Dental pain prevalence among health care personnel*

BACKGROUND AND OBJECTIVES : Dental pain is a major reason for looking for dental services. Toothache may prevent or impair daily activities, such as working, having fun or socializing. This study aimed at evaluating dental pain prevalence in the last six months, among employees of the Teaching Hospital, Vitoria, ES. METHODS : This was an analytical, observational cross-sectio-nal study. Data were collected by six trained interviewers by me-ans of standardized interviews filling a questionnaire previously used by other studies about toothache among employees of the state of Espirito Santo, which included demographic and social information, as well as toothache report, type of pain (sponta-neous or induced), use of dental services and employment bond. Confidence level of 95%, error of 5% and expected prevalence of 50% were used for sample calculation. Final sample was made up of 265 employees. The association between studied va-riables and dental pain prevalence was observed using Pearson Chi-square test with significance level of 5%. Odds Ratio and respective confidence intervals (CI-95%) were estimated for sta-tistically significant variables. RESULTS : Dental pain prevalence was 65.7%. Employees with up to 39 years of age (p=0.004, OR=2.081 CI 95%=1.226; 3.530), of economic classes C and D (p=0.007, OR=1.968 CI 95%=1.173; 3.30) and those receiving up to three minimum wages have reported higher dental pain prevalence (p=0.000, OR=2.829 CI=1.611; 4.967). CONCLUSION : There has been high dental pain prevalence among employees. Strategies to decrease such event should be im-plemented aiming at improving quality of life of such employees.


INTRODUCTION
Dental pain is the most impacting oral disease and is considered public health problem due to its high prevalence, for being preventable and for the major impact on daily lives of people.For individuals in productive age, dental pain may generate productivity loss, prevent or impair daily activities, such as working, having fun and relating to other people   Epidemiological studies also show that toothache is a major reason for looking for dental services due to potential distress generated to individuals 2 .According to National Survey by Home Sample (PNAD) 3 data, it is estimated that 29.6 million people (18.7% of Brazilian population) have never been to a dentist 3 .This number has decreased in a survey from 2003 where 15.9% of Brazilians have stated never having been to dental office.In the state of Espirito Santo, numbers are also alarming: 15.23% (503,764 people) have never been to a dentist 3 .PNAD data (2008) showed increased access to dental services; however 11.67% are still excluded from the service 4 .In a recent national survey on oral health conditions, it was observed that 23% of all respondents have reported dental pain in the six months previous to the survey.This percentage was decreased to 10% among the elderly aged from 65 to 74 years, probably due to teeth loss 5 .Toothache is considered a difficulty faced by populations and individuals who do not find in health services adequate means for oral health care and adopt self-medication as alternative to solve the suffering 6 .This study aimed at evaluating toothache prevalence among employees of a Teaching Hospital in Vitoria, ES.

METHODS
The Teaching Hospital Cassiano Antonio Moraes (HU-CAM) is currently considered the largest public hospital of Espirito Santo, considering the number of performed procedures, especially those of high complexity.It is located in the district of Maruipe, city of Vitoria.Its coverage goes beyond the state of Espirito Santo, receiving patients especially from the states of Bahia and Minas Gerais.This analytical, observational study used a crossover design.This study design refers to a single point in time where "cause" and "effect" are simultaneously evaluated.A representative sample of employees linked to HUCAM (effective and/or outsourced) was randomly selected from a universe of 960 individuals.Sample calculation parameters were confidence level of 95%, error of 5% and expected prevalence of 50%, resulting in n of 300 employees.Inclusion criteria were being HUCAM worker, aged between 18 and 60 years.Employees on medical or disability leave were excluded.Toothache was the outcome considered in the study.Statistical analysis has evaluated possible association among independent variables: gender, age group, income, socioeconomic condition (SEC) and education level.Six trained interviewers have collected data by the standardized interview method filling a questionnaire about toothache previously used by other studies with workers of the state of Espirito Santo.Items included participants' demographic and social information, as well as toothache report (spontaneous or provoked), use of dental services and type of employment relationship.Participants' socioeconomic classification has followed Brazil Economic Classification Criteria, which establishes cutoff points based on the ownership of assets declared by respondents.Data were analyzed by frequency tables with absolute and percentage numbers for each survey tool item.Data analysis has used Pearson Chi-square test with significance level of 5%.Odds Ratio (OR) and respective 95% confidence interval were estimated to check the magnitude of the association.Statistical package SPSS -Statistical Package for the Social Sciences, version 15 was used for analyses.
The study was approved by the Research Ethics Committee, Federal University of Espirito Santo under protocol 110/2010.

