Individual and contextual factors associated with malocclusion
          in Brazilian children

Brizon, Valéria Silva Cândido; Cortellazzi, Karine Laura; Vazquez, Fabiana Lima; Ambrosano, Gláucia Maria Bovi; Pereira, Antônio Carlos; Gomes, Viviane Elisângela; Oliveira, Ana Cristina

doi:10.1590/S0034-8910.2013047004426

OBJECTIVE:

To assess the association between the prevalence of malocclusion in Brazilian 12 years-olds with individual and contextual variables.

METHODS:

A cross-sectional, analytical study was conducted with data from the Brazilian Oral Health Survey – SBBrazil 2010. The outcome studied was malocclusion, categorized as absent, set, severe and very severe. The independent variables were classified as individual and contextual. Data were analyzed using a multilevel model with a 5% significance level.

RESULTS:

It was found that the prevalence of severe and very severe malocclusion in 12-year-olds did not differ between the Brazilian regions, although variation between the cities was significant (p < 0.001). Male children (p = 0.033), those on lower income (p = 0.051), those who had visited a dentist (p = 0.009), with lower levels of satisfaction with mouth and teeth (p < 0.001) and embarrassed to smile (p < 0.001) had more severe malocclusion. The characteristics of the cities also affected the severity of malocclusion; cities with more families on social benefits per 1,000 inhabitants, with lower scores on the health care system performance index and lower gross domestic product per capita were significantly associated with malocclusion.

CONCLUSION:

Significant associations between the presence and severity of malocclusion were observed at the individual and contextual level.

Child; Malocclusion, epidemiology; Socioeconomic Factors; Health Inequalities; Dental Health Surveys; Oral Health; Multilevel Analysis

[TFN01t01_en] ^a Chi-squared test

Region	Malocclusion					p-value
Region	Absent	Set	Severe	Very Severe	Total	p-value

North	962	327	131	147	1,567	0.0176 ^a a Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Coordenação Nacional de Saúde Bucal. SB2010: Pesquisa Nacional de Saúde Bucal. Resultados principais. Brasília (DF); 2011[cited 2012 Feb 08]. Available from: http://dab.saude.gov.br/cnsb/sbbrasil/download.htm
	61.4%	20.9%	8.4%	9.4%	100,0%
Northeast	959	311	173	164	1,607
	59.7%	19.4%	10.8%	10.2%	100,0%
Southeast	617	245	139	97	1,098
	56.2%	22.3%	12.7%	8.8%	100,0%
South	330	124	68	60	582
	56.7%	21.3%	11.7%	10.3%	100,0%
Central-West	506	196	84	70	856
	59.1%	22.9%	9.8%	8.2%	100,0%
Total	3,374	1,203	595	538	5,710
	59.1%	21.1%	10.4%	9.4%	100,0%

Variable	Frequency	Percentage (%)

