Association of Oral Health Literacy and School Factors with Untreated Dental Caries among 12-Year-Olds: A Multilevel Approach

Abstract

Dental caries are a global health problem that affects all age groups and must be considered a public health priority due to its significant financial costs and impact on the quality of life. This study evaluated the association between oral health literacy (OHL), school factors, and untreated dental caries in 12-year-old Brazilian adolescents using a multilevel approach. A population-based cross-sectional study was carried out with 740 adolescents randomly selected from private and public schools in Campina Grande, Brazil. Two dentists were trained and calibrated to diagnose dental caries using the Nyvad index and OHL using the Brazilian Rapid Estimate of Literacy in Dentistry (BREALD-30). The caregivers of the adolescents reported demographic data (sex, skin color, and socioeconomic status). Data of school factors such as the type of school and the school grade retention rate were classified through a 2-step hierarchical cluster analysis to obtain the school environment. A robust multilevel log-linear negative binomial regression for complex samples was performed (p < 0.05). In the analysis, adjusted by individual determinants, nonwhite skin color (RR = 2.20; 95% CI 1.56–3.12), a low socioeconomic status (RR = 1.60; 95% CI 1.09–2.34), a low OHL score (RR = 0.94; 95% CI 0.91–0.98), and low satisfaction with the last dental appointment (RR = 2.25; 95% CI 1.67–3.04) were associated with untreated dental caries. The following factors remained associated with untreated dental caries in the final model: students from an unfavorable learning environment (RR = 2.20; 95% CI 1.27–3.80), nonwhite skin color (RR = 1.92; 95% CI 1.27–2.91), a low socioeconomic status (RR = 1.82; 95% CI 1.12–2.94), a low OHL score (RR = 0.95; 95% CI 0.91–0.98), and low satisfaction with the last dental appointment (RR = 2.07; 95% CI 1.47–2.91). Untreated dental caries in early adolescence were impacted by the school environment, the socioeconomic status, OHL, and the adolescent’s satisfaction with the last dental appointment.

Contributions of school context to caries on anterior teeth: a multilevel analysis

“…A quantitative measure was used in the present study, which is more sensitive to the severity of dental caries since such a measure provides data on the number of teeth affected by caries and not simply the absence or presence of the condition, making the data more robust. A study conducted with 12-year-old adolescents found an average of 1.31 (SD = 2.71) teeth with untreated caries, differing from the present investigation by considering both the anterior and posterior regions 7 . Differences in the prevalence of dental caries between the anterior and posterior regions may be explained by the greater ease of cleaning the anterior teeth.…”

“…Adolescents with inadequate and marginal OHL had more caries than those with adequate OHL. Previous studies with this population demonstrated similar results considering untreated caries in anterior and posterior regions 10,11 , suggesting that low OHL in adolescents is an important issue to address since this determinant affects oral health outcomes in this population 7 . Therefore, appropriate health strategies should be formulated to improve communication between dentists and these individuals 15 .…”

“…The school setting is important to the learning process of adolescents as well as oral health practices 27 . A previous study involving 12-year-old adolescents found that individuals enrolled at public schools and with a higher failure rate (students that held back two or more consecutive times) had a greater number of dental caries in general 7 . Thus, a school environment that does not contribute to learning seems to favor the occurrence of dental caries 30 , likely due to the difficulty in implementing and perpetuating oral health prevention in this environment.…”

“…Studies addressing caries on the anterior teeth are important due to the greater esthetic impact compared to other regions of the oral cavity 4,5 and the negative influence on the quality of life of adolescents 6 . Therefore, it is important to explore individual factors and aspects of the school context associated with untreated caries on anterior teeth, as studies of this nature could contribute to caries control strategies for adolescents 7 , which would have better repercussions in adulthood.…”

“…Associations between untreated dental caries in adolescents and school contextual factors, such as the number of students in the classroom, the number of dental services in the district where the school is located, and the average income of the district, should be explored, as these factors indicate standards to which adolescents are submitted and information on such factors could assist in the establishment of caries prevention policies. Thus, studies that use a multilevel approach could assist in identifying priority groups for oral health actions 7 .…”