International Journal of

Environmental Research
and Public Health

Article
Caries Experience and Risk Indicators in a Portuguese
Population: A Cross-Sectional Study
Eduardo Guerreiro 1, * , João Botelho 1,2 , Vanessa Machado 1,2 , Luís Proença 1,2 , José João Mendes 1,2
and Ana Cristina Manso 1

1 Clinical Research Unit (CRU), Egas Moniz Center for Interdisciplinary Research, Egas Moniz—School of
Health and Science, 2829-511 Almada, Portugal
2 Evidenced-Based Hub, Egas Moniz Center for Interdisciplinary Research, Egas Moniz—School of Health and
Science, 2829-511 Almada, Portugal
* Correspondence: [email protected]

Abstract: Oral health surveys are essential for assessing the dental caries experience and to influence
national policies. This retrospective cross-sectional study aims to analyze dental caries experience for
which dental treatment was sought in a reference university dental hospital at the Lisbon Metropolitan
Area between January 2016 and March 2020. Full-mouth examination, and sociodemographic,
behavior, and medical information were included. Descriptive analyses and logistic regression
analysis were applied to ascertain risk indicators associated with dental caries experience. A final
sample of 9349 participants (5592 females/3757 males) were included, aged 18 to 99 years old. In
this population, caries experience was 91.1%, higher in female participants. Age (OR = 1.01, 95%
CI [1.00–1.02], occupation (OR = 2.94, 95% CI [2.37–3.65], OR = 3.35, 95% CI [2.40–4.67], OR = 2.55,
95% CI [1.66–3.91], for employed, unemployed, and retired, respectively), overweight (OR = 1.52,
95% CI [1.18–1.96]), reporting to have never visited a dentist (OR = 0.38, 95% CI [0.23–0.64], and
self-reported week teeth status (OR = 2.14, 95% CI [1.40–3.28]) were identified as risk indicators for
the presence of dental caries, according to adjusted multivariable logistic analyses. These results
highlight a substantial rate of dental experience in a Portuguese cohort and will pave the way for
Citation: Guerreiro, E.; Botelho, J.; future tailored oral public health programs in Portugal.
Machado, V.; Proença, L.; Mendes, J.J.;
Manso, A.C. Caries Experience and Keywords: dental caries; caries experience; epidemiology; prevalence; risk; public health
Risk Indicators in a Portuguese
Population: A Cross-Sectional Study.
Int. J. Environ. Res. Public Health 2023,
20, 2511. https://doi.org/10.3390/ 1. Introduction
ijerph20032511
Dental caries is still one of the most common diseases worldwide, affecting 2.3 billion
Academic Editors: Carmen Llena and people with the permanent dentition [1], and is characterized by oral biofilm dysbiosis
Maria Melo Almiñana driven by fermentable carbohydrates [1–4]. Due to pH variations, alternated periods of
Received: 13 January 2023
demineralization and remineralization may exist, and if demineralization predominates,
Revised: 23 January 2023
tooth structures will be irreversibly damaged. In the absence of treatment, this lesion
Accepted: 28 January 2023
progresses to the dentine–pulp interface causing pain and discomfort [2].
Published: 31 January 2023 Dental caries experience is directly linked to a lower perceived quality of life as well as
with considerable economic burden [5–7]. If inappropriately managed, people with active
dental caries can develop eating problems, tooth loss, and toothache, slower language
development in children, as well as absenteeism from school and work [8,9]. Dental
Copyright: © 2023 by the authors. caries is unequally distributed among the population, with multiple population groups at
Licensee MDPI, Basel, Switzerland. higher risk [1,10]. This increased risk includes different factors (i.e., presence of bacteria
This article is an open access article with cariogenic properties or a cariogenic diet) and indicators (e.g., lifetime exposure to
distributed under the terms and fluoridation in water, oral hygiene habits, dental anxiety, socioeconomic status, education
conditions of the Creative Commons level, smoking habits, among others) [5,10,11].
Attribution (CC BY) license (https://
Robust knowledge of these factors at the populational level contributes to accurate
creativecommons.org/licenses/by/
oral health promotion strategies and policies [5,12]. This knowledge partially arises from
4.0/).

Int. J. Environ. Res. Public Health 2023, 20, 2511. https://doi.org/10.3390/ijerph20032511 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 2511 2 of 12

cross-sectional studies [13], making them of high scientific relevance. Considering the
need for aggregated information on caries experience and associated factors [14,15], we
retrospectively analyzed a sample of first-incoming patients at a reference Portuguese
university dental hospital. Ultimately, we aimed to measure caries experience and identify
its risk indicators in the studied population.

2. Materials and Methods

2.1. Study Design
This retrospective cross-sectional study is a secondary analysis of first-incoming pa-
tients at a university dental hospital (Egas Moniz Dental Clinic, Almada, Portugal). This
was an uninterrupted data analysis (a non-probability sampling technique) from January
2016 until March of 2020. The end-period time was defined abruptly due to an imposed
COVID-19 lockdown by the Portuguese government. This study is reported following the
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guide-
line [16,17]. We conducted this research in accordance with the Declaration of Helsinki
of 1975, as revised in 2013, and was approved by the Egas Moniz Ethics Committee (ID
number 898). Written informed consent was obtained from all participants at the first
appointment.

2.2. Study Setting and Sample Size

The original data was sourced from an ongoing database of first-incoming patients.
In the first appointment, a mandatory triage includes a self-reported health questionnaire,
full-mouth clinical observation, and radiographic examinations (along with a panoramic
X-ray and/or bitewings). The self-reported questionnaire includes age, sex, education level,
employment status, general medical history and medication, smoking habits, and oral
hygiene habits. After examination, patient is informed of their status and treatment plan.
The participants were observed by dental students, and the final diagnosis validated by
qualified clinical assistants.
To be included in this study, patients were required to be willing to participate in the
study, to provide written consent, and to be 18 years old or older. Patients were excluded if
they were edentulous or had incomplete data. Edentulism was part of the exclusion criteria
because it could result from dental caries. Considering this population is reported to have
higher prevalence of periodontitis [18,19], this could be a source of overestimation of dental
caries experience, particularly the missing teeth component of the Decayed, Missing, and
Filled Teeth (DMFT) index. Patients with developmental disorders or special needs were
not included in this study because they are followed at the Special Needs Department at
the EMDC.