Demographic
Domain
Capital	5,578	76.12
Interior	1,750	23.88
Region
North	1,743	23.79
Northeast	2,041	27.85
Southeast	1,342	18.31
South	1,010	13.78
Central-West	1,192	16.27
Sex
Male	3,639	49.66
Female	3,689	50.34
Skin color
White	2,897	39.53
Brown	712	9.72
Yellow	144	1.97
Dark brown	3,513	47.94
Indigenous	62	0.85
Oral health problems
Trauma
No trauma	5,630	78.11
Enamel Fracture	1,282	17.79
Enamel/dentine fracture	262	3.63
Fracture with pulp exposure	21	0.29
Absence due to trauma	13	0.18
Treatment necessity
Not necessary	3,528	48.68
Necessary	3,719	51.32
Socioeconomic
Number of Individuals
	1	0.01
1	11	0.15
2	235	3.21
3	1,079	14.76
4	2,264	30.97
5	1,745	23.87
6	889	12.16
7	477	6.52
8	258	3.53
9	141	1.93
> 10	211	2.89
Number of rooms
	2	0.03
1	539	7.37
2	2,560	35.02
3	1,931	26.42
4	778	10.64
5	602	8.24
6	397	5.43
7	231	3.16
8	121	1.66
9	68	0.93
>10	81	1.08
Number of consumer goods
	042	0.58
1	105	1.45
2	138	1.90
3	390	5.37
4	877	12.07
5	1,102	15.17
6	1,070	14.73
7	989	13.61
8	852	11.73
9	528	7.27
10	394	5.42
11	779	10.72
Income per capita (R$)
Below 250.00	313	4.52
251.00 to 500.00	1,084	15.64
501.00 to 1,500.00	3,694	53.31
1,501.00 to 2,500.00	1,082	15.62
2,501.00 to 4,500.00	494	7.13
4,501.00 to 9,500.00	196	2.83
over 9,500.00	66	0.95
Years of Schooling
	19	0.26
1	42	0.58
2	75	1.03
3	235	3.22
4	727	9.95
5	1,432	19.61
6	2,241	30.69
7	1,503	20.58
8	625	8.56
9	202	2.77
10	85	1.16
11	49	0.67
12	34	0.47
13	7	0.10
14	5	0.07
15	22	0.30
Schooling, morbidity and use of orthodontic services Self-perception and impact on health
Perception of need for treatment
No	2,228	32.07
Yes	4,720	67.93
Toothache (last 6 months)
No	5,559	76.29
Yes	1,728	23.71
Severity of pain (intensity – from 1 to 5)
1	244	14.49
2	323	19.18
3	485	28.8
4	277	16.45
5	355	21.08
Dentist appointment
No	1,337	18.43
Yes	5,918	81.57
Frequency of appointments
Less than one year	3,570	61.19
From 1 to 2 years	1,669	28.61
3 years or more	595	10.20
Where was your last dental appointment?
Public Service	3,207	54.59
Private Service	1,898	32.31
Health plan/Agreements	690	1.74
Other	80	1.36
Reason for appointment
Check-up	2,172	37.05
Pain	748	12.76
Extraction	708	12.08
Treatment	2,082	35.52
Other	152	2.59
Level of satisfaction with teeth
Very satisfied	798	11.10
Satisfied	3,522	49.01
Neither satisfied nor dissatisfied	1,215	16.91
Dissatisfied	1,540	21.43
Very Dissatisfied	111	1.54
Difficulty eating
No	6,067	83.26
Yes	1,220	16.74
Discomfort when brushing
No	6,382	87.54
Yes	908	12.46
Nervousness and irritation
No	6,513	89.46
Yes	767	10.54
Influence on leisure
No	6,860	94.05
Yes	434	5.95
Influence on sport
No	6992	95.82
Yes	305	4.18
Difficulty talking
No	6,959	95.42
Yes	334	4.58
Embarrassed to smile
No	6,297	86.40
Yes	991	13.60
Difficulty working/studying
No	6,920	94.85
Yes	376	5.15
Difficulty sleeping
No	6,653	91.26
Yes	637	8.74
Contextual
Homogenous groups
High IDSE ¹ and High MAC ²	4,581	62.51
High IDSE and Medium MAC	1,297	17.70
Medium IDSE and Low MAC	436	5.95
Low IDSE and Low MAC	394	5.38
Medium IDSE and No MAC	277	3.78
Low IDSE and No MAC	343	4.68
Fluoridated tap water
No	1,433	20.67
Yes	5,501	79.33

Contextual	Mean	Standard Deviation	Median	Minimum value	Maximum value

Family Allowance ^a	54.56	33.82	55.81	3.59	189.10
IDSUS	5.68	0.80	5.76	3.12	7.63
GDP per capita	17,517.13	12,558.34	14,095.00	1,721.00	71,407.00
HDI ^c	0.79	0,06	0.80	0.80	0.89

	Model 1		Model 2		Model 3

	Intercept only		Level 1 variables		Complete model

	Estimate	p-value	Estimated	p-value	Estimated	p-value
	(Standard error)	p-value	(Standard error)	p-value	(Standard error)	p-value

Level 1 variables (individual)
Intercept	1.689 (0.029)	< 0.001	1.425 (0.077)	< 0.001	0.955 (0.193)	< 0.001
Sex
(Ref ^a Female)			0.056 (0.026)	0.033	0.059 (0.026)	0.032
Income (Ref. more than R$ 9,500.00)			0.026 (0.013)	0.051	0.025 (0.013)	0.005
Consultation ^b (Ref. Yes)			-0.090 (0.034)	0.009	-0.881 (0.034)	0.011
Satisfaction (Ref. Very satisfied)			0.115 (0.014)	< 0.001	0.114 (0.014)	< 0.001
Ashamed to smile (Ref. No)			0.267 (0.042)	< 0.001	0.267 (0.042)	< 0.001
Level 2 variables (cities)
Family Allowance (Ref. less allowance)					0.001 (0.001)	0.018
IDSUS (Ref. higher IDSUS)					0.054 (0.028)	0.054
GDP per capita (Ref. higher PIB)					5.89 x 10 ^-6 (3.04 x 10 ^-6 )	0.052
Variances
Variance between cities	0.062 (0.015)	< 0.001	0.058 (0.014)	< 0.001	0.053 (0.014)	0.001
Variance between participants in city	0.945 (0.028)	< 0.001	0.921 (0.018)	< 0.001	0.921 (0.018)	< 0.001

Brasil

Brasil

Individual and contextual factors associated with malocclusion in Brazilian children

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION: