The relationship between oral health education and quality of life in adolescents

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1 DOI: /ipd The relationship between oral health education and quality of life in adolescents JEFFERSON CALIXTO CARVALHO 1, MARIA AUGUSTA BESSA REBELO 2 & MARIO VIANNA VETTORE 3 1 Faculdade de Odontologia, Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, AM, Brazil, 2 Faculdade de Odontologia, Universidade Federal do Amazonas, Manaus, AM, Brazil, and 3 Instituto de Estudos em Saúde Coletiva, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil International Journal of Paediatric Dentistry 2013; 23: Background. There is no study on the association between oral health education and oral health quality of life (OHQoL). Aim. To assess the relationship between oral health education activities integrated into primary care services and OHQoL in adolescents. Design. A retrospective observational survey was conducted on 300 randomly selected yearsof-age adolescents living in two publicly funded health service administrative areas in Manaus, Brazil. Between 2006 and 2008, dental treatment and oral health education were offered in one area (DT/OHE group), whereas in the other area, only dental treatment was provided (DT group). Collected data included socio-demographic characteristics, health services use, health-related behaviours, dental pain, dental caries and Child-OIDP. Independent variables were compared between groups by Mann Whitney and chi-square tests. The association between one or more OIDP (Child-OIDP 1) and DT group tested using multivariate logistic regression. Results. Caries, use of dental services and healthrelated behaviours did not differ between groups (P > 0.05). Child-OIDP 1 was higher in DT group (90.0%) compared with DT/OHE group (79.3%) (P = 0.01). Child-OIDP 1 was independently associated with DT group [OR = 4.4 (1.1; 17.0)]. Conclusions. Adolescents living in an area where OHE and DT were provided had better OHRQoL than those living in an area where only DT was provided. Introduction Health promoting activities, such as oral health promotion, preventive advice and screening, are seldom integrated with dental care 1. Improvements in oral health resulting from oral health promotion activities are more sustainable and can reduce inequalities through action directed at the underlying determinants of oral health 2. There is good evidence that preventive and oral health education approaches are more effective, both clinically and cost-effective, than standard dental care 2 7. Preventive therapies including application of fluoride/chlorhexidine varnish reduced the caries increment among Correspondence to: Mario Vianna Vettore, Instituto de Estudo em Saúde Coletiva, Universidade Federal do Rio de Janeiro, Praça Jorge Machado Moreira, Ilha do Fundão Cidade Universitária., Rio de Janeiro, RJ, CEP , Brazil. mariovettore@gmail.com caries-active children in Finland 2. In the same sample, Hietasalo et al. 5,6, assessed the cost effectiveness of the provision of dietary and hygiene counselling sessions on caries and children s practical brushing skills. The preventive approach was slightly more effective and more cost-effective after 3 years than the standard dental care. Plutzer and Spencer 4 reported that guidance about oral hygiene and proper nutrition during pregnancy and childhood reduced the occurrence of early childhood caries. Temporary improvements on knowledge and attitudes can be achieved through dental health education. Long-term effectiveness of educational intervention on oral healthrelated behaviours such as changing diets and improvement on toothbrushing cannot be inferred 8. The low impact of disease-specific didactical education on health has been reported when other diseases were considered 9,10. As targeting knowledge alone seems insufficient to promote children s and adolescent s health, it has been pointed out 286

2 Oral health education and quality of life in adolescents 287 the increase in health literacy may have a positive impact on health outcomes The increasing concern about the shortcomings of clinical measures of oral health that do not capture the multidimensional concepts of oral health lead to the development of measures of oral health-related quality of life (OHRQoL) 14. The theoretical framework of OHRQoL measures is that oral health disease processes are strongly associated with subjective perceptions of oral health needs and perceived oral impacts 15,16. The Child-OIDP is a relevant indicator of quality of life related to oral health, identifying the subjects with higher scores of the impacts caused by dental problems 17,18. The Child-OIDP was originally developed and validated in Thailand and was later translated and validated for use in Brazil 2,19. Most of the abovementioned intervention studies on the effectiveness of oral health education concentrated on clinical