Do progression rates of initial and moderate caries lesions and sound surfaces of primary teeth increase significantly after 7 years?

BACKGROUND: Initial caries lesions in primary teeth have presented a low progression rate after 2 years, but it could be higher in longer follow-ups. AIM: To evaluate the progression rates of sound surfaces and initial and moderate caries lesions after 7 years. DESIGN: This prospective 7-year cohort study included 639 preschool children aged 1-5 years in 2010. In 2017, 449 children were reassessed (70.3% retention rate). Dental caries was collected using the International Caries Detection and Assessment System (ICDAS) in both assessments. Incidence rate (IR) per 100 surface-years estimated the progression rates of sound surfaces and initial and moderate lesions for worse conditions. Cox regression with shared frailty evaluated the possible risk factors. RESULTS: IR was 1.0% for sound surfaces, 2.8% and 4.2% for ICDAS scores 1 and 2, respectively, and about 17.0% for moderate lesions. The most significant risk factor for the progression was the presence of cavitated lesions in other teeth. The type of surface and tooth also influenced the outcome. CONCLUSION: The progression rate of initial caries lesions in primary teeth remains low even after 7 years, but cavitated caries lesions in other teeth increase this risk. Moderate lesions demonstrate a higher risk of progression when compared to sound surfaces and initial caries lesions.

Discriminant validity of the current gingivitis classification in adolescents: a cohort study.

OBJECTIVES: To compare the prevalence of gingivitis estimated by the 2018 European Federation of Periodontology/American Academy of Periodontology (EFP/AAP) classification with the other case definitions and assess the ability of this classification system in discriminating sociodemographic and clinical factors associated with the presence of gingivitis in a cohort study. MATERIALS AND METHODS: A multistage random sample of 1134 12-year-old adolescents was submitted to a full-mouth examination according to the Community Periodontal Index. Socioeconomic and clinical variables were collected at baseline. Gingivitis was considered according to the following criteria: (a) ≥ 10% of bleeding sites (the 2018 EFP/AAP criteria); (b) ≥ 15% of bleeding sites; and (c) the mean full-mouth bleeding sites. Adjusted multilevel Poisson regression assessed the association between independent variables at baseline and each definition of gingivitis at 2-year follow-up. RESULTS: Seven hundred forty-two 14-year-old adolescents were re-revaluated at follow-up. The prevalence of gingivitis was 28.7% according to 10% of bleeding threshold. The 2018 EFP/AAP criteria and other definitions showed higher prevalence and mean of gingivitis for low-household income adolescents and for those with higher levels of dental plaque and untreated dental caries. Nonetheless, the highest strengths of association were observed for the threshold of ≥ 15% of bleeding sites. CONCLUSION: The 2018 EFP/AAP case definition of gingivitis showed a similar discriminant validity compared to the 15% threshold and the mean full-mouth bleeding sites. CLINICAL RELEVANCE: The 2018 EFP/AAP classification allows the discrimination of important risk factors and should be used for the establishment of priorities for large-scale therapeutic programs.

Gingival inflammation influences oral health-related quality of life in individuals living in a rural area of southern Brazil.

AIM: The aim of the present cross-sectional study was to evaluate whether the extent levels of gingival inflammation (GI) in whole mouth or restricted to the anterior region are independently associated with oral health-related quality of life (OHRQoL) in individuals living in a rural area of southern Brazil. MATERIALS AND METHODS: A probability sample of 688 individuals was submitted to a full-mouth periodontal examination at six sites on each tooth. Extent levels of GI in whole mouth and restricted to anterior region were dichotomously considered when bleeding on probing (BoP) occurred at 20% or more of whole-mouth sites and at 10% or more of anterior region sites, respectively, in individuals with probing depths ≤3 mm, totalling 121 individuals analysed, aged 15-82 years. OHRQoL was assessed using the simplified version of the Oral Health Impact Profile (OHIP14 ) questionnaire. Adjusted multilevel Poisson regression analysis was used with a conceptual hierarchical approach to calculate the rate ratio (RR) of OHIP14 scores. RESULTS: In the adjusted model, higher extent levels of full-mouth GI (RR = 1.23; 95% confidence interval [CI]: 1.06-1.44; p = .004) and GI restricted to the anterior region (RR = 1.29; 95% CI: 1.11-1.51; p ≤ .001) were significantly associated with poorer OHRQoL. CONCLUSIONS: The extent of GI in whole mouth (≥20% of sites with BoP) and in the anterior region (≥10% of sites with BoP) was independently associated with OHRQoL in individuals living in a rural area.

