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  Vol  4,  No  1  (2016)   ISSN  2167-­‐8677  (online)   DOI  10.5195/d3000.2016.58      

Multilevel  modeling  for  dental  caries  among  adolescents  in  a  Bra-­‐ zilian  large  city      1

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Giovana  Daniela  Pecharki ,  João  Armando  Brancher ,  Márcia  Olandoski ,  Andrea  Duarte  Doetzer ,  Samuel  Jorge  Moyses ,  Paula  Cris%na  Trevi-­‐ 1 la!o  

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 School  of  Health  and  Biosciences,  Pon&'cia  Universidade  Católica  do  Paraná  (PUCPR),  Rua  Imaculada  Conceição,  Curi'ba,  PR,  Brazil  

Abstract   Dental   caries   is   a   complex   disease,   which   needs   an   approach   that   considers   caries   influenc-­‐ ing  factors  at  different  levels  and  their  integra2on.  Mul$level  Modeling  is  a  clustered  analy-­‐ sis  of  variables  from  the  individual  to  the  community  level.  The  aim  of  this  study  was  to  in-­‐ ves$gate  the  associa$on  of  social  and  biological  factors  grouped  into  hierarchical  levels,  in   students   with   caries.   A   sample   of   687   students   was   evaluated   from   public   and   private   schools   of   Curi,ba.   The   parameters   evaluated   were:   individual   level,   school   level   and   dis-­‐ trict  level.  Individual  variables  had  a  highly  significant  associa6on  with  caries  experience,  al-­‐ so  in  the  presence  of  school  and  district  levels.  Male  sex  nega4vely  associated  with  caries   experience.  However,  the  interac2on  between  male  sex  and  no  fluoride  use  was  posi2vely   associated  with  caries.  Lower  socioeconomic  status,  dental  biofilm,  and  fluorosis  were  as-­‐ sociated  with  caries.  Nevertheless,  the  interac3on  between  dental  biofilm  and  fluorosis  was   nega%vely  associated  with  caries  experience.  The  interac%on  between  no  flossing  and  use   of  public  dental  services  were  also  associated  with  caries  outcome.  Individual  factors  were   associated   with   caries   experience   even   with   the   inclusion   of   contextual   variables   in   the   study  popula+on.  

Cita%on:  Pecharki,  et  al.  (2016)     Mul$level  Modeling  for  Dental  Caries  among   Adolescents  in  a  Brazilian  Large  City.     Den$stry  3000.  1:a001   doi:10.5195/d3000.2016.58   Received:  July  22,  2016   Accepted:    July  29  ,  2016   Published:    October  3,  2016   Copyright:  ©2016  Pecharki,  et  al.  This  is  an  open   access   ar!cle   licensed   under   a   Crea!ve   Com-­‐ mons   A!ribu%on   Work   4.0   United   States   Li-­‐ cense.   Email:  [email protected]

 

Introduction   Dental  caries  is  an  infec-­‐ tious  and  multifactorial  disease.   The  prevalence  of  caries  has  re-­‐ duced  significantly,  including  in   Latin  America  and  Brazil   (DMFT=2.07  for  12  years-­‐old)  [1,2]   possibly  due  to  the  increased   availability  of  fluoride  and  oral   health  programs  [3,2].   Nevertheless,  groups  of   children  have  still  been  showing   high  caries  activity.  It  is  estimated   that  20  to  25%  of  children  and  ad-­‐ olescents  in  Brazil  concentrate  60   to  80%  of  caries  prevalence  [2].   The  phenomenon  of  disease  con-­‐  

 

 

 

centration  in  small  groups  is   termed  polarization  and  repre-­‐ sents  one  of  the  epidemiological   disease  aspects,  where  a  popula-­‐ tion  portion  focuses  most  needs   for  treatment  [2,4].  Thus,  the  early   identification  of  caries  risk  indica-­‐ tors  is  fundamental  for  measures   of  prevention,  control  and  reduc-­‐ tion  of  damage,  with  obvious  epi-­‐ demiological,  human  and  econom-­‐ ical  consequences  [5].  

main  risk  factors  influencing  indi-­‐ vidual  susceptibility  to  caries.   However,  there  has  been  a  shift   from  individual  to  population– level  approach  when  researching   the  risk  indicators  for  chronic  dis-­‐ eases  [10].  As  previously  pub-­‐ lished,  individual  factors  are  usual-­‐ ly  influenced  by  the  population   context  [7,10].  Also,  a  higher  car-­‐ ies  experience  and  a  lower  dental   care  index  (the  ratio  between  the   number  of  filled  teeth  and  DMFT)   Socioeconomic  status  [6],   were  observed  in  children  attend-­‐ oral  health  behavior,  including  diet   ing  public  schools  than  for  those   [7],  gender,  ethnicity  [3]  and  bio-­‐ enrolled  in  private  schools  [3]  and   logical  factors,  such  as  biofilm   in  areas  with  lower  levels  of  em-­‐ formation  and  saliva  properties   powerment  and  income  [11,  12].   [8,9],  have  been  considered  the   There  has  been  seen  significant  

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http://dentistry3000.pitt.edu  

This  journal  is  published  by  the  University  Library  System,  University  of  Pittsburgh  as  part  of  its  D-­‐Scribe  Digital  Publishing  Program  and  is  cosponored   by  the  University  of  Pittsburgh  Press.  

