Tooth loss in Brazil: analysis of the 2010 Brazilian Oral Health Survey

Abstracts

OBJECTIVE:

To estimate the mean number of missing teeth, lack of functional dentition and total tooth loss (edentulism) among adolescents, adults and the elderly in Brazil, comparing the results with those of 2003.

METHODS:

Data from 5,445 adolescents aged 15-19, 9,779 adults aged 35-44 and 7,619 elderly individuals aged 65-74, participants in the Brazilian Oral Health Survey (SBBrasil) 2010, were analyzed. The mean missing teeth, proportion of lack of functional dentition (< 21 natural teeth) and proportion of edentulism (total tooth loss) were estimated for each age group, each state Capital and each macro region. Multivariable logistic regression (tooth loss) and Poisson (absence of functional dentition and edentulism) analyses were performed in order to identify socioeconomic factors and demographic characteristics associated with each outcome.

RESULTS:

The prevalence of tooth loss among adolescents was 17.4% (38.9% in 2002-03) ranging from 8.1% among those earning higher income to almost 30% among those with less schooling. Among adolescents, females, those with black or brown skin and those with the lowest levels of income and schooling had a higher prevalence of tooth loss. Lack of functional dentition affected nearly ¼ of adults, it was higher among women, among those with black and brown skin and among those with the lowest levels of income and schooling. Mean missing teeth in adults decreased from 13.5 in 2002-03 to 7.4 in 2010. More than half of elderly is edentulous (similar to the 2002-03 findings); higher prevalence of edentulism was found among women and those with the lowest levels of income and schooling. Among adolescents the mean missing teeth ranged from 0.1 (in Curitiba, South Brazil and Vitória, Southeast Brazil) to 1.2 (in the North countryside). Among adults the lowest mean missing teeth was found in Vitória (4.2) and the highest in Rio Branco, North Brazil (13.6).

CONCLUSIONS:

A remarkable reduction in tooth loss among adolescents and adults was identified between 2010 and 2003. Among the elderly, tooth loss figure remained the same. In spite of important achievements in tooth loss figures, social and regional inequalities persist.

Tooth Loss, epidemiology; Socioeconomic Factors; Health Inequalities; Dental Health Surveys; Oral Health

OBJETIVO:

Analisar a perda dentária com base em estimativas do número médio de dentes perdidos, prevalência de ausência de dentição funcional e edentulismo em adolescentes, adultos e idosos brasileiros, comparando-a com resultados de 2003.

MÉTODOS:

Os dados referem-se à Pesquisa Nacional de Saúde Bucal (SBBrasil 2010): adolescentes de 15 a 19 anos (n = 5.445), adultos entre 35 e 44 anos (n = 9.779) e idosos entre 65 e 74 anos (n = 7.619). O número de dentes perdidos, a prevalência de indivíduos sem dentição funcional (< 21 dentes naturais) e de edentulismo (perda total dos dentes) foram estimados para cada grupo etário, capitais e macrorregiões brasileiras. Foram realizadas análises de regressão logística (perdas dentárias) e de Poisson (ausência de dentição funcional e edentulismo) multivariáveis para identificar fatores socioeconômicos e demográficos associados a cada desfecho.

RESULTADOS:

A prevalência de perdas dentárias entre adolescentes foi de 17,4% (38,9% em 2002-3), variando de 8,1% entre os estratos de maior renda a quase 30% entre os menos escolarizados. Entre adolescentes, as mulheres, pardos e pretos, os de menor renda e escolaridade apresentaram maiores prevalências de perdas. Ausência de dentição funcional ocorreu em aproximadamente ¼ dos adultos, sendo superior nas mulheres, nos pretos e pardos, nos de menor renda e escolaridade. A média de dentes perdidos em adultos declinou de 13,5 em 2002-3 para 7,4 em 2010. Mais da metade da população idosa é edêntula (similar em 2002-3); maiores prevalências de edentulismo em idosos foram observadas em mulheres, nos de menores renda e escolaridade. A média de dentes perdidos em adolescentes variou de 0,1 (Curitiba e Vitória) a 1,2 (interior da região Norte). Entre adultos, a menor média encontrada foi 4,2 (Vitória) e a maior 13,6 (Rio Branco).

CONCLUSÕES:

Houve importante redução nas perdas dentárias em adolescentes e adultos em comparação com dados de 2003, mas não entre os idosos. As perdas dentárias apresentam marcadas desigualdades sociais e regionais.

Perda de Dente, epidemiologia; Fatores Socioeconômicos; Desigualdades em Saúde; Inquéritos de Saúde Bucal; Saúde Bucal

OBJETIVO:

Analizar la pérdida dentaria con base en estimaciones del número promedio de dientes perdidos, prevalencia de ausencia de dentición funcional y edentulismo en adolescentes, adultos y ancianos brasileños, comparándola con resultados de 2003.

MÉTODOS:

Los datos se refieren a la Investigación Nacional de Salud Bucal (SBBrasil): adolescentes de 15 a 19 años (n=5.445), adultos entre 35 y 44 años (n=9.779) y ancianos entre 65 y 74 años (n=7.619). El número de dientes perdidos, la prevalencia de individuos sin dentición funcional (< 21 dientes naturales) y de edentulismo (pérdida total de los dientes), fueron estimados para cada grupo etario, capitales y macro regiones brasileñas. Se realizaron análisis de regresión logística (pérdidas dentarias) y de Poisson (ausencia de dentición funcional y edentulismo) multivariables para identificar factores socioeconómicos y demográficos asociados a cada aspecto.

RESULTADOS:

La prevalencia de pérdidas dentarias entre adolescentes fue de 17,4% (38,9% en 2002-3) variando de 8,1% entre los estratos de mayor renta a casi 30% entre los menos escolarizados. Entre adolescentes, las mujeres, pardos y negros, los de menor renta y escolaridad presentaron mayores prevalencias de pérdidas. La ausencia de dentición funcional ocurrió en aproximadamente ¼ de los adultos, siendo superior en las mujeres, en los negros y pardos, en los de menor renta y escolaridad. El promedio de dientes perdidos en adultos declinó de 13,5 en 2002-3 a 7,4 en 2010. Más de la mitad de la población anciana es edéntula (similar en 2002-3); mayores prevalencias de edentulismo en ancianos fueron observadas en mujeres, en los de menor renta y escolaridad. El promedio de dientes perdidos en adolescentes varió de 0,1 (Curitiba y Vitória) a 1,2 (interior de la región Norte). Entre adultos, el menor promedio encontrado fue 4,2 (Vitória) y el mayor 13,6 (Rio Branco).

