Pediatric Dentistry

Pediatric Dentistry

Impact of dental caries on preschool

childrens quality of life: an update*
Marcelo Bnecker(a)
Jenny Abanto(a)
Gustavo Tello(a)
Luciana Butini Oliveira(b)

Disciplina de Odontopediatria, Univ de So

Paulo - USP, So Paulo, SP, Brazil.

(a)

(b)

Faculdade de Odontologia, Centro de

Pesquisas Odontolgicas So Leopoldo
Mandic, Campinas, SP, Brazil.

Abstract: The literature reports that dental caries can cause functional,
physical and aesthetic impairment, often with repercussions on childrens
general health at an early age. Moreover, recent studies have investigated
how caries lesions can compromise childrens quality of life. This paper
aims to describe the current situation of dental caries prevalence in children and how this oral health disease can impact their quality of life.
Descriptors: Quality of Life; Dental Caries; Child, Preschool.

Introduction

* Paper presented at the Oral Health Under

an Integrality Perspective International
Symposium, held at the 17th Congress of
the Brazilian Association for Oral Health
Promotion (ABOPREV), May 31 to June 2,
2012, Salvador, BA, Brazil.

Declaration of Interests: The authors

certify that they have no commercial or
associative interest that represents a conflict
of interest in connection with the manuscript.

Corresponding Author:
Marcelo Bnecker
E-mail: [email protected]

Submitted: Aug 23, 2012

Accepted for publication: Oct 16, 2012
Last revision: Nov 05, 2012

The oral health problems affecting Brazilian children have received

special attention in epidemiology and contemporary dentistry. Although
Brazil does not have a national epidemiological survey to identify all the
basic oral health problems in children under 5 years of age, the results of
some regional studies allow us to assert that the most frequent problems
are dental caries lesions,1,2 traumatic lesions, 3,4 and dental erosion. 5
Unless a healthy lifestyle, good oral hygiene and nutrition are established, caries lesions may affect the teeth in the primary dentition, as
soon as they erupt into the oral cavity. At this stage of growth and development, the most often affected teeth are the upper incisors.
Some children often have a high degree of destruction in this region.
This may reduce chewing efficiency, promote parafunctional habits
such as tongue interpositioncause loss of vertical dimension, and affect
aesthetics, with intense psychological repercussions.
A healthy smile has considerable bearing on social interaction, which
plays an important role in how children are seen, felt and perceived by
others.
Dentofacial aesthetics is an important determinant of overall physical
aesthetics. From the standpoint of child psychology, a healthy smile is
conducive to how children start building up interpersonal relationships
and self-steem.6
Dental disease or dental facial abnormalities bring about disadvantageouspsychosocial consequences that affect children, in addition to impairing their speech and eatinghabits. Thus influenced, children do not
smile as often as they would like to.
Changes caused by dental caries, either because of pain or aesthetic
changes, affect the childrens quality of life. This has led to a greater
search for both an aesthetic treatment and a healthy smile, in both general and pediatric dental visits in recent years.

Braz Oral Res., (So Paulo) 2012;26(Spec Iss 1):103-7

103

Impact of dental caries on preschool childrens quality of life: an update

Prevalence of dental caries

in children
The SB Brazil Project conducted in 2010reported early involvement of caries lesions. Among the
children who were examined and presented caries,
the mean dmft index for 5-year-old children was
2.43 and 53.4%, whereas the mean DMFT at 12
years of age was 2.07 and 56.5%. In Brazil, there
has been a trend toward a decrease in dental caries,
as shown in Figure 1. Progressive national epidemiological surveys indicate that tooth decay has been
declining consistently in 12 year-old children7-11
and slightly in 5 year-oldchildren.9-11 On the other
hand, data based on the last national epidemiological surveyin Brazil also showed that the prevalence
of untreated caries lesions in 5 year-old children is
high (80%). Therefore, it is necessary to evaluate the
impact of disease on preschool childrens quality of
life in order to encourage dental treatment and promote better quality of life.
In Brazil, there is no data follow-up for groups
of children under 5 years old. However, a decrease
in caries prevalence has been observed in recent
years in children under 3 years old. This finding was
reached through a sequence of cross-sectional studies performed using the same methodology, in the
city of Diadema.12 Nonetheless, there is no sequence
of national data relating to caries and quality of life
for children 5 years old or less. The prevalence of
dental caries in 4-year-old children varies widely
8
12 years
5 years
3 years

DMFT/dmft

6
5
4
3
2
1
0

86

88

90

92

94

96

98

00

02

04

06

08

10

Years of Study

Figure 1 - Caries trend in 3-, 5- and 12-year-old Brazilian

children.

