ABSTRACT
The concept of quality of life (QoL) developed from early studies on subjective wellbeing and satisfaction with life, interpreted as resulting from living conditions, and recognized by means of objective indicators. Indicators have been developed and validated to measure the relationship between quality of life and health Aim: To determine, during an Educational Social Practice, the association between presence of dental caries lesions and its impact on quality of life of adolescents living in rural and urban areas in Argentina.
Materials and Method
This was an observational cross-sectional study in (a) a rural area (Tres Isletas; Chaco Province/Schools No. 601 and 477) and (b) an urban area (Villa Soldati; Buenos Aires City/Nuestra Sra. Fátima School). The sample included 40 students from the urban area (UG) and 30 from the rural area (RG). A calibrated researcher (Kappa 0.80) collected the survey data and performed the clinical examinations. The following were recorded: (a) sociodemographic distribution in terms of age and gender; (b) presence of dental biofilm according to Silness and Löe; caries lesions according to ICDAS II /INTCy criteria, and (d) DMFT, total and per component. Quality of life was assessed using the CPQ 11-14r. Statistical processing included calculation of frequency distribution of the variables (X± DS), and chi-square and Mann-Whitney tests to calculate association and comparisons between groups.
Results
The sample included 47 girls (67.1%) and 23 boys (32.9%). Distribution according to sex and age did not differ significantly between sites (UG:12.9 years ± 0.5 and RG:11.8 years ±1.1). No significant difference was found between sites for a) plaque biofilm (p=0.759); b) DMFT, total value and per component, or c) individual and grouped ICDAS scores. Percentage analysis of the CPQr 1-14 scores showed significant differences between groups for questionnaire total scores (26.9% ± 2.2 in UG and 4.1% ± 0.8 in RG) and for the different domains.
Conclusion
Perceived impact on quality of life caused by dental caries lesions was significantly higher in urban than the rural group, although neither the dental caries process nor the amount of biofilm differed significantly between groups.
Keywords: quality of life, dental caries, population gr
RESUMEN
El concepto de calidad de vida (CV) se desarrolló a partir de estudios tempranos sobre bienestar subjetivo y satisfacción con la vida3, interpretado como resultante de las condiciones de vida empleando para su reconocimiento. Para medir su relación con la salud se han desarrollado y validado indicadores.
Objetivo
Determinar la asociación entre presencia de lesiones de caries dental y el impacto que producen sobre la calidad de vida de adolescentes residentes en áreas rural y urbana República Argentina), en un caso de Practica Social Educativa.
Materiales y Método
Estudio observacional de corte transversal en (a) área rural (Tres Isletas; Provincia Chaco/escuelas N° 601 y N° 477) y (b) área urbana (Villa Soldati; CABA/ escuela Nuestra Sra. Fátima). La muestra incluyó 40 escolares residentes en área urbana (GU) y 30 residentes en área rural (GR). Un investigador calibrado (Kappa 0.80) realizó el relevamiento de datos y el examen clínico Se registraron (a) distribución sociodemográfica en términos de edad y género; (b) presencia de biofilm dental segùn Silness y Löe; lesiones de caries según criterios ICDAS II /INTCy (d) cálculo de CPOD total y por componente. La calidad de vida fue evaluada mediante cuestionario CPQ 11-14r. El procesamiento estadístico incluyó cálculo de distribución de frecuencias de las variables (X± DS) y las pruebas chi cuadrado y Mann- Whitney.para calcular asociacion y comparaciones. entre grupos.
Resultados
La muestra incluyó 47 mujeres (67,1%) y 23 hombres (32,9%). La distribución según sexo y edad no mostró diferencias significativas entre las sedes (GU:12,9 años ± 0,5 y GR:11,8 años ±1,1). No se encontraron diferencias significativas entre las sedes al comparar a) biofilm de placa (p=0,759); b) CPOD, valor total y por componentes y c) códigos de ICDAS individuales y agrupados. El análisis porcentual del índice CPQr 1-14 reveló diferencias significativas en el puntaje total (26,9% ± 2.2 en GU y 4,1% ± 0.8 en GR) y en los respectivos dominios del instrumento.