2.3. Dependent Variables

Caries experience was measured through the DMF index and was the main dependent
variable. The most used dental caries index is the DMF index, which counts the number
of DMFT resulting from dental caries. This index captures an individual’s cumulative
experience of past and present dental caries, whether untreated (the number of decayed
teeth) or treated (filled teeth or missing teeth extracted as a result of dental caries) [2].

2.4. Independent Variables

Sociodemographic and behavior information were collected from the self-reported
questionnaire. Health determinants and sociodemographic factors included important
independent variables for subsequent analysis such as age, sex, education level, and
occupation. These variables are common predictors of caries [8,20,21].
Caries experience was used as a dichotomous variable (yes or no). Furthermore, DMF
was used as a continuous variable. Sex was divided into two groups: male and female. Age
was recorded as a continuous variable (years) and then we used the following age groups
Int. J. Environ. Res. Public Health 2023, 20, 2511 3 of 12

to organize the information and realize the descriptive analyses: 18–24; 25–44; 45–64; and
≥65.
Education level was categorized following the 2011 International Standard Classi-
fication of Education (ISCED-2011): No education (ISCED 0 level), Elementary (ISCED
1–2 levels), Middle (ISCED 3–4 levels), and Higher (ISCED 5–8 levels) [22].
Occupation of each subject was classified as: student, employed, unemployed, and
retired. This classification is the same used by Botelho, Machado [19]; and Machado,
Botelho [18].
Smoking habits were defined as non-smoker and active smoker. The group of smoker
was further divided into three categories: light smokers (<10 cigarettes per day), medium
smokers (10–20 cigarettes per day), and heavy smokers (>20 cigarettes per day). This
division was also used by Botelho, Machado [19]’ and Machado, Botelho [18].
Alcohol consumption was registered as a dichotomous variable (yes or no).
Body Mass Index (BMI) was calculated as the ratio of the individual’s body weight
to the square of their height. The height of the participants was measured in centimeters,
using a hard ruler installed vertically and secured with a stable base. Weight was as-
sessed in kilograms (Kg) using mechanical scales. Four BMI categories were defined using
World Health Organization (WHO) criteria [23]: underweight (18.5 kg/m2 ), normal weight
(18.5–24.9 kg/m2 ), overweight (25–29.9 kg/m2 ), and obese (≥30 kg/m2 ). Variables about
oral heath were adapted following the WHO Oral Health Surveys: Basic Methods [24].
Comorbidity was defined as an occurrence of one or more self-reported systemic disor-
ders including endocrine disorders, blood vascular disorders, orthopedic diseases (arthritis,
rheumatoid arthritis), hypertension, and allergy [25]. The number of comorbidities were
divided in 4 groups (low—1, moderate—2 or 3, high—4 or 5, and very high—≥6) according
to Browne et al. [26].
The time elapsed since last dental consult was classified into five categories (never
visited, less than one year, 1–2 years, 3–4 years, 5 years or over). Appointment reasons were
classified as routine, aesthetics, pain, functional, or other. Oral hygiene habits were assessed
by information on toothbrush frequency (2–3 times/daily, 1 time daily, 2–6 times/weekly,
and never), dental floss use, and mouthwash use. The oral self-perception was divided
in two groups, Teeth Health and Gums Health, each one classified into five categories
(excellent, very good, good, weak, and very weak).

2.5. Statistical Analysis

Data analysis was performed using IBM SPSS Statistics version 28.0 for Windows
(IBM Corp., Armonk, NY, USA). Descriptive and inferential statistics methodologies were
applied. The homogeneity of variance was calculated with Kolmogorov–Smirnov test and
Levene’s test.
For variables with more than two independent samples, normal distribution, and
homogeneous variance, we use ANOVA I and Tukey HSD as post hoc tests to compare
clinical data with sociodemographic variables. The Kruskal–Wallis test and pairwise com-
parison with Bonferroni correlation are performed when the data are normally distributed
and homogeneity of variance is rejected or when the data are not normally distributed.
In cases where two independent samples are normally distributed and homogeneity of
variance is accepted, we use the parametric Student’s t-test. If homogeneity of variance
is rejected, we use the parametric Welch test. Mann–Whitney is used when data are not
normally distributed.
Logistic regression analysis explored the relationship between dental caries and con-
ceivable risk indicators. Preliminary analyses were performed using univariate models.
Next, a multivariate model constructed using variables showing a significance p ≤ 0.25
in the univariate model were included in the multivariate stepwise procedure. Among
the predictor variables were sex, age (years), education level, occupation, smoking and
drinking alcohol habits, BMI, last dental visit, appointment reasons, toothbrush frequency,
dental floss use, mouthwash use, tooth and gums health perception, and presence of comor-
Int. J. Environ. Res. Public Health 2023, 20, 2511 4 of 12

bidities. The contribution of each variable to the model was evaluated by Wald statistics.
Interactions were also analyzed for all tested variables. The final reduced model included:
occupation (student, employed, unemployed, and retired), BMI (overweight), last dental
visit (never), and dental status perception (week). Odds ratio (OR) and 95% confidence
intervals (95% CI) were calculated for both univariate and multivariate analyses. The level
of statistical significance was set at p ≤ 0.05.

3. Results
3.1. Participant Inclusion and Characteristics
From a total of 9860 incoming patients, 9349 (94.8%) fulfilled the eligibility criteria,
while 511 participants were excluded from the study. Among the excluded individuals, 306
(59.9%) were younger than 18 years, 204 (39.9%) were edentulous, and one (0.2%) had an
incomplete triage questionnaire.
Regarding the 9349 participants, the majority were female participants (59.8%) and
age ranged between 25 and 64 years old (64.3%). Most participants reported having an
elementary or middle school education (65.9%) and being employed (53.3%). In addition,
73.8% were not smokers, 52.5% reported alcoholic habits, and 49.6% were overweight and
obese. Overall, 52.0% of this sample had at least one comorbidity (Table 1).

Table 1. Sociodemographic, health, and behavior characterization of the participants (n = 9349).

