ORIGINAL ARTICLE
Age of First Dental Visit and Predictors for Oral Healthcare Utilisation in Preschool Children Thiago Machado Ardenghia/Fabiana Vargas-Ferreirab/Chaiana Piovesanc/ Fausto Medeiros Mendesd Purpose: To assess the age the of the first dental visit and the association of self-perceived oral health, socioeconomic and clinical indicators with healthcare utilisation in Brazilian preschool children. Materials and Methods: An epidemiological survey with 455 5- to 59-month-old children was conducted on National Children’s Vaccination Day in Santa Maria, RS, Brazil. Data about age and reasons for the first dental visit, healthcare utilisation, socioeconomic status and self-perceived oral health were collected by means of a parental semi-structured questionnaire. Calibrated examiners evaluated the prevalence of dental caries (WHO) and dental trauma. The assessment of the association used Poisson regression models (prevalence ratio; 95% confidence interval [CI]). Results: A total of 24.2% (95% CI: 20.3% to 28.4%) of the study sample had already had a first dental visit. Older children, those with dental caries and dental trauma and whose mothers had a higher level of education were more likely to have gone to the dentist. Children of low socioeconomic status were more likely to have visited public than private healthcare services. The reasons for the first dental visit were associated with clinical indicators of the sample. The distribution of utilisation of the types of oral healthcare services (public or private) varied across the socioeconomic groups. Non-white children with dental caries and dental trauma tended to visit a dentist only for treatment reasons. Conclusion: Socioeconomic and clinical indicators are associated with the use of dental services, indicating the need for strategies to promote public health and reorientation of services that facilitate dental access for preschool children. Key words: accessibility, health services, oral health, socioeconomic indicators Oral Health Prev Dent 2012; 10: 17-27
D
isparities in oral healthcare utilisation have been described in terms of socioeconomic and personal behaviours (Antunes et al, 2005; Fisher and Mascarenhas, 2007; Noro et al, 2008; Pizarro et al, 2009). However, in most developing countries, data about child use of dental care services are scarce. In Brazil, the last nation-wide oral health survey showed that 14% of adolescents between 15 and 19 years old had never gone to the dentist a
Adjunct Professor, Department of Stomatology, Federal University of Santa Maria, UFSM, Santa Maria, Brazil.
b
PhD Student of Epidemiology, Department of Social Medicine, Federal University of Pelotas, UFPEL, Pelotas, Brazil.
c
PhD Student of Pediatric Dentistry, Department of Orthodontics and Pediatric Dentistry, University of São Paulo, USP, São Paulo, Brazil.
d
Adjunct Professor, Department of Orthodontics and Pediatric Dentistry, University of São Paulo, USP, São Paulo, Brazil.
Correspondence: Thiago Machado Ardenghi, Rua Cel.Niederauer 917/208, Santa Maria - RS, Brazil 97.015-121. Tel: +55-55-99989694. Email:
[email protected]
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Submitted for publication: 26.09.10; accepted for publication: 22.02.11
(Brasil Ministerio da Saude, 2004). In the same study, regional inequality could be seen in the healthcare services utilisation according to the socioeconomic development of the region, namely, the most developed Brazilian regions have the lowest percentage of people who had never gone to the dentist compared to the least developed regions. Previous studies suggest that such inequalities could explain the reasons for seeking dental care services as well as the age for the child’s first dental visit (Savage et al, 2004; Kramer et al, 2008; Noro et al, 2008). It has been strongly recommended that children see a dentist for a dental screening as early as 6 months of age and no later than 6 months after the first tooth erupts (Ismail et al, 2003; AAPD, 2007). This first dental visit should be a strategy to establish primary prevention for caregivers as well as an early intervention for harmful effects of dental disease (AAPD, 2007; Stijacic et al, 2008). Evidence suggests that children who had
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an early preventive dental visit were more likely to use subsequent preventive services and experience lower dentally related costs (Savage et al, 2004). However, findings from the USA show that 68% of children younger than 18 months old had never been seen by a dentist (Edelstein, 2000). In developing countries, a worse scenario has been demonstrated (Barros and Bertoldi, 2002; Pinheiro and Torres, 2006). Data from an official Brazilian publication showed that 81.9% of children under 4 years old had never gone to the dentist (Pinheiro and Torres, 2006). Recently, a regional finding from Brazil shows that socioeconomic conditions acted as predictors for child use of dental services, with lower socioeconomic status being one of the main reasons for the inequality in the access to healthcare services (Noro et al, 2008). Inequality in the access to healthcare and in the utilisation of dental care services has been receiving increased attention, and several conceptual models have been proposed to address this issue (Pizarro et al, 2009). In general, a clear association between socioeconomic status and the use of dental care services is demonstrated, where the great variability of the outcome is explained by variables such as age, mother’s level of education, race and income (Fisher et al, 2004; Pinilla and González, 2006; Sohn et al, 2007; Freddo et al, 2008). However, data about the interaction of different pathway predictors for dental care utilisation are rarely assessed in Brazilian preschool children. The majority of these studies investigated the use of child dental care services in developed countries. Therefore, the objective of this cross-sectional study was to assess the age and the predictors for the first dental visit in a representative sample of preschoolers living in a southern Brazilian city. This is important from a public health perspective, mainly because these results could serve as a basis for the implementation of public health policies focusing on the reduction of inequality in dental care services utilisation at an early age, as well as to prioritise the target population according to their risk for underutilisation of dental services, which would lead to a better use of resources (Seirawan, 2008).
