ORIGINAL

Oliveira
ARTICLE
et al

Impact of Oral Health Status on the

Oral Health-Related Quality of Life of Brazilian
Male Incarcerated Adolescents

Diego Canavese Oliveiraa/Fernanda Morais Ferreirab/Imara de Almeida Castro

Morosinic/Cassius Carvalho Torres-Pereirad/ Saul Martins Paivae/Fabian Calixto Fraizf

Purpose: To assess the impact of oral health status on the oral health-related quality of life (OHRQoL) of incarcerated
Brazilian male adolescents.

Materials and Methods: A cross-sectional survey with 102 male adolescents incarcerated at the São Francisco Juve-
nile Detention Facility, Piraquara, Brazil in 2010 was carried out. Dental caries, oral hygiene, periodontal status, maloc-
clusion, dental fluorosis and dental trauma were analysed. The Oral Health Impact Profile (OHIP-14) was administered
to measure OHRQoL, along with a questionnaire addressing sociodemographic variables, health-related aspects and
dental experience. Descriptive statistical analysis and univariate and multiple Poisson regression with robust variance
were performed.

Results: The prevalence of adolescents who reported an impact on OHRQoL was 64% (95% CI: 54–73) and the mean
OHIP-14 score was 6.69 (SD = 8.79; median = 3.00). In the multiple regression model, the prevalence of a negative
impact on OHRQoL was significantly higher among individuals with untreated caries (PR = 1.74; 95% CI: 1.10–2.77),
those who reported having discomfort in the teeth or mouth (PR = 1.33; 95% CI: 1.03–1.73), using tobacco prior to
internment (PR = 1.53; 95% CI: 1.04–2.24) and maintaining a stable relationship (PR = 1.31; 95% CI: 1.01–1.70) in
comparison to individuals who did not exhibit these conditions. Moreover, each month of internment represented an
increase in the prevalence of an impact on OHRQoL (PR = 1.03; 95% CI: 1.01–1.06).

Conclusion: Incarcerated male adolescents reported that oral health problems exerted an influence on quality of life,
with untreated caries exhibiting the greatest impact.

Key words: adolescent, institutionalised, oral health, quality of life

Oral Health Prev Dent 2015;13:417-425 Submitted for publication: 21.05.13; accepted for publication: 15.10.13
doi: 10.3290/j.ohpd.a33922

F actors that affect health, including the mouth

and teeth, have the potential to compromise
well-being and quality of life.5,9,27,29,30 While the
Every teenager experiences adolescence in a dif-
ferent manner. The construction of identity is both
personal and social, occurring in an interactive
studies cited have demonstrated the effect of oral fashion through exchanges between the individual
health status on the quality of life of adolescents, and his/her environment. Thus, perceptions re-
no such studies have been carried out involving in- garding the impact of oral health status on quality
carcerated adolescents. of life occur in a particular manner and determining

a e
Dentist, Department of Stomatology, Universidade Federal do Full Professor, Department of Paediatric Dentistry and Orthodon-
Paraná, Curitiba, Paraná, Brazil. Study concept and design, data tics, Universidade Federal de Minas Gerais, Belo Horizonte, Mi-
collection and analysis, co-wrote manuscript, reviewed final draft. nas Gerais, Brazil. Study concept and design, data analysis, co-
b
Adjunct Professor, Department of Stomatology, Universidade Fed- wrote manuscript, critically revised and reviewed final draft.
eral do Paraná, Curitiba, Paraná, Brazil. Study concept and de-
sign, data analysis, co-wrote manuscript, reviewed final draft. f
Associate Professor, Department of Stomatology, Universidade
c
Adjunct Professor, Department of Stomatology, Universidade Fed- Federal do Paraná, Curitiba, Paraná, Brazil. Data analysis, co-
eral do Paraná, Curitiba, Paraná, Brazil. Data collection and analy- wrote manuscript, critically revised and reviewed final draft.
sis, co-wrote manuscript, critically revised and reviewed final draft.
d
Adjunct Professor, Department of Stomatology, Universidade Fed- Correspondence: Dr. Fabian Calixto Fraiz, Rua Francisco de Paula
eral do Paraná, Curitiba, Paraná, Brazil. Data collection and anal- Guimarães, 465/ 303, Curitiba, Paraná, Brazil 80540-040. Tel: +55-
ysis, contributed substantially to manuscript, reviewed final draft. 41-9619-7610, Fax: +55 41 33604134. Email: [email protected]

