laitala ML, Vástyán A, Nagy Á, Sándor GK, et al. Validating and assessing the oral health-related quality of life among Hungarian children with cleft lip and palate using Child-OIDP scale. Eur Arch Paediatr Dent. 2021 Feb;22(1):57-65. https://doi.org/10.1007/s40368-020-00525-x
https://doi.org/10.1007/s40368-020-00525...
The degree of impact of caries on OHRQoL is directly related to the number of affected teeth,1616. Biazevic MG, Rissotto RR, Michel-Crosato E, Mendes LA, Mendes MO. Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res. 2008;22(1):36-42. https://doi.org/10.1590/S1806-83242008000100007
https://doi.org/10.1590/S1806-8324200800...
,1717. Chukwumah NM, Folayan MO, Oziegbe EO, Umweni AA. Impact of dental caries and its treatment on the quality of life of 12- to 15-year-old adolescents in Benin, Nigeria. Int J Paediatr Dent. 2016 Jan;26(1):66-76. https://doi.org/10.1111/ipd.12162
https://doi.org/10.1111/ipd.12162...
lesion severity,1818. Pinheiro SA, Rodrigues HB, Santos JT, Granja GL, Lussi A, Leal SC, et al. Association of dental caries morbidity stages with oral health-related quality of life in children and adolescents. Int J Paediatr Dent. 2020 May;30(3):293-302. https://doi.org/10.1111/ipd.12605
https://doi.org/10.1111/ipd.12605...
intraoral distribution1919. Severo Alves L, Dam-Teixeira N, Susin C, Maltz M. Association among quality of life, dental caries treatment and intraoral distribution in 12-year-old South Brazilian schoolchildren. Community Dent Oral Epidemiol. 2013 Feb;41(1):22-9. https://doi.org/10.1111/j.1600-0528.2012.00707.x
https://doi.org/10.1111/j.1600-0528.2012...
and dental pain.2020. Barasuol JC, Santos PS, Moccelini BS, Magno MB, Bolan M, Martins–Júnior PA, et al. Association between dental pain and oral health–related quality of life in children and adolescents: a systematic review and meta–analysis. Community Dent Oral Epidemiol. 2020 Aug;48(4):257–63. https://doi.org/10.1111/cdoe.12535
https://doi.org/10.1111/cdoe.12535...
Not only cavitated caries lesions, but also moderate caries lesions, such as underlying dentin shadows (UDS), can have a potentially negative impact on OHRQoL. Classified as code 4 by the International Caries Detection and Assessment System (ICDAS),2121. Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007 Jun;35(3):170-8. https://doi.org/10.1111/j.1600-0528.2007.00347.x
https://doi.org/10.1111/j.1600-0528.2007...
UDS appear as a discolored dentin shadow visible through an apparently intact enamel surface, which may or may not show signs of localized breakdown. The darkened area is an intrinsic shadow that may appear gray, blue or brown, and may influence the self-perception of oral health, mainly among adolescents. Despite this assumption, no previous study has investigated this issue to date.
Although the prevalence of this lesion was recently found to be low in young populations,2222. Marquezan PK, Alves LS, Damé-Teixeira N, Maltz M, Zenkner JE. Prevalence and risk indicators for underlying dentin shadows among 12-year-old southern Brazilian schoolchildren. Braz Oral Res. 2021 Nov;35:e105. https://doi.org/10.1590/1807-3107bor-2021.vol35.0105
https://doi.org/10.1590/1807-3107bor-202...
,2323. Marquezan PK, Comim LD, Oliveira Racki DN, Nora ÂD, Alves LS, Amaral Zenkner JE. Prevalence, extent, risk indicators, and intraoral distribution of underlying dentin shadows (ICDAS 4) among 15-19-year-old South Brazilian adolescents. J Conserv Dent. 2022;25(6):630-5. https://doi.org/10.4103/jcd.jcd_324_22
https://doi.org/10.4103/jcd.jcd_324_22...
its possible relationship with OHRQoL must be investigated. Therefore, the aim of this study was to assess the association between UDS in the occlusal surfaces of permanent posterior teeth and OHRQoL among 15–19-year-old adolescents from southern Brazil. The hypothesis was that adolescents who present UDS have poorer OHRQoL.
Methods
Study design and sample
A population-based cross-sectional study was carried out to assess the oral health status of adolescents aged 15–19 years old from Santa Maria, a mid-sized city located in southern Brazil. All the 37 high schools in the municipality were invited to participate in the study (26 public and 11 private), 31 of which agreed to participate (22 public and 9 private).
A total of 1,066 adolescents were found to be needed for the study. The sample size calculation used the following parameters: a prevalence rate of 50% (worst case scenario), a 95% confidence interval (CI), a power of 80%, and a precision level of 3%. Considering a non-participation rate of 50%, 1,600 adolescents were invited to participate.
