Factors associated with dental pain in toddlers detected using the dental discomfort questionnaire

Abstract

Background:
Dental pain is one of the most common symptoms of untreated oral problems and exerts a strong impact on the well-being of children.

Aims:
The aim of this study was to evaluate the associated factors with dental pain in children aged 1-3 years using the Brazilian version of the Dental Discomfort Questionnaire (DDQ-B).

Methods:
A cross-sectional study was conducted in the city of Diamantina, Brazil. A total of 318 randomly selected children were submitted to an oral clinical examination for the evaluation of tooth injuries and dental caries (International Caries Detection and Assessment System, [ICDAS]). The caregivers of the children were asked to answer the DDQ-B as well as a questionnaire addressing demographic and socioeconomic aspects of the family. Statistical analysis was performed and involved the description of frequencies as well as Poisson hierarchical regression analysis.

Results:
Dental pain was associated with a household income less than the Brazilian minimum monthly wage (Prevalence ratios [PRs] = 1.33, 95% confidence interval [CI]: 1.07-1.66, P = 0.011) and dental caries in dentin - ICDAS codes 5 and 6 (PR = 1.48, 95% CI: 1.13-1.94, P = 0.004).

Conclusions:
Greater frequencies of dental pain were found in 1-3-year-old children from families with a low monthly income and dental caries with visible dentin with or without pulp involvement.

Full text

© 2018 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
250
ABSTRACT
Background: Dental pain is one of the most
common symptoms of untreated oral problems
and exerts a strong impact on the well‑being
of children. Aims: The aim of this study was to
evaluate the associated factors with dental pain in
children aged 1–3 years using the Brazilian version
of the Dental Discomfort Questionnaire (DDQ‑B).
Methods: A cross‑sectional study was conducted
in the city of Diamantina, Brazil. A total of 318
randomly selected children were submitted to an
oral clinical examination for the evaluation of tooth
injuries and dental caries (International Caries
Detection and Assessment System, [ICDAS]). The
caregivers of the children were asked to answer
the DDQ‑B as well as a questionnaire addressing
demographic and socioeconomic aspects of
the family. Statistical analysis was performed
and involved the description of frequencies as
well as Poisson hierarchical regression analysis.
Results: Dental pain was associated with a
household income less than the Brazilian minimum
monthly wage (Prevalence ratios [PRs] = 1.33,
95% condence interval [CI]: 1.07–1.66, P = 0.011)
and dental caries in dentin – ICDAS codes 5
and 6 (PR = 1.48, 95% CI: 1.13–1.94, P = 0.004).
Conclusions: Greater frequencies of dental pain
were found in 1–3‑year‑old children from families
with a low monthly income and dental caries with
visible dentin with or without pulp involvement.
KEYWORDS: Children, dental caries, dental pain
Factors associated with dental pain in toddlers detected
using the dental discomfort questionnaire
Izabella Barbosa Fernandes, Patrícia Reis‑Sá, Rafaela Lopes Gomes, Luciane Rezende Costa1,
Joana Ramos‑Jorge2, Maria Letícia Ramos‑Jorge
Department of Pediatric Dentistry, School of Dentistry, Federal University of Vales do Jequitinhonha e Mucuri, Diamantina, 1Department
of Pediatric Dentistry, School of Dentistry, Federal University of Minas Gerais, Goiânia, 2Department of Pediatric Dentistry, School of
Dentistry, Federal University of Goiás, Belo Horizonte, Brazil
ranges from 10.1% to 53.4%.[2,4‑7] However, specically,
data on children aged 1–3 years are not available in the
literature.
The inuence of social, demographic, and psychological
determinants on dental pain experience in children has
been demonstrated.[5,8,9] Likewise, oral problems, such
as ulcerations, tooth injuries, and tooth eruption, have
been associated with dental pain,[6,10] with untreated
dental caries the most strongly associated clinical
nding.[2,10]
Achieving a reliable description of pain can be
challenging with very young children due to cognitive
Address for correspondence:
Dr. Izabella Barbosa Fernandes,
Rua da Glória 187, Centro Diamantina,
Minas Gerais, 39100000, Brazil.