Vol 13, No 5, 2015 417

Oliveira et al

this impact is multidimensional, involving biopsy- tal trauma was assessed using the criteria de-
chosocial aspects.17 scribed by Andreasen and Andreasen.2
The particularity of incarcerated adolescents re-
quires an interpretation that considers the socio-
cultural framework, the burden of past personal Calibration process
history and the environment in which such individu-
als live. There are more than 16,000 incarcerated The calibration process was performed in two phas-
adolescents in Brazil and approximately 960 in the es. The theoretical phase involved a discussion on
state of Paraná.7 However, information is lacking the diagnosis of the different dental disorders stud-
on the oral health status of such individuals and no ied using projected photographic images and plas-
studies have described the impact of oral health on ter casts. An expert (FMF) with extensive experi-
their quality of life. Studies carried out in the USA ence in clinical data collection in epidemiological
report that adolescents in juvenile detention cen- studies (gold standard in the theoretical framework)
tres have an unfavourable oral health status;1,6 coordinated this step, training a general dentist
moreover, dental care was among the most com- (DCO) on how to perform the examination.
mon reasons for healthcare visits among incarcer- The second phase was conducted with different
ated adolescents in the state of Washington.1 methodologies, as the conditions evaluated were
Understanding the oral health status of incarcer- very different. Twenty-five adolescents were clini-
ated adolescents from a clinical standpoint as well cally examined for caries, periodontal disease and
as a multidimensional perspective will enable the oral hygiene status and re-examined after a 15-day
planning, implementation and evaluation of oral interval with regard to the first two variables. It was
health promotion programmes. Thus, the aim of not possible to determine intra-examiner agree-
the present study was to assess the impact of oral ment for the IHO-S (oral hygiene status). For dental
health status on the quality of life of incarcerated trauma and dental fluorosis, 39 and 30 images, re-
Brazilian male adolescents. spectively, were analysed by the same examiner on
two occasions and in a different order with a 15-day
interval between analyses. For the DAI, 22 plaster
MATERIALS AND METHODS casts of the adolescents’ dentition were analysed
by the same examiner on two occasions with a 15-
Ethical considerations day interval between analyses. Weighted Cohen’s
Kappa values and intraclass correlation coefficients
The study received approval from the Human Re- were > 0.80 for the DAI. For the other parameters,
search Ethics Committee of the Federal University weighted Cohen’s Kappa values (Dean’s index, CPI,
of Parana (Brazil) and carried out according to the IHO-S) and Kappa values (DMFT, dental trauma)
Declaration of Helsinki. The legal guardians and were ≥ 0.80 for inter-examiner agreement. For all
adolescents signed a statement of informed con- conditions, intra-examiner agreement was ≥ 0.80.
sent authorising participation in the study.

Pilot study
Study population and study design
A pilot study was first carried out, involving a con-
A cross-sectional census study was carried out with venience sample of 10 incarcerated male adoles-
all incarcerated adolescents (N = 103) incarcerat- cents incarcerated in another social education centre
ed for at least 30 days at the São Francisco Social in the state of Paraná to test the methods and under-
Education Centre in the city of Piraquara, state of standing of the questionnaires. The results revealed
Paraná, southern Brazil, from January to June 2010. no need to change the initially proposed methods.
The following indices were assessed: caries using
the Decayed, Missing and Filled Teeth (DMFT) index,
periodontal status using the Community Periodontal Data collection and questionnaires
Index (CPI), malocclusion using the Dental Aesthetic
Index (DAI) and dental fluorosis using Dean’s Dental Clinical exams were performed with the aid of a
Fluorosis Index.32 Oral hygiene was assessed using disposable mouth mirror (PRISMA; São Paulo, SP,
the Simplified Oral Hygiene Index (IHO-S)13 and den- Brazil) and standard periodontal probe (WHO-621,

