Periodontal conditions in adolescents and young Brazilians and associated factors: Cross-sectional study with data from the Brazilian oral health survey, 2010.

BACKGROUND: Diseases of the gingival tissues are considered a global public health problem concern. These diseases show great differences in their distribution and prevalence in the different localities investigated. This study aimed to estimate the prevalence of the periodontal conditions of gingival bleeding and dental calculus in Brazilian adolescents and young people, as well as to verify the associated factors.
MATERIALS AND METHODS: This is a cross-sectional population-based study that used secondary data from the National Oral Health Survey (SB Brazil 2010) performed by the Ministry of Health. This study assessed 7328 adolescents aged 12 years and 5445 young people aged 15-19 years. The characteristics of the periodontal conditions were obtained by the community periodontal index, which provided the outcome variables of gingival bleeding and dental calculus. The predictor variables were demographic, socioeconomic, and oral clinical data.
RESULTS: The results showed a high prevalence of gingival bleeding (32%) and dental calculus (33.1%) in the individuals assessed. In addition, as observed after adjusting to the Poisson regression model, the variables of 12 years of age, no tooth loss, fewer household residents, >6 years of education, and no need for dental treatment were considered protective factors for gingival bleeding and dental calculus.
CONCLUSIONS: The variables of nonwhite skin color, certain regions of the country, and low monthly household income were considered risk factors for the outcomes. Boys presented a higher prevalence of dental calculus than girls.

INTRODUCTION

Periodontal disease is characterized by a chronic infection produced by bacteria, resulting in an inflammatory response of the host. It evolves continuously and its progression is favored by the morphological characteristics of the affected tissues, presenting high prevalence levels and being the second largest cause of dental pathologies in the world population.[123]

Bacterial plaque is the etiological factor considered the main trigger of the periodontal disease, due to the deficiency of oral hygiene. However, this condition may be aggravated when associated with risk factors such as increased age, the presence of systemic diseases (diabetic and immunosuppressed patients, and among others), behavioral problems (harmful food or hygiene habits), underprivileged socioeconomic and demographic conditions, as well as individual issues (hormonal matters such as pregnancy and menopause).[4567] The most common form of periodontal disease manifests in the form of gingivitis, which clinical signs are gingival bleeding, edema, hyperemia, and the presence of exudate and calculus, and it may be present in the oral environment since childhood.[7]

National and international epidemiological surveys aiming to evaluate the periodontium show high frequencies of calculus and gingival bleeding in different ages and populations.[89] This is a major public health problem.

Such periodontal conditions, if left untreated, may progress to periodontitis, which is the most advanced and severe form of periodontal disease and may lead to tooth loss, causing the patient to become vulnerable to bacterial access and even to serious organic compromises.[101112]

Several studies have sought to analyze the association of daily activities, quality of life, and other psychological indicators with oral problems in adolescents.[131415] The results of a study carried out in the state of São Paulo, Brazil, indicated the impact of oral health, including poor periodontal conditions, on the daily activities of adolescents, with the influence of sociodemographic determinants.[1516] These facts show the importance of researching periodontal problems in young people instead of only dental caries, which is more frequent in publications.

Although there are some studies on diseases affecting the periodontium, the literature shows great differences in their distribution and prevalence.[1617] Regional and socioeconomic characteristics and environmental and behavioral factors may partially explain the disparities found in the different study locations.[161819] Diseases of the gingival tissues are considered a global public health problem concern.[20]

This study aimed to estimate the prevalence of gingival bleeding and dental calculus in Brazilian adolescents and young people, as well as to verify the factors associated with these conditions, using data from the Brazilian Oral Health Survey (Pesquisa Nacional de Saúde Bucal) – SB-Brasil, 2010.[21]

MATERIALS AND METHODS

This is a cross-sectional population-based study that used secondary data from the Brazilian Oral Health Survey – Project SB Brazil 2010,[21] performed by the Ministry of Health.

The SB Brazil 2010 was a nationwide epidemiological survey carried out to characterize the oral health conditions of the population according to different age groups. The total sample consisted of 37,519 individuals from 32 geographic domains, including 26 state capitals, the Federal District and five domains of the interior municipalities of each Brazilian geographical macroregion (North, Northeast, Central-West, Southeast, and South).