E‑mail: bellahfernandes@hotmail.com
Access this article online
Quick response code Website:
www.jisppd.com
DOI:
10.4103/JISPPD.JISPPD_167_17
PMID:
******
How to cite this article: Fernandes IB, Reis-Sá P, Gomes RL,
Costa LR, Ramos-Jorge J, Ramos-Jorge ML. Factors associated
with dental pain in toddlers detected using the dental discomfort
questionnaire.JIndianSocPedodPrevDent2018;36:250‑6.
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new
creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
Introduction
Dental pain is one of the most common symptoms of
untreated oral problems and exerts a strong impact on
the well‑being of children, with negative consequences
to the quality of life.[1‑3] Studies report that the
prevalence of dental pain among preschool children
Original Article
[Downloaded free from http://www.jisppd.com on Monday, September 24, 2018, IP: 158.46.169.124]

Fernandes, et al.: Dental pain in toddlers
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018 251
immaturity and the consequent difculty in perceiving,
understanding, remembering, and verbalizing feelings
of pain.[2,11,12] However, dental pain can be recognized
through behaviors such as difculties to eat or to
sleep.[11,13] The Dental Discomfort Questionnaire (DDQ)
is an assessment tool used to recognize dental pain
in children 2–5 years of age through the reports
of parents/caregivers regarding their children’s
behavior.[14,15] The DDQ has recently been culturally
adapted and validated for use on Brazilian children
(DDQ‑B).[15]
Most studies addressing factors associated with
dental pain have involved adults, adolescents, or
schoolchildren. However, investigations involving
the evaluation of dental pain in younger children are
scarce and have shown that one of the main factors
associated with dental pain is dental caries.[5,6,9,10] Still,
such studies have failed for the following reasons:
they do not use the validated instrument for assessing
dental pain in preverbal children and/or evaluate
the occurrence of dental caries without detailing the
different stages of carious lesions that may or may not
associate with pain. This is the rst study to evaluate
factors associated with dental pain in children aged
1–3 years employing validated tools for assessing
dental pain (DDQ‑B) and caries (International Caries
Detection and Assessment System, [ICDAS]).[16]
Moreover, we also sought for the association of dental
pain with other potential problems in this age range,
i.e., traumatic dental injuries and symptoms during
tooth eruption (teething).
The use of this tool for the assessment of dental pain in
children <5 years of age constitutes an opportunity to
gain a better understanding of dental pain experience in
the primary dentition. Such knowledge is fundamental
to the establishment of priorities in public health‑care
policies for areas in which dental caries is highly
prevalent.
The aim of the present study was to evaluate the
prevalence of dental pain and associated factors in
children aged 1–3 years using the Brazilian version of
the DDQ (DDQ‑B).
Methods
Ethical considerations
This study received approval from the Human
Research Ethics Committee of the Universidade
Federal dos Vales do Jequitinhonha e Mucuri (Brazil)
under process number 470.863. All parents/caregivers
received clarications regarding the objectives of the
study and signed a statement of informed consent.
Study population
A cross‑sectional study was conducted in the city of
Diamantina, which is located in the northern portion of
the state of Minas Gerais in southeast Brazil. Children
aged 1–3 years were selected from a list provided by
the State Secretary of Health of individuals who used
public health services during vaccination campaigns
in 2013 and 2014. Efforts were made to maintain
the proportion of the sample in relation to age.
A simple randomization procedure was performed to
determine the children for inclusion in the study and
ensure representativeness. The parents/caregivers
of the selected children were asked to appear at the
pediatric dentistry clinic of the Universidade Federal
dos Vales do Jequitinhonha e Mucuri.