Eligibility criteria
Adolescents born in the years 1999–2003, attending any school period (morning, afternoon, or night), and not using fixed orthodontic appliances were considered eligible. Students with special needs (cognitive or physical impairments that prevented them from answering the questionnaire, or from being clinically examined in the school setting) were not considered eligible for the study. A list of all eligible schoolchildren was compiled for each school, and those eligible were selected using a table of random numbers (http://www.random.org).
Data collection
Data collection was conducted from March to November 2018, and included questionnaires and a clinical examination. A self-administered questionnaire was used to gather information on sociodemographic characteristics (sex, age, skin color, mother’s level of education, and socioeconomic status). It was sent to the parents/legal guardians of the selected students to be completed at home.
The Oral Health Impact Profile-14 (OHIP-14) was used to evaluate the OHRQoL. This questionnaire is an instrument that measures people’s perception of the social impact of oral disorders on their well-being.2424. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol. 1997 Aug;25(4):284-90. https://doi.org/10.1111/j.1600-0528.1997.tb00941.x
https://doi.org/10.1111/j.1600-0528.1997...
The OHIP-14 was translated into Brazilian Portuguese and validated for the language.2525. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol. 2005 Aug;33(4):307-14. https://doi.org/10.1111/j.1600-0528.2005.00225.x
https://doi.org/10.1111/j.1600-0528.2005...
It is the short version of a longer instrument, and is composed of 14 questions related to seven conceptually formulated dimensions: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. The answers to each question are based on a Likert scale grade: never = 0 point, rarely = 1 point, sometimes = 2 points, often = 3 points, and always = 4 points. The sum of the answers provides a score ranging from 0 to 56 points – the higher the score, the poorer the OHRQoL.2424. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol. 1997 Aug;25(4):284-90. https://doi.org/10.1111/j.1600-0528.1997.tb00941.x
https://doi.org/10.1111/j.1600-0528.1997...
25. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol. 2005 Aug;33(4):307-14. https://doi.org/10.1111/j.1600-0528.2005.00225.x
https://doi.org/10.1111/j.1600-0528.2005...
-2626. Baker SR. Testing a conceptual model of oral health: a structural equation modeling approach. J Dent Res. 2007 Aug;86(8):708-12. https://doi.org/10.1177/154405910708600804
https://doi.org/10.1177/1544059107086008...
The OHIP-14 was applied to the selected adolescents in the school setting, just before the clinical oral examination.
Clinical examinations were conducted at the schools, with the students in a supine position, using portable equipment (artifical light and air compressor). A sterile clinical mirror and a periodontal probe were also used. The teeth were cleaned with a toothbrush and dried prior to caries examination. Cotton rolls were used to ensure proper moisture control, and dental caries was recorded by two calibrated examiners. Caries examination included the recording of both non-cavitated and cavitated lesions, as well as caries activity assessment.2727. Maltz M, Barbachan e Silva B, Carvalho DQ, Volkweis A. Results after two years of non-operative treatment of occlusal surface in children with high caries prevalence. Braz Dent J. 2003;14(1):48-54. https://doi.org/10.1590/S0103-64402003000100009
https://doi.org/10.1590/S0103-6440200300...
In addition, the presence of UDS was also recorded, as defined by the ICDAS.2121. Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007 Jun;35(3):170-8. https://doi.org/10.1111/j.1600-0528.2007.00347.x
https://doi.org/10.1111/j.1600-0528.2007...
In addition, traumatic dental injuries (TDI) were assessed by using the O’Brien classification,2828. O'Brien M. Children's dental health in the United Kingdom. London: Her Majesty's Station Off; 1994. gingivitis, by using the gingival bleeding index (GBI),2929. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J. 1975 Dec;25(4):229-35. and malocclusion, according to the dental aesthetic index (DAI).3030. World Health Organization. Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization; 1997.
Training and calibration
Clinical examination was performed by two calibrated examiners (DNOR, ADN). Training sessions using photographs, study models, and clinical exams were performed under the supervision of a benchmark examiner. The examiners’ calibration was assessed in 10 adolescents before the start of the study, and its continued validity during the survey was checked by repeated examinations of 20 schoolchildren out of every 400 examined (totaling 5% of the sample). The minimal time interval between examinations was 7 days. The minimal value of the intraexaminer kappa coefficient was 0.81 for dental caries and 0.89 for TDI, while the minimal interexaminer kappa value was 0.80 for dental caries and 0.77 for TDI. The minimal intraclass correlation coefficient for DAI measures was 0.89 (intraexaminer) and 0.87 (interexaminer). As for the GBI, training was performed under the supervision of an experienced periodontist, but no calibration was performed due to the temporary nature of the condition.
Ethical aspects
The Research Ethics Committee of the Federal University of Santa Maria approved the study protocol (# 2.178.299). All participants (≥ 18 years old) or their parents/legal guardians signed a written informed consent form. Underage participants signed a written assent form. The students received a report of their oral health status, and were referred to dental treatment when needed.