Conclusión
: La percepción del impacto sobre la calidad de vida generado por las lesiones de caries dental resultó significativamente mayor en los escolares urbanos que en los rurales, aunque ni el proceso de caries dental ni la cantidad de biofilm encontrados en cada grupo, revelaron diferencias significativas.
Palabras clave: calidad de vida, caries dental, grupos de población
INTRODUCTION
The Department of Preventive and Community Dentistry at Buenos Aires University’s School of Dentistry (FOUBA) coordinates education, clinical care and research within the different subjects taught. In doing so, it undertakes to generate knowledge, implement that knowledge in real scenarios, and develop competencies that will ensure the quality of care provided and the safety of the population covered. Developing protocols to implement knowledge in real scenarios involves specific steps, which include the identification of problems and potential evidence-based solutions, and the analysis of the local and institutional situations. It is also necessary to know about the association between oral health problems and the impact on quality of life perceived by the social actors involved.
It has been demonstrated that people or communities have a perception of the impact of diseases on quality of life, lifestyle, and even on availability of care 1 , 2 . Within this framework, models have been developed on care of dental caries lesions interpreted as therapeutic expression of NCCD (non-communicable chronic diseases), even based on knowledge of genetics and epigenetics. These models have oriented diagnosis and therapy approaches.
The concept of quality of life (QoL) developed from early studies on subjective wellbeing and satisfaction with life 3 , interpreted as resulting from living conditions, and recognized by means of objective indicators 4 . However, this concept was criticized by Shen and Lai 5 , who incorporated cultural, economic and political criteria. Bishop et al. 6 , Michalos 7 , and Caqueo et al. 8 , 9 related quality of life to subjective wellbeing and satisfaction with life 10-12 , and Cummins 13 recognizes social psychology studies as a theoretical framework 14-21 .
The WHO currently interprets quality of life as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a multi-dimensional concept influenced by the person’s physical health, psychological status, level of independence, social relations, and relationship with the environment, and constitutes a dynamic process ruled by the values and criteria of wellbeing, satisfaction and multidimensionality, and includes subjective/
objective contents 22-25 .
Indicators have been developed and validated to measure the relationship between quality of life and health. The Child Perception Questionnaire CPQ11-14 26 assesses self-perceived oral health status in early adolescents. It is organized into four domains: oral symptoms (OS), functional limitation (FL), emotional wellbeing (EW) and social wellbeing (SW). The original version consists of 47 multiple choice questions, and based upon it, abbreviated versions containing 16 and 8 items have been developed and duly validated ( ISF-16 and ISF-8 , respectively) 27-30 . Evidence shows the negative association between the extent of the pathology and quality of life estimated by the OHRQol 31 questionnaire, and that treatment of dental caries lesions improves perceived quality of life in children and adolescents 32 . The aim of this study was to determine the association between dental caries lesions and perceived impact on quality of life in a case of educational social practice conducted in rural and urban areas in Argentina on students in the 6th grade of basic schooling.
MATERIALS AND METHOD
Analysis of the situation in the territorial context: Tres Isletas (Chaco Province, Argentina) and Villa Soldati (Comuna 8, Buenos Aires City, Argentina)
Tres Isletas, population is 16,976 (INDEC, 2010), is a town in the center-north of Chaco Province (Argentina) and is the municipal seat of Maipú Department. It is accessed via the paved Carretera 95 (national) and Carretera 9 (provincial), while the other access roads are unpaved (Ruta Provincial 46 and Ruta Provincial 27). The town is located in the warm tropical zone with dry season, with mean annual temperature 21 °C. Healthcare is available at “Nueva Alianza” Healthcare Center and Hospital “Jorge O. Vázquez”.
