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Original Paper

Caries Res 2012;46:102–106 DOI: 10.1159/000336387

Untreated Cavitated Dentine Lesions: Impact on Children’s Quality of Life

S.C. Leal a E.M. Bronkhorst b M. Fan d J.E. Frencken c

a Department of Dentistry, Faculty of Health Sciences, University of Brasília, Asa Norte , Brazil; b Department of Preventive and Restorative Dentistry and c Department of Global Oral Health, College of Dental Sciences,Radboud University Nijmegen Medical Centre, Nijmegen , The Netherlands; d Wuhan University, School and Hospital of Stomatology, Wuhan , China

Oral health-related quality of life (OHRQoL) is a mul-tidimensional concept which reflects people’s comfort when eating or sleeping, and their satisfaction with respect to their oral health [Surgeon General, 2000]. Oral prob-lems, including dental pain, malocclusion and untreated dental caries lesions, have a negative impact on the quality of life of adolescents [Mashoto et al., 2009; Piovesan et al., 2010], while the presence and severity of early childhood caries affect preschool children’s quality of life, according to their parents [Abanto et al., 2011]. It has been shown that functional limitations that result from oral health prob-lems are associated with worse health perceptions, which are linked to lower quality of life [Baker et al., 2010].

Although the most recent epidemiological survey in Brazil showed that the mean dmf-t score for 5-year-old children decreased in the last decade, 80% of the den-tine cavities remained untreated [Brazilian Ministry of Health, 2010], a scenario also found in many other coun-tries in different parts of the world [Cadavid et al., 2010; Singh et al., 2011]. Relevant consequences of cavitated dentine lesions such as pain and chewing difficulties can affect the child’s learning and growth processes [Pourat and Nicholson, 2009] and are related to the need for chil-dren’s hospitalization [Wadhawan et al., 2003]. There-fore, the consequences of untreated cavitated lesions on both children and their families’ quality of life need to be investigated.

Different instruments have been developed that aimto assess the well-being and quality of life with regard to

Key Words

Child � Dental caries � Oral health � Quality of life � Toothache � Tooth extraction

Abstract

The aim of the present investigation was to assess the impact of dental caries prevalence and the consequences of un-treated cavitated dentine lesions on quality of life of 6- and 7-year-old Brazilian children. A total of 826 schoolchildren were assessed using ICDAS and pufa (to score consequences of dental caries on soft tissues) indices. History of extraction and toothache was recorded. Oral health-related quality of life was assessed using the Brazilian version of the Early Childhood Oral Health Impact Scale (B-ECOHIS). A multiple logistic regression model was used to analyze the relation-ship between the prevalence of dentine carious lesions, pufa, history of extraction and toothache with the B-ECOHIS scores. A total of 587 questionnaires were analyzed. The prevalence of cavitated dentine lesions and pufa was 74.8 and 26.2%, respectively. Some 21.8% of children reported toothache and 9.2% had had at least one tooth extraction. The chance (OR) for children with cavitated dentine lesions, pufa 6 1, history of extraction and toothache of having high-er B-ECOHIS scores than those not affected was 1.90 (95% CI: 1.18–3.06), 6.26 (95% CI: 3.63–10.83), 6.87 (95% CI: 2.75–17.16) and 3.68 (95% CI: 2.12–6.39), respectively. Children’s quality of life was negatively influenced by untreated cavitated den-tine lesions and their consequences.

Copyright © 2012 S. Karger AG, Basel

Received: October 11, 2011 Accepted after revision: December 21, 2011 Published online: March 6, 2012

Prof. S.C. Leal Campus Darcy Ribeiro, Departamento de Odontologia Faculdade de Ciências da Saúde, Universidade de Brasília – Asa Norte Brasília-DF, CEP 70710-900 (Brazil), Tel. +55 61 8118 4949 E-Mail sorayaodt   @   yahoo.com, or for Prof. M. Fan: kqyywjtx   @   public.wh.hb.cn

© 2012 S. Karger AG, Basel0008–6568/12/0462–0102$38.00/0

Accessible online at:www.karger.com/cre

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Caries and Quality of Life Caries Res 2012;46:102–106 103

oral health, particularly for the adult population. These instruments vary in length and measure different di-mensions and domains [Slade, 1997]. However, the as-sessment of children’s OHRQoL is more complicated, as their comprehension of what is being assessed can be af-fected by factors such as age and cognitive development [McGrath et al., 2004].

