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INTRODUCTION
Caries is a multifactorial disease considered as a public health problem due to its high prevalence. In permanent teeth, untreated caries is the most prevalent condition worldwide, while it ranks tenth in deciduous teeth.1 In Peru, the prevalence of dental caries in children under 11 years of age is 85% and in children aged 3 to 5 years it is 76%, according to studies conducted by Peru’s Ministry of Health.2 This condition may affect the quality of life of individuals, representing an extra expense for families and health systems.3,4,5 There are preventive measures for the onset of dental caries, with fluoride being frequently used due to its high effectiveness. Fluoride is most commonly present in toothpastes.2,3,5,6 Decreasing the prevalence of cavities also requires changes among the population, with good habits and behaviors, which should be developed throughout life.2,7
It is important for health promotion policies to implement strategies to promote oral hygiene habits both individually and collectively.5 To this end, public and private institutions should provide information in an appropriate and easily accessible manner.8,9 One of the most important habits is toothbrushing, which main objective is to eliminate and prevent the development of bacterial plaque in dental areas. It should be done daily and at least twice a day, with a toothpaste of ³1000 ppm of fluoride.2,6 It is recommended to start tooth brushing by the age of 6 months, with the eruption of the first tooth.6 Research has found that toothbrushing frequency is related to factors such as age and socioeconomic position.10,11
Due to the importance of toothbrushing for good oral health and the acquisition of knowledge for an adequate oral hygiene practice, the objective of this study was to determine the impact of access to oral care and hygiene information on toothbrushing practices in children under 12 years of age in Peru in 2017. The results will support decision-making for new strategies for the promotion and prevention of oral health.
METHODS
This cross-sectional study used data from the 2017 National Survey on Demographics and Family Health (Encuesta Nacional en Demografía y Salud Familiar, ENDES). ENDES collects data through household interviews about socioeconomic and demographic characteristics, health status, risk factors, and access to health services. Originally, 36,595 households were selected, with a non-response rate of 2.2% and 34,879 households interviewed. For the study population, the database was analyzed, showing 42,349 records of children aged 0 to 11 years, including dental care data and oral hygiene information.12 Records with complete data were included, removing those that did not have all the information related to the study’s variables. 18,273 records were excluded (16,103 cases in the independent variable and 2,170 in all other variables) for a final sample of 24,076 children (Figure 1).
The database on the National Institute for Statistics and Informatics’ (Instituto Nacional de Estadística e Informática, INEI) website was accessed. The information was available in modules, and those that showed the variables of interest were accessed and merged into a single database. Three dependent variables comprising the reported toothbrushing practices were considered: daily toothbrushing (yes/no), frequency of toothbrushing (1 time a day/2 or more times a day) and use of toothpaste (yes/no). The independent variable was access to information on oral care and hygiene of teeth, tongue, and mouth (yes/ no). The covariables included: provider of information on oral care and hygiene, which was recategorized into 7 categories: MINSA (Peru’s Ministry of Health or Ministerio de Salud), EsSalud (Peru’s Social Security agency), Armed Forces and Police Forces (known in Peru as FF. AA. and FF. PP.), Private sector, Mass Media, Educational Institutions and No Information. Other covariables included as possible confounding factors were sex (male/female); age presented as quantitative variable, which was grouped and presented as a dichotomous variable: 0 to 5 years and 6 to 11 years, taking into account an approximate age of dental replacement, i.e. deciduous dentition and mixed teething; natural region (Lima Metropolitan Area, Coast, Highlands, and Jungle), and area of residence (urban and rural).
The descriptive analysis was run by obtaining absolute and relative frequencies, followed by an analysis using the Chi- square and Chi-square linear trend test with 95% CI to observe the associations of brushing practices with other variables. The association between brushing practices and access to oral care and hygiene information was measured with generalized models (Poisson), using one crude and one adjusted model for all covariables. Since the practice of toothbrushing is a prevalent condition, prevalence ratio (PR) was reported as an association measure. The study had a 95% confidence interval and a p < 0.05. The statistical program STATA SE/15.1 was used. Data analysis incorporated the survey design. Sampling patterns were specified as stratification, primary sampling unit and weights, to obtain representative estimates.
The study was approved by the Institutional Ethics Committee of the Universidad Peruana Cayetano Heredia on March 6, 2019. ENDES has a publicly accessible database and the identification of participants is encrypted to ensure confidentiality.