418 Oral Health & Preventive Dentistry

 Oliveira et al

Trinity; São Paulo, SP, Brazil) by a single examiner often’ response) or absence of impact (only ‘never’
(DCO) with the subject seated in a dental chair un- and ‘hardly ever’ responses on all items). The reports
der the artificial light of the reflector. The clinical of rare events (response options of ‘never’ and ‘hard-
exam followed a standardised order, with oral hy- ly ever’) were ignored, as they may not represent a
giene and periodontal status evaluated first, fol- significant impact on quality of life.28 The clinical vari-
lowed by the determination of dental trauma, fluo- ables were also dichotomised: oral hygiene: ‘satisfac-
rosis, caries and malocclusion. The average time tory’ (OHI-S < 1) and ‘unsatisfactory’ (OHI-S ≥ 1); un-
spent on each adolescent was 30 min. treated caries: ‘presence’ (D component of DMFT
The adolescents completed a questionnaire in index ≥ 1) and ‘absence’ (D component of DMFT in-
interview format addressing sociodemographic fac- dex = 0); malocclusion: ‘presence’ (DAI > 25) and
tors, health-related aspects and dental experience, ‘absence’ (DAI ≤ 25); dental fluorosis: ‘presence’
with items on marital status, formal schooling, em- (Dean’s Index > 1) and ‘absence’ (Dean’s index ≤ 1);
ployment prior to internment, living prior to intern- periodontal status: ‘healthy’ (CPI < 1) and ‘unhealthy’
ment with at least one parent, first internment, (CPI ≥ 1); dental trauma: ‘presence’ (clinical signs of
visit to dentist prior to internment, type of dental dental trauma, from enamel fracture to avulsion) and
office, reported discomfort in teeth and mouth and ‘absence’ (no clinical signs of dental trauma). The so-
use of tobacco prior to internment. ciodemographic, health-related aspects and dental
On the same occasion, the short form of the Oral experience variables were dichotomised as follows:
Health Impact Profile,28 cross-culturally adapted marital status (single/stable relationship); schooling
and validated for Brazilian Portuguese,24 was ad- (> 8 years/≤ 8 years); employed prior to internment
ministered through interviews by a single trained (yes/no); lived with at least one parent (yes/no); first
researcher (DCO) to measure the impact on oral internment (yes/no); visit to dentist prior to intern-
health related quality of life (OHRQoL). This assess- ment (yes/no); type of dental office (private office,
ment tool has been employed in a large number of public office); discomfort in teeth and mouth (yes/
dentistry studies and has a solid conceptual basis, no); user of tobacco prior to internment (no = never,
with known psychometric properties and easy ad- rarely / yes = sometimes, constantly, always).
ministration. The questionnaire has six subscales,
each with two items: physical limitation, physical
pain, psychological discomfort, physical disability, RESULTS
psychological disability, social disability and handi-
cap. The rating scale response options are scored One hundred three incarcerated adolescents met
as follows: never = 0; hardly ever = 1; occasionally the inclusion criteria. One loss occurred due to in-
= 2; fairly often = 3; very often = 4. The previous complete answers. Thus, one hundred two adoles-
month of incarceration was the timeframe used. cents between 15 and 19 years of age participated
The sum of the points attributed to the responses in the present study (response rate = 99%).
given to each item (0 to 4) were totaled for the over- These adolescents had a mean age of 16.8
all OHIP-14 score, which ranged from 0 to 56 points. (standard deviation [SD] = 0.94) years. Mean time
of incarceration was 6.2 (SD = 4.1) months. Prior
to internment, most of the participants lived with at
Statistical analysis least one parent (72.5%) and 52.9% worked. Only
7.8% had completed more than eight years of for-
The data were analysed using the Statistical Package mal schooling and 36% were repeat offenders.
for the Social Sciences (SPSS for Windows, version The prevalence of oral health-related impact on
16.0, SPSS; Chicago, IL, USA). Descriptive and Pois- quality of life was 64% (95% CI: 54–73) and the
son’s univariate regression analysis were performed mean OHIP-14 score was 6.7 (SD = 8.8; medi-
to test associations between oral health conditions an = 3; range: 0 to 38) (Table 1). ‘Felt pain in mouth
and the co-variables as well as self-reported impact or teeth’ (item 3) and ‘worried about problems with
on quality of life. Variables with p < 0.20 in the uni- mouth or teeth’ (Item 5) were the aspects of quality
variate analyses were incorporated into the Poisson of life most affected by oral health status (Table 2).
multiple regression model with robust variance. For A total of 36.3% of the participants reported feel-
the analysis of associations, OHIP-14 scores were di- ing discomfort in their teeth or mouth at the mo-
chotomised as the presence of impact on quality of ment of the interview. A statistically significant as-
life (at least one ‘occasionally’, ‘fairly often’ or ‘very sociation was detected between this condition and