Socioeconomic inequalities in oral health-related quality of life in adolescents: a cohort study.

PURPOSE: Socioeconomic inequalities are recognized as a major problem with people in low socioeconomic groups having worse subjective oral health outcomes, including oral health-related quality of life (OHRQoL). However, only a few longitudinal studies assessed the impact of contextual and individual socioeconomic determinants in adolescents' OHRQoL. We estimate the impact of socioeconomic inequalities on adolescents' OHRQoL over a 2-year period. METHODS: This study followed up a random sample of 1134 12-year-old schoolchildren for 2 years in Brazil. OHRQoL was assessed by the Brazilian version of the Child Perceptions Questionnaire for 11- to 14-year-old Children (CPQ11-14) at baseline and follow-up. Participants were clinically examined for dental caries, gingival bleeding, and malocclusion. The schoolchildren's parents answered a questionnaire regarding socioeconomic status, social capital, and adolescents' use of dental service. Socioeconomic contextual variables were collected from official city publications. Multilevel linear regression models fitted the associations between socioeconomic factors and overall CPQ11-14 scores over time. RESULTS: A total of 747, 14-year-old adolescents were reassessed for OHRQoL (follow-up rate of 66%). Adolescents with lower mean income school's neighborhood (P < 0.05), household income (P < 0.05), and maternal schooling (P < 0.05) had higher overall CPQ11-14 scores. Female sex, attending a dentist by toothache, dental caries, and malocclusion were also associated with higher overall CPQ11-14 scores. CONCLUSIONS: Adolescents from low socioeconomic background reported worse OHRQoL at 2-year follow-up compared to those from high socioeconomic background. Actions toward health inequalities need to address socioeconomic factors in adolescence.

Presence of Initial Caries Lesions as a Risk Factor for Caries in Preschool Children: A Cohort Study.

The aim of this study was to evaluate the influence of initial noncavitated caries lesions on cavitated caries increment in preschool children. A 2-year cohort study was designed to include the participants of a survey on dental caries performed in 2010. Preschool children (12-59 months old) were examined for dental caries and classified as children with no caries lesions, with only initial lesions, with at least 1 moderate caries lesion, and with extensive lesions. Socioeconomic data were also collected. After 2 years, 466 children were re-examined (follow-up rate of 72.9%) only for cavitated lesions. Association between caries incidence at 2 levels of severity and caries experience and other variables was evaluated using hierarchical Poisson regression analysis. The children with moderate and extensive caries lesions at baseline presented a higher risk of presenting both outcomes than the children with no caries lesions. Nevertheless, the children with only initial lesions had a higher risk of developing at least 1 new cavitated carious lesion, but not for a more severe increment in caries. Subgroup analysis stratified by the children's age showed that the influence of the presence of initial caries lesions on cavitated caries increment was only observed in children aged 12-35 months. In conclusion, although the presence of moderate and extensive lesions at baseline is a significant predictor for cavitated caries increment after 2 years in preschool children at all ages, the presence of only initial caries lesions is also associated, but with less severe caries incidence.

Sensitivity of an oral health-related quality-of-life questionnaire in detecting oral health impairment in preschool children.