Data analysis
The outcome of this study was OHRQoL, measured as the overall and domain-specific OHIP-14 scores. The main predictor variable was the extent of UDS, defined as the number of permanent posterior teeth with occlusal UDS per individual (0, 1–2 or 3–4).
Sociodemographic adjusting variables included sex (male or female), age (15, 16, 17 or 18–19 years), skin color (non-white or white), and socioeconomic status (SES). The SES categories were defined by using the cutoff points proposed by the standard Brazilian economic classification,3131. Associação Brasileira de Estudos Populacionais. Critério de classificação econômica brasileira. São Paulo: Associação Brasileira de Estudos Populacionais; 2015. and households were classified as having a low (≤ 16), mid-low (≥ 17 to ≤ 22), mid-high (≥ 23 to ≤ 28) or high (≥ 29 point) SES. Clinical adjusting variables were malocclusion (absent [DAI ≤ 25], or present [DAI > 25]),3232. Jenny J, Cons NC. Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale. Aust Dent J. 1996 Feb;41(1):43-6. https://doi.org/10.1111/j.1834-7819.1996.tb05654.x
https://doi.org/10.1111/j.1834-7819.1996...
dental caries experience at the cavity level (absent [DMFT = 0], or present [DMFT ≥ 1]),3030. World Health Organization. Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization; 1997. and gingivitis (absent [<10% of sites with bleeding on probing], or present [≥ 10% of sites with bleeding on probing]).3333. Trombelli L, Farina R, Silva CO, Tatakis DN. Plaque-induced gingivitis: case definition and diagnostic considerations. J Clin Periodontol. 2018 Jun;45(S20 Suppl 20):S44-67. https://doi.org/10.1111/jcpe.12939
https://doi.org/10.1111/jcpe.12939...
Figure presents all the variables included in the study.
Variables included in the study (DAI, Dental Aesthetic Index; DMFT, Decayed, Missing or Filled Teeth Index).
Data analysis was performed using STATA software (Stata 11.1 for Windows; Stata Corporation, College Station, USA), which used survey commands that performed all the descriptive analyses according to the survey design. A weight variable was used to adjust for potential bias in the population estimates, based on the probability of selection and population distribution according to sex and school type. The overall and the domain-specific OHIP-14 mean scores and standard errors (SE) were reported. Preliminary analysis comparing the mean OHIP-14 scores among the categories of the predictors was done using the Wald test.
The association between UDS (main predictor variable) and OHRQoL was assessed using multilevel Poisson regression models. The multilevel model considered the adolescent as the first-level unit, and the school as the second-level unit. The multilevel model used the scheme of fixed effect with random intercept. Unadjusted and adjusted rate ratios (RR) and 95% confidence intervals (CI) were estimated. All the variables were included and maintained in the adjusted model, irrespective of their p-values. The level of significance was set at 5%.
Results
A representative sample of 1,197 out of the 1,656 15–19-year-old adolescents was included in the study, thus representing a response rate of 72.3%. A total of 106 adolescents presented at least one occlusal UDS in a permanent posterior tooth, corresponding to 8.8% (95%CI: 0.65–0.13) of the sample. The mean OHIP–14 score was 8.25 (95%CI: 7.75–8.75), ranging from 0 to 49. Table 1 summarizes the distribution of the sample and the OHIP–14 scores, according to sociodemographics and clinical characteristics. OHIP–14 scores differed significantly among the categories of all the variables studied, except for gingivitis, TDI, and UDS.
The association between UDS and the overall and domain–specific OHIP–14 scores is shown in Table 2. In the unadjusted models, the presence of 1–2 UDS lesions was significantly associated with social disability, while the presence of 3–4 UDS lesions was significantly associated with psychological disability and handicap. The adjusted models, including sociodemographic and clinical variables, showed that adolescents with 1–2 UDS had a poorer OHRQoL than adolescents without UDS in the social disability domain (RR = 1.30; 95%CI: 1.02–1.64). In comparison, adolescents with 3–4 UDS lesions had a poorer OHRQoL for the physical disability (RR = 1.74; 95%CI: 1.04–2.91), psychological disability (RR = 1.72; 95%CI: 1.13–2.64), social disability (RR =1 .82, 95%CI: 1.00–3.30) and handicap domains (RR = 2.32, 95%CI: 1.24–4.34). Overall, adolescents with 1–2 UDS had an OHIP–14 score 8% higher than individuals without UDS (RR = 1.08; 95%CI: 1.01–1.17), and those with 3–4 UDS presented a more notable difference, with 35% higher mean scores than adolescents without UDS (RR = 1.35; 95%CI: 1.12–1.63). As for the other variables included in the adjusted models, all of them were significantly associated with the overall OHIP–14 score (p < 0.05).
Discussion
This study assessed the association between UDS and OHRQoL among 15–19–year–old adolescents from southern Brazil. Our main finding was that individuals with UDS had poorer OHRQoL than those without UDS, even after adjusting for important cofactors, thus confirming the study hypothesis. To the best of our knowledge, this was the first study to assess this association.
