Inequalities in self-rated oral health in adults

Luchi, Carla Antoni; Peres, Karen Glazer; Bastos, Joao Luiz; Peres, Marco Aurelio

doi:10.1590/S0034-8910.2013047004364

Abstract

OBJECTIVE

To investigate the link between self-rated oral health and socio-demographic inequalities.

METHODS

Cross-sectional study, carried out with 2,016 adults between 20 and 59 years of age in 2009, in Florianopolis, SC, Southern Brazil. We adopted a two-stage sampling design (census tracts and households). Data were collected through face-to-face interviews, conducted in the participants’ households. The outcome was self-rated oral health. The exploratory variables were demographic characteristics, indicators of socioeconomic position, dental service utilization and adverse self-reported oral health conditions. Analysis was performed using multivariable poisson regression, which allowed the estimation of prevalence ratios and 95% confidence intervals.

RESULTS

The prevalence of negative self-rated oral health was 33.2% (95%CI 29.8;36.6). In the adjusted analysis, being of an older age, self-classifying as light-skinned black, lower education, the most recent dental appointment being three years or more ago, attending public dental surgeries, having less than 10 natural teeth in at least one arch, self-reporting need for dental treatment, reporting dry mouth, and difficulty eating due to tooth problems were associated with negative self-rated oral health.

CONCLUSIONS

Self-rated oral health reflects social inequalities in health, and it is associated with low socioeconomic status, less frequent use of dental services and poorer self-reported oral health conditions.

Adult; Diagnostic Self Evaluation; Oral Health; Health Inequalities; Dental Health Surveys; Cross-Sectional Studies

INTRODUCTION

Oral health problems, such as tooth decay, periodontal disease and tooth loss are determined by demographic and socioeconomic factors and use of health care services. ²⁴24 . Silva DD, Rihs LB, Sousa MLR. Factors associated with maintenance of teeth in adults in the State of São Paulo, Brazil. Cad SaudePublica. 2009;25(11):2407-18. DOI:10.1590/S0102-311X2009001100011
https://doi.org/10.1590/S0102-311X200900... These health problems have a negative impact on the daily life of the individual, as they create functional difficulties, problems chewing and talking, and problems with sociability, such as being unhappy with appearance, difficulties being accepted socially and limiting access to the job market. ²⁵25 . Vargas AMD, Paixão HH. Perda dentária e seu significado na qualidade de vida de adultos usuários de serviço público de saúde bucal do Centro de Saúde Boa Vista, em Belo Horizonte. Cienc Saude Coletiva. 2005;10(4):1015-24. DOI:10.1590/S1413-81232005000400024
https://doi.org/10.1590/S1413-8123200500...

Oral health problems are measured using clinical indices. However, they tend not to measure the impact of oral health conditions on the individual’s daily life. A study with adults observed that aspects linked to oral health which were assessed using non-clinical parameters affected the daily life of 20.7% of participants, with 11.4% of respondents greatly affected. There have been significant advances in the development of measures that consider the impact of non-lethal health problems and subjective aspects associated with the concepts of health, well-being and satisfaction.

Using subjective measures to assess general and oral health is becoming increasingly important. Studies show that assessing oral health as one single item constitutes a summary measure of the individual’s oral health. ⁹9 . Kieffer JM, Hoogstraten J. Linking oral health, general health, and quality of life. Eur J Oral Sci. 2008;116(5):445-50. DOI:10.1111/j.1600-0722.2008.00564.x
https://doi.org/10.1111/j.1600-0722.2008... This use means the individual’s and society’s status of oral health can be diagnosed. ⁷7 . Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
https://doi.org/10.1111/j.1600-051X.2008... Self-rated oral health is linked to the general state of health and to functional capacity and contributes independently to long term well-being and satisfaction. ¹²12 . Locker D, Mscn EW, Jokovic A. What Do Older Adults’ Global Self-ratings of Oral Health Measure? J Public Health Dent. 2005;65(3):146-52. DOI:10.1111/j.1752-7325.2005.tb02804.x
https://doi.org/10.1111/j.1752-7325.2005...

Individuals who report more oral health symptoms, impairment and disabilities have worse self-reported oral health, ⁹9 . Kieffer JM, Hoogstraten J. Linking oral health, general health, and quality of life. Eur J Oral Sci. 2008;116(5):445-50. DOI:10.1111/j.1600-0722.2008.00564.x
https://doi.org/10.1111/j.1600-0722.2008... whereas individuals who assess their oral health as negative have worse clinical conditions compared with those who rate their oral health positively. ¹²12 . Locker D, Mscn EW, Jokovic A. What Do Older Adults’ Global Self-ratings of Oral Health Measure? J Public Health Dent. 2005;65(3):146-52. DOI:10.1111/j.1752-7325.2005.tb02804.x
https://doi.org/10.1111/j.1752-7325.2005... The prevalence of negatively self-rated oral health was 40% higher in those who had periodontal disease in a study which assessed the link between periodontal disease and self-rated oral health. ⁷7 . Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
https://doi.org/10.1111/j.1600-051X.2008... Using self-rated oral health in population surveys, an easier measure than carrying out examinations, quickly identifies the state of the population’s oral health and associated factors, ²⁰20 . Pattussi MP, Peres KG, Boing AF, Peres MA, Costa JSD. Self-rated oral health and associated factors in Brazilian elders. Community Dent Oral Epidemiol. 2010;38(4):348-59. DOI:10.1111/j.1600-0528.2010.00542.x
https://doi.org/10.1111/j.1600-0528.2010... contributing to health care planning according to the population’s needs. ⁷7 . Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
https://doi.org/10.1111/j.1600-051X.2008...

Obtaining information from adults on their oral health and its impact on their lives could contribute to reducing the social and physical consequences of oral health problems, with the goal of preventing tooth loss and improving health and quality of life in this age group. This will be reflected in the population’s future health, considering the increase in life expectancy. ²³23 . Silva DD, Souza MLR, Wada RS. Saúde bucal em adultos e idosos na cidade de Rio Claro, São Paulo, Brasil. Cad Saude Publica. 2004;20(2):626-31. DOI:10.1590/S0102-311X2004000200033
https://doi.org/10.1590/S0102-311X200400...

In research conducted in December 2011 using the Medline-PubMed database, the search terms (“Oral health”[mesh] AND (“self-concept”[mesh] OR “self-assessment”[mesh]), were found in 391 studies carried out with a variety of populations and age groups. Only one Brazilian epidemiological population based study was found using self-rated oral health as the objective of the investigation in adults. ¹⁶16 . Matos DL, Lima-Costa MF. Auto-avaliação da saúde bucal entre adultos e idosos residentes na Região Sudeste: resultados do Projeto SB-Brasil, 2003. Cad Saude Publica. 2006;22(8):1699-707. DOI:10.1590/S0102-311X2006000800018
https://doi.org/10.1590/S0102-311X200600... This study aims to analyze the link between self-rated oral health in adults and socio-demographic inequalities.

METHODS

This study is part of the population based, base line cohort study Epi Floripa – Epidemiologic Study of the Health of the Adult Population of Florianópolis, SC, Southern Brazil, which took place between September 2009 and January 2010. Florianópolis, the state capital of Santa Catarina, has a population of 404,224 and a Human Development Index of 0.875, ^aaInstituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro; 2010.placing it fourth among Brazilian municipalities. The population studied was made up of adults aged between 20 and 59 at the time of the study, of both sexes, living in the community and resident in the urban area of the municipality.