and behavioural outcomes such as caries increment and improvement in oral hygiene. There is no study on the possible association between oral health education and oral health quality of life outcomes. Therefore, it was decided to conduct a retrospective study to compare the impacts of oral health quality of life in adolescents living in two areas with different oral health care approaches; dental treatment plus oral health education activities and dental treatment only. It was hypothesized that the prevalence and severity of oral health-related impacts was lower in an area where oral health education activities were integrated with primary care services compared with an area where only dental treatment was provided. Material and methods Ethical issues All procedures in this study were in accordance with the Helsinki Declaration and with the ethical standards of the Brazilian National Committee of Ethics and Research (CONEP). The study protocol was submitted and approved by the Committee of Ethics and Research of the Federal University of Amazonas (Protocol no ). Study design A retrospective observational survey was conducted where existing programmes were evaluated using primary and secondary data through dental clinical examinations and information from reports of health services. In addition, a Child-OIDP questionnaire, which is subjective measure of oral health-related problems experienced in the past 3 months, was used on a random selection of adolescents. Sample size calculation The sample size of 300 adolescents (150 in each group) was calculated based on 80% of prevalence of at least one impact of oral health problems on daily activities (Child- OIDP 1) 19, with 80% power and 5% Type I error probability to detect 5% of differences between groups. Sample characteristics Adolescents between 12 and 14 year of age were recruited into the study in June 2008 in the city of Manaus, State of Amazonas, Brazil. They were selected from state-funded schools in two catchment areas with different oral health care approaches; dental treatment plus oral health education activities (DT/OHE area) and dental treatment only (DT area). Period of research The study extended between March 2006 and June 2008 (recruitment period), and data collection of all participants occurred on July Inclusion criteria The inclusion criteria was that all students should be aged from 12 to 14 years, should be enroled in state-funded schools living in the two study areas were listed since March Students from the DT/OHE area should also have attended all oral health education sessions from March 2006 and June The parents of eligible adolescents were asked for permission for their child to participate in the

3 288 J. C. Carvalho, M. A. B. Rebelo & M. V. Vettore study. All parents who agreed with the participation of their children signed a consent form informing the aim of the study and the private interview and examination of adolescents. Selection of areas of study Initially, the DT/OHE area was randomly selected among those areas served for at least 2 years by oral health teams integrated into family health programme, which is a publicly funded, community-oriented, multidisciplinary care system serving people organized into small groups. Then, the DT area was randomly selected from those areas with similar demographic and social indicators of the DT/ OHE area, and those where only dental treatment was provided to the residents; namely, the oral health teams were not integrated into the family health programme. As the provision of oral health care in Brazil s National Health System is managed by the municipalities, it was assumed that the activities of dental health teams were similar across the areas in the city according to the two modalities of oral health care; integrated and not integrated into family health programme. The dental treatment offered in the DT and DT/OHE areas included restorative procedures such as dental restorations and replacement of dental restorations, tooth extractions, supragingival scaling and professional prophylaxis. Both selected areas have oral health teams composed of one dentist and one dental nurse, have approximately 1000 families (3000 residents approximately) and a similar Human Development Index, and Oral health education area The oral health team in the Oral Health Education area (DT/OHE Area) had been integrated into the family health programme since March The provision of dental treatment was provided on a regular basis in a dental office located in the medical clinic of the family health programme. In addition, oral health education activities were developed in a multidisciplinary perspective with other health professionals (doctors, nurses and community health agents). Based on health service reports and information provided by the oral health team, the oral health education activities included empowermentcentred oral and general health