**1. Introduction**

Oral health problems have been increasingly recognized as having significant negative impacts on the daily performance and quality of life of individuals and society. In addition to causing pain, oral diseases cause suffering, psychological embarrassment, social deprivation, difficulties in food and well-being, causing individual and collective damages [1, 2].

Caries is still the most common cause of tooth pain [3–5], and the association between untreated caries and toothache is more frequent in populations with lower access, in groups with lower socioeconomic status and in populations where caries is not widely treated, leading to impact on daily activities [6]. Despite the multifactorial nature of caries, more recent studies have shown a strong association between caries and sociodemographic factors [7–11]. It is also important to highlight the

role of socioeconomic, behavioral, and environmental factors as a determinant of self-care and oral complaints [12].

Since the World Health Organization (WHO) changed the concept of quality of life adding social domains on the definition instead of only the absence of disease, oral health has also been included as one of the contributing factors to general health. Thus, oral health is also perceived as an important aspect of quality of life, which includes a variety of aspects or consequences that oral health can have in the physical, social, and psychological domains. Among these aspects, the ability to eat, talk, smile and the occurrence of pain and discomfort are considered, respectively, the positive and negative aspects most related to the mouth and quality of life [13].

At present, great importance has been given to research involving the impact of oral diseases on the quality of life of individuals [1, 4, 14–17], and measuring instruments have been developed and tested that allow oral health status and dental treatment needs are investigated in order to assess the impact of oral health on the lives of children and their families [18].

Studies have shown that there is no linear association between clinical conditions and indicators of quality of life related to oral health. Therefore, these indicators that evaluate not only clinical aspects are associated with personal, social, and environmental factors [19–21]. Socioeconomic status, age, general health perception, and oral health conditions are some of the factors identified as significantly associated with the impact related to the quality of life [22–25].

Adolescents are constantly developing biologically, psychologically, and socially, with negligible behaviors with their health care. Therefore, it is considered a period of increased risk for caries and other oral diseases, due to the precarious plaque control and less care with brushing [26, 27], increased sugar intake, smoking [28], and alcoholic beverages [27, 29].

Considering that studies have shown that oral diseases affect the daily life of adolescents and the need to identify the factors associated with greater or lesser impact on the quality of life of adolescents, the present study aimed to evaluate the association of behavioral and psychosocial factors, such as mediators of the impact of oral health conditions related to adolescents' quality of life.

### **2. Methods**

A cross-sectional study was carried out with adolescents of both sexes aged 15–19 enrolled in public schools (municipal and state) from São Lourenço da Mata (PE), excluding those with systemic diseases, cognitive, auditory, or visual difficulties that compromised their participation in the research.

The sample was calculated using the two-ratio comparison formula, a ratio of 1:1 in the comparison groups, with a power of 80% to detect differences when an odds ratio of 1.5 is observed, with a random error of 2.5% and a confidence interval (CI) of 95%. As part of an oral health survey, the prevalence of 20% nonexposed toothache observed in a previous study was used as a parameter for the sample calculation [30]. The Epi Info 6 calculation program and the Fleiss bibliographic database were used [31]. In this way, a minimum sample of 1380 adolescents was obtained, with a 20% increase to compensate for possible losses and increases the effect of the study, resulting in a total sample of 1656 students.

Regarding the schools participating in the survey, seven were state schools and four municipal schools; they were selected because the students were aged between 15 and 19 in the group of interest and provided the list of students. The list of 15- to 19-year-old students enrolled in the 11 schools totaled 3604 students, from which

**151**

**3. Results**

of the impacts studied.

*Behavioral and Psychosocial Factors as Mediators of the Oral Health Impact on Adolescents…*

the draw of the students was carried out with a selected interval of 2.17, thus obtain-

Before starting to collect data, the five researchers were calibrated, obtaining an inter-examiner agreement that ranged from 0.86 to 0.99, showing an excellent degree of agreement, and the intra-examiner had a concordance greater than 92%. Data collection was performed from August to November 2012, through clinical and nonclinical data. Nonclinical data were obtained through a self-administered questionnaire, after a previous explanation of the objectives and method of the study, and all the doubts that emerged at the moment of the research were removed. The dependent variable on the study "impact on the quality of life-related to oral health" was evaluated through the Oral Impact on Daily Performances (OIDP) index [32]. The independent variables were as follows: dental caries evaluated through the DMFT index; periodontal disease evaluated through the PDI index (behavior variables: tooth brushing, flossing, sugar consumption, smoking, alcohol use, and dental care standard); and psychosocial variables (birth order, history of