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Table 1 Prevalence of impact on OHRQoL and OHIP-14 scores among Brazilian male incarcerated adolescents
(N = 102); Piraquara, Brazil, 2010
Scores
Frequency (%) of
OHIP-14 subscales Mean ± SD Min Max Median impact on OHRQoL

Functional limitation 0.4 ± 1.2 0 8 0 14 (13.7)

Physical pain 1.8 ± 2.1 0 8 1 47 (46.1)

Psychological discomfort 1.8 ± 2.3 0 8 1 43 (42.2)

Physical disability 1.0 ± 1.8 0 8 0 26 (25.5)

Psychological disability 0.8 ± 1.4 0 6 0 26 (25.5)

Social disability 0.5 ± 1.2 0 6 0 15 (14.7)

Handicap 0.4 ± 1.0 0 4 0 12 (11.8)

Total OHIP 6.7 ± 8.8 0 38 3 65 (63.7)

SD = standard deviation; OHRQoL = oral health-related quality of life.

Table 2 Frequency of reported impact on each item of OHIP-14 among Brazilian male incarcerated adolescents
(N = 102); Piraquara, Brazil, 2010
Absence of impact Presence of impact

OHIP-14 subscales N (%) N (%)

Functional Item 1 95 (93.1) 7 (6.9)

limitation Item 2 93 (91.2) 9 (8.8)

Item 3 63 (61.8) 39 (38.2)

Physical pain
Item 4 73 (71.6) 29 (28.4)

Psychological Item 5 63 (61.8) 39 (38.2)

discomfort Item 6 82 (80.4) 20 (19.6)

Physical Item 7 79 (77.5) 23 (22.5)

disability Item 8 88 (86.3) 14 (13.7)

Psychological Item 9 85 (83.3) 17 (16.7)

disability Item 10 87 (85.3) 15 (14.7)

Social Item 11 89 (87.3) 13 (12.7)

disability Item 12 96 (94.1) 6 (5.9)

Item 13 90 (88.2) 12 (11.8)

Handicap
Item 14 101 (99.0) 1 (1.0)
Absence of impact = never or hardly ever; presence of impact = occasionally, fairly often or very often.

the report of an oral health-related impact on qual- between the use of tobacco prior to internment and
ity of life (prevalence ratio [PR] = 1.51; 95% CI: OHRQoL (PR = 1.66; 95% CI: 1.12–2.46) (Table 3).
1.14–1.98). The prevalence of impact on OHRQoL Caries was found in 93% (95% CI: 88–98) of the
was significantly higher in adolescents who main- participants. The mean DMFT index was 5.9
tained a stable relationship (PR = 1.37; 95% CI: (SD = 4.5). The ‘decayed’ component contributed
1.05–1.81) (Table 3). The Poisson univariate analy- most to this index (mean = 2.8; SD = 3.3) and the
sis revealed a statistically significant association ‘missing’ component contributed the least