The sample size was calculated using the formula to calculate prevalence for simple causal samples, adding the estimated relative value of design effect (due to it being cluster sampling) in two. As a variety of health outcomes were investigated, an outcome prevalence of 50%, error of four percentage points and 95% confidence level were used, giving a sample of 1,198 individuals. The final sample size was 2,016 individuals, with an added 10% to cover refusals and 20% to control for confounding factors in the multivariate analysis. This sample was deemed adequate to test the link between negative self-rated oral health and the factors in question in this study, with a power of 80% (error type II, β = 20%) and error type I equal to 5% in order to estimate the prevalence ratio of 1.3, considering the prevalence of negatively rated oral health among those not exposed to be equal to 24%.

Sampling was conducted in two stages. The first sample units were the 420 urban census tracts which make up the municipality. The census tracts were stratified in ascending order of the head of the household’s income, 60 tracts were systematically selected with a sampling share equal to seven, giving six tracts for each income decile. The second sample units were the residences. The number of residences varied from 61 to 754 between the tracts. The tracts were reorganized by merging and splitting these units to reduce the coefficient of variation. The initial coefficient of variation was 55% (n = 60 tracts) and the final one was 32% (n = 63 sectors). These 16,755 residences made up the 63 sectors of the sample. The residences were selected with a sample share equal to eight, giving a total of 2,094 selected. Thus, a sample size of 2,016 adults, or 32 adults per census tract, was obtained.

Data were collected by 35 interviewers. The face-to-face interviews took place individually in the residences. The interviewers were trained and a pre-test of the questionnaire was accomplished with 30 adults in the same age group as the population studied. A pilot study, in which each interviewer conducted at least three interviews, was carried out. Approximately 15% (n = 248) of the interviews were selected for quality control and the interviews were repeated using a questionnaire with a smaller number of questions. The reproducibility of the questionnaire was deemed to be satisfactory, with kappa and coefficient of correlation values between 0.6 and 0.9.

The dependent variable was self-rated oral health, obtained by asking “Concerning your teeth, are you: very happy, satisfied, neither satisfied nor dissatisfied, dissatisfied or very dissatisfied”. The variable was dichotomized into positive (very happy, satisfied) and negative (neither satisfied nor dissatisfied, dissatisfied or very dissatisfied) self-rated oral health. This form of categorization has been used in various national ¹⁴14 . Martins AMEBL, Barreto SM, Pordeus IA. Objective and subjective factors related to self-rated oral health among the elderly. Cad Saude Publica. 2009;25(2):421-35. DOI:10.1590/S0102-311X2009000200021
https://doi.org/10.1590/S0102-311X200900... ^, ¹⁶16 . Matos DL, Lima-Costa MF. Auto-avaliação da saúde bucal entre adultos e idosos residentes na Região Sudeste: resultados do Projeto SB-Brasil, 2003. Cad Saude Publica. 2006;22(8):1699-707. DOI:10.1590/S0102-311X2006000800018
https://doi.org/10.1590/S0102-311X200600... ^, ²⁰20 . Pattussi MP, Peres KG, Boing AF, Peres MA, Costa JSD. Self-rated oral health and associated factors in Brazilian elders. Community Dent Oral Epidemiol. 2010;38(4):348-59. DOI:10.1111/j.1600-0528.2010.00542.x
https://doi.org/10.1111/j.1600-0528.2010... and international studies. ⁸8 . Coulter I, Yamamoto JM, Marcus M, Freed J, Der-Martirosian C, Guzman-Becerra N, et al. Self-reported oral health of enrollees in capitated and fee-for-service dental benefit plans. J Am Dent Assoc. 2004;135(11):1606-15.

The independent variables were divided into blocks.

The first was made up of the demographic variables: sex, age in full years (in groups of ten years, from 20 to 59 years old), self-reported skin color (white, dark, black, yellow and indigenous).

The second block was made up of socioeconomic and education variables: per capita income in terciles (total income, in reais, of all household members in the month preceding the interview, divided by the number of household members; 3^rdtercile ≥ R$ 1,314.00, 2^ndtercile between R$ 561.00 and R$ 1,300.00, 1^sttercile ≤ R$ 560.00) and schooling in full years studied (≥ 12, nine to 11, five to eight and ≤ 4 years).

The third block contained variables concerning use of health care services: length of time since last dentist appointment (< 1 year, one to two years and ≥ 3 years) and type of appointment (private, public or other).

The last block constituted variables concerning self-reported oral health conditions: number of natural teeth (ten or more, fewer than ten or none in both dental arches).

The other variables concerning oral health conditions were: a combination of responses in categories of ≥ 10 teeth in both dental arches, < 10 in at least one arch and no teeth. Perceived need for dental treatment (yes; no), use of complete denture (yes; no), dry mouth (never, sometimes, often, always and unknown, categorized as never or occasionally – sometimes, often and always), difficulty eating due to teeth (never, rarely, sometimes, often, always and unknown, categorized as never or occasionally – sometimes, often, always) and toothache in the last six months (yes; no).

Sample weighting and design effect were considered in all of the analyses, using the svy command. Bivariate analysis, when appropriate, was carried out using the Rao Scott test. ²¹21 . Rao JNK, Scott AJ. The analysis of categorical data from complex sample surveys: chi-squared tests for goodness-of-fit and independence in two-way tables. J Am Stat Assoc . 1981;76:221-230. Variables which showed a statistical link (p < 0.20 with the outcome were then subject to Poisson multivariate regression analysis, and prevalence ratios (PR) and 95% confidence intervals were estimated. ³3 . Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. DOI:10.1186/1471-2288-3-21
https://doi.org/10.1186/1471-2288-3-21...

The variables were inputted for the multivariate analysis, according to a hypothetical theoretical model for determining the self-assessment of oral health. ²⁶26 . Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual framework in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26(1):224-7. DOI:10.1093/ije/26.1.224
https://doi.org/10.1093/ije/26.1.224... The model used ( Figure ) considers that the way in which an individual evaluates their oral health is influenced by demographic and socioeconomic factors, by use of dental health care services and their oral health conditions.

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Figure
Hypothetical model applied to the multivariate analysis. Florianópolis, SC, Southern Brazil, 2009 to 2010.

The demographic conditions (ski color, sex and age) occupy a distal position in determining oral health problems, influencing socioeconomic conditions (income and schooling). ²2 . Barbato PR, Nagano HCM, Zanchet FN, Boing AF, Peres MA. Perdas dentárias e fatores sociais, demográficos e de serviços associados em adultos brasileiros: uma análise dos dados do Estudo Epidemiológico Nacional (Projeto SB Brasil 2002-2003). Cad Saude Publica. 2007;23(8):1803-14. DOI:10.1590/S0102-311X2007000800007
https://doi.org/10.1590/S0102-311X200700... Males and females, indigenous populations, blacks and whites occupy distinct positions in social hierarchies and also bring with them different experiences of being born, living, falling ill and dying. ¹³13 . Lopes F. Beyond the numbers barrier: racial inequalities and health. Cad Saude Publica. 2005;21(5):1595-601. DOI:10.1590/S0102-311X2005000500034
https://doi.org/10.1590/S0102-311X200500... Skin color and sex can lead to discrimination and job and wage segregation, causing income disparities and affecting the population’s socioeconomic conditions. ¹³13 . Lopes F. Beyond the numbers barrier: racial inequalities and health. Cad Saude Publica. 2005;21(5):1595-601. DOI:10.1590/S0102-311X2005000500034
https://doi.org/10.1590/S0102-311X200500...