Canadian researchers have developed a series of ques-tionnaires, Child Oral Health Quality of Life, in which the child is targeted [Jokovic et al., 2002]. These question-naires are related to three different age groups: 6–7, 8–10 and 11–14. The first questionnaire has not been tested; the latter two have. More recently, another questionnaire, called Early Childhood Oral Health Impact Scale (ECO-HIS), was presented, tested [Pahel et al., 2007] and vali-dated in the Brazilian Portuguese language [Tesch et al., 2008; Scarpelli et al., 2011]. Although it was developed for 2- to 5-year-old children, it was based on a pool of items derived from previously tested questions aimed at assess-ing oral health problems of 6- to 14-year-old children and their families.

The present study aimed to investigate the impact of the prevalence of cavitated dentine lesions in primary teeth and the consequences of untreated cavitated den-tine lesions on the quality of life of Brazilian low-income schoolchildren, through the application of the Brazilian version of the ECOHIS (B-ECOHIS).

Subjects and Methods

Study Population An epidemiological survey that was part of a cost-effectiveness

study was carried out in Paranoá, a low socioeconomic suburban area of Brasília, Brazil’s Federal District. This community pre-sents the lowest income per capita per month amongst all satellite cities in Brasília, and therefore, is categorized as low social class.

All 6- to 7-year-old children registered in grades 1 and 2 at all six public schools from Paranoá were invited to participate in the study. Children whose parents did not sign the informed consent form and those with special needs which did not allow the oral examination were excluded.

The research protocol was approved by the local Human Re-search Ethics Committee (081/2008) and registered at the Dutch Trial Registration Centre (1699).

Oral Examination Prior to the dental examination, three examiners participated

in a calibration exercise carried out in children of comparable ages to those that were enrolled in the epidemiological survey. The training for pufa index was part of the calibration exercise that was performed as follows: 1 day of theory; 5 days of calibrating the examiners, using 5 children each day; 5 days of determining the reliability amongst the 3 examiners, on ten 6- to 7-year-old

children per day. The calibration exercise for pufa was based on a Power Point program that was received from the originators of the index. An experienced epidemiologist supervised the examiners during the training sessions in assessing dental caries using the ICDAS II index [ICDAS Coordinating Committee, 2009] and in determining the consequences of untreated cavitated dentine le-sions, using the PUFA/pufa index [Monse et al., 2010] ( table 1 ).

The examinations were performed at the schools in a well-equipped dental unit (two schools) and on the school compound or in the office of the four other schools using portable equipment comprising a bed, light source and compressor air.

The history of dental extraction due to dental caries was re-corded and children were asked whether or not they had tooth-ache at the moment of the dental examination. For those who said yes, children were asked to point out in the mouth which tooth was painful. Teeth were brushed immediately before the assess-ment of caries and the recording of the consequences of untreated cavities for primary teeth.

OHRQoL Assessment OHRQoL was assessed using the B-ECOHIS, which is a ques-

tionnaire that comprises 13 questions, divided into two sections. The first 9 questions are related to the oral health impact on the child’s quality of life (child section) while the last 4 questions con-cern the oral health impact on the quality of life of the child’s par-ents (family section).

The ECOHIS was created aiming to provide a short instru-ment to assess the impact of oral problems and related treatment experiences on the quality of life, which could be used in epide-miological surveys to discriminate between children with and without dental disease experience [Pahel et al., 2007].

The B-ECOHIS was sent out to the parents of the children that took part in an epidemiology survey. Parents were contacted by phone to reinforce the need for filling in the questionnaire. Those questionnaires that were returned fully completed were consid-ered for analysis.

Data Analysis The data were analyzed by a biostatistician using SPSS, version

16. A multiple logistic regression model was used to analyze the

Table 1. C odes and description of the pufa index for primary den-tition

Code Description

p Pulpal involvement: the opening of the pulpal chamber is visible or the coronal tooth structures have been destroyed by caries and only roots or root fragments are left

u Ulceration due to trauma: sharp edges of a dislocated tooth with pulpal involvement or root fragments have caused traumatic ulceration of the surrounding soft tissues

f Fistula: presence of pus realizing sinus tract related to a tooth with pulpal involvement

a Abscess: presence of pus-containing swelling related to a tooth with pulpal involvement

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Leal   /Bronkhorst   /Fan   /Frencken   Caries Res 2012;46:102–106104

relationship between the caries-related variables: prevalence of dentine carious lesions in primary teeth (yes/no), pufa (0 or 6 1), history of extraction (yes/no) and toothache (yes/no) with theB-ECOHIS scores. For this purpose, the B-ECOHIS score was di-chotomized using its median value (0.33) as a cutoff point.