420 Oral Health & Preventive Dentistry

 Oliveira et al

Table 3 Frequency distribution of sociodemographic variables, report of discomfort in teeth and mouth, tobacco use
and impact on OHRQoL among Brazilian male incarcerated adolescents (N = 102); Piraquara, Brazil, 2010
Impact on OHRQoL Univariate analysis

Without impact With impact Total Unadjusted PR

Variables N (%) N (%) N (%) p* [95% CI]

Single (ref.) 32 (41.6) 45 (58.4) 77 (75.5) 1.37

Marital status 0.024
Stable relationship 5 (20.0) 20 (80.0) 25 (24.5) [1.05–1.81]

> 8 years (ref.) 5 (62.5) 3 (37.5) 8 (7.8) 1.78

Schooling 0.222
≤ 8 years 32 (34.0) 62 (66.0) 94 (92.2) [0.71–4.34]

Employed prior Yes (ref.) 22 (40.7) 32 (59.3) 54 (52.9) 1.16

0.320
to internment No 15 (31.2) 33 (68.8) 48 (47.1) [0.86–1.56]

Lived with at Yes (ref.) 26 (35.1) 48 (64.9) 74 (72.5)

0.94
least one 0.705
No 11 (39.3) 17 (60.7) 28 (27.5) [0.66–1.33]
parent

First intern- Yes (ref.) 26 (40) 39 (60.0) 65 (63.7) 1.17

0.283
ment No 11 (29.7) 26 (70.3) 37 (36.3) [0.87–1.56]

Been to dentist Yes (ref.) 33 (37.9) 54 (62.1) 87 (85.3)

1.19
prior to 0.346
No 4 (26.7) 11 (73.3) 15 (14.7) [0.84–1.69]
internment

Type of dental Public service (ref.) 25 (37.9) 41 (62.1) 66 (75.9) 0.99

0.986
office Private office 8 (38.1) 13 (61.9) 21 (24.1) [0.68–1.47]

Discomfort in No (ref.) 30 (46.2) 35 (53.8) 65 (63.7)

1.51
teeth and 0.003
Yes 7 (18.9) 30 (81.1) 37 (36.3) [1.14–1.98]
mouth

Non-User (ref.) 20 (55.6) 16 (44.4) 36 (35.6) 1.66

Tobacco 0.011
User 17 (26.2) 48 (73.8) 65 (64.4) [1.12–2.46]

* p-value referring to Poisson univariate regression analysis; results significant at 5%(p < 0.05) level. OHRQoL = oral health-related quality of
life; PR = prevalence ratio; CI = confidence interval. Ref: reference.

(mean = 0.5; SD = 0.9). The mean number of teeth In the multiple regression model, untreated car-
among the participants was 28.5 (SD = 1.5), 22.4 ies, discomfort in teeth or mouth, use of tobacco
(SD = 4.4) of which were sound teeth. High preva- and marital status were significantly associated
lence rates were found for periodontal problems with OHRQoL (p < 0.05). The prevalence of an oral
(82.3%) (95% CI: 75–90) and malocclusion (60.8%) health-related impact on quality of life was higher
(95% CI: 51–70). Thirty-three participants (32.4%) among individuals with untreated caries (PR = 1.74;
(95% CI: 23–42) exhibited some type of dental 95% CI: 1.10–2.77), those who reported discom-
trauma – from enamel fracture to avulsion. Fluoro- fort in the teeth or mouth (PR = 1.33; 95% CI:
sis was detected in 15 individuals (15.6%) (95% CI: 1.03–1.73), those who reported using tobacco pri-
7–22), ranging from very mild to severe. Univariate or to internment (PR = 1.53; 95% CI: 1.04–2.24)
analysis was used to test associations between all and those who maintained a stable relationship
clinical indicators and OHRQoL. A statistically sig- (PR = 1.31; 95% CI: 1.01–1.70) in comparison to
nificant association was found between untreated individuals who did not exhibit these conditions.
caries and OHRQoL (PR = 1.81; 95% CI: 1.07– Moreover, each month of internment represented
3.08). Oral hygiene also had an impact on OHRQoL an increase in the prevalence of an oral health-re-
(PR = 1.47; 95% CI: 1.13–1.87). No statistically lated impact on quality of life (PR = 1.03; 95% CI:
significant associations were detected between 1.01–1.06) (Table 5).
the other clinical conditions and OHRQoL (Table 4).