104

Braz Oral Res., (So Paulo) 2012;26(Spec Iss 1):103-7

across countries, especially between developed and

developing countries. Developing countries, such
as China13 (53%), India14 (53%) and South Africa15
(46%), report greater caries prevalence, as compared to developed countries like England16 (32%)
and Italy (22%).17
Despite the lower dental caries prevalence in developed countries, the issue of quality of life related
to oral health hasbeen increasingly discussed in the
literatureoverthelast two decades.

Impact of dental caries in

childrens quality of life
Among the many problems compromising the
oral health of child patients, tooth decay is the affection that most frequently evokes aesthetic and
functional complaints in a childs clinical routine,
affecting his/her quality of life. It has also been observed that the greater the number of teeth affected
or lost, the greater the negative impact on a patients
quality of life.
Thus, dental treatment may offer a positive psychosocial impact on these patients, not only for recovering their oral health, but also for promoting an
improvement of their quality of life.
The negative impact of caries on childrens lives
includes: symptoms and functional alterations, such
as chewing and speech impairment, schooling factors, such as preschool absenteeism, psychological issues, such astrouble sleeping, and irritability,
among other factors related to social interaction,
such as smiling and refraining from speaking.
School performance may also decline.18-22
These effects are generally expressed as a cumulative experience that worsens as the disease progresses, presenting oral clinical symptoms that indirectly
affect a patients quality of life.18-27 In more severe
cases, the caries disease may not only adversely influence the affected patient himself, but also interfere in
his daily activities and those of others around him.26
Few studies have been conducted with children to
assess how a toothache caused by caries may impact
their daily activities. Some authors assert that having
meals and sleeping are the most affectedactivities.28
It has also been estimated that sixty million school
hours are lost each year due to tooth pain.29 Sur-

Bnecker M, Abanto J, Tello G, Oliveira LB

veys measuring quality of life related to oral health

in school children with dental caries show that life
quality is strongly correlated with its negative impact on oral symptoms, followed by functional limitations, and finally its impact on emotional and social well-being.30 However, recent studies show that
dental treatment in both healthy and disabled children considerably enhances their quality of life.25,31,32

Discussion
The concept of health in regard to Health Promotion has expanded to include other issues, such
as socioeconomic, environmental and behavioral
factors that interfere in individual and collective
health. Thus, the concept of oral health now encompasses quality of life, as well as oral symptoms,
functional limitations, and emotional and social
well-being, factors not considered previously.33 The
indicators used in clinical dentistry have been restricted to people who notice symptoms such as
pain, discomfort and aesthetic changes. 34
It is not yet common practice to measure the
impact that these indicators have on childrens
lives when performing a diagnosis or carrying out
a treatment plan. Over the last two decades, there
has been a substantial development of an indicator
known as COHQoL - child oral-health-related quality of life.35 Currently there are some available tools
that can be used to measure functional and psychosocial oral disease outcomes; most of these are
targeted at adults. Since the evaluation in children
should be considered differently from that in adults,
the interest in assessing the impact of oral disease on
quality of life in pediatric populations has increased,
especially as of 2003. Children have been the major
focus of public health dentistry; this concern highlights the urgent need to apply the oral-health-related quality of life concept at this stage of life. 33 The
responsibility for young childrens health usually belongs to their parents, who are often responsible for
making decisions about their health. Therefore, it is
of utmost importance to evaluate parents perception toward their childrens oral health problems,
including how related symptoms, diseases and treatments may influence their childrens quality of life.
Evidence also suggests that early childhood caries