In this study, data from a sample of 12,773 adolescents were used, wherein 7328 were 12 years old and 5445 were 15–19-years old, corresponding to 34.04% of the total. This survey (SB Brazil 2010) composes a study based on a sample of 37,519 individuals residing in the 26 Brazilian capitals, the Federal District, and in >30 inland cities of each Brazilian region, totaling 177 cities, which details may be accessed in a specific publication.[21] In this study, data from a sample of 12,773 adolescents were used, wherein 7328 were 12 years old and 5445 were 15–19-years old, corresponding to 34.04% of the total. It is an epidemiological survey with representativeness for the state capitals and the Federal District, as well as for the five natural regions divided by the Brazilian Institute of Geography and Statistics.[21]

It is an epidemiological survey with representativeness for the state capitals and the Federal District, as well as for the five natural regions divided by the Brazilian Institute of Geography and Statistics.[21] The sampling plan consisted of domains from the capitals and inland cities. Each capital from a federal unit (states and the Federal District) composed a domain, and all inland cities of each region composed another domain representing such cities. There are 27 geographical domains for the capitals and five for inland cities, one for each region, resulting in 32 domains.[21] In SB Brazil 2010, this recommendation was used with some modifications. The descriptions given below have been partially extracted from the 4th edition of the World Health Organization (WHO) Handbook (Oral Health Surveys: Basic methods) from 1997.[22] For oral health studies, the WHO suggests samples to be composed at certain ages and age group index, to be sufficiently capable of expressing the conditions of other ages and age groups.[23]

For this study, the main source of reference for the sample calculation is the SB Brazil 2003, from which information may be extracted regarding all aggravations and age groups according to the size of cities and region. The sample size was calculated for the ages of 5 and 12 years and for the age groups of 15–19, 35–44, and 65–74 years. For obtaining clinical parameters, dental examinations were performed by trained and calibrated dental surgeons. The methodology regarding oral health data followed the recommendations of the WHO.[22]

Demographic and socioeconomic data were collected in the survey, and the oral health self-assessment was performed using questionnaires. The characteristics of the periodontal conditions were obtained by the Community Periodontal Index (CPI), which provided the outcome variables of gingival bleeding (yes or no) and dental calculus (yes or no). The periodontal examination was performed with the ballpoint probe using the CPI. Each sextant for bleeding on probing, dental calculus, shallow periodontal pocket (4–5 mm), deep periodontal pocket (≥6 mm), and excluded sextant were recorded.[21] In addition, the loss of periodontal insertion in each sextant was evaluated with the loss of periodontal insertion index (LPI), considering values up to 3 mm, 4–5 mm, 6–8 mm, 9–11 mm, and 12 mm or more, and excluded sextant. The following codes were used in the CPI: 0-healthy sextant; 1 – bleeding sextant (observed directly or with a mirror, after probing); 2 - calculus (any amount, but with the entire black area of the probe visible); 3 - pocket of 4 mm to 5 mm (gingival margin in the black area of the probe); 4 - pocket of 6 mm or more (black area of the probe not visible); X-excluded sextant (<2 teeth present); 9 - unexamined sextant.[21]

The exposure variables were as follows:

Demographic variables – Sex (male, female) and age group (12 years, 15–19 years). The Brazilian Statute of Children and Adolescents[23] defines adolescent as an individual between 12 and 18 incomplete years. The term young person is usually used to designate the person between 15 and 29-year-old, following the international trend. Thus, young people may be considered young adolescents (15–17-year-old), young people (18–24-year-old), and young adults (25–29-year-old), ethnicity/skin color (white, black, yellow, brown, and indigenous), and geographic region of the country (north, northeast, south, southeast, and Midwest)

Socioeconomic variables – Monthly household income (up to US$ 800.00 – equivalent to one and a half minimum wages; and more than US$ 801.00), years of education (up to 6 years and >6 years), number of household residents (up to 4, and 5 or more), and number of rooms in the household (up to 2, and 3 or more)

Clinical variables – Toothache over the past 6 months (yes or no), tooth loss (yes or no), the presence of periodontal pocket (shallow or deep), and need for dental treatment (yes or no).