Quality of life indicators related to oral health are fundamental for understanding and measuring the physical and psychological influence of oral diseases in aggravating individual lives, particularly, joy of living, possibility of speaking, chewing capacity, social inclusion,2020. Barasuol JC, Santos PS, Moccelini BS, Magno MB, Bolan M, Martins–Júnior PA, et al. Association between dental pain and oral health–related quality of life in children and adolescents: a systematic review and meta–analysis. Community Dent Oral Epidemiol. 2020 Aug;48(4):257–63. https://doi.org/10.1111/cdoe.12535
https://doi.org/10.1111/cdoe.12535...
and, more recently, happiness.3535. Tuchtenhagen S, Ortiz FR, Ardenghi TM, Antunes JL. Oral health and happiness in adolescents: A cohort study. Community Dent Oral Epidemiol. 2021 Apr;49(2):176-85. https://doi.org/10.1111/cdoe.12589
https://doi.org/10.1111/cdoe.12589...
In the present study, we found that adolescents with UDS had higher OHIP–14 scores than those without UDS, and that the magnitude of the association was related to the number of affected teeth – the higher the number of UDS, the greater the negative association with OHRQoL. After adjusting for important sociodemographic factors and oral conditions, we found that adolescents with 1–2 UDS had 8% higher overall OHIP–14 scores, while those with 3–4 UDS had 35% higher scores. Since it is not uncommon for many adolescents to feel embarrassed to admit issues regarding their appearance,3636. Colussi PR, Hugo FN, Muniz FW, Rösing CK. Oral Health-Related Quality of Life and Associated Factors in Brazilian Adolescents. Braz Dent J. 2017;28(1):113-20. https://doi.org/10.1590/0103-6440201701098
https://doi.org/10.1590/0103-64402017010...
this is a plausible finding. The clinical aspect of these lesions, in black, blue or gray shadows, may make adolescents feel frustrated or worried about their teeth. This concern regarding aesthetics/appearance may explain the association between UDS and both the psychological disability and social disability domains, even considering that molars are the most commonly affected teeth.2323. Marquezan PK, Comim LD, Oliveira Racki DN, Nora ÂD, Alves LS, Amaral Zenkner JE. Prevalence, extent, risk indicators, and intraoral distribution of underlying dentin shadows (ICDAS 4) among 15-19-year-old South Brazilian adolescents. J Conserv Dent. 2022;25(6):630-5. https://doi.org/10.4103/jcd.jcd_324_22
https://doi.org/10.4103/jcd.jcd_324_22...
Adolescents with 3–4 UDS had approximately 72% higher OHIP–14 scores in the psychological disability domain than their counterparts without UDS, thus indicating that they were more likely to have difficulty relaxing, or to feel embarrassed because of tooth–related problems. As for the social disability domain, a significant gradient was observed, namely that adolescents with 1–2 UDS and those with 3–4 UDS presented 30% and 82% higher scores, respectively, than those without UDS. This means that these individuals with UDS, versus those without it, were more commonly irritated by other people, or had more difficulty performing their usual activities because of teeth–related problems. It can be speculated that even the association with the handicap domain might be related to aesthetic issues, since it involves a feeling of being less satisfied with life due to oral problems.
Although we are dealing with UDS in posterior teeth, aesthetic–related demands for restorative procedures in posterior teeth are routine in clinical practice. This clearly indicates that aesthetics in the posterior segment is a concern for some individuals. Replacement of amalgam by tooth–colored restorations for aesthetic reasons have been reported in the literature.3737. Pouralibaba F, Joulaei M, Kashefimehr A, Pakdel F, Jamali Z, Esmaeili A. Clinical evaluation of reasons for replacement of amalgam restorations in patients referring to a dental school in iran. J Dent Res Dent Clin Dent Prospect. 2010;4(2):56-9. https://doi.org/10.5681/joddd.2010.015
https://doi.org/10.5681/joddd.2010.015...
,3838. Al-Asmar AA, Ha Sabrah A, Abd-Raheam IM, Ismail NH, Oweis YG. Clinical evaluation of reasons for replacement of amalgam vs composite posterior restorations. Saudi Dent J. 2023 Mar;35(3):275-81. https://doi.org/10.1016/j.sdentj.2023.02.003
https://doi.org/10.1016/j.sdentj.2023.02...
Similarly, Spelid et al. showed that aesthetics were important to young Norwegian and Danish patients, even in scenarios dealing with restorations in posterior teeth.3939. Espelid I, Cairns J, Askildsen JE, Qvist V, Gaarden T, Tveit AB. Preferences over dental restorative materials among young patients and dental professionals. Eur J Oral Sci. 2006 Feb;114(1):15-21. https://doi.org/10.1111/j.1600-0722.2006.00282.x
https://doi.org/10.1111/j.1600-0722.2006...
