Impact of dental pain on daily living of five-year-old Brazilian preschool children: prevalence and associated factors.
Abstract: AIM: To assess the impact of dental pain on the daily living of 5-year-old preschool children using reports from parents/guardians. DESIGN AND METHODS: A cross-sectional study was carried out involving 549 five-year-old children randomly selected from preschools in the city of Belo Horizonte, Brazil. Data were collected using a previously validated parent-reported questionnaire. The children received dental examinations from a single calibrated examiner. The following outcome variables were selected: age, gender, dental caries, filled teeth, missing teeth, caries involving pulp and social class. Simple and multiple logistic regression analyses were performed on the data. RESULTS: According to parents' reports, 11.1% of children were affected by dental pain in the previous 4 months and of these 72.6% had their daily activities hampered by pain. The majority of these children had difficulty in eating, brushing teeth, sleeping, playing and going to school. The impact of dental pain had a statistically significant association with gender (p = 0.001), social class (p = 0.009), dental caries (p < 0.001), missing teeth (p < 0.001), filled teeth (p < 0.001) and caries involving pulp (p < 0.001). CONCLUSION: The prevalence of difficulties performing tasks of daily living due to dental pain was relatively high among the children studied.

Key words: Dental pain, impact, preschool children
Article Type: Report
Subject: Dental caries (Care and treatment)
Preschool children (Diseases)
Prevalence studies (Epidemiology) (Usage)
Authors: Moura-Leite, F.R.
Ramos-Jorge, J.
Ramos-Jorge, M.L.
Paiva, S.M.
Vale, M.P.
Pordeus, I.A.
Pub Date: 12/01/2011
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Dec, 2011 Source Volume: 12 Source Issue: 6
Geographic: Geographic Scope: Brazil Geographic Code: 3BRAZ Brazil
Accession Number: 277106790
Full Text: Introduction

A number of studies have reported that dental pain exerts considerable impact on the psycho-social wellbeing of children [Shepherd et al., 1999; Agostini et al., 2001; Moura-Leite et al., 2008]. Conditions such as oral ulcers, dental trauma, gingivitis and dental caries can cause pain and have an impact on daily living [Slade, 2001]. The prevalence of dental pain among children with untreated caries in the primary dentition ranges from 46-67% [Levine et al., 2002; Moura-Leite et al., 2008]. Although caries is the main cause of dental pain, a large proportion of 5-year-olds experience dental pain due to physiological causes such as mobility and the eruption of permanent teeth [Moura-Leite et al., 2008].

Dental caries is a highly prevalent childhood disease in Brazil [Peres et al., 2005; Ferreira et al., 2007]. The evaluation of the impact of dental pain on the daily living of the children could provide useful data for the establishment of public oral health policies as well as preventive measures and treatment priorities [Moura-Leite et al., 2008]. The current use of specific assessment tools for the determination of associations between oral health and quality of life serves as a complement to clinical indicators in children [Goursand et al., 2008]. Experts report that parents may be the best proxy measures available for preschool children [Versloot et al., 2006; Moura-Leite et al., 2008]. The few assessment tools applicable to the preschool population are in the process of cross-cultural adaptation and validation for use in Brazil [Tesch et al., 2008].

The aim of the present study was to evaluate the impact of dental pain on the daily living of 5-year-old Brazilian preschool children, using reports provided by parents/guardians.

Materials and methods

Sample characteristics

A cross-sectional study was carried out on 549 male and female 5-year-old children attending public or private preschools in the city of Belo Horizonte, Brazil. The participants were selected from a population of 35,026 5-year-olds (58% of whom were enrolled in preschools) and constituted a representative sample of 5-year-old preschool children in the city in question. Belo Horizonte is the capital of the state of Minas Gerais (Brazil) and is an industrialised city with considerable economic, social and cultural disparities. The city has approximately two million inhabitants and is geographically divided into nine administrative districts.