Univariate and bivariate analyses were performed using absolute and relative frequency measurements, and central tendency and variability measurements were used for descriptive data. For the analytical data, Pearson's Chi-squared test (categorical variables) was used in the Statistical Package for Social Science, version 20.0 (IBM, Armonk, New York, USA). to determine the associations between periodontal conditions (bleeding and calculus) and exposure variables, at value of P < 0.05. The variables with bivariate association at P < 0.10 were included in the multivariate analyses. Prevalence ratios (PR) and their respective 95% confidence intervals (95% CI) were estimated crude and adjusted using Poisson regression models with robust variance.

In accordance to Resolution 466/12 of the Brazilian National Health Council central nervous system (CNS), the ethical aspects of the research were observed by the SB Brazil 2010 Survey, which was submitted to and approved by the Research Ethics Committee of the Ministry of Health. It was registered in the Brazilian National Commission of Research Ethics (CONEP) of the CNS under number 15,498, on January 7, 2010. Copies of the project, the Free and Informed Consent Form used, and the opinion by the CONEP are available at the project's website.[21]

RESULTS

Table 1 shows the frequencies of the demographic variables of the participants, indicating that 48% were boys and 52% were girls, and 57.24% were 12-year-old and 42.6% were 15–19-year-old. The skin color of most participants was brown (47%), followed by white (32.9%). Among the geographic regions, most participants resided in the northeast (27.2%) and north (24.3%) regions. The frequencies of socioeconomic variables are also presented, showing that 43.1% of participants studied for 6 years. From the individuals surveyed, 67.4% had a monthly household income of up to US$ 800.00.

Table 1

Distribution of frequencies of demographic and socioeconomic variables for the 12,773 Brazilian adolescents and young people (SB Brazil, 2010)

Variables	n (%)
Sex
Male	6136 (48.0)
Female	6637 (52.0)
Age group (years)
12	7328 (57.24)
15-19	5445 (42.6)
Ethnicity
White	5100 (32.9)
Black	1310 (10.3)
Brown	6004 (47.0)
Yellow	248 (1.9)
Indigenous	111 (0.9)
Total	12,773 (100)
Region
North	3110 (24.3)
Northeast	3479 (27.2)
Southeast	2255 (17.7)
South	1828 (14.3)
Midwest	2101 (16.4)
Years of study (years)
Up to 6	5506 (43.1)
>6	7267 (56.9)
Household residents
Up to 4 people	5278 (41.3)
5 or more people	7495 (58.7)
Total	12,773 (100.0)
Rooms in the household
Up to 2	228 (1.8)
3 or more	12545 (98.2)
Total	12,773 (100)
Monthly household income (US$)
Up to 800.00	8607 (67.4)
>801.00	4166 (32.6)

No of subjects – 12,773

Table 2 shows the frequencies of the clinical variables. Regarding tooth loss, 13.5% of the individuals had already experienced tooth loss and 76.1% had experienced toothache over the past 6 months. Thus, 65.2% of participants currently require treatment. According to the periodontal conditions observed by the CPI, the prevalence of gingival bleeding was 32%, calculus was 33.1%, the shallow pocket was 4.5%, and the deep pocket was 0.3%.

Table 2

Distribution of frequencies of the variables of oral clinical conditions for the 12,773 Brazilian adolescents and young people (SB Brazil, 2010)

Variables	n (%)
Tooth loss
No	11,052 (86.5)
Yes	1721 (13.5)
Need for dental treatment
No	4448 (34.8)
Yes	8325 (65.2)
Toothache over the last 6 months
No	9721 (76.1)
Yes	3052 (23.9)
Bleeding
No	8682 (68.0)
Yes	4091 (32.0)
Calculus
No	8547 (66.9)
Yes	4226 (33.1)
Shallow pocket
No	12,204 (95.5)
Yes	569 (4.5)
Deep pocket
No	12,736 (99.7)
Yes	37 (0.3)

No of subjects – 12,773

The relationships of exposure variables and gingival conditions with bleeding and calculus are presented in Table 3. Statistically significant associations were found between the gingival bleeding outcome and age, ethnicity, level of education, geographic region, number of household residents, income, and need for treatment (P < 0.001).