Income affects eating and living patterns, access to knowledge and health care, which have a direct effect on exposure to risk factors for various diseases, including oral health problems. ⁵5 . Boing AF, Peres MA, Kovaleski DF, Zange SE, Antunes JL. Estratificação sócio-econômica em estudos epidemiológicos de cárie dentária e doenças periodontais: características da produção na década de 90. Cad Saude Publica. 2005;21(3):673-8. DOI:10.1590/S0102-311X2005000300002
https://doi.org/10.1590/S0102-311X200500... Poor socioeconomic status and precarious living conditions make it difficult to prioritize oral health and lead to difficulties accessing orthodontic services, with the consequence of poor quality dental care and tooth loss. ¹⁷17 . Moreira TP, Nations MK, Alves MSCF. Dentes da desigualdade: marcas bucais da experiência vivida na pobreza pela comunidade do Dendê, Fortaleza, Ceará, Brasil. Cad Saude Publica. 2007;23(6):1383-92. DOI:10.1590/S0102-311X2007000600013
https://doi.org/10.1590/S0102-311X200700... The connection between the social structure and oral health could be due to material, behavioral and psychosocial bias. ⁴4 . Bastos JLD, Gigante DP, Peres KG, Nedel FB. Determinação social da odontalgia em estudos epidemiológicos: revisão teórica e proposta de um modelo conceitual. Cienc Saude Coletiva. 2007;12(6):1611-21. DOI:10.1590/S1413-81232007000600022
https://doi.org/10.1590/S1413-8123200700... Although, in health outcomes, causal relationships are not immediate, schooling plays an important role in understanding inequalities in the population’s levels of health, ⁵5 . Boing AF, Peres MA, Kovaleski DF, Zange SE, Antunes JL. Estratificação sócio-econômica em estudos epidemiológicos de cárie dentária e doenças periodontais: características da produção na década de 90. Cad Saude Publica. 2005;21(3):673-8. DOI:10.1590/S0102-311X2005000300002
https://doi.org/10.1590/S0102-311X200500... schooling is one of the main barriers affecting the use of dental services. ¹⁵15 . Matos DL, Lima-Costa MF, Guerra HL, Marcenes W. Projeto Bambuí: estudo de base populacional dos fatores associados com o uso regular de serviços odontológicos em adultos. Cad Saude Publica. 2001;17(3):661-8. DOI:10.1590/S0102-311X2001000300020
https://doi.org/10.1590/S0102-311X200100...

Using dental health care services influences the population’s state of health, as the risk of disease is reduced through care and prevention. Using these services reduces unfavorable health conditions, by controlling and treating oral health problems, and access to health care services is strongly influenced by social conditions, income and schooling. ¹⁷17 . Moreira TP, Nations MK, Alves MSCF. Dentes da desigualdade: marcas bucais da experiência vivida na pobreza pela comunidade do Dendê, Fortaleza, Ceará, Brasil. Cad Saude Publica. 2007;23(6):1383-92. DOI:10.1590/S0102-311X2007000600013
https://doi.org/10.1590/S0102-311X200700... Oral health problems such as tooth decay, periodontal disease and tooth loss are determined by demographic and socioeconomic factors and using dental health care services ²⁴24 . Silva DD, Rihs LB, Sousa MLR. Factors associated with maintenance of teeth in adults in the State of São Paulo, Brazil. Cad SaudePublica. 2009;25(11):2407-18. DOI:10.1590/S0102-311X2009001100011
https://doi.org/10.1590/S0102-311X200900... which, in turn, negatively affect self-rated oral health. ⁷7 . Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
https://doi.org/10.1111/j.1600-051X.2008... ^, ¹²12 . Locker D, Mscn EW, Jokovic A. What Do Older Adults’ Global Self-ratings of Oral Health Measure? J Public Health Dent. 2005;65(3):146-52. DOI:10.1111/j.1752-7325.2005.tb02804.x
https://doi.org/10.1111/j.1752-7325.2005...

The data were analyzed using the Stata 9.0 program (Stata Corp, College Station, TX, USA).

The project was submitted to and approved by the Human Research Ethics Committee of the Universidade Federal de Santa Catarina (Process nº 351/08, on 15^thDecember 2008). Participants signed an informed consent form.

RESULTS

Among the 1,720 interviewees (response rate of 85.3%), 33.2% rated their oral health negatively. This condition was significantly more prevalent in those with lower levels of income and schooling. Having fewer than ten teeth in at least one dental arch and perceived need for dental treatment were strongly associated with negatively self-rated oral health.

The interviewees were predominantly female (55.6%), with self-reported skin color white (83.9%), aged between 20 and 29 years old, in the upper income tercile ≥ R$ 1,314.00 and 12 or more years of schooling.

Most individuals had seen a dentist within the last year (76.3% privately); 82.0% of individuals had ten or more teeth in both dental arches and a little over half report needing dental treatment. A small proportion of the sample used dentures, had difficulty eating and had had toothache in the last six months ( Table 1 ).

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Table 1
Description of the sample according to the characteristics evaluated. Florianópolis, SC, Southern Brazil, 2009 to 2010.

Negatively self-rated oral health was significantly higher in those with lower incomes, lower schooling, who had not seen a dentist for three or more years, and used a public dental service.

Most interviewees perceived the need for dental treatment; and almost half of these reported toothache within the last six months. Those who reported having a dry mouth and difficulty eating showed a higher prevalence of negative self-rated oral health ( Table 2 ).

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Table 2
Prevalence of negative self-rated oral health, according to demographic, socioeconomic and behavioral variables and self-rated oral health in adults aged 20 to 59. Florianópolis, SC, Southern Brazil, 2009 to 2010.

Being female (PR = 1.2; 95%CI 1.0;1.3), being aged between 30 and 39 (PR = 1.3, 95%CI 1.1;1.6) and 50 and 59 (PR = 1.3, 95%CI 1.0;1.7), having self-reported dark skin (PR = 1.2, 95%CI 1.0;1.4),having up to four years schooling (PR = 1.6, 95%CI 1.2;2.0), between five and eight years of schooling (PR = 1.6, 95%CI 1.2;2.0) and from nine to 11 years of schooling (PR = 1.4, 95%CI 1.1;1.7) remained linked to negatively self-rated oral health in the adjusted analysis. Not having seen a dentist for three or more year (PR = 1.3, 95%CI 1.1;1.5), using a public dental service for the most recent dental appointment (PR = 1.1, 95%CI 1.0;1.2) and having fewer than ten teeth in at least one dental arch (PR = 1.3, 95%CI 1.1;1.6) remained associated with poor self-rated oral health. Reporting the need for dental treatment (PR = 4.4, 95%CI 3.3;6.0), having a dry mouth (PR = 1.2, 95%CI 1.1;1.5) and difficulty eating (PR = 1.3, 95%CI 1.2;1.5) remained associated with negative self-rated oral health after adjustment ( Table 3 ).

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Table 3
Association between negative self-rated oral health according to socioeconomic and demographic variables, use of service self-reported oral health conditions. Poisson raw and multivariate analysis. Florianópolis, SC, Southern Brazil, 2009 to 2010.

