
==== Front
Braz Oral Res
Braz Oral Res
bor
Brazilian Oral Research
1806-8324
1807-3107
Sociedade Brasileira de Pesquisa Odontológica - SBPqO

38922206
00701
10.1590/1807-3107bor-2024.vol38.0046
Original Research/Cariology
Association between underlying dentin shadows (ICDAS 4) and OHRQoL among adolescents from southern Brazil
https://orcid.org/0000-0001-5061-6039
MARQUEZAN Patrícia Kolling (a)
https://orcid.org/0000-0002-9386-4785
COMIM Letícia Donato (b)
https://orcid.org/0009-0002-6613-3717
RACKI Débora Nunes de Oliveira (b)
https://orcid.org/0000-0001-6053-9591
DALLA NORA Ângela (c)
https://orcid.org/0000-0003-0110-7929
ALVES Luana Severo (b)
https://orcid.org/0000-0003-0302-4449
ZENKNER Julio Eduardo do Amaral (c)
(a) Universidade Federal de Santa Maria – UFSM, Department of Microbiology and Parasitology, Santa Maria, RS, Brazil
(b) Universidade Federal de Santa Maria – UFSM, Department of Restorative Dentistry, Santa Maria, RS, Brazil
(c) Universidade Federal de Santa Maria – UFSM, Department of Stomatology, Santa Maria, RS, Brazil
Corresponding Author: Luana Severo Alves E-mail: luanaseal@gmail.com
Declaration of Interests: The authors certify that they have no commercial or associative interest that represents a conflict of interest in connection with the manuscript.

24 6 2024
2024
38 e04625 7 2023
27 11 2023
16 2 2024
https://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

This study aimed to assess the association between underlying dentin shadows (UDS) and oral health-related quality of life (OHRQoL) among 15-19-year-old adolescents from southern Brazil. This population-based cross-sectional study included a representative sample of 1,197 15–19-year-old adolescents attending 31 public and private schools from Santa Maria, Brazil. The Oral Health Impact Profile-14 (OHIP-14) was used to evaluate the OHRQoL, and clinical examinations were performed by two calibrated examiners (intra/interexaminer kappa values for caries examination ≥ 0.80) to diagnose UDS (ICDAS code 4 caries lesions). Sociodemographic information and clinical characteristics (overall caries experience, traumatic dental injury, malocclusion, and gingivitis) were also collected as adjusting variables. Multilevel Poisson regression models were used to assess the association between UDS and OHRQoL. Rate ratios (RR) and 95% confidence intervals (CI) were estimated. The UDS prevalence was 8.8% (n = 106 adolescents). In the adjusted models, adolescents with UDS had poorer OHRQoL than those without UDS, and the strength of the association was dependent on the number of lesions per individual. Individuals with 1-2 UDS had a mean OHIP-14 score 8% higher (RR = 1.08; 95%CI: 1.01–1.17) than adolescents without UDS, while those with 3-4 UDS had a mean score 35% higher (RR = 1.35; 95%CI: 1.12–1.63). This negative association was related to physical disability, psychological disability, social disability, and handicap domains. This study showed that UDS was associated negatively with OHRQoL among 15–19-year-old adolescents from southern Brazil. The negative effect of UDS on OHRQoL emphasizes the importance of addressing issues regarding OHRQoL even in the posterior teeth of adolescents.

Dental Caries
Adolescent
Quality of Life
Cross-Sectional Study
Epidemiology
==== Body
pmcIntroduction

The concept of health includes biopsychosocial models in which physical, emotional, and social well-being is interconnected. 1 Oral health strongly influences this process, given its bearing on the ability to speak, eat, and socialize. 2 Poor oral health directly affects one’s oral health-related quality of life (OHRQoL), defined as a multidimensional construct that describes an individual’s subjective perspective, based on his/her oral symptoms and experiences. 3 Major challenges during adolescence involve achieving good oral health and improving the OHRQoL, since this stage of life represents a period of constant changes, adaptations to new environmental and psychological structures, and the construction of the adolescents’ identity. 4 Poor oral health behaviors in this age group make adolescence a high-risk period for the development of caries lesions. 5

