Paulo Nadanovsky

A systematic review and meta‐analysis of the effects of fluoride toothpastes on the prevention of dental caries in the primary dentition of preschool children

OBJECTIVES To assess the effects of fluoride (F) toothpastes on the prevention of dental caries in the primary dentition of preschool children. STUDY DESIGN Systematic review and meta-analysis. METHODS A search for randomized or quasi-randomized clinical trials was carried out, without idiom restraints, in six electronic databases, registers of ongoing trials, meeting abstracts, dentistry journals and reference lists of potentially eligible studies. The search yielded 1932 records and 159 full-text articles were independently read by two examiners. Data regarding characteristics of participants, interventions, outcomes, length of follow-up and potential of bias were independently extracted by two examiners on the basis of predetermined criteria. Any disagreement was solved by consensus after consulting a third examiner. Pooled prevented fractions (PF) and relative risks (RR) were estimated separately for studies testing low F toothpastes (<600 ppm) and those testing standard F toothpastes (1000–1500 ppm). RESULTS Eight clinical trials fulfilled the inclusion criteria and most of them compared F toothpastes associated with oral health education against no intervention. When standard F toothpastes were compared to placebo or no intervention, significant caries reduction at surface (PF = 31%; 95% CI 18–43; 2644 participants in five studies), tooth (PF = 16%; 95% CI 8–25; 2555 participants in one study) and individual (RR = 0.86; 95% CI 0.81–0.93; 2806 participants in two studies) level were observed. Low F toothpastes were effective only at surface level (PF = 40%; 95% CI 5–75; 561 participants in two studies). CONCLUSION Standard F toothpastes are effective in reducing dental caries in the primary teeth of preschool children and thus their use should be recommended to this age group.

The individual and contextual pathways between oral health and income inequality in Brazilian adolescents and adults

We evaluate the association between income inequality (Gini index) and oral health and in particular the role of alternative models in explaining this association. We also studied whether or not income at the individual level modifies the Gini effect. We used data from an oral health survey in Brazil in 2002-2003. Our analysis included 23,568 15-19 and 22,839 35-44 year-olds nested in 330 municipalities. Different models were fitted using multilevel analysis. The outcomes analysed were the number of untreated dental caries (count), having at least one missing tooth (dichotomous) and being edentulous (dichotomous). To assess interaction as a departure from additivity we used the Synergy Index. For this, we dichotomized the Gini coefficient (high vs low inequality) by the median value across municipalities and the individual income in the point beyond which it showed roughly no association with oral health. Adjusted rate ratio of mean untreated dental caries, respectively for the 15-19 and 35-44 age groups, was 1.12 and 1.16 for each 10 points increase in Gini scale. Adjusted odds ratio of a 15-19 year-old having at least one missing tooth or a 35-44 year-old being edentulous was, respectively, 1.19 and 1.01. High income inequality had no statistically significant synergistic effect with being poor or living in a poor municipality. Higher levels of income inequality at the municipal level were associated with worse oral health and there was an unexplained residual effect after controlling for potential confoundings and mediators. Municipal level income inequality had a similar, detrimental effect, among individuals with lower or higher income.

How much of the income inequality effect can be explained by public policy? Evidence from oral health in Brazil.

OBJECTIVES To evaluate the association between income inequality, a public policy scale and to oral health. METHODS Analysis, using the Brazilian oral health survey in 2002-2003, included 23,573 15-19-year-old subjects clustered in 330 municipalities. Missing and decayed teeth and malocclusion assessments were the outcomes. Gini coefficient and a novel Scale of Municipal Public Policies were the main exposure variables. Individual level covariates were used as controls in multilevel regressions. RESULTS An increase from the lowest to the highest Gini value in Brazil was associated with an increase in the number of missing (rate ratio, RR=2.11 confidence interval 95% 1.18-3.77) and decayed teeth (RR=2.92 CI 95% 1.83-4.65). After adjustment for public policies and water fluoridation, the Gini effect was non-significant and public policies explained most of the variation in missing and decayed teeth. The public policy scale remained significant after adjustment with a rate ratio of 0.64 for missing and 0.72 for decayed teeth. Neither Gini nor public policies were significantly related to malocclusion. The public policy effect on missing and decayed teeth was stronger among those with higher education and income. CONCLUSIONS Income inequality effect was explained mainly by public policies, which had an independent effect that was greater among the better-off.