counselling on attitudes towards health (3). Oral health education activities Oral health education sessions (45 min each) took place at approximately 3-month intervals and comprised nine visits from March 2006 and June Adolescents and pregnant women registered in the family health programme were grouped into groups of people for oral health education activities held in a house of one member of the group. The house with an appropriate lounge was chosen considering the best location for the members of the group. The attendance at the oral health education activities was voluntary, and all invited people participated in all sections. Oral health education activities were performed by a dentist, dental nurse and community health agents. The content of sessions was similar for all groups. Initially, a session of 30 min of oral health education was conducted by a dentist, in which information was provided on the importance of adequate oral hygiene and nutrition, general health-related behaviours and their relationship with systemic health. The process of tooth decay was explained to them, placing emphasis on the potential caries-preventive benefits of health-related practices. Fluoride toothpaste and toothbrushes were provided free of charge. After that, a dental examination was conducted by the dentist, and appointments were made for those with treatment needs. Priority for dental appointments was given to those with dental pain and those with high levels of untreated decay. Finally, supervised tooth brushing was performed and topical gel fluoride 1,23% applied by the dentist and dental nurse. Dental treatment area The oral health team of the control area (DT area) provided only dental treatment to the residents. Although the population living in DT area was also served by the family health

4 Oral health education and quality of life in adolescents 289 programme, the oral health team activities were not integrated with the primary health care activities. Groups of comparison Participants from DT/OHE area and DT area were assigned into two groups of comparison: DT/OHE group and DT group, respectively. Measures Assessment of oral impacts on daily performances. The impact of oral health on daily activities of adolescents was assessed using the Brazilian version of the child oral impacts on daily performances (Child-OIDP) index 17,19. The Child-OIDP is applied in two stages. Initially, children were asked to record in a self-completed questionnaire on 17 oral health-related problems experienced in the past 3 months. In addition, children could record other non-listed problems. Thereafter, face-to-face interviews were conducted to collect data on the impacts of oral problems, considering eight common daily performances: eating, speaking, cleaning mouth, sleeping, emotional status, smiling, studying and social contact. In the event that the impact on a performance was reported the severity of the impact (low, moderate or severe) was recorded as well as its frequency 19,20. In the calculation of the Child-OIDP score, the frequency of the impact is multiplied by the severity of each performance. The Child- OIDP score is obtained by adding the values for the eight performances, in a scale ranging from 0 to 72. The score is multiplied by 100 and divided by 72, which results a final score of Child-OIDP from 0 to Covariates. Demographic data, socioeconomic characteristics, oral health-related behaviours and use of dental services were collected through mothers self-reported questionnaires and adolescents interviews. Socioeconomic data were children s schooling, parents schooling, financial governmental support, number of people per room in home and family income. Oral health-related behaviours assessed were eating before sleeping and oral cleanliness before sleeping. Use of dental services and information regarding the last dental visit were also recorded. Dental clinical measurements. Dental clinical measurements included levels of caries in primary and permanent teeth. Caries was assessed using the DMFT index (decayed, missing and filled teeth index). Dental probes (Stainless, Trinity Indústria e Comércio LTDA., São Paulo-SP, Brazil), Oral plain mirrors (Probem, Probem laboratório de produtos farmacêuticos e odontológicos S/A, Catanduva-SP, Brazil) and a head light (Nautika, Nautika Comercial de Artigos para Lazer LTDA., Guarulhos-SP, Brazil) were used to facilitate dental examinations. Dental pain in the last 3 months was also recorded. The severity of dental pain was assessed using a five-point Likert scale 21. Each adolescent was interviewed and examined in private. Reliability Test retest reliability was carried out to assess the external reliability of the dental clinical measurements and Child-OIDP measure. Twenty-eight adolescents (9.3% of the sample) were examined and answered the Child-OIDP in twice on 7 days interval. Kappa coefficients and intraclass coefficients were used to assess the variability of DMFT and Child-OIDP scores between 2 weeks. The reliability coefficients for clinical examination and Child-OIDP questionnaire during the main study were excellent 22 ; Kappa coefficient was 0.95 (95% CI = 0.94; 0.96) for DMFT index, and intraclass coefficient for Child-OIDP was 0.93 (95% CI = 0.84; 0.97). Pilot study Twenty year-old adolescents and their mothers from both areas of study were selected to test the questionnaires, for training the examiner for interview and to assess the internal consistency and reliability of the Child-OIDP questionnaire. No modifications