To ensure sample representativity, distribution was determined in proportion to the actual distribution among preschools in the city. Initially, the percentage distribution of 5-year-old children living in each district was calculated from information furnished by local authorities (Health Council and Education Council). Participant distribution was then determined in proportion to the population of each respective school system using data from the sample size calculation. Eighteen preschools (nine public and nine private) were randomly selected. In order to provide each individual in the study population an equal chance of being included, a second set was selected using the list of names furnished by each preschool. The sample size was calculated to give a standard error of 4.5%. A 95% confidence interval and 23.8% prevalence of dental pain [Feitosa et al., 2005] were used for the calculation. A correction factor of 1.5 was used to increase precision due to the fact that multi-stage sampling was adopted rather than a random sampling technique [Kirkwood and Stern, 2003]. The minimum sample size to satisfy the requirements was estimated at 516 children (344 x 1.5 = 516). To compensate for possible losses during data acquisition, the sample size was increased by 12%, totalling 578 preschool children (516 + 12% = 578).

Non-clinical data acquisition

Authorisation to undertake the study was obtained from the schools and day care centres. After meetings with the directors of the institutions, a letter of presentation, informed consent forms and questionnaires were left with the teachers to be distributed to the children for delivery to parents/ guardians. The questionnaire was developed in England and has been validated in Brazil [Shepherd et al., 1999; Barreto et al., 2004]. It contains 21 items on the occurrence of past experiences with dental pain, socio-demographic data and the impact of pain on the child's life. Parents were asked about the occurrence of dental pain over the child's lifetime as well as in the previous four months. Information was gathered on the child's gender, family's social class and the presence/absence of impact from dental pain in the previous four months on the child's quality of living (outcome variable).

The Social Vulnerability Index (SVI) was used for the determination of socio-economic status. This index measures social exclusion in the city of Belo Horizonte and encompasses over 20 variables that quantify access to housing, schooling, income, employment, legal assistance, health and nutrition. Thus, the SVI measures social access to basic services and determines to what extent the population of each district of the city is vulnerable to social exclusion [Nahas et al., 2000]. The SVI score ranges from 0 to 1, for which values closer to 1 indicate greater social vulnerability or worse living conditions. These scores were calculated for each administrative district in a previous study carried out in Belo Horizonte [Nahas et al., 2000; Moura-Leite et al., 2008]. The children's SVI scores were determined based on the respective index score for the neighbourhood in which they live. As children usually live near their preschools and this social environment is similar to that of their homes, the administrative district in which the preschool was located was used for the social classification.

Clinical data acquisition

The children were examined at either the school or day care centre. Examinations were carried out by a single dentist (FM), who had participated in a calibration exercise for the criteria used to identify each clinical condition investigated. Twenty-four children participated in the calibration process. The criteria of the World Health Organisation were used for the diagnosis of dental caries. Filled teeth with the need for restoration were classified as filled and decayed. Intra-examiner agreement on a tooth-by-tooth basis was high (minimal and maximal Cohen's kappa values: 0.75 and 1.00, respectively). Training for the clinical diagnosis entailed the use of colour photographs displaying the major clinical characteristics of each condition of interest and the conditions to be considered for the differential diagnosis. Examinations were performed during daytime class hours, with the examiner seated in front of the child, who remained standing. A dental headlight (PELTZ[R], Tikka XP, Crolles, FR) and disposable mouth mirror (PRISMA[R], Sao Paulo, SP, Brazil) were used. The examiner visited each school on two separate occasions to compensate for absenteeism and used appropriate individual cross-infection protection equipment. Dental instruments and materials were packed and sterilised in sufficient quantities for each workday.

Pilot study

The methods were tested in a pilot study with a sample of 50 children. The children in the pilot study did not participate in the main study. The results of the pilot study indicated no need for any modifications to the methods.

Ethical considerations

The study received approval from the Human Research Ethics Committee of the Universidade Federal University de Minas Gerais (Brazil). Parents/guardians signed statements of informed consent.

Statistical analysis

Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS for Windows, version 15.0, SPSS Inc, Chicago, IL, USA). Data analysis included descriptive statistics (frequency distribution and cross-tabulation). Statistical significance was determined for associations between the impact of dental pain on quality of life and the following variables: gender, dental caries, missing teeth, filled teeth, caries involving pulp and social vulnerability. Simple logistic regression was first carried out for each variable. All variables were then included in the model to adjust for the possible contribution of each explanatory variable. The level of significance was set to 5% (p < 0.05).


