Anelise Daher

Early Childhood Caries and Body Mass Index in Young Children from Low Income Families

The relationship between early childhood caries (ECC) and obesity is controversial. This cross-sectional survey investigated this association in children from low-income families in Goiania, Goias, Brazil and considered the role of several social determinants. A questionnaire examining the characteristics of the children and their families was administered to the primary caregiver during home visits. In addition, children (approximately 6 years of age) had their height, weight, and tooth condition assessed. The primary ECC outcome was categorized as one of the following: caries experience (decayed, missing, filled tooth: “dmft” index > 0), active ECC (decayed teeth > 0), or active severe ECC (decayed teeth ≥ 6). Descriptive, bivariate and logistic regression analyses were conducted. The participants in the current study consisted of 269 caregiver-child dyads, 88.5% of whom were included in the Family Health Program. Caregivers were mostly mothers (67.7%), were 35.3 ± 10.0 years old on average and had 9.8 ± 3.1 years of formal education. The mean family income was 2.3 ± 1.5 times greater than the Brazilian minimum wage. On average, the children in the current study were 68.7 ± 3.8 months old. Of these, 51.7% were boys, 23.4% were overweight or obese, 45.0% had active ECC, and 17.1% had severe ECC. The average body mass index (BMI) of the children was 15.9 ± 2.2, and their dmft index was 2.5 ± 3.2. BMI was not associated with any of the three categories of dental caries (p > 0.05). In contrast, higher family incomes were significantly associated with the lack of caries experience in children (OR 1.22, 95%CI 1.01–1.50), but the mother’s level of education was not significantly associated with ECC.

Practices and opinions on nitrous oxide/oxygen sedation from dentists licensed to perform relative analgesia in Brazil.

BackgroundRelative analgesia (RA), defined as the use of inhalation sedation with nitrous oxide and oxygen, is one of the most common pharmacological behavior management techniques used to provide sedation and analgesia for dental patients. This study aimed to assess RA licensed Brazilian dentists’ practices and opinions about nitrous oxide/oxygen sedation in the dental setting.MethodsA cross sectional national survey was conducted with 281 dentists who were certified to perform RA, using an electronically mailed self-administered questionnaire containing closed questions about their practices and opinions regarding RA. Practice and opinion were individually analyzed by descriptive statistics. Non-parametric tests assessed the relationships between RA practice and independent variables. To test the interplay between practices and opinions, a k-means clusters analysis was used to divide the group for statistical comparisons.ResultsThe response rate was 45.2%. Women made up 64.6% of the respondents, the mean age was 39.1 years (SD = 9.8), and the mean time since graduation in dentistry was 16 years (SD = 9.7). Seventy-seven percent of respondents reported the use of RA in clinical practice, most of them ‘sometimes’ (53.5%), and focusing more on adult patients. Patients with certain physical or mental deficiencies were indications associated with RA practice. ‘Equipment acquisition’ (p < 0.001) and ‘living in Southeast and South regions’ (p < 0.02) were also associated with RA practice. The scores for dentists’ opinions ranged from 15 to 41 points (mean 29.2, SD = 5.6), based on nine items scored from 1 to 5. Two clusters representing more favorable (n = 65) and less favorable (n = 55) opinions were established. Dentists who were women (p = 0.04), practiced RA in dental settings (p < 0.01) or practiced it frequently (p < 0.001), had more favorable opinions about RA.ConclusionMost of the RA licensed Brazilian dentists interviewed currently use RA. Current practice of RA and frequency of use determined the degree of favorable opinion about this inhalation sedation among this group of respondents.

Screening preschool children with toothache: validation of the Brazilian version of the Dental Discomfort Questionnaire