Associação entre procedimentos preventivos no serviço público de odontologia e a prevalência de cárie dentária

OBJETIVO: Avaliar a associacao entre as atividades odontologicas preventivas do servico publico de odontologia e a saude bucal de jovens. METODOS: Foram utilizados dados de 4.033 jovens de 15 a 19 anos, de 85 municipios do estado do Rio Grande do Sul, obtidos no inquerito epidemiologico Saude Bucal Brasil, realizado no periodo de 2002-2003. As variaveis estudadas foram: idade, sexo renda, escolaridade, tempo desde a ultima visita ao dentista, motivo da visita, e presenca de fluor na agua de abastecimento. Dados sobre as atividades odontologicas foram extraidos da base de dados do Sistema de Informacoes Ambulatoriais do Sistema Unico de Saude. Para analise estatistica foi utilizada a regressao logistica multinivel. RESULTADOS: Os individuos dos 21 municipios com menores taxas de procedimentos (por 100 habitantes) de procedimentos individuais preventivos (limpeza + fluor + selante) tiveram 2,27 (IC 95%: 1,45;3,56) vezes mais chance de ter uma carie nao restaurada do que residentes dos 21 municipios com maiores taxas. Essa chance permaneceu mesmo depois de ajustada por fatores individuais e contextuais, mas decresceu para 1,76 (IC 95%: 1,13;2,72). A proporcao da variabilidade atribuivel aos municipios foi de 14,1% para o modelo vazio e 10,5% para o modelo cheio. CONCLUSOES: O servico publico de odontologia no Rio Grande do Sul pode ter contribuido para a reducao no numero de caries nao restauradas em jovens. Porem, nao foi possivel detectar influencia desse servico na experiencia total da carie .

The relationship between levels of income inequality and dental caries and periodontal diseases

The objective of this study was to evaluate the association between income inequality at a lagged time of 2 and 11 years with two short latency outcomes (untreated dental caries and gingivitis) and two long latency outcomes (edentulism and periodontal attachment loss > 8mm). We used data from the Brazilian oral health survey in 2002-2003. Our analysis included 13,405 subjects aged 35-44 years. Different lagged Gini at municipal level were fitted using logistic and negative binomial multilevel analyses. Covariates included municipal per capita income, equivalized income, age, sex, time since last dental visit and place of residence (rural versus urban). Crude estimates showed that only untreated dental caries was associated with current and lagged Gini, but in adjusted models only current Gini remained significant with a ratio of 1.19 (95%CI: 1.09-1.30) for every ten-point increase in the Gini coefficient. We conclude that lagged Gini showed no association with oral health; and current income Gini was associated with current dental caries but not with periodontal disease.

Inconsistencies in recommendations on oral hygiene practices for children by professional dental and paediatric organisations in ten countries.

BACKGROUND Some of the basic dental health practices that are recommended to the public by professionals are not evidence based. Incorrect oral health messages may adversely affect childrens oral health behaviours. AIM To identify and list the recommendations concerning childrens oral hygiene practices provided by dental and paediatric organisations, and to assess how these recommendations relate to the scientific evidence currently available. DESIGN Cross-sectional. The authors contacted professional organisations in ten countries requesting items (brochures, leaflets or folders) containing messages on childrens oral hygiene practices. They then listed these recommendations and assessed how they related to scientific evidence obtained from systematic reviews available at PubMed and the Cochrane Library. RESULTS Fifty-two of 59 (88%) organisations responded to our request and 24 dental health education materials were submitted to the authors. They mentioned recommendations on oral hygiene practices for children, such as toothbrushing frequency, supervision and technique; when to start and how long toothbrushing should last; toothbrush design and replacement; flossing; gums/teeth wiping; tongue cleaning; type and amount of toothpaste and advice on toothpaste ingestion. The search at PubMed and the Cochrane Library resulted in 11 systematic reviews addressing these topics. CONCLUSIONS Several oral hygiene messages delivered by professional organisations showed inconsistencies and lacked scientific support.

Preferências por alimentos doces e cárie dentária em pré-escolares

OBJECTIVE To assess the preference for sweetness among preschool children and differences between less and more deprived groups. In addition, to assess whether sweet taste preference was associated with presence of caries. METHODS The sample was composed by 572 preschool children aged between 4 and 6, distributed in three day nurseries of varied socioeconomic background. Cross-sectional study developed in two steps. Preference for sweetness was assessed using a modified version of the Sweet Preference Inventory. The solutions varied in sugar concentration from 0 to 1,17 molar (0 to 400 g / litre). The presence of caries was assessed using the defs index. The socioeconomic status of the sample was classified according to the origin of domicile. RESULTS The variation in preference for sweetness in our sample was too small. Most children preferred the sweetest juice. This reduced the ability of this variable to explain variation in caries prevalence. Despite this limitation, our results showed that socioeconomic level influenced preference for sweetness, which in turn was associated with caries prevalence. CONCLUSION The socioeconomic status influence the sweetness preference and this, in turn, is associated with the dental caries prevalence.OBJETIVO: Avaliar as preferencias pelo sabor doce e sua associacao com as condicoes socioeconomicas e a prevalencia de carie dentaria em pre-escolares. METODOS: A amostra foi composta por 572 criancas de 4 a 6 anos, matriculadas em pre-escolas, dividida em estratos socioeconomicos segundo a procedencia (um bairro central, um periferico e Programa de Desfavelamento). Estudo transversal, foi desenvolvido em duas etapas. A preferencia pelo sabor doce foi avaliada atraves do Sweet Preference Inventory modificado. A concentracao das solucoes variou de 0 a 400 g/litro (0 a 1,17 molar). Foi utilizado o indice ceos para verificar a prevalencia de carie. RESULTADOS: Foram encontradas diferencas estatisticamente significantes entre as criancas do Programa de Desfavelamento e dos demais grupos na preferencia pelo sabor doce e no consumo de acucar, bem como associacao entre a procedencia e o percentual de criancas livres de carie, sendo o grupo do Desfavelamento o menos favorecido (p<0,05). CONCLUSAO: Os achados sustentam a hipotese de que o nivel socioeconomico influencia a preferencia por acucar e esta, por sua vez, esta associada a prevalencia de carie dentaria na denticao decidua.

