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Original article

Prevalence and severity of dental caries are associated with the worstsocioeconomic conditions: A Brazilian cross-sectional study among

18-year-old malesMarco A. Peres, Ph.D.a,*, Karen G. Peres, Ph.D.b,c, Jefferson Traebert, Ph.D.b,c,

Nirbal E. Zabot, B.D.S.d, and Josimari T. de Lacerda, M.Sc.caDepartment of Public Health, Health Science Centre, Federal University of Santa Catarina, Florianópolis, Brazil

bPublic Health Research Group, West of Santa Catarina University, Joaçaba, BrazilcPublic Dental Health Research Group, Southern Santa Catarina University, Tubarão, Brazil

dMunicipal Health Authority, Blumenau, Brazil

Manuscript received January 30, 2004; manuscript accepted August 3, 2004

bstract Purpose: The aim of the present study was to assess the prevalence and severity of dental cariesamong 18-year-old Brazilian males and to test the associations between dental caries and socio-economic conditions.Methods: It was carried out a cross-sectional study among 18-year-old male conscripts of theBrazilian Army in Blumenau, Southern Brazil. The main outcomes measured were the occurrenceof dental caries (decayed, missing and filled teeth [DMFT] � 1) and high dental caries (DMFT �8). Socioeconomic variables were collected by interviews. Simple and multiple regression analysiswere performed.Results: The mean DMFT was 5.7 (95% confidence interval [CI] 5.3–6.1), the proportion ofcaries-free subjects was 11.4% (95% CI 8.5–14.3) and the proportion of subjects with all 28 naturalteeth was 67.2% (95% CI 63.0–71.4). In the multiple regression analysis, mothers’ educational levelremained associated with dental caries after being controlled by conscripts’ schooling. It wasobserved that the lower the mothers’ and the conscripts’ schooling, the stronger the risk of theconscripts to show a high dental caries status.Conclusion: A gap between socioeconomic groups was observed. Subjects from families with loweducational level presented poorer dental health. Mothers’ schooling could be a good predictor fordental caries in young adults. © 2005 Society for Adolescent Medicine. All rights reserved.

Journal of Adolescent Health 37 (2005) 103–109

eywords: Dental caries epidemiology; Adolescents; Socioeconomic conditions; Brazil; Inequalities in health

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The great majority of epidemiological studies on dentalaries are about schoolchildren [1]. This is of concern owingo the importance of implementing a dental caries surveil-ance system for all ages, and not only for children. Sec-ndly, with the important decline of dental caries prevalencen most developed countries [2,3] as well as in Brazil [4–8],here is an increasing possibility of extending public dental

*Address correspondence to: Dr. Marco Aurélio Peres, Universidadeederal de Santa Catarina, Centro de Ciências da Saúde, Departamento deaúde Pública, Campus Universitário-Trindade, Florianópolis-SC, Brasil.

nE-mail address: mperes@ccs.ufsc.br

054-139X/05/$ – see front matter © 2005 Society for Adolescent Medicine. Alloi:10.1016/j.jadohealth.2004.08.016

ealth services to new population groups such as youngdults, workers, and the elderly, instead of providing publicental care almost exclusively to schoolchildren, as is tra-itionally done in Brazil.

Several studies have been performed in developed coun-ries regarding the epidemiological situation of dental cariesmong young adults [9–14], but in developing countriesuch as Brazil, there have been very few investigations, withopulation-based data on dental caries in young adults com-ng from only two studies [15,16].

The Brazilian Ministry of Health performed the first

ational oral health survey in 1986 in 16 of the most im-

rights reserved.

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104 M.A. Peres et al. / Journal of Adolescent Health 37 (2005) 103–109

ortant cities [15], and the mean DMFT index, correspond-ng to the average number of decayed, missed, and filledermanent teeth, among 15–19-year-olds was found to be2.7. In 1999, Gonçalves et al. [16] found a caries preva-ence of 81.0% and a mean DMFT of 4.5 among 18-year-ld males in Florianópolis, the capital of the Southern Bra-ilian State of Santa Catarina.