BackgroundThe Dental Discomfort Questionnaire (DDQ) is an observational instrument intended to measure dental discomfort and/or pain in children under 5 years of age. This study aimed to validate a previously cross-culturally adapted version of DDQ in a Brazilian children sample.MethodsParticipants included 263 children (58.6% boys, mean age 43.5 months) that underwent a dental examination to assess dental caries, and their parent that filled out the cross-culturally adapted DDQ on their behalf. Exploratory factor analysis (principal component analysis form) and psychometric tests were done to assess instrument’s dimensionality and reliability.ResultsExploratory factor analysis revealed a multidimensional instrument with 3 domains: ‘eating and sleeping problems’ (Cronbach’s alpha 0.81), ‘earache problems’ (alpha 0.75), and ‘problems with brushing teeth’ (alpha 0.78). The assessment had excellent stability (weighted-kappa varying from 0.68 to 0.97). Based on the factor analysis, the model with all 7 items included only in the first domain (named DDQ-B) was further explored. The items and total median score of the DDQ-B were related to parent-reported toothache and the number of decayed teeth, demonstrating good construct and discriminant validities.ConclusionsDDQ-B was proven a reliable pain assessment tool to screen this group of Brazilian children for caries-related toothache, with good psychometric properties.Portuguese abstractProposiçãoO Dental Discomfort Questionnaire (DDQ) é um instrumento observacional usado para avaliar dor de dente/desconforto em crianças menores de 5 anos de idade. Este estudo objetivou validar uma versão brasileira do DDQ, previamente adaptada transculturalmente.Métodos263 crianças participaram do estudo (58.6% meninos, com idade média de 43,5 meses), as quais foram examinadas clinicamente para avaliar a ocorrência de cárie, e seus pais preencheram individualmente a versão brasileira do DDQ. Para avaliar a dimensionalidade e confiabilidade do instrumento, foram realizados análise fatorial exploratória (tipo: análise de componentes principais) e testes psicométricos.ResultadosA análise exploratória fatorial revelou um instrumento multidimensional com 3 domínios: ‘problemas durante a mastigação e sono’ (alfa de Cronbach 0,81), ‘problemas relacionados à dor de ouvido’ (alfa 0,75), e ‘problemas durante a escovação’ (alfa 0,78). O instrumento mostrou excelente estabilidade (kappa ponderado variando de 0,68 a 0,97). Baseado nos resultados da análise fatorial exploratória, o modelo com os 7 itens incluídos no primeiro domínio, denominado DDQ-B, foi adicionalmente explorado. A frequência dos itens e o escore total do DDQ-B associaram-se a dor de dente relatada pelos pais das crianças e ao número de dentes cariados, confirmando as validades de construto e discriminante.ConclusãoO DDQ-B mostrou-se confiável e com boas propriedades psicométricas para avaliar este grupo crianças brasileiras apresentando dor de dente por cárie.

Factors Associated with No Dental Treatment in Preschoolers with Toothache: A Cross-Sectional Study in Outpatient Public Emergency Services

Many parents rely on emergency services to deal with their children’s dental problems, mostly pain and infection associated with dental caries. This cross-sectional study analyzed the factors associated with not doing an oral procedure in preschoolers with toothache attending public dental emergency services. Data were obtained from the clinical files of preschoolers treated at all nine dental emergency centers in Goiania, Brazil, in 2011. Data were children’s age and sex, involved teeth, oral procedures, radiography request, medications prescribed and referrals. A total of 531 files of children under 6 years old with toothache out of 1,108 examined were selected. Children’s mean age was 4.1 (SD 1.0) years (range 1–5 years) and 51.6% were girls. No oral procedures were performed in 49.2% of cases; in the other 50.8%, most of the oral procedures reported were endodontic intervention and temporary restorations. Primary molars were involved in 48.4% of cases. With the exception of “sex”, the independent variables tested in the regression analysis significantly associated with non-performance of oral procedures: age (OR 0.7; 95% CI 0.5–0.8), radiography request (OR 3.8; 95% CI 1.7–8.2), medication prescribed (OR 7.5; 95% CI 4.9–11.5) and patient referred to another service (OR 5.7; 3.0–10.9). Many children with toothache received no oral procedure for pain relief.

Recognizing preschool children with primary teeth needing dental treatment because of caries-related toothache

OBJECTIVES The Dental Discomfort Questionnaire (DDQ), which is an observational instrument that assesses dental pain in preschool children, has not been extensively tested for its ability to identify dental treatment needs in this population. This study aimed to explore the accuracy of the Brazilian version of the DDQ (DDQ-B) to identify preschool children needing dental treatment. METHODS The participants were 326 children (57.7% boys), aged 15-72 months [mean 49.8, standard deviation (SD) 14.8], who were examined to assess their dental treatment needs at the same time that their parents filled out the DDQ-B. The DDQ-B median score (outcome variable) was compared to the median index of dental treatment needs or categories (nonparametric tests). The area under the receiver operating characteristic (ROC) curve (AUC) and diagnostic tests were performed to test the DDQ-B accuracy for identifying preschoolers with untreated teeth needing dental treatment. The data were analysed using SPSS 19.0, and the significance level was set at 5%. RESULTS Overall, 326 questionnaires were completed and considered for analyses. Additionally, 63.5% of children had untreated teeth needing dental care. The median DDQ-B score, 2.0 (first-third quartile 1.0-5.0), was positively associated with the median index for needing dental care, 3.0 (0.0-5.0) (ρ = 0.49, P < 0.001). Children with more invasive intervention needs, such as pulp therapy, 5.0 (2.0-7.0), and extraction, 6.0 (4.0-8.5), had the highest DDQ-B scores (P < 0.001). The DDQ-B could identify children with more invasive dental care needs [AUC 0.86, 95% confidence interval (CI) 0.80-0.91, P < 0.001]. A score of 5 or higher was a reliable cut-off point to confirm that children who were screened with caries-related toothache by the DDQ-B do, in fact, have untreated teeth needing dental treatment, especially for pulpal care and extraction. CONCLUSIONS The DDQ-B is an accurate observational tool for identifying preschool children with dental treatment needs; children who scored 5 or higher require dental care for more invasive procedures.