AIM: This two-year cohort study evaluated whether the Early Childhood Oral Health Impact Scale (ECOHIS) is responsive to detect changes related to dental caries. DESIGN: Preschool children were examined in 2010 regarding dental caries, and their parents responded to the ECOHIS. After 2 years, 352 children (response rate = 73.6%) were re-examined and a new ECOHIS was responded. Children were categorized according to caries increment (no new caries, 1-3 surfaces with new lesions, and four or more decayed surfaces). The outcome variables were related to the decline of quality of life as determined via ECOHIS: decline, severe decline, and differences between baseline and follow-up scores. Effect sizes (ES) were calculated, and the associations were evaluated through Poisson regression. RESULTS: ES was small for children with 1-3 new lesions (ES = 0.19) and moderate for children with four or more new carious lesions (ES = 0.61). Children who developed 1-3 new lesions were significantly associated with all outcome variables compared to children with no new lesions, but the associations were stronger for children with four or more new carious lesions. CONCLUSIONS: The ECOHIS is sensitive to the deterioration of quality of life due to caries increments in preschool children.

Responsiveness of the Early Childhood Oral Health Impact Scale (ECOHIS) is related to dental treatment complexity.

BACKGROUND: The responsiveness of the Early Childhood Oral Health Impact Scale (ECOHIS) has varied greatly across studies; hence, we hypothesized that this discrepancy could be related to the complexity of dental treatment received. Thus, we aimed to evaluate the responsiveness of the ECOHIS to changes in oral health-related quality of life (OHRQoL) following dental treatments of varying complexity in preschool children. METHODS: Preschool children aged 3 to 6 years were selected; their parents responded to the ECOHIS at baseline. The parents responded to the ECOHIS again and a global transition question 30 days after the children were treated. The type of treatment received by the children was categorized according to complexity, as follows: 1) non-operative treatment only, 2) restorative treatment, and 3) endodontic treatment and/or tooth extraction. Change scores and effect sizes (ES) were calculated for total scores, as well as considering the different treatment types and global transition question responses. RESULTS: Of the 152 children who completed the study, the ECOHIS yielded large ES for total scores (0.89). The children showed increasing ES values associated with better perception of improvement, assessed by the global transition question. The magnitude of ES after treatment was related to treatment complexity (0.53, 0.92 and 1.43, for children who received non-operative treatment only, restorative treatment, and endodontic treatment and/or tooth extraction, respectively). CONCLUSIONS: Parents whose children required more complex dental treatment are more likely to perceive treatment-related changes to OHRQoL assessed with the ECOHIS.

Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study.

AIM: To investigate the risk of sound surfaces, and initial and moderate caries lesions to progress to dentine cavitation in preschool children. DESIGN: A cohort study was designed with 639 children (12-59 months old) who had been examined by visual inspection during a survey in 2010. After 2 years, 469 children were re-examined regarding the presence of dentine cavitations. The probability of progression was calculated for sound and carious (initial and moderate lesions) surfaces. Relative risk of progression and 95% confidence intervals for each condition compared with sound surfaces were calculated using multilevel Poisson regression analysis. Association with explanatory variables, including caries experience of the children, was also investigated. RESULTS: The higher the initial score attributed to the dental surface, the more likely was the progression. Moreover, children with severe lesions at baseline had higher risk of having a sound surface or a non-cavitated caries lesion progressing to cavitation when compared with caries-free children; however, this increased risk was not observed in children with only initial caries lesions. CONCLUSIONS: Initial caries lesions present a low frequency of progression. Moreover, sound surfaces and initial caries lesions in children already presenting cavitations are more likely to progress to more severe conditions.

The Role of School Social Environment on Dental Caries Experience in 8- to 12-Year-Old Brazilian Children: A Multilevel Analysis.

