Dental Caries and Dental Care in Brazilian Adolescents Aged 10 to 15ABSTRACT
Objective: To analyze the presence of dental caries and the relationship with dental care in adolescents aged 10 to 15 years at a municipal public school in a city in southern Brazil.
Material and Methods: This cross-sectional, school-based study used data collected from a representative sample of 10- to 15-year-old adolescents enrolled in municipal public schools. The analyzed variables included sociodemographic and economic factors, dental care, and dental caries. These were collected through questionnaires and clinical oral examinations, respectively. For the statistical analysis, the presence or absence of caries was considered the dependent variable. Bivariate and binomial logistic regression analyses were performed.
Results: A total of 517 adolescents took part. The prevalence of caries was 32.69%. The risk factors for caries were female gender, age 13-15 years, and mouthwash use. The number of brushes after meals was a protective factor.
Conclusion: Oral hygiene guidance provided by the dentist was associated with caries. The results are essential for developing educational programs that promote adequate oral hygiene habits among adolescents.
Keywords:
Adolescent; Dental Caries; Dental Care; Oral Health.
Introduction
Dental caries is the most prevalent oral disease in adolescence [1,2]. Considered a public health problem, caries affects adolescents worldwide, with prevalence rates ranging from 19.1% to 97.3% [3]. In Brazil, the most recent national oral health survey, "SB Brasil 2023", released in 2025, found a caries prevalence of 50% at 12 years of age and 66% at 15 to 19 years of age [4].
Caries has a multifactorial etiology, which makes it a complex condition that involves biological, behavioral, and socioeconomic factors. Dental care plays a significant role in preventing caries. The accumulation of microorganisms on the tooth surface, known as biofilm, is one of the main risk factors for the development of the disease [5]. Maintaining oral hygiene aims to disrupt the biofilm, making it essential for preventing and controlling the disease [6].
Some factors associated with the development of caries in adolescence include greater independence in self-care, coupled with lower parental and school surveillance. Biofilm control practices can be inadequate, leading to an imbalance that favors mineral loss and, over time, may result in the appearance of caries lesions [7].
Epidemiological studies provide data on the prevalence of caries and dental care of individuals. However, few studies have examined this topic in adolescent populations. International studies show a high prevalence of dental caries in adolescents and an association with behavioral and socioeconomic factors, such as oral hygiene habits, sugar consumption, and access to dental services [8-10]. In Brazil, despite the reduction in the disease in recent decades, adolescents still have significant rates and weaknesses in oral care [11]. In this sense, this study aims to analyze the presence of dental caries and its relationship with dental care in adolescents aged 10 to 15 years, students of the municipal public education in Blumenau, Santa Catarina, Brazil.
Material and Methods
Study Design and Ethical Clearance
This is a cross-sectional, population-based study of adolescents aged 10 to 15 years enrolled in municipal public education in Blumenau, SC, Brazil. This study followed guidelines and regulatory standards for research involving humans (Decision nº 4.574.897). Parents or guardians and the participants signed the TCLE and TALE, respectively, before data collection.
Scenario and Sample Calculation
According to the Municipal Department of Education (SEMED), in 2023, there were 46 municipal public schools in the city, with 11,865 students enrolled from the 5th to the 9th grade. Blumenau is divided into six macro-regions, according to the local civil defense monitoring system. For this study, two macro-regions were unified, resulting in five macro-regions considered.
The tool used for the sample calculation was OpenEpi®. We considered a caries prevalence of 66% based on data from the national SB Brasil 2023 survey for the 15-19 age group [4], a margin of error of 5%, a confidence level of 95%, and a design effect of 1.5. With these parameters, the minimum statistically defined sample size was 503 adolescents.