Their study was designed to examine how dental professionals and young patients valued three attributes of dental restorations, namely expected longevity, appearance, and risk of adverse reaction. The authors showed that young patients were willing to sacrifice longevity much more than dentists, if it meant avoiding a highly visible restoration.3939. Espelid I, Cairns J, Askildsen JE, Qvist V, Gaarden T, Tveit AB. Preferences over dental restorative materials among young patients and dental professionals. Eur J Oral Sci. 2006 Feb;114(1):15-21. https://doi.org/10.1111/j.1600-0722.2006.00282.x
https://doi.org/10.1111/j.1600-0722.2006...
The increasing number of studies dealing with the aesthetic properties of composite resin restorations in molars is further evidence that aesthetics matters even in posterior teeth.4040. Miletic V, Marjanovic J, Veljovic DN, Stasic JN, Petrovic V. Color stability of bulk-fill and universal composite restorations with dissimilar dentin replacement materials. J Esthet Restor Dent. 2019 Sep;31(5):520-8. https://doi.org/10.1111/jerd.12529
https://doi.org/10.1111/jerd.12529...
In this sense, dental professionals should be aware that patients may seek treatment for UDS in posterior teeth because of aesthetics/appearance.
As previously suggested in the literature, most UDS may present either no radiolucency, or radiolucency at the enamel–dentin junction, with only a few cases showing an obvious spread to dentin.4343. Bertella N, Moura S, Alves LS, Damé-Teixeira N, Fontanella V, Maltz M. Clinical and radiographic diagnosis of underlying dark shadow from dentin (ICDAS 4) in permanent molars. Caries Res. 2013;47(5):429-32. https://doi.org/10.1159/000350924
https://doi.org/10.1159/000350924...
,4444. Marquezan PK, Alves LS, Dalla Nora A, Maltz M, Zenkner JEA. Radiographic pattern of underlying dentin lesions (ICDAS 4) in permanent teeth. Clin Oral Investig. 2019 Oct;23(10):3879-83. https://doi.org/10.1007/s00784-019-02818-y
https://doi.org/10.1007/s00784-019-02818...
Unfortunately, radiographs of the sample cannot be obtained because of the field conditions under which epidemiological studies are conducted. However, considering the lack of an association between the OHIP–14 scores and both the functional limitation and physical pain domains, it is likely that the UDS observed in this study were not deep caries lesions, as corroborated by the literature on this topic.4343. Bertella N, Moura S, Alves LS, Damé-Teixeira N, Fontanella V, Maltz M. Clinical and radiographic diagnosis of underlying dark shadow from dentin (ICDAS 4) in permanent molars. Caries Res. 2013;47(5):429-32. https://doi.org/10.1159/000350924
https://doi.org/10.1159/000350924...
,4444. Marquezan PK, Alves LS, Dalla Nora A, Maltz M, Zenkner JEA. Radiographic pattern of underlying dentin lesions (ICDAS 4) in permanent teeth. Clin Oral Investig. 2019 Oct;23(10):3879-83. https://doi.org/10.1007/s00784-019-02818-y
https://doi.org/10.1007/s00784-019-02818...
Considering that most UDS present no radiographically evident spread to dentin,4343. Bertella N, Moura S, Alves LS, Damé-Teixeira N, Fontanella V, Maltz M. Clinical and radiographic diagnosis of underlying dark shadow from dentin (ICDAS 4) in permanent molars. Caries Res. 2013;47(5):429-32. https://doi.org/10.1159/000350924
https://doi.org/10.1159/000350924...
,4444. Marquezan PK, Alves LS, Dalla Nora A, Maltz M, Zenkner JEA. Radiographic pattern of underlying dentin lesions (ICDAS 4) in permanent teeth. Clin Oral Investig. 2019 Oct;23(10):3879-83. https://doi.org/10.1007/s00784-019-02818-y
https://doi.org/10.1007/s00784-019-02818...
and that the progression rate is low, as recently shown by our research group,4545. Marquezan PK, Alves LS, Comim LD, Zenkner JE. Underlying dentin shadows (ICDAS 4) in occlusal surface of permanent teeth have low progression rate after 1-2 years. Caries Res. 2023;57(5-6):584-91. https://doi.org/10.1159/000533155
https://doi.org/10.1159/000533155...
the indication of operatory treatment should be avoided whenever possible to avert the repetitive restorative cycle, mainly among young patients. Sharing this knowledge with patients could make them less concerned about their oral health, and ultimately improve their quality of life.
Our study was composed of a representative sample of 1,197 adolescents attending public and private schools at an undetermined school period, unlike other studies, which included only public school attendees.2020. Barasuol JC, Santos PS, Moccelini BS, Magno MB, Bolan M, Martins–Júnior PA, et al. Association between dental pain and oral health–related quality of life in children and adolescents: a systematic review and meta–analysis. Community Dent Oral Epidemiol. 2020 Aug;48(4):257–63. https://doi.org/10.1111/cdoe.12535
https://doi.org/10.1111/cdoe.12535...