The response rate was higher than expected, resulting in a sample size larger than the minimum size estimated to satisfy the requirements. A total of 578 questionnaires were distributed to parents/guardians, 549 of which were returned completely filled out (response rate: 95.0%). The age of the children ranged from 60-71 months (mean: 66 months). Males accounted for 50.1% of the sample and 49.7% were from the most vulnerable social classification.

Table 1 displays the prevalence (95% CI) of dental pain in the 549 children and the impact of pain in the previous four months. Dental pain hampered activities of daily living in the previous four months in 11.1% of the overall sample (95% CI: 8.5 to 13.7). When considering only the children who had experienced dental pain in the previous four months (n = 84), activities of daily living were hampered in 61 children (72.6%) (95% CI: 63.1 to 82.1), the majority of whom experienced difficulty eating, brushing teeth, sleeping, playing and going to school (Table 1).

Among the children having experienced impact from dental pain in the previous four months, 85.2% had at least one carious lesion, 11.5% had missing teeth, 36.1% had restorations and 24.6% had caries with pulp involvement. Most of the children with impact from dental pain were female and belonged in the most vulnerable social class. Statistically significant associations were found between the impact of pain and the variables gender, social class, dental caries, missing teeth, filled teeth and caries involving pulp (Table 2). The variables were incorporated in the logistic regression model, which revealed that gender, dental caries, filled teeth and caries involving pulp remained statistically significant following the adjustment for social class (Table 3).


Untreated dental caries in children may lead to dental pain and exert an impact on activities of daily living, such as play, sleep, eating and school activities [Slade, 2001]. Dental pain is a public health problem due to its impact on society in the form of the high cost of curative treatment, absenteeism from school and the use of medications [Borges et al., 2008]. Access to oral health services is limited in Brazil, particularly in impoverished areas. A previous Brazilian study reports that 91% of the poorest children up to three years of age have never been to the dentist, whereas this figure is 55% among the wealthiest children [Acs et al., 1992]. Although the prevalence of dental caries is dropping in the paediatric population, dental pain is cited as a common reason for seeking dental care [Borges et al., 2008; Moura-Leite et al., 2008].

In the present study, the overall prevalence of impact due to dental pain in the previous four months was 11.1%. Considering only children who experienced toothache in the previous four months, pain had a negative effect on daily activities in 72.6% of the cases. This is similar to findings described in other studies carried out with preschoolers or schoolchildren in Brazil [Barretto et al., 2004; Feitosa et al., 2005] and other countries, such as the United States, Canada, England and Sri Lanka [Acs et al., 1992; Low et al., 1999; Shepherd et al., 1999; Naidoo et al., 2001; Ratnayake and Ekanayake, 2005]. In the present study, the majority of children had difficulty eating, brushing their teeth, sleeping, playing and going to school during episodes of dental pain, which is in agreement with previous studies [Acs et al., 1992; Low et al., 1999; Barretto et al., 2004]. Another Brazilian study found that 49% of children with severe caries had difficulty eating and 26% missed school due to episodes of dental pain [Feitosa et al., 2005].

The impact of dental pain was more frequent among females. This finding has also been described in studies involving adolescents [Borges et al., 2008] and adult populations [Unell et al., 1999; Bastos et al., 2008]. Due to the differences in age, direct comparisons with the present study cannot be made. However, this gender difference may be explained by the greater prevalence of dental caries among females [Declerck et al., 2008], which would explain the more frequent reports of pain and impact from pain among girls. Moreover, the girls in the present study with a history of dental caries (treated and untreated) had a greater chance of having their quality of life affected by the occurrence of toothache.

The present study has limitations inherent to the cross-sectional design, which does not allow the determination of a causal relation between the variables investigated and the outcome. The positive points of this study are the sample size and population representativity obtained with a high questionnaire response rate on the part of the parents/ guardians (95%). Further studies using qualitative and quantitative methods should be carried out in order to gain a more in-depth understanding regarding the extent of the impact of dental pain on children and their families. Such studies could offer innovative perspectives in this field of research.

Establishing the prevalence of impact caused by toothache provides information on the extent and distribution of dental pain for the assessment of the burden of oral diseases in children and their perceived dental care needs [Pau et al., 2008]. The negative impact of dental pain on the lives of children underscores the need for priority public actions in oral health to ensure the principle of equity and broaden access to oral healthcare services among low-income populations.

