|Year : 2018 | Volume
| Issue : 3 | Page : 250-256
Factors associated with dental pain in toddlers detected using the dental discomfort questionnaire
Izabella Barbosa Fernandes1, Patrícia Reis-Sá1, Rafaela Lopes Gomes1, Luciane Rezende Costa2, Joana Ramos-Jorge3, Maria Letícia Ramos-Jorge1
1 Department of Pediatric Dentistry, School of Dentistry, Federal University of Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
2 Department of Pediatric Dentistry, School of Dentistry, Federal University of Minas Gerais, Goiânia, Brazil
3 Department of Pediatric Dentistry, School of Dentistry, Federal University of Goiás, Belo Horizonte, Brazil
|Date of Web Publication||24-Sep-2018|
Dr. Izabella Barbosa Fernandes
Rua da Glória 187, Centro Diamantina, Minas Gerais, 39100000
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dental pain is one of the most common symptoms of untreated oral problems and exerts a strong impact on the well-being of children. Aims: The aim of this study was to evaluate the associated factors with dental pain in children aged 1–3 years using the Brazilian version of the Dental Discomfort Questionnaire (DDQ-B). Methods: A cross-sectional study was conducted in the city of Diamantina, Brazil. A total of 318 randomly selected children were submitted to an oral clinical examination for the evaluation of tooth injuries and dental caries (International Caries Detection and Assessment System, [ICDAS]). The caregivers of the children were asked to answer the DDQ-B as well as a questionnaire addressing demographic and socioeconomic aspects of the family. Statistical analysis was performed and involved the description of frequencies as well as Poisson hierarchical regression analysis. Results: Dental pain was associated with a household income less than the Brazilian minimum monthly wage (Prevalence ratios [PRs] = 1.33, 95% confidence interval [CI]: 1.07–1.66, P = 0.011) and dental caries in dentin – ICDAS codes 5 and 6 (PR = 1.48, 95% CI: 1.13–1.94, P = 0.004). Conclusions: Greater frequencies of dental pain were found in 1–3-year-old children from families with a low monthly income and dental caries with visible dentin with or without pulp involvement.
Keywords: Children, dental caries, dental pain
|How to cite this article:|
Fernandes IB, Reis-Sá P, Gomes RL, Costa LR, Ramos-Jorge J, Ramos-Jorge ML. Factors associated with dental pain in toddlers detected using the dental discomfort questionnaire. J Indian Soc Pedod Prev Dent 2018;36:250-6
|How to cite this URL:|
Fernandes IB, Reis-Sá P, Gomes RL, Costa LR, Ramos-Jorge J, Ramos-Jorge ML. Factors associated with dental pain in toddlers detected using the dental discomfort questionnaire. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2021 Oct 27];36:250-6. Available from: https://www.jisppd.com/text.asp?2018/36/3/250/241964
| Introduction|| |
Dental pain is one of the most common symptoms of untreated oral problems and exerts a strong impact on the well-being of children, with negative consequences to the quality of life.,, Studies report that the prevalence of dental pain among preschool children ranges from 10.1% to 53.4%.,,,, However, specifically, data on children aged 1–3 years are not available in the literature.
The influence of social, demographic, and psychological determinants on dental pain experience in children has been demonstrated.,, Likewise, oral problems, such as ulcerations, tooth injuries, and tooth eruption, have been associated with dental pain,, with untreated dental caries the most strongly associated clinical finding.,
Achieving a reliable description of pain can be challenging with very young children due to cognitive immaturity and the consequent difficulty in perceiving, understanding, remembering, and verbalizing feelings of pain.,, However, dental pain can be recognized through behaviors such as difficulties to eat or to sleep., The Dental Discomfort Questionnaire (DDQ) is an assessment tool used to recognize dental pain in children 2–5 years of age through the reports of parents/caregivers regarding their children's behavior., The DDQ has recently been culturally adapted and validated for use on Brazilian children (DDQ-B).
Most studies addressing factors associated with dental pain have involved adults, adolescents, or schoolchildren. However, investigations involving the evaluation of dental pain in younger children are scarce and have shown that one of the main factors associated with dental pain is dental caries.,,, Still, such studies have failed for the following reasons: they do not use the validated instrument for assessing dental pain in preverbal children and/or evaluate the occurrence of dental caries without detailing the different stages of carious lesions that may or may not associate with pain. This is the first study to evaluate factors associated with dental pain in children aged 1–3 years employing validated tools for assessing dental pain (DDQ-B) and caries (International Caries Detection and Assessment System, [ICDAS]). Moreover, we also sought for the association of dental pain with other potential problems in this age range, i.e., traumatic dental injuries and symptoms during tooth eruption (teething).