CONCLUSIONES:

Hubo importante reducción en las pérdidas dentarias en adolescentes y adultos en comparación con datos del 2003, sin embargo, no se evidenció entre los ancianos. Las pérdidas dentarias presentan marcadas desigualdades sociales y regionales.

Pérdida de Diente, epidemiología; Factores Socioeconómicos; Desigualdades en la Salud; Encuestas de Salud Bucal; Salud Bucal

INTRODUCTION

Tooth loss is considered to be one of the principal oral health problems due to its high prevalence and the aesthetical, functional, psychological and social effects it brings with it. ^{3 , 9 , 26} However, in many cases tooth loss is avoidable. It reflects oral health problems accumulated throughout life, cultural aspects and the decision to extract a tooth as an orthodontic treatment option. ^{15 , 18} Epidemiological studies show that tooth loss constitutes a marker of social inequality in diverse societies; population groups at the bottom of the socioeconomic hierarchy have higher rates of tooth loss than those situated at the top of the scale. ^{3 , 6 , 7 , 15 , 16}

In Brazil, the national oral health survey in 1986 revealed that, for adolescents (aged 15-19) the mean number of teeth lost was 1.9, representing 15.2% of the DMFT (decayed, missing and filled teeth) index. For adults aged 35-44, the rate was 14.9 (66.5%) and it was 23.4 (86%) of the index for individuals aged between 50 and 59. Regional disparities were present in all age groups, with the lowest percentages in the South and the highest in the North. ^a In the 2002-03 National Oral Health Survey, the mean number of teeth lost fell to 0.9 and 13.2 in adolescents and adults, respectively, and reached 25.8 in the elderly aged 65 to 74. The proportion of the “missing” component remained stable between the two studies: around 15% in adolescents and 65% in adults (aged 35-44 ) and more than 90% in the elderly. These observations show the magnitude and significance of tooth loss as a public health problem in this country. ^b

The measurement and presentation of the data in the studies on tooth loss varies according to the age group in question. In adolescents, it is preferable to measure the prevalence of loss instead of the number of teeth affected, as this health problem is relatively rare in this age group, even in Brazil. ⁴ In adults and the elderly, lack of functional dentition and edentulism have been proposed as ways of measuring tooth loss. Functional dentition is viewed as the minimum number of natural teeth which an individual needs in order to function adequately without the need for a prosthesis. ¹⁷ Individuals with fewer than 21 natural teeth may suffer problems chewing, restricting the food they can consume and their nutrient intake. ^{11 , 27} Edentulism is the loss of all natural teeth. ⁷

The aim of this study was to analyze tooth loss based on estimates of the mean number of teeth lost, prevalence of lack of functional dentition and edentulism in Brazilians and compare these results with those of the 2003 survey. In addition, the association of these oral health problems with the participants’ economic conditions and demographic characteristics was also investigated.

METHODS

The database from the Pesquisa Nacional de Saúde Bucal (Brazilian Oral Health Survey) – (SBBrasil) 2010 was used. The sampling plan was made up of domains regarding the state capitals and municipalities in the interior. Each state capital and the Federal District was one domain and the municipalities in the interior of each macro-region of Brazil (North, Northeast, Central-West, Southeast and South) was another. There were 27 geographical domains (state capitals and the Federal District) and five from the interior of each macro-region, making 32 in total. Thirty municipalities in the interior of each region were randomly selected. The primary sampling units were: (a) municipality in the interior of the regions and (b) census tracts for each of the capitals. Individuals aged five, aged 12 and those in the 15 to 19-year olds age group, those +aged 35 to 44 and those aged 65 to 74 were interviewed and examined within their homes. ^c Detailed information on the sampling procedure can be obtained elsewhere. ²⁵ This study used data from adolescents aged 15 to 19 (n = 5,888), adults aged 35 to 44 (n = 10,199) and elderly individuals between 65 and 74 (n = 8,000).

Data collection involved oral examinations and interviews. Tooth loss in adolescents was considered due to dental caries, whereas in adults and the elderly it was defined as any loss of natural teeth due to extraction, for any reason (codes 4 and 5 of the DMFT index). ³⁰

The number of teeth lost (component M in the DMFT index ≥ 1), the prevalence of individuals without functional dentition (presence of < 21 natural teeth) and of edentulism (loss of all natural teeth) were estimated for adolescents, adults and the elderly for each macro-region and state capital.

Interviews within the home were carried out using a structured questionnaire with questions on sex, age, self-reported skin color, schooling and household income, which were considered to be the independent variables. Age was collected and analyzed in complete years; skin color followed the classification of the Brazilian Institute of Geography and Statistics – Instituto Brasileiro de Geografia e Estatística (white, brown-skinned, black, yellow and indigenous). Household income was collected in reais, considering the total income of all members of the household in the month prior to the interview and categorized into the following groups (below R$ 500.00; R$ 501.00 to R$ 1,500.00; R$ 1,500.00 to R$ 4,500.00; over R$ 4,500.00). The participants’ schooling was investigated according to the number of years successfully passed in the education system and categorized as up to four years, between five and eight years, between nine and 11 years and 12 or more years.

All oral examinations were carried out within the participants’ homes. The field work trams were composed of an examiner (a dental surgeon) and a note taker, who had been trained in 32-hour regional workshops. The state capitals had ten field work teams and the municipalities in the interior between two and six, depending on the population size. In each of the workshops, up to ten teams took part at the same time; however, in the classes focusing on carrying out the oral examinations, the teams were divided into two groups – each with an instructor. The calibration procedures were planned so as to anticipate (simulate) the conditions which the examiners would encounter, especially with regards to the conditions in question and the different population groups. The calibration technique adopted was that of consensus, ¹⁴ calculating concordance between each examiner and the results obtained by group consensus. The reference was the model proposed by the World Health Organization (WHO) ²⁹ and the weighted kappa coefficient was calculated for each examiner, age group and oral health problem, with the acceptable limit being 0.65.