Variable Sub-Variable n (%)

Female 5592 (59.8)
Sex
Male 3757 (40.2)
18–24 1867 (20.0)
25–44 2907 (31.1)
Age group (years)
45–64 3101 (33.2)
≥65 1474 (15.8)
Without studies 38 (0.4)
Elementary 2668 (28.5)
Education
Middle 3492 (37.4)
Higher 3151 (33.7)
Student 1616 (17.3)
Employed 4980 (53.3)
Occupation
Unemployed 1083 (11.6)
Retired 1670 (17.9)
Smoker 2453 (26.2)
Smoking habits
Non-smoker 6896 (73.8)
Light 1132 (46.1)
Active smokers
Medium 1306 (53.2)
(Cigarettes per day)
Heavy 15 (0.6)
No 4438 (47.5)
Alcohol consumption
Yes 4911 (52.5)
Underweight 1035 (11.1)
Normal weight 3683 (39.4)
BMI (Kg/m2 )
Overweight 2960 (31.7)
Obese 1671 (17.9)
No 4488 (48.0)
Comorbidity
Yes 4861 (52.0)
Low 2559 (27.4)
Moderate 1866 (20.0)
Number of comorbidities
High 349 (3.7)
Very High 87 (0.9)
Abbreviations: BMI—Body Mass Index; n—number of participants.
Int. J. Environ. Res. Public Health 2023, 20, 2511 5 of 12

Regarding oral health self-reported perception, 51.7% claimed to have seen a dentist in
the last year and the most common appointment reason was a functional complaint (46.1%)
followed by routine (28.1%) and a pain event (18.9%) (Table 2). About 80.2% reported they
brush their teeth 2–3 times a day, yet only 36.7% said they performed interproximal hygiene
with dental floss. A few participants (1.8%) considered their teeth to be excellent, while
43.1% and 46.7% considered them good and weak/very weak, respectively. Regarding
gum health self-perception, the majority (53.9%) considers their gums to be good.

Table 2. Oral health care, dental caries experience, and self-reported perception about oral health
condition descriptive data (n = 9349).

Variables n (%)
Never 112 (1.2)
<1 year 4.835 (51.7)
Last dental visit 1–2 years 1.401 (15.0)
3–4 years 1.450 (15.5)
≥5 years 1.551 (16.6)
Routine 2.628 (28.1)
Aesthetics 408 (4.4)
Appointment reasons Pain 1.768 (18.9)
Functional 4.312 (46.1)
Other 233 (2.5)
2–3 times/daily 7.496 (80.2)
1 time/daily 1.550 (16.6)
Toothbrush frequency
2–6 times/weekly 156 (1.7)
Never 147 (1.6)
No 5.917 (63.3)
Dental floss usage
Yes 3.432 (36.7)
No (DMFT = 0) 204 (2.2)
Yes (DMFT > 0) 9.145 (97.8)
Dental caries experience DT 8.521 (91.1)
MT 6.730 (72.0)
FT 6.365 (68.1)
No 5.143 (55.0)
Gum bleeding
Yes 4.206 (45.0)
Excellent 166 (1.8)
Very good 790 (8.5)
Teeth health perception Good 4.030 (43.1)
Weak 2.886 (30.9)
Very weak 1.477 (15.8)
Excellent 333 (3.6)
Very good 1.033 (11.0)
Gums health perception Good 5.041 (53.9)
Weak 2.291 (24.5)
Very weak 651 (7.0)
Abbreviations: n—number of participants; D: Decayed Teeth; M: Missing teeth; F: Filled Teeth.

3.2. Dental Caries Experience

Out of the 9349 participants, 8521 (91.1%) had caries experience, of which 59.7%
(n = 5090) were female subjects (Table 3). Males had significant higher decayed teeth
(p < 0.001) and lower filled teeth (p < 0.001) than female participants, while no differences
were found for missing teeth (p = 0.842).
Int. J. Environ. Res. Public Health 2023, 20, 2511 6 of 12

Table 3. Dental caries data (presented as mean and standard deviation) as function of sociodemo-
graphic, health, and behavior factors (n = 9349).

Variable n (%) DT MT FT DMFT

Female 5.090 (59.7) 5.8 (4.3)a 6.6 (7.4) a 3.3 (3.6) a 15.7 (8.2) a
Sex
Male 3.431 (40.3) 6.3 (4.8) b 6.5 (7.4) a 2.7 (3.3) b 15.5 (8.2) a

18–24 1.496 (17.6) 4.6 (4.5) a 0.7 (1.5) a 1.9 (2.6) a 7.3 (6.3) a
Age group 25–44 2.702 (31.7) 6.9 (4.9) b 3.5 (4.5) b 3.6 (3.7) b 14.1 (7.0) b
(years) 45–64 2.932 (34.4) 6.2 (4.1) c 9.4 (7.2) c 3.7 (3.8) c 19.2 (6.7) c
≥65 1.391 (16.3) 5.5 (4.1) d 13.9 (7.9) d 2.1 (2.8) a 21.5 (7.0) d

Elementary 2.544 (29.9) 6.9 (4.9) a 11.5 (8.3) a 1.9 (2.7) a 20.3 (7.5) a
Middle 3.176 (37.3) 6.0 (4.5) b 5.5 (6.5) b 3.1 (3.5) b 14.7 (7.9) b
Education
Higher 2.764 (32.4) 5.1 (4.1) c 3.5 (4.9) c 4.0 (3.9) c 12.6 (7.3) c
Without studies 37 (0.4) 6.5 (4.8) abc 12.5 (7.9) a 1.4 (2.5) a 20.5 (7.1) a

Student 1.255 (14.7) 4.1 (4.2) a 0.9 (2.2) a 2.2 (2.8) a 7.2 (5.5) a
Employed 4.661 (54.7) 6.4 (4.5) b 5.7 (6.2) b 3.7 (3.8) b 15.8 (7.3) b
Occupation
Unemployed 1.024 (12.0) 7.4 (5.1) c 8.3 (7.9) c 2.7 (3.4) b 18.4 (7.5) c
Retired 1.581 (18.6) 5.6 (4.1) d 13.4 (8.0) d 2.2 (2.8) a 21.2 (7.1) d

Smoking Non-smoker 6.277 (73.7) 6.0 (4.6) a 7.1 (7.6) a 2.9 (3.4) a 15.9 (8.4) a
habits Smokers 2.244 (26.3) 6.0 (4.4) a 5.2 (6.4) b 3.6 (3.7) b 14.7 (7.7) b