AIM: Although children spend most of their time involved in activities related to school, few studies have focused on the association between school social environment and oral health. This cross-sectional study assessed individual and school-related social environment correlates of dental caries in Brazilian schoolchildren aged 8-12 years. METHODS: A sample of children from 20 private and public schools (n=1,211) was selected. Socio-economic data were collected from parents, and data regarding children characteristics were collected from children using a questionnaire. Dental examinations were performed to assess the presence of dental plaque: dental caries experience (DMFT≥1) and dental caries severity (mean dmf-t/DMF-T). The social school environment was assessed by a questionnaire administered to school coordinators. Multilevel Poisson regression was used to investigate the association between school social environment and dental caries prevalence and experience. RESULTS: The dental caries prevalence was 32.4% (95% confidence interval: 29.7-35.2) and the mean dmf-t/DMF-T was 1.84 (standard deviation: 2.2). Multilevel models showed that the mean dmf-t/DMF-T and DMFT≥1 were associated with lower maternal schooling and higher levels of dental plaque. For contextual variables, schools offering after-hours sports activities were associated with a lower prevalence of dental caries and a lower mean of dmf-t/DMF-T, while the occurrence of violence and theft episodes was positively associated with dental caries. CONCLUSIONS: The school social environment has an influence on dental caries in children. The results suggest that strategies focused on the promotion of healthier environments should be stimulated to reduce inequalities in dental caries.

Community and individual socioeconomic inequalities and dental caries from childhood to adolescence: A 10-year cohort study.

PURPOSE: To evaluate the effect of individual and contextual socioeconomic inequalities in the occurrence of untreated dental caries during the transition from childhood to adolescence. METHODS: This 10-year prospective cohort study followed up an initial sample of 639 1-5 years old schoolchildren from southern Brazil. After 7 and 10 years from the baseline (T1), two other reassessments were conducted (T2 and T3), respectively. Untreated dental caries was measured through the International Caries Detection and Assessment System (ICDAS- scores 3, 5 and 6) at T1 and T3. Socioeconomic status (SES) at the contextual and individual level was assessed at T1. At T2, socioeconomic, behavioural and psychosocial characteristics were evaluated as possible pathways of explanation. Structural equation modelling was used to estimate the direct and indirect effects among the variables over 10 years. RESULTS: A total of 429 adolescents were reevaluated at 10-year follow-up (cohort retention rate of 67.1%). About 30.6% presented untreated dental caries at T3. Low individual SES at T1 directly impacted a higher occurrence of dental caries at T3. Non-white skin colour at T1 also indirectly impacted a higher occurrence of dental caries at T3 through low individual SES at T1 and lower household income at T2. Contextual SES did not predict, directly or indirectly, dental caries at T3. CONCLUSION: There is strong evidence that socioeconomic inequalities at the individual level play an important role on the occurrence of dental caries from childhood to adolescence. On the other hand, there was no evidence that contextual SES influences the occurrence of dental caries over time.

Traumatic dental injury with treatment needs negatively affects the quality of life of Brazilian schoolchildren.

BACKGROUND: Traumatic dental injury (TDI) has been considered a significant problem in youth, not only because of its consequences to the craniofacial structures but also for its potential impact on the quality of life of affected individuals. AIM: The aim of this study was to investigate the impact of TDI with treatment needs on the oral health-related quality of life (OHRQoL) of South Brazilian schoolchildren. DESIGN: A cross-sectional study was performed in Porto Alegre, Brazil, using a multistage probability sampling strategy. Of 1837 eligible 12-year-old schoolchildren attending public and private schools, 1528 were examined. OHRQoL was assessed by the Brazilian version of the Child Perceptions Questionnaire for 11-to 14-year-old children (CPQ11-14) - 16-item short form. Clinical examination was conducted to assess the presence of TDI in permanent incisors (Children's Dental Health Survey criteria), malocclusion, and dental caries. Parents/legal guardians answered questions on socioeconomic status. Statistical analyses were performed using Poisson regression models. RESULTS: The overall CPQ11-14 score was not associated with TDI. In the functional limitations domain, individuals presenting TDIs with treatment needs experienced significantly higher mean CPQ11-14 than individuals with no TDI or without treatment needs (RR = 1.21; 95% CI = 1.05-1.39), after adjusting for malocclusion, dental caries, gender, and socioeconomic status. No other domains were associated with TDI. CONCLUSIONS: This study revealed that TDI with treatment needs negatively affects the OHRQoL in this population of 12-year-old schoolchildren and that this impact is related to oral functions.