DISCUSSION

A third of those questioned reported their self-rated oral health to be negative. Those who were older, dark skinned and had fewer years of schooling, who had gone a longer time without visiting the dentist, with teeth, perceiving themselves as needing dental treatment, those who reported experiencing dry mouth and difficulty chewing were associated with negative self-rated oral health in the adjusted analysis.

The study had a higher response rate than other studies on the subject with similar methodology. ⁷7 . Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
https://doi.org/10.1111/j.1600-051X.2008... The response rate was similar for all income groups. Demographic characteristics; income and schooling were similar throughout the population of the municipality, suggesting that there was no selection bias. Possible confounding factors were able to be controlled using multivariate analysis, contributing to pinpointing the effects of different factors on self-rated oral health in the adult population.

Studies with a similar methodology indicate rates of prevalence of negative self-rated oral health of between 44.6% ¹⁹19 . Pattussi MP, Olinto MTA, Hardy R, Sheiham A. Clinical, social and psychosocial factors associated with self-rated oral health in Brazilian adolescents. Community Dent Oral Epidemiol. 2007;35(5):377-86. DOI:10.1111/j.1600-0528.2006.00339.x
https://doi.org/10.1111/j.1600-0528.2006... and 53.3%, ¹⁸18 . Nunes CIP, Abegg C. Factors associated with oral health perception in older Brazilians. Gerodontology . 2008;25(1):42-8. DOI:10.1111/j.1741-2358.2007.00163.x
https://doi.org/10.1111/j.1741-2358.2007... higher than those in this study (33.3%). This may occur because the sample was composed of a population with higher income and levels of schooling. A limitation of the study is that self-rated measures vary according to cultural aspects and individual expectations, and thus do not totally correspond with clinical assessments of the conditions investigated.

Problems related to oral health, such as difficulty chewing, talking or pain are more commonly reported by women, ¹¹11 . Locker D, Clarke M. Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res. 2000;79(4):970-5. DOI:10.1177/00220345000790041301
https://doi.org/10.1177/0022034500079004... with a prevalence of negatively self-rating their oral health 20.0% higher than among men. However, there is no consensus in the literature regarding this result and studies have reported no difference between the sexes. ¹⁴14 . Martins AMEBL, Barreto SM, Pordeus IA. Objective and subjective factors related to self-rated oral health among the elderly. Cad Saude Publica. 2009;25(2):421-35. DOI:10.1590/S0102-311X2009000200021
https://doi.org/10.1590/S0102-311X200900... ^, ²²22 . Sanders AE, Spencer AJ. Social inequality in perceived oral health among adults in Australia. Aust N Z J Public Health. 2004;28(2):159-66. DOI:10.1111/j.1467-842X.2004.tb00930.x
https://doi.org/10.1111/j.1467-842X.2004...

Older individuals have a positive perception of their oral health conditions. ¹⁴14 . Martins AMEBL, Barreto SM, Pordeus IA. Objective and subjective factors related to self-rated oral health among the elderly. Cad Saude Publica. 2009;25(2):421-35. DOI:10.1590/S0102-311X2009000200021
https://doi.org/10.1590/S0102-311X200900... ^, ²¹21 . Rao JNK, Scott AJ. The analysis of categorical data from complex sample surveys: chi-squared tests for goodness-of-fit and independence in two-way tables. J Am Stat Assoc . 1981;76:221-230. ^, ²³23 . Silva DD, Souza MLR, Wada RS. Saúde bucal em adultos e idosos na cidade de Rio Claro, São Paulo, Brasil. Cad Saude Publica. 2004;20(2):626-31. DOI:10.1590/S0102-311X2004000200033
https://doi.org/10.1590/S0102-311X200400... However, in this study, they showed a higher prevalence of negatively self-rating their oral health, indicating greater perception of oral health problems compared to younger individuals.

Research carried out in the United States show that whites report their oral health more positively than non-whites ⁸8 . Coulter I, Yamamoto JM, Marcus M, Freed J, Der-Martirosian C, Guzman-Becerra N, et al. Self-reported oral health of enrollees in capitated and fee-for-service dental benefit plans. J Am Dent Assoc. 2004;135(11):1606-15. and than blacks. ⁶6 . Borrell LN, Taylor GW, Borgnakke WS, Woolfolk MW, Nyquist LV. Perception of general and oral health in White and African American adults: assessing the effect of neighborhood socioeconomic conditions. Community Dent Oral Epidemiol. 2004;32(5):363-73. DOI:10.1111/j.1600-0528.2004.00177.x
https://doi.org/10.1111/j.1600-0528.2004... The stress experienced daily by blacks and dissatisfaction with their situations lead to changes in the quality of life, as well as increasing vulnerability to disease. ¹³13 . Lopes F. Beyond the numbers barrier: racial inequalities and health. Cad Saude Publica. 2005;21(5):1595-601. DOI:10.1590/S0102-311X2005000500034
https://doi.org/10.1590/S0102-311X200500... Those who reported themselves to be dark skinned had a prevalence rate of negatively self-rating their oral health 20.0% higher than white individuals, irrespective of gender. This association remained after adjusting for socioeconomic variables (income and schooling) and other possible factors linking skin color and perceived oral health.

Individuals who report more oral health symptoms, impairment and disabilities assess their oral health more negatively. ¹²12 . Locker D, Mscn EW, Jokovic A. What Do Older Adults’ Global Self-ratings of Oral Health Measure? J Public Health Dent. 2005;65(3):146-52. DOI:10.1111/j.1752-7325.2005.tb02804.x
https://doi.org/10.1111/j.1752-7325.2005... Experiencing dry mouth and difficulty eating were linked to higher prevalence of negative self-rated oral health. Both difficulty eating ¹¹11 . Locker D, Clarke M. Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res. 2000;79(4):970-5. DOI:10.1177/00220345000790041301
https://doi.org/10.1177/0022034500079004... and experiencing dry mouth may reflect oral health problems. Unfavorable clinical oral health conditions, like tooth decay ¹⁷17 . Moreira TP, Nations MK, Alves MSCF. Dentes da desigualdade: marcas bucais da experiência vivida na pobreza pela comunidade do Dendê, Fortaleza, Ceará, Brasil. Cad Saude Publica. 2007;23(6):1383-92. DOI:10.1590/S0102-311X2007000600013
https://doi.org/10.1590/S0102-311X200700... and periodontal disease, ⁷7 . Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
https://doi.org/10.1111/j.1600-051X.2008... are associated with negatively self-rated oral health. Having fewer teeth increased the prevalence of negative self-rated oral health by 30.0%; reporting the need for dental treatment was strongly linked to a negative perception of oral health, reflecting the negative impact perceived by those who suffer from tooth loss and dental problems.

The percentage of negative self-rated oral health among individuals with levels of income and schooling reflects the link between oral health and social inequalities. Economically disadvantaged adults tend to perceive greater negative impact of problems with their teeth, mouth or dentures, report greater tooth loss and assess oral health less favorably than adults in better economic conditions. ¹¹11 . Locker D, Clarke M. Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res. 2000;79(4):970-5. DOI:10.1177/00220345000790041301
https://doi.org/10.1177/0022034500079004... Likewise, a higher level of education is associated with better health, suggesting a direct relationship between years of schooling and good self-rated oral health. ¹²12 . Locker D, Mscn EW, Jokovic A. What Do Older Adults’ Global Self-ratings of Oral Health Measure? J Public Health Dent. 2005;65(3):146-52. DOI:10.1111/j.1752-7325.2005.tb02804.x
https://doi.org/10.1111/j.1752-7325.2005...