5 290 J. C. Carvalho, M. A. B. Rebelo & M. V. Vettore were needed in all questionnaires. Child- OIDP Cronbach s alpha was Complete explanations on how to answer the questionnaire were provided to mothers. In addition, previous to adolescent s individual interviews, the interviewer enlightened all items of the questionnaire to the participants. Calibration study One examiner was calibrated for oral clinical examination for caries index (DMFT). The selected adolescents from the pilot study were examined two times within a 7-day period of interval. Kappa coefficient of agreement findings for DMFT index was 0.87 (95% CI = 0.70; 1.00) for anterior teeth and 0.95 (95% CI = 0.91; 0.99) for posterior teeth. The overall kappa coefficient was 0.95 (95% CI = 0.91; 0.98). Data Analysis The normal distributions of continuous variable were tested by Kolmogorov Smirnov test. Continuous variables were compared between DT group and DT/OHE group using Mann Whitney test. Categorical data were analysed by chi-square test. Cronbach s alpha was used to assess the internal consistency of the Child-OIDP. The association between DT group and the prevalence of at least one impact of oral health on daily activities (Child-OIDP 1) was tested by multivariate logistic regression analysis to adjust for potential confounders. All covariates with P value < 0.10 in bivariate analysis were selected for multivariate analysis using the Backward logistic regression procedure. All tests were performed using the program SPSS 17.0 (IBM Corporation, NY, USA). The significance level established for all analyses was 5% (P 0.05). Results The response rate was 77.1%. The mean age of the participants was 12.9 ± 0.8 years old, and 53.3% of the sample were female adolescents. Adolescents in the DT/OHE group were older than those from the DT area (P < 0.05). The majority of adolescents were from families with low or medium socioeconomic status. Family income higher than three minimal wages was reported by only 10.6% of the sample. The prevalence of families supported by governmental aid, with low father s schooling and low mother s schooling was 35.5%, 52.0% and 27.8%. There was a statistically significant difference in age (P = 0.042), maternal age (P = 0.036) and family financial governmental support of adolescents (P = 0.049) between groups. Low number of years of father s schooling was high in adolescents from DT/OHE group compared with those from DT group with borderline statistical association (P = 0.055) (Table 1). In relation to oral health-related behaviours, 59% reported eating before sleeping on some occasions and 60.3% performed oral hygiene before bedtime. Ninety per cent of the adolescents had used dental services, 9.3% are under treatment and 37% had a dental visit in the last year. No statistical differences were observed for oral health-related behaviours and dental services use between the two groups (Table 1). The mean of DMF-T of the total sample was 2.42 ± Decayed component represented 53.2% of the index followed by filled component (41.4%). The prevalence of dental pain in the last 3 months was 33.7%. Oral treatment needs were reported by 66.0% of the participants. No statistically significant difference was found between the two groups concerning clinical measures for caries, prevalence of dental pain and perceived treatment needs. Moderate or high severity of dental pain was statistically higher in DT group compared with DT/OHE group (Table 2). The internal consistency of Child-OIDP questionnaire was good (26); the overall standardized Cronbach s Alpha was 0.70, DT/OHE group = 0.70 and DT group = Overall, the frequency of adolescents with at least one oral impact affecting their daily performance in the past 3 months was 84.7%. The most prevalent impact was difficulty eating (65.3% of adolescents), followed by impacts on cleaning teeth (37.0%), smiling (33.3%) and relaxing (29.3%). Doing schoolwork, sleeping and social contact were the least prevalent