Data were analyzed through the SPSS program version 17.0. The descriptive analysis was performed for the categorical variables, through simple frequencies, and for the continuous variables, and measures of central tendency and variability. For analytical statistical analysis of OIDP [32], the scores produced were dichotomized, regarding the median to create a binary variable: low and high impact. Inferential analysis was performed using association and correlation tests (Pearson's Chi-square and Multiple Logistic Regression). For regression analysis, only the variables that showed significance in the bivariate analysis were considered, except for sex. The variables entered the block model by the ENTER method, and the consistency of the models was evaluated by the Hosmer-Lemeshow test, and the unadjusted and adjusted estimates were presented with their respective 95% CI. The project was approved by the Research Ethics Committee of the University of

The present study obtained a response rate of 85.5%, resulting in a final sample of 1417 adolescents with a mean age of 16.03 years (SD = 1.16), being 56.2% (797) of the sex female. Among the adolescents surveyed, 66.1% (936) presented at least one

Regarding the psychosocial factors, 49.4% (697) of the adolescents had been disapproved, 53% (751) was part of the traditional family, 42% (595) reported

Regarding the behavioral factors, the majority performed regular brushing 95.1% (1348), only 38.7% (549) were using dental floss, and in 57.8% (805), high sugar consumption was observed. Alcoholic beverages had already been tried daily by 59.4% (842) of the adolescents, and of these, 40.8% (344) made regular use, representing 24.2% of the total. Regarding cigarette smoking, 20.5% (291) had already tried it, 30.6% (89) of whom were considered regular smokers, representing 6.3% of the total sample. Only 17% (248) presented a pattern of regular dental care. Regarding the oral conditions of the adolescents, a caries prevalence of 51.29% (711) was found, with an average DMFT score of 2.72 (SD = 3.10). Regarding the periodontal condition, the prevalence of gingival bleeding was 49.60% (703), the presence of calculus 48% (680) and shallow periodontal pockets 5.4% (77). Toothache in the last 6 months was reported in 73.6% (1042) of adolescents.

being the first child, and 11% (1559) were the fourth child or beyond.

*DOI: http://dx.doi.org/10.5772/intechopen.89567*

school failure, and family structure).

Pernambuco, under opinion 105/12 in June 2012.

ing the proposed sample of 1656 adolescents.

#### *Behavioral and Psychosocial Factors as Mediators of the Oral Health Impact on Adolescents… DOI: http://dx.doi.org/10.5772/intechopen.89567*

the draw of the students was carried out with a selected interval of 2.17, thus obtaining the proposed sample of 1656 adolescents.

Before starting to collect data, the five researchers were calibrated, obtaining an inter-examiner agreement that ranged from 0.86 to 0.99, showing an excellent degree of agreement, and the intra-examiner had a concordance greater than 92%.

Data collection was performed from August to November 2012, through clinical and nonclinical data. Nonclinical data were obtained through a self-administered questionnaire, after a previous explanation of the objectives and method of the study, and all the doubts that emerged at the moment of the research were removed.

The dependent variable on the study "impact on the quality of life-related to oral health" was evaluated through the Oral Impact on Daily Performances (OIDP) index [32]. The independent variables were as follows: dental caries evaluated through the DMFT index; periodontal disease evaluated through the PDI index (behavior variables: tooth brushing, flossing, sugar consumption, smoking, alcohol use, and dental care standard); and psychosocial variables (birth order, history of school failure, and family structure).

Data were analyzed through the SPSS program version 17.0. The descriptive analysis was performed for the categorical variables, through simple frequencies, and for the continuous variables, and measures of central tendency and variability. For analytical statistical analysis of OIDP [32], the scores produced were dichotomized, regarding the median to create a binary variable: low and high impact. Inferential analysis was performed using association and correlation tests (Pearson's Chi-square and Multiple Logistic Regression). For regression analysis, only the variables that showed significance in the bivariate analysis were considered, except for sex. The variables entered the block model by the ENTER method, and the consistency of the models was evaluated by the Hosmer-Lemeshow test, and the unadjusted and adjusted estimates were presented with their respective 95% CI. The project was approved by the Research Ethics Committee of the University of Pernambuco, under opinion 105/12 in June 2012.

## **3. Results**

*Quality of Life - Biopsychosocial Perspectives*

self-care and oral complaints [12].

lives of children and their families [18].

and alcoholic beverages [27, 29].