RESULTS
The results obtained in surveys about toothbrushing practices show that 86.8% of children and/or their parents reported they brush their teeth daily. Regarding daily toothbrushing frequency, 42.5% reported they brush their teeth 2 times a day, a similar percentage (42.4%) indicated that they brush 3 to more times a day, and 15.2% only 1 time a day. Most respondents (98.5%) reported using toothpaste while brushing. 62.4% of children reported access to oral health and hygiene information. Regarding providers of oral health information, the public sector was the main provider with MINSA (32.1%) and EsSalud (7.2%), followed by the private sector with 11.4%. Concerning demographic characteristics, there was a predominance of males with 51.1% and the 6-11-year-old group with 63.6%. As for natural region, Lima Metropolitan area showed the highest concentration with 31.7% and the urban area accounted for 75.8% of the sample (Table 1).
Table 1 Sample characteristics
| Variable | n | % |
|---|---|---|
| Received information on oral hygiene | ||
| Yes | 14,679 | 62.4 |
| No | 9,397 | 37.6 |
| Source of information | ||
| No information received | 9,397 | 37.6 |
| MINSA | 8,659 | 32.1 |
| ESSALUD | 1,559 | 7.2 |
| FF. AA. and FF. PP. | 41 | 0.2 |
| Private sector | 1,935 | 11.4 |
| Mass Media | 1,213 | 5.8 |
| Institutional education | 1,272 | 5.8 |
| How many times a day | ||
| 1 time a day | 3,329 | 15.2 |
| 2 times a day | 7,805 | 42.50 |
| 3 or more times a day | 7,606 | 42.4 |
| Use of toothpaste when brushing | ||
| No | 421 | 1.5 |
| Yes | 2,1746 | 98.5 |
| Sex | ||
| Male | 12,200 | 51.1 |
| Female | 11,876 | 48.9 |
| Age | ||
| 0-5 years | 11,137 | 36.4 |
| 6-11 years | 12,939 | 63.6 |
| Natural region | ||
| Metropolitan Lima | 2,604 | 31.7 |
| Coast | 7,397 | 25.4 |
| Highlands | 7,823 | 27.5 |
| Jungle | 6,252 | 15.4 |
| Area of residence | ||
| Urban | 16,775 | 75.8 |
| Rural | 7,301 | 24.2 |
n: Absolute frequency
%: Proportion with weights
Source: by the authors
The bivariate analysis showed that all associations were significant (p < 0.001) in evaluating daily toothbrushing against other variables: getting oral health and hygiene information, providers of oral hygiene information, age, natural region, and area of residence, with the exception of gender. When analyzing toothbrushing frequency against all variables, it was found that the associations were statistically significant (p < 0.05). Regarding to the for association of the use of toothpaste while brushing with all variables, these were not significant except for age (p < 0.001), finding out that 87.8% of children aged 0-5 years did not use toothpaste when brushing (Table 2).
Table 2 Analysis of toothbrushing against the study variables
N: Absolute frequency
P-value: The Chi2 and Chi2 linear trend test was used
* FF. AA. and FF. PP. were not considered to assess association
%: Proportions with weights Source: by the authors
The multivariate analysis showed that, in analyzing the relationship between daily brushing information and access to oral hygiene information in the crude model, children who received oral hygiene information were 3% more likely to brush their teeth daily (95% CI 1.02-1.05; p <0.001). In the final model, after adjusting for the covariables, the estimates remained, finding out that children who received information were 4% more likely to brush their teeth daily (95% CI 1.02-1.06; p <0.001), compared to children who did not receive oral hygiene information. The analysis of association of brushing frequency and access to oral hygiene information in the unadjusted model showed that children who received information were 6% more likely to brush their teeth 2 or more times a day (95% CI 1.04-1.08; p <0.001), compared with children who did not receive oral hygiene information. In the final model, after adjusting by covariables, the estimates remained virtually unchanged. No statistically significant association was found in the crude model (95% CI 1.00-1.01; p = 0.238) nor in the adjusted model (95% CI 1.00-1.01; p = 0.187) among children who received oral hygiene information and use toothpaste while brushing. When evaluating all the associations analyzed in the final models, sex was not a significant variable, while age was significant, with the older group most likely to practice brushing compared to the younger age group (p < 0.001). In addition, the Highlands region and the rural area were less likely to brush daily and have a lower frequency of brushing compared to Metropolitan Lima and the urban area (Table 3).