A pilot study was then performed with a sample of
32 children aged 1–3 years and their parents/caregivers
to test the data collection methods and acquire
information for the determination of the sample size
of the main study. The sample in the pilot study was
not included in the main study and no changes to the
methods were deemed necessary.
The sample size was calculated based on a 25%
prevalence rate of dental pain experience (determined
during the pilot study), a 95% condence interval (CI),
and a 5% standard error. The minimum sample size
was determined to be 288 child–parent/caregiver
pairs, to which 15% was added to compensate
for possible dropouts. Thus, the total sample was
330 child–parent/caregiver pairs.
For inclusion in the study, the parents/caregivers
needed to be uent in Portuguese, have adequate
reading skills, and are the main caregiver, spending
at least 12 h/day with the child, including the period
of sleep. Children with systemic health problems that
required medical assistance and greater care on the
part of the parents/caregivers were excluded from the
study.
Data collection
The parents/caregivers of the selected children were
asked to bring their child to the pediatric dentistry
clinic of the university. On the day scheduled, the
parents/caregivers were instructed to answer the
DDQ‑B as well as another questionnaire addressing
sociodemographic aspects and characteristics of the
child and family. The oral clinical examinations of the
children were also performed for the evaluation of
dental caries and traumatic dental injury.
Before the data collection, two examiners and two
interviewers underwent training exercises. The
two interviewers were trained for the reading and
intonation of each question as well as the response
options. The two examiners underwent training for the
diagnosis of untreated dental caries using the criteria
of the ICDAS[16] and for the evaluation of traumatic
dental injury using the criteria proposed by Andreasen
and Andreasen.[17] Training occurred in two steps.
First, images of different clinical situations of untreated
dental caries and traumatic dental injury were shown.
[Downloaded free from http://www.jisppd.com on Monday, September 24, 2018, IP: 158.46.169.124]

Fernandes, et al.: Dental pain in toddlers
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018
252
Second, three examiners, one of whom was considered
the gold standard, performed two clinical examinations
with a 14‑day interval between occasions on a sample
of 50 4‑ and 5‑year‑old children selected for the
determination of inter‑ and intra‑examiner agreement
regarding the different clinical conditions. Minimum
Kappa coefcients were 0.83 and 0.86, respectively.
Nonclinical data
Sociodemographic information and characteristics of
child and family
A questionnaire was created to gather information of
sociodemographic aspects as well as characteristics
of the child and family. This questionnaire was
administered to the parents/caregivers in interview
form. The interviewers were blinded to the clinical
conditions of the children. The parents/caregivers
provided information on the child’s age, sex, family
situation (nuclear or nonnuclear), type of preschool or
day‑care center (none, private, or public), the child’s
access to a dentist (yes or no), mother’s age (≤25 years
or >25 years), number of child’s siblings (none, one,
two, or more), mother’s schooling (years of study),
household income (categorized based on the Brazilian
monthly minimum wage, which was equivalent
to US$ 255.58 at the time of the study), and number
of individuals who depended on the household
income (≤3 or >3 individuals). The parents/caregivers
were also asked about the occurrence of signs and
symptoms associated with tooth eruption in their
children such as increased salivation, increased
temperature, loss of appetite, irritability, itchy gums,
and sleep disorders.
Dental discomfort questionnaire
The DDQ is a tooth pain assessment tool for children
<5 years of age that was originally developed
in the Netherlands.[14] This questionnaire has
been adapted and validated for use on Brazilian
children (DDQ‑B).[15] The DDQ‑B was designed as a
self‑administered questionnaire for parents/caregivers
that is composed of seven items on different behaviors
possibly associated with dental pain or discomfort
due to untreated caries, such as crying during meals
or difculty chewing. For each item, the respondent is
asked to state how often the child demonstrated a given
behavior. The response options are “never” (scored 0),
“sometimes” (scored 1 point), and “often” (scored 2
points). The total score is calculated by the sum of the
response options, with higher scores denoting greater
dental pain experience.