Light 1.014 (41.3) 5.6 (4.5) a 4.1 (6.0) a 3.4 (3.7) a 13.2 (7.6) a
Active Medium 1.216 (49.6) 6.2 (4.3) b 6.0 (6.6) b 3.7 (3.6) b 16.0 (7.5) b
smokers
Heavy 14 (0.6) 6.5 (4.9) b 7.5 (6.5) ab 5.0 (5.2) ab 19.1 (5.2) bc

Underweight 913 (10.7) 5.6 (4.7) a 5.3 (7.0) a 3.1 (3.5) a 14.1 (8.4) a
BMI Normal weight 3.252 (38.2) 5.7 (4.6) a 4.9 (6.7) a 3.1 (3.5) a 13.7 (8.2) a
(Kg/m2 ) Overweight 2.786 (32.7) 6.3 (4.4) b 7.6 (7.6) b 3.2 (3.6) a 17.1 (7.7) b
Obese 1.570 (18.4) 6.3 (4.5) b 9.0 (7.8) c 2.7 (3.3) b 18.1 (7.9) c

No 4.102 (48.1) 6.0 (4.5) a 6.7 (7.5) a 3.1 (3.5) a 15.8 (8.1) a
Comorbidity
Yes 4.419 (51.9) 5.9 (4.6) a 6.4 (7.3) a 3.1 (3.5) a 15.4 (8.3) a
Data are mean (standard deviation). Different letters indicate statistically different mean values (Tukey HSD test,
p < 0.05). Abbreviations: BMI—Body Mass Index; DMFT: Decayed, Missing, Filled Teeth index; DT: decayed teeth;
MT: missing teeth; FT: filled teeth.; DMFT—Decayed, Missing, and Filled Teeth index; n—number of participants.
Statistical analysis for a significance level p < 0.05.

With regard to the age intervals, people ranging 25 and 44 years had the highest
average number of decayed teeth (6.9), with a significant difference among the remaining
age groups (p < 0.001).
The elementary education group (6.9) has more decayed teeth than the higher edu-
cation group (5.1). The elementary education, middle education, and higher education
groups have significantly different decayed tooth rates (p < 0.001). The higher education
group (5.1%) has fewer decayed teeth. The mean number of decayed teeth in the primary
education group is the highest. There is a significant difference between the number of
missing teeth between the elementary, middle, and higher education groups (p = 0.001),
with the higher education group having a lower missing tooth rate (3.5), and groups with
no studies (12.5) and elementary studies having a higher missing tooth rate (11.5).
According to this cross-sectional study, of the 8521 participants with past caries experi-
ence, 6277 (73.7%) are non-smokers, whereas 2244 (26.3%) smoke. Despite the difference in
experience between smokers and non-smokers, there is no statistically significant difference
in the mean number of decayed teeth (p = 0.644). Although there is no statistically signifi-
cant difference between smokers and non-smokers regarding the number of dental caries,
data suggest that dental caries incidence depends on the type of active smoker. A 49.6%
caries rate was observed among active smokers who smoked between 10 and 20 cigarettes a
day. Additionally, their mean number of DMFT was higher. Heavy smokers (>20 cigarettes
a day) have the highest mean number of DMFT.
Int. J. Environ. Res. Public Health 2023, 20, 2511 7 of 12

Dental caries was estimated to occur in 34.8% of normal-weight people, 29.8% of

obese people, and 16.8% of underweight people. Despite normal weight representing the
group with the highest caries experience (38.2%), there is a statistically significant difference
(p = 0.001) between overweight and obese groups regarding decayed and missing teeth.
With a self-reported systemic disorder (51.9%), the results show a high caries rate.
Despite the caries experience exceeding 50%, there is no statistically significant difference
between the mean number of decayed (p = 0.346), missing (p = 0.051), or filled teeth
(p = 0.989).
Oral health care and self-reported perceptions about oral health were associated with
higher levels of decayed teeth as well as negative self-perceptions about tooth health
(Table 4). A similar pattern has been observed in the mean number of missing teeth, except
for those who thought their teeth were excellent, whose mean number of missing teeth was
higher. Among these groups, there is a statistically significant difference in decayed teeth,
except for the “weak” and “very weak” groups.

Table 4. Oral health care and self-reported perception about oral health condition (n = 9349).

Variable Sub- n (%) DT MT FT DMFT

Variable

<1 year 4.374 (51.3) 5.9 (4.5) a 6.0 (7.1) a 3.1 (3.5) a 15.0 (8.2) a
1–2 years 1.291 (15.2) 6.1 (4.5) a 6.4 (7.3) ab 3.1 (3.5) a 15.6 (8.2) b
Last dental 3–4 years 1.320 (15.5) 6.1 (4.5) a 6.7 (7.5) b 3.1 (3.5) a 15.8 (8.0) cb
visit
≥5 years 1.444 (16.9) 6.2 (4.6) a 8.3 (7.8) cd 3.0 (3.5) a 17.4 (8.0) d
Never 92 (1.1) 5.5 (4.9) b 7.5 (8.7) abd 2.6 (3.2) a 15.5 (9.1) abcd

2–3 times/ 6.802 (72.8) 6.0 (4.6) a 6.1 (7.1) a 3.1 (3.5) a 15.1 (8.2) a
daily
Toothbrush 1 time/daily 1.436 (15.4) 6.0 (4.4) a 8.2 (8.1) b 3.0 (3.4) ab 17.1 (8.2) b
frequency 2–6 times/
weekly 140 (1.5) 5.9 (4.4) a 9.6 (8.4) c 2.7 (3.5 bc 18.2 (8.1) bc
Never 143 (1.5) 6.9 (4.9) a 10.8 (8.4) c 2.4 (3.3) c 20.0 (8.0) c

Excellent 131 (1.5) 4.6 (4.5) a 3.1 (5.7) a 2.5 (3.1) a 10.2 (7.9) a
Teeth Very good 671 (7.9) 5.3 (4.7) b 2.8 (5.0) a 2.6 (3.3) a 10.6 (7.6) a
health Good 3.625 (42.5) 5.9 (4.6) c 5.7 (7.1) b 3.0 (3.4) b 14.5 (8.2) b
perception Weak 2.711 (31.8) 6.2 (4.4) d 7.9 (7.5) c 3.3 (3.5) c 17.3 (7.7) c
Very weak 1.383 (16.2) 6.3 (4.5) d 8.9 (7.8) d 3.2 (3.8) bc 18.5 (7.6) d