MATERIALS AND METHODS Ethics The study was approved by the Ethics in Research Committee of the Federal University of Santa Maria,
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and parents’ consent was obtained prior to the study. A letter was given to all parents explaining the aims of the study and asking them for consent for their children to participate in the study. Examiners assured parents there would be no prejudice toward the children who chose not to participate in the study.
Sample A survey was conducted in a representative sample of 1- to 5-year-old children of Santa Maria-RS, Brazil. Santa Maria is a medium-size city located in the south of Brazil, with an estimated population of 263,403 inhabitants including 27,520 children under 6 years old. To explore the association between the use of dental care services and independent variables (our primary outcome), we adopted the following parameters for the sample size calculation: 5% standard error, 80% power, 95% confidence interval, 10% non-response, ratio unexposed to exposed 2:1 and a prevalence ratio to be detected of at least 1.8. As we used a multistage random sample instead of a simple random scheme, respondents tended to be clustered and an adjustment for the sample design of 1.4 was adopted (design effect). The minimum sample size to satisfy the requirements was estimated to be 456 children. For the sample calculation to assess the prevalence of children that had already gone to the dentist (secondary outcome), we adopted the following parameters: standard error 5%, a confidence interval level of 95% and an expected prevalence of 18% (Pinheiro and Torres, 2006). In addition, a design effect of 1.4 and adding 10% to non-response were applied. The minimum sample size to satisfy the requirements was estimated to be 350 children.
Participant selection Participants were randomly selected from children attending a National Day of Children’s Vaccination. The vaccination programme consistently had uptake rates above 97%. A sampling quota was selected from all children attending at health centres in the city of Santa Maria. Health centres were used as sampling points because the city is administratively divided into 5 regions and each has public health centres that are responsible for the vaccination of those living in that area. For this
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study, 8 health centres were cluster selected from a total of 20 health centres of the city. These centres were selected because they represent the major health centres in the city, which corresponds to nearly 90% of the children attending the vaccination programme. During the survey, each fifth child in the queue for vaccination was invited to participate. If parents did not agree to participate, the next parent in the queue was selected. To avoid selection bias, and relatives were excluded. This random process was the same for all 8 health centres.
Data collection Data were collected through clinical oral examinations and structured interviews. Eight examiners and 24 auxiliaries worked in the study. They were previously trained and calibrated for data collection before the survey. The calibration process was performed prior to the survey with a group of dental examiners (n = 10), who had previous experience in epidemiological surveys. Theoretical and clinical training and calibration exercises were arranged for a total of 36 hours. For this purpose, a total of fifteen 12- to 59-month-old children were examined twice by the same examiner with an interval of two weeks between each examination to assess intraexaminer reliability. A benchmark dental examiner conducted the complete examiner training and the calibration process. At the end of the calibration process, the 8 dentists who had the best intra- and inter-reliability scores were selected to work in the survey. Dental examinations were performed at dental offices in healthcare centres under artificial light with a dental mirror and a WHO periodontal probe. Children were examined in a dental chair. Their teeth were dried and examined under standard illumination provided by a conventional operating light. Clinical examination for recording dental caries (WHO, 1997) and dental trauma (O’Brien, 1994) was performed. The examination for dental trauma included only anterior teeth. Data about children’s use of dental services as well the socioeconomic status of the target population were collected by means of a structured questionnaire. The questionnaire presented a series of multiple choice and ‘yes/no’ questions regarding the age at which the child first visited the dentist, reasons for the first dental visit (preventive or other reasons), type of healthcare service used (private or
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public) and sociodemographic characteristics (age, sex, mother’s and father’s level of education, race, family income, caregiver’s perception of child’s oral health and mother’s occupation). The educational level compared those fathers and mothers who completed eight years of formal instruction, which in Brazil corresponds to primary school, with those who only completed a lower education (less than eight years of formal education). Household income was measured in terms of the Brazilian minimum wage, a standard for this type of assessment, which corresponded to approximately 280 US dollars during the period of data gathering. Occupational status distinguished between the employed and unemployed parents. The ethnic groups of the children were assessed according to their mother’s self-report: children were classified as ‘black’ (black children of African and mixed descent) and ‘white’ (children of European descent). The feasibility of the questionnaire was assessed previously in a sample of 20 parents during the calibration process.