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Table 4 Frequency distribution of clinical conditions and impact on OHRQoL among Brazilian male incarcerated ado-
lescents (N = 102); Piraquara, Brazil, 2010
Impact on OHRQoL Univariate analysis

Without impact With impact Total Unadjusted PR

p*
Variables N (%) N (%) N (%) [95% CI]

Untreated dental Absent (ref.) 14 (60.9) 9 (39.1) 23 (22.5) 1.81

0.028
caries Present 23 (29.1) 56 (70.9) 79 (77.5) [1.07–3.08]

Satisfactory (ref.) 32 (37.6) 53 (62.4) 85 (85.5) 1.47

Oral hygiene 0.003
Unsatisfactory 1 (9.1) 10 (90.9) 11 (11.5) [1.13–1.87]

Healthy (ref.) 7 (41.2) 10 (58.8) 17 (17.7) 1.14

Periodontal status 0.546
Unhealthy 26 (32.9) 53 (67.1) 79 (82.3) [0.75–1.75]

Absent (ref.) 17 (42.5) 23 (57.5) 40 (39.2) 1.18

Malocclusion 0.311
Present 20 (32.3) 42 (67.7) 62 (60.8) [0.86–1.62]

Absent (ref.) 26 (32.1) 55 (67.9) 81 (84.4) 0.79

Dental fluorosis 0.340
Present 7 (46.7) 8 (53.3) 15 (15.6) [0.48–1.29]

Absent (ref.) 23 (33.3) 46 (66.7) 69 (67.6) 0.86

Dental trauma 0.394
Present 14 (42.4) 19 (57.6) 33 (32.4) [0.62–1.21]

* p-value referring to Poisson univariate regression analysis; results significant at 5% (p < 0.05) level. OHRQOL = oral health-related quality of
life; PR = prevalence ratio; CI = confidence interval.

DISCUSSION Items related to social interaction had little im-

pact on OHRQoL in this study. Among the socio-
In the present study, the majority of participants demographic variables, only marital status was as-
reported that oral health problems exerted an influ- sociated with reports of an impact. Most of the
ence on OHRQoL. However, the average OHIP-14 participants were single and a statistically signifi-
score was low, suggesting little impact on OHRQoL. cant association was found between those in a sta-
Similar findings have been reported in studies con- ble relationship and OHRQoL, which remained sig-
ducted with Brazilian adolescents who were not in- nificant even after controlling for confounding
carcerated/institutionalised.5,10 variables. Although studies indicate that marital
‘Worried about problems with the mouth or status affects health-related quality of life31 and
teeth’ (item 5) was reported with high frequency OHRQoL,16 more research is needed to understand
and achieved the greatest number of ‘very often’ this relationship and its consequences. The fact
responses. Items related to psychological discom- that the adolescents received weekly visits from
fort and psychological disability had a considerable family members and girlfriends may mean that con-
impact on the OHIP score, accounting for 39% of cerns regarding the mouth and teeth, especially
the overall score. As reported for non-incarcerated those related to aesthetics, have major importance
adolescents in Brazil,5,10 psychological discomfort to individuals in love relationships.
was among the domains that most affected the Incarceration time was related to OHRQoL. It is
daily activities of the adolescents, the score of therefore suggested that adolescents with a longer
which was only surpassed by the physical pain sub- internment time tend to experience a diminishment
scale. On items related to psychological aspects, in self-esteem and worsening with regard to issues
the present findings are similar to those described related to self-perception. Thus, oral health condi-
for non-incarcerated Brazilian adolescents regard- tions that may affect bio-psychosocial aspects tend
ing the mean value10 and frequency of impact.5 to take on more importance to such individuals,
This may be a characteristic of adolescence itself thereby causing a greater impact on quality of life.
and therefore also present in those deprived of Although the majority of the adolescents had used
freedom. some type of drug prior to internment, only the use of