Excellent 287 (3.4) 5.5 (4.6) a 4.2 (5.8) a 2.8 (3.4) a 12.5 (8.0) a
Gums Very good 905 (10.6) 5.6 (4.8) a 4.1 (4.3) a 2.7 (3.3) ab 12.4 (8.3) a
health Good 4.600 (54.0) 6.0 (4.5) b 6.7 (7.4) b 3.1 (3.5) ac 15.7 (8.2) b
perception Weak 2.122 (24.9) 6.0 (4.4) b 7.3 (7.6) c 3.2 (3.5) c 16.5 (7.9) c
Very weak 607 (7.1) 6.2 (4.5) b 8.5 (7.6) d 3.4 (3.8) c 18.1 (7.6) d
Data are mean (standard deviation). Different letters indicate statistically different mean values (Tukey HSD test,
p < 0.05). Abbreviations: BMI—Body Mass Index; DMFT: Decayed, Missing, Filled Teeth index; DT: decayed teeth;
MT: missing teeth; FT: filled teeth.; DMFT—Decayed, Missing and Filled Teeth index; n—number of participants.
Statistical analysis for a significance level p < 0.05.

3.3. Analysis of Risk Indicators

After univariate logistic regression analyses (Supplementary Table S1), significant
variables were explored with multivariate logistic regression (Table 5). Age was a significant
variable for DMFT (OR = 1.01, p = 0.018). Occupation also showed significance, with retired
people showing the highest risk towards caries (OR = 3.35, p < 0.001). Regarding body
weight distribution, overweight and obese people showed higher likeliness to present
dental caries (OR = 1.52, p = 0.001; OR = 1.36, p = 0.038, respectively).
Int. J. Environ. Res. Public Health 2023, 20, 2511 8 of 12

Table 5. Multivariate logistic regression analysis (final reduced model *) towards the outcome variable
‘caries presence’ (n = 9349).

Variable OR (95% CI) p

1.01 (1.00–1.02) 0.018
Age
- <0.001
Student 1 -
Employed 2.94 (2.37–3.65) <0.001
Occupation
Unemployed 3.35 (2.40–4.67) <0.001
Retired 2.55 (1.66–3.91) <0.001
Underweight 1 -
Normal weight 1.04 (0.83–1.29) 0.756
BMI (kg/m2 )
Overweight 1.52 (1.18–1.96) 0.001
Obese 1.36 (1.02–1.81) 0.038
<1 year 1 -
1–2 years 1.13 (0.91–1.42) 0.266
Last dental visit 3–4 years 0.90 (0.73–1.11) 0.337
≥5 years 0.99 (0.79–1.25) 0.932
Never 0.38 (0.23–0.64) <0.001
Excellent 1 -
Very good 1.47 (0.95–2.27) 0.084
Teeth health
Good 1.65 (1.10–2.48) 0.015
perception
Weak 2.14 (1.40–3.28) <0.001
Very weak 1.79 (1.13–2.82) 0.013
* The model was statistically significant, χ2 (15) = 417.443, p < 0.001, explained 9.7% (Nagelkerke R2 ) of the
variance, and correctly classified 91.1% of cases. Abbreviations: n—number of participants; BMI—Body Mass
Index; CI—Confidence Interval; OR—Odds Ratio.

People reporting to have never visited a dentist had a significantly lower risk of
presenting dental caries (OR = 0.38, p < 0.001). Oral health self-perception was also linked
to dental caries presence.

4. Discussion
This study retrospectively analyzed dental caries experiences in a Portuguese adult
population based on both clinical and radiographic examinations. Nine out of ten partici-
pants had some level of caries experience at the time of observation, according to the DMFT
index. Among the significant risk indicators, age, employment status, body fat based on
height and weight, self-perceived teeth status, and frequency of dental check-ups were the
most relevant to the prediction of dental caries experience.
Overall, these results are relevant to the studied population based on the characteristics
and oral health system in place. The oral healthcare system in Portugal is mainly based
upon private practice [2]. In 2005, the Portuguese Public Oral Health Program (PPOHP)
launched a “dental voucher” program for children, adolescents, and vulnerable groups [3].
These dental vouchers are then used by patients at primarily private practice clinics,
despite existing dental care in the Portuguese National Health System which reveals its
insufficiency to respond to population needs. The final application of this research is to
serve as a baseline for a different approach to the management of dental caries.
In this study, women were observed with a higher rate of dental caries, yet their
caries experience was not statistically different from men, in line with other studies [27,28];
nevertheless, sex differences in caries experience have also been reported [8]. Culture,
subsistence systems, dietary patterns, and even hormonal fluctuations can influence caries
experiences differently between males and females [29–31].
Age was also a significant risk indicator for dental caries experience, expectedly, possi-
bly due to higher exposure to a cariogenic diet [29]. In accordance with literature [30,32,33],
age remains a relevant risk indicator and our results are no exception. This link may also
be explained by several other factors that could be attributed to ageing such as xerostomia,
Int. J. Environ. Res. Public Health 2023, 20, 2511 9 of 12

polypharmacy, functional and cognitive impairment, or an intraoral ecological alteration

throughout time [30,32].
Participants’ schooling and employment activity are also revealed to be relevant.
Lower education or unemployed participants had higher levels of dental caries and dental
caries experience. Our results are consistent with other studies where jobless people had
poorer clinically determined oral health compared to the employed [34–36]. Occupational
environments have a significant impact on oral health [21,36–38].
Several factors can harm adults’ oral health, such as stress at work, healthcare policies,
and health-insurance companies [34]. Uncertainties about how unemployment affects oral
health are yet unanswered, but there are some hypotheses that could explain the reality
such as the fact that dental care is considered expensive even for employed adults and
that public dental care is almost nonexistent in some countries [34,39]. The Portuguese
government has implemented a few policies and programs to improve oral health in the
country, including initiatives to increase access to dental care for disadvantaged groups
and to promote oral hygiene and preventive care. Despite these efforts in oral health care,
more initiatives should be carried out to improve access to oral health [40,41].
Our results also show that body fat based on height and weight measured through the
BMI is also linked significantly to the presence of dental caries, particularly with people who
are overweight/obese having higher levels, and are consistent with other studies [42–44].
It is possible that the increased experience of caries in the overweight and obese groups is
due to other factors, such as dietary habits such as the consumption of sugary drinks and
foods [42,45]. However, even though the results of this study demonstrate a link between a
higher BMI Index and dental caries, a more in-depth understanding of how obesity affects
oral health, including dental caries, is necessary because there also findings that suggest an
inverse relationship between dental caries experience and obesity [46,47].
These findings demonstrate that people reporting to have never visited a dentist
had had a significantly lower risk of presenting dental caries (OR = 0.38, p < 0.001). It
is important to remind readers that from 9.349 participants of this study, only 112 (1.2%)
report that they have never visited a dentist. Appointment motivations may explain this
result. Our data show that only 2.620 participants (28.1%) looked for routine appointments.
This led us to believe that it was more common to see patients who were “problem-
oriented” than those who were “prevention-oriented” and these conclusions are shared
with other similar studies [8,48,49] and by the oral health report of the Portuguese Dental
Association [50].
The results of this cross-sectional study are useful for providing evidence that dental
caries is a disease that is not equally distributed among the population, affecting several
population groups.