**2. Methods**

role of socioeconomic, behavioral, and environmental factors as a determinant of

Since the World Health Organization (WHO) changed the concept of quality of life adding social domains on the definition instead of only the absence of disease, oral health has also been included as one of the contributing factors to general health. Thus, oral health is also perceived as an important aspect of quality of life, which includes a variety of aspects or consequences that oral health can have in the physical, social, and psychological domains. Among these aspects, the ability to eat, talk, smile and the occurrence of pain and discomfort are considered, respectively, the positive and negative aspects most related to the mouth and quality of life [13]. At present, great importance has been given to research involving the impact of oral diseases on the quality of life of individuals [1, 4, 14–17], and measuring instruments have been developed and tested that allow oral health status and dental treatment needs are investigated in order to assess the impact of oral health on the

Studies have shown that there is no linear association between clinical conditions and indicators of quality of life related to oral health. Therefore, these indicators that evaluate not only clinical aspects are associated with personal, social, and environmental factors [19–21]. Socioeconomic status, age, general health perception, and oral health conditions are some of the factors identified as significantly

Adolescents are constantly developing biologically, psychologically, and socially, with negligible behaviors with their health care. Therefore, it is considered a period of increased risk for caries and other oral diseases, due to the precarious plaque control and less care with brushing [26, 27], increased sugar intake, smoking [28],

Considering that studies have shown that oral diseases affect the daily life of adolescents and the need to identify the factors associated with greater or lesser impact on the quality of life of adolescents, the present study aimed to evaluate the association of behavioral and psychosocial factors, such as mediators of the impact

A cross-sectional study was carried out with adolescents of both sexes aged 15–19 enrolled in public schools (municipal and state) from São Lourenço da Mata (PE), excluding those with systemic diseases, cognitive, auditory, or visual difficul-

The sample was calculated using the two-ratio comparison formula, a ratio of 1:1 in the comparison groups, with a power of 80% to detect differences when an odds ratio of 1.5 is observed, with a random error of 2.5% and a confidence interval (CI) of 95%. As part of an oral health survey, the prevalence of 20% nonexposed toothache observed in a previous study was used as a parameter for the sample calculation [30]. The Epi Info 6 calculation program and the Fleiss bibliographic database were used [31]. In this way, a minimum sample of 1380 adolescents was obtained, with a 20% increase to compensate for possible losses and increases the

Regarding the schools participating in the survey, seven were state schools and four municipal schools; they were selected because the students were aged between 15 and 19 in the group of interest and provided the list of students. The list of 15- to 19-year-old students enrolled in the 11 schools totaled 3604 students, from which

associated with the impact related to the quality of life [22–25].

of oral health conditions related to adolescents' quality of life.

ties that compromised their participation in the research.

effect of the study, resulting in a total sample of 1656 students.

**150**

The present study obtained a response rate of 85.5%, resulting in a final sample of 1417 adolescents with a mean age of 16.03 years (SD = 1.16), being 56.2% (797) of the sex female. Among the adolescents surveyed, 66.1% (936) presented at least one of the impacts studied.

Regarding the psychosocial factors, 49.4% (697) of the adolescents had been disapproved, 53% (751) was part of the traditional family, 42% (595) reported being the first child, and 11% (1559) were the fourth child or beyond.

Regarding the behavioral factors, the majority performed regular brushing 95.1% (1348), only 38.7% (549) were using dental floss, and in 57.8% (805), high sugar consumption was observed. Alcoholic beverages had already been tried daily by 59.4% (842) of the adolescents, and of these, 40.8% (344) made regular use, representing 24.2% of the total. Regarding cigarette smoking, 20.5% (291) had already tried it, 30.6% (89) of whom were considered regular smokers, representing 6.3% of the total sample. Only 17% (248) presented a pattern of regular dental care.

Regarding the oral conditions of the adolescents, a caries prevalence of 51.29% (711) was found, with an average DMFT score of 2.72 (SD = 3.10). Regarding the periodontal condition, the prevalence of gingival bleeding was 49.60% (703), the presence of calculus 48% (680) and shallow periodontal pockets 5.4% (77). Toothache in the last 6 months was reported in 73.6% (1042) of adolescents.

#### **Figure 1.** *Impact on quality of life and the oral health status of adolescent students, São Lourenço da Mata/PE, 2014.*


#### **Table 1.**

*Impact on quality of life and behavioral variables in adolescent students, São Lourenço da Mata/PE, 2014.*

**153**

*Behavioral and Psychosocial Factors as Mediators of the Oral Health Impact on Adolescents…*

**Low High**

Second child 272 65.7 142 34.3 414 100.00 Third 120 62.2 73 37.8 193 100.00 Fourth or more 84 54.2 71 45.8 155 100.00

No 478 70.1 204 29.9 682 100.0

Other 61 67.0 30 33.0 91 100.0

**Psychosocial variables Impact on the quality of life Total X2 P**

First born child 432 71.6 171 28.4 603 100.00 21.877 \*

Yes 440 63.1 257 36.9 697 100.0 12.16 \*

**n (%) n (%) n (%)**

26 55.3 21 44.7 47 100.00

16 48.5 17 51.5 33 100.0

277 64.7 151 35.3 428 100.0

476 66.2 243 33.8 719 100.0 1080 0.782

≤0.001

0.002

There was an association between the impact on quality of life and dental caries variables (p ≤ 0.001), gingival bleeding (p ≤ 0.001) and pain (p ≤ 0.001) (**Figure 1**); tooth brushing (p = 0.009), dental care standard (p ≤ 0.001), and sugar consumption (p ≤ 0.001) (**Table 1**); birth order (p ≤ 0.001) and history of disap-