Table 3

Prevalence of gingival bleeding and dental calculus, and univariate analysis between exposure variables and periodontal conditions (gingival bleeding and dental calculus) for the 12,773 Brazilian adolescents and young people (SB Brazil, 2010)

Variables	Gingival bleeding		Dental calculus
	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)
Sex
Male	4157 (47.9)	1979 (48.4)	4012 (46.9)	2124 (50.3)
Female	4525 (52.1)	2112 (51.6)	4535 (53.1)	2102 (49.7)
P	0.308		<0.01*
Age group (years)
12	5164 (59.5)	2164 (52.9)	5326 (62.3)	2002 (47.4)
15-19	3518 (40.5)	1927 (47.1)	3221 (37.7)	2224 (52.6)
P	<0.01*		<0.01*
Ethnicity
White	3684 (42.4)	1416 (34.6)	3591 (42.0)	1509 (35.7)
Nonwhite	4998 (57.6)	2775 (65.4)	4956 (58.0)	2717 (64.3)
P	<0.01*		<0.01*
Years of study
Up to 6	3627 (41.8)	1879 (45.9)	3730 (43.6)	1776 (42.0)
>6	5555 (58.2)	2212 (54.1)	4217 (56.4)	2450 (58.0)
P	<0.01*		0.084
Region
North	1830 (21.1)	1280 (31.3)	1638 (19.2)	1472 (34.8)
Northeast	2514 (29.0)	965 (23.6)	2497 (29.2)	982 (23.2)
Southeast	1585 (18.3)	670 (16.4)	1654 (19.4)	601 (14.2)
South	1194 (13.8)	634 (15.5)	1223 (14.3)	605 (14.3)
Midwest	1559 (18.0)	542 (13.2)	1535 (18.0)	566 (13.4)
P	<0.01*		<0.01*
Household residents
Up to 4	3478 (40.1)	1800 (44.0)	3498 (40.9)	1780 (42.1)
5 or more	5204 (59.9)	2291 (56.0)	5049 (59.1)	2446 (57.9)
P	<0.01*		0.102
Rooms
Up to 2	146 (1.7)	82 (2.0)	141 (1.6)	87 (2.1)
3 or more	8536 (98.3)	4009 (98.0)	8406 (98.4)	4139 (97.9)
P	0.112		0.058
Monthly income (US$)
Up to 800.00	5697 (65.6)	2910 (71.1)	5587 (65.4)	3020 (71.5)
>801.00	2285 (34.4)	1181 (28.9)	2960 (34.6)	1206 (28.5)
P	<0.01*		<0.01*
Tooth loss
Yes	1038 (12.0)	683 (16.7)	967 (11.3)	754 (17.8)
No	7644 (88.0)	3408 (83.3)	7580 (88.7)	3472 (82.2)
P	<0.01*		<0.01*
Need for treatment
Yes	5277 (60.8)	3048 (74.5)	5240 (61.3)	3085 (73.0)
No	3405 (39.2)	1043 (25.5)	3307 (38.7)	1141 (27.8)
P	<0.01*		<0.01*

*P<0.05 - Statistically significant. Pearson’s Chi-square test. P<0,05; no of subjects – 12,773

The younger the adolescents, the less gingival bleeding (59.5%). As for socioeconomic conditions, nonwhite individuals (65.45%), fewer years of education (58.2%), more household residents (59.9%), and lower income (71.1%) showed a higher prevalence of gingival bleeding. The north region of the country showed a prevalence of 31.3% of individuals with gingival bleeding. The individuals presented the higher need for treatment associated with a greater presence of gingival bleeding (74.5%).

Table 3 also shows the results of the relationships between the dental calculus outcome and the exposure variables. After analysis, a direct association was verified among sex, age, ethnicity, level of education, geographic region, income, and need for treatment. Girls presented less dental calculus than boys (53.1%). The younger the adolescents, the less dental calculus (62.3%). Regarding demographic conditions, nonwhite individuals (64.3%) and lower income (71.5%) showed a higher prevalence of dental calculus. In addition, the north region of the country showed a prevalence of 34% of individuals with dental calculus. Individuals who presented greater need for treatment were associated with a greater presence of dental calculus (73%).