result in parents work absenteeism,33 since they must

stay home to care for their children, or spend time
and money to have the disease treated.28 Thus, these
issues concerning parents must also be investigated as
part of the OHQoL evaluation in younger children.
According to child development psychology, the
age of six years is a landmark for inception of abstract thinking and building of ones self image.6,36,37
At this age, children start comparing their physical characteristics and personality traits with those
of other children. Their ability to make judgments
about their appearance, the quality of their friendships, their thoughts, their emotions and the behavior of others gradually also develops at this age.6
The idea of aesthetics linked to health now begins to
be incorporated in the mind of the child, interfering
with his/her concept of self-esteem. 36
OHQoL measurement in preschool children involves some methodological issues, such as changes
in the ability to understand the child at different
ages, and difficulty in separating the childs perceptions from those of his/her parents. 37 However,
a number of recently developed tools have shown
that, by applying an appropriate technique, questionnaires for parents could produce valid and reliable information about their childrens OHQoL. 38,39
The fact that the information provided by the
parents complements that of the patient does not
mean it is equivalent to that of the patient.40,41 Today, it is highly recommended that the childs voice
also be heard, insofar as it may introduce points
of view different from those stated by parents.42,43
Nonetheless, only one parent-related information
collecting tool44 was used to assess the impact of
caries and dental trauma in 2-to-5-year-old childrens OHQoL. 25,44-47 Recently, the SOHO-5 (scale
of oral health outcomes for 5-year-old children) was
developed and validated in the United Kingdom
(UK). This tool was developed to facilitate the evaluation of childrens OHQoL, as reported by them
and by their parents.48
ECOHIS and SOHO-5 were designed and validated to measure oral health problems that affect
young children, and also call attention to children
with different levels of oral health issues. A yet additional role for these tools is to evaluate and demon-

Braz Oral Res., (So Paulo) 2012;26(Spec Iss 1):103-7

105

Impact of dental caries on preschool childrens quality of life: an update

strate possible changes in OHQoL, in both individuals and groups.49 This is the goal of future studies.

Conclusion
Whenever cases of caries lesions compromise the
health of a child patient, the dentist should make use
of all resources available to restore the individual
to his/her previous state, recovering his/her self-esteem, and thus improving sleep quality, weight gain,

and pain levels. Recognition of dental treatment not

only by the parents but also by the children may
also be rewarding for professionals.
A healthy smile is certainly one way of developing interpersonal relationships and self-esteem.
Therefore, rehabilitation and clinical treatment follow-up are necessary, insofar as oral health plays an
important role in the overall life of children and in
their emotional well-being.

References
1. Ferreira SH, Beria JU, Kramer PF, Feldens EG, Feldens CA.
Dental caries in 0- to- 5-year-old Brazilian children: prevalence, severity, and associated factors. Int J Paediatr Dent.
2007Jul;17(4):289-96.
2. Dini EL, Holt RD, Bedi R. Prevalence and severity of caries in
3- to 12-year-old children from three districts with different
fluoridation histories in Araraquara, SP, Brazil. Community
Dent Health. 1998 Mar;15(1):44-8.
3. Oliveira LB, Marcenes W, Ardenghi TM, Sheiham A, Bnecker M. Traumatic dental injuries and associated factors
among Brazilian preschool children.Dent Traumatol. 2007
Apr;23(2):7681.
4. Beltrao EM, Cavalcanti AL, Albuquerque SS, Duarte RC.Prevalence of dental trauma children aged 13 years in Joao Pessoa
(Brazil). Eur Arch Paediatr Dent. 2007 Sep;8(3):1413.
5. Murakami C, Oliveira LB, Sheiham A, Corra MSNP, Haddad
AE, Bnecker M. Risk indicators for erosive tooth wear in
Brazilian preschool children.Caries Res. 2011 Mar;45(2):121-9.
6. Rebok G, Riley A, Forrest C, Starfield B, Green B, Robertson J, et al.. Elementary school-aged childrens reports of
their health: a cognitive interviewing study. Qual Life Res.
2001;10(1):59-70.
7. Brasil. Ministrio da Sade. Coordenao Nacional de Sade
Bucal. Condies de sade bucal da populao brasileira. Resultados principais. Braslia (DF): Ministrio da Sade; 2010
[cited 2012 Aug 15]. Available from: http://189.28.128.100/
dab/docs/geral/projeto_sb2010_relatorio_final.pdf.
8. Brasil. Ministrio da Sade. Levantamento Epidemiolgico
em Sade Bucal: Brasil, zona urbana, 1986. Diviso Nacional
de Sade Bucal; fundao Servios de Sade Pblica. Braslia
(DF): Centro de Documentao do Ministrio da Sade; 1988.
137 p.
9. Servio Social da Indstria. Estudo epidemiolgico sobre prevalncia da crie dental em crianas de 3 a 14 anos: Brasil,
1993. Braslia (DF): Sesi-DN; 1996. 52 p.
10. Brasil. Coordenao de Sade Bucal do Ministrio da Sade.
Levantamento Epidemiolgico em sade Bucal Crie dental
Brasil 1996. Braslia (DF): Coordenao de Sade Bucal
do Ministrio da Sade; 1998.102 p.