Strenghts and Limitations

We have strengths and limitations to consider in our study, which are worth taking
into consideration. One of the limitations of this study is related to the study design. This
study is observational and therefore hinders any cause-and-effect testing, but it is especially
noteworthy that the number of participants was large. There was also a limitation related
to the fact that students primarily observed the participants. This limitation was offset by
the fact that all diagnostics were validated by qualified teachers.
The lack of control for other potential variables of interest such as exposure to fluoride,
salivary flow, or socioeconomic status where most patients declined to provide their
socioeconomic status constitutes potential limitations of this study.
Other limitations important to mention are related to the DMFT index. When deter-
mining the DMFT index, the mix of decayed, missing, and filled teeth is not considered, nor
is it considered whether teeth are lost due to other reasons besides caries. The DMFT index
validity is therefore compromised [51]. The DMF does not indicate the need for dental
treatment. However, the ratio of decayed teeth to the total number of teeth in the DMF
(D/DMF) can be used as an estimate of unmet treatment needs. Similarly, the ratio of filled
Int. J. Environ. Res. Public Health 2023, 20, 2511 10 of 12

teeth to the total number of teeth in the DMF (F/DMF) can be interpreted as a measure of
a person’s access to dental care. However, we emphasize that radiographic confirmation
of dental caries may be seen as an advantage of our clinical confirmation of dental caries,
increasing the consistency of our estimate.
The BMI index also has several limitations when it comes to evaluating the risk or
experience of dental caries. This index may be a useful tool for assessing overall health
and risk of certain diseases, but it should not be used as the sole indicator of dental caries
experience. It is important to consider a range of factors, including diet, oral hygiene, and
overall health status, when evaluating an individual’s risk of dental caries [45].
Nevertheless, this study is reported upon an international and widely accepted guide-
line [16,17].

5. Conclusions
Our results show a high burden of dental caries experience. Age, occupation, body
fat based on height and weight, dental health self-perception, and frequency of dental
check-ups were the significant risk indicators. These results will pave the way for future
tailored public health programs for dental caries.

Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/ijerph20032511/s1, Table S1. Univariate logistic regression analysis
of sociodemographic, behavioral, anthropometric and oral hygiene variables towards the outcome
variable ‘caries presence’ (n = 9349).
Author Contributions: E.G., V.M. and J.B. conceived and designed the experiments, performed the
experiments, analyzed the data, contributed reagents/materials/analysis tools, prepared figures
and/or tables, authored or reviewed drafts of the paper, and approved the final draft. A.C.M. and
J.J.M. analyzed the data, contributed reagents/materials/analysis tools, authored or reviewed drafts
of the paper, and approved the final draft. L.P. conceived and designed the experiments, analyzed
the data, prepared figures and/or tables, authored or reviewed drafts of the paper, and approved the
final draft. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Committee of Instituto Universitario Egas Moniz (ID no. 898
on 24 September 2020).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: All data generated or analyzed during this study are included in this
article. Further enquiries can be directed to the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Fontana, M.; Gonzalez-Cabezas, C. Evidence-Based Dentistry Caries Risk Assessment and Disease Management. Dent. Clin. N.
Am. 2019, 63, 119–128. [CrossRef] [PubMed]
2. Peres, M.A.; Macpherson, L.M.D.; Weyant, R.J.; Daly, B.; Venturelli, R.; Mathur, M.R.; Listl, S.; Celeste, R.K.; Guarnizo-Herreno,
C.C.; Kearns, C.; et al. Oral diseases: A global public health challenge. Lancet 2019, 394, 249–260. [CrossRef] [PubMed]
3. Yassin, S.M.; Tikare, S.; AlKahtani, Z.M.; AlFaifi, F.J.; AlFaifi, W.S.; AlFaifi, E.; Omair, A.; Ravi, K.S. Caries preventive practices
and dental caries among boys aged 6–15 in Saudi Arabia. Eur. J. Paediatr. Dent. 2020, 21, 97–102.
4. Machiulskiene, V.; Campus, G.; Carvalho, J.C.; Dige, I.; Ekstrand, K.R.; Jablonski-Momeni, A.; Maltz, M.; Manton, D.J.; Martignon,
S.; Martinez-Mier, E.A.; et al. Terminology of Dental Caries and Dental Caries Management: Consensus Report of a Workshop
Organized by ORCA and Cariology Research Group of IADR. Caries Res. 2020, 54, 7–14. [CrossRef]
5. Hagman, J.; Wide, U.; Werner, H.; Hakeberg, M. Oral health and oral health behavior in young adults with caries disease. BDJ
Open 2021, 7, 28. [CrossRef] [PubMed]
6. Hujoel, P.P.; Hujoel, M.L.A.; Kotsakis, G.A. Personal oral hygiene and dental caries: A systematic review of randomised controlled
trials. Gerodontology 2018, 35, 282–289. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 2511 11 of 12

