Association between dental pain and absenteeism among public workers from Southeastern Brazil *

BACKGROUND AND OBJECTIVES: Studies carried out worldwide have shown that the incidence of dental pain is one reason leading people to look for dental services and that it impairs quality of life. This study aimed at observing the prevalence of dental pain, pain-related absenteeism and possible associations with sociodemographic characteristics. METHODS: This was an analytical, observational and transversal study using a randomized sample of 312 public servants obtained from a universe of 994 employees of the City Hall of Marataízes, ES. A structured script with 27 items was used for data collection, which was carried out between May and June 2009, by three qualified servants. Chi-square and Fisher Exact tests were used to compare dental pain percentages and absenteeism to sociodemographic factors. RESULTS: The prevalence of dental pain among employees was 57.0%, with higher prevalence among those with socioeconomic condition C/D/E (OR= 1.560). From those reporting dental pain, 17.8% have missed work, with higher prevalence of those of socioeconomic condition C/D/E (OR= 3.816) and with incomplete high school (OR= 2.298). CONCLUSION: High dental pain prevalence was observed and enough to produce absenteeism, with higher frequency among workers of less favored economic classes and with lower education level.


INTRODUCTION
Epidemiological studies show that pain is the primary reason for looking for health services and is one of the major causes of human suffering, impairing quality of life (QL) and psychosocial and economic status 1 .Dental pain is one of the most common pains affecting humankind.It is responsible for a large number of work losses.Absences from work due to health problems reflect incapacity to perform labor activities 2 .Absenteeism caused by oral problems is poorly studied in Brazil.There are no updated data on the number of lost working days due to dental pain, in national, state and municipal lev- els.There is also no information about the burden brought by such absences, such as the psychosocial impact for workers.There are two types of absenteeism: type 1 is characterized by absence from work; type 2 is characterized by physical presence with individuals working with pain 3 .Dental problems may produce pain, discomfort and generate signs and symptoms, which go from decreased attention to work, to absence, in addition to social behaviors of isolation.This fact reaffirms the need for and the importance of dentists (D) participating in multidisciplinary teams 3 .The compartmentalization which sees the mouth separated from the body is outdated.It is impossible to talk about integral workers' health attention without inserting Dentistry actions, which should be carried out within Occupational Health Medical Control Programs (OHMCP) by duly qualified Ds to deal with the specificity of oral health and work relationship 5 .The proposal of legislative bill 422/2007 is based on this understanding and tries to contribute to close the existing gap, promoting the expansion of the number of actions aimed at preventing and assisting occupational diseases, with incorporation of Labor Dentistry actions.This is the only way for companies to comply with their social duty of promoting integral health assistance to their workers 6 .Oral problems may directly impact professional performance.Because labor health promotion programs have a limited number of specific actions for oral health, there is the need to implement an oral health promotion protocol within companies.The implementation of such program would avoid absenteeism and decrease in productivity.Workers' oral health teams should orient their actions to promote health 7 .This study aimed at measuring the frequency of dental pain in the last six months, and the possible occurrence of absenteeism caused by toothache and associations with sociodemographic variables of employees of the local government of Marataízes, ES.

METHODS
This is a transversal study with representative sample of local government workers of a resort to the South of the State, 200 km far from the capital.Parameters used for sample calculation were: expected prevalence of 35% -results found in studies carried out in the region -confidence level of 95%, error of 5% and n=994.Calculation has resulted in a sample of 260 employees plus 52 more individuals, considering a possible loss of up to 20%.The study has used a randomized sample of 312 employees.Those in maternal or medical leave were excluded from the study.Data were collected by means of a validated questionnaire with 27 items regarding sociodemographic characteristics, need for total or partial prosthesis, dentition status (presence or total absence of teeth), dental pain, absenteeism, and type of service used for treatment.Scripts were used as standardized interviews and were applied by three trained interviewers, non-participant public servants, assuring cultural, economic and social equivalence with respondents, between May and June 2009.Chi-square and Fisher Exact tests were used to check possible associations.Significance level was 5%.Odds Ratio (OR) and respective Confidence Intervals were calculated to check association power.Research was carried out according to ethical principles and was approved by the Research Ethics Committee, Federal University of Espirito Santo in March 24, 2009, protocol 023/09.All participants have signed the Free and Informed Consent Term.