The mean number of teeth lost and the respective 95% confidence intervals (95%CI) for each domain (state capital and the interior of each of the five macro-regions) in each age group were estimated. Next, the prevalence and the confidence interval were estimated for each outcome – loss of at least one tooth (no/yes), lack of functional dentition (no/yes) and edentulism (no/yes) – for adolescents, adults and the elderly, respectively. Finally, multi-level logistic regression (tooth loss) and Poisson regression (lack of functional dentition and edentulism) analyses were carried out to identify socioeconomic and demographic factors associated with each outcome. Logistic regression was used for tooth loss in adolescents, an outcome with prevalence lower than 20%, and Poisson regression for functional dentition and edentulism, outcomes with prevalence higher than 20%. Unadjusted analysis was carried out first for each outcome, with a p value of ≤ 0.20 being the criterion for inclusion in the multivariable models. The inclusion of explanatory variables in the adjusted models was ordered by group, first the demographic variables (sex and skin color), followed by the socioeconomic variables (household income and years of schooling).

All of the analyses were carried out using STATA 11.0 (2009), taking into account the complex sampling plan and the sampling weights.

The SBBrasil 2010 Project followed the standards set by the Declaration of Helsinki and was approved by the Conselho Nacional de Ética em Pesquisa , record no. 15,498, 7 ^th January 2010.

RESULTS

There were 5,445 adolescents aged 15-19, 9,779 adults aged 35 to 44 and 7,619 elderly individuals aged between 65 and 74 investigated in the study, indicating sampling losses of 7.6%, 4.2% and 4.8% respectively. Overall prevalence of tooth loss in adolescents was 17.4%, varying between 8.1% in those on higher incomes to almost 30% among those who had fewer than four years of schooling. Adolescents, women, those with black and brown skin and those with lower levels of schooling and income had the highest prevalence of tooth loss. The proportion of adolescents aged 18 years who had not lost any teeth was 81.2% (95%CI 75.1;86.1). Lack of functional dentition occurred in approximately one-quarter of adults, with a higher prevalence in women, those with black and brown skin and those with lower levels of schooling and income. The highest prevalence of lack of functional dentition in adults occurred among those who had fewer than four years of schooling (40.2%) and the lowest among those participants with household income above R$ 4,500.00 per month (7%). Edentulism was common in the elderly (53.7%); higher among women, those with lower levels of schooling and income and did not vary according to skin color. Almost 60% of the elderly with the lowest levels of income and schooling suffered from edentulism, whereas only 10% of the elderly with household income above R$ 4,500.00 per month suffered from it ( Table 1 ).

Table 1
. Description of the sample and the prevalence of tooth loss according to socio-demographic variable for 15 to 19-year olds, 35 to 44-year-olds and 65 to 74-year-olds. SBBrasil 2010.

Variable	Sample						Tooth loss		No functional dentition		Edentulism
	15 to 19 years old		35 to 44 years old		65 to 74 years old		15 to 19 years old		35 to 44 years old		65 to 74 years old
	n	%	n	%	n	%	% (95%CI)	p	% (95%CI)	p	% (95%CI)	p
Sex (n = 22,843)	5,445	100.0	9,779	100.0	7,619	100.0	17.4 (14.7;20.4)	0.017	22.4 (19.9;25.2)	< 0.001	53.7 (49.8;57.6)	0.043
Male	2,497	45.9	3,374	34.5	2,903	38.1	13.8 (10.4;18.1)		18.1 (15.1;21.4)		49.64 (45.10;54.19)
Female	2,948	54.1	6,405	65.5	4,716	61.9	20.7 (17.0;25.0)		21.4 (22.0;28.1)		56.16 (50.93;61.26)
Skin color (n = 22,843)	5,445	100.0	9,779	100.0	7,619	100.0	17.4 (14.7;20.4)	0.039	22.4 (19.9;25.2)	0.019	53.7 (49.8;57.6)	0.662
White	2,203	40.5	4,137	42.3	3,577	46.9	14.5 (10.9;19.0)		20.0 (17.1;23.4)		52.5 (47.5;57.4)
Brown skinned	2,491	45.7	4,386	44.9	2,970	39.0	20.3 (16.9;24.1)		24.4 (20.6;28.6)		54.2 (48.0;60.3)
Black	598	11.0	1,020	10.4	879	11.5	20.1 (14.8;26.6)		27.4 (22.0;33.6)		55.8 (46.4;64.9)
Yellow	104	1.9	164	1.7	121	1.6	9.6 (4.1;21.1)		13.8 (8.5;21.6)		61.6 (43.8;76.7)
Indigenous	49	0.9	72	0.7	72	1.0	18.0 (4.8;48.6)		20.0 (9.5;37.3)		72.4 (40.8;90.9)
Household income (n = 21,998)	5,125	100.0	9,535	100.0	7,338	100.0	17.3 (14.6;20.4)	0.018	22.5 (20.0;25.3)	< 0.001	53.7 (49.6;57.7)	< 0.001
Over R$ 4,500.00	246	4.8	519	5.4	461	6.3	8.1 (2.5;23.7)		7.0 (3.2;14.5)		10.2 (5.6;17.9)
R$ 4,500.00-R$ 1,501.00	1,363	26.6	2,813	29.5	1,999	27.2	11.9 (7.2;19.2)		15.1 (11.9;19.0)		49.8 (43.4;56.1)
R$ 1,500.00-R$ 501.00	2,650	51.7	4,783	50.2	4,029	54.9	18.9 (15.7;22.6)		25.3 (22.0;28.8)		57.4 (52.7;62.0)
Below R$ 500.00	866	16.9	1,420	14.9	849	11.6	24.3 (19.0;30.4)		33.0 (28.1;38.3)		58.1 (46.2;69.1)
Years of schooling (n = 22,543)	5,429	100.0	9,693	100.0	7,421	100.0	17.3 (14.6;20.4)	< 0.001	22.4 (19.9;25.1)	< 0.001	53.6 (49.7;57.4)	< 0.001
12 or more	761	14.0	2,297	23.7	738	9.9	13.3 (8.3;20.7)		7.7 (5.2;11.1)		21.8 (13.0;34.2)
9 to 11	2,643	48.7	3,025	31.2	870	11.7	13.8 (10.6;17.6)		16.9 (13.2;21.2)		37.0 (28.2;46.7)
5 to 8	1,821	33.5	2,718	28.0	1,568	21.2	23.8 (19.6;28.5)		26.1 (22.2;30.5)		54.1 (47.1;60.8)
4 or fewer	204	3.8	1,653	17.1	4,245	57.2	29.6 (19.0;43.0)		40.2 (35.3;45.3)		59.4 (54.1;64.4)