Results

Of the 826 children that were examined, 587 returned the questionnaires, which gave a response rate of 71%. The final sample comprised 296 boys and 291 girls with a mean age of 6.3 8 0.47 years.

The outcomes of the epidemiological part of the study, including kappa coefficients for intra- and interexaminer agreement, were reported in detail by de Amorim et al. [2011] and showed a high level of reliability.

Toothache was reported by 21.8% of the children and 9.2% of them had already been subjected to a tooth ex-traction due to caries. The prevalence of cavitated lesions (ICDAS II codes 5 and 6) was 74.8% and its mean score was 4.82 (SD: 3.1). The prevalence of pufa was 26.2%.

Of the 128 children that reported pain, 70 (55%) also reported a positive score for one of the pufa scores, show-ing an association between pufa and toothache (p ! 0.001).

There was a statistically significant relationship be-tween the caries-related variables and the B-ECOHIS scores (p ! 0.01). The chance that children with at least one cavitated dentine lesion would have higher B-ECO-HIS scores was about twice as high as for those without a cavitated dentine lesion (odds ratio, OR = 1.90; 95% con-fidence interval, 95% CI: 1.18–3.06). Children with pufa 6 1 (OR = 6.26; 95% CI: 3.63–10.83), those with a history of extraction (OR = 6.87; 95% CI: 2.75–17.16) and those with toothache (OR = 3.68; 95% CI: 2.12–6.39) had a high-er chance of having higher B-ECOHIS scores than their peers that were not affected by these conditions ( table 2 ).

Discussion

Usually, children’s oral health problems are investigat-ed through the use of clinical measurements, like the DMFT index for dental caries assessment. The results ob-tained with this type of data collection do not provide much insight into the consequences of oral diseases for children’s lives [McGrath et al., 2004]. For that reason, OHRQoL assessment has been widely recommended as a complementary tool to better understand the impact of oral health problems on the individual’s daily perfor-mance. Besides that, the outcomes derived from the as-sessment of OHRQoL are considered a better instrument for communicating with policy makers than merely the use of a quantitative measure such as the DMFT index and are, therefore, vital to planning oral healthcare pro-grams and providing access to care [Allen, 2003; al Sham-rany, 2006].

One of the difficulties encountered during the orga-nization of the present study was related to the absence of an instrument specifically developed and tested to as-sess children’s OHRQoL at the age of 6. Probably, this is the reason that no publication related to the OHRQoL among 6- and 7-year-olds was found. Most of the publi-cations in this field investigated adolescents, either through the application of the Children Perception Questionnaire [Locker, 2007; Piovesan et al., 2010] or through the Child-Oral Impact on Daily Performance [Mashoto et al., 2009].

The ECOHIS is an instrument designed for use with 2- to 5-year-old children. It should be filled in by the child’s parents and has the potential to be applied in epi-demiological surveys to discriminate between children with and without dental disease experience [Pahel et al., 2007]. Taking all available arguments into account, the B-ECOHIS was considered the best instrument to be used in the present investigation. Although self-reporting is considered the best way of measuring perceived quality of life, parent proxy-reporting is a good alternative when age, cognitive impairment or health condition are limita-tions to the use of self-reporting instruments [Varni et al., 2007].

This is the first time that the level of well-being of young children has been related both to the presence of untreated cavitated dentine lesions and to its consequenc-es, such as cavities with pulpal involvement, teeth with abscesses and fistulas, and toothache. With regard to the four dental caries-associated variables investigated in the present study, the presence of untreated cavitated dentine lesions was the one that impacted least on the children’s

Table 2. Results of multiple logistic regression between caries-related variables (yes/no) and oral health-related quality of life assessed using B-ECOHIS

Caries-related variables p OR 95% CI

pufa <0.001 6.26 3.63–10.83Toothache <0.001 3.68 2.12–6.39History of extraction <0.001 6.87 2.75–17.16Cavitated dentine lesion 0.004 1.90 1.18–3.06

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quality of life. Children that had had a tooth extraction due to caries, those presenting pulp exposure, fistula and abscess, and those that reported toothache at the moment of the oral examination had increased chances of also having higher B-ECOHIS scores, showing that both child and family quality of life were affected by the child’s oral health condition.