Clinical data
Oral clinical examination
Two examiners performed the clinical examinations
under articial light following prophylaxis and air drying
of the teeth. The children were examined seated on a
dental stretcher for children, and the parents/caregivers
held very young children when necessary. Untreated
dental caries was evaluated using the ICDAS criteria.
Each tooth surface was evaluated and classied based
on the stages of dental caries (independently of lesion
activity) as initial lesions (ICDAS codes 1 and 2),
established lesions (ICDAS codes 3 and 4), and severe
cavitated lesions (ICDAS codes 5 and 6). Each child was
classied based on the most advanced stage of tooth
decay, that is, if a child had one tooth surface with an
initial lesion and another with a severe lesion, only the
latter was recorded.
Traumatic dental injury as well as signs and
symptoms of tooth eruption were also evaluated.
The clinical diagnosis of traumatic dental injury was
performed using the criteria proposed by Andreasen
and Andreasen,[17] including the evaluation of tooth
discoloration. The ndings were recorded as either
absent or present.
Statistical analysis
Data analysis was conducted using the (Statistical
Package for the Social Sciences for Windows,
version 20.0, SPSS Inc., Chicago, IL, USA). Descriptive
analysis and frequency analysis were performed for
all DDQ‑B items. The independent variables were
sociodemographic aspects and characteristics of the
child and family (mother’s schooling, household
income, number of individuals who live on income,
type of preschool/day care center, child’s access to
a dentist, child’s sex, child’s age, family situation,
number of siblings, parent’s/caregiver’s age, and
occurrence of dental pain in parent/caregiver) as well
as oral clinical conditions (untreated dental caries,
traumatic dental injury, and signs and/or symptoms
related to tooth eruption). The dependent variable was
dental pain evaluated using the DDQ‑B assessed by
the total score.
The variables were grouped into a hierarchy
of categories ranging from distal to proximal
determinants:[18] Sociodemographic aspects,
characteristics of the family, child’s characteristics, and
oral clinical conditions (in that order). On each level,
Poisson regression analysis with robust variance was
used to test the strength of associations between the
total DDQ‑B score and each independent variable. This
analysis was performed to eliminate variables with a
P ≥ 0.20. After adjusting for variables on the same or
previous levels, explanatory variables with P < 0.05
were maintained in the nal models. Prevalence ratios
and 95% CI were calculated.
Results
A total of 330 children aged 1–3 years were initially
included in the study, 318 (96.4%) of whom participated
through to the end. Twelve children appeared at the
pediatric dentistry clinic of the university accompanied
by an individual who was not the main caregiver and
were therefore excluded from the study.
[Downloaded free from http://www.jisppd.com on Monday, September 24, 2018, IP: 158.46.169.124]

Fernandes, et al.: Dental pain in toddlers
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018 253
Mean age of the children was 29.04 months (standard
deviation [SD] = 10.01 months) and the female sex
accounted for 53.8% of the sample (n = 165). The
prevalence of dental caries was 65.1%, with 21.1%
of the children presenting initial lesions (ICDAS
codes 1 and 2) as the worst stage in the oral cavity, 8.8%
presenting established lesions (ICDAS code 3 and 4),
and 35.5% presenting severe cavitated lesions (ICDAS
codes 5 and 6). A history of traumatic dental injury
was found in 26.1% of the children. The majority of
mothers (51.6%) had 9–12 years of schooling. Household
income was between one and two times the Brazilian
monthly minimum wage among 47.5% of the families.
The mean DDQ‑B score was 2.42 (SD = 2.31). Table 1
shows the distribution of the responses to each item
of the DDQ‑B. The most frequent items reported by
the parents/caregivers were “suddenly cries at night,”
“puts away [refuses] something nice to eat,” and “bites
with molars instead of front teeth.”