Table 2 shows that mean tooth loss in adolescents was less than half a tooth for the country overall, varying form 0.1 in Curitiba and Vitória to 1.2 in the interior of the North. For adults, the mean for Brazil was 7.4 teeth lost, with the lowest mean in Vitória (4.2) and the highest in Rio Branco (13.6). The mean number of teeth lost in the elderly was almost 26.0, with the lowest mean being in Porto Alegre (18.7) and the highest in the interior of the Northeast (27.3).

Table 2
. Means (95%CI) and medians of the number of teeth lost for 15 to 19-year-olds, 35 to 44-year-olds and 65 to 74-year-olds according to domain (state capitals and the interior). SBBrasil 2010.

Domain	Teeth lost
	15-19 years old		35-44 years old		65-74 years old
	Mean (95%CI)	Median	Mean (95%CI)	Median	Mean (95%CI)	Median
Porto Velho	0.8 (0.6;1.0)		10.7 (9.4;12.0)	10	26.8 (25.3;28.2)	32
Rio Branco	0.5 (0.4;0.7)		13.6 (11.8;15.4)	12	27.2 (25.5;29.0)	32
Manaus	0.6 (0.2;1.1)		11.0 (9.9;12.2)	9	26.2 (25.0;27.3)	28
Boa Vista	0.8 (0.5;1.0)		9.7 (8.4;11.1)	8	26.3 (24.6;27.9)	32
Belém	0.6 (0.4;0.8)		9.0 (8.0;10.1)	7	25.5 (24.1;26.9)	26
Macapá	0.6 (0.2;1.0)		7.0 (5.6;8.4)	6	24.2 (22.3;26.0)	27
Palmas	0.5 (0.2;0.8)		8.8 (7.8;9.8)	7	26.5 (25.3;27.7)	32
São Luís	0.2 (0.1;0.4)		6.0 (4.4;7.7)	3	24.1 (22.1;26.2)	30
Teresina	0.3 (0.1;0.5)		7.5 (6.7;8.6)	5	25.8 (24.4;27.2)	32
Fortaleza	0.2 (0.1;0.3)		7.9 (6.6;9.1)	6	24.9 (22.8;26.9)	29
Natal	0.7 (0.0;1.5)		9.4 (7.7;11.0)	7	24.3 (22.7;25.9)	27
João Pessoa	0.6 (0.2;1.0)		8.5 (7.3;9.7)	7	24.3 (22.3;26.4)	29
Recife	0.7 (0.3;1.1)		9.1 (7.2;10.9)	6	22.9 (20.7;25.2)	26
Maceió	0.3 (0.2;0.4)		8.0 (6.8;9.2)	7	22.2 (19.6;24.8)	24
Aracaju	0.3 (0.1;0.4)		9.0 (8.1;9.9)	8	21.2 (19.3;23.2)	23
Salvador	0.2 (0.1;0.3)		6.4 (5.3;7.6)	5	23.4 (22.0;24.7)	26
Belo Horizonte	0.2 (0.1;0.3)		5.0 (4.2;5.9)	3	24.1 (21.9;26.2)	30
Vitória	0.1 (0.0;0.2)		4.2 (2.7;5.8)	2	19.9 (17.1;22.8)	23
Rio de Janeiro	0.3 (0.1;0.5)		7.7 (6.5;8.9)	5	26.0 (24.2;27.9)	32
São Paulo	0.4 (0.2;0.6)		7.0 (5.8;8.1)	5	22.8 (21.4;24.3)	26
Curitiba	0.1 (0.0;0.2)		6.1 (4.9;7.4)	4	23.0 (20.8;25.1)	26
Florianópolis	0.2 (0.1;0.3)		5.1 (3.6;6.6)	2	22.2 (20.5;23.9)	26
Porto Alegre	0.3 (0.2;0.4)		4.3 (3.4;5.1)	3	18.7 (16.1;21.3)	20
Campo Grande	0.2 (0.1;0.3)		7.4 (6.5;8.3)	4	23.1 (21.2;25.0)	27
Cuiabá	0.3 (0.1;0.5)		7.5 (6.1;8.9)	5	25.6 (23.6;27.6)	32
Goiânia	0.2 (0.1;0.3)		7.1 (5.8;8.4)	5	26.6 (24.9;28.3)	32
Federal District	0.2 (0.1;0.3)		7.0 (5.7;8.3)	5	23.2 (20.6;25.8)	27
Interior - North	1.2 (0.9;1.4)		11.3 (10.0;12.6)	10	27.4 (26.5;28.3)	32
Interior - Northeast	0.8 (0.4;1.2)		11.3 (9.4;13.1)	9	27.3 (26.3;28.3)	32
Interior - Southeast	0.3 (0.1;0.5)		6.5 (5.4;7.6)	5	25.8 (24.2;27.4)	32
Interior - South	0.2 (0.1;0.3)		8.5 (6.9;10.1)	5	25.7 (23.7;27.7)	32
Interior - Central-West	0.4 (0.3;0.6)		9.0 (7.1;10.8)	6	26.2 (24.5;27.9)	32
Brasil	0.4 (0.3;0.5)		7.4 (6.9;8.0)	6	25.4 (24.6;26.1)	29

Tooth loss affected 17.4% of Brazilian adolescents, with statistically higher proportions in Rio Branco, Recife, Boa Vista, Porto Velho and the interior of the North and lower in Vitória ( Figure 1 ). Among adults, 22.4% had fewer than 21 natural teeth. Vitória, Porto Alegre, Florianópolis and Belo Horizonte had the lowest rates of prevalence, whereas the interior of the Northeast, Manaus, Porto Velho, the interior of the North and Rio Branco had rates of prevalence above the national average ( Figure 2 ). More than half of elderly individuals in Brazil (53.7%) were edentulous. Porto Alegre, Aracaju, Salvador, Vitória, Belém, Florianópolis and Macapá had rates below the national average, whereas in the interior of the Northeast and Rio Branco are where the highest rates were found ( Figure 3 ).