The link between poor health and socioeconomic condi-ions has been well established. In general, the lower theocioeconomic condition, the worse the health status, in-luding dental caries. Several socioeconomic indicatorsave been used in health research, such as educational level,amily income, and social class [17]. As a chronic disease,ental caries measured during adolescence reflects not onlyhe current but also the cumulative effect of harmful socio-conomic, biological, and behavioral factors that occurreduring the lifespan of a person. Therefore, the investigationf family and individual characteristics related to childhoodould elucidate their influence on disease patterns.

The objective of the present study was to assess therevalence and severity of dental caries among 18-year-oldales in Blumenau, Southern Brazil. In addition, the asso-

iations between dental caries and socioeconomic condi-ions were tested. The study was developed in a publicealth service context instead of an academic one. Weubmitted the project to our institutions, Federal Universityf Santa Catarina, Brazilian Dental Association, and Blu-enau Health Authority to obtain the necessary permission.oreover, the study was submitted and proved by the Blu-enau Health Council.

ethods

The study was undertaken in Blumenau, a city of61,808 inhabitants (2000) located in Santa Catarina State,outhern Brazil. Blumenau has higher socioeconomic andealth indicators than Brazil as a whole [18].

A cross-sectional dental caries study was carried outmong 2704 18-year-old male conscripts of the Brazilianrmy in Blumenau in 2000. The sample size was calculatedith a level of significance of 5%, with an estimated prev-

able 1escriptive statistics of DMFT index and components among 18-year-old

Decayed Missed Filled

ean 2.3 0.7 2.795%CI) (2.0–2.6) (0.6–0.8) (2.4–3

40.3 12.3 47.4inimum 0 0 0

5th quartile 0 0 0edian 1 0 2

5th quartile 3 1 4aximum 28 18 17

95% CI � 95% Confidence interval; DMFT � decayed, missing, and fi

lence of dental caries of 50%, owing to unavailable previ-

us epidemiological data about 18-year-olds, and a samplerror of 4.5% [19]. The minimum required sample size was03. To compensate for possible refusals, 75 more peopleere added, with a final sample size of 478 individuals. Tenercent of the subjects were examined twice by all exam-ners to calculate diagnostic reliability using the Kappa testn a tooth-by-tooth basis as previously described [20].

In Brazil, there is a mandatory law obligating all 18-year-ld males to report to the Brazilian Army to be listed and toe medically and dentally examined. In Blumenau this as-embly occurs only in one Brazilian Army Quarter. Theouth must be presented during 1 month, in our case, fromuly 17 to August 20, 2000. There is no recommendation orriteria for the presentation, but there is a predefined limit ofround 100 presentations each day. Each day the first 15pplicants who reported to the Brazilian Army were se-ected, examined, and interviewed by a team of four dentistsnd four clerks who had been trained and calibrated beforehe fieldwork.

Examiners’ calibration exercises were performed with 208–19-year-old army recruits, according to the methodol-gy previously described [14]. One of the authors (NEZ)ith experience in oral epidemiologic studies was the “gold

tandard.” The pretest questionnaire and a pilot study wereerformed with 40 recruits, with the objective of testing thexamination methodology and the management aspects.

(n � 473), Blumenau, Brazil, 2000

DMFT DMFT0 (%) % with all teeth

5.7 11.4 67.2(5.3–6.1) (8.5–14.3) (63.0–71.4)100.0 - -

0 - -2 - -5 - -8 - -

28 - -

eth.

able 2escriptive statistics of socioeconomic variables among 18-year-oldales (n � 473), Blumenau, Brazil, 2000

Familyincome(BMW)

Mother’sschooling

Father’sschooling

Conscript’sschooling

ean 5.96 5.47 6.14 7.43tandarddeviation 4.12 3.34 3.64 2.34inimum 1.00 Zero Zero Zero

5th quartile 3.00 4.00 4.00 6.00edian 5.00 4.00 4.00 8.00

5th quartile 7.00 8.00 8.00 9.00aximum 15.00 16.00 16.00 13issing values 7 19 45 4

males

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BMW � Brazilian minimum wage.