The use of dental services, and the frequency of their use affects oral health conditions. Individuals who had visited the dentist within the last year or once every two years perceived their oral health more positively compared with those who had not seen a dentist in a longer time. Not visiting the dentist for routine check-ups ¹1 . Afonso-Souza G, Nadanovsky P, Chor D, Faerstein E, Werneck GL, Lopes CS. Association between routine visits for dental checkup and self-perceived oral health in an adult population in Rio de Janeiro: the Pró-saúde study. Community Dent Oral Epidemiol. 2007;35(5):393-400. DOI:10.1111/j.1600-0528.2006.00343.x
https://doi.org/10.1111/j.1600-0528.2006... or waiting more than three years between visits increases the prevalence of negative self-rated oral health, ¹⁴14 . Martins AMEBL, Barreto SM, Pordeus IA. Objective and subjective factors related to self-rated oral health among the elderly. Cad Saude Publica. 2009;25(2):421-35. DOI:10.1590/S0102-311X2009000200021
https://doi.org/10.1590/S0102-311X200900... as oral health problems may progress without professional care, causing pain, discomfort and irreversible damage to teeth. ¹1 . Afonso-Souza G, Nadanovsky P, Chor D, Faerstein E, Werneck GL, Lopes CS. Association between routine visits for dental checkup and self-perceived oral health in an adult population in Rio de Janeiro: the Pró-saúde study. Community Dent Oral Epidemiol. 2007;35(5):393-400. DOI:10.1111/j.1600-0528.2006.00343.x
https://doi.org/10.1111/j.1600-0528.2006... Using a public dental service for the most recent appointment increased the prevalence of negative self-rated oral health by 10.0%, even after adjusting for socioeconomic and demographic variables. The public dental services’ greater burden of oral health problems and limited ability to resolve them may partially explain these findings.

By identifying factors associated with self-rated oral health, those groups whose oral health care should be prioritized can be identified and, consequently, public resources can be better allocated. Distal (age, skin color, schooling, frequency of visiting the dentist and type of service used) and proximal factors (number of teeth in the dental arches, reported need for dental treatment, experiencing dry mouth and difficulty eating) were linked to negative self-rated oral health. Negative self-rated oral health reflects inequalities in the population’s oral health and is linked to worse socioeconomic conditions, lower use of health care services and worse oral health conditions. More studies using self-rated oral health are needed so that it becomes better understood and so it can be more widely used in assessing health.

Thanks to the technicians at the Instituto Brasileiro de Geografia e Estatística (IBGE) for supporting and training the interviewers with regards improving the approach to the participants in households; to Professor Nilza Nunes da Silva, of the Department of Epidemiology, Faculdade de Saúde Pública, Universidade de São Paulo , for her contributions to the sampling procedure; to the Secretaria Municipal de Saúde , Florianópolis, for the help in carrying out the research; and to the students on the Post-Graduate Programs in Public Health, Physical Education and Nutrition, of the Universidade Federal de Santa Catarina , for their contribution to supervising the study.

References

¹
Afonso-Souza G, Nadanovsky P, Chor D, Faerstein E, Werneck GL, Lopes CS. Association between routine visits for dental checkup and self-perceived oral health in an adult population in Rio de Janeiro: the Pró-saúde study. Community Dent Oral Epidemiol. 2007;35(5):393-400. DOI:10.1111/j.1600-0528.2006.00343.x
» https://doi.org/10.1111/j.1600-0528.2006.00343.x
²
Barbato PR, Nagano HCM, Zanchet FN, Boing AF, Peres MA. Perdas dentárias e fatores sociais, demográficos e de serviços associados em adultos brasileiros: uma análise dos dados do Estudo Epidemiológico Nacional (Projeto SB Brasil 2002-2003). Cad Saude Publica. 2007;23(8):1803-14. DOI:10.1590/S0102-311X2007000800007
» https://doi.org/10.1590/S0102-311X2007000800007
³
Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. DOI:10.1186/1471-2288-3-21
» https://doi.org/10.1186/1471-2288-3-21
⁴
Bastos JLD, Gigante DP, Peres KG, Nedel FB. Determinação social da odontalgia em estudos epidemiológicos: revisão teórica e proposta de um modelo conceitual. Cienc Saude Coletiva. 2007;12(6):1611-21. DOI:10.1590/S1413-81232007000600022
» https://doi.org/10.1590/S1413-81232007000600022
⁵
Boing AF, Peres MA, Kovaleski DF, Zange SE, Antunes JL. Estratificação sócio-econômica em estudos epidemiológicos de cárie dentária e doenças periodontais: características da produção na década de 90. Cad Saude Publica. 2005;21(3):673-8. DOI:10.1590/S0102-311X2005000300002
» https://doi.org/10.1590/S0102-311X2005000300002
⁶
Borrell LN, Taylor GW, Borgnakke WS, Woolfolk MW, Nyquist LV. Perception of general and oral health in White and African American adults: assessing the effect of neighborhood socioeconomic conditions. Community Dent Oral Epidemiol. 2004;32(5):363-73. DOI:10.1111/j.1600-0528.2004.00177.x
» https://doi.org/10.1111/j.1600-0528.2004.00177.x
⁷
Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
» https://doi.org/10.1111/j.1600-051X.2008.01337.x
⁸
Coulter I, Yamamoto JM, Marcus M, Freed J, Der-Martirosian C, Guzman-Becerra N, et al. Self-reported oral health of enrollees in capitated and fee-for-service dental benefit plans. J Am Dent Assoc. 2004;135(11):1606-15.
⁹
Kieffer JM, Hoogstraten J. Linking oral health, general health, and quality of life. Eur J Oral Sci. 2008;116(5):445-50. DOI:10.1111/j.1600-0722.2008.00564.x
» https://doi.org/10.1111/j.1600-0722.2008.00564.x
¹⁰
Lacerda JT, Castilho EA, Calvo MCM, Freitas SFT. Saúde bucal e o desempenho diário de adultos em Chapecó, Santa Catarina, Brasil. Cad Saude Publica. 2008;24(8):1846-58. DOI:10.1590/S0102-311X2008000800013
» https://doi.org/10.1590/S0102-311X2008000800013
¹¹
Locker D, Clarke M. Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res. 2000;79(4):970-5. DOI:10.1177/00220345000790041301
» https://doi.org/10.1177/00220345000790041301
¹²
Locker D, Mscn EW, Jokovic A. What Do Older Adults’ Global Self-ratings of Oral Health Measure? J Public Health Dent. 2005;65(3):146-52. DOI:10.1111/j.1752-7325.2005.tb02804.x
» https://doi.org/10.1111/j.1752-7325.2005.tb02804.x
¹³
Lopes F. Beyond the numbers barrier: racial inequalities and health. Cad Saude Publica. 2005;21(5):1595-601. DOI:10.1590/S0102-311X2005000500034
» https://doi.org/10.1590/S0102-311X2005000500034
¹⁴
Martins AMEBL, Barreto SM, Pordeus IA. Objective and subjective factors related to self-rated oral health among the elderly. Cad Saude Publica. 2009;25(2):421-35. DOI:10.1590/S0102-311X2009000200021
» https://doi.org/10.1590/S0102-311X2009000200021
¹⁵
Matos DL, Lima-Costa MF, Guerra HL, Marcenes W. Projeto Bambuí: estudo de base populacional dos fatores associados com o uso regular de serviços odontológicos em adultos. Cad Saude Publica. 2001;17(3):661-8. DOI:10.1590/S0102-311X2001000300020
» https://doi.org/10.1590/S0102-311X2001000300020
¹⁶
Matos DL, Lima-Costa MF. Auto-avaliação da saúde bucal entre adultos e idosos residentes na Região Sudeste: resultados do Projeto SB-Brasil, 2003. Cad Saude Publica. 2006;22(8):1699-707. DOI:10.1590/S0102-311X2006000800018
» https://doi.org/10.1590/S0102-311X2006000800018
¹⁷
Moreira TP, Nations MK, Alves MSCF. Dentes da desigualdade: marcas bucais da experiência vivida na pobreza pela comunidade do Dendê, Fortaleza, Ceará, Brasil. Cad Saude Publica. 2007;23(6):1383-92. DOI:10.1590/S0102-311X2007000600013
» https://doi.org/10.1590/S0102-311X2007000600013
¹⁸
Nunes CIP, Abegg C. Factors associated with oral health perception in older Brazilians. Gerodontology . 2008;25(1):42-8. DOI:10.1111/j.1741-2358.2007.00163.x
» https://doi.org/10.1111/j.1741-2358.2007.00163.x
¹⁹
Pattussi MP, Olinto MTA, Hardy R, Sheiham A. Clinical, social and psychosocial factors associated with self-rated oral health in Brazilian adolescents. Community Dent Oral Epidemiol. 2007;35(5):377-86. DOI:10.1111/j.1600-0528.2006.00339.x
» https://doi.org/10.1111/j.1600-0528.2006.00339.x
²⁰
Pattussi MP, Peres KG, Boing AF, Peres MA, Costa JSD. Self-rated oral health and associated factors in Brazilian elders. Community Dent Oral Epidemiol. 2010;38(4):348-59. DOI:10.1111/j.1600-0528.2010.00542.x
» https://doi.org/10.1111/j.1600-0528.2010.00542.x
²¹
Rao JNK, Scott AJ. The analysis of categorical data from complex sample surveys: chi-squared tests for goodness-of-fit and independence in two-way tables. J Am Stat Assoc . 1981;76:221-230.
²²
Sanders AE, Spencer AJ. Social inequality in perceived oral health among adults in Australia. Aust N Z J Public Health. 2004;28(2):159-66. DOI:10.1111/j.1467-842X.2004.tb00930.x
» https://doi.org/10.1111/j.1467-842X.2004.tb00930.x
²³
Silva DD, Souza MLR, Wada RS. Saúde bucal em adultos e idosos na cidade de Rio Claro, São Paulo, Brasil. Cad Saude Publica. 2004;20(2):626-31. DOI:10.1590/S0102-311X2004000200033
» https://doi.org/10.1590/S0102-311X2004000200033
²⁴
Silva DD, Rihs LB, Sousa MLR. Factors associated with maintenance of teeth in adults in the State of São Paulo, Brazil. Cad SaudePublica. 2009;25(11):2407-18. DOI:10.1590/S0102-311X2009001100011
» https://doi.org/10.1590/S0102-311X2009001100011
²⁵
Vargas AMD, Paixão HH. Perda dentária e seu significado na qualidade de vida de adultos usuários de serviço público de saúde bucal do Centro de Saúde Boa Vista, em Belo Horizonte. Cienc Saude Coletiva. 2005;10(4):1015-24. DOI:10.1590/S1413-81232005000400024
» https://doi.org/10.1590/S1413-81232005000400024
²⁶
Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual framework in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26(1):224-7. DOI:10.1093/ije/26.1.224
» https://doi.org/10.1093/ije/26.1.224