Laboratorial training of examiners for using a visual caries detection system in epidemiological surveys.

BACKGROUND: In epidemiological surveys, a good reliability among the examiners regarding the caries detection method is essential. However, training and calibrating those examiners is an arduous task because it involves several patients who are examined many times. To facilitate this step, we aimed to propose a laboratory methodology to simulate the examinations performed to detect caries lesions using the International Caries Detection and Assessment System (ICDAS) in epidemiological surveys. METHODS: A benchmark examiner conducted all training sessions. A total of 67 exfoliated primary teeth, varying from sound to extensive cavitated, were set in seven arch models to simulate complete mouths in primary dentition. Sixteen examiners (graduate students) evaluated all surfaces of the teeth under illumination using buccal mirrors and ball-ended probe in two occasions, using only coronal primary caries scores of the ICDAS. As reference standard, two different examiners assessed the proximal surfaces by direct visual inspection, classifying them in sound, with non-cavitated or with cavitated lesions. After, teeth were sectioned in the bucco-lingual direction, and the examiners assessed the sections in stereomicroscope, classifying the occlusal and smooth surfaces according to lesion depth. Inter-examiner reproducibility was evaluated using weighted kappa. Sensitivities and specificities were calculated at two thresholds: all lesions and advanced lesions (cavitated lesions in proximal surfaces and lesions reaching the dentine in occlusal and smooth surfaces). RESULTS: Regarding the reproducibility, the mean (range) of kappa values was 0.781 (0.529-0.927) for occlusal surfaces, 0.568 (0.191-0.881) for smooth surfaces, and 0.844 (0.698-0.971) for proximal surfaces. Considering all lesions, sensitivity and specificity mean values were respectively 0.724 and 0.844 for occlusal, 0.635 and 0.943 for smooth and 0.658 and 0.927 for proximal surfaces. For detecting advanced lesions, sensitivities and specificities were 0.563 and 0.920 for occlusal, 0.670 and 0.985 for smooth, and 0.838 and 0.985 for proximal surfaces. CONCLUSION: The methodology purposed for training and calibration of several examiners designated for epidemiological surveys of dental caries in preschool children using the ICDAS is feasible, permitting the assessment of reliability and accuracy of the examiners previously to the survey's development.

Early childhood factors in the development of oral health behaviours in adolescence: A structural equation modelling approach.

OBJECTIVES: Oral health behaviour is a learning process that begins in the early years of an individual's life. The aim of this study was to evaluate the associations between demographic, socioeconomic, and psychosocial factors and oral health behaviours during the transition period from childhood to adolescence. METHODS: This was a cohort study with a follow-up of 7 years. The baseline assessment occurred in 2010 with a random sample of 639 preschool children from southern Brazil. Demographic, socioeconomic and psychosocial oral health conditions were assessed at baseline. Oral health habit variables were collected at follow-up and included questions regarding dental care and oral hygiene behaviours. Structural equation modelling was performed to assess the direct and indirect relationships between predictors at baseline in oral health behaviours at follow-up. RESULTS: A total of 449 children were re-examined at follow-up (70.3% cohort retention rate). Factors directly related to poorer oral health behaviours (lower use of dental services, dental visits for emergency reasons and lower frequency of toothbrushing) were lower household income, lower maternal education, lower frequency of visits to neighbours or friends, and male sex. Considering indirect pathways, the household income and maternal education at baseline influenced oral health behaviours at follow-up via visits to neighbours or friends. CONCLUSIONS: Our findings suggest that household income, maternal education and social capital play an important role in the development of oral health behaviours during the transition from childhood to adolescence. Acquisition of healthy oral behaviours is an important factor to consider in childhood. With this knowledge, public health policies can be developed to intervene in specific causal factors and improve oral health during this transitional period.