RESULTS
The study got a final sample of 265 validated questionnaires, recording a loss of 11.66%.Most employees were females, between 30 and 49 years of age, with education level above high school, inserted in economic classes B and C, income between 2-6 minimum wages, and employment relationship by means of public tender (Table 1).Prevalence of reported toothache was 65.7% for the last six months.Pain has determined the use of dental services for 46.6% of subjects.Observing the number of visits to the dentist, 45.7% needed three visits or more to solve the episode, which may suggest more complexity of the event or questionable resolution of the service.Considering the number of individuals not looking for assistance, unawareness of the need has been the primary barrier for using the service (Table 2).toothache frequency in the last six months.Participants of this survey had complimentary dental service offered by the university and close to the hospital.It was expected that this fact would positively impact the frequency of such pain episodes by decreasing it.It is known that the use of dental services may be influenced by several variables and that service availability is not always able to generate demand.Other features might be involved with perception of the need, in addition to cultural factors and health beliefs 2 .Some studies show huge variations in pain prevalence due to the time period respondents have reported having dental pain, as well as to different oral health conditions presented by participants 9 .A study carried out in Rio de Janeiro has found a very low prevalence of approximately 2.9% among employees of a university, difference explained by the fact that reported pain period was the last two weeks 10 .With regard to age group, this study has found higher pain prevalence among employees aged up to 39 years, in line with the national study which has found age as a determining factor for pain 11 , and different from studies carried out in Espirito Santo 2.7,8 .Comparison with some studies might be impaired by different cutoff points used to select the groups [12][13][14] .In terms of income, this study has observed higher pain prevalence among those with reported income of up to three minimum wages, differently from other studies carried out in the region 2,7,8 .Similar results were found for different Brazilian regions: Recife 13 , Rio de Janeiro 10 and Southern Brazil 12,15 .This study has found higher reported pain prevalence among employees of economic classes C and D, in line with other studies results 2,16 .In light of the strong association of oral diseases and social components, SEC might be a factor influencing the maintenance of oral health care, thus contributing to prevent dental pain 16 .Although considering toothache prevalence very high, it was enough to generate dental service use by just 46.6% of those reporting toothache in the last six months.This result is in line with those found by different studies, confirming that toothache is not always enough to generate service demand 17,18 .This fact should be better evaluated by further studies investigating not only the type of pain but also its intensity and frequency.Studies involving estimates of health services usage should try to identify possible barriers for the usage with focus on the implementation of measures aimed at improving the access of communities.Studies have shown that the lack of perceived need by people has been one of the major barriers for the use 17,19,20 .Other associated variables are fear, cost and factors related to poor organization of the local health service.In our study, results have shown that among 93 subjects (53.4%) reporting not having used dental services during the pain episode, unawareness of the need was reported as the most frequent reason (60.2%) for not looking for the service.This fact might be "masking" the possibility of selfmedication, a very common practice in our society and still potentially encouraged by the ease with which health employees get drugs.
A study carried out in an emergency dental service in Minas Gerais has observed self-medication prevalence of 79.3% of users of such service 21 .The Brazilian Association of Pharmaceutical Industries (ABIFARMA) estimates that 80 million people practice self-medication 22 .This is a worrisome public health problem and may be an indicator of the barrier for using health services 22 .Notwithstanding the scarcity of studies evaluating self-medication for dental pain episodes, a study carried out in Recife has confirmed this attitude as routine among families whose children had toothache 13 .In Rio Grande do Sul, 72.6% of individuals looking for urgency services have reported using drugs previously to looking for professional help 23 .Health promotion policies aiming at informing and improving the access to routine dental services should be implemented.Toothache is a very frequent event in Brazil 13,23 and leads to absenteeism 2,7,8 and strong impact on quality of life 14 .

CONCLUSION
The prevalence of dental pain among HUCAM, Vitoria, ES employees may be considered high and worrisome.Younger employees of less favored classes, with income below three minimum wages were those reporting the highest prevalence of toothache.Strategies toward decreasing this event should be implemented aiming at improving quality of life of these employees. 1

Table 1 .
Socio-demographic data of health employees, 2011

Table 3
shows the association of dental pain and sociodemographic variables of health professionals of a teaching hospital of UFES, city of Vitoria/ES.
5prevalences were 43 and 57%, respectively.In a food industry in the Southeastern region there has been 46.7% prevalence of pain2. Tlatest national survey has indicated a frequency of 27.5% for Brazil and of 30.8% for the Southeastern region in the population between 35 and 44 years of age5.All above-mentioned studies have measured

Table 2 .
Data on toothache among health employees, 2011

Table 3 .
Association of dental pain and sociodemographic factors of health employees, 2011