Mother’s age, mother’s schooling, monthly household
income, severe dental caries, and a number of erupted
teeth were associated with higher DDQ‑B scores
(P < 0.05) in the univariate analysis [Table 2]. In the
multivariate model, a lower monthly household
income (PR = 1.33, 95% CI: 1.07–1.66, P = 0.011) and
severe dental caries (ICDAS codes 5 and 6) (PR = 1.48,
95% CI: 1.13–1.94, P = 0.004) were associated with
higher DDQ‑B scores [Table 3].
Discussion
This study investigated factors associated with
dental pain detected using the Brazilian version of
the DDQ‑B.[15] This is the rst study to determine
such associations in children aged 1–3 years using a
validated pain assessment tool. Strong associations
were found between dental pain and both cavitated
dental caries and monthly household income. These
ndings are of considerable importance to gaining
a better understanding of the determinants of pain
in childhood and can assist in the establishment of
priorities in public health policies directed at young
children and their families. Considering the impact
on the growth and well‑being of affected children, the
study of dental pain is relevant.[5]
The only oral clinical condition associated with higher
DDQ‑B scores was severe dental caries. The association
between dental pain and dental caries experience has
also been reported in previous studies.[6,9,19,20] More
advanced stages of dental caries require more invasive
treatment and involve greater pain experience, thereby
restricting the daily activities of affected children.[12]
This nding is in agreement with data described in
studies addressing the impact of the severity of caries
of the quality of life of preschool children.[21,22] Thus, it
is of extreme importance for pain to be recognized in
children aged 1–3 years and for appropriate treatment
to be instituted to eliminate pain and the negative
impact of this condition exerts on quality of life.
Besides dental caries, other oral problems, such as
traumatic dental injury and symptoms associated with
tooth eruption, are also reported to be possible reasons
for the occurrence of dental pain. However, no such
associations were found in the present study, which
was likely due to the low prevalence of severe traumatic
dental injuries (0.7%) and reports of the occurrence of
teething in nearly the entire sample (87.8%).
As in the present investigation, the association
between tooth pain and socioeconomic factors has
been described in the literature,[1,6,8‑10,19] which may be
the result of inequalities in the distribution of dental
caries that are inuenced by such factors. Cultural or
behavioral theories seek explanations for health with
regard to social classes.[1,19] The social component exerts
a strong inuence on access to health‑care services,
reecting the negative effects of a low socioeconomic
status.[10] Moreover, socioeconomic differences can
exert an important inuence on parents’/caregivers’
perceptions. Studies have demonstrated that
parents/caregivers with a lower socioeconomic status
have more pessimistic opinions and are more prone
to evaluating their children’s oral health as poor in
comparison to those with a higher socioeconomic
status.[21,22]
Although the present study offers original evidence,
the cross‑sectional design does not permit the
determination of causality among the variables
analyzed. Thus, studies with a prospective design
are needed to clarify the associations found in this
investigation.
Table 1: Distribution of Dental Discomfort Questionnaire‑B responses in survey of parents in
population‑based sample (n=318)
DDQ items Never, n (%) Sometimes, n (%) Often, n (%)
Bites with molar instead of front teeth 218 (68.6) 60 (18.9) 40 (12.6)
Puts away something nice to eat 190 (59.7) 100 (31.4) 28 (8.8)
Crying during meals 244 (76.7) 64 (20.1) 10 (3.1)
Problems chewing 269 (84.6) 38 (11.9) 11 (3.5)
Chewing on one side 246 (77.4) 54 (17.0) 18 (5.7)
Reaching for the cheek while eating 267 (84.0) 45 (14.2) 6 (1.9)
Suddenly cries at night 175 (55.0) 122 (38.4) 21 (6.6)
DDQ=Dental Discomfort Questionnaire
[Downloaded free from http://www.jisppd.com on Monday, September 24, 2018, IP: 158.46.169.124]

Fernandes, et al.: Dental pain in toddlers
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018
254
While self‑reports are the gold standard for the
evaluation of dental pain, parents/caregivers are
considered the best available proxy for individuals
with incomplete cognitive development.[14,23] The
DDQ‑B is a reliable, useful assessment tool for the
investigation of behaviors related to dental pain in
children <5 years of age.[12] Thus, this questionnaire
can serve as an important tool in the organization of
health‑care services and the application of oral health
promotion policies directed at children aged 1–3 years.