The district Comuna 8 in Buenos Aires City comprises the neighborhoods Villa Soldati, Villa Riachuelo and Villa Lugano, among which Villa Soldati has the second highest population density, with surface area 8.6 Km2 and population 46,779 (2010). The district’s urban fabric is characterized by fragmentation. It has reasonable road infrastructure, with public transportation, highways and large avenues.
Villa Soldati has two level 1 healthcare centers (CESAC No. 6 and No. 24) dependent on the programmatic area of Hospital Piñeiro. CESAC 6 provides healthcare activities including clinical medicine, nursing, pharmacy, speech and hearing therapy, general medicine, nutrition, obstetrics, dentistry, pediatrics, psychology, educational psychology, OBGYN, and includes social work. CESAC No. 24 provides, among other specialties, anthropology, nursing, speech and hearing therapy, gynecology, physiotherapy, education, general and/ or family medicine, nutrition, obstetrics, dentistry and social work.
Institutional intervention scenarios
The educational social practices in the rural area were conducted at two government-run rural schools in Tres Isletas , Maipú Department , Chaco Province: (a) School No. 601 for Personalized Special Education (Paraje Lalelay) and (b) School No. 477 (M. M. Güemes) for Basic General Education.
The practices in the urban area were conducted at the school Nuestra Sra. de Fátima (Villa Soldati; Comuna 8, Buenos Aires City), a privately managed, coeducational, extended-shift religious school, which depends on Buenos Aires City’s Ministry of Education
The study sites had not participated previously in educational extension programs provided by the Department of Preventive and Community Dentistry run by Buenos Aires University’s School of Dentistry (FOUBA).
Sample
The sample consisted of 40 6th graders from Nuestra Sra. de Fátima school (Urban Group: UG) and 30 6th graders from the schools in Tres Isletas (Rural Group: RG).
Diagnosis and statistical analysis
On-site research was conducted by a single researcher calibrated for gathering data (Kappa: 0.80)
Analysis of sociodemographic distribution
Sociodemographic distribution in terms of age and gender was analyzed in both groups. The frequency distribution of the variables in the CPQr 11-14 questionnaire was established, including identification of students’ language comprehension level according to reports from local teams of teachers (Argentine Ministry of Education and Sport, 2016).
Analysis of dental plaque biofilm and dental caries lesions
Each child was diagnosed for plaque biofilm according to the de Silness/Loe Index 33 , and for dental caries lesions according to the DMFT index. Lesions per tooth were recorded according to the ICDAS 2 and INTC 34 criteria.
Results from the two sites were compared using Mann-Whitney’s U test.
Analysis of perceived impact of caries lesions on Quality of Life
Data on quality of life were gathered in compliance with ethical and legal requirements. The questionnaire CPQ 11-14 (abbreviated version 8) validated in Spanish and adjusted for semantic equivalence was applied. No suggestions were provided on how it should be completed.
Perceived impact of dental caries on quality of life was recorded and analyzed for both groups, per domain and per item, applying the independence test (chi-square).
RESULTS
Analysis of the sample
The total sample included 47 girls (67.1%) and 23 boys (32.9%) ( Table 1 ).
Table 1. Distribution of total sample according to zone of residence and gender.
| n | % | ||
|---|---|---|---|
| GENDER | Male | 23 | 32.9% |
| Female | 47 | 67.1% | |
| TOTAL | 70 | 100.0% | |
| ZONE OF RESIDENCE | BUENOS AIRES CITY | 40 | 57.1% |
| TRES ISLETAS | 30 | 42.9% | |
| TOTAL | 70 | 100.0% | |
Mean age was 12.9 years ± 0.5 in the urban area and 11.8 years ±1.1 in the rural area. In the urban area, mean age was 13 years ± 0.3 for girls and 12.9 years ± 0.7 for boys. In the rural area, mean age was 11.9 years ± 1.1 for girls and 11.8 years ± 0.9 de for boys ( Table 2 ).