Social capital and oral health in children and adolescents: A systematic review and meta-analysis.

OBJECTIVES: To systematically evaluate the association of individual and contextual social capital with oral health outcomes in children and adolescents. METHODS: Electronic searches were performed in PubMed/Medline, Embase, Web of Science and Scopus databases for articles published from 1966 up to June 2021. Two calibrated reviewers screened and critically appraised the identified papers. Observational studies that evaluated the relationship of individual or/and contextual social capital or their proxies with oral health outcomes in children and adolescents using validated methods were included. Quality assessment was conducted using the Newcastle-Ottawa Scale. Data were extracted for narrative synthesis and meta-analysis followed by a meta-regression model. Meta-analysis using random effects method was used to estimate pooled prevalence ratio (PR) and 95% confidence intervals (CI). RESULTS: Of the 3060 studies initially retrieved, 31 were included in the systematic review and 21 in the meta-analysis, totalling 81 241 individuals. The clinical outcomes included dental caries and gingival bleeding and subjective outcomes were oral health-related quality of life (OHRQoL) and self-rated oral health (SROH). Individuals with lower levels of individual social capital had a higher prevalence of poor clinical (PR 1.11; 95%CI 1.02-1.22) and subjective (PR 1.25; 95%CI 1.09-1.45) oral health conditions. The prevalence of worse clinical (PR 1.34; 95%CI 1.11-1.61) and subjective (PR 1.56; 95%CI 1.13-2.16) oral health outcomes were also associated with lower levels of contextual social capital. In general, the contextual level of social capital exerted more impact, and the subjective oral health outcomes were the more affected. CONCLUSIONS: Contextual and individual social capital were positively related to oral health outcomes, such as dental caries, gingival bleeding, SROH and OHRQoL in children and adolescents.

Oral health and happiness in adolescents: A cohort study.

OBJECTIVES: To investigate the influence of oral health conditions, socioeconomic status and dental care utilization on subjective happiness and identify the factors associated with changes in happiness among adolescents. METHODS: Data were collected in 2012 and 2014. Oral health conditions were evaluated by performing clinical examinations; socioeconomic status and dental care utilization were assessed by using a questionnaire. The participants answered the Child Perceptions Questionnaire 11-14 for the evaluation of the impact of these variables on oral health-related quality of life (OHRQoL). Happiness was assessed using the Brazilian version of the Subjective Happiness Scale. For longitudinal data analysis, a mixed-effect model of linear regression was used to assess the factors related to happiness and multinomial logistic regression to appraise prospective changes in happiness. RESULTS: A total of 1134 12-year-old adolescents were examined at baseline (response rate: 93%), and 770 were reevaluated after 2 years (retention rate: 68%). The adolescents who lived in households with lower equivalized income and greater overcrowding, had not visited the dentist in the later 6 months, had a higher number of cavitated carious lesions, and reported a higher impact on OHRQoL in 2012 presented lower happiness levels. Additionally, the adolescents with a higher number of decayed, missing or filled teeth and who reported a higher impact on OHRQoL were more likely to belong to the most unfavourable happiness trajectory categories. CONCLUSIONS: The presence of dental caries, socioeconomic conditions, dental care utilization and OHRQoL influence happiness in adolescents. Having more teeth affected by dental caries and worse self-perception in early adolescence can lead to a decrease in happiness.

The vicious cycle of dental fear at age 31 in a birth cohort in Southern Brazil.

