Dental pain in Brazilian schoolchildren: a cross-sectional study

DOI: 10.1111/j.1365-263X.2012.01235.x

Dental pain in Brazilian schoolchildren: a cross-sectional study

JOSIMARI T. DE LACERDA1, MARIANA DE BEM PEREIRA2 & JEFFERSON TRAEBERT2

1Department of Public Health, Universidade Federal de Santa Catarina, Florianopolis, SC, Brazil, and 2Public Dental Health

Research Group, Universidade do Sul de Santa Catarina, Tubarao, SC, Brazil

International Journal of Paediatric Dentistry 2012;

Aim. To estimate the prevalence, intensity and

associated factors of dental pain in 7- and 8-year-

old schoolchildren in a Southern Brazilian city.

Design. A cross-sectional study was carried out

involving a representative sample (n = 401) of

schoolchildren of Tubarao, Brazil. The data were

obtained through oral examinations, following

WHO criteria. Dental pain was analysed using a

specific questionnaire developed to measure it.

Prevalence and intensity of spontaneous pain and

pain caused by cold and hot food and liquids were

analysed. Association studies were carried out

using chi-square test followed by nonconditional

multiple logistic regression analysis to test for

Correspondence to:

Jefferson Traebert, Public Dental Health Research Group,

Universidade do Sul de Santa Catarina, Rua Dr. Armınio

Tavares, 111 ⁄ 302, 88015-250 Florianopolis, SC, Brazil.

Email: [email protected] and

[email protected]

� 2012 The Authors

International Journal of Paediatric Dentistry � 2012 BSPD, IAPD and Bla

independence of association between outcomes

and explanatory variables.

Results. The prevalence of spontaneous dental

pain and dental pain caused by cold and hot food

and liquids was 31.7 and 28.1%, respectively.

Females and schoolchildren who had visited the

dentist at least once showed statistically higher

prevalence of spontaneous pain and pain caused

by cold and hot food and liquids. Eight-year-old

schoolchildren and those presenting cavities in the

primary dentition also showed higher prevalence

of spontaneous dental pain.

Conclusions. The prevalence and intensity of den-

tal pain were considered high. The prevalence

showed to be associated with female gender,

higher age, the presence of cavities in the primary

dentition and dental visit.

Introduction

Dental pain is primarily associated with teeth

and their supporting structures and can result

from dental caries, periodontal disease or

trauma. Usually it is an alarming and dis-

abling condition, which often impacts daily

life, interfering with work, study and sleep1.

Pain is generally considered as a public health

problem; toothache is classified as a dental

emergency and can indicate the effectiveness

and efficiency of health services2. It has been

suggested to include its occurrence in the last

30 days as one of the items for priority

groups’ identification for dental care3.

The prevalence of dental pain among chil-

dren in European countries varies between

47.5 and 61.0% 4,5 causing intense suffering6.

A survey on its impact, as measured among

English 8-year-old schoolchildren who had

pain in the month preceding the study,

pointed out to important limitations on chil-

dren’s daily activities performance, especially

in eating, sleeping, playing and going to

school4.

Few authors have addressed dental pain in

children in developing countries. A research

carried out in Pakistan showed a prevalence

of 30.4% of dental pain with intensity

enough to generate search for dental care.

This demand was associated with sleeping

and playing difficulty7. In Sri Lanka, the

prevalence reported was 49% among children

aged 8 years old and the most common cause

was dental caries8.

Brazilian prevalence studies have found

high proportions of children affected by den-

tal pain. Recent studies showed that dental

pain generates considerable impact on teenag-

ers’ and their families’ daily activities, being

associated with female gender and low socio-

economic conditions9,10. About 33% of school-

children aged 14–15 years old in a great

Northern Brazilian city reported dental pain

ckwell Publishing Ltd 1

2 J. T. de Lacerda, M. de Bem Pereira & J. Traebert

in the 6 months preceding the survey.

Among those affected, approximately 20%

reported severe or very severe intensity1.