The cross-cultural process of adapting observational tools for pediatric pain assessment: the case of the Dental Discomfort Questionnaire

BackgroundA rigorous cross-cultural adaptation process of an existing instrument could be the best option for measuring health in different cultures, instead of developing a new tool, and prior to psychometric and validation testing. The Dental Discomfort Questionnaire (DDQ), a validated instrument for assessing toothache in young children, has not been cross-culturally adapted so far. This study aimed to explore the detailed phases of the cross-cultural adaptation process of a pain assessment tool, presenting the example of the DDQ Brazilian-Portuguese adapted version.MethodsThe study design was based on the universalist approach, which consists of a sequential analysis to assess the relevant phases of a cross-cultural process before testing the measures of the instrument: conceptual, item, semantic, and operational equivalences. Systematic information was gathered from the literature, expert discussions, translations, and pre-testing through cognitive interviews with Brazilian population.ResultsDetailed description of the three major phases for a cross-cultural adaptation process was given. Notes of the changes done in the structure of the presented instrument (DDQ) were specifically pointed out at each phase. Conceptual and item analyses showed that there are similarities in the DDQ construct between the original and Brazilian cultures that require minor modifications. Translations and back-translations allowed the development of the preliminary Brazilian-Portuguese version of the DDQ, which was tested and underwent other minor changes to improve its comprehensibility.ConclusionsDescribing the phases was important to show how changes are made in a cross-cultural adaptation process of an instrument. This also could help researchers in adapting similar pediatric pain assessment tools to different cultures. A Brazilian-Portuguese version of the DDQ was presented.

What is the level of evidence for the amnestic effects of sedatives in pediatric patients? A systematic review and meta-analyses.

Background Studies have suggested that benzodiazepines are amnestic drug par excellence, but when taken together, what level of evidence do they generate? Are other sedatives as amnestic as benzodiazepines? The aim of this study was to assess the level of scientific evidence for the amnestic effect of sedatives in pediatric patients who undergo health procedures. Methods The literature was searched to identify randomized controlled trials that evaluated anterograde and retrograde amnesia in 1-19-year-olds who received sedative drugs during health procedures. Electronic databases, including PubMed, Scopus and Cochrane Library besides clinical trial registries and grey literature were searched. Two independent reviewers performed data extraction and risk of bias assessment using the Cochrane Collaborations Tool. The meta-analyses were performed by calculating relative risk (RR) to 95% confidence intervals (CI). The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach. Results Fifty-four studies were included (4,168 participants). A higher occurrence of anterograde amnesia was observed when benzodiazepines, the most well-studied sedatives (n = 47), were used than when placebo was used (n = 12) (RR = 3.10; 95% CI: 2.30–4.19, P<0.001; I2 = 14%), with a moderate level of evidence. Higher doses of alpha2-adrenergic agonists (clonidine/dexmedetomidine) produced more anterograde amnesia than lower doses (n = 2) (RR = 1.83; 95% CI: 1.03–3.25; P = 0.038; I2 = 0%), with a low level of evidence; benzodiazepines’ amnestic effects were not dose-dependent (n = 3) (RR = 1.54; 95% CI: 0.96–2.49; P = 0.07; I2 = 12%) but the evidence was low. A qualitative analysis showed that retrograde amnesia did not occur in 8 out of 10 studies. Conclusions In children, moderate evidence support that benzodiazepines induce anterograde amnesia, whereas the evidence for other sedatives is weak and based on isolated and small studies. Further clinical trials focused on the amnesia associated with non-benzodiazepine sedatives are therefore needed. Trial registration PROSPERO CRD42015017559.

Is pain during pediatric dental sedation associated with children’s pre-operative characteristics? An exploratory study

Introduction Little is known about the factors associated with the pain of children in dental treatment under conscious sedation. Objective To investigate the association between preoperative characteristics and pain during pediatric dental treatment under sedation. Material and method This exploratory study was conducted with 27 children in restorative treatment under sedation. Information on age, sex and experience of the children with previous dental treatment was obtained through interviews with parents. Oral health status, determined from the presence of dental caries, was verified using the dmf-t index. Pain was assessed by analyzing videos of the dental treatments by two previously calibrated examiners, using the items “legs”, “activity” and “crying” of the observational scale “face, legs, activity, consolability and crying” (FLACC). Data were analyzed using bivariate tests. Result Most of the children (n=14, 51.8%) had no pain during dental treatment under sedation. Among the other children, lower or moderate pain scores (median 1.1; minimum 0 to 3.8) were observed. The FLACC scores did not vary according to sex (P=0.38), previous experience with dental treatment (P=0.32) and history with local anesthesia (P=0.96). The FLACC scores did not correlate significantly with age (Spearman rho= -0.08, P=0.67) and dmf-t (Spearman rho= -0.04, P=0.84). Conclusion In this group of children, pain during dental treatment under sedation was of low frequency and intensity and did not associate with age, sex, oral condition and previous dental experience.