In addition, although previous studies showed the relationship between dental caries and OHRQoL,88. Bastos RS, Carvalho ES, Xavier A, Caldana ML, Bastos JR, Lauris JR. Dental caries related to quality of life in two Brazilian adolescent groups: a cross-sectional randomised study. Int Dent J. 2012 Jun;62(3):137-43. https://doi.org/10.1111/j.1875-595X.2011.00105.x
https://doi.org/10.1111/j.1875-595X.2011...
none specifically assessed UDS. Furthermore, we carried out a clinical examination protocol that included dental cleaning and drying, highly reproducible examiners, and a validated questionnaire to assess OHRQoL, thus providing methodological consistency and high internal validity. Another strength of this study was the statistical adjustment for a set of other variables that admittedly could explain the OHIP–14 scores. The lack of radiographic examination is a limitation of this study, as previously discussed. Knowledge of the radiographic presence/depth of the clinically detected UDS would help better understand the association between UDS and OHRQoL found in this study. It should also be borne in mind that this was a cross–sectional study, and that no causal relationship can be established. In conclusion, the present study showed that adolescents with UDS had poorer OHRQoL than those without UDS – the higher the number of lesions, the stronger the association.
Acknowledgments
We would like to acknowledge the support of the National Coordination of Post–graduate Education (Capes), the Brazilian Ministry of Education, and the Federal University of Santa Maria.
References
-
1Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2(6):576-82. https://doi.org/10.1370/afm.245
» https://doi.org/10.1370/afm.245 -
2Petersen PE, Kjøller M, Christensen LB, Krustrup U. Changing dentate status of adults, use of dental health services, and achievement of national dental health goals in Denmark by the year 2000. J Public Health Dent. 2004;64(3):127-35. https://doi.org/10.1111/j.1752-7325.2004.tb02742.x
» https://doi.org/10.1111/j.1752-7325.2004.tb02742.x -
3Sischo L, Broder HL. Oral health-related quality of life: what, why, how, and future implications. J Dent Res. 2011 Nov;90(11):1264-70. https://doi.org/10.1177/0022034511399918
» https://doi.org/10.1177/0022034511399918 -
4Xiang B, Wong HM, Perfecto AP, McGrath CP. The association of socio-economic status, dental anxiety, and behavioral and clinical variables with adolescents' oral health-related quality of life. Qual Life Res. 2020 Sep;29(9):2455-64. https://doi.org/10.1007/s11136-020-02504-7
» https://doi.org/10.1007/s11136-020-02504-7 -
5Warren JJ, Van Buren JM, Levy SM, Marshall TA, Cavanaugh JE, Curtis AM, et al. Dental caries clusters among adolescents. Community Dent Oral Epidemiol. 2017 Dec;45(6):538-44. https://doi.org/10.1111/cdoe.12317
» https://doi.org/10.1111/cdoe.12317 -
6James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 [published correction appears in Lancet. 2019 Jun 22;393(10190):e44]. Lancet. 2018 Nov;392(10159):1789-858. https://doi.org/10.1016/S0140-6736 (18)32279-7
» https://doi.org/10.1016/S0140-6736 (18)32279-7 -
7Ministério da Saúde (BR). Projeto SB Brasil 2010. Pesquisa Nacional de Saúde Bucal. Resultados Principais. Brasília, DF: Ministério da Saúde; 2012.
-
8Bastos RS, Carvalho ES, Xavier A, Caldana ML, Bastos JR, Lauris JR. Dental caries related to quality of life in two Brazilian adolescent groups: a cross-sectional randomised study. Int Dent J. 2012 Jun;62(3):137-43. https://doi.org/10.1111/j.1875-595X.2011.00105.x
» https://doi.org/10.1111/j.1875-595X.2011.00105.x -
9Pulache J, Abanto J, Oliveira LB, Bönecker M, Porras JC. Exploring the association between oral health problems and oral health-related quality of life in Peruvian 11- to 14-year-old children. Int J Paediatr Dent. 2016 Mar;26(2):81-90. https://doi.org/10.1111/ipd.12160
» https://doi.org/10.1111/ipd.12160 -
10Aimée NR, van Wijk AJ, Maltz M, Varjão MM, Mestrinho HD, Carvalho JC. Dental caries, fluorosis, oral health determinants, and quality of life in adolescents. Clin Oral Investig. 2017 Jun;21(5):1811-20. https://doi.org/10.1007/s00784-016-1964-3
» https://doi.org/10.1007/s00784-016-1964-3 -
11Maia CV, Mendes FM, Normando D. The impact of oral health on quality of life of urban and riverine populations of the Amazon: A multilevel analysis. PLoS One. 2018 Nov;13(11):e0208096. https://doi.org/10.1371/journal.pone.0208096
» https://doi.org/10.1371/journal.pone.0208096 -
12Sfreddo 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 -