The number of students to be evaluated in each macro-region was determined based on the percentage of representation of students enrolled. Schools were stratified according to size (large: ≥ 500 students; medium: 200 to 499 students; and small: < 200 students) [12]. Those classified as medium or large were selected. In total, 34 schools participated in the draw. First, the schools of each macro-region were drawn, and then, the classes. All students of the selected classes were invited to participate in the research. It was decided to include all eligible students present in the selected classes on the day of data collection, resulting in a final sample larger than the initially defined size. The inclusion criterion was adolescents aged 10-15 years. The exclusion criterion was adolescents who used braces or had cognitive impairment.
Variables and Data Collection
The variables considered for this study were sociodemographic and economic, presence of dental caries, and dental care. Sociodemographic and economic variables were collected from the SEMED class report, and a questionnaire prepared by the researchers was printed for students and completed by their parents or guardians. Gender, age group, race, parents' education, number of residents in the residence, and per capita income relative to the minimum wage were considered.
The presence of dental caries was assessed through clinical oral examinations conducted in a school setting, in accordance with the WHO [13]. The examinations were conducted by three trained evaluators, one of whom was a dental surgeon and two were students in the final stage of their dentistry course, using headlamps, with the adolescents seated and in the presence of a previously trained note-taker. Safety protocols were adopted and the examination was conducted individually to ensure privacy. The assessment of interand intra-examiner reliability using the Kappa coefficient was not performed; however, all evaluators participated in prior theoretical training and underwent technical standardization of clinical procedures before data collection began. The prevalence of dental caries was evaluated by calculating the Index of Decayed, Missing, and Filled Permanent Teeth (DMFT) [14], using the diagnostic criteria proposed by the WHO [13].
Variables related to dental care were collected using a questionnaire prepared by the researchers, adapted from the National School Health Survey [15]. It was applied to the adolescents through individual interviews conducted in the school environment. Oral hygiene habits and dental services were investigated. In relation to dental brushing, frequency and times were considered. The number of times adolescents brushed after meals was tallied. The number of times the adolescents brushed after meals was added up. We evaluated whether they brushed at school, used dental floss and mouthwash, the frequency of dental visits, reasons for seeking dental services, and the dental service model used. Finally, we verified whether the adolescents received oral hygiene guidance and who was responsible for that.
The collection procedure took place in stages. In the first stage, the study was presented to adolescents; then, the Informed Consent Form (TCLE) was handed to the adolescent's parents or guardians to obtain their authorization for the adolescent's participation. In the second stage, the collection was conducted at the school and organized into stations. At the “Reception Station”, the signed TCLE was returned, the Permission Term (TALE) was signed, and the students were distributed across the other stations. At the "Oral Health Station", the dental care questionnaire was administered to each adolescent, followed by the oral clinical examination.
Data Analysis
The data were tabulated using double entry in Epi Info software version 7.2.5.0® (Centers for Disease Control and Prevention, Atlanta, GA, USA). The validation of tabs, aimed at identifying differences, was carried out using the same software, version 3.3.2®. Nominal variables related to sociodemographic, economic, and dental care conditions were presented as frequencies and percentages. The scalar variables "DMFT" and "number of brushings after meals" were reported as medians and, as dispersion measures, minimum and maximum values, since the application of the Kolmogorov-Smirnov test indicated non-normality.. The association analyses were carried out by applying the Chi-square test, evaluating the presence or absence of caries with other sociodemographic, economic, and dental care conditions. The significance level of 0.05 was accepted. Binomial logistic regression analysis was performed, establishing the presence or absence of caries as a dependent variable and considering as independent variables those that showed a significant association with the dependent variable (p < 0.05).
Results
A total of 517 adolescents were included. Table 1 shows their sociodemographic and economic characteristics. There was a prevalence of females, aged 10 to 12 years, white, and enrolled in the morning hours. The prevalence of caries was 32.69%, and the mean DMFT index was 0.59 (median = 0; minimum = 0 and maximum = 5). Gender and age were associated with the presence of caries. There was a predominance of caries in females and in the age group from 13 to 15 years (Table 1).