6 Oral health education and quality of life in adolescents 291 Table 1. Demographic and socioeconomic characteristics, oral health-related behaviour and use of dental services. Demographic and socioeconomic characteristics DT/OHE group (N = 150) DT group (N = 150) Total P Adolescents Age, n (%)* 12 years old 47 (31.3) 59 (39.3) 106 (35.3) years old 54 (36.0) 61 (40.7) 115 (38.3) 14 years old 49 (32.7) 30 (20.0) 79 (26.3) Sex, n (%)* Male 77 (51.3) 63 (42.0) 140 (46.7) Female 73 (48.7) 87 (58.0) 160 (53.3) Years of schooling, mean (±SD) 5.75 ± ± ± No of people per room, mean (±SD) 2.18 ± ± ± Parents Mothers age, mean (±SD) ± ± ± Financial governmental support, n (%)* Yes 28 (29.5) 27 (45.0) 55 (35.5) No 67 (70.5) 33 (55.0) 100 (64.5) Father s schooling (years), n (%)* 7 48 (54.5) 29 (48.3) 77 (52.0) (23.9) 8 (13.3) 29 (19.6) (21.6) 23 (38.3) 42 (28.4) Mother s schooling (years), n (%)* 7 26 (31.7) 11 (19.6) 37 (26.8) (24.4) 13 (23.2) 33 (23.9) (43.9) 32 (57.1) 68 (49.3) Family income, n (%)* <1 MW 41 (50.6) 31 (60.8) 72 (54.5) MW 30 (37.0) 16 (31.4) 46 (34.8) >3 MW 10 (12.3) 4 (7.8) 14 (10.6) OHP/DT group DT group Total P Oral health-related behaviours Eating before sleeping, n (%)* Yes, always 26 (17.3) 30 (20.0) 56 (18.7) Yes, sometimes 91 (60.7) 86 (57.3) 177 (59.0) No 33 (22.0) 34 (22.7) 67 (22.3) Oral cleanliness before sleeping, n (%)* Yes, always 95 (63.3) 86 (57.3) 181 (60.3) Yes, sometimes 46 (30.7) 57 (38.0) 103 (34.3) No 9 (6.0) 7 (4.7) 16 (5.3) Dental services use Dental services use, n (%)* Yes 136 (90.7) 134 (89.3) 270 (90.0) No 14 (9.3) 16 (10.7) 30 (10.0) Last dental visit, n (%)* Current treatment 12 (8.0) 16 (10.7) 28 (9.3) <6 months 33 (22.0) 30 (20.0) 63 (21.0) 7 12 months 27 (18.0) 21 (14.0) 48 (16.0) 1 2 years 18 (12.0) 13 (8.7) 31 (10.3) >2 years 9 (6.0) 5 (3.3) 14 (4.7) Do not remember 37 (24.7) 49 (32.7) 86 (28.7) MW, minimal wages; DT, dental treatment; OHE, oral health education. *Cui-square test. Mann Whitney test. Parents information, N = 161. impacts, occurring in 19.9%, 19.3% and 13.7% of adolescents (Table 3). When groups were compared, statistically significant differences were noted. The occurrence of at least one impact on daily performances and the proportion of adolescents performances eating, cleaning mouth and smiling were statistically higher in the

7 292 J. C. Carvalho, M. A. B. Rebelo & M. V. Vettore Table 2. Dental clinical measures for caries levels, dental pain and perceived oral treatment needs. OHE/DT group DT group Total P DMFT, mean (±SD)* 2.23 ± ± ± % DMFT components, mean (±SD)* Decayed ± ± ± Filled ± ± ± Missing 5.73 ± ± ± Dmf, mean (±SD)* 0.21 ± ± ± Decayed 0.07 ± ± ± Filled 0.00 ± ± ± Missing 0.15 ± ± ± % sound teeth, mean (±SD)* ± ± ± % decayed teeth, mean (±SD)* 4.42 ± ± ± % filled teeth, mean (±SD)* 3.56 ± ± ± % missing teeth, mean (±SD)* 0.57 ± ± ± Dental pain (3 months), n (%) Yes 45 (30) 56 (37.3) 101 (33.7) No 105 (70) 94 (62.7) 199 (66.3) Severity of dental pain (3 months), n (%) Moderate or high 22 (48,9) 40 (71,4) 62 (61,4) Low 23 (51,1) 16 (28,6) 39 (38,6) Perceived oral treatment needs, n (%) Yes 98 (65.3) 100 (66.7) 198 (66.0) No 52 (34.7) 50 (33.3) 102 (34.0) DT, dental treatment; OHE, oral health education. *Mann Whitney test. Cui-square test. DT group compared with DT/OHE group (P < 0.05). Doing schoolwork and social contact were also higher in the DT group with of borderline statistical association. The mean overall impact scores of the total sample was ± (Range 0 51). There were statistical significant differences between DT/ OHE and DT groups in Child-OIDP overall impact scores as well as for the scores on the impacts on eating and smiling (P < 0.05). Associated factors with at least one impact of oral health on daily activities (Child- OIDP 1) in bivariate analysis were mother s age [OR 0.92 (95% CI: )], DT group [OR 2.35 (95% CI: )] and dental pain [OR 4.98 (95% CI: )] (Table 4). The results of multivariate logistic regression of the associated factors with Child-OIDP 1 are presented in Table 5. Adolescents with 13 years of age were 4.84 more times to report at least one impact of oral health on daily activities compared with those with 12 years old. Adolescents from DT group were 4.34 times more likely to report at least one impact of oral health on daily activities compared with those living from DT/OHE group. The odds of having at least one impact of oral health on daily activities were significantly higher for adolescents from families without financial government support compared with those from families supported by governmental aid (OR = 10.45). Adolescents whose fathers had attended school for between 8 and 10 years compared with those with 11 years or more of schooling were 4.34 more likely to report at least one impact of oral health on daily activities. Maternal age remained associated with the occurrence of having at least one impact of oral health on daily activities (OR = 0.84). Discussion Main findings The hypothesis that oral health-related impacts differ in adolescents living in areas with different oral health care approaches was confirmed. This study showed that adolescents from the area where only dental treatment was provided reported significantly higher impact scores of Child-OIDP compared with those living in the area where oral