A study addressing orofacial pain trend in

12-year-old children indicated a prevalence

of 66.6%, with a reduction of about 13% in

a period of 6 years. In both studied years, the

most common type was dental pain caused

by cold and hot food and drinks11. A study

involving a birth cohort showed a prevalence

of 11% associated with female gender and

high severity of caries9. Finally, a 35.6%

prevalence rate of dental pain among Brazil-

ian adolescents was reported from a nation-

ally based survey. This prevalence was

associated with female gender, socioeconomic

disadvantage and high levels of caries and

dental calculus9.

Pain has been the object of study with

emphasis on the clinical and individual

aspects because it is an event of significant

prevalence and impact in daily life10. How-

ever, there is still a lack of epidemiological

data enabling a better analysis of its distribu-

tion and determinants among children in

developing countries. This study aimed to

estimate the prevalence, severity and associ-

ated factors of dental pain in schoolchildren

aged 7- to 8 years old in a Southern Brazilian

city.

Material and methods

A cross-sectional study was carried out

involving schoolchildren aged 7- to 8-year old

enrolled in public schools of the city of

Tubarao, Southern Brazilian State of Santa

Catarina.

The following parameters were used for

sample size calculation: study population of

1435 children; 95% confidence interval; rela-

tive error of 5%; an unknown prevalence

was assumed (P = 0.5), as this value provides

the greatest degree of variance. A correction

factor of 1.2 was applied according to the

study design. Another 10% was added

to compensate for any refusals to participate

in the study. The final sample size consisted

of 401 students. Schoolchildren were

randomly selected from lists containing the

schools grouped by size according to the

International Journal of Pa

number of students, divided into tertiles. The

sample was proportionately selected from

these groups of schools.

Clinical information was obtained according

to World Health Organization12 criteria.

DMFT index (number of decayed, missing

because of caries and filled teeth in perma-

nent dentition) and dmft index (number of

decayed, missing because of caries and filled

teeth in primary dentition) were calculated.

The exams were performed in large rooms,

good lighting with students lying on benches

simulating stretchers. The data were collected

by three examiners supported by secretaries.

They were previously calibrated to obtain

diagnosis uniformity and reproducibility. The

calibration exercises were conducted with 20

schoolchildren who were not participating in

the sampling plan, according to a methodol-

ogy described elsewhere13.

Dental pain assessment was based on a spe-

cific questionnaire proposed by Locker and

Grushka14. Other nonclinical information

consisted of gender, age and questions relat-

ing to access to dental services, obtained

through a structured interview conducted

immediately after the clinical examination.

A pilot study involving 45 students was car-

ried out to test the methodology. There was

no need for the adjustments. Aiming to assess

the diagnostic reproducibility within and

between examiners, 10% of the sample sub-

jects were examined twice by each of the

examiners, randomly selected at the end of

each working day.

Descriptive statistics of each studied variable

were performed. The chi-square test was used

to detect possible associations between expla-

natory and dependent variables. Models of

unconditional logistic regression were used

for the multivariate analysis. Odds ratio (OR)

and their respective confidence intervals were

estimated for spontaneous dental pain, dental

pain caused by hot and cold food and liquids

and spontaneous severe ⁄very severe dental

pain outcomes. In the modelling process, a

value of P < 0.20 was adopted as a necessary

requirement for inclusion of the variable into

the model. A value of P < 0.05 was adopted

to keep the variable into the final model. A

stepwise forward procedure15 in SPSS� version


ediatric Dentistry � 2012 BSPD, IAPD and Blackwell Publishing Ltd

Table 1. Type and severity of dental pain, current or pasthistory of dental caries, and presence of cavities in theprimary and permanent dentition.

Variables n % 95% CI

Spontaneous dental painVery mild and mild 38 9.9 7.0; 12.8Moderate 27 7.0 4.5; 9.5Severe and very severe 57 14.8 11.3; 18.3Total 122 31.7 27.1; 36.3

Dental pain caused by cold and hot foods and liquidsVery mild and mild 46 11.9 8.7; 15.1Moderate 23 6.0 3.7; 8.3Severe and very severe 39 10.1 7.1; 13.1Total 108 28.0 25.9; 30.1

Dental cariesDMFT > 0 94 24.4 20.1; 28.7dmft > 0 284 73.8 69.4; 78.2Cavities in primary teeth 232 60.3 55.5; 65.2Cavities in permanent teeth 73 19.0 15.1; 22.9

Prevalence of dental pain 3

16.0 (SPSS, Inc., Chicago, IL, USA) statistical

software was used. Prevalence ratios (PR)

were calculated according to the recommen-

dations made by Schiaffino et al.16

Ethical issues included prior contacts with

the local health and education authorities for

permission to conduct the study. A consent

form was sent out to children’s parents or

guardians asking for their signed permission.