106

Braz Oral Res., (So Paulo) 2012;26(Spec Iss 1):103-7

11. Brasil. Ministrio da Sade. Coordenao Nacional de Sade

Bucal. Projeto SB Brasil 2003: condies de sade bucal da
populao brasileira 2002-2003. Resultados principais. Braslia (DF): Ministrio da Sade; 2005. 67 p. (Srie C. Projetos, Programas e Relatrios). [cited 2012 Aug 15]. Available
from: http://dtr2001.saude.gov.br/editora/produtos/livros/
pdf/05_0053_M.pdf.
12. Bnecker M, Ardenghi TM, Oliveira LB, Sheiham A, Marcenes W.Trends in dental caries in 1- to 4-year-old children in
a Brazilian city between 1997 and 2008.Int J Paediatr Dent.
2010 Mar;20(2):125-31.
13. Shang XH, Li DL, Huang Y, Chen H, Sun RP.Prevalence of
dental caries among preschool children in Shanghe County
of Shandong Province and relevant prevention and treatment
strategies.Chin Med J (Engl).2008 Nov 20;121(22):2246-9.
14. Simratvir M, Moghe GA, Thomas AM, Singh N, Chopra S.
Evaluation of caries experience in 3-6-year-old children, and
dental attitudes amongst the caregivers in the Ludhiana city.
J Indian Soc Pedod Prev Dent. 2009Jul-Sep;27(3):164-9.
15. Cleaton-Jones P, Williams S, Green C, Fatti P.Dental caries
rates in primary teeth in 2002, and caries surveillance trends
1981-2002, in a South African city.Community Dent Health.
2008Jun;25(2):79-83.
16. Pitts NB, Boyles J, Nugent ZJ, Thomas N, Pine CM. The
dental caries experience of 5-year-old children in Great Britain
(2005/6). Surveys co-ordinated by the British Association for
the study of community dentistry.Community Dent Health.
2007 Mar;24(1):59-63.
17. Campus G, Solinas G, Strohmenger L, Cagetti MG, Senna
A, Minelli L, et al..National pathfinder survey on childrens
oral health in Italy: pattern and severity of caries disease in
4-year-olds.Caries Res. 2009;43(2):155-62.
18. Oliveira LB, Sheiham A, Bnecker M. Exploring the association of dental caries with social factors and nutritional
status in Brazilian preschool children. Eur J Oral Sci. 2008
Feb;116(1):37-43.
19. Acs G, Shulman R, Ng MW, Chussid S. The effect of dental
rehabilitation on the body weight of children with early childhood caries. Pediatr Dent. 1999 Mar-Apr;21(2):109-13.

Bnecker M, Abanto J, Tello G, Oliveira LB

20. Feitosa S, Colares V, Pinkham J. The psychosocial effects of

severe caries in 4-year-old children in Recife, Pernambuco,
Brazil. Cad Saude Publica. 2005 Sep-Oct;21(5):1550-6.
21. Filstrup SL, Briskie D, Fonseca M, Lawrence L, Wandera
A, Inglehart MR. Early childhood caries and quality of
life: child and parent perspectives.Pediatr Dent. 2003 SepOct;25(5):431-40.
22. Aces G, Pretzer S, Foley M, Ng MW. Perceived outcomes and
parental satisfaction following dental rehabilitation under
general anesthesia. Pediatr Dent. 2001 Sep-Oct; 23(5):419-23.
23. Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on height, body weight and head circumference.
J Clin Pediatr Dent. 1996;20(3):209-12.
24. Low W, Tan S, Schwartz S. The effect of severe caries on the
quality of life in young children. Pediatr Dent. 1999 SepOct;21(6):325-6.
25. Abanto J, Carvalho TS, Mendes FM, Wanderley MT, Bnecker M,Raggio DP. Impact of oral diseases and disorders
on oral health-related quality of life of preschool children.
Community Dent Oral Epidemiol.2011 Apr;39(2):105-14.
26. Abanto J,Paiva SM,Raggio DP,Celiberti P,Aldrigui JM,Bnecker M.The impact of dental caries and trauma in children
on family quality of life. Community Dent Oral Epidemiol.2012 Aug;40(4):323-31.
27. Shepherd MA,Nadanovsky P,Sheiham A. The prevalence and
impact of dental pain in 8-year-old school children in Harrow,
England.Br Dent J.1999Jul;187(1):38-41.
28. Gift HC, Reisine ST, Larach DC. The social impact of
dental problems and visits. Am J Public Health. 1992
Dec;82(12):1663-8.
29. Do LG, Spencer A. Oral health-related quality of life of children by dental caries and fluorosis experience. J Public Health
Dent. 2007;67(3):132-9.
30. Baens-Ferrer C, Roseman MM, Dumas HM, Haley SM. Parental perceptions of oral health-related quality of life for children
with special needs: impact of oral rehabilitation under general
anesthesia. Pediatr Dent. 2005 Mar-Apr;27(2):13742.
31. Thomas CW,Primosch RE. Changes in incremental weight
and well-being of children with rampant caries following
complete dental rehabilitation. Pediatr Dent. 2002 MarApr;24(2):109-13.
32. Abanto J,Carvalho TS,Bnecker M,Ortega AO,Ciamponi
AL, Raggio DP.Parental reports of the oral health-related
quality of life of children with cerebral palsy. BMC Oral
Health.2012Jun;12(1):15. [Epub ahead of print].
33. Jokovic A, Locker D, Stephens M, Kenny D, Tompson B,
Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life.J Dent Res.
2002Jul;81(7):459-63.
34. Marques LS, Ramos-Jorge ML, Paiva SM, Pordeus IA.Malocclusion: esthetic impact and quality of life among Brazilian schoolchildren.Am J Orthod Dentofacial Orthop. 2006
Mar;129(3):424-7.