An estimated 2.3 billion people worldwide suffer from tooth decay in the permanent dentition. 6 According to Brazil’s last national oral health survey, 35.8% of adolescents aged 15–19 years had decayed teeth. 7 Epidemiological studies have consistently found that caries is negatively associated with OHRQoL in adolescents. 8-15 The degree of impact of caries on OHRQoL is directly related to the number of affected teeth, 16,17 lesion severity, 18 intraoral distribution 19 and dental pain. 20 Not only cavitated caries lesions, but also moderate caries lesions, such as underlying dentin shadows (UDS), can have a potentially negative impact on OHRQoL. Classified as code 4 by the International Caries Detection and Assessment System (ICDAS), 21 UDS appear as a discolored dentin shadow visible through an apparently intact enamel surface, which may or may not show signs of localized breakdown. The darkened area is an intrinsic shadow that may appear gray, blue or brown, and may influence the self-perception of oral health, mainly among adolescents. Despite this assumption, no previous study has investigated this issue to date.

Although the prevalence of this lesion was recently found to be low in young populations, 22,23 its possible relationship with OHRQoL must be investigated. Therefore, the aim of this study was to assess the association between UDS in the occlusal surfaces of permanent posterior teeth and OHRQoL among 15–19-year-old adolescents from southern Brazil. The hypothesis was that adolescents who present UDS have poorer OHRQoL.

Methods

Study design and sample

A population-based cross-sectional study was carried out to assess the oral health status of adolescents aged 15–19 years old from Santa Maria, a mid-sized city located in southern Brazil. All the 37 high schools in the municipality were invited to participate in the study (26 public and 11 private), 31 of which agreed to participate (22 public and 9 private).

A total of 1,066 adolescents were found to be needed for the study. The sample size calculation used the following parameters: a prevalence rate of 50% (worst case scenario), a 95% confidence interval (CI), a power of 80%, and a precision level of 3%. Considering a non-participation rate of 50%, 1,600 adolescents were invited to participate.

Eligibility criteria

Adolescents born in the years 1999–2003, attending any school period (morning, afternoon, or night), and not using fixed orthodontic appliances were considered eligible. Students with special needs (cognitive or physical impairments that prevented them from answering the questionnaire, or from being clinically examined in the school setting) were not considered eligible for the study. A list of all eligible schoolchildren was compiled for each school, and those eligible were selected using a table of random numbers (http://www.random.org).

Data collection

Data collection was conducted from March to November 2018, and included questionnaires and a clinical examination. A self-administered questionnaire was used to gather information on sociodemographic characteristics (sex, age, skin color, mother’s level of education, and socioeconomic status). It was sent to the parents/legal guardians of the selected students to be completed at home.

The Oral Health Impact Profile-14 (OHIP-14) was used to evaluate the OHRQoL. This questionnaire is an instrument that measures people’s perception of the social impact of oral disorders on their well-being. 24 The OHIP-14 was translated into Brazilian Portuguese and validated for the language. 25 It is the short version of a longer instrument, and is composed of 14 questions related to seven conceptually formulated dimensions: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. The answers to each question are based on a Likert scale grade: never = 0 point, rarely = 1 point, sometimes = 2 points, often = 3 points, and always = 4 points. The sum of the answers provides a score ranging from 0 to 56 points – the higher the score, the poorer the OHRQoL. 24-26 The OHIP-14 was applied to the selected adolescents in the school setting, just before the clinical oral examination.

Clinical examinations were conducted at the schools, with the students in a supine position, using portable equipment (artifical light and air compressor). A sterile clinical mirror and a periodontal probe were also used. The teeth were cleaned with a toothbrush and dried prior to caries examination. Cotton rolls were used to ensure proper moisture control, and dental caries was recorded by two calibrated examiners. Caries examination included the recording of both non-cavitated and cavitated lesions, as well as caries activity assessment. 27 In addition, the presence of UDS was also recorded, as defined by the ICDAS. 21 In addition, traumatic dental injuries (TDI) were assessed by using the O’Brien classification, 28 gingivitis, by using the gingival bleeding index (GBI), 29 and malocclusion, according to the dental aesthetic index (DAI). 30