OBJECTIVES: This longitudinal study assessed the prevalence of dental fear in adulthood and the association with socio-economic, behavioural and clinical variables. Also, the existence of a vicious cycle of dental fear was tested. METHODS: A random sample of adults (n = 535) from the 1982 Pelotas Birth Cohort, Brazil, was selected. Socio-economic data, behavioural characteristics and clinical variables were collected during different cohort waves. Oral health data were collected at ages 15, 24 and 31 years old, using questionnaires and oral examination. Dental fear (the outcome) was assessed by the question: 'Are you afraid of going to the dentist?', with possible responses: dichotomized into 'No' or 'A little/Yes/A lot'. Exposure variables were as follows: dental visit in the last years (at the ages 15 and 31); caries experience (DMFT ≥ mean) at the ages 15 and 31; the trajectory of caries prevalence from 15 to 31 years old; dental pain in the last six months in the two ages evaluated; and self-rated oral health at age 31. Several multivariable Poisson regression models were used to investigate the association between each of the exposure variables and dental fear. RESULTS: Dental fear prevalence was 22.1%, and it was more prevalent among non-white individuals and females. After controlling for potential confounders, dental fear was more likely to be reported by those individuals who had dental pain or a higher prevalence of dental caries at the age 15. Dental fear was also associated with a worse trajectory of dental caries, negative self-rated oral health at age 31 and with not having visited the dentist in the last year (at the age 31). Results supported the proposed vicious cycle of dental fear. CONCLUSIONS: Dental fear in adulthood was related to exposures occurring across the lifecourse. Also, it was possible to observe the occurrence of the vicious cycle of dental fear in the 1982 Pelotas Birth Cohort. Therefore, preventive measures during different periods of the life course are required to prevent dental fear and adulthood.

Socioeconomic inequalities in the distribution of dental caries in Brazilian preschool children.

OBJECTIVES: This study assessed the inequality in caries distribution and the association between socioeconomic indicators and caries experience of preschool children in a city in Brazil. METHODS: A cross-sectional study in a multistage random sample of 455, 1-5-year-old children was conducted on National Children's Vaccination Day in Santa Maria, Brazil. Calibrated examiners evaluated the prevalence of dental caries and parents provided information about several socioeconomic indicators by means of a semistructured questionnaire. Data were analyzed using Poisson regression model. RESULTS: The caries prevalence was 23.5 percent and the means for the decayed, missing and filled primary teeth was 0.8. A high inequality in the caries distribution with Gini coefficient of 0.8 and Significant Caries Index of 2.8 was observed. The oldest children, non-white, with mothers having low level of education and from low household income had the highest prevalence of dental caries. CONCLUSION: Socioeconomic factors are strong predictors for the inequality in caries distribution in Brazilian preschool children.

The impact of cyberbullying on schoolchildren's dental anxiety in Brazil: A cross-sectional multi-level study.

OBJECTIVES: This cross-sectional study assessed the correlation between individual and school-related social environment variables with dental anxiety in Brazilian schoolchildren aged 8-12 years. METHODS: A sample of children from 20 private and public schools (n = 1211) from Pelotas, Brazil, were selected. Socioeconomic data were collected from parents, and data regarding children characteristics were collected using a questionnaire. Dental anxiety (the outcome) was assessed by the following question: 'Are you afraid of going to the dentist?' Dental examinations were performed to assess caries experience (DMFT ≥ 1). The social school environment was assessed by a questionnaire administered to schools' coordinators and considered: type of school, verbal violence between students, presence of gangs at school and cyberbullying episodes. Multilevel Poisson regression was used to investigate the association between school social environment and dental anxiety. RESULTS: The prevalence of dental anxiety was 9.1% (95%CI 7.5-10.8). For the individual variables, anxiety was more prevalent in girls [1.85 (1.21-2.81)], in children with less-educated mothers [1.50 (1.00-2.27)] and in children who never attended to the dentist [2.48 (1.65-3.72)]. For contextual variables, episodes of cyberbullying in school increased the prevalence of dental anxiety by almost 80% [1.78 (1.14-2.78)]. CONCLUSIONS: The school social environment influences dental anxiety. The results suggest that it is important to establish strategies focused on promoting healthier environments and preventing cyberbullying in order to reduce the occurrence of dental anxiety.