It has been claimed that self-reporting of toothacheby young children might lead to underreporting, owing to the recall bias. To overcome this problem, reportingby parents/guardians can be used [Ratnayake and Eka-nayake, 2005]. Nevertheless, the assessment of clinical consequences of untreated dentine caries lesions also presents the same problem of underreporting when a cross-sectional investigation is being performed. The manifestation of dental abscesses can be episodic [Pine et al., 2006]. It means that an underestimation of sepsis as a result of the dental caries process might also occur. In addition, it has already been shown that toothache, for preschool children, is mostly associated with the pres-ence of root remnants, fistula and pulp caries [Moura-Leite et al., 2008]. For that reason, the report of toothache at the time of the clinical examination allowed the inves-tigators of the present study to obtain a more realistic picture of the association between toothache and pufa scores. Our results showed that in more than half of the cases in which toothache was reported by the child, it was associated with the presence of one of the pufa scores. These clinical findings support the reported responses by parents that children with toothache and those posi-tive to pufa were negatively impacted in terms of quality of life, indicating the probable absence of an underscore of these conditions as retrieved from the B-ECOHIS questionnaire.

Surprisingly, history of extraction was a variable amongst those tested that was strongly related to OHRQoL. It is obvious that a 6- or 7-year-old child who has had a tooth extracted has gone through the entire process of carious lesion development and probably end-ed up with toothache which may or may not be associated with sepsis manifestation. The treatment of extraction can be very traumatic for such a young child. In theory, these arguments can explain the great impact of history of extraction on the child and family’s quality of life. However, this hypothesis needs to be tested and should be the focus of further investigations.

These findings are extremely relevant and are consid-ered the most important outcome of the current study. Although it was not possible to compare the prevalence of the consequences of untreated cavitated dentine le-

sions found in this study with other studies carried out in populations of comparable age, the results of the present study highlight the necessity of identifying communities in which these problems occur in order to better plan oral health programs. If children at an early age are already facing difficulties in different aspects of life (oral func-tion, appearance, etc.) due to dental caries, which is a pre-ventable disease, it means that the present oral health promotion and preventive programs are not effective in controlling the disease. It also tells the dental commu-nity – researchers, policy makers and practitioners – that the common way of assessing dental caries lesions, through the exclusive use of clinical parameters, is insuf-ficient to portray the severity of caries and its conse-quences on people’s daily lives.

The socioeconomic background of the children in-cluded in the present investigation is also an aspect that requires attention. The community selected for this in-vestigation presents the lowest income per capita per month (EUR 137) amongst all satellite cities of Brasília [CODEPLAN, 2008]. This fact can partially explain the high scores of dental caries lesions and the high number of untreated cavitated dentine lesions, which led to an expressive report of toothache (21.8%) by the children themselves. This scenario reflects the lack of oral health promotion and prevention programs and highlights a serious problem that the oral health authorities of Paranoá district need to deal with [Figueiredo et al., 2011]. These findings are in accordance with the litera-ture that shows a well-established link between dental caries, disparities in access to dental care and social eco-nomic status [Oliveira et al., 2008; Edelstein and Chinn, 2009]. More recently, the relationship between socioeco-nomic inequalities and Brazilian adolescents’ OHRQoL was shown, indicating that socioeconomic status and OHRQoL should be taken into consideration in the planning of oral health programs [Piovesan et al., 2010]. Moreover, based on the prevalence of toothache, par-ticularly among vulnerable groups such as poor and low-income adults and children, toothache has been proposed as a potential quality indicator that reflects disparities in oral health for a population [Lewis and Stout, 2010].

In summary, the incorporation of tools that assess se-vere consequences of the carious process, such as pufa, and those tools that impact on an individual’s quality of life, such as the ECOHIS for young children, would great-ly benefit the understanding of the disease, its behavior and its effects in a specific community. Oral health ac-tivities should then be developed to satisfy the needs of

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that community, increasing the people’s quality of life and improving the effectiveness of existing oral health programs.

It can be concluded that Paranoá children’s quality of life was negatively influenced by the presence of untreat-ed cavitated dentine lesions and their consequences (fis-tula, abscess and pulp exposure), history of extraction and toothache.

Acknowledgments

The authors thank the children, parents, directors and teach-ers of the public schools in Paranoá for participating in the study. They are grateful to FAP-DF Brasilia (Fundação de Apoio à Pes-quisa do Distrito Federal), Brazil and the Radboud University Ni-jmegen, The Netherlands, for financially supporting the study. A special thanks to all dentists who participated in this study.

Disclosure Statement

None of the authors have any financial or personal conflict of interest to declare.

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