Table 3 Multivariate analysis using Poisson models
| Variable | DAILY TOTHBRUSHING | TOOTHBRUSHING FREQUENCY | USE OF TOOTHPASTE | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Model 1 Crude | Model 2 Adjusted | Model 1 Crude | Model 2 Adjusted | Model 1 Crude | Model 2 Adjusted | |||||||||||||
| PR | 95% CI | p | PR | 95% CI | p | PR | 95% CI | p | PR | 95% CI | p | PR | 95% CI | p | PR | 95% CI | p | |
| Received oral hygiene information | ||||||||||||||||||
| No | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. | ||||||||||||
| Yes | 1.03 | 1.02-1.05 | <0.001 | 1.04 | 1.02-1.06 | <0.001 | 1.06 | 1.04 - 1.08 | <0.001 | 1.06 | 1.04-1.08 | <0.001 | 1 | 1-1. 01 | 0. 238 | 1 | 1-1.01 | 0. 187 |
| Sex | ||||||||||||||||||
| Male | Ref. | Ref. | Ref. | |||||||||||||||
| Female | 1 | 0.99-1.01 | 0.916 | 1.01 | 0. 99-1.03 | 0.396 | 1 | 0.99-1 | 0.73 | |||||||||
| Age | ||||||||||||||||||
| 0-5 years | Ref. | Ref. | Ref. | |||||||||||||||
| 6-11 years | 1.1 | 1.08-1.11 | <0.001 | 1. 06 | 1.04-1.08 | <0.001 | 1.04 | 1.03-1.04 | <0.001 | |||||||||
| Natural Region | ||||||||||||||||||
| Metropolitan Lima | Ref. | Ref. | Ref. | |||||||||||||||
| Coast | 1 | 0.99-1.03 | 0.513 | 0.99 | 0.97-1.02 | 0. 943 | 0. 99 | 0.99 -1 | 0.043 | |||||||||
| Highlands | 0.9 | 0.88-0.92 | <0.001 | 0.93 | 0.90-0.95 | <0.001 | 0. 99 | 0.99-1 | 0.049 | |||||||||
| Jungle | 1.02 | 1-1.04 | 0.049 | 0.99 | 0.96-1.01 | 0.331 | 1.01 | 1-1.01 | 0.066 | |||||||||
| Area of residence | ||||||||||||||||||
| Urban | Ref. | Ref. | Ref. | |||||||||||||||
| Rural | 0.96 | 0.95-0.98 | <0.001 | 0.98 | 0.96-1 | 0.082 | 1 | 1-1.01 | 0.549 |
Source: by the authors
DISCUSSION
The findings of the present study showed a significant association between daily toothbrushing and frequency of brushing with access to oral care and hygiene information in children under the age of 12 in Peru. It is worth noting that the extent of this association may be considered as either irrelevant or strong because of the obtained results (4% and 6% more compared to their counterparts). This result might suggest that other factors not included in this analysis, in addition to oral hygiene information, may be more relevant for the practice of toothbrushing. The literature shows that the Social Determinants of Health (SDOH), specifically the structural ones, such as socioeconomic conditions and public policies, can influence intermediate determinants such as personal habits and lifestyles.13 It is therefore necessary to focus on the SDOH as it is fundamental to achieve a substantial change. However, health education cannot be neglected. The acquisition of knowledge on the improvement of oral health depends to a large extent on the programs, institutions and health policies produced.14 One of the basics for the prevention of tooth decay is oral hygiene, which includes proper toothbrushing accompanied by the proper use of toothpaste as it contains fluoride. All this oral care and hygiene information can be acquired from various sources, but the literature shows that it is mainly acquired through the dental professional,10 as shown in the present study.