Prevalência e fatores associados à ocorrência da dor de dente que impediu a realização de tarefas habituais em uma população de funcionários públicos no Rio de Janeiro, Brasil

The aims of this study were to estimate the prevalence of dental pain preventing the performance of routine tasks and to assess its association with socioeconomic factors, minor psychiatric disorders, number of missing teeth, and dental consultation patterns. A cross-sectional study was conducted using a self-completed questionnaire answered by 4,030 administrative employees at a university in Rio de Janeiro, Brazil (the Pró-Saúde Study). Data were analyzed using multiple logistic regression. Prevalence of toothache preventing the performance of routine tasks in the two weeks prior to the interview was 2.9% (95%CI: 2.5-3.6). Men (OR = 1.6; 95%CI: 1.1-2.4), individuals with minor psychiatric disorders (OR = 1.7; 95%CI: 1.2-2.6), individuals with extensive tooth loss (OR = 3.4; 95%CI: 1.5-7.8), and those failing to appear for regular dental checkups (OR = 2.5; 95%CI: 1.8-17.3) showed increased odds of experiencing dental pain. Dental pain was an important problem in this population. Unfavorable living conditions and lack of regular dental checkups increased the odds of dental pain.

Trends in socioeconomic disparities in the utilization of dental care in Brazil and Sweden

Aims: To describe trends in socioeconomic disparities in utilization of dental care. Methods: We obtained cross-sectional data from Sweden in the period 1968—2000 and from Brazil in 1986 and 2002 for 16 state capitals. The outcome was the percentage of people who reported that they had visited the dentist in the last 12 months, calculated for a higher and a lower income group and stratified by sex, age (two groups: young and adults) and dental status. Adjusted prevalence differences and prevalence ratios were produced using Poisson regression. Results: In Brazil, there was a decline in use of dental care among the 15—19 year olds in the period 1986—2002, but not among the 35—44 year olds. In Sweden, there was a decline among the young and adults between 1991 and 2000. Overall, socioeconomic disparities in use of dental services between the higher and the lower economic groups showed a decline in both countries. The reduction in disparities among young Brazilians was 1.1 percentage points per year (p < 0.01), but among the other age groups the decline was not significant (p>0.01). In the last surveys, the gap remained in both countries and age groups (p < 0.01). Conclusions: The recent decline in utilization of dental care and in the socioeconomic gap may mirror improvements in oral health. However, there are still relevant and persistent disparities in utilization of dental care in both countries, with a higher proportion of people of higher socioeconomic status visiting the dentist.

The relative contribution of income inequality and imprisonment to the variation in homicide rates among Developed (OECD), South and Central American countries

Homicide rates vary widely across and within different continents. In order to address the problem of violence in the world, it seems important to clarify the sources of this variability. Despite the fact that income inequality and imprisonment seem to be two of the most important determinants of the variation in homicide rates over space and time, the concomitant effect of income inequality and imprisonment on homicide has not been examined. The objective of this cross-sectional ecological study was to investigate the association of income inequality and imprisonment with homicide rates among Developed (OECD), South and Central American countries. A novel index was developed to indicate imprisonment: the Impunity Index (the total number of homicides in the preceding decade divided by the number of persons in prison at a single slice in time). Negative binomial models were used to estimate rate ratios of homicides for young males and for the total population in relation to Gini Index and Impunity Index, controlling for infant mortality (as a proxy for poverty levels), Gross Domestic Product per-capita, education, percentage of young males in the population and urbanization. Both low income inequality and low impunity (high imprisonment of criminals) were related to low homicide rates. In addition, we found that countries with lower income inequality, lower infant mortality (less poverty), higher average income (GDP per-capita) and higher levels of education had low impunity. Our results are compatible with the hypothesis that both low income inequality and imprisonment of criminals, independent of each other and of other social-structural circumstances, may greatly contribute to the reduction in homicide rates in South and Central American countries, and to the maintenance of low levels of homicides in OECD countries. The Impunity Index reveals that countries that show greater commitment to education and to distribution of income also show greater commitment to punish serious criminal behavior.