Pathways of socioeconomic inequalities in gingival bleeding among adolescents.

OBJECTIVES: To explore the pathways through which the socioeconomic inequalities may influence gingival bleeding in adolescents, assessing the direct and indirect effects of material and psychosocial variables. METHODS: This cohort study followed a multistage, random sample of 1134 12-year-old adolescents from 20 public schools of Santa Maria, a city in southern Brazil. The percentage of teeth with gingival bleeding was recorded according to the Community Periodontal Index criteria (scored as healthy or bleeding) at baseline and at 2-year follow-up. Biological (dental plaque, caries, and dental crowding), material (socioeconomic position [SEP] operationalized as family income and parents' education), psychosocial (parents' religiosity, self-rated health, and happiness) and behavioural (use of dental service by adolescents) factors were collected at baseline. Structural equation modelling (SEM) was guided by the adapted Commission on the Social Determinants of Health model linking material, psychosocial, biological, and behaviour variables to health. The SEM was employed to estimate standardized direct, indirect, and total effects of material and psychosocial factors on gingival bleeding at follow-up. RESULTS: A total of 770 14-year-old adolescents were reassessed (follow-up rate of 68%). The lower SEP at baseline had a higher direct effect (standard coefficient [SC] = -0.17, P < 0.01) than a mediated effect on percentage of teeth with gingival bleeding at 2-year follow-up. The lower indirect effect (SC = -0.06, P < 0.01) from SEP to gingival bleeding at follow-up ran through biological factors-dental plaque (baseline and follow-up) and gingival bleeding at baseline. The lower religiosity of the parents as a psychosocial aspect had only a small direct effect (SC = -0.10, P = 0.03) on gingival bleeding at follow-up. CONCLUSIONS: Material factors such as SEP contributed most to explanations on inequalities in adolescents' periodontal health because of their higher direct effect and additional shared (indirect) effect (through biological factors) on gingival bleeding. Religious practice as a psychosocial factor only explained part of percentage of teeth with gingival bleeding at follow-up.

Partial-mouth periodontal examination protocols for the determination of the prevalence and extent of gingival bleeding in adolescents.

OBJECTIVE: To compare the performance of partial-mouth periodontal examination (PMPE) protocols with different cut-off points to the full-mouth examination (FME) in the assessment of the prevalence and extent of gingival bleeding in adolescents. METHODS: A cross-sectional study was conducted involving 12-year-old adolescents. Following a systematic two-stage cluster sampling process, 1134 individuals were evaluated. Different PMPE protocols were compared to the FME with six sites per tooth. Sensitivity, specificity, area under the ROC curve (AUC), intraclass correlation coefficient (ICC), relative and absolute biases and the inflation factor were assessed for each PMPE protocol with different cut-off points for the severity of gingival bleeding. RESULTS: The highest AUC values were found for the six-site two-diagonal quadrant (2-4) (0.97), six-site random half-mouth (0.95) and Community Periodontal Index (0.95) protocols. The assessment of three sites [mesiobuccal (MB), buccal (B) and distolingual (DL)] in two diagonal quadrants and the random half-mouth protocol had higher sensitivity and lower specificity than the same protocols with distobuccal (DB) sites. However, the use of DB sites led to better specificity and improved the balance between sensitivity and specificity, except for the two-diagonal quadrant (1-3) protocol. The ≥1 cut-off point led to the most discrepant results from the FME. CONCLUSION: Six-site two-diagonal quadrant (2-4) and random half-mouth assessments perform better in the evaluation of gingival bleeding in adolescents. However, when a faster protocol is needed, a two-diagonal quadrant assessment using only MB, B and DL sites can be used with no important loss of information.