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105M.A. Peres et al. / Journal of Adolescent Health 37 (2005) 103–109

For the attainment of the intra-observer diagnostic repro-ucibility degree during the fieldwork, 10% from the sam-le total was examined twice by all examiners and theappa test was used to measure reliability [15].This study was supported by the Blumenau Municipal

ealth Authority. A formal consent was required from eachf the youths selected. A letter was provided to the youthsxplaining the aim, characteristics, and importance of thetudy, and asking for their consent, and the conscripts wereeassured that refusal to participate in the study would note held against them.

The examinations were performed in an Army sickroom,ith the recruits lying down under a white light. Oral

linical mirrors, CPI-type milimetric probes, and woodenpatulas, as well as sterilized gauze, were used. All bio-ecurity standards were rigorously followed.

Clinical data were collected according to the Worldealth Organization dental caries diagnostic criteria [21].he DMFT index, corresponding to the average number ofecayed, missing, and filled permanent teeth, was the out-ome analyzed.

In addition, a questionnaire was applied, with questionsbout the educational level of the respondents and of theirarents in terms of number of years of schooling, and familyncome in Brazilian currency (reais), expressed as mini-um wages per month (approximately 80 American dol-

ars). The socioeconomic data were collected as an openuestion. After that they were categorized according to bothheoretical and statistical reasons. Schooling categorization

able 3MFT index and components according to the socioeconomic conditions

Decayed Mean (SD) Missed Mean (S

amily income� 6 BMW 1.5 (2.38) 0.5 (1.03)3–6 BMW 2.3 (3.74) 0.6 (1.16)� 3 BMW 3.2 (3.88) 0.9 (2.02)p* .003 .209other’s schooling� 9 years 1.0 (1.89) 0.3 (1.31)5–8 years 0.8 (2.73) 0.5 (1.17)� 4 years 2.8 (3.93) 0.8 (1.66)p* �.01 �.01

ather’s schooling� 9 years 1.0 (2.07) 0.2 (0.78)5–8 years 2.4 (3.27) 0.6 (1.27)� 4 years 2.7 (3.77) 0.8 (1.37)p* �.01 �.01

onscript’s schooling� 9 years 1.0 (1.88) 0.3 (0.81)5–8 years 2.8 (3.75) 0.7 (1.33)� 4 years 4.0 (4.20) 1.5 (2.83)p* �.01 �.01

SD � standard deviation; BMW � Brazilian minimum wage; DMFT �* Kruskal-Wallis test.Missing values were excluded.

ollowed the current (for the youth) and the former (for the q

arents) Brazilian educational system; up to 4 years asrimary school, up to 8 years as elementary school, and �years corresponding to high school or college. The eth-

icity, a core issue in research focusing on inequalities inealth, was not investigated. Although Brazil presents theecond world’s second largest afro-descendent population,lumenau, as the name indicates, was founded by Germanigrants, and the majority of its inhabitants are from this

rigin; thus the afro-descendent population is very small.Theoretically, it was assumed that parental schooling

epresented the conscript’s early socioeconomic living con-itions, whereas the conscript’s schooling and family in-ome represented the current socioeconomic status. Differ-nt socioeconomic variables were considered to measureifferent aspects involved in the complex social circum-tances. A pilot study was conducted among 12 youngeople to test all the aspects involved in fieldwork. Statis-ical analyses included descriptive statistics of DMFT indexnd its components, and difference in DMFT index and itsomponents according to socioeconomic variables using theruskal-Wallis test. The choice of this statistic test waswing to the skewed distribution of dental caries variablesuch as DMF-T. Thus, the nonparametrical is the mostppropriate test in that situation. Differences in proportionsere tested using chi-square test.In addition, unconditional multiple logistic regression

nalysis was performed to identify the socioeconomic riskactors for dental caries (DMFT � 1) and for high dentalaries (DMFT � 8). This cut-off point represented the last

ear-old males (n � 473), Blumenau, Brazil, 2000

Filled Mean (SD) DMFT Mean (SD) DMFT � 0 (%)

2.6 (2.85) 4.5 (3.81) 14.12.7 (3.02) 5.6 (4.73) 12.32.4 (2.85) 6.5 (5.23) 11.2.187 .086 .789