Table 4 presents the crude and adjusted PR. As observed in the regression model, the variables of 12 years of age (PR = 0.76; 95% CI 0.72–0.81), no tooth loss (PR = 0.90; 95% CI 0.85–0.97), fewer household residents (PR = 0.90; 95% CI 0.85–0.94), >6 years of education (PR = 0.81; 95% CI 0.76–0.86), and no current need for dental treatment (PR = 0.68; 95% CI 0.64–0.72) were considered protective factors for gingival bleeding, even after adjusting to the other exposure variables.

Table 4

Crude and adjusted prevalence ratio of gingival bleeding and dental calculus (outcomes) of Brazilian adolescents and young people (SB Brazil, 2010) (=2773)

Variables	Crude PR (95% CI)	P*	Adjusted PR (95% CI)	P*	Crude PR (95% CI)	P*	Adjusted PR (95% CI)	P*
	Gingival bleeding				Dental calculus
Sex
Female	-	-	-	-	1.00		1.00
Male					1.09 (1.04-1.14)	<0.001	1.13 (1.08-1.19)	<0.001
Age group (years)
15-19	1.00		1.00		1.00		1.00
12	0.83 (0.79-0.87)	<0.001	0.76 (0.72-0.81)	<0.001	0.66 (0.63-0.70)	<0.001	0.62 (0.58-0.66)	<0.001
Ethnicity
White	1.00		1.00		1.00		1.00
Nonwhite	1.25 (1.19-1.32)	<0.001	1.19 (1.12-1.26)	<0.001	1.19 (1.13-1.26)	<0.001	1.09 (1.03-1.15)	0.002
Region
Midwest	1.00		1.00		1.00		1.00
North	1.59 (1.46-1.73)	<0.001	1.52 (1.40-1.65)	<0.001	1.75 (1.62-1.90)	<0.001	1.68 (1.55-1.82)	<0.001
Northeast	1.07 (0.98-1.17)	0.11	1.05 (0.96-1.15)	0.261	1.04 (0.95-1.14)	0.299	1.03 (0.94-1.12)	0.471
Southeast	1.15 (1.04-1.26)	0.004	1.15 (1.05-1.27)	<0.003	0.98 (0.89-1.09)	0.830	0.99 (0.90-1.09)	0.978
South	1.34 (1.22-1.48)	<0.001	1.49 (1.35-1.64)	<0.001	1.22 (1.11-1.35)	<0.001	1.31 (1.19-1.44)	<0.001
Tooth loss
Yes	1.00		1.00		1.00		1.00
No	0.77 (0.72-0.82)	<0.001	0.90 (0.85-0.97)	0.004	0.71 (0.67-0.76)	<0.001	0.91 (0.86-0.97)	0.006
Household residents
5 people or more	1.00		1.00		1.00		1.00
Up to 4 people	0.89 (0.85-0.84)	<0.001	0.90 (0.85-0.94)	<0.001	0.96 (0.92-1.01)	0.197	0.94 (0.89-0.99)	0.019
Number of rooms in the household
3 or more	-	-	-	-	1.00		1.00
Up to 2					1.15 (0.97-1.36)	0.088	1.07 (014-1.26)	0.379
Monthly income (US$)
>801.00	1.00		1.00		1.00		1.00
Up to 800.00	1.19 (1.12-1.26)	<0.001	1.07 (1.01-1.14)	0.011	1.21 (1.14-1.28)	<0.001	1.12 (1.06-1.19)	<0.001
Level of education - years of education
Up to 6	1.00		1.00		1.00		1.00
>6	0.89 (0.84-0.93)	<0.001	0.81 (0.76-0.86)	<0.001	1.04 (0.99-1.09)	0.088	0.85 (0.80-0.90)	<0.001
Need for treatment
Yes	1.00		1.00		1.00		1.00
No	0.64 (0.60-0.68)	<0.001	0.68 (0.64-0.72)	<0.001	0.69 (0.65-0.73)	<0.001	0.73 (0.69-078)	<0.001

*Wald test (<0.05 - statistically significant). PR – Prevalence ratio; 95% CI – 95% confidence interval; CI – Confidence interval; P<0,05; no of subjects – 12,773

The variables of nonwhite skin color (PR = 1.19; 95% CI 1.12–1.26); north (PR = 1.52; 95% CI 1.40–1.65), southeast (PR = 1.15; 95% CI 1.05–1.27), and south (PR = 1.49; 95% CI 1.35–1.64) regions of the country; and monthly household income of up to US$ 800.00 (PR = 1.07; 95% CI 1.01–1.14) were considered risk factors for bleeding in the adolescents and young people investigated.