The use of this tool for the assessment of dental pain in children <5 years of age constitutes an opportunity to gain a better understanding of dental pain experience in the primary dentition. Such knowledge is fundamental to the establishment of priorities in public health-care policies for areas in which dental caries is highly prevalent.
The aim of the present study was to evaluate the prevalence of dental pain and associated factors in children aged 1–3 years using the Brazilian version of the DDQ (DDQ-B).
| Methods|| |
This study received approval from the Human Research Ethics Committee of the Universidade Federal dos Vales do Jequitinhonha e Mucuri (Brazil) under process number 470.863. All parents/caregivers received clarifications regarding the objectives of the study and signed a statement of informed consent.
A cross-sectional study was conducted in the city of Diamantina, which is located in the northern portion of the state of Minas Gerais in southeast Brazil. Children aged 1–3 years were selected from a list provided by the State Secretary of Health of individuals who used public health services during vaccination campaigns in 2013 and 2014. Efforts were made to maintain the proportion of the sample in relation to age. A simple randomization procedure was performed to determine the children for inclusion in the study and ensure representativeness. The parents/caregivers of the selected children were asked to appear at the pediatric dentistry clinic of the Universidade Federal dos Vales do Jequitinhonha e Mucuri.
A pilot study was then performed with a sample of 32 children aged 1–3 years and their parents/caregivers to test the data collection methods and acquire information for the determination of the sample size of the main study. The sample in the pilot study was not included in the main study and no changes to the methods were deemed necessary.
The sample size was calculated based on a 25% prevalence rate of dental pain experience (determined during the pilot study), a 95% confidence interval (CI), and a 5% standard error. The minimum sample size was determined to be 288 child–parent/caregiver pairs, to which 15% was added to compensate for possible dropouts. Thus, the total sample was 330 child–parent/caregiver pairs.
For inclusion in the study, the parents/caregivers needed to be fluent in Portuguese, have adequate reading skills, and are the main caregiver, spending at least 12 h/day with the child, including the period of sleep. Children with systemic health problems that required medical assistance and greater care on the part of the parents/caregivers were excluded from the study.
The parents/caregivers of the selected children were asked to bring their child to the pediatric dentistry clinic of the university. On the day scheduled, the parents/caregivers were instructed to answer the DDQ-B as well as another questionnaire addressing sociodemographic aspects and characteristics of the child and family. The oral clinical examinations of the children were also performed for the evaluation of dental caries and traumatic dental injury.
Before the data collection, two examiners and two interviewers underwent training exercises. The two interviewers were trained for the reading and intonation of each question as well as the response options. The two examiners underwent training for the diagnosis of untreated dental caries using the criteria of the ICDAS and for the evaluation of traumatic dental injury using the criteria proposed by Andreasen and Andreasen. Training occurred in two steps. First, images of different clinical situations of untreated dental caries and traumatic dental injury were shown. Second, three examiners, one of whom was considered the gold standard, performed two clinical examinations with a 14-day interval between occasions on a sample of 50 4- and 5-year-old children selected for the determination of inter- and intra-examiner agreement regarding the different clinical conditions. Minimum Kappa coefficients were 0.83 and 0.86, respectively.
Sociodemographic information and characteristics of child and family
A questionnaire was created to gather information of sociodemographic aspects as well as characteristics of the child and family. This questionnaire was administered to the parents/caregivers in interview form. The interviewers were blinded to the clinical conditions of the children. The parents/caregivers provided information on the child's age, sex, family situation (nuclear or nonnuclear), type of preschool or day-care center (none, private, or public), the child's access to a dentist (yes or no), mother's age (≤25 years or >25 years), number of child's siblings (none, one, two, or more), mother's schooling (years of study), household income (categorized based on the Brazilian monthly minimum wage, which was equivalent to US$ 255.58 at the time of the study), and number of individuals who depended on the household income (≤3 or >3 individuals). The parents/caregivers were also asked about the occurrence of signs and symptoms associated with tooth eruption in their children such as increased salivation, increased temperature, loss of appetite, irritability, itchy gums, and sleep disorders.