*Impact on quality of life and psychosocial variables in adolescent students, São Lourenço da Mata/PE, 2014.*

Variables associated with the impact on the quality of life related to oral health were taken to the multiple logistic regression model. After adjusting the variables for dental brushing, dental care standard, sugar consumption, birth order, and failure history, the statistical significance of birth order (p < 0.01), irregular dental

The data of the present study help to clarify how the association of psychosocial and behavioral factors in determining the impact on the quality of life related to oral health happens. It was evidenced that, in this population of schoolchildren of the public network, a greater impact was reported by female adolescents, who are younger children of families that have more than one child, presenting an irregular

The reports of impacts on the quality of life related to oral health have been the subject of several investigations, being universally accepted that the impact of the oral and dental condition on the daily life of the people [1, 3, 15–17, 33]. The present study ratifies these results and brings us to the reflection on the factors involved in this process.

care standard (p < 0.01), and high sugar consumption (p < 0.01) (**Table 3**).

behavior of dental care and high consumption of sugar.

*DOI: http://dx.doi.org/10.5772/intechopen.89567*

Birth order

Do not know/do not

Do not know/do not

Uniparental (father or

Family structure Traditional (father and

recall

Failure

recall

mother)

mother)

**Table 2.**

proval (p = 0.002) (**Table 2**).

**4. Discussion**


*Behavioral and Psychosocial Factors as Mediators of the Oral Health Impact on Adolescents… DOI: http://dx.doi.org/10.5772/intechopen.89567*

#### **Table 2.**

*Quality of Life - Biopsychosocial Perspectives*

**Behavioral variables Impact on quality of life Total X2 P**

*Impact on quality of life and the oral health status of adolescent students, São Lourenço da Mata/PE, 2014.*

Regular 901 66.8 447 33.2 936 100.0 6.824 \*

Yes 566 65.2 302 34.8 868 100.0 0.718 0.397

Yes 185 63.6 106 36.4 291 100.0 0.906 0.341

Yes 541 64.3 301 35.7 842 100.0 2.421 0.120

Yes 794 65.4 420 34.6 1214 100.0 1.868 0.172

162 69.2 72 30.8 234 100.0

Regular consults 197 79.4 51 20.6 248 100.0 34.07 \*

Yes 431 70.4 181 29.6 612 100.0 11.4 \*

*Impact on quality of life and behavioral variables in adolescent students, São Lourenço da Mata/PE, 2014.*

**n (%) n (%) n (%)**

0.009

≤0.001

≤0.001

**Low High**

Irregular 35 51.5 33 48.5 68 100.0

No 370 67.4 179 32.6 549 100.0

No 736 66.5 370 33.5 1106 100.0

No 381 68.3 177 31.7 558 100.0

No 140 70.4 59 29.6 199 100.0

Irregular consults 511 60.0 341 40.0 852 100.0

No 368 61.2 233 38.8 601 100.0

**152**

**Table 1.**

Brushing

**Figure 1.**

Flossing

Smoking

Alcohol consumption

Has been to the dentist

Consultation pattern

Do not go to dental

Sugar consumption

*\*Statistically significant.*

consults

*Impact on quality of life and psychosocial variables in adolescent students, São Lourenço da Mata/PE, 2014.*

There was an association between the impact on quality of life and dental caries variables (p ≤ 0.001), gingival bleeding (p ≤ 0.001) and pain (p ≤ 0.001) (**Figure 1**); tooth brushing (p = 0.009), dental care standard (p ≤ 0.001), and sugar consumption (p ≤ 0.001) (**Table 1**); birth order (p ≤ 0.001) and history of disapproval (p = 0.002) (**Table 2**).

Variables associated with the impact on the quality of life related to oral health were taken to the multiple logistic regression model. After adjusting the variables for dental brushing, dental care standard, sugar consumption, birth order, and failure history, the statistical significance of birth order (p < 0.01), irregular dental care standard (p < 0.01), and high sugar consumption (p < 0.01) (**Table 3**).

### **4. Discussion**

The data of the present study help to clarify how the association of psychosocial and behavioral factors in determining the impact on the quality of life related to oral health happens. It was evidenced that, in this population of schoolchildren of the public network, a greater impact was reported by female adolescents, who are younger children of families that have more than one child, presenting an irregular behavior of dental care and high consumption of sugar.

The reports of impacts on the quality of life related to oral health have been the subject of several investigations, being universally accepted that the impact of the oral and dental condition on the daily life of the people [1, 3, 15–17, 33]. The present study ratifies these results and brings us to the reflection on the factors involved in this process.


#### *Quality of Life - Biopsychosocial Perspectives*