In the regression model for the variable of dental calculus, an association remained for the variables of 12 years of age (PR = 0.62; 95% CI 0.58–0.66), no tooth lost (PR = 0.91; 95% CI 0.86–0.97), fewer household residents (PR = 0.94; 95% CI 0.89–0.99; 95% IC), more years of education (PR = 0.85; 95% CI 0.80–0.90), and no need for dental treatment (PR = 0.73; 95% CI 0.69–0.78), considered protective factors. The variables of male sex (PR = 1.13; 95% CI 1.08–1.19), nonwhite skin color (PR = 1.09; 95% CI 1.03–1.15), north (PR = 1.68; 95% CI 1.55–1.82) and south (PR = 1.31; 95% CI 1.19–1.44) regions of the country, and monthly household income of up to US$ 800.00 (PR = 1.12; 95% CI 1.06–1.19) were set as risk factors for dental calculus. The variable of number of rooms in the household did not remain associated in the model.

DISCUSSION

The present study aimed to estimate the prevalence of periodontal conditions and their associations with potentially aggravating factors in Brazilian adolescents and young people, based on secondary data from the Brazilian Oral Health Survey – Project SB Brazil 2010. Hence, the presence and absence of gingival bleeding and dental calculus were evaluated separately.

The results of this study show that the population investigated presented a high prevalence of gingival bleeding and dental calculus, whereas the prevalence of calculus (33.1%) was slightly higher than that of bleeding (32%). However, these results were lower than in some studies. In a study conducted by Gesser et al.,[24] a prevalence of 86% of gingival bleeding was observed and 50.7% of dental calculus, in 18-year-old boy, but the authors pointed out that despite high rates of gingival bleeding, only 7.3% presented the six sextants compromised. Almeida et al.[10] investigated young people aged 15–19 years and showed 52.2% of gingival bleeding, 36.2% of bleeding and dental calculus, and 8% of calculus only. Moreover, Bendoraitienė et al.[25] who evaluated 18-year-old in Lithuania, found gingival bleeding, sub- and supra-gingival dental calculus, and shallow pockets in 77.1% of individuals, and only 22.9% of the population were periodontally healthy, which shows that periodontal problems are common on a global scale. Global differences may be based on economic and political aspects, government influence on health-related programs, and oral hygiene habits in each country. However, some trends in the prevalence of periodontal diseases and conditions may still be observed.[26] Some studies have shown less frequent findings for the periodontal problems investigated, as in the case of the study by Antunes et al.,[27] in which slightly more than a third (34.3%) of the adolescents presented unhealthy gingival conditions in one or more sextants of the mouth, 21.5% of the sample presented gingival bleeding, and 19.4% presented dental calculus. Even though the results of the present study somewhat differed from other studies performed with adolescents, the poor periodontal conditions were present, constituting a problem and representing a sign of periodontal inflammations.[2829] The findings regarding the prevalence of gingival bleeding and dental calculus in the adolescent population and their potential aggravating factors are important, considering that the presence of these signs influences both the current condition and the progression of the periodontal disease.[92628293031]

Periodontitis presents high prevalence in adults. However, its occurrence is low in adolescents and young, but not least. When it manifests itself in the young population, the disease develops in a more aggressive, destructive and fast way, leading to the loss of supporting structures until the loss of the tooth. In this sense, it is important to develop epidemiological studies at the age when young people already have all permanent teeth (12 and 15–19-year-old) for the construction of strategies aimed at prevention, early diagnosis and therapeutics, aiming at the reduction of periodontal problems. In this study, both gingival bleeding and dental calculus were associated with age, indicating that the youngest age group studied (12-year-old) is a protective factor for these periodontal conditions. Antunes et al.[27] found no statistical difference when studying the association between gingival bleeding and age. On the other hand, da Cunha et al.[14] investigated adolescents aged 15 through 19 years and observed an association between periodontal condition (bleeding and calculus) and age, emphasizing that the younger the age, the better the periodontal conditions, which agrees with the findings of the present study. For this reason, early diagnosis, treatment, and prevention among adolescents are extremely important to prevent severe periodontal diseases in advanced age.[2632]