Table 2 presents aspects related to dental care and the presence or absence of caries. Most adolescents reported brushing three times a day and not brushing at school. The median daily brushing was 3 (minimum=0, maximum=6), and the median post-meal brushing was 2 (minimum=0, maximum=4). Approximately 50% use dental floss and 40% use mouthwash. Most of them sought dental services only when they had a problem. The most common reason for seeking dental services was evaluation, followed by restoration and cleaning. The most used dental service model was private. Approximately 90% reported having received oral hygiene guidance. A relative or friend was responsible for the most prevalent oral hygiene guidance.
The number of brushings after meals was lower in adolescents with caries (median=1; minimum=0, and maximum=4) compared to those with absence of caries (median=2, minimum= 0, and maximum=4; p=0.001). The use of mouthwash and oral hygiene guidance by a dentist were associated with the presence of caries (Table 2).
In the binomial logistic regression, the risk factors for caries were female sex, age 13-15 years, and mouthwash use. The number of brushings after meals was a protective factor (Table 3). This model was significant (Chi-square model 37.342; p-value 0.000; Hosmer-Lemeshow 0.115; Nagelkerke R-square 0.097).
Discussion
In the study, the prevalence of caries among adolescents aged 10 to 15 years enrolled in municipal public education in Blumenau, Brazil, was 32.69%. The identified risk factors included being female, aged 13-15 years, and using mouthwash, while the number of brushings after meals was a protective factor. In addition, oral hygiene orientation by a dentist was associated with caries.
The prevalence of caries found in the present study was lower than that found in a previous study conducted in the same city in 2001 involving adolescents aged 12 years enrolled in public schools [16]. This finding suggests a reduction in the prevalence of caries in the city, possibly due to the increase in the number of health units, which provided greater access to dental services, and the implementation of the Programa Saúde na Escola [17] in 2007 in Brazil, which promoted oral health education in the school environment [17,18].
In addition, the prevalence of caries in the present study was significantly lower than that reported in studies conducted with adolescents from different regions of Brazil [19,20] and on a global scale [8,21]. This can be explained by the fact that caries prevalence is related to social and developmental indicators, which can influence the DMFT indices of populations across different geographic contexts [22]. Blumenau is a city in the Médio Vale do Itajaí region of Santa Catarina, Brazil. It has the third-largest population in the state and a high Human Development Index [23].
The mean DMFT of the adolescents was 0.59, classified as very low and below the WHO target, which at 12 years old should be less than 1.5 [24]. Although the DMFT index is very low, some adolescents had DMFT scores of 5, indicating that caries remains polarized, as found in another study [25]. This finding highlights the individual and behavioral character of the disease, even though the adolescents are inserted in the same context. The etiology of caries is not limited to the microbiological or access to dental services, but is strongly linked to the motivational aspect of self-care [26].
Being female was a risk factor for the presence of caries in this study. In another study, there was also a significant predominance of caries in girls [21]. Consideration should be given to the early eruption of permanent teeth in girls and, consequently, their longer exposure time to a cariogenic environment. The eruption of permanent teeth occurs around the age of six in girls, a phase in which children are still very dependent on parents or another adult for hygiene and eating habits [27]. In addition, some parents do not know that the eruption of some permanent teeth happens behind deciduous teeth and that they will not be replaced [28]. Another possible reason to consider is the variation in the composition of the oral microbiota between boys and girls. Research found a higher concentration of microorganisms associated with cariogenic activity in girls than in boys [29].
The older age group was also a risk factor for caries, in line with the literature, which indicates that DMFT values increase with age [21]. The supervision of parents and school tends to decrease as the age progresses in adolescence, while autonomy increases. In this period of life, there is greater exposure to different environments and foods, and it coincides with a phase in which the search for new experiences is marked, which makes preventing caries an even bigger challenge [30].