2.9 (3.16) 4.1 (3.76) 24.63.0 (3.08) 5.4 (4.06) 12.52.6 (3.13) 6.3 (5.14) 8.6

.292 �.01 � .01

3.4 (3.28) 4.6 (3.74) 17.02.9 (3.13) 5.8 (4.65) 13.92.5 (2.98) 6.0 (4.89) 9.4.077 .079 .154

3.2 (3.27) 4.6 (3.83) 17.92.6 (3.07) 6.1 (4.77) 9.22.0 (2.45) 7.5 (6.11) 6.4

�.01 �.01 .014

ed, missing, and filled teeth.

of 18-y

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uartile of the DMFT frequency distribution. The p level for

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106 M.A. Peres et al. / Journal of Adolescent Health 37 (2005) 103–109

variable to be included in the multiple regression logisticodel was .20 [22]. Each variable was included in theultiple logistic regression following stepwise forward pro-

edure. A variable remained in the final model if statisticalignificance was .05 or less or was a control variable. Theoftware SPSS (SPSS Inc., Chicago, IL) was used for thenalysis.

esults

A total of 473 conscripts aged 18 years were examinednd interviewed, representing a response rate of 99%. Intra-xaminer reliability was assessed using the Kappa coeffi-ient, with values ranging from .69 to 1.00.

The variations in the dental health indicators included inhe study are shown in Table 1. The mean DMFT was 5.795% confidence interval [CI] 5.3–6.1), the proportion ofaries-free subjects was 11.4% (95% CI 8.5–14.3) and theroportion of subjects with all natural teeth, which means all8 teeth excluding third molars, was 67.2% (95% CI 63.0–1.4). Among the DMFT components, decayed (D), missingM), and filled (F) teeth represented 40.3%, 12.3%, and7.4%, respectively.

Descriptive statistics of socioeconomic variables among8-year-old males are presented in Table 2. It is seen thathe mean of conscripts schooling is higher (7.43) than theirarents. Half of the studied population earns no more thanve Brazilian Minimum Wages monthly.

When the DMFT index and its components are comparedn terms of socioeconomic variables in general, it can beeen that the lower the socioeconomic status, the higher theMFT index and its components, except for filled teeth.ow conscript schooling was strongly associated withoorer dental caries indicators (p � .01). The worst decayednd missing tooth levels and DMFT were observed amongubjects with lower mothers’ schooling (p � .01), whereasower fathers’ schooling was associated with higher de-ayed and missing teeth (p � .01). Family income showedo association with any DMFT components, except forecayed teeth. The lower the family income, the higher theumber of decayed teeth (p � .01) (Table 3).

Table 4 shows the comparison of subjects with highental caries (DMFT � 8) according to socioeconomicariables. Lower family income (p � .022), lower mothers’chooling (p � .012), and lower conscripts’ schooling (p �034) were associated with high dental caries.

Table 5 summarizes simple and multiple logistic regres-ion analysis of dental caries (DMFT � 1). The results ofimple regression analysis showed a significant associationmong mothers’ schooling, conscripts’ schooling, and den-al caries. Family income did not show association withental caries; however, the variable did not enter the mul-iple regression logistic model owing to its p value above20. Fathers’ schooling lost its statistic significance (p �

20) when it was entered in the model, thus it was removed. s

n the multiple regression analysis, mothers’ educationalevel remained associated with dental caries after beingontrolled for conscripts’ schooling. A young adult whoseother had an educational level of 4 years or less showed a

.9 times higher occurrence of dental caries in comparisonith those whose mothers had � 9 years of study. This

ffect was independent of the other variables.The same technical procedure as described above was

ollowed when high dental caries was the outcome analyzedTable 6). In the simple regression analysis, family incomend mothers’ and conscripts’ schooling were associatedith high dental caries (p � .05) When multiple regression

nalysis was performed, it was observed that most of theariables were found to show no statistical significance.nly a lower level of mothers’ and conscripts’ schooling

howed a weak association. The lower the mothers’ and theonscripts’ schooling, the stronger the risk (odds ratio [OR]

2.7 and OR � 2.3, respectively) of the conscripts to showhigh dental caries status.

iscussion

The sample procedure, the high response rates, the highntra-examiner reliability, and the similarity between the

able 4igh dental caries index (DMFT � 8) according to the socioeconomic

onditions of 18-year-old males (n � 473), Blumenau, Brazil, 2000

DMFT � 8n (%)