7. Smith, J.; Griffiths, K.; Judd, J.; Crawford, G.; D’Antoine, H.; Fisher, M.; Bainbridge, R.; Harris, P. Ten years on from the World
Health Organization Commission of Social Determinants of Health: Progress or procrastination? Health Promot. J. Austr. 2018, 29,
3–7. [CrossRef] [PubMed]
8. Bogale, B.; Engida, F.; Hanlon, C.; Prince, M.J.; Gallagher, J.E. Dental caries experience and associated factors in adults: A
cross-sectional community survey within Ethiopia. BMC Public Health 2021, 21, 180. [CrossRef]
9. Frencken, J.E.; Sharma, P.; Stenhouse, L.; Green, D.; Laverty, D.; Dietrich, T. Global epidemiology of dental caries and severe
periodontitis—A comprehensive review. J. Clin. Periodontol. 2017, 44 (Suppl. 18), S94–S105. [CrossRef]
10. Chapple, I.L.; Bouchard, P.; Cagetti, M.G.; Campus, G.; Carra, M.C.; Cocco, F.; Nibali, L.; Hujoel, P.; Laine, M.L.; Lingstrom, P.;
et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: Consensus report of
group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J. Clin. Periodontol. 2017,
44 (Suppl. 18), S39–S51. [CrossRef]
11. Roberts-Thomson, K.; Stewart, J.F. Risk indicators of caries experience among young adults. Aust. Dent. J. 2008, 53, 122–127;
quiz 186. [CrossRef] [PubMed]
12. Doitchinova, L.; Kirov, D.; Nikolova, J.; Topalova-Pirinska, S. Caries Risk Assessment in Adults Using the Cariogram. Folia Med.
2020, 62, 831–837. [CrossRef] [PubMed]
13. Broadbent, J.M.; Thomson, W.M.; Poulton, R. Progression of dental caries and tooth loss between the third and fourth decades of
life: A birth cohort study. Caries Res. 2006, 40, 459–465. [CrossRef] [PubMed]
14. Zewdu, T.; Abu, D.; Agajie, M.; Sahilu, T. Dental caries and associated factors in Ethiopia: Systematic review and meta-analysis.
Environ. Health Prev. Med. 2021, 26, 21. [CrossRef]
15. Fraihat, N.; Madae’en, S.; Bencze, Z.; Herczeg, A.; Varga, O. Clinical Effectiveness and Cost-Effectiveness of Oral-Health
Promotion in Dental Caries Prevention among Children: Systematic Review and Meta-Analysis. Int. J. Environ. Res. Public Health
2019, 16, 2668. [CrossRef] [PubMed]
16. von Elm, E.; Altman, D.G.; Egger, M.; Pocock, S.J.; Gotzsche, P.C.; Vandenbroucke, J.P.; Initiative, S. The Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int. J.
Surg. 2014, 12, 1495–1499. [CrossRef]
17. Cuschieri, S. The STROBE guidelines. Saudi J. Anaesth. 2019, 13, S31–S34. [CrossRef]
18. Machado, V.; Botelho, J.; Amaral, A.; Proenca, L.; Alves, R.; Rua, J.; Cavacas, M.A.; Delgado, A.S.; Mendes, J.J. Prevalence and
extent of chronic periodontitis and its risk factors in a Portuguese subpopulation: A retrospective cross-sectional study and
analysis of Clinical Attachment Loss. PeerJ 2018, 6, e5258. [CrossRef]
19. Botelho, J.; Machado, V.; Proenca, L.; Alves, R.; Cavacas, M.A.; Amaro, L.; Mendes, J.J. Study of Periodontal Health in Almada-
Seixal (SoPHiAS): A cross-sectional study in the Lisbon Metropolitan Area. Sci. Rep. 2019, 9, 15538. [CrossRef]
20. Ghasemianpour, M.; Bakhshandeh, S.; Shirvani, A.; Emadi, N.; Samadzadeh, H.; Moosavi Fatemi, N.; Ghasemian, A. Dental caries
experience and socio-economic status among Iranian children: A multilevel analysis. BMC Public Health 2019, 19, 1569. [CrossRef]
21. Costa, S.M.; Martins, C.C.; Bonfim Mde, L.; Zina, L.G.; Paiva, S.M.; Pordeus, I.A.; Abreu, M.H. A systematic review of
socioeconomic indicators and dental caries in adults. Int. J. Environ. Res. Public Health 2012, 9, 3540–3574. [CrossRef] [PubMed]
22. Schneider, S.L. The International Standard Classification of Education 2011. In Class and Stratification Analysis; Elisabeth Birkelund,
G., Ed.; Emerald Group Publishing Limited: Bingley, UK, 2013; Volume 30, pp. 365–379.
23. Kopelman, P.G. Obesity as a medical problem. Nature 2000, 404, 635–643. [CrossRef] [PubMed]
24. Petersen, P.E.; Baez, R.J.; World Health, O. Oral Health Surveys: Basic Methods, 5th ed.; World Health Organization: Geneva,
Switzerland, 2013.
25. Aimetti, M.; Perotto, S.; Castiglione, A.; Mariani, G.M.; Ferrarotti, F.; Romano, F. Prevalence of periodontitis in an adult population
from an urban area in North Italy: Findings from a cross-sectional population-based epidemiological survey. J. Clin. Periodontol.
2015, 42, 622–631. [CrossRef] [PubMed]
26. Browne, J.; Edwards, D.A.; Rhodes, K.M.; Brimicombe, D.J.; Payne, R.A. Association of comorbidity and health service usage
among patients with dementia in the UK: A population-based study. BMJ Open 2017, 7, e012546. [CrossRef]
27. Kassebaum, N.J.; Bernabe, E.; Dahiya, M.; Bhandari, B.; Murray, C.J.; Marcenes, W. Global burden of untreated caries: A systematic
review and metaregression. J. Dent. Res. 2015, 94, 650–658. [CrossRef]
28. Shaffer, J.R.; Wang, X.; McNeil, D.W.; Weyant, R.J.; Crout, R.; Marazita, M.L. Genetic susceptibility to dental caries differs between
the sexes: A family-based study. Caries Res. 2015, 49, 133–140. [CrossRef]
29. Lukacs, J.R.; Largaespada, L.L. Explaining sex differences in dental caries prevalence: Saliva, hormones, and “life-history”
etiologies. Am. J. Hum. Biol. 2006, 18, 540–555. [CrossRef]
30. Nicklisch, N.; Oelze, V.M.; Schierz, O.; Meller, H.; Alt, K.W. A Healthier Smile in the Past? Dental Caries and Diet in Early
Neolithic Farming Communities from Central Germany. Nutrients 2022, 14, 1831. [CrossRef]
31. Qureshi, A.; Safdar, N.F.; Qureshi, H.; AlFawaz, Y.F.; Al Ahdal, K.; Shabib, S.; Al-Aali, K.A.; Naseem, M.; Vohra, F.; Abduljabbar, T.
Dietary Factors Influencing the Caries Status of Adults in Karachi, Pakistan: Initial Findings. Int. J. Environ. Res. Public Health
2022, 19, 6980. [CrossRef]
32. Gavriilidou, N.N.; Belibasakis, G.N. Root caries: The intersection between periodontal disease and dental caries in the course of
ageing. Br. Dent. J. 2019, 227, 1063–1067. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 2511 12 of 12