a
Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro; 2010.
The study was based on the Master’s dissertation by Luchi C. A., entitled: “Desigualdades na autoavaliação da saúde bucal em adultos”, presented to the Post-Graduate program in Dentistry, Universidade Federal de Santa Catarina , in 2012.

Publication Dates

Publication in this collection
Aug 2013

History

Received
17 May 2012
Accepted
4 Mar 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹
Afonso-Souza G, Nadanovsky P, Chor D, Faerstein E, Werneck GL, Lopes CS. Association between routine visits for dental checkup and self-perceived oral health in an adult population in Rio de Janeiro: the Pró-saúde study. Community Dent Oral Epidemiol. 2007;35(5):393-400. DOI:10.1111/j.1600-0528.2006.00343.x
» https://doi.org/10.1111/j.1600-0528.2006.00343.x

[2] ²
Barbato PR, Nagano HCM, Zanchet FN, Boing AF, Peres MA. Perdas dentárias e fatores sociais, demográficos e de serviços associados em adultos brasileiros: uma análise dos dados do Estudo Epidemiológico Nacional (Projeto SB Brasil 2002-2003). Cad Saude Publica. 2007;23(8):1803-14. DOI:10.1590/S0102-311X2007000800007
» https://doi.org/10.1590/S0102-311X2007000800007

[3] ³
Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. DOI:10.1186/1471-2288-3-21
» https://doi.org/10.1186/1471-2288-3-21

[4] ⁴
Bastos JLD, Gigante DP, Peres KG, Nedel FB. Determinação social da odontalgia em estudos epidemiológicos: revisão teórica e proposta de um modelo conceitual. Cienc Saude Coletiva. 2007;12(6):1611-21. DOI:10.1590/S1413-81232007000600022
» https://doi.org/10.1590/S1413-81232007000600022

[5] ⁵
Boing AF, Peres MA, Kovaleski DF, Zange SE, Antunes JL. Estratificação sócio-econômica em estudos epidemiológicos de cárie dentária e doenças periodontais: características da produção na década de 90. Cad Saude Publica. 2005;21(3):673-8. DOI:10.1590/S0102-311X2005000300002
» https://doi.org/10.1590/S0102-311X2005000300002

[6] ⁶
Borrell LN, Taylor GW, Borgnakke WS, Woolfolk MW, Nyquist LV. Perception of general and oral health in White and African American adults: assessing the effect of neighborhood socioeconomic conditions. Community Dent Oral Epidemiol. 2004;32(5):363-73. DOI:10.1111/j.1600-0528.2004.00177.x
» https://doi.org/10.1111/j.1600-0528.2004.00177.x

[7] ⁷
Cascaes AM, Peres KG, Peres MA. Periodontal disease is associated with poor self-rated oral health among Brazilian adults. J Clin Periodontol. 2009;36(1):25-33. DOI:10.1111/j.1600-051X.2008.01337.x
» https://doi.org/10.1111/j.1600-051X.2008.01337.x

[8] ⁸
Coulter I, Yamamoto JM, Marcus M, Freed J, Der-Martirosian C, Guzman-Becerra N, et al. Self-reported oral health of enrollees in capitated and fee-for-service dental benefit plans. J Am Dent Assoc. 2004;135(11):1606-15.