Participants with severe signs or symptoms of

oral diseases were referred for emergency

treatment. Schoolchildren received educa-

tional guidance and their parents or guardians

were informed of possible needs for treat-

ment. The research project was approved by

the Ethics Committee on Human Research of

the Universidade do Sul de Santa Catarina,

Brazil.

Table 2. Results of correlation studies between theintensity of spontaneous dental pain, dental pain caused byhot and cold food and liquids, and DMF-T ⁄ dmf-t.

Pearson’s r

Intensity of spontaneous dental pain and DMF-T 0.027Intensity of dental pain caused by cold and hotfoods and liquids and DMF-T

0.028

Intensity of spontaneous dental pain and dmf-t 0.220Intensity of dental pain caused by cold and hotfoods and liquids and dmf-t

0.120

Intensity of spontaneous dental pain and ‘d’component of dmf-t

0.157

Results

In total, 385 schoolchildren were examined

resulting in a response rate of 96.0%. The

results of the duplicate examinations showed

kappa values ranging from 0.63 to 1.00.

The prevalence of spontaneous dental pain

was 31.7% (95% CI 27.1; 36.4) and dental

pain caused by hot and cold food and liquids

was 28.1% (95% CI 23.6; 32.6). About 46%

of schoolchildren who reported dental pain

rated it as severe or very severe. The preva-

lence of dental caries was 24.4% (95% CI

20.1; 28.7) in permanent dentition. The mean

DMF-T found was 0.41 (SD = 0.85); and the

mean ‘D’ component was 0.29 (SD = 0.69)

representing 70.7% of the total DMF-T. The

prevalence of dental caries in primary denti-

tion was 73.8% (95% CI 69.4; 78.2). The

mean dmf-t found was 2.95 (SD = 2.78) and

the mean ‘‘d’ component was 1.94 (SD = 2.40)

representing 65.7% of dmf-t (Table 1).

Studies of the correlation between the

intensity of spontaneous dental pain, dental

pain caused by hot and cold food and liquids,

and DMF-T ⁄dmf-t showed weak correlations

(Table 2).

Tables 3–5 present results of univariate and

multivariate analysis. Females had 26%

[PR = 1.26 (95% CI 0.92; 1.73)] higher prev-

alence of spontaneous dental pain compared

to males. This difference became statistically



significant in the multivariate analysis,

increasing the prevalence ratio (PR) to 1.56

(95% CI 1.01; 2.41). In the case of dental

pain caused by cold and hot food and liquids,

females had 49% [PR = 1.49 (95% CI 1.07;

2.06)] higher prevalence compared to males,

and the PR increased to 1.55 (95% CI 1.06;

2.25) after adjustment.

Age and the presence of cavities in primary

teeth were associated with the prevalence of

spontaneous dental pain. A prevalence ratio

of 1.60 (95% CI 1.04; 2.46) was observed

when comparing 8- to 7-year-old children,

and a PR of 3.44 (95% CI 2.15; 5.50) was

observed when comparing schoolchildren

with the presence of cavities in primary teeth

in relation to schoolchildren without this con-

dition, both in multivariate analysis. Also, the

presence of cavities in primary teeth showed

ckwell Publishing Ltd

Table 3. Association between spontaneous dental pain anddemographic factors, dental caries, and dental visits.