Figure 1
. Prevalence of teeth lost in individuals aged 15 to 19, according to domain (state capitals and interior). SBBrasil 2010.

Figure 2
. Prevalence of individuals with no functional dentition (< 21 natural teeth) in individuals aged 35 to 44 according to domain (state capitals and interior). SBBrasil 2010.

Figure 3
. Proportion of individuals aged 65 to 74 with edentulism, according to domain (state capitals and interior). SBBrasil 2010.

Among adolescents, women, those with less schooling and the poorest had, respectively, a 59%, 124% and 184% higher chance of tooth loss than men, those with fewer than four years of schooling and those with a household income above R$ 4,500.00 ( Table 3 ). In adults, sociodemographic factors associated with lack of functional dentition were the same as those for adolescents and were of similar magnitude, although the prevalence of lack of functional dentition among those with fewer than four years of schooling was almost five times higher than among those with 12 or more years of schooling ( Table 4 ). Among the elderly, only income and schooling were associated with edentulism. As income decreased, the prevalence of edentulism increased, creating a gradient. Among the elderly on the lowest level of income, edentulism was almost four times more prevalent than among those on the highest level of income, whereas edentulism is twice as prevalent among those with the least amount of schooling compared to those with the most ( Table 5 ).

Table 3
. Multivariate logistic regression of the association between tooth loss in adolescents (15 to 19 years old) and sociodemographic variables. SBBrasil 2010.

	Unadjusted	Adjusted
Variable		Model 1			Model 2		Model 3
	OR (95%CI)	p	OR (95%CI)	p	OR (95%CI)	p	OR (95%CI)	p
Sex		0.018		0.018		0.055		0.037
Male	1		1		1		1
Female	1.63 (1.09;2.45)		1.63 (1.08;2.44)		1.51 (0.99;2.30)		1.59 (1.03;2.43)
Skin color		0.103		0.125
White	1		1
Brown skinned	1.50 (1.07;2.12)		1.49 (1.07;2.07)
Black	1.48 (0.94;2.33)		1.47 (0.94;2.31)
Yellow	0.63 (0.25;1.58)		0.60 (0.23;1.57)
Indigenous	1.29 (0.27;6.22)		1.21 (0.23;6.40)
Household income		0.004				0.007		0.033
Over R$ 4,500.00	1				1		1
R$ 4,500.00- R$ 1,501.00	1.53 (0.44;5.35)				1.48 (0.43;5.07)		1.61 (0.45;5.76)
R$ 1,500.00- R$ 501.00	2.63 (0.76;9.11)				2.42 (0.72;8.19)		2.42 (0.68;8.56)
Below R$ 500.00	3.62 (1.01;13.01)				3.33 (0.94;11.79)		2.84 (0.78;10.41)
Years of schooling		< 0.001						< 0.001
12 or more	1						1
9 to 11	1.04 (0.58;1.86)						1.00 (0.53;1.86)
5 to 8	2.03 (1.15;3.57)						1.84 (1.01;3.34)
4 or fewer	2.74 (1.33;5.64)						2.24 (1.05;4.80)

• Model 1: Sex and skin color; Model 2: Household income adjusted for sex (skin color excluded from the model – p > 0.20);
• Model 3: Years of schooling adjusted for income and sex. OR: Odds Ratio.

Table 4
. Multivariate Poisson regression analyses of the association between functional dentition in adults (35 to 44) and sociodemographic variables. SBBrasil 2010.

	Unadjusted	Adjusted
Variable		Model 1			Model 2		Model 3
	PR (95%CI)	p	PR (95%CI)	95%CI	PR (95%CI)	p	PR (95%CI)	p
Sex		< 0.001		< 0.001		< 0.001		< 0.001
Male	1		1		1		1
Female	1.38 (1.17;1.62)		1.39 (1.18;1.63)		1.38 (1.16;1.63)		1.53 (1.30;1.80)
Skin color		0.023		0.018		0.487
White	1		1		1
Brown skinned	1.22 (1.01;1.46)		1.22 (1.02;1.46)		1.07 (0.90;1.27)
Black	1.37 (1.07;1.76)		1.38 (1.08;1.78)		1.16 (0.90;1.50)
Yellow	0.69 (0.41;1.14)		0.68 (0.42;1.11)		0.61 (0.35;1.06)
Indigenous	1.00 (0.50;2.01)		1.02 (0.50;2.08)		0.86 (0.42;1.78)
Household income		< 0.001				< 0.001		0.016
Over R$ 4,500.00	1				1		1
R$ 4,500.00- R$ 1,501.00	2.17 (1.04;4.52)				2.12 (1.03;4.35)		1.53 (0.80;2.97)
R$ 1,500.00- R$ 501.00	3.63 (1.69;7.80)				3.52 (1.67;7.40)		1.83 (0.93;3.62)
Below R$ 500.00	4.74 (2.20;10.17)				4.50 (2.14;9.49)		1.99 (1.01;3.93)
Years of schooling		< 0.001						< 0.001
12 or more	1						1
9 to 11	2.20 (1.40;3.45)						2.00 (1.25;3.20)
5 to 8	3.40 (2.33;4.95)						3.17 (2.12;4.73)
4 or fewer	5.23 (3.66; 7.47)						4.71 (3.17;7.00)

• Model 1: Sex and skin color; Model 2: Household income adjusted for sex and skin color; Model 3: Years of schooling adjusted for income and sex (skin color excluded from the model – p > 0.20). PR: Prevalence ratio.

Table 5
. Multivariate Poisson regression analyses of the association between edentulism in the elderly (65 to 74) and sociodemographic variables. SBBrasil 2010.