All in all, this report stresses the occurrence of dental
pain in children as young as 1‑year‑old, which is
associated with dental caries severity. This outcome
Table 2: Univariate analysis for association between oral clinical conditions, characteristics of children,
sociodemographic and economic factors in relation to dental pain (Dental Discomfort Questionnaire‑B)
Covariates n (%) PR (95% CI) P
Gender
Female 171 (53.8) 1
Male 147 (46.2) 0.98 (0.79‑1.22) 0.884
Age
1 year 104 (32.7) 1
2 years 120 (37.7) 1.10 (0.88‑1.39) 0.397
3 years 94 (29.6) 1.12 (0.85‑1.46) 0.430
Mother’s age
>25 years 155 (48.7) 1
≤25 years 163 (51.3) 1.30 (1.05‑1.59) 0.013
Number of siblings
None 147 (46.2) 1
One 105 (33.0) 0.93 (0.73‑1.17) 0.522
Two or more 66 (20.8) 0.82 (0.62‑1.10) 0.194
Mother’s schooling (years of study)
≥12 years 99 (31.1) 1
9‑11 years 164 (51.6) 1.05 (0.83‑1.32) 0.676
<8 years 55 (17.3) 1.59 (1.17‑2.16) 0.003
Household income
≥2 minimum wage 118 (37.1) 1
<2 minimum wage 200 (62.9) 1.39 (1.11‑1.73) 0.003
Number of individuals living on income
<3 144 (45.3) 1
>3 174 (54.7) 0.90 (0.73‑1.11) 0.325
Family situation
Nuclear 213 (67.0) 1
Nonnuclear 105 (33.0) 1.29 (1.04‑1.60) 0.019
Type of preschool
None 177 (55.7) 1
Private 32 (10.1) 0.80 (0.58‑1.11) 0.177
Public 109 (34.3) 0.92 (0.73‑1.15) 0.456
Child’s access to a dentist
Yes 125 (39.3) 1
No 193 (60.7) 0.95 (0.77‑1.18) 0.649
Early childhood caries
Caries free 110 (34.6) 1
Initial lesion 67 (21.1) 1.13 (0.86‑1.47) 0.391
Established lesion 28 (8.8) 1.29 (0.97‑1.72) 0.081
Severe lesion 113 (35.5) 1.60 (1.25‑2.05) <0.001
Traumatic dental injury
Absence 235 (73.9) 1
Presence 83 (26.1) 0.92 (0.74‑1.14) 0.441
Signs and symptoms of tooth eruption
No 38 (11.9) 1
Yes 280 (88.1) 1.22 (0.81‑1.83) 0.340
Number of erupted teeth ‑ mean (SD) 16.85 (SD=4.69) 1.02 (1.00‑1.04) 0.039
PR=Prevalence ratio; SD=Standard deviation; CI=Condence interval
[Downloaded free from http://www.jisppd.com on Monday, September 24, 2018, IP: 158.46.169.124]

Fernandes, et al.: Dental pain in toddlers
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018 255
emphasizes the need to initiate educational and
preventive programs on oral health from the 1st year
of a child’s life.
Conclusions
Greater frequencies of dental pain were found in
1–3‑year‑old children from families with a low monthly
income and dental caries with visible dentin with or
without pulp involvement.
Acknowledgments
We show our appreciation to the members of Babies
Oral Health Group (BOHG), for promoting, organizing
and conducting all procedures related to this study and
others. The contributors are: Túlio Silva Pereira, Ana
Beatriz Rodrigues, Hlorrany Jayne Barroso de Queiroz,
Janine Emanuelle de Almeida Gomes, Priscila Seixas
Mourão, Valéria Silveira Coelho, Anny Karoline Silva
Mercês, Tássio Alvim Corrêa de Barros, Felipe Alisson
Prates Mota.