The results of the present study demonstrate that dental caries and a greater degree of social exclusion are associated to the impact of dental pain. Based on parents/guardians' reports, the daily activities most affected by dental pain were eating, tooth brushing and sleeping, which are essential activities to child development and health maintenance.


The prevalence of difficulties performing tasks of daily living due to dental pain was relatively high among the children studied.


This study was supported by the Brazilian fostering agency CAPES, Ministry of Education.


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F.R. Moura-Leite *, J. Ramos-Jorge *, M.L. Ramos-Jorge **, S.M. Paiva *, M.P. Vale *, I.A. Pordeus *

Department of Paediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG. ** Department of Paediatric Dentistry, School of Dentistry, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, MG, Brazil

Postal address: Prof. S.M. de Paiva, Faculdade de Odontologia, Universidade Federal de Minas Gerais--UFMG, Av. Bandeirantes, 2275/500--Mangabeiras, CEP: 30.210-420 Belo Horizonte MG, Brazil.

Table 1. Frequency distribution of dental pain in 549
Brazilian children and impact caused by pain over the
previous four months.

                                      n     %       95% CI
Presence of dental pain (n=549)
Lifetime                             137   25.0   (21.4-28.6)
Previous 4 months                    84    15.3   (12.3-18.3)
Total impact in previous 4 months    61    11.1   (8.5-13.7)

Pain prevented child from (n=84) *
Eating                               47    56.0   (45.4-66.6)
Brushing teeth                       33    39.3   (28.9-49.7)
sleeping                             19    22.6   (13.7-31.5)
Playing                              16    19.0   (10.6-27.4)
Going to school                      11    13.1   (5.9-20.3)
Total impact **                      61    72.6   (63.1-82.1)

* Answers are not mutually exclusive; ** At least
one daily activity affected in previous four months

Table 2. Frequency distribution of impact of
dental pain according to independent variables and
significance (Chi-square test and Fisher exact

                                   Impact of dental pain in
                                      previous 4 months

                               Yes n (%)    No n (%)        p
Dental caries

=0                             9 (14.8)    337 (69.1)   <0.001 (c)
>0                             52 (85.2)   151 (30.9)

Missing teeth

=0                             54 (61.1)   477 (97.7)   0.002 (f)
>0                             7 (38.9)     11 (2.3)

Filled teeth

=0                             39 (63.9)   435 (89.1)   <0.001 (c)
>0                             22 (36.1)   53 (10.9)

Caries involving pulp

=0                             46 (75.4)   466 (95.5)   <0.001 (c)
>0                             15 (24.6)    22 (4.5)

social class (svi)

Less vulnerable (0.12-0.45)    21 (34.4)   255 (52.3)   0.009 (c)
More vulnerable (0.46-0.59)    40 (65.6)   233 (47.7)


Male                           18 (29.5)   257 (52.7)   0.001 (c)
Female                         43 (70.5)   231 (47.3)

C--Chi-square test

F--Fisher exact test

Table 3. Logistic regression for associations
between impact of dental pain in previous 4 months
and clinical variables, social class and gender.

                    unadjusted      p-value     Adjusted *     p-value
                    OR (95% CI)                OR (95% CI)

Dental caries

=0                      1.0                        1.0         <0.001
>0                12.9 (6.2-26.8)   <0.001    8.9 (4.0-19.8)

missing teeth

=0                      1.0
>0                5.6 (2.1-15.1)     0.001         n.s.

Filled teeth

=0                      1.0                        1.0          0.020
>0                 4.6 (2.5-8.4)    <0.001    2.3 (1.1-4.4)

Caries involving pulp

=0                      1.0                        1.0          0.027
>0                6.9 (3.3-14.2)    <0.001    2.4 (1.1-5.3)

social class (SVI)

Less vulnerable         1.0                        1.0          0.336
More vulnerable    2.1 (1.2-3.4)     0.010    1.4 (0.7-2.6)


Male                    1.0                        1.0          0.001
Female             2.7 (1.5-4.7)     0.001    2.9 (1.6-5.5)

n.s.= non-significant
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