Variables n (%)PRcrude

(95% CI)PRadjusted

(95% CI)

GenderMale 54 (28.3) 1.00 1.00Female 68 (35.1) 1.26 (0.92; 1.73) 1.56 (1.01–2.41)

P value 0.153 0.047

Age (years)7 65 (35.9) 1.00 1.008 57 (27.9) 1.28 (0.96; 1.71) 1.60 (1.04–2.46)

P value 0.094 0.033

Cavities in primary teethNo 27 (17.6) 1.00 1.00Yes 95 (40.9) 2.32 (1.63; 3.30) 3.44 (2.15–5.50)

P value <0.001 <0.001

Cavities in permanent teethNo 92 (29.5) 1.00 *Yes 30 (42.1) 1.39 (0.99; 1.95)

P value 0.056

DMFTZero 88 (30.2%) 1.00 *>0 34 (36.2%) 1.20 (0.86; 1.67)

P value 0.283

dmftZero 19 (18.8) 1.00 *>0 103 (36.3) 1.93 (1.29; 2.89)

P value 0.001

Ever been to the dentistNo 12 (17.4) 1.00 1.00Yes 110 (34.8) 2.00 (1.22; 3.28) 2.83 (1.49–5.38)

P value 0.006 0.002Dental visit in the last year

No 62 (30.4) 1.00 *Yes 58 (34.7) 1.44 (0.62; 3.34)

P value 0.374

PR, prevalence ratio.*Variables discarded from the model due to significance missing.Hosmer and Lemeshow test P = 0.977.

Table 4. Association between dental pain caused by hotand cold foods and demographic factors, dental caries, anddental visits.


(95% CI)PRadjusted

(95% CI)Gender

Male 43 (22.5%) 1.00 1.00Female 65 (33.5%) 1.49 (1.07; 2.06) 1.55 (1.06–2.25)

P value 0.017 0.022

Age (years)7 57 (27.9%) 1.00 *8 51 (28.2%) 1.01 (0.70; 1.46)

P value 0.959

Cavities in primary teethNo 40 (26.1%) 1.00 *Yes 68 (29.3%) 1.12 (0.80; 1.55)

P value 0.499

Cavities in permanent teethNo 85 (27.2%) 1.00 *Yes 23 (31.5%) 1.57 (0.46; 5.26)

P value 0.466

DMFTZero 82 (28.2%) 1.00 *>0 26 (27.7%) 1.02 (0.69; 1.51)

P value 0.922

dmftZero 26 (25.7%) 1.00 *>0 82 (28.9%) 1.12 (0.77; 1.62)

P value 0.548

Ever been to the dentistNo 12 (17.4%) 1.00 1.00Yes 96 (30.4%) 1.74 (1.05; 2.89) 1.78 (1.03–3.08)

P value 0.032 0.040Dental visit in the last year

No 62 (30.4%) 1.00 *Yes 58 (34.7%) 1.34 (0.97; 1.85)

P value 0.374

PR, prevalence ratio.*Variables discarded from the model because of significancemissing.Hosmer e Lemeshow test P = 0.428.


to be associated with severe ⁄very severe spon-

taneous dental pain, compared to the group of

schoolchildren reporting very mild ⁄mild ⁄mod-

erate dental pain. The PR was 1.76 (IC95%

1.12; 2.77). This variable showed to be collin-

ear with other variable – dmft. To avoid this

problem, it was decided to remove it from the

model, as it seems to be more appropriate to

maintain ‘‘cavities in the primary teeth’’ than

the dmf-t as a whole. Finally, to have visited

the dentist at least once showed to be associ-

ated with the prevalence of both spontaneous


dental pain and dental pain caused by cold and

hot food and liquids, with statistically signifi-

cant differences in both univariate and multi-

variate analysis. The adjusted PRs were 2.83

(95% CI 1.49; 5.38) and 1.36 (95% CI 1.02;

1.81), respectively.

Discussion

The good response rate, the calibration of

examiners, and the high degree of diagnostic



Table 5. Association between spontaneous severe ⁄ verysevere dental pain and demographic factors, dental caries,and dental visits.