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 Oliveira et al

Table 5 Poisson multiple regression model for impact of oral health status on quality of life among Brazilian male in-
carcerated adolescents (N = 102); Piraquara, Brazil, 2010
Variables p-value Adjusted PR 95% CI

No (ref.)
Untreated dental caries 0.019 1.74 1.10–2.77
Yes

Discomfort in teeth or No (ref.)

0.031 1.33 1.03–1.73
mouth Yes

Non-User (ref.)
Tobacco 0.030 1.53 1.04–2.24
User

Single (ref.)
Marital status 0.048 1.31 1.01–1.70
Stable relationship

Time of incarceration (in months) 0.022 1.03 1.01-1.06

p-value refers to Poisson multivariate regression; PR= prevalence ratio; CI = confidence interval. Ref: reference.

tobacco prior to internment was significantly associ- In the present study, individuals with untreated
ated with OHRQoL, even after adjusting for the other caries had a 1.81-fold greater prevalence of impact
co-variables in the multiple regression model. An as- on OHRQoL than those without this condition and
sociation has been demonstrated between smoking the association remained significant even after
and poor oral health status, especially oral cancer12 controlling for confounding variables (adjusted
and periodontal disease,15 and that smoking may PR = 1.74). This finding may be explained by the
negatively affect dental health perceptions.22 In a co- fact that caries is a cumulative disease that can
hort of Spanish university graduates, smokers report- cause pain, functional limitations, aesthetic impair-
ed a greater impact on quality of life than nonsmok- ment and concern or disappointment with regard to
ers on the subscales of a generic health measure the mouth and teeth, especially untreated carious
(SF-36), such as physical function, social well-being, lesions, thereby affecting various aspects of quali-
emotional well-being and mental health.14 Moreover, ty of life.
smokers were found to have worse OHRQoL in all di- The most affected OHIP subscales were those
mensions in a national cohort in Thailand.33 that can be influenced by the consequences of un-
In this study, the adolescents reported that ‘pain treated caries. Among non-incarcerated adoles-
in mouth or teeth’ (OHIP-14, item 3) had the great- cents in Brazil, an association between caries and
est effect on OHRQoL. Although no adolescents OHRQoL has been demonstrated in previous stud-
reported feeling acute pain at the time of the inter- ies.3,5 However, the literature is inconclusive with
view, 36.3% reported some degree of discomfort in regard to this association. The age group analysed,
the mouth or teeth at the time of the interview and the prevalence of caries and the method of analys-
38.2% reported impact on daily activities due to ing this variable may account for the divergence in
pain in the mouth or teeth in the previous 30 days the findings. In the present study, caries was di-
(OHIP-14, item 3). Moreover, physical pain has also chotomised based on the ‘decayed’ component of
been found to be an important OHIP-14 item among the DMFT index. Previous studies involving Brazilian
adolescents who are not incarcerated.3,5 schoolchildren have also found that untreated car-
A statistically significant association was found ies exerted an influence on OHRQoL.19,26 While
between the report of discomfort in the teeth or Paula et al25 found no such association, the authors
mouth and OHRQoL in both the univariate and mul- report that the low prevalence rate of caries in their
tivariate analyses. This association was expected; it sample may have contributed to the absence of sta-
confirms the negative repercussions of factors that tistical significance in the multivariate analysis be-
affect the mouth and teeth in the daily lives of ado- tween this clinical condition and OHRQoL.
lescents and demonstrates the consistency of the Individuals with unsatisfactory oral hygiene had
method used to assess the impact of oral health on a 1.47-fold greater prevalence of impact than those
the quality of life of adolescents (OHIP-14). with satisfactory oral hygiene. A greater frequency