13Cadenas de Llano-Pérula M, Ricse E, Fieuws S, Willems G, Orellana-Valvekens MF. Malocclusion, dental caries and oral health-related quality of life: a comparison between adolescent school children in urban and rural regions in Peru. Int J Environ Res Public Health. 2020 Mar;17(6):2038. https://doi.org/10.3390/ijerph17062038
» https://doi.org/10.3390/ijerph17062038 -
14Paula JS, Zina LG, Jamieson L, Mialhe FL. The effect of caries increment on oral health-related quality of life among adolescents in Brazil: a 3-year longitudinal study. Braz Oral Res. 2020;34:e107. https://doi.org/10.1590/1807-3107bor-2020.vol34.0107
» https://doi.org/10.1590/1807-3107bor-2020.vol34.0107 -
15Karki S, Horváth J, Laitala ML, Vástyán A, Nagy Á, Sándor GK, et al. Validating and assessing the oral health-related quality of life among Hungarian children with cleft lip and palate using Child-OIDP scale. Eur Arch Paediatr Dent. 2021 Feb;22(1):57-65. https://doi.org/10.1007/s40368-020-00525-x
» https://doi.org/10.1007/s40368-020-00525-x -
16Biazevic MG, Rissotto RR, Michel-Crosato E, Mendes LA, Mendes MO. Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res. 2008;22(1):36-42. https://doi.org/10.1590/S1806-83242008000100007
» https://doi.org/10.1590/S1806-83242008000100007 -
17Chukwumah NM, Folayan MO, Oziegbe EO, Umweni AA. Impact of dental caries and its treatment on the quality of life of 12- to 15-year-old adolescents in Benin, Nigeria. Int J Paediatr Dent. 2016 Jan;26(1):66-76. https://doi.org/10.1111/ipd.12162
» https://doi.org/10.1111/ipd.12162 -
18Pinheiro SA, Rodrigues HB, Santos JT, Granja GL, Lussi A, Leal SC, et al. Association of dental caries morbidity stages with oral health-related quality of life in children and adolescents. Int J Paediatr Dent. 2020 May;30(3):293-302. https://doi.org/10.1111/ipd.12605
» https://doi.org/10.1111/ipd.12605 -
19Severo Alves L, Dam-Teixeira N, Susin C, Maltz M. Association among quality of life, dental caries treatment and intraoral distribution in 12-year-old South Brazilian schoolchildren. Community Dent Oral Epidemiol. 2013 Feb;41(1):22-9. https://doi.org/10.1111/j.1600-0528.2012.00707.x
» https://doi.org/10.1111/j.1600-0528.2012.00707.x -
20Barasuol JC, Santos PS, Moccelini BS, Magno MB, Bolan M, Martins–Júnior PA, et al. Association between dental pain and oral health–related quality of life in children and adolescents: a systematic review and meta–analysis. Community Dent Oral Epidemiol. 2020 Aug;48(4):257–63. https://doi.org/10.1111/cdoe.12535
» https://doi.org/10.1111/cdoe.12535 -
21Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007 Jun;35(3):170-8. https://doi.org/10.1111/j.1600-0528.2007.00347.x
» https://doi.org/10.1111/j.1600-0528.2007.00347.x -
22Marquezan PK, Alves LS, Damé-Teixeira N, Maltz M, Zenkner JE. Prevalence and risk indicators for underlying dentin shadows among 12-year-old southern Brazilian schoolchildren. Braz Oral Res. 2021 Nov;35:e105. https://doi.org/10.1590/1807-3107bor-2021.vol35.0105
» https://doi.org/10.1590/1807-3107bor-2021.vol35.0105 -
23Marquezan PK, Comim LD, Oliveira Racki DN, Nora ÂD, Alves LS, Amaral Zenkner JE. Prevalence, extent, risk indicators, and intraoral distribution of underlying dentin shadows (ICDAS 4) among 15-19-year-old South Brazilian adolescents. J Conserv Dent. 2022;25(6):630-5. https://doi.org/10.4103/jcd.jcd_324_22
» https://doi.org/10.4103/jcd.jcd_324_22 -
24Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol. 1997 Aug;25(4):284-90. https://doi.org/10.1111/j.1600-0528.1997.tb00941.x
» https://doi.org/10.1111/j.1600-0528.1997.tb00941.x -
25Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol. 2005 Aug;33(4):307-14. https://doi.org/10.1111/j.1600-0528.2005.00225.x
» https://doi.org/10.1111/j.1600-0528.2005.00225.x -
26Baker SR. Testing a conceptual model of oral health: a structural equation modeling approach. J Dent Res. 2007 Aug;86(8):708-12. https://doi.org/10.1177/154405910708600804
» https://doi.org/10.1177/154405910708600804 -
27Maltz M, Barbachan e Silva B, Carvalho DQ, Volkweis A. Results after two years of non-operative treatment of occlusal surface in children with high caries prevalence. Braz Dent J. 2003;14(1):48-54. https://doi.org/10.1590/S0103-64402003000100009
» https://doi.org/10.1590/S0103-64402003000100009 -
28O'Brien M. Children's dental health in the United Kingdom. London: Her Majesty's Station Off; 1994.
-
29Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J. 1975 Dec;25(4):229-35.
-
30World Health Organization. Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization; 1997.