[9] ⁹
Kieffer JM, Hoogstraten J. Linking oral health, general health, and quality of life. Eur J Oral Sci. 2008;116(5):445-50. DOI:10.1111/j.1600-0722.2008.00564.x
» https://doi.org/10.1111/j.1600-0722.2008.00564.x

[10] ¹⁰
Lacerda JT, Castilho EA, Calvo MCM, Freitas SFT. Saúde bucal e o desempenho diário de adultos em Chapecó, Santa Catarina, Brasil. Cad Saude Publica. 2008;24(8):1846-58. DOI:10.1590/S0102-311X2008000800013
» https://doi.org/10.1590/S0102-311X2008000800013

[11] ¹¹
Locker D, Clarke M. Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res. 2000;79(4):970-5. DOI:10.1177/00220345000790041301
» https://doi.org/10.1177/00220345000790041301

[12] ¹²
Locker D, Mscn EW, Jokovic A. What Do Older Adults’ Global Self-ratings of Oral Health Measure? J Public Health Dent. 2005;65(3):146-52. DOI:10.1111/j.1752-7325.2005.tb02804.x
» https://doi.org/10.1111/j.1752-7325.2005.tb02804.x

[13] ¹³
Lopes F. Beyond the numbers barrier: racial inequalities and health. Cad Saude Publica. 2005;21(5):1595-601. DOI:10.1590/S0102-311X2005000500034
» https://doi.org/10.1590/S0102-311X2005000500034

[14] ¹⁴
Martins AMEBL, Barreto SM, Pordeus IA. Objective and subjective factors related to self-rated oral health among the elderly. Cad Saude Publica. 2009;25(2):421-35. DOI:10.1590/S0102-311X2009000200021
» https://doi.org/10.1590/S0102-311X2009000200021

[15] ¹⁵
Matos DL, Lima-Costa MF, Guerra HL, Marcenes W. Projeto Bambuí: estudo de base populacional dos fatores associados com o uso regular de serviços odontológicos em adultos. Cad Saude Publica. 2001;17(3):661-8. DOI:10.1590/S0102-311X2001000300020
» https://doi.org/10.1590/S0102-311X2001000300020

[16] ¹⁶
Matos DL, Lima-Costa MF. Auto-avaliação da saúde bucal entre adultos e idosos residentes na Região Sudeste: resultados do Projeto SB-Brasil, 2003. Cad Saude Publica. 2006;22(8):1699-707. DOI:10.1590/S0102-311X2006000800018
» https://doi.org/10.1590/S0102-311X2006000800018

[17] ¹⁷
Moreira TP, Nations MK, Alves MSCF. Dentes da desigualdade: marcas bucais da experiência vivida na pobreza pela comunidade do Dendê, Fortaleza, Ceará, Brasil. Cad Saude Publica. 2007;23(6):1383-92. DOI:10.1590/S0102-311X2007000600013
» https://doi.org/10.1590/S0102-311X2007000600013

[18] ¹⁸
Nunes CIP, Abegg C. Factors associated with oral health perception in older Brazilians. Gerodontology . 2008;25(1):42-8. DOI:10.1111/j.1741-2358.2007.00163.x
» https://doi.org/10.1111/j.1741-2358.2007.00163.x

[19] ¹⁹
Pattussi MP, Olinto MTA, Hardy R, Sheiham A. Clinical, social and psychosocial factors associated with self-rated oral health in Brazilian adolescents. Community Dent Oral Epidemiol. 2007;35(5):377-86. DOI:10.1111/j.1600-0528.2006.00339.x
» https://doi.org/10.1111/j.1600-0528.2006.00339.x

[20] ²⁰
Pattussi MP, Peres KG, Boing AF, Peres MA, Costa JSD. Self-rated oral health and associated factors in Brazilian elders. Community Dent Oral Epidemiol. 2010;38(4):348-59. DOI:10.1111/j.1600-0528.2010.00542.x
» https://doi.org/10.1111/j.1600-0528.2010.00542.x

[21] ²¹
Rao JNK, Scott AJ. The analysis of categorical data from complex sample surveys: chi-squared tests for goodness-of-fit and independence in two-way tables. J Am Stat Assoc . 1981;76:221-230.

[22] ²²
Sanders AE, Spencer AJ. Social inequality in perceived oral health among adults in Australia. Aust N Z J Public Health. 2004;28(2):159-66. DOI:10.1111/j.1467-842X.2004.tb00930.x
» https://doi.org/10.1111/j.1467-842X.2004.tb00930.x

[23] ²³
Silva DD, Souza MLR, Wada RS. Saúde bucal em adultos e idosos na cidade de Rio Claro, São Paulo, Brasil. Cad Saude Publica. 2004;20(2):626-31. DOI:10.1590/S0102-311X2004000200033
» https://doi.org/10.1590/S0102-311X2004000200033

[24] ²⁴
Silva DD, Rihs LB, Sousa MLR. Factors associated with maintenance of teeth in adults in the State of São Paulo, Brazil. Cad SaudePublica. 2009;25(11):2407-18. DOI:10.1590/S0102-311X2009001100011
» https://doi.org/10.1590/S0102-311X2009001100011

[25] ²⁵
Vargas AMD, Paixão HH. Perda dentária e seu significado na qualidade de vida de adultos usuários de serviço público de saúde bucal do Centro de Saúde Boa Vista, em Belo Horizonte. Cienc Saude Coletiva. 2005;10(4):1015-24. DOI:10.1590/S1413-81232005000400024
» https://doi.org/10.1590/S1413-81232005000400024

[26] ²⁶
Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual framework in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26(1):224-7. DOI:10.1093/ije/26.1.224
» https://doi.org/10.1093/ije/26.1.224

Variable	n	%	95%CI

Self-rated oral health (N = 1,719)
Positive (very good and good)	1,137	66.8	63.4;70.2
Negative (regular, bad and very bad)	582	33.2	29.8;36.6
Self-rated health (N = 1,720)
Positive (very good and good)	1,373	81.2	78.3;84.1
Negative (regular, bad and very bad)	347	18.8	15.9;21.7
Sex (N = 1,720)
Male	761	44.4	42.2;46.6
Female	959	55.6	53.4;57.7
Self-reported skin color (N = 1,715)
White	1,444	83.9	80.3;87.4
Dark	147	8.9	6.5;11.2
Black	87	5.0	3.3;6.7
Yellow	17	1.0	0.5;1.5
Indigenous	20	1.2	0.6;1.7
Age (years) (N = 1,720)
20 to 29	540	32.7	28.2;37.17
30 to 39	392	22.9	20.3;25.5
40 to 49	438	25.0	21.8;28.1
50 to 59	350	19.4	16.9;21.9
Income in terciles (N = 1,685)
3 ^rd tercile (≥ R$ 1,314.00)	559	34.1	27.8;40.4
2 ^nd tercile (R$ 561,00 to R$ 1,300.00)	562	33.3	29.6;36.9
1 ^st tercile (≤ R$ 560.00)	564	32.6	26.1;39.0
Schooling (years) (N = 1,716)
12 or more	737	43.8	37.0;50.8
9 to 11	568	33.4	28.1;38.0
5 to 8	253	14.0	11.2;16.7
Up to 4	158	8.8	6.4;11.1
Last visit to the dentist (years) (N = 1,705)
Less than one	1,136	66.9	63.0;70.7
1 to 2	381	22.4	19.1;25.7
3 or more	188	10.7	8.6;12.8
Type of service used (N = 1,707)
Private	1,293	76.3	72.4;80.3
Public	331	19.0	14.9;23.0
Other	83	4.7	3.1;6.3
Number of teeth (N = 1,717)
≥ 10 teeth in both dental arches	1,394	82.0	79.1;84.9
< 10 teeth in at least one dental arch	279	15.6	12.9;18.2
No teeth	44	2.4	1.6;3.3
Perceived need for dental treatment (N = 1,715)
No	726	42. 7	38.9;46.4
Yes	989	57.3	53.5;61.0
Use complete dentures (N = 1,698)
No	1,575	92.9	91.1;94.7
Yes	123	7.1	5.2;8.9
Dry mouth (N = 1,716)
Never	888	52.5	47.8;57.1
Sometimes	676	47.5	42.8;52.2
Difficulty eating (N = 1,712)
Never or rarely	1,573	92.1	90.1;93.8
Sometimes	139	7.9	6.1;9.6
Toothache (N = 1,674)
No	1,422	85.2	83.2;86.7
Yes	252	14.8	13.3;16.8