Another risk factor for the presence of caries was the use of mouthwash. This fact can be explained because mouthwash only aids oral hygiene since biofilm removal is only possible through the use of dental floss, brushing, and periodic visits to the dentist for professional prophylaxis. If these practices are not performed independently of the use of mouthwash, the biofilm will persist, favoring the development of caries [31]. The literature presents other disadvantages regarding the use of mouthwashes that contain alcohol in their composition. There is a possible association between the frequent use of mouthwash with alcohol and an increase in the risk of mouth cancer [32]. In addition, its frequent use can cause dryness of the oral mucous membranes, creating a favorable environment for caries development.
The number of post-meal brushings was a protective factor against caries. The goal of brushing after each meal is to disorganize the biofilm, avoiding its prolonged permanence on the dental surface. Thus, proper orientation on the best time to brush is after each meal [33].
Most adolescents reported seeking dental services only when facing oral health problems. These results are aligned with another survey [8]. Adolescence is a phase in which individuals seek less health care. However, it is also a phase in which situations of risk are experienced, which can impair the quality of life [34]. In relation to dental services, adolescents seek care only when they have already suffered the direct impact of problems such as caries, manifested, for example, by pain.
A relative or friend was the most prevalent person responsible for oral hygiene guidance reported by adolescents. A possible explanation may be found in the association between the presence of caries and oral hygiene guidance performed by a dentist. This can be attributed to the fact that adolescents only seek a dentist when facing specific dental problems, and only at this moment it is possible to receive professional guidance on oral hygiene. The PSE, an important program for maintaining oral health, has not been active in all schools, which can make parents or relatives the main people responsible for oral hygiene guidance.
Approximately 50% of the adolescents reported not using dental floss, which is aligned with the results of other studies [11,19]. Dental floss is effective in removing biofilm located in the interdental region [27]. Although no association was found between the presence of caries and the use of dental floss, it is important to highlight that the clinical examination performed allowed the identification of dental caries lesions on the free surfaces.
This study had some limitations. The generalizability of the results should be approached with caution, as the study did not include adolescents from state and private schools in Blumenau. However, most adolescents aged 10 to 15 attend municipal schools. It is important to consider the city of Blumenau's geographical and sociodemographic context when comparing results with those of other localities. There was no Kappa coefficient for agreement between the evaluators. However, the examination was conducted by only three evaluators and there was standardization of the technique and practical training prior to data collection. The use of the DMFT index is the most suitable for population studies; however, the absence of radiography tests, essential for the diagnosis of caries between teeth, may also have impacted the results obtained.
As strengths, this research revealed the prevalence of dental caries among adolescents aged 10 to 15 years enrolled in the municipal public network of Blumenau. This study presented a reality that had not been previously evaluated, including all variables and using the methodological rigor characteristic of a population study.
The associations observed between caries and dental care among adolescents reinforce the importance of the strategies adopted by the PSE to promote oral health. The PSE proposes the promotion and evaluation of oral health. One of the activities developed is topical fluoride application, which helps reduce caries rates. The actions are developed by primary health care, with schools as its setting and students as the target population. Their families and the community also benefit indirectly from these actions [35]. Given the constant flow of children and adolescents in and out of schools, ongoing efforts are necessary to ensure these strategies reach all students. This dynamic of continuous flow can result in a significant reduction in dental caries prevalence. In addition to the actions performed by the PSE, other collective measures, such as water fluoridation, should be emphasized to further reduce caries rates [36].
Conclusion
The prevalence of dental caries among adolescents aged 10 to 15 years enrolled in the municipal public education system in Blumenau, Brazil, was approximately one-third. The risk factors for caries were female age 13-15 years and mouthwash use. The number of brushings after meals was a protective factor. Oral hygiene orientation performed by a dentist was associated with the presence of caries. These results allow a better understanding of caries disease in adolescents aged 10 to 15 years, which is fundamental for the development of educational health programs aimed at promoting dental care. Thus, the results of this study provide valuable information to guide PSE actions in schools.
Financial Support
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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