Statistical analyses Data analyses were performed using STATA software 9.0 (Stata; College Station, TX, USA). Descriptive, unadjusted analysis provided summary statistics assessing the association between the outcome and predictor variables. Three outcomes were considered in the analyses: (a) prevalence of children who have never gone to the dentist, (b) reasons for the first dental visit (preventive/other than preventive), and (c) type of healthcare service used (public/private). Multivariate Poisson regression models taking into account the cluster sample were performed to assess the association between the predictor variables and the outcomes. This strategy allowed estimating the prevalence ratios among the comparison groups (which correspond to the prevalence of the outcome in the exposed group divided by the prevalence of the outcome in the unexposed group) and their respective 95% confidence interval. A backward stepwise procedure was used to include or exclude explanatory variables in the fitting of the models. Explanatory variables presenting a P value ≤ 0.20 in the assessment of correlation with each outcome (unadjusted analyses) were included in the fitting of the models. Explanatory variables were selected for the final models only if they had a P value ≤ 0.05 after adjustment.
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RESULTS A total of 455 children (mean age = 34 months), 53.8% boys and 46.2% girls, were enrolled in the study. The response rate was 98% of all children invited. Reasons for non-participation were mainly due to children who were not accompanied by their parents on the day of the vaccination. Inter- and intra-examiner agreement for dental caries ranged from 0.80 to 0.90 and from 0.90 to 1.0, respectively. For dental trauma, the values ranged from 0.80 to 0.85 and from 0.85 to 1.0, respectively, for inter- and intra-examiner agreement. Table 1 summarises the demographic characteristics of the sample. Prevalence of caries and dental trauma were 23.5% and 31.5%, respectively. A similar percentage of respondents could be found regarding age and sex. Most of the children were white; their parents mostly presented a high educational level. Near 8 of 10 parents rated their child’s oral health as ‘good to excellent’. More than a half of the mothers were unemployed with a household income equal to or greater than 2 Brazilian Minimum Wages (BMW), which corresponded to nearly 560 US dollars during the period of data collection. Whether or not the children had ever visited the dentist (termed ‘prevalence’ in the following) and factors associated with this are shown in Table 2. The majority of the sample had never gone to the dentist (75.8%). The unadjusted analysis demonstrated that the prevalence of the dental visit was associated with age, mother’s level of education, caregiver’s perception of child oral health, dental trauma and caries. No association was found regarding gender, income, father’s level of education, race or mother’s occupation. In the multiple regression analyses, a set of clinical variables, mother’s level of education and age of the children remained associated with the prevalence of the dental visit after the adjustment. Older children and those with caries and/or dental trauma were more likely to have seen the dentist than their counterparts. Moreover, children whose mothers had a lower level of education were 12% (PR: 1.12, 95% CI: 1.06– 1.42) more likely to have never gone to the dentist when compared to those whose mothers had completed 8 years of formal education. Table 3 expresses the reasons for the child’s first dental visit and associated factors. Unadjusted analyses demonstrate that the prevalence of children who had gone to the dentist for ‘reasons other than preventive’ was associated with age, race, caries and dental trauma. These variables re-
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mained associated with the outcome even after the adjustment. The probability of having visited the dentist for ‘reasons other than preventive’ was 2.10 times higher for children older than 4 years when compared to the younger ones. This probability was 2.22 times higher for non-white than white children, and 2.17 times higher for children with dental trauma than their counterparts. Moreover, children with caries were 2.57 times more likely to have visited the dentist for non-preventive reasons than those who were caries free. The results of Table 4 show that the use of private or public healthcare services was associated with clinical and sociodemographic variables. The majority of the sample had visited public services (61.5%). Unadjusted analyses demonstrated that the variables race, income, mother’s level of education, father’s level of education and caregiver’s perception of child oral health were associated with the prevalence of children that sought care at public services. In the multiple regression analyses, only race and household income remained associated with the prevalence of children who had sought care at public services. Non-white children (PR: 1.38; 95% CI: 1.07–1.76) and those of low household income (PR: 1.87; CI: 1.37–2.55) were more likely to seek care at a public service than were their counterparts.
DISCUSSION This paper analysed the inequity in the use of oral healthcare services in preschoolers and in the age of their first dental visit. In general, our results demonstrated that a high proportion of preschool children had never gone to the dentist and showed an association between socioeconomic status and the use of dental care services. The lower use of oral healthcare services in this age group (Table 2) is similar to the data observed in other population-based studies conducted in Brazil. A study evaluated 1092 Brazilian children of preschool age and showed that only 13.3% of them had already consulted the dentist (Kramer et al, 2008). In contrast, a different study observed that 50.9% of them had had access to dental services at least once in their life (Noro et al, 2008). Previous authors have described that such a low demand for dental care services could be related to socioeconomic status (Jiang et al, 2005) and demographic factors such as race (Antunes et al, 2005), level of education and availability of dental care
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N
Sex
(%)
455
Male
245
53.8
Female
210
46.2
Age (years)
454
≤1
112
24.7
2
103
22.7
3
120
26.4
≥4
119
26.2
Skin colour
455
White
345
75.8
Non-white
110
24.2
Income*
444
≥2 BMW
241
54.3