Financial support and sponsorship
This study was nancially supported by Conselho
Nacional de Desenvolvimento Cientíco e Tecnológico
(CNPq), Fundação de Amparo à Pesquisa de Estado
de Minas Gerais (Fapemig) and Coordenação de
Avaliação e Melhoramento de Pessoal de Educação
Superior (CAPES).
Conicts of interest
There are no conicts of interest.
References
1. Ratnayake N, Ekanayake L. Prevalence and impact of oral
pain in 8-year-old children in Sri Lanka. Int J Paediatr Dent
2005;15:105-12.
2. Moure-Leite FR, Ramos-Jorge J, Ramos-Jorge ML, Paiva SM,
Vale MP, Pordeus IA, et al. Impact of dental pain on daily
livingofve‑year‑oldbrazilianpreschoolchildren:Prevalence
and associated factors. Eur Arch Paediatr Dent 2011;12:293-7.
3. Clementino MA, Gomes MC, Pinto-Sarmento TC, Martins CC,
Granville-Garcia AF, Paiva SM, et al. Perceived impact of
dentalpainonthequalityoflifeofpreschoolchildrenandtheir
families. PLoS One 2015;10:e0130602.
4. Boeira GF, Correa MB, Peres KG, Peres MA, Santos IS,
Matijasevich A, et al. Caries is the main cause for dental
pain in childhood: Findings from a birth cohort. Caries Res
2012;46:488-95.
5. Ortiz FR, Tomazoni F, Oliveira MD, Piovesan C, Mendes F,
Ardenghi TM, et al. Toothache, associated factors, and its
impact on oral health‑related quality of life (OHRQoL) in
preschool children. Braz Dent J 2014;25:546-53.
6. Ferreira-Júnior OM, Freire Mdo C, Moreira Rda S, Costa LR.
Contextual and individual determinants of dental pain
in preschool children. Community Dent Oral Epidemiol
2015;43:349-56.
7. Khanh LN, Ivey SL, Sokal-Gutierrez K, Barkan H,
Ngo KM, Hoang HT, et al. Early childhood caries, mouth
pain, and nutritional threats in Vietnam. Am J Public Health
2015;105:2510-7.
8. Barrêtto EP, Ferreira EF, Pordeus IA. Determinant factors of
toothache in 8- and 9-year-old schoolchildren, belo horizonte,
MG, brazil. Braz Oral Res 2009;23:124-30.
9. Schuch HS, Correa MB, Torriani DD, Demarco FF,
Goettems ML. Perceived dental pain: Determinants and impact
on Brazilian schoolchildren. J Oral Facial Pain Headache
2015;29:168-76.
10. Slade GD. Epidemiology of dental pain and dental caries
among children and adolescents. Community Dent Health
2001;18:219-27.
11. Versloot J, Veerkamp JS, Hoogstraten J. Dental discomfort
questionnaire for young children before and after treatment.
Acta Odontol Scand 2005;63:367-70.