-
31Associação Brasileira de Estudos Populacionais. Critério de classificação econômica brasileira. São Paulo: Associação Brasileira de Estudos Populacionais; 2015.
-
32Jenny J, Cons NC. Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale. Aust Dent J. 1996 Feb;41(1):43-6. https://doi.org/10.1111/j.1834-7819.1996.tb05654.x
» https://doi.org/10.1111/j.1834-7819.1996.tb05654.x -
33Trombelli L, Farina R, Silva CO, Tatakis DN. Plaque-induced gingivitis: case definition and diagnostic considerations. J Clin Periodontol. 2018 Jun;45(S20 Suppl 20):S44-67. https://doi.org/10.1111/jcpe.12939
» https://doi.org/10.1111/jcpe.12939 -
34Sheiham A. Oral health, general health and quality of life. Bull World Health Organ. 2005 Sep;83(9):644.
-
35Tuchtenhagen S, Ortiz FR, Ardenghi TM, Antunes JL. Oral health and happiness in adolescents: A cohort study. Community Dent Oral Epidemiol. 2021 Apr;49(2):176-85. https://doi.org/10.1111/cdoe.12589
» https://doi.org/10.1111/cdoe.12589 -
36Colussi PR, Hugo FN, Muniz FW, Rösing CK. Oral Health-Related Quality of Life and Associated Factors in Brazilian Adolescents. Braz Dent J. 2017;28(1):113-20. https://doi.org/10.1590/0103-6440201701098
» https://doi.org/10.1590/0103-6440201701098 -
37Pouralibaba F, Joulaei M, Kashefimehr A, Pakdel F, Jamali Z, Esmaeili A. Clinical evaluation of reasons for replacement of amalgam restorations in patients referring to a dental school in iran. J Dent Res Dent Clin Dent Prospect. 2010;4(2):56-9. https://doi.org/10.5681/joddd.2010.015
» https://doi.org/10.5681/joddd.2010.015 -
38Al-Asmar AA, Ha Sabrah A, Abd-Raheam IM, Ismail NH, Oweis YG. Clinical evaluation of reasons for replacement of amalgam vs composite posterior restorations. Saudi Dent J. 2023 Mar;35(3):275-81. https://doi.org/10.1016/j.sdentj.2023.02.003
» https://doi.org/10.1016/j.sdentj.2023.02.003 -
39Espelid I, Cairns J, Askildsen JE, Qvist V, Gaarden T, Tveit AB. Preferences over dental restorative materials among young patients and dental professionals. Eur J Oral Sci. 2006 Feb;114(1):15-21. https://doi.org/10.1111/j.1600-0722.2006.00282.x
» https://doi.org/10.1111/j.1600-0722.2006.00282.x -
40Miletic V, Marjanovic J, Veljovic DN, Stasic JN, Petrovic V. Color stability of bulk-fill and universal composite restorations with dissimilar dentin replacement materials. J Esthet Restor Dent. 2019 Sep;31(5):520-8. https://doi.org/10.1111/jerd.12529
» https://doi.org/10.1111/jerd.12529 -
41Batista GR, Borges AB, Zanatta RF, Pucci CR, Torres CR. Esthetical properties of single-shade and multishade composites in posterior teeth. Int J Dent. 2023 Sep;2023:7783321. https://doi.org/10.1155/2023/7783321
» https://doi.org/10.1155/2023/7783321 -
42Mahrous AI, Salama AA, Shabaan AA, Abdou A, Radwan MM. Color stability of two different resin matrix ceramics: randomized clinical trial. BMC Oral Health. 2023 Sep;23(1):665. https://doi.org/10.1186/s12903-023-03364-6
» https://doi.org/10.1186/s12903-023-03364-6 -
43Bertella N, Moura S, Alves LS, Damé-Teixeira N, Fontanella V, Maltz M. Clinical and radiographic diagnosis of underlying dark shadow from dentin (ICDAS 4) in permanent molars. Caries Res. 2013;47(5):429-32. https://doi.org/10.1159/000350924
» https://doi.org/10.1159/000350924 -
44Marquezan PK, Alves LS, Dalla Nora A, Maltz M, Zenkner JEA. Radiographic pattern of underlying dentin lesions (ICDAS 4) in permanent teeth. Clin Oral Investig. 2019 Oct;23(10):3879-83. https://doi.org/10.1007/s00784-019-02818-y
» https://doi.org/10.1007/s00784-019-02818-y -
45Marquezan PK, Alves LS, Comim LD, Zenkner JE. Underlying dentin shadows (ICDAS 4) in occlusal surface of permanent teeth have low progression rate after 1-2 years. Caries Res. 2023;57(5-6):584-91. https://doi.org/10.1159/000533155
» https://doi.org/10.1159/000533155
Publication Dates
-
Publication in this collection
24 June 2024 -
Date of issue
2024
History
-
Received
25 July 2023 -
Accepted
27 Nov 2023 -
Reviewed
16 Feb 2024