Mul$level  modeling  for  dental  caries  among  adolescents  in  a  Brazilian  large  city     Vol  4,  No  1  (2016)        DOI  10.5195/d3000.2016.58  

variation  in  the  severity  of  caries   between  low-­‐income  neighbor-­‐ hood  clusters.  Indeed,  neighbor-­‐ hood  features  were  seen  to  be  as-­‐ sociated  with  self-­‐reported  oral   health  [13].     Caries  is  a  complex  disease   and  an  approach  that  can  evaluate   the  factors  influencing  the  disease   at  different  levels  and  their  inte-­‐ gration  is  suitable.  To  date  there   are  only  few  studies  evaluating   caries  in  a  multilevel  approach,  

siders  factors  related  to  the  indi-­‐ vidual  together  with  the  commu-­‐ nity  level,  organized  in  hierarchical   levels.  Thus,  the  aim  of  this  study   was  to  investigate  the  association   of  individual  and  community  fac-­‐ tors,  grouped  into  hierarchical   levels  by  Multilevel  Modeling.     Methods   Six  districts  in  Curitiba-­‐  PR,   Brazil  with  similar  socioeconomic   aspects  were  assessed  in  this  

income).  Then,  two  larger  schools   from  each  district,  one  public  and   one  private,  with  a  minimum  of   1500  students,  were  chosen  using   a  table  of  random  numbers  totaliz-­‐ ing  twelve  schools.  All  12-­‐year-­‐old   students  or  those  which  would   complete  this  age  in  the  year  of   the  study  were  invited  to  partici-­‐ pate  on  each  school.  An  informed   consent  form  was  given  to  every   student  caregiver  in  each  school.   Adolescents  whose  caregiv-­‐

Table 1. Districts demographic and socioeconomic aspects. ! !

DISTRICTS' 1!

!

DEMOGRAPHIC! ASPECTS!

2! 3! 4! 5! 6! 155,794! 248,698! 215!503! 197!346! 168,425! 243!506! inhabitants! inhabitants!or! inhabitants!or! inhabitants! inhabitants!or! inhabitants!or! or!8.9%!of! 14.2%!of!the! 12.3%!of!the! or!11.3%!of! 9.6%!of!total! 13.9%!of!the! total! total! total! the!total! Municipality! total! Municipality! Municipality! Municipality! Municipality! ! Municipality! ! 47427! 42125! 41297!M! 42125! 45711! 42087! children!!!!0M children! children!!!!!!0M children!!!!!!!!!! children!!!!!!!! children!!!!!!!!!!!!! 14!years!old! 0M14!years! 14!years! 0M14!years! 0M14!years! 0M14!years!old! (19.1%!of!the! old!(40.4%!of! (20.9%!of!the! (17.3%!of!the! old!(21.2%!of! (25.0%!of!the! regional! the!regional! regional! regional! the!regional! regional! population)! population)! population)! population)! population)! population)! ! ! ! !

!!!!!!!!!!!!!!INCOME! PER!CAPITA!–! 45.9%! 42.5%! 44.3%! 50.4%! 2010*!!!!!!!!!!!(*1! received!over! received!over! received!over! received!over! minimum!wage,!! 1!to!3!MW! 1!to!3!MW! 1!to!3!MW! 1!to!3!MW! MW=!$130)! SOCIOECONOMIC! ASPECTS!

44.9%! 40.0%! received!over! received!over! 1!to!3!MW! 1!to!3!MW!

WATER!SUPPLY!

99.2%!of! households! connected!to! the!water! network!

98.8%!of! households! connected!to! the!water! network!

99.4%!of! households! connected!to! the!water! network!

99.7%!of! households! connected!to! the!water! network!

99.0%!of! households! connected!to! the!water! network!

98.9%!of! households! connected!to! the!water! network!

SEWAGE! NETWORK!

82.7%!of! households! connected!to! sewage! network!

86.6%!of! households! connected!to! sewage! network!

94.8%!!of! households! connected!to! sewage! network!

93.9%!of! households! connected!to! sewage! network!

89.4%!of! households! connected!to! sewage! network!