As periodontal diseases are not yet the main concern of oral health programs and their severity tends to increase with age, health promotion actions for oral health education and dental hygiene should be performed routinely to promote the periodontal health of children and adolescents. Regarding the variable of sex, it remained associated only with the dental calculus outcome, and the male sex was a risk factor for this periodontal condition. There are differences between sexes in oral health behavior, in which female adolescents are more careful with toothbrushing, flossing, eating, using dental services, among others.[33] Some studies suggest that women present optimum periodontal conditions because they are more concerned with appearance and aesthetics, thus seeking health services more often.[34]

Regarding ethnicity data, nonwhite individuals presented higher prevalence and were considered a risk factor for gingival bleeding and dental calculus in the adolescents and young people investigated. In another study performed in the state of Minas Gerais, Brazil, brown skin color was predominant in the region studied, and the relationship with gingival bleeding was significant, whereas nonwhite individuals presented worse periodontal conditions.[10] Because Brazil is a country characterized by mixed ethnicities, there are significant racial differences across regions.[3335]

The absence of tooth loss or extractions due to oral problems, as well as no current need for dental treatment was protective factors in the regression analysis adjusted for both periodontal conditions evaluated-gingival bleeding and dental calculus. A relationship between gingivitis in adolescents and not using oral health services were observed in a study with adolescents, and the authors verified the presence of dental calculus in 44.88% of the sample, which indicates the nonuse of these services.[10] Studies indicate that, in Brazil, the nonwhite school-age population and residents of rural areas have lower access to dental services.[36] These differences agree with the findings of the present study and may reinforce the need to investigate demographic, social, and cultural characteristics, as well as local health services.

Among the socioeconomic conditions evaluated, the more years of education (higher level of education), the lower the prevalence of gingival bleeding and dental calculus. A study by Lorenzo et al.[4] found that in households which the residents completed higher education, the index of periodontitis was almost three times lower than those in which no resident had a university diploma. In addition, Bastos et al.[37] described that low level of education increases the potential for developing oral problems. Thus, the higher the social class, the better the periodontal health conditions. Level of education is considered a proxy for measuring social and cultural inequality, and it is a factor for perceiving the need for treatment, including periodontal conditions, because the higher the level of education, the higher the perception on the importance of oral health and on the need of dental treatment.[38]

Fewer household residents were considered protection for periodontal conditions, in this study. Corroborating these findings, a study by Antunes et al.[27] found that adolescents aged 15 through 19 years living in crowded households were more likely to present bleeding and calculus than those who lived with fewer people in the same household. According to Martins et al.,[39] this may be explained by the fact that several people sharing the same environment may represent low income and lower access to proper health and hygiene conditions, resulting in the lack of personal and dental care and unfavorable periodontal conditions.

Lower monthly household income was considered a risk factor for gingival bleeding and dental calculus in adolescents and young people, corroborating the findings by Souza et al.[40] who verified an association between periodontal conditions and income of the population investigated, in which most of the individuals with the worst periodontal conditions earned less than six minimum wages. In a study with young people at enlistment, the oral examination indicated that bleeding and calculus were significantly associated with household income and level of education of adolescents and their parents.[41] Several national and international studies show an association between income inequalities and periodontal disease, indicating that the lower the income, the higher the potential for worse periodontal conditions.[424344] The findings of the study by Vettore et al.[20] performed with adults aged 35 through 44 years using the same epidemiological survey of the present study, found similar results, although they were evaluated by odds ratio. Thus, the chance of having periodontal disease was higher for older male adults, brown-skinned, with lower household income and lower level of education. In addition, the lower the income and the years of study, the higher the chance of having periodontal disease, which corroborates our results.