Variable	n	%	95%CI	p

Sex				0.017 ^a
Male	234	30.2	26.3;34.2
Female	348	35.5	31.7;39.3
Self-reported skin color				0.003 ^a
White	461	31.2	27.6;34.7
Dark	68	45.8	37.5;54.1
Black	35	39.7	28.6;50.8
Yellow	8	52.8	27.7;77.9
Indigenous	8	31.9	8.8;55.2
Age (years)				< 0.001 ^a
20 to 29	132	23.7	18.9;28.6
30 to 39	136	35.9	29.4;42.5
40 to 49	163	37.5	31.0;39.9
50 to 59	151	42.8	36.9;48.7
Income in terciles				< 0.001 ^b
3 ^rd tercile (≥ R$ 1,314.00)	115	19.9	15.8;24.1
2 ^nd tercile (R$ 561,00 to R$ 1,300.00)	202	35.7	31.7;39.7
1 ^st tercile (≤ R$ 560.00)	255	44.7	40.4;49.0
Schooling (years)				< 0.001 ^b
12 or more	149	19.5	16.5;22.6
9 to 11	211	36.9	31.9;41.8
5 to 8	133	53.2	46.3;60.1
Up to 4	87	54.9	47.4;62.4
Last visit to the dentist (year )				< 0.001 ^b
Less than one	347	29.8	26.2;33.4
1 to 2	133	34.7	27.1;42.2
3 or more	99	52.5	46.0;59.1
Type of service used				< 0.001 ^a
Private	391	29.9	26.4;33.3
Public	166	48.7	42.2;55.2
Other	23	28.3	18.9;37.8
Number of teeth				< 0.001 ^b
≥ 10 teeth in both dental arches	399	28.2	24.5;31.9
< 10 teeth in at least one dental arch	167	59.1	53.1;65.1
No teeth	16	36.0	22.8;49.1
Perceived need for dental treatment				< 0.001 ^a
No	66	9.0	6.6;11.4
Yes	515	52.1	47.2;55.3
Use complete dentures				< 0.001 ^a
No	519	32.5	28.9;36.0
Yes	63	49.0	39.3;58.9
Dry mouth				< 0.001 ^a
Never	260	28.4	24.7;32.1
Sometimes	322	38.6	34.3;42.9
Difficulty eating				< 0.001
Never or rarely	476	29.6	26.5;32.8
Sometimes	103	73.8	66.3;81.3
Toothache (N = 1,674)				< 0.001
No	447	30.7	27.1;34.3
Yes	119	47.2	39.2;55.1

Variable	Raw analyse		Model 1 ^a		Model 2 ^b		Model 3 ^c		Model 4 ^d

	PR	95%CI	PR	95%CI	PR	95%CI	PR	95%CI	PR	95%CI

Age (year)
20 to 29	1		1		1		1		1
30 to 39	1.5	1.2;1.9	1.5	1.2;1.9	1.5	1.2;1.8	1.5	1.2;1.8	1.3	1.1;1.6
40 to 49	1.5	1.2;1.9	1.5	1.2;1.9	1.4	1.2;1.8	1.4	1.1;1.7	1.1	0.9;1.4
50 to 59	1.8	1.4;2.3	1.8	1.4;2.3	1.7	1.3;2.1	1.6	1.3;2.1	1.3	1.0;1.7
Self-reported skin color
White	1		1		1		1		1
Dark	1.5	1.2;1.8	1.5	1.2;1.9	1.3	1.1;1.6	1.3	1.1;1.6	1.2	1.0;1.4
Black	1.3	1.0;1.7	1.4	1.0;1.8	1.0	0.8;1.4	1.1	0.8;1.5	1.0	0.8;1.3
Yellow	1.7	1.1;2.6	1.6	1.0;2.4	1.3	0.8;2.1	1.4	0.8;2.1	1.3	0.8;2.1
Indigenous	1.0	0.5;2.0	1.0	0.5;2.0	0.8	0.4;1.6	1.0	0.5;1.8	0.8	0.4;2.1
Sex
Male	1		1		1		1		1
Female	1.2	1.0;1.3	1.1	1.0;1.3	1.1	1.0;1.3	1.2	1.0;1.3	1.2	1.0;1.3
Income in terciles
3 ^rd tercile (≥ R$ 1,314.00)	1				1		1		1
2 ^nd tercile (R$ 561.00 to R$ 1,300.00)	1.8	1.4;2.2	–		1.5	1.2;2.0	1.5	1.2;2.0	1.3	1.0;1.6
1 ^st tercile (≤ R$ 560.00)	2.2	1.8;2.8	–		1.6	1.2;2.1	1.5	1.1;2.1	1.2	0.9;1.5
Schooling (years)
12 or more	1				1		1		1
9 to 11	1.9	1.6;2.3	–		1.6	1.3;2.0	1.6	1.3;1.9	1.4	1.1;1.7
5 to 8	2.7	2.2;3.4	–		2.0	1.6;2.6	1.9	1.4;2.4	1.6	1.2;2.0
Up to 4	2.8	2.3;3.5	–		1.9	1.5;2.5	1.8	1.4;2.3	1.6	1.2;2.0
Last visit to the dentist (years)
Less than one	1		–		–		1		1
1 to 2	1.2	1.0;1.5	–		–		1.1	0.9;1.3	1.0	0.9;1.2
3 or more	1.8	1.5;2.1	–		–		1.2	1.0;1.5	1.3	1.1;1.5
Type of service used
Private	1		–		–		1		1
Public	1.6	1.4;1.9	–		–		1.1	1.0;1.3	1.1	1.0;1.2
Other	1.0	0.7;1.3	–		–		1.0	0.7;1.3	1.0	0.8;1.4
Number of teeth
≥ 10 teeth in both dental arches	1		–		–		–		1
< 10 teeth in at least one dental arch	2.1	1.8;2.4	–		–		–		1.3	1.1;1.6
No teeth	1.3	0.9;1.9	–		–		–		1.1	0.6;1.6
Perceived need for dental treatment
No	1		–		–		–		1
Yes	5.7	4.3;7.5	–		–		–		4.4	3.3;6.0
Use complete dentures
No	1		–		–		–		1
Yes	1.5	1.2;1.9	–		–		–		0.9	0.7;1.2
Dry mouth
Never	1		–		–		–		1
Sometimes	1.4	1.2;1.6	–		–		–		1.2	1.1;1.5
Difficulty eating
Never or rarely	1		–		–		–		1
Sometimes	2.5	2.1;2.9	–		–		–		1.3	1.2;1.5
Toothache
No	1								1
Yes	1.5	1.2;1.9							1.1	0.9;1.3