Training and calibration

Clinical examination was performed by two calibrated examiners (DNOR, ADN). Training sessions using photographs, study models, and clinical exams were performed under the supervision of a benchmark examiner. The examiners’ calibration was assessed in 10 adolescents before the start of the study, and its continued validity during the survey was checked by repeated examinations of 20 schoolchildren out of every 400 examined (totaling 5% of the sample). The minimal time interval between examinations was 7 days. The minimal value of the intraexaminer kappa coefficient was 0.81 for dental caries and 0.89 for TDI, while the minimal interexaminer kappa value was 0.80 for dental caries and 0.77 for TDI. The minimal intraclass correlation coefficient for DAI measures was 0.89 (intraexaminer) and 0.87 (interexaminer). As for the GBI, training was performed under the supervision of an experienced periodontist, but no calibration was performed due to the temporary nature of the condition.

Ethical aspects

The Research Ethics Committee of the Federal University of Santa Maria approved the study protocol (# 2.178.299). All participants (≥ 18 years old) or their parents/legal guardians signed a written informed consent form. Underage participants signed a written assent form. The students received a report of their oral health status, and were referred to dental treatment when needed.

Data analysis

The outcome of this study was OHRQoL, measured as the overall and domain-specific OHIP-14 scores. The main predictor variable was the extent of UDS, defined as the number of permanent posterior teeth with occlusal UDS per individual (0, 1–2 or 3–4).

Sociodemographic adjusting variables included sex (male or female), age (15, 16, 17 or 18–19 years), skin color (non-white or white), and socioeconomic status (SES). The SES categories were defined by using the cutoff points proposed by the standard Brazilian economic classification, 31 and households were classified as having a low (≤ 16), mid-low (≥ 17 to ≤ 22), mid-high (≥ 23 to ≤ 28) or high (≥ 29 point) SES. Clinical adjusting variables were malocclusion (absent [DAI ≤ 25], or present [DAI > 25]), 32 dental caries experience at the cavity level (absent [DMFT = 0], or present [DMFT ≥ 1]), 30 and gingivitis (absent [<10% of sites with bleeding on probing], or present [≥ 10% of sites with bleeding on probing]). 33 Figure presents all the variables included in the study.

Figure Variables included in the study (DAI, Dental Aesthetic Index; DMFT, Decayed, Missing or Filled Teeth Index).

Data analysis was performed using STATA software (Stata 11.1 for Windows; Stata Corporation, College Station, USA), which used survey commands that performed all the descriptive analyses according to the survey design. A weight variable was used to adjust for potential bias in the population estimates, based on the probability of selection and population distribution according to sex and school type. The overall and the domain-specific OHIP-14 mean scores and standard errors (SE) were reported. Preliminary analysis comparing the mean OHIP-14 scores among the categories of the predictors was done using the Wald test.

The association between UDS (main predictor variable) and OHRQoL was assessed using multilevel Poisson regression models. The multilevel model considered the adolescent as the first-level unit, and the school as the second-level unit. The multilevel model used the scheme of fixed effect with random intercept. Unadjusted and adjusted rate ratios (RR) and 95% confidence intervals (CI) were estimated. All the variables were included and maintained in the adjusted model, irrespective of their p-values. The level of significance was set at 5%.

Results

A representative sample of 1,197 out of the 1,656 15–19-year-old adolescents was included in the study, thus representing a response rate of 72.3%. A total of 106 adolescents presented at least one occlusal UDS in a permanent posterior tooth, corresponding to 8.8% (95%CI: 0.65–0.13) of the sample. The mean OHIP–14 score was 8.25 (95%CI: 7.75–8.75), ranging from 0 to 49. Table 1 summarizes the distribution of the sample and the OHIP–14 scores, according to sociodemographics and clinical characteristics. OHIP–14 scores differed significantly among the categories of all the variables studied, except for gingivitis, TDI, and UDS.

Table 1 Sample distribution and OHIP–14 scores by predictor variables.

Variables	n (%)	Mean (SE)**	Range	
Socio–demographics	
Sex	
Boys	513 (42.9)	7.