According to the data from this study, the prevalence of access to oral hygiene information in children under 12 years of age was 62.4%. Villavicencio-Montenegro and León-Manco conducted a research project with ENDES between 2013 and 2016, reporting that access to oral care and hygiene information increased over the years, being 61.7% for the last year of their study; our findings in 2017 show a slight increase.15 Caldeira et al found that schoolchildren who received information on how to avoid oral problems had optimal oral health behaviors.16 Similarly the present study showed that children who received oral hygiene information were more likely to brush their teeth, compared to children who did not receive such information. This study found that the main providers of oral health information were public sector institutions: MINSA with the highest coverage percentage (32.1%), followed by EsSalud with 7.2% and Armed and Police Forces with 0.2%, while the private sector accounted for 11.4%. On the contrary, a study conducted in Brazil found that the main provider of information was the private sector.14 Both studies and others conducted in Europe show that the main provider of hygiene and oral care information is the dental professional.10
The frequency of toothbrushing is an important component. The literature recommends brushing at least twice a day using a fluoridated toothpaste ³1000 ppm.2,7 In this study, brushing 2 or more times a day was more prevalent than brushing once a day. A research project in Brazil in 12-year-olds found similar results. In the present study, children who received oral hygiene information were 6% more likely to brush their teeth 2 or more times a day; this could be due to the fact that several years ago Peru released a technical standard which emphasizes that toothbrushing should be performed 2 or more times a day, and this is the information currently being provided.2 Most interviewees reported using toothpaste when brushing their teeth. No statistically significant association was found between children who received oral care and hygiene information and the use of toothpaste while brushing, suggesting that its use may be associated with simple repetition of behaviors or habits, or also that people infer its use when brushing their teeth.
In adjusting by covariables, age was the only significant variable, finding out that the use of toothpaste while brushing was less prevalent in children aged 0-5 years. The MINSA’s “Clinical Practice Guideline for the Prevention, Diagnosis and Treatment of Tooth Decay in Children” (“Guía de práctica clínica para la prevención, diagnóstico y tratamiento de la caries dental en niñas y niños”) differentiates the amount of toothpaste by children, emphasizing that, in kids under 3 years of age, it should be the size of a “grain of rice”, while in kids over 3 years of age it should be the size of a “pea”.2,7 However, the literature is scarce regarding the start of brushing with toothpaste. The evidence shows that the sooner the brushing and use of toothpaste starts, the less likely tooth decay will occur. Toothbrushing that starts before the age of one year keeps 88% of children free from carious lesions, while starting after age 2 keeps only 66% of children free of carious lesions.17,18,19 The same database of the 2017 ENDES survey shows that 35.9% of children in their first year of life had visited a dental service (results not shown). Some findings agree with these results, such as those by Schwendler et al in Brazil, where educational actions aimed at the population receiving Primary Health Care were prioritized, with 35% having their first visit during the first year of life,20 similar to the situation in Peru. By contrast, a population study in the UK found that 57% of children under the age of 1 visited a dentist,9 a situation that contrasts with that of Latin America, where less access to health services, fewer resources, more social inequities, and less emphasis on prevention and more on treatment delay the first visit to the dental professional, thus reducing the access to health care and oral hygiene information.
To the authors’ knowledge, this is the first national study that evaluates the association of access to oral care and hygiene information with toothbrushing practices. New and useful information was offered to public health policymakers. However, the study had certain limitations, as a large proportion of data was lost due to incomplete information on the variables of interest. Nevertheless, being a national survey, with stratification and weights, the information is reliable, of quality, and representative of the population. The present study is highly important because it shows Peru’s reality regarding access to information on oral care and hygiene and the reported information on toothbrushing practices in children under the age of 12, showing a significant association even after adjusting for possible confounding factors.
It is critical for children to receive dental care during the eruption of the first deciduous tooth following the MINSA’s recommendations, because it serves as an opportunity to evaluate the eating habits and risk factors children may be exposed to;21 in addition, there is a wealth of information that they can receive from their parents to contribute to the prevention of oral diseases and the development of proper oral hygiene habits. A correct approach to national oral health policies is recommended to improve access to information by parents of children in deciduous teeth. It is also recommended for future studies on access to information and toothbrushing in children to take into account the socioeconomic position when evaluating these variables, in order to determine its impact.
CONCLUSIONS
It can be concluded that there was an association between access to oral hygiene information and daily toothbrushing and brushing frequency in children under 12 years of age in Peru in 2017, even after adjusting for possible confounding factors such as age, sex, natural region, and area of residence, with children aged 6 to 11 and living in the urban area being the ones who most practice dental brushing and at an appropriate frequency. However, no association was found between access to oral hygiene information and use of toothpaste while brushing.