Variable	Unadjusted		Adjusted
			Model 1		Model 2
	RP (IC95%)	p	PR(95%CI)	p	PR(95%CI)	p
Sex		0.041		0.067
Male	1		1
Female	1.13 (1.00;1.27)		1.10 (0.97;1.25)
Skin color		0.273
White	1
Brown skinned	1.03 (0.90;1.18)
Black	1.06 (0.88;1.29)
Yellow	1.17 (0.88;1.55)
Indigenous	1.38 (0.91;2.08)
Household income		< 0.001		< 0.001		0.036
Over R$ 4,500.00	1		1		1
R$ 4,500.00-R$ 1,501.00	4.86 (2.72;8.68)		4.76 (2.66;8.52)		3.66 (1.99;6.76)
R$ 1,500.00-R$ 501.00	5.60 (3.13;10.02)		5.50 (3.07;9.85)		3.90 (2.09;7.27)
Below R$ 500.00	5.67 (3.10;10.39)		5.60 (3.06;10.24)		3.92 (2.05;7.51)
Years of schooling		< 0.001				< 0.001
12 or more	1				1
9 to 11	1.70 (0.99;2.91)				1.35 (0.79;2.29)
5 to 8	2.48 (1.53;4.02)				1.85 (1.15;2.98)
4 or fewer	2.73 (1.65;4.50)				2.02 (1.24;3.29)

• Model 1: Sex and skin color; Model 2: Household income and schooling adjusted for sex (skin color excluded from the model – p > 0.20). PR: Prevalence ratio.

DISCUSSION

When comparing the 2010 and 2003 nationwide studies carried out by the Ministério da Saúde, significant decreases in rates of tooth loss were recorded in adolescents and adults, while edentulism in the elderly remained stable. This is the first nationwide study which shows decreases in tooth loss among adults. In adolescents, the mean number of teeth lost fell by more than half, from 0.96 to 0.40; the prevalence of having lost at least one tooth dropped from 38.9% to 17.4% and the proportion of 18-year-olds who had not lost any teeth was above 80%, approaching the 85% proposed by the WHO as a goal for the year 2000. ¹² The mean number of teeth lost for adults fell from 13.5 to 7.4. Edentulism in the elderly remained around 54% in both studies. ^{b , c}

Despite advances, regional and social inequalities remain. In adolescents, the magnitude of the association between tooth loss in females compared with males and between the highest and lowest income groups increased between 2003 and 2010 (prevalence ration from 1.15 to 1.59 and from 1.37 to 3.62, respectively). This was similar for adults, suggesting that the decrease in tooth loss has been accompanied by an increase in inequality. Antunes et al ² identified a similar pattern for dental caries in school children in the state of São Paulo, using the Gini index as a measure of inequality. Peres et al ^{22 , 23} identified unequal distribution of fluoridation of tap water in municipalities in Santa Catarina and in Brazil, highlighting the “inverse law of equality” ²⁸ as a hypothesis to explain these findings. According to this “law”, populations with better social conditions, living in municipalities in more affluent regions tend to be the first to benefit from preventative programs and activities in health care, including those carried out almost exclusively by the state, such as the national immunization program or the national program to fluoridate water supplies.

The decreased tooth loss in adolescents and adults observed over the last ten years indicates, possibly, a combination of the cohort effect, improvements in socioeconomic conditions, especially in education, ¹⁶ and in the health care system with the fluoridation of tap water and widespread use of fluoridated toothpastes. In the 1980s and 90s these two measures achieved broad coverage of the population and largely explain the reduction in the prevalence of dental caries, the principal cause of tooth loss, in Brazil. During the 1980s and 90s, the adolescents and adults examined in 2010 were exposed to these measures; the elderly examined in 2010 did not benefit from these effects during their own childhood and adolescence. It is expected that decreased edentulism in those aged 65-74 as a cohort effect will only be identified in epidemiological studies in the 2050s.

Among the elderly aged over 65 in Brazil, the prevalence of edentulism is still among the highest in the world, behind Turkey where the rate is 67% (2007) and Portugal, 70% (2000). At the other end of the scale, the USA, with 24% (1999 - 2002) and Australia, 20% (2004-06), Norway (2008) and France (2000), both with 16%, have the lowest prevalence of tooth loss, when nationwide studies carried out after the year 2000 are considered. ⁵

Regional inequalities in tooth loss are striking, especially among youths and adults. In general, those living in the state capitals and the interior of the North and Northeast have a higher prevalence of tooth loss than those living in the South and Southeast. This situation reflects different coverage of population measures recognized to prevent tooth loss, such as fluoridated water supplies, concentrated in the South and Southeast of the country. ²² Moreover, use of and access to oral health care services are lower in the poorer areas. According to data from the Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Telephone Monitoring System for Risk and Protection Factors for Chronic Diseases - VIGITEL) 2009, the prevalence of lack of access to orthodontic services (needing but not receiving care) varied considerably between state capitals. In Manaus, Macapá, Belém and Rio Branco approximately one in four did not receive treatment when they needed it. This value is around five times higher than that reported by residents in Curitiba. ²⁴ Data from the SBBrasil 2010 show that more than 80% of the population in all age groups had visited a dentist, with the use of private services predominantly in the Southeast and South among adults and the elderly. ^c

Social, economic and demographic characteristics are consistently associated with tooth loss. The higher prevalence in women, both for adolescents and for adults, had already been observed in studies before the 2000s. However, results from 2010 show higher prevalence ratios of tooth loss between sexes, indicating increased inequality between men and women. This finding, although consistent with other investigations, ^{3 , 4 , 21} is not easy to interpret. Higher use of orthodontic services by women may, depending on the type of practice, result in over-treatment. Types of orthodontic services based on pay-per-procedure, normally invasive, may result in loss of dental tissue in each consultation which, cumulatively, may accelerate tooth loss. ¹⁰ Data from VIGITEL 2009 show that more than 60% of the population in the state capitals had visited a private dentist where the type of payment encouraged intervention. ²⁴ A study by Caldas Jr et al ⁸ reinforced this hypothesis, showing a strong association between the number of teeth extracted due to dental caries and the frequency with which they were filled. As there are still restrictions to access and use of specialist orthodontic services within the Sistema Único de Saúde (Brazilian public health system), especially when it comes to carrying out endodontic treatment, it is very probable that extraction becomes the unavoidable treatment option in cases of advanced dental caries, especially for those on lower incomes.