95.8%!of! households! connected!to! sewage! network!

and  they  do  not  analyze  all  factors   that  may  be  contributing  to  its   complex  development  [7].    Multi-­‐ level  Analysis  is  a  model  that  con-­‐  http://dentistry3000.pitt.edu  

study  (Table  1).  In  Brazil,  the  soci-­‐ oeconomic  status  generally  im-­‐ plies  in  the  type  of  school,  public   (lower  income)  or  private  (higher  

ers/parents  did  not  return  the   consent  form  were  not  included   for  study  along  with  smokers,  or-­‐ thodontic  appliances  users,  and   2  

Mul$level  modeling  for  dental  caries  among  adolescents  in  a  Brazilian  large  city     Vol  4,  No  1  (2016)        DOI  10.5195/d3000.2016.58   Table&2.&Individual)and)contextual)characteristics)of)students)(n=687))and)caries)status.) Frequency& Variables& n& Proportion&of&DMFT≥1&(%)& (%)& ! 687) 100.0) ) Level!1:!Student! ) ) ) Sociodemografic) ) ) ) Ethnic'group' ) ) ) ) White)) 606) 88.2) 48.5a) ) LightD)and)darkDskinned)black) 62) 9.0) 69.3b) ) Yellow) 19) 2.8) 63.2a,b) Sex' ) ) ) ) Female)) 377) 54.9) 52.2ª) ) Male) 310) 45.1) 49.0a) Behavioural) ) ) ) Toothbrushing'frequency) ) ) ) ) 2)or)more/day) 644) 93.7) 49.8ª) ) Until)once/day) 43) 6.3) 65.1ª) Flossing' ) ) ) ) Yes) 443) 64.5) 47.2a) ) No) 244) 35.5) 57.4b)) Fluoride'use'(solution,varnish,gel)' ) ) ) ) Yes) 405) 59.0) 47.4a)) ) No) 282) 41.0) 55.7b) Dental'visits'frequency' ) ) ) ) 2)times)or)more/year) 304) 44.2) 48.7a) ) Once/year) 315) 45.9) 50.8a) ) No) 68) 9.9) 60.3a) Sugar'consumption'between'meals' ) ) ) ) No) 69) 10.0) 50.7ª) ) Yes) 618) 90.0) 50.8ª) Socioeconomic) ) ) ) Dental'access' ) ) ) ) Private) 427) 62.2) 41.4ª) ) Public) 260) 37.8) 66.1b) Individual'socieconomic'status' ) ) ) ) A1/A2)(highest)) 175) 25.5) 32.6ª) ) B1/B2) 310) 45.1) 51.9b) ) C) 166) 24.2) 65.1c) ) D/E)(lowest)) 36) 5.2) 63.9b,c) Clinical) Plaque'Index'(modified)' ) ) ) ) 0) 95) 13.8) 38.9ª) ) >0)and)0.5)mL/min) 522) 76.0) 51.0a) ) ≤0.5)mL/min) 165) 24.0) 50.3a) Salivary'buffering'capacity' ) ) ) ) pH>3.9) 670) 97.5) 50.9ª) ) pH≤3.9) 17) 2.5) 47.1a) Level!2:!School! ) ) ) Type'of'school' ) ) ) )))Private) 334) 48.6) 41.3ª) )))Public) 353) 51.4) 59.8b) Oral'health'education'' ) ) ) )))Yes) 240) 34.9) 52.5a)) )))No) 447) 65.1)) 49.9a) Permission'for'sweet'consumption'' ) ) ) )))Non)permitted) 228) 33.2)) 37.3a) )))Permitted) 459) 66.8) 57.5b) Level!3:!District& ) ) ) Fluoride'concentration'in'water'supply' ) ) ) )))≥0.7)mL/L) 333) 48.5) 49.2a) )))3.9   and  deficient  for  pH≤3.9.     School  level  (level  2)   Twelve  large  schools  were   randomly  chosen,  being  1  public   and  1  private  from  each  of  the  6   health  districts  studied.  Besides   the  type  of  school,  it  was  also  veri-­‐ fied  permission  or  not  for  sweet-­‐

ies’  consumption  in  the  classroom   and  other  areas  in  the  institution   and  the  presence  or  not  of  oral   health  education  programs.   District  level  (level  3)   Means  of  fluoride  concen-­‐ tration  in  water  supply  in  2006   were  obtained  for  6  Health  Dis-­‐ tricts  from  the  Municipal  Health   Secretary  of  Curitiba  and  dichot-­‐ omized  into  0(and(0.5(mL/min((ref)( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ≤0.5(mL/min( (0.641 (0.64(–( (0.631 ( ( ( 0.732( 0.94( 0.729( 0.93( 0.753( 0.94( ( ( 1.37)( 1.37)( 1.40)( Salivary&buffering& ( ( ( ( ( ( ( ( ( ( ( ( ( ( capacity& ( pH>3.9((ref)( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( pH≤3.9( (0.251 (0.25(–( (0.211 ( ( ( 0.484( 0.69( 0.543( 0.72( 0.459( 0.65( ( ( 1.94)( 2.05)( 2.03)(