Dental discomfort questionnaire
The DDQ is a tooth pain assessment tool for children <5 years of age that was originally developed in the Netherlands. This questionnaire has been adapted and validated for use on Brazilian children (DDQ-B). The DDQ-B was designed as a self-administered questionnaire for parents/caregivers that is composed of seven items on different behaviors possibly associated with dental pain or discomfort due to untreated caries, such as crying during meals or difficulty chewing. For each item, the respondent is asked to state how often the child demonstrated a given behavior. The response options are “never” (scored 0), “sometimes” (scored 1 point), and “often” (scored 2 points). The total score is calculated by the sum of the response options, with higher scores denoting greater dental pain experience.
Oral clinical examination
Two examiners performed the clinical examinations under artificial light following prophylaxis and air drying of the teeth. The children were examined seated on a dental stretcher for children, and the parents/caregivers held very young children when necessary. Untreated dental caries was evaluated using the ICDAS criteria. Each tooth surface was evaluated and classified based on the stages of dental caries (independently of lesion activity) as initial lesions (ICDAS codes 1 and 2), established lesions (ICDAS codes 3 and 4), and severe cavitated lesions (ICDAS codes 5 and 6). Each child was classified based on the most advanced stage of tooth decay, that is, if a child had one tooth surface with an initial lesion and another with a severe lesion, only the latter was recorded.
Traumatic dental injury as well as signs and symptoms of tooth eruption were also evaluated. The clinical diagnosis of traumatic dental injury was performed using the criteria proposed by Andreasen and Andreasen, including the evaluation of tooth discoloration. The findings were recorded as either absent or present.
Data analysis was conducted using the (Statistical Package for the Social Sciences for Windows, version 20.0, SPSS Inc., Chicago, IL, USA). Descriptive analysis and frequency analysis were performed for all DDQ-B items. The independent variables were sociodemographic aspects and characteristics of the child and family (mother's schooling, household income, number of individuals who live on income, type of preschool/day care center, child's access to a dentist, child's sex, child's age, family situation, number of siblings, parent's/caregiver's age, and occurrence of dental pain in parent/caregiver) as well as oral clinical conditions (untreated dental caries, traumatic dental injury, and signs and/or symptoms related to tooth eruption). The dependent variable was dental pain evaluated using the DDQ-B assessed by the total score.
The variables were grouped into a hierarchy of categories ranging from distal to proximal determinants: Sociodemographic aspects, characteristics of the family, child's characteristics, and oral clinical conditions (in that order). On each level, Poisson regression analysis with robust variance was used to test the strength of associations between the total DDQ-B score and each independent variable. This analysis was performed to eliminate variables with a P ≥ 0.20. After adjusting for variables on the same or previous levels, explanatory variables with P < 0.05 were maintained in the final models. Prevalence ratios and 95% CI were calculated.
| Results|| |
A total of 330 children aged 1–3 years were initially included in the study, 318 (96.4%) of whom participated through to the end. Twelve children appeared at the pediatric dentistry clinic of the university accompanied by an individual who was not the main caregiver and were therefore excluded from the study.
Mean age of the children was 29.04 months (standard deviation [SD] = 10.01 months) and the female sex accounted for 53.8% of the sample (n = 165). The prevalence of dental caries was 65.1%, with 21.1% of the children presenting initial lesions (ICDAS codes 1 and 2) as the worst stage in the oral cavity, 8.8% presenting established lesions (ICDAS code 3 and 4), and 35.5% presenting severe cavitated lesions (ICDAS codes 5 and 6). A history of traumatic dental injury was found in 26.1% of the children. The majority of mothers (51.6%) had 9–12 years of schooling. Household income was between one and two times the Brazilian monthly minimum wage among 47.5% of the families.