Income and schooling, but not skin color, proved to be associated with tooth loss in adolescents, adults and the elderly, after adjusting for socioeconomic and demographic variables. There is a social gradient to tooth loss: the lower the income and schooling the higher the tooth loss. Less well-off individuals and those with less schooling live in areas with lower coverage of fluoridated tap water ²² and of orthodontic services, ¹³ consume more sugar ¹⁷ and brush their teeth less frequently. ¹ All of these factors contribute to the increased prevalence and extent of dental caries and, consequently, to tooth loss. In this study, skin color ceased to be associated with tooth loss after adjusting for social and economic variables, indicating, in this case, that social and economic conditions have higher weighting than race.

This study originates from the third Brazilian epidemiological survey into oral health conditions carried out with adolescents, adults and the elderly. The first, in 1986, took place in 16 state capitals and the elderly were those aged between 50 and 59. ^b The second, in 2003, took place in 250 municipalities in all states. ^b The methodology of the 2010 study showed some improvements compared to the previous studies, including 32 domains (26 state capitals, the Federal Disctrict and the interior of the five macro-regions) and the database provided sampling weights so as to avoid the limitations of the previous studies. ²² As these three studies adopted different methodologies, caution is recommended when comparing their results. However, the difference in tooth loss between the two most recent studies (2003 and 2010) are significant; therefore, it is not probable that they are merely reflective of differences in the methodological procedures.

A significant decrease in tooth loss among adolescents and adults was recorded compared with the first decade of the 2000s. Among the elderly, the situation of almost half of individuals suffering from edentulism remained the same. In spite of advances, social and regional inequalities remain, suggesting that, in conjunction with universal population measures, the most vulnerable should also receive prioritized health care (proportionate universalism).