33. Chan, A.K.Y.; Tamrakar, M.; Jiang, C.M.; Lo, E.C.M.; Leung, K.C.M.; Chu, C.H. A Systematic Review on Caries Status of Older
Adults. Int. J. Environ. Res. Public Health 2021, 18, 662. [CrossRef] [PubMed]
34. Irie, K.; Tsuneishi, M.; Saijo, M.; Suzuki, C.; Yamamoto, T. Occupational Difference in Oral Health Status and Behaviors in
Japanese Workers: A Literature Review. Int. J. Environ. Res. Public Health 2022, 19, 8081. [CrossRef]
35. Schwendicke, F.; Dorfer, C.E.; Schlattmann, P.; Foster Page, L.; Thomson, W.M.; Paris, S. Socioeconomic inequality and caries: A
systematic review and meta-analysis. J. Dent. Res. 2015, 94, 10–18. [CrossRef] [PubMed]
36. Costa, S.M.; Martins, C.C.; Pinto, M.Q.C.; Vasconcelos, M.; Abreu, M. Socioeconomic Factors and Caries in People between 19 and
60 Years of Age: An Update of a Systematic Review and Meta-Analysis of Observational Studies. Int. J. Environ. Res. Public Health
2018, 15, 1775. [CrossRef] [PubMed]
37. de Araújo Nobre, M.A.; Sezinando, A.M.; Fernandes, I.C.; Araújo, A.C. Influence of Smoking Habits on the Prevalence of Dental
Caries: A Register-Based Cohort Study. Eur. J. Dent. 2021, 15, 714–719. [CrossRef] [PubMed]
38. Abdel Fattah, M.A.; Barghouth, M.H.; Wassel, M.O.; Deraz, O.H.; Khalil, A.E.; Sarsik, H.M.; Mohsen, A.M.A.; Qenawy, A.S.; Abou
El Fadl, R.K. Epidemiology of dental caries in permanent dentition: Evidence from a population-based survey in Egypt. BMC
Public Health 2022, 22, 2438. [CrossRef] [PubMed]
39. Al-Sudani, F.Y.; Vehkalahti, M.M.; Suominen, A.L. The association between current unemployment and clinically determined
poor oral health. Community Dent. Oral Epidemiol. 2015, 43, 325–337. [CrossRef] [PubMed]
40. Santos, J.; Antunes, L.; Namorado, S.; Kislaya, I.; Joao Santos, A.; Rodrigues, A.P.; Braz, P.; Gaio, V.; Barreto, M.; Lyshol, H.; et al.
Oral hygiene habits in Portugal: Results from the first Health Examination Survey (INSEF 2015). Acta Odontol. Scand 2019, 77,
334–339. [CrossRef] [PubMed]
41. Antunes, M.; Ramos, L.M.; Lourenco, O.; Quintal, C. Access to healthcare in Portugal in the wake of the crisis. Not everything is
money? Cad. Saude Publica 2020, 36, e00248418. [CrossRef]
42. Chen, D.; Zhi, Q.; Zhou, Y.; Tao, Y.; Wu, L.; Lin, H. Association between Dental Caries and BMI in Children: A Systematic Review
and Meta-Analysis. Caries Res. 2018, 52, 230–245. [CrossRef]
43. Alshehri, Y.F.A.; Park, J.S.; Kruger, E.; Tennant, M. Association between body mass index and dental caries in the Kingdom of
Saudi Arabia: Systematic review. Saudi Dent. J. 2020, 32, 171–180. [CrossRef] [PubMed]
44. Paisi, M.; Kay, E.; Bennett, C.; Kaimi, I.; Witton, R.; Nelder, R.; Lapthorne, D. Body mass index and dental caries in young people:
A systematic review. BMC Pediatr. 2019, 19, 122. [CrossRef] [PubMed]
45. Alam, B.F.; Abbasi, N.; Hussain, T.; Khan, M.A.; Chaudhary, M.A.G.; Ijaz, F. Relationship of BMI with the diet, physical activity
and oral hygiene practices amongst the dental students. BMC Oral Health 2022, 22, 311. [CrossRef] [PubMed]
46. Cheng, Y.H.; Liao, Y.; Chen, D.Y.; Wang, Y.; Wu, Y. Prevalence of dental caries and its association with body mass index among
school-age children in Shenzhen, China. BMC Oral Health 2019, 19, 270. [CrossRef]
47. Stangvaltaite-Mouhat, L.; Furberg, A.S.; Drachev, S.N.; Trovik, T.A. Common social determinants for overweight and obesity, and
dental caries among adolescents in Northern Norway: A cross-sectional study from the Tromso Study Fit Futures cohort. BMC
Oral Health 2021, 21, 53. [CrossRef] [PubMed]
48. Rambabu, T.; Koneru, S. Reasons for use and nonuse of dental services among people visiting a dental hospital in urban India: A
descriptive study. J. Educ. Health Promot. 2018, 7, 99. [CrossRef]
49. Obeidat, S.R.; Alsa’di, A.G.; Taani, D.S. Factors influencing dental care access in Jordanian adults. BMC Oral Health 2014, 14, 127.
[CrossRef]
50. Ordem dos Médicos Dentistas. Barómetro de Saúde Oral. 2022. Available online: https://www.omd.pt/content/uploads/2022
/11/VII-Barometro-Nacional-de-Saude-Oral_2022.pdf (accessed on 6 January 2022).
51. Shulman, J.D.; Cappelli, D.P. Chapter 1—Epidemiology of Dental Caries. In Prevention in Clinical Oral Health Care; Cappelli, D.P.,
Mobley, C.C., Eds.; Mosby: Saint Louis, MO, USA, 2008; pp. 2–13. [CrossRef]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.