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Oliveira et al

of oral hygiene measures performed is reported to juvenile delinquency, and perhaps the great fre-
be associated with a lower prevalence of impact on quency of dental trauma reduces their impact on
the quality of life of Australian young adults8 and social relationships. Unlike findings reported in
Tanzanian adolescents.20 case-control studies involving 12- to 14-year-old
Most individuals did not exhibit severe periodon- Brazilian9 and Canadian11 adolescents, no signifi-
tal problems and no impact from these conditions cant association was found between dental trauma
on OHRQoL was reported. This result is similar to and quality of life. An analysis of the OHIP-14 items
findings described in a previous Brazilian study reveals that issues related to aesthetics and social
with adolescents5 that also used the CPI, which relations are not overly important to these incarcer-
defines periodontal disease based on the pres- ated adolescents, likely due to their lack of freedom
ence of bleeding upon probing. However, an asso- and consequently restricted social interactions.
ciation between periodontal disease and quality of This group of male adolescents lives under spe-
life among Chilean adolescents was found when cial conditions with strict rules, isolated from a
more serious aspects were analysed, such as at- large part of social life. Thus, caution should be
tachment loss and necrotising ulcerative gingival exercised when making comparisons and inferenc-
lesions.18 es, as generalisations are not possible.
Despite the large number of adolescents with One of the limitations of the present study was
malocclusion, these conditions were not signifi- the possibility that the adolescents may have exag-
cantly associated with an impact on OHRQoL. Bra- gerated their reports of a negative impact on
zilian studies demonstrated an association be- OHRQoL in an attempt to obtain priority with regard
tween quality of life (as assessed with the Oral to dental treatment. Moreover, the sample was
Impacts on Daily Performances Index) and maloc- composed only of male adolescents, whereas the
clusion among adolescents, as aesthetic aspects discussion addressed studies involving both males
have the greatest impact on the quality of life.4,30 and females.
This is likely explained by the high prevalence of
malocclusion relevant to aesthetic issues, which
influences appearance, self-esteem and interper- CONCLUSION
sonal relationships. However, adolescents deprived
of freedom most often have restricted social inter- Understanding the oral health status of incarcerat-
actions and such issues may lose their importance ed adolescents from a multidimensional perspec-
in this context. In Brazilian adolescents, when the tive will allow healthcare professionals to develop
OHRQoL was assessed by the OHIP-14, no associa- better oral health programmes for this particular
tion was found with DAI,10 similar to this study. This group. Most individuals reported an impact on qual-
could be explained by the fact that OHIP-14 was not ity of life stemming from oral health problems.
developed specifically to measure the impact of or- Sociodemographic aspects were found to exert a
thodontic problems on OHRQoL and some of the substantial impact on OHRQoL of the adolescents.
items may not be relevant to patients with maloc- Some conditions that are important from the clinic-
clusion.10 Furthermore, the DAI allows categorising al standpoint did not present a great impact on
the presence or absence of malocclusion from clin- ORHQoL, such as malocclusion and dental trauma.
ical measurements, but it fails to analyse self-per- However, untreated caries was the most important
ception of aesthetics. clinical aspect influencing the OHRQoL in this
As in previous cross-sectional studies carried group. Therefore, for these adolescents, efforts
out in Brazil,5,21 no association was found between must be made to prioritise caries treatment and to
dental fluorosis and quality of life in adolescents, prevent tooth decay. There is urgent need for fur-
which may be explained by the low prevalence and ther studies for comparison and discussion pur-
low degree of severity of the condition, as the ma- poses.
jority of cases were questionable or very mild.
Brazilian adolescents who experienced adverse
psychosocial environments throughout life had ACKNOWLEDGEMENTS
more traumatic dental injuries.23 A great number of
individuals with fractured teeth was observed, as This study was supported by the Fundação Araucária, support for
scientific and technological development do Paraná and by the Bra-
expected since the population studied was made zilian Coordination for Higher Education (CAPES), Ministry of Educa-
up of young males with a history of violence and tion, Brazil.

424 Oral Health & Preventive Dentistry

 Oliveira et al

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