The mean DDQ-B score was 2.42 (SD = 2.31). [Table 1] shows the distribution of the responses to each item of the DDQ-B. The most frequent items reported by the parents/caregivers were “suddenly cries at night,” “puts away [refuses] something nice to eat,” and “bites with molars instead of front teeth.”
|Table 1: Distribution of Dental Discomfort Questionnaire-B responses in survey of parents in population-based sample (n=318)|
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Mother's age, mother's schooling, monthly household income, severe dental caries, and a number of erupted teeth were associated with higher DDQ-B scores (P < 0.05) in the univariate analysis [Table 2]. In the multivariate model, a lower monthly household income (PR = 1.33, 95% CI: 1.07–1.66, P = 0.011) and severe dental caries (ICDAS codes 5 and 6) (PR = 1.48, 95% CI: 1.13–1.94, P = 0.004) were associated with higher DDQ-B scores [Table 3].
|Table 2: Univariate analysis for association between oral clinical conditions, characteristics of children, sociodemographic and economic factors in relation to dental pain (Dental Discomfort Questionnaire-B)|
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|Table 3: Final Poisson regression model for covariates associated with Dental Discomfort Questionnaire-B|
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| Discussion|| |
This study investigated factors associated with dental pain detected using the Brazilian version of the DDQ-B. This is the first study to determine such associations in children aged 1–3 years using a validated pain assessment tool. Strong associations were found between dental pain and both cavitated dental caries and monthly household income. These findings are of considerable importance to gaining a better understanding of the determinants of pain in childhood and can assist in the establishment of priorities in public health policies directed at young children and their families. Considering the impact on the growth and well-being of affected children, the study of dental pain is relevant.
The only oral clinical condition associated with higher DDQ-B scores was severe dental caries. The association between dental pain and dental caries experience has also been reported in previous studies.,,, More advanced stages of dental caries require more invasive treatment and involve greater pain experience, thereby restricting the daily activities of affected children. This finding is in agreement with data described in studies addressing the impact of the severity of caries of the quality of life of preschool children., Thus, it is of extreme importance for pain to be recognized in children aged 1–3 years and for appropriate treatment to be instituted to eliminate pain and the negative impact of this condition exerts on quality of life.
Besides dental caries, other oral problems, such as traumatic dental injury and symptoms associated with tooth eruption, are also reported to be possible reasons for the occurrence of dental pain. However, no such associations were found in the present study, which was likely due to the low prevalence of severe traumatic dental injuries (0.7%) and reports of the occurrence of teething in nearly the entire sample (87.8%).
As in the present investigation, the association between tooth pain and socioeconomic factors has been described in the literature,,,,,, which may be the result of inequalities in the distribution of dental caries that are influenced by such factors. Cultural or behavioral theories seek explanations for health with regard to social classes., The social component exerts a strong influence on access to health-care services, reflecting the negative effects of a low socioeconomic status. Moreover, socioeconomic differences can exert an important influence on parents'/caregivers' perceptions. Studies have demonstrated that parents/caregivers with a lower socioeconomic status have more pessimistic opinions and are more prone to evaluating their children's oral health as poor in comparison to those with a higher socioeconomic status.,
Although the present study offers original evidence, the cross-sectional design does not permit the determination of causality among the variables analyzed. Thus, studies with a prospective design are needed to clarify the associations found in this investigation.
While self-reports are the gold standard for the evaluation of dental pain, parents/caregivers are considered the best available proxy for individuals with incomplete cognitive development., The DDQ-B is a reliable, useful assessment tool for the investigation of behaviors related to dental pain in children <5 years of age. Thus, this questionnaire can serve as an important tool in the organization of health-care services and the application of oral health promotion policies directed at children aged 1–3 years.
All in all, this report stresses the occurrence of dental pain in children as young as 1-year-old, which is associated with dental caries severity. This outcome emphasizes the need to initiate educational and preventive programs on oral health from the 1st year of a child's life.
| Conclusions|| |
Greater frequencies of dental pain were found in 1–3-year-old children from families with a low monthly income and dental caries with visible dentin with or without pulp involvement.
We show our appreciation to the members of Babies Oral Health Group (BOHG), for promoting, organizing and conducting all procedures related to this study and others. The contributors are: Túlio Silva Pereira, Ana Beatriz Rodrigues, Hlorrany Jayne Barroso de Queiroz, Janine Emanuelle de Almeida Gomes, Priscila Seixas Mourão, Valéria Silveira Coelho, Anny Karoline Silva Mercês, Tássio Alvim Corrêa de Barros, Felipe Alisson Prates Mota.
Financial support and sponsorship
This study was financially supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Fundação de Amparo à Pesquisa de Estado de Minas Gerais (Fapemig) and Coordenação de Avaliação e Melhoramento de Pessoal de Educação Superior (CAPES).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]