REFERÊNCIAS

• ¹
  Abegg C. Hábitos de higiene bucal de adultos porto-alegrenses. Rev Saude Publica. 1997;3(6):586-93. DOI: 10.1590/S0034-89101997000700007
  » https://doi.org/10.1590/S0034-89101997000700007
• ²
  Antunes JL, Jahn GM, Camargo MA. Increasing inequalities in the distribution of dental caries in the Brazilian context. Community Dent Health. 2005;22(2):94-100.
• ³
  Barbato PR, Nagano HCM, Zanchet FN, Boing AF, Peres MA. Perdas dentárias e fatores sociais, demográficos e de serviços associados em adultos brasileiros: uma análise dos dados do Estudo Epidemiológico Nacional (Projeto SB Brasil 2002-2003). Cad Saude Publica. 2007;23(8):1803-14. DOI: 10.1590/S0102-311X2007000800007
  » https://doi.org/10.1590/S0102-311X2007000800007
• ⁴
  Barbato PR, Peres MA. Perdas dentárias em adolescentes brasileiros e fatores associados: estudo de base populacional. Rev Saude Publica. 2009;43(1):13-25. DOI: 10.1590/S0034-89102009000100003
  » https://doi.org/10.1590/S0034-89102009000100003
• ⁵
  Beaglehole R, Benzian H, Crail J, Mackay J. The Oral Health Atlas. Mapping a neglected global health issue. Coitrin, Switzertland: FDI World Health Federation; 2009.
• ⁶
  Bernabé E, Marcenes W. Income inequality and tooth loss in the United States. J Dent Res. 2011:90(6):724-9. DOI: 10.1177/0022034511400081
  » https://doi.org/10.1177/0022034511400081
• ⁷
  Burt BA, Eklund SA. Tooth loss. In: Burt BA, Eklund SA, editor. Dentistry, dental practice and the Community. 4. ed. Phyladelphia: W.B. Sauders Company;1992. p.83.
• ⁸
  Caldas Jr AF, Silveira RCJ, Marcenes W. The impact of restorative treatment on tooth loss prevention. Pesqui Odontol Bras. 2003;17(2):166-70. DOI: 10.1590/S1517-74912003000200013
  » https://doi.org/10.1590/S1517-74912003000200013
• ⁹
  De Marchi RJ, Hugo FN, Hilgert JB, Padilha DM. Number of teeth and its association with central obesity in older Southern Brazilians. Community Dent Health. 2012;29(1):85-9.
• ¹⁰
  Elderton R. Overtreatment with restorative dentistry: when to intervene? Int Dent J. 1993;43(1):17-24.
• ¹¹
  Ervin RB, Dye BA. The effect of functional dentition on Healthy Eating Index scores and nutrient intakes in a nationally representative sample of older adults. J Public Health Dent. 2009;69(4):207-16. DOI: 10.1111/j.1752-7325.2009.00124.x
  » https://doi.org/10.1111/j.1752-7325.2009.00124.x
• ¹²
  Fédération Dentaire Internationale. Global goals for oral health by the year 2000. Int Dent J. 1982;32(1):74-7.
• ¹³
  Fernandes LS, Peres MA. Associação entre atenção básica em saúde bucal e indicadores socio-econômicos municipais. Rev Saude Publica. 2005;39(6):930-6. DOI: 10.1590/S0034-89102005000600010
  » https://doi.org/10.1590/S0034-89102005000600010
• ¹⁴
  Frias AC, Antunes JLF, Narvai PC. Precisão e validade de levantamentos epidemiológicos em saúde bucal: cárie dentária na cidade de São Paulo, 2002. Rev Bras Epidemiologia. 2004;7(2):144-54. DOI: 10.1590/S1415-790X2004000200004
  » https://doi.org/10.1590/S1415-790X2004000200004
• ¹⁵
  Gilbert GH, Duncan RP, Shelton BJ. Social determinants of tooth loss. Health Serv Res .2003;38(6 Pt 2):1843-62. DOI: 10.1111/j.1475-6773.2003.00205.x
  » https://doi.org/10.1111/j.1475-6773.2003.00205.x
• ¹⁶
  Haugejorden O, Klock KS, Trovik TA. Incidence and predictors of self-reported tooth loss in a representative sample of Norwegian adults. Community Dent Oral Epidemiol. 2003;31(4):261-8. DOI: 10.1034/j.1600-0528.2003.00004.x
  » https://doi.org/10.1034/j.1600-0528.2003.00004.x
• ¹⁷
  Hobdell MH, Myburgh NG, Kelman M, Hausen H. Setting global goals for oral health for the year 2010. Int Dent J. 2000;50(5):245-9. DOI: 10.1111/j.1875-595X.2000.tb00560.x
  » https://doi.org/10.1111/j.1875-595X.2000.tb00560.x
• ¹⁸
  Kay EJ, Blinkhorn AS. A qualitative investigation of factors governing dentists’ treatment philosophies. Br Dent J. 1996;180(5):171-6. DOI: 10.1038/sj.bdj.4809010
  » https://doi.org/10.1038/sj.bdj.4809010
• ¹⁹
  Levy RB, Claro RM, Mondini L, Sichieri R, Monteiro CA. Regional and socioeconomic distribution of household food availability in Brazil, in 2008-2009. Rev Saude Publica. 2012;46(1):6-15. DOI: 10.1590/S0034-89102011005000088
  » https://doi.org/10.1590/S0034-89102011005000088
• ²⁰
  Narvai PC, Antunes JL, Moysés SJ, Frazão P, Peres MA, Peres KG et al. Scientific validity of epidemiological knowledge based on data from the Brazilian Oral Health Survey (SB Brazil 2003). Cad Saude Publica. 2010;26(4):647-70. DOI: 10.1590/S0102-311X2010000400002
  » https://doi.org/10.1590/S0102-311X2010000400002
• ²¹
  Pattussi MP, Peres KG, Boing AF, Peres MA, da Costa JS. Self-rated oral health and associated factors in Brazilian elders. Community Dent Oral Epidemiol. 2010;38(4):348-59. DOI: 10.1111/j.1600-0528.2010.00542.x
  » https://doi.org/10.1111/j.1600-0528.2010.00542.x
• ²²
  Peres MA, Antunes JL, Peres KG. Is water fluoridation effective in reducing inequalities in dental caries distribution in developing countries? Recent findings from Brazil. Soz Praventivmed. 2006;51(5):302-10. DOI: 10.1007/s00038-006-5057-y
  » https://doi.org/10.1007/s00038-006-5057-y
• ²³
  Peres MA, Fernandes S, Peres KG. Inequality of water fluoridation in Southern Brazil-the inverse equity hypothesis revisited. Soc Sci Med. 2004;58(6):1181-9. DOI: 10.1016/S0277-9536(03)00289-2
  » https://doi.org/10.1016/S0277-9536(03)00289-2
• ²⁴
  Peres MA, Iser BPM, Boing AF, Yokota RTC, Malta DC, Peres KG. Desigualdades no acesso e na utilização de serviços odontológicos no Brasil: análise do Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (VIGITEL 2009). Cad Saude Publica . 2012;28 Suppl:90-100. DOI: 10.1590/S0102-311X2012001300010
  » https://doi.org/10.1590/S0102-311X2012001300010
• ²⁵
  Roncalli AG, Moyses, SJ, Marques R, Pinto RS, Goes PSA, Figueiredo N, et al. Aspectos metodológicos do projeto SB Brasil 2010 de interesse para Inquéritos Nacionais de Saúde. Cad Saude Publica. 2012;28Suppl:40-57. DOI: 10.1590/S0102-311X2012001300006
  » https://doi.org/10.1590/S0102-311X2012001300006
• ²⁶
  Sanders AE, Slade GD, Turrell G, Spencer AJ, Marcenes W. Does psychological stress mediate social deprivation in tooth loss? J Dent Res. 2007;86(12):1166-70. DOI: 10.1177/154405910708601205
  » https://doi.org/10.1177/154405910708601205
• ²⁷
  Sheiham A, Steele JG, Marcenes W, Finch S, Walls AWG. The impact of oral health on stated ability to eat certain foods; National Diet and Nutrition Survey of older people in Great Britain. Gerodontology . 1999;16(1):11-20. DOI: 10.1111/j.1741-2358.1999.00011.x
  » https://doi.org/10.1111/j.1741-2358.1999.00011.x
• ²⁸
  Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet . 2000; 356(9235):1093-8. DOI: 10.1016/S0140-6736(00)02741-0
  » https://doi.org/10.1016/S0140-6736(00)02741-0
• ²⁹
  World Health Organization. Calibration of Examiners for Oral Health Epidemiology Surveys. Technical Report. Geneva;1993.
• ³⁰
  World Health Organization. Oral Health Survey. Basic Methods. 4. ed. Geneva; 1997.

• a
  Ministério da Saúde (BR). Secretaria Nacional de Programas Especiais de Saúde. Fundação de Serviços de Saúde Pública. Divisão Nacional de Saúde Bucal. Levantamento epidemiológico em saúde bucal: Brasil, zona urbana, 1986. Brasília (DF); 1988.
• b
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Projeto SB Brasil 2003: condições de saúde bucal da população brasileira 2002-2003. Resultados principais. Brasília (DF); 2004.
• c
  Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Coordenação Nacional de Saúde Bucal. SB2010. Pesquisa Nacional de Saúde Bucal. Resultados principais. Brasília (DF); 2011.
• The Pesquisa Nacional de Saúde Bucal 2010 (SBBrasil 2010, Brazilian Oral Health Survey) was financed by the General Coordination of Oral Health/Brazilian Ministry of Health (COSAB/MS), through the Centro Colaborador do Ministério da Saúde em Vigilância da Saúde Bucal , Faculdade de Saúde Pública at Universidade de São Paulo (CECOL/USP), process no. 750398/2010.
• This article underwent the peer review process adopted for any other manuscript submitted to this journal, with anonymity guaranteed for both authors and reviewers.
• Editors and reviewers declare that there are no conflicts of interest that could affect their judgment with respect to this article.
  The authors declare that there are no conflicts of interest.
• Article available from: www.scielo.br/rsp

Correspondence: Marco A Peres. Australian Research Centre for Population Oral Health (ARCPOH). School of Dentistry. The University of Adelaide. 122 Frome Street. Adelaide SA 5000 - Australia. Email: [e-mail]

Publication Dates

• Publication in this collection
  Dec 2013

History

• Received
  25 Feb 2012
• Accepted
  12 Nov 2012