35. Robinson P, Gibson B, Khan F, Birnbaum W. Validity of two

oral health-related quality of life measures. Community Dent
Oral Epidemiol. 2003 Apr;31(2):90-9.
36. Casamassimo PS. Relationships between oral and systemic
health. Pediatr Clin North Am. 2000 Oct;47(5):1149-57.
37. Barbosa TS, Gavio MB. Oral health-related quality of life in
children: part III. Is there agreement between parents in rating
their childrens oral health-related quality of life? A systematic
review.Int J Dent Hyg. 2008 May;6(2):108-13.
38. Jokovic A,Locker D,Stephens M,Kenny D,Tompson B,Guyatt,
G. Measuring parental perceptions of child oral health-related
quality of life.J Public Health Dent. 2003 Spring;63(2):67-72.
39. Pahel BT, Rozier RG, Slade GD. Parental perceptions of childrens oral health: the Early Childhood Oral Health Impact
Scale (ECOHIS). Health Qual Life Outcomes. 2007Jan;5:6.
40. Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: Implications of
cross-informant correlations for situational specificity. Psychol
Bull. 1987 Mar;101(2):213-32.
41. Sprangers MAG, Aaronson NK. The role of health care providers and significant others in evaluating the quality of life
of patients with chronic disease: a review. J Clin Epidemiol.
1992Jul;45(7):743-60.
42. Varni JW, Burwinkle TM, Lane MM. Health-related quality
of life measurement in pediatric clinical practice: An appraisal
and precept for future research and application. Health Qual
Life Outcomes. 2005 May 16;3:34.
43. Jokovic A, Locker D, Guyatt G. How well do parents know
their children? Implications for proxy reporting of child healthrelated quality of life.Qual Life Res. 2004 Sep;13(7):1297-307.
4 4. Aldrigui JM, Abanto J, Carvalho TS, Mendes FM, Wanderley
MT, Bnecker M, et al.. Impact of traumatic dental injuries
and malocclusions on quality of life of young children.Health
Qual Life Outcomes. 2011 Sep;24;9:78.
45. Wong HM, McGrath CP, King NM, Lo EC. Oral healthrelated quality of life in Hong Kong preschool children. Caries
Res. 2011;45(4):370-6.
46. Gradella CM,Bernab E,Bnecker M,Oliveira LB.Caries
prevalence and severity, and quality of life in Brazilian 2- to
4-year-old children.Community Dent Oral Epidemiol. 2011
Dec;39(6):498-504.
47. Goettems ML,Ardenghi TM,Romano AR,Demarco FF,Torriani DD.Influence of maternal dental anxiety on oral healthrelated quality of life of preschool children. Qual Life Res.
2011 Aug;20(6):951-9.
48. Tsakos G,Blair YI,Yusuf H,Wright W,Watt RG,Macpherson LM. Developing a new self-reported scale of oral health
outcomes for 5-year-old children (SOHO-5).Health Qual Life
Outcomes.2012Jun 7;10:62.
49. Li S, Malkinson S, Veronneau J, Allison PJ. Testing responsiveness to change for the early childhood oral health impact
scale (ECOHIS). Community Dent Oral Epidemiol. 2008
Dec;36(6):542-8.

Braz Oral Res., (So Paulo) 2012;26(Spec Iss 1):103-7

107

Copyright of Brazilian Oral Research is the property of Brazilian Oral Research and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.