(95% CI)PRadjusted

(95% CI)

GenderMale 24 (44.4) 1.00 *Female 33 (48.5) 1.08 (0.77; 1.51)

P value 0.635

Age (years)7 31 (47.7) 1.00 *8 26 (45.6) 1.04 (0.74; 1.45)

P value 0.818

Cavities in primary teethNo 7 (25.9) 1.00 1.00Yes 50 (52.6) 1.56 (1.08; 2.24) 1.76 (1.12–2.77)

P value 0.014 0.015

Cavities in permanent teethNo 42 (45.7) 1.00 *Yes 15 (54.5) 1.09 (0.72; 1.64)

P value 0.679

DMFTZero 41 (46.6) 1.00 *>0 16 (47.1) 1.01 (0.67; 1.52)

P value 0.963

dmftZero 4 (21.1) 1.00 **>0 53 (51.5) 1.63 (1.08; 2.46)

P value 0.015

Ever been to the dentistNo 3 (25.0) 1.00 *Yes 54 (49.1) 1.47 (0.89; 2.41)

P value 0.112

Dental visit in the last yearNo 32 (55.2) 1.00 *Yes 25 (40.3) 1.33 (0.94; 1.88)

P value 0.104

Reference group: schoolchildren presenting very mild, mild, andmoderate pain.PR, prevalence ratio.*Variables discarded from the model because of significancemissing.**Variable removed from the model due to be collinear with thevariable ‘cavities in primary teeth’.Hosmer and Lemeshow test P = 0.988.


reproducibility obtained during the process of

data collection suggest a good internal validity

of the study.

The prevalence rates of dental pain in this

study are higher than those reported in other

studies conducted in Brazil9 and in some

other countries like Spain and Sweden5. In a



study of a representative sample of a London

district, Shepherd et al.4 found that the preva-

lence of dental pain was 47.5% among

8-year-old children. The authors also pointed

out that dental pain was severe enough to

make children cry in 17.7% of cases. How-

ever, comparisons between these prevalence

rates should be made with caution because of

the different age groups and research proto-

cols used.

There are few studies relating to types of

dental pain in the literature. Richard and

Scourfield17 found a prevalence of 35.2% of

stimulated dental pain, whereas Newton

et al.18 found a prevalence ranging between

8.0% and 26.9% of dental pain caused by

eating certain types of food. Variations are

expected and can be attributed to cultural,

behavioural and pain measurement issues5.

The results of logistic regression models

showed that the prevalence of reported dental

pain was statistically higher among girls than

among boys, regardless of other studied fac-

tors. This result supports the literature review

conducted by Kosminsky and Goes19 in

which female gender was listed as a predictor

of dental pain. This difference could represent

ways of expressing pain in compliance with

socially imposed standards of typically male

or female behaviour. In this case, it seems

that boys have a higher resistance to dental

pain than girls, or at least in the way of

expressing it20.

Dental caries can be regarded as one of

dental pain triggers. In this study, a statisti-

cally significant association was found

between the presence of cavities in primary

dentition and the prevalence of spontaneous

dental pain, corroborating findings of other

studies21. Studies conducted in Brazil also

pointed out dental caries as a predictor of

dental pain in schoolchildren9,11 and adoles-

cents22. However, this study did not find a

correlation between the intensity of dental

pain and the number of decayed, missing and

filled teeth. Indeed, a numeric dose–response

relationship between DMF-T and dmf-t is not

expected because it is reasonable to think that

one deep cavity could be more related to

spontaneous or stimulated dental pain than a

greater number of shallow cavities.



Access to dental services was one of the sig-

nificantly associated variables in this study in

both spontaneous dental pain and dental pain

caused by cold and hot food and liquids.

These associations were expected and support

Kosminsky and Goes19 who have stated that

dental pain is the most common reason for

health services consultation in developing

countries. The predominantly pain intensity

found in this study was severe and very

severe, significantly associated with the pres-

ence of cavities in primary teeth, which could

also explain part of this association, consider-

ing that suffering leads individuals to seek

health services. All these findings can contrib-

ute to the evidence that dental pain, espe-

cially in childhood, can be an appropriate and

valid indicator for priority setting in primary

oral health care.

It can be concluded that dental pain had

high prevalence and severity among school-

children in the studied population. This prev-

alence was higher among girls than boys

and was associated with dental caries in the

primary dentition and with the demand for

dental services.

Why this study is important to paediatric

dentists?d Paediatric dentists, mainly those from developing

countries, should be aware that dental pain has still a

high prevalence among young schoolchildren, in spite

of the declining tendency of caries in the permanent

dentition. The high prevalence found in this study is

associated, among other factors, with the presence of

cavities in the primary dentition.

Conflict of interest

The authors declare no conflict of interest.

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Dental pain in Brazilian schoolchildren: a cross-sectional study