DMFT � 8n (%)

amily income� 6 BMW 83 (82.2) 18 (17.8)3–6 BMW 123 (75.0) 41 (25.0)� 3 BMW 103 (66.9) 51 (33.1)Total 309 (73.7) 110 (26.3)p 0.022other’s schooling� 9 years 55 (88.7) 7 (11.3)5–8 years 102 (72.3) 39 (27.7)� 4 years 176 (70.1) 75 (29.9)Total 333 (73.3) 121 (26.7)p 0.012

ather’s schooling� 9 years 72 (80.0) 18 (20.0)5–8 years 83 (69.2) 37 (30.8)� 4 years 160 (973.4) 58 (26.6)Total 315 (73.6) 113 (26.4)p 0.211

onscript’s schooling� 9 years 132 (80.0) 33 (20.0)5–8 years 181 (71.0) 74 (29.0)� 4 years 34 (64.2) 19 (35.8)Total 347 (73.4) 126 (26.6)p 0.034

Chi-square test.Missing values were excluded.DMFT � decayed, missing, and filled teeth.

ocial characteristics of the conscripts and of the population,

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107M.A. Peres et al. / Journal of Adolescent Health 37 (2005) 103–109

s identified in a previous publication [23], suggest internalalidity of this study.

Epidemiological studies of dental caries in young adultsre less usual than in other ages, such as schoolchildren.ifferences in diagnostic criteria and in sample selectionrocedures impair a comparison among studies [24]. Nev-rtheless, considering the data with caution, it was observedhat the mean DMFT found (5.7) was clearly lower thanhose found in 1986 (13.8) among 15–19-year-old subjectsn Southern Brazil [15]. On the other hand, in Florianópolis,he capital of the Southern State of Santa Catarina, oralgures provided by a study undertaken in 1999 showed aMFT of 4.5, a proportion of caries-free subjects of 19%,

Table 5Results of simple and multiple logistic regression a� 1) in a sample of conscripts aged 18 years (n �

Variables Unadjusted OddsRatio (95%CI)

Family income� 6 BMW 1.03–6 BMW 1.2 (0.6–2.6)� 3 BMW 1.4 (0.7–3.0)

Father’s schooling� 9 years 1.05–8 years 1.3 (0.6–2.7)� 4 years 2.0 (1.0–4.1)

Mother’s schooling� 9 years 1.05–8 years 2.3 (1.1–4.9)� 4 years 3.5 (1.7–7.3)

Conscript’s schooling� 9 years 1.05–8 years 2.2 (1.2–3.9)� 4 years 3.2 (0.9–11.0)

DMFT � decayed, missing, and filled teeth.* Did not enter in the multiple regression analyse** Removed from the final model due p � .20 in

Table 6Results of simple and multiple logistic regression a(DMFT � 8) in a sample of conscripts aged 18 yea

Variables Unadjusted OddsRatio (95%CI)

Family income� 6 BMW 1.03–6 BMW 1.5 (0.8–2.9)� 3 BMW 2.3 (1.2–4.2)

Mother’s schooling� 9 years 1.05–8 years 3.0 (1.3–7.1)� 4 years 3.3 (1.5–7.7)

Conscript’s schooling� 9 years 1.05–8 years 1.6 (1.0–2.6)� 4 years 2.2 (1.1–4.4)

DMFT � decayed, missing, and filled teeth.

nd 82.5% of the entire studied population presented all 28atural teeth [16] in comparison with 5.7, 11.4%, and7.2%, respectively, in our study. The comparison betweenhese two Brazilian studies is feasible because both wereonducted using the same methods.