8 Oral health education and quality of life in adolescents 293 Table 3. Frequency of adolescents with impact of oral health on daily activities and Child-OIDP mean scores in each performance. Frequency of adolescents with impact of oral health on daily activities (n = 300) Child-OIDP mean scores (±SD) in each performance (0 100) OHE/DT group N (%) DT group N (%) Total N (%) P* OHE/DT group DT group Total P CI95% (Total) Eating 88 (58.7) 108 (72.0) 196 (65.3) ± ± ± Speaking 23 (15.3) 27 (18.0) 50 (16.7) ± ± ± Cleaning 47 (31.3) 64 (42.7) 111 (37.0) ± ± ± mouth Sleeping 24 (16.0) 34 (22.7) 58 (19.3) ± ± ± Sustain 38 (25.3) 50 (33.3) 88 (29.3) ± ± ± emotional status without stress Smiling and 38 (25.3) 62 (41.3) 100 (33.3) ± ± ± showing teeth without shame School tasks 22 (14.7) 35 (23.3) 57 (19.0) ± ± ± performance Having contact 15 (10.0) 26 (17.3) 41 (13.7) ± ± ± with other people One or more performances above 119 (79.3) 135 (90) 254 (84.7) ± ± ± < DT, dental treatment; OHE, oral health education. *Cui-square test. Mann Whitney test. health education activities were integrated with primary care services. However providing oral health education did not a greater affect on dental caries, oral health-related behaviours and use of dental services in the DT/OHE group compared with DT group. Possible explanations for the findings This was the first study that assessed oral health education activities integrated into primary care services on impacts of oral health on daily performances in adolescents. Possible explanations concerning the effectiveness of the oral health education activities on the oral health-related quality of life measures include the frequent contact between the dental team and the population out of the dental office, which may have positively affected the oral self-perception on impacts of the adolescents. Previous studies have demonstrated the effectiveness of health interventions when peer workers and health teams are in frequent contact with the community members. Health promotion and health care provided by community leaders and community health workers were positively associated with cessation of tobacco use, reduction in neonatal mortality and pregnancy outcomes. People constantly visited by health workers tend to feel in control and satisfied with their health 23,24. Although no differences were found concerning use of dental services and proportion of filled teeth between the two groups, another explanation for our findings may be that the timing between caries diagnosis and treatment was shorter in the DT/OHE group because they were examined every 3 months. Oral health promotion, oral health education and health services Studies on the evaluation of oral health promotion activities within health services are scarce. A randomized clinical trial on an

9 294 J. C. Carvalho, M. A. B. Rebelo & M. V. Vettore Table 4. Unadjusted logistic regression for impact of oral health on daily activities (Child-OIDP 1) Crude OR 95% CI P value Demographic and socioeconomic characteristics Age 12 years old 1 13 years old ; years old ; Sex Male 1 Female ; Years of schooling ; N of people per room ; Mothers age ; Financial governmental support Yes 1 No ; Father s schooling ; ; Mother s schooling ; ; Family income <1 MW MW ; >3 MW ; Oral health-related behaviours Eating before sleeping Yes, always 1 Yes, sometimes ; No ; Oral cleanliness before sleeping Yes, always 1 Yes, sometimes ; No ; Do not eat before sleeping ; Dental services use Dental services use Yes 1 No ; Last dental visit >1 year 1 1 year or less ; Current treatment ; Oral health approaches OHE/DT group 1 DT group ; Oral health measures DMFT ; % DMFT components Decayed ; Missing ; Filled ; Dental pain (3 months) No 1 Yes ; Severity of dental pain (3 months) Low Moderate or high ;15.68 DT, dental treatment; OHE, oral health education. Table 5. Multivariate logistic regression for impact of oral health on daily activities (Child-OIDP 1). Crude OR 95% CI Adjusted OR 95% CI Age 12 years old years old ; ; years old ; ;12.11 Oral health approaches OHE/DT group 1 1 DT group ; ;17.16 Financial governmental support Yes No ; ;42.15 Father s schooling ; ; ; ;17.13 Mother s age ; ;0.94 Dental pain (3 months) No 1 1 Yes ; ;15.57 DT, dental treatment; OHE, oral health education. intensive regimen for caries control was conducted in public dental clinics, Finland. Adolescents submitted to preventive procedures centred in oral health behaviours modifications showed lower caries during the whole post-trial period than those in the standard dental care approach 2,5,6. A study on the assessment of a dental health programme focused on oral health promotion activities at community level was conducted in remote Aboriginal communities of Australia. The adjusted caries increment was significantly lower in the children receiving fluoride