RESULTS
Final sample was made up of 286 employees, above the original calculation (n=252).There has been predominance of females (64%), young individuals, 65% below 40 years of age, and 61.2% were married..
In our study, toothache was not associated to gender, being in agreement with other studies 16,17 .There are reports showing that males have higher chance of having dental pain 18,19 .
Classes C/D/E workers had 56% more chance of experiencing toothache as compared to those of more privileged classes.Extensive literature has shown a higher prevalence of tooth decay and its consequences in more destituted classes.Worst indices worldwide are found in regions of social deprivation.Social status is the fundamental cause of the disease, because it mediates the access to society resources and this determines the access to all points of the causal chain of the health/disease process 20 .Most studies on oral health social determinants associate social class, socioeconomic class, income and education level to oral health conditions 21 .
Our study has not found statistically significant difference in family income and the prevalence of dental pain, being in disagreement with studies showing that low income families were more susceptible to dental pain 12,17,18,22,23 .A possible explanation to this finding is that, in our study, Brazilian salary inequality was not reproduced, having salary proximity at the cutoff point for the analysis of the variable.Absenteeism due to dental pain in our study was 17.8%, very close to results found in Espírito Santo and Brazil 15,19 .This study has shown that 20.0% of employees with toothache have reported loss of productivity during their labor activities due to poor attention or mistakes when carrying out tasks.This is important not only due to decreased productivity, but also to the increased risk of labor accidents.Gemeli 24 has investigated labor accidents and has found that in 11.0% of cases, respondents have reported dental pain on the day of the accident suggesting possible interference of dental pain on workers' attention and concentration.Brazil is a champion in labor accident statistics.It is always important to remind that such statistics reflect accidents recorded by Social Security.It estimated that in Brazil there is still a high rate of underreporting of accidents 25 .
Our study has observed that 39.9% of participants with dental pain have looked for dental services.Most widely used type of service was public service (47.7%), followed by private service (40%).Since sample is made up of municipal employees, this could, in a way, have motivated the use of public oral health services.But even with large part (46%) reporting family income of up to two minimum wages, a large percentage has used the private system.Studies are needed to understand oral health values and beliefs and the existence of barriers which may affect the use of public services.Studies are also needed to understand the fact that 6.2% of workers have looked for a fake professional, although being employees of a local government of the Southeastern Region where dental services are available and which, according to the Brazilian Constitution 26 , should assure access to all citizens, especially in urgent cases 27 .The use of oral health services is determined by several variables with different prediction power 28 .Several studies have shown perception of need as the characteristic with highest explanation power for the search for dental assistance.Dental pain is not always enough to motivate a visit to the dental service 29 .From workers reporting toothache in the last six months and not having looked for oral health services, 46.9% have not perceived the need and 12.0% failed to do it due to lack of money, which may suggest a lack of third shift dental assistance in the public service or not having been waived for treatment.The high prevalence of pain and absenteeism found in this study justifies the implementation of actions, going from the creation of health public service third shift to the insertion of Ds in the company 8 .One cannot discard the possibility of self-medication, very popular and concerning procedure in Brazil for being inadequately and abusively done and, most of the times, with drugs subject to medical prescription 30 .Self-medication is also very popular in other countries.With poorly-structured health system, going to the pharmacy is the first option to solve a health-related problem.Simpler and more commonly used drugs, such as analgesics, are available in pharmacies and even in supermarkets, may be purchased without medical prescription and are the most widely used as self-medication 31,32 .
Our study has found that employees with socioeconomic condition C/D/E had almost four times more chance of missing work due to dental pain, as compared to classes A/B.Mentioned Brazilian studies have not considered this variable; international studies use a different tool to classify subjects according to social status, thus making comparisons difficult.
Our results have shown that employees with lower education level had 2.3 times more chance of missing work due to toothache.These results are similar and comparable to other studies 8,18,33 .

CONCLUSION
Our study has observed high prevalence of toothache generating absenteeism, with higher frequency among workers from less privileged economic classes and with lower education levels.
Strategies directed to health promotion and to better access to dental services certainly will be able to decrease observed frequencies.

Table 3
When testing variable SEC, p value (0.054) was very close to nominal limit, showing potentially significant result (Table4).Prevalence of absenteeism was higher among employees of socioeconomic classes C/D/E (OR= 3.816, CI 95% = 1.094;13.333),thatis, the chance of classes C/D/E individuals missing work due to toothache was 3.816 times higher as compared to that of classes A and B. Workers with education level up to incomplete high school had 2.298 times more chance of missing work due to toothache (OR= 2.298, CI 95% = 1.005;5.255),ascomparedto those with higher level education (Table5).
).With regard to variables gender, age group, socioeconomic condition (SEC), family income and education level, results have shown no statistically significant association with the prevalence of toothache.

Table 4 .
Data on dental pain and sociodemographic characteristics of civil servants.Marataízes/ES

Table 2 .
Data on dental pain of civil servants.Marataízes/ES groups, observation intervals (last two weeks, six months or even 12 months), and different regions within Brazil and worldwide.It is important to stress that methodological aspects of future epidemiological studies on the subject should be standardized to provide more reliable comparisons

Table 5 .
Data on absenteeism due to toothache of employees of the local government of Marataízes/ES, 2009