Table 3: Final Poisson regression model for
covariates associated with Dental Discomfort
Questionnaire‑B
Covariates PR (95% CI) P
Socioeconomic characteristics ‑ level 1
Mother’s schooling (years of study)
≥12 years 10
9‑11 years 0.95 (0.73‑1.24) 0.693
<8 years 1.39 (0.97‑2.00) 0.069
Household income
≥2 minimum wage 1
<2 minimum wage 1.31 (1.02‑1.68) 0.037
Type of preschool
None 1
Private 0.91 (0.64‑1.30) 0.620
Public 0.90 (0.72‑1.12) 0.336
Sociodemographic characteristics ‑ level 2
Mother’s age
>25 years 1
≤25 years 1.15 (0.93‑1.42) 0.193
Family situation
Nuclear 1
Nonnuclear 1.13 (0.89‑1.42) 0.323
Number of siblings
None 1
One 0.96 (0.77‑1.21) 0.742
Two or more 0.82 (0.61‑1.11) 0.201
Household income
≥2 minimum wage 1
<2 minimum wage 1.32 (1.03‑1.68) 0.027
Oral clinical conditions ‑ level 3
Early childhood caries
Caries free 1
Initial lesion 1.08 (0.82‑1.43) 0.574
Established lesion 1.17 (0.85‑1.61) 0.337
Severe lesion 1.48 (1.13‑1.94) 0.004
Number of erupted teeth 1.01 (0.98‑1.03) 0.545
Household income
≥2 minimum wage 1
<2 minimum wage 1.33 (1.07‑1.66) 0.011
Model adjusted for the variables signicant in the nal model of previous
levels. PR=Prevalence ratio; CI=Condence interval
[Downloaded free from http://www.jisppd.com on Monday, September 24, 2018, IP: 158.46.169.124]

Fernandes, et al.: Dental pain in toddlers
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018
256
12. Daher A, Abreu MH, Costa LR. Recognizing preschool
children with primary teeth needing dental treatment because
of caries-related toothache. Community Dent Oral Epidemiol
2015;43:298-307.
13. Clementino MA, Pinto-Sarmento TC, Costa EM, Martins CC,
Granville-Garcia AF, Paiva SM, et al. Association between
oral conditions and functional limitations in childhood. J Oral
Rehabil 2015;42:420-9.
14. Versloot J, Veerkamp JS, Hoogstraten J. Dental discomfort
questionnaire:Assessmentofdentaldiscomfortand/orpaininvery
young children. Community Dent Oral Epidemiol 2006;34:47-52.
15. Daher A, Versloot J, Leles CR, Costa LR. Screening preschool
children with toothache: Validation of the brazilian version
of the dental discomfort questionnaire. Health Qual Life
Outcomes 2014;12:30.
16. Criteria Manual: International Caries Detection and
Assessment System (ICDAS) Coordinating Committee,
Bogota and Budapest; 2009. Available from: http://www.
icdas.org/downloads. [Last accessed on 2016 Jan 20].
17. Andreasen JO,Andreasen FM. Classication, Etiology and
Epidemiology. Textbook and Color Atlas of Traumatic Injuries
to the Teeth. 3rd ed. Copenhagen: Munksgaard; 1994.
18. Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role
of conceptual frameworks in epidemiological analysis:
A hierarchical approach. Int J Epidemiol 1997;26:224-7.
19. Barrêtto Ede P, Ferreira e Ferreira E, Pordeus IA. Evaluation
of toothache severity in children using a visual analogue scale
of faces. Pediatr Dent 2004;26:485-91.
20. Ferraz NK, Nogueira LC, Pinheiro ML, Marques LS,
Ramos-Jorge ML, Ramos-Jorge J, et al.Clinicalconsequences
of untreated dental caries and toothache in preschool children.
Pediatr Dent 2014;36:389-92.
21. Ramos‑JorgeJ, PordeusIA, Ramos‑Jorge ML, Marques LS,
PaivaSM.Impactofuntreateddentalcariesonqualityoflifeof
preschool children: Different stages and activity. Community
Dent Oral Epidemiol 2014;42:311-22.
22. Gomes MC, Pinto-Sarmento TC, Costa EM, Martins CC,
Granville-Garcia AF, Paiva SM, et al. Impact of oral health
conditionsonthequalityoflifeofpreschoolchildrenandtheir
families: A cross-sectional study. Health Qual Life Outcomes
2014;12:55.
23. Perera I, Ekanayake L. Factors inuencing perception of
oral health among adolescents in Sri Lanka. Int Dent J
2008;58:349-55.
[Downloaded free from http://www.jisppd.com on Monday, September 24, 2018, IP: 158.46.169.124]