varnish application and whose parents received tooth brushing demonstration and advice concerning sugar consumption and use of fluoride-containing toothpaste 7. In reviewing dental health education, Freeman and Ismail 24 concluded that The current research evidence does not support the practice of giving instructions or advice to patients as a means of modifying their attitudes or changing their health behaviours. The shortcomings include over-reliance on individual-level factors, lack of emphasis on systemlevel factors and too little on analytical studies and research on demonstration projects, lack of a clear delineation of the interrelations among various causal factors, insufficient or no understanding of the impact of socioeconomic

10 Oral health education and quality of life in adolescents 295 constraints, lack of historic approach to analysis and lack of a good theoretical basis 25. The individual behavioural change approach in dental settings has been relatively ineffective at producing long-term sustainable changes in oral health behaviours and failed to address inequalities in oral health The integration of dental team into primary care service may shift the emphasis on the conventional dominant health education model, focused on the individual and lifestyle factors alone to a broad oral health promotion approach 28. The major implication of this is that dental team must be directed towards action on the social determinants of oral health, which requires close cooperation between many different sectors of society. In this sense, health benefits are possible when a comprehensive approach is adopted. A successful example of policy related to partnerships to improve health and oral health that should be widespread is the Health Promoting Schools 29. Oral health measures Although the sample of this study cannot be considered representative of the population of the city of Manaus, dental caries measures and dental services use were similar to those observed in adolescents from the last Brazilian National Oral Health Survey (SB Brasil 2010) 30. The mean of DMFT in this study was slightly higher than SB Brasil 2010 (2.42 vs 2.07), whereas use of dental services was 90% in this study and 80.5% in the SB Brasil Notwithstanding, the prevalence of dental pain in this study was almost 10% higher than the one from SB Brasil 2010 (33.7% vs 24.6%). The frequency of adolescents with at least one oral impact affecting their daily performance in the past 3 months was significantly higher than the one reported in SB Brasil 2010 (84.7% vs 35%). Possible explanations for these discrepancies between this study and the SB Brasil 2010 may be the age of participants (12 14 years old vs 12 years old), the period regarding dental pain (3 months vs 6 months). In addition, the original version of the Child-OIDP questionnaire was used this study, whereas a modified version of Child-OIDP was employed in the SB Brasil Strengths and limitations Positive aspects of this study include the natural setting where the study was performed and the adequate internal validity. Our findings about the association between oral health care approach and the impact of oral health on daily activities were controlled for confounding factors, such as age, dental pain and parents characteristics, through multivariate statistical analysis to reduce bias as far as possible. Detailed information about the activities of dental health teams were collected in both areas under study, which allowed appropriate comparisons between them. Our findings cannot be generalized for other areas served by the two modalities of oral health care in Brazil s National Health System. Implications for future research This study represents an innovative methodological approach on the assessment of the potential benefits of oral health promotion on oral health as normative measures of oral health were employed so far. Further studies are needed to evaluate the efficiency of oral health promotion activities within the primary care services on oral health-related quality of life measures. In addition, future studies on the assessment of the effectiveness of oral health promotion interventions must consider local contextual features of the studied population such as their cultural, social and political characteristics. What this paper adds This was the first study to show that oral health education was positively associated with oral healthrelated quality of life in adolescents. Why this paper is important to Paediatric Dentists It emphasizes the importance of using oral health subjective measures such as oral health-related quality of life in studies in oral health promotion and in the assessment of prevention programmes. It shows an innovative approach using oral healthrelated quality of life measures to evaluate the preventive strategies in adolescents oral health.

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