Table 2. Age according to zone of residence and gender.
| SAMPLE | AGE | ||||||
|---|---|---|---|---|---|---|---|
| ZONE OF RESIDENCE | n | GENDER | n | Mean | Median | Standard error | |
| BUENOS AIRES CITY | 40 | Male | 11 | 12.9 | 13.0 | 0.7 | |
| Female | 29 | 13.0 | 13.0 | 0.3 | |||
| TRES ISLETAS | 30 | Male | 12 | 11.8 | 11.5 | 0.9 | |
| Female | 18 | 11.9 | 11.5 | 1.1 | |||
Distribution per sex did not differ significantly between sites.
Analysis of dental plaque biofilm and dental caries lesions
Plaque biofilm valúes (Silness/Loe Index) did not differ significantly (p=0.759) between sites. Subjects’ caries history (DMFT and components D, M or F) did not differ significantly between sites, as shown by the Z value ( Table 3 ).
Table 3. Comparison of dental caries lesions (DMFT) between sites.
| STATISTICAL TECHNIQUE | INDICATOR | |||
| D/DMFT | M/DMFT | F/DMFT | DMFT | |
| Mann-Whitney's U test | ||||
| 565.500 | 562.000 | 530.000 | 585.500 | |
| Wilcoxon's W | 1030.500 | 1382.000 | 1350.000 | 1050.500 |
| Z | -0.412 | -0.866 | -1.010 | -0.173 |
| Asymptotic Sig. (bilateral) | 0.680 | 0.386 | 0.312 | 0.863 |
No significant difference was found between groups for dental caries lesion values, including ICDAS levels 1 and 2 ( Tables 4 and 5 ).
Table 4. Active dental caries lesions (ICDAS II) at both sites.
| DENTAL CARIES LESIONS | SITES | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BUENOS AIRES CITY | TRES ISLETAS | TOTAL | |||||||||||
| Mean | Median | Standard deviation | Standard error | Mean | Median | Standard deviation | Standard error | Mean | Median | Standard deviation | Standard error | ||
| ICDAS 1 | 0.1 | 0.0 | 0.6 | 0.109 | 0.0 | 0.0 | 0.2 | 0.031 | 0.1 | 0.0 | 0.4 | 0.047 | |
| ICDAS 2 | 0.8 | 0.0 | 1.7 | 0.310 | 1.1 | 0.0 | 1.8 | 0.126 | 0.9 | 0.0 | 1.7 | 0.203 | |
| ICDAS 3 | 3.4 | 3.0 | 2.9 | 0.521 | 3.0 | 2.5 | 3.3 | 0.521 | 3.2 | 3.0 | 3.1 | 0.370 | |
| ICDAS 4 | 0.8 | 0.0 | 1.9 | 0.346 | 0.4 | 0.0 | 1.1 | 0.173 | 0.6 | 0.0 | 1.6 | 0.191 | |
| ICDAS 5 | 1.1 | 0.0 | 1.5 | 0.273 | 1.5 | 1.0 | 1.8 | 0.284 | 1.3 | 1.0 | 1.6 | 0.191 | |
| ICDAS 6 | 1.7 | 0.0 | 3.2 | 0.584 | 2.0 | 0.0 | 3.3 | 0.521 | 1.9 | 0.0 | 3.2 | 0.382 | |
Table 5. Results of comparison between active dental caries lesions recorded at the two sites. Comparison between active dental caries lesions recorded at the two sites.
| Statistical technique | Comparison between active dental caries lesions recorded at the two sites | |||||
|---|---|---|---|---|---|---|
| ICDAS 1 | ICDAS 2 | ICDAS 3 | ICDAS 4 | ICDAS 5 | ICDAS 6 | |
| Mann-Whitney's U test | 589.000 | 556.000 | 528.000 | 546.500 | 502.000 | 562.500 |
| Wilcoxon's W | 1054.000 | 1376.000 | 993.000 | 1011.500 | 1322.000 | 1382.500 |
| Z | -0.372 | -0.626 | -0.866 | -0.936 | -1.243 | -0.514 |
| Asymptotic Sig. (bilateral) | 0.710 | 0.531 | 0.387 | 0.349 | 0.214 | 0.607 |
There were significant differences between sites for perceived impact of dental caries lesions on quality of life, both considering the average CPQ 11-14 scores, which were 26.9% for UG and 4.1% for RG, and per domain.