Comparison with international studies showed that therevalence of dental caries found in the current study88.6%) was similar to that detected in Australia [25] andn Finland in 1991 [26]. In contrast, the prevalence foundas higher than that detected in the United Kingdom

mong 16 – 24-year-olds in 1998 [12]. In addition, theresence of all natural teeth in 85% of the entire popu-ation, a goal established by the World Health Organiza-

of explanatory variables of dental caries (DMFTBlumenau, Brazil, 2000

p Adjusted OddsRatio (95%CI)

p

.701 *

.586

.410 **

.161

.539

.064�. 01 .038

1.0.036 1.9 (0.9–4.3) .099

� .01 2.8 (1.3–6.1) .011.017 .138

1.0.012 1.6 (0.9–3.1) .125.065 3.4 (0.8–15.1) .112

� .20 in the simple logistic regression analyses.ltiple logistic regression.

of explanatory variables of high dental caries473) in Blumenau, Brazil, 2000

p Adjusted OddsRatio (95%CI)

p

.024 .3831.0

.174 1.1 (0.6–2.1) .742� .01 1.5 (0.8–2.9) .232

.017 .1511.0

.013 2.5 (0.9–7.1) .084� .01 2.7 (1.0–7.6) .050

.036 .1161.0

.039 1.5 (0.9–2.7) .151

.020 2.3 (1.0–5.0) .041

nalysis473) in

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108 M.A. Peres et al. / Journal of Adolescent Health 37 (2005) 103–109

ion [27] for 18-year-olds, was not achieved in theresent survey.

Despite the generally favorable epidemiological pictureound when the time trend is analyzed, inequalities accord-ng to socioeconomic conditions are identified. In general,he lower the socioeconomic indicators, the higher the den-al caries prevalence and severity. The link between socio-conomic status and health has been very well established.everal measures have been used to assess socioeconomicosition, but all of them have limitations. Consequently,nvestigators have used at least two socio-indicators [28].urthermore, many studies related to health and familyocioeconomic position have failed to adjust each socialndicator to the others [29]. In our study we used familyncome and parents’ and conscripts’ education, consideringeveral dimensions of social position.

In the simple logistic regression analysis, mothers’ andonscripts’ schooling were associated with dental caries,hereas conscripts’ schooling, mothers’ schooling, and

amily income were associated with high dental caries.owever, after adjusting each variable to the others, onlyothers’ schooling remained significant for dental caries,

nd lower categories of mothers’ and conscripts’ schoolingemained associated with high caries levels.

Educational level is an important marker of socioeco-omic position. It is useful because it can be applied to bothenders, is applicable to persons not in the labor force, hastability over the adult lifespan, and is comparable betweenifferent regions. In addition, higher educational level gen-rally is predictive of better jobs, higher incomes, betterousing and socioeconomic position [30]. Maternal educa-ional level is one of the best predictors for children’sealth, especially in developing countries [29], and could bemarker of social position during childhood. Additionally,

everal studies have indicated the impact on oral and overallealth of a harmful socioeconomic environment occurringery early in life, such as low levels of maternal education29] and low birth weight [31]. These phenomena appear toncrease the risk for dental caries and are more prevalentmong deprived people. Social and biological risks accu-ulated since childhood have been proposed to have con-

equences for the subsequent health status of adults [32] ande used parental schooling as a proxy for socioeconomic

onditions in conscripts’ childhood. On the other hand,onscripts’ schooling reveals the phenomena that occurredn the recent past.

The gap between socioeconomic status, measured byocial class and dental caries, was also found by Antoft et al.11] among Danish recruits in 1972, 1982, and 1993. Theental caries reduction was 27% in the highest socioeco-omic groups from 1972 to 1982, and 50% from 1982 to993 when compared with 24% and 43%, respectively, inocial groups in the bottom of the scale.

Based on findings from this study, recommendations to

eneral and health policy decision-makers to improve con-

cripts’ oral health include improvement in general socio-conomic indicators such as educational level and a social-riented approach to access dental care. On the other hand,trategies for oral health care should include intersectoralpproaches to health promotion based upon a populationtrategy, because dental caries and other chronic diseaseshared common risks.

In summary, it was suggested that the gap betweenroups with different socioeconomic conditions favor thoseith better socioeconomic indicators. Mothers’ schooling

ould be a good predictor for dental caries in young adults,nd both mothers’ schooling and conscripts’ schooling maye used as a predictor for high dental caries.

cknowledgments

This study was supported by the Blumenau Municipalealth Authority (Secretaria Municipal da Saúde de Blu-enau, Santa Catarina, Brazil). We thank the fieldwork

eam formed by a dentist and clerks.

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