association  (SSA)  with  the  out-­‐ come,  and  iii)  interactions  at  level   1,  which  have  made  sense  as  hy-­‐ potheses  and  also  demonstrated   SSA.  Interactions  at  second  and   third  levels  did  not  reach  statistical   significance  and  thus  were  not  in-­‐ cluded  in  this  model.  In  Model  5,  it   was  included  i)  all  variables  at  lev-­‐ el  1  which  showed  significance  in   Model  4  ii)  all  variables  at  level  2   and  3,  and  iii)  all  individual  inter-­‐ actions  that  have  made  sense  as   hypotheses  and  showed  signifi-­‐ cance  in  Model  4.  The  results  were   presented  as  odds  ratios  (OR)  and   their  95%  confidence  intervals  (CI).   For  each  logistic  model  the  intra-­‐ class  correlation  (ICC)  was  calcu-­‐ lated  using  an  approach  described   by  Hox  [21].    http://dentistry3000.pitt.edu  

Results   Individuals  from  level  1   (n=687),  schools  from  level  2   (n=12)  and  districts  from  level  3   (n=6)  were  evaluated  in  this  study.   Caries  status  according  to  individ-­‐ ual  and  contextual  aspects  is   shown  in  Table  2.     Out  of  the  students,  338   subjects  (49.2%)  were  caries-­‐free   (DMFT=0)  and  349  (50.8%)  had   caries  experience  (DMFT≥1).  The   mean  DMFT  for  students  with  car-­‐ ies  experience  was  2.88±1.79  and   the  general  mean  DMFT  was   1.46±1.92,  being  1.82±2.05  for   public  and  1.08±1.70  for  private   schools.  

( ( ( (0.88(–( 2.46)( ( ( (1.15(–( 2.77)( (1.01(–( 3.32)( (0.60(–( 3.63)( ( ( ( ( (1.23(–( 3.96)( (2.36(–( 10.37)( ( ( ( ( ( (1.21(–( 8.08)( ( ( ( ( ( (

In  the  exploratory  study,  it   was  observed  an  association  of   caries  experience  with  the  varia-­‐ bles  i)  ethnic  group  (light-­‐  and   dark-­‐skinned  black),  no  flossing,   no  fluoride  use  (solution,  varnish,   gel),  public  dental  access,  lower   individual  socioeconomic  status,   higher  plaque  index,  presence  of   gingivitis  (level  1),  ii)  public  school,   permission  for  candy  or  gum  con-­‐ sumption  (level  2),  and  iii)  worse   living  conditions  in  the  district  so-­‐ cioeconomic  condition  (level  3).  3   presents  the  findings  of  a  multi-­‐ level  logistic  regression  with  the   variable  outcome   DMFT=0⁄DMFT≥1.     Model  1  (Null  Model)   showed  that  the  variation  be-­‐ 6  

Mul$level  modeling  for  dental  caries  among  adolescents  in  a  Brazilian  large  city     Vol  4,  No  1  (2016)        DOI  10.5195/d3000.2016.58  

Table&3&(Continued).&Multilevel(modeling(of(121yr1old(students,(considering(individual,(school(and(district(hierarchical(levels(in(relation(to(caries(experience( ! ( ( ( ( ( ( ( ( ( ( ( ( ( ( LEVEL!2:!SCHOOL! Type&of&school& ( ( ( ( ( ( ( ( ( ( ( ( ( ( Private((ref)( ( ( ( ( ( ( ( ( ( ( ( ( ( ( Public( (0.54(–( (0.501 0.948( 1.02( ( ( ( ( ( ( 0.894( 0.96( 0.796( 0.92( 1.70)( 1.69)( Oral&health&education&& ( ( ( ( ( ( ( ( ( ( ( ( ( ( Yes((ref)( ( ( ( ( ( ( ( ( ( ( ( ( ( ( No( (0.53(–( (0.561 0.676( 0.90( ( ( ( ( ( ( 0.517( 0.85( 0.850( 0.95( 1.38)( 1.61)( Permission&for&candy&or&gum& ( ( ( ( ( ( ( ( ( ( ( ( ( ( consumption&& Non(permitted((ref)( ( ( ( ( ( ( ( ( ( ( ( ( ( ( Permitted( (0.88(–( (0.821 0.228( 1.43( ( ( ( ( ( ( 0.136( 1.51( 0.193( 1.48( 2.61)( 2.68)( ! ( ( ( ( ( ( ( ( ( ( ( ( ( ( LEVEL!3:!DISTRICT& Fluoride&concentration&in&water& ( ( ( ( ( ( ( ( ( ( ( ( ( ( supply& ≥0.7(mL/L((ref)( ( ( ( ( ( ( ( ( ( ( ( ( ( (