Mean scores on the scale, recorded per domain and per item, differed significantly ( Table 6 ).
Table 6. Correlation between mean scores for total CPQr and domains at the sites.
| CPQr 11-14 | SITES | N of the sample | Mean | Standard Deviation | Standard Error | p |
|---|---|---|---|---|---|---|
| Oral Symptoms | Buenos Aires City | 40 | 3.23 | 1.75 | 0.28 | 0.001 |
| Tres Isletas | 30 | 1.30 | 1.37 | 0.25 | ||
| Total | 70 | 2.40 | 1.85 | 0.22 | ||
| Functional Limitation | Buenos Aires City | 40 | 2.38 | 1.92 | 0.30 | 0.001 |
| Tres Isletas | 30 | 0.13 | 0.43 | 0.08 | ||
| Total | 70 | 1.41 | 1.85 | 0.22 | ||
| Emotional wellebeing | Buenos Aires City | 40 | 1.78 | 1.85 | 0.29 | 0.001 |
| Tres Isletas | 30 | 0.07 | 0.25 | 0.05 | ||
| Total | 70 | 1.04 | 1.64 | 0.20 | ||
| Social wellbeing | Buenos Aires City | 40 | 1.23 | 2.01 | 0.32 | 0.001 |
| Tres Isletas | 30 | 0.00 | 0.00 | 0.00 | ||
| Total | 70 | 0.70 | 1.63 | 0.19 | ||
| Total | Buenos Aires City | 40 | 8.60 | 4.54 | 0.72 | 0.001 |
| Tres Isletas | 30 | 1.30 | 1.37 | 0.25 | ||
| Total | 70 | 5.47 | 5.07 | 0.61 |
DISCUSSION
Social determinants of health are recognized as factors, conditions or circumstances that influence the level of health in individuals and populations, condition general health, and affect and influence the oral component. They have been conceptualized 35 with translation to health systems 36 by authors who have analyzed the consequences of social determinants on the creation of inequities. Lask and Fosson 37 recognized situations that generated predisposing, precipitating, perpetuating and protective factors, and Frenk 38 posed the existence of basic, structural and immediate context determinants.
Eid et al. 39 demonstrated that: a) Egyptian adolescents with DMFT<3 or DT = 0 had significantly lower CPQ scores11_14, with valúes of p<0.01 and p<0.0001, respectively; b) untreated caries lesions were associated with mothers’ lower socioeconomic and educational level, and with less regular dental appointments, determining a significant negative impact on 11- to 14-year-olds’ QoL 32 .
Cadenas de Llano-Pérula et al. 40 evaluated prevalence of caries and malocclusion in urban and rural areas in Perú and compared them to perceived oral health. They found that caries experience and untreated caries lesions were associated with lower socioeconomic level, lower level of maternal education and less frequent toothbrushing, leading to a significant negative impact on students’ QoL.
In a critical review on low income and poor oral health, Singh et al. 41 summarized evidence on associations between individual/family income and oral health and the inequalities related to those variables. Studies in the US, Japan and Brazil have shown associations between unequal income in given areas and poor oral health, even though that evidence is not conclusive due to the differences in context and in dental care.
The findings in the current study support the importance ofincluding, in educational social practice projects or studies on populations, an analytical component including family sociodemographic variables, mapping analysis to identify causes and effects of the problem under study, and adequate prioritization of alternatives for solutions. The findings also support the importance of recognizing the perception of dental caries lesions as one of the factors involved in healthcare and provide a basis for the need to increase relevant learning among young adolescents in rural or marginal urban areas by means of intersectoral association between academia and healthcare services.
CONCLUSIONS
Perceived impact of oral health on quality of life was significantly higher among urban than rural stu-dents, although no significant difference was found between groups either in the dental caries process or in quantity of biofilm.
Footnotes
FUNDING
None.
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