A systematic review by Bastos et al.[44] analyzed the Brazilian epidemiological data on periodontal conditions and sociodemographic aspects, from 1999 to 2008, highlighting that 29 scientific articles were included in the review, which shows that production growth in the last 4 years suggests an inverse relationship of socioeconomic indicators of income and level of education with periodontal outcomes. However, most of the studies observed are concentrated in the south and southeast regions of the country. The results of the review suggest that there is an inverse relationship between socioeconomic indicators and periodontal outcomes, especially for indicators of income and level of education.

As for the regions of the country, the north, southeast, and south were associated, representing risk factors for gingival bleeding. Regarding dental calculus, the north and south regions had higher prevalence in the adjusted analysis. The assessment of studies shows that regions with worse socioeconomic conditions are also associated with the worst periodontal conditions of adolescents, which occurs in Brazil and in other parts of the world.[9314546] According to the SB Brazil-2010 survey,[21] great diversities among regions, capitals, and inland cities may be perceived in all ages, including the age group of the study in question. In addition to regional diversity, the gingival and periodontal diseases may be linked to the characteristics of each geographic region of the country, which is obtained by regional epidemiological studies.[46] In the present study, the south and southeast regions of Brazil stand out for not presenting better periodontal conditions.

The characteristics of the north region differ from the rest of the country, and the south and southeast seem to present indications of a better organization for prevention and offer of dental services, which could minimize the occurrence of oral diseases.[47] However, according to the study, oral health inequality also among races is presented more often in the southeast region. The Brazilian Council of dentistry acknowledges that the southeast region has the highest concentration of dentists and dentistry schools in the country. Although this region stands out by its GDP, dental services are not offered to adolescents with brown and black skin color to the same extent as to white ones. Although it is a low inequality, it may be considered avoidable and unjust.[38]

The National Oral Health Policy establishes the guarantee of dental care for the population, and the present study shows the need to offer oral health services to adolescents, as well as promoting self-care. To meet basic health care needs in a given region, surveys are required to investigate priorities.[930] The knowledge on the prevalence of gingival bleeding and dental calculus in the adolescent population is important for preventing further periodontal diseases, considering that these are indicators of unfavorable periodontal conditions and lack of access to oral health services.[3132]

The scientific research usually contributes with important data for the formulation of public health care policies, but government actions are required for implementing these policies in an adequate and planned manner, as these actions affect the improvement of the prevention and treatment of oral diseases for the population.[48] Paim et al.[49] stated that the implementation of the Unified Oral Health Service has helped reducing the unequal access to services, but the data from the present national study show that adolescents still experience differences for sociodemographic conditions relative to periodontal conditions. Mello et al.[50] reported the investments in technology, personnel, and physical structure of oral health units, which shows improvement in the quantity and quality of services. Despite this progress, the conditions of misery stand out in urban centers and highly contribute to the prevalence of oral diseases. It is also important that the training of health professionals is more flexible to assist the reality of the Brazilian population. This may occur by means of curricular reforms that include the principles of humanized, integral, and decentralized care for the population.[51]

The present study has some limitations that should be considered when interpreting the results. The cross-sectional design of the research does not allow establishing cause-effect relationships between the periodontal conditions and the variables investigated. In addition, the data are secondary, which may have caused difficulties in the analyses of this study, because the database is already prepared. However, the sample criteria, sample calculation, randomness, and the careful and systematic selection of participants were performed in this Brazilian oral health survey, which validates and shows the importance of analyzing and working on data from such a significant national study. Our findings show that the presence of gingival bleeding and dental calculus can be considered a relevant public health problem, suggesting the need for preventive measures to avoid to periodontitis in future.

CONCLUSIONS

From the results obtained in the present work, it could be concluded that:

There is a high prevalence of gingival bleeding and dental calculus in adolescents and young people, based on the data from the National Survey SB Brazil 2010.

There was an influence from some exposure and outcome variables, with a higher prevalence of gingival bleeding and dental calculus in young people with worse socioeconomic conditions (income, level of education, number of household residents, and need for dental treatment) and older age. Boys presented a higher prevalence of dental calculus than girls.

In addition, we may finish by pointing out the differences between the geographic regions of Brazil and the ethnic groups of young people, with worse conditions in the north and south regions and for nonwhite individuals, also with higher prevalence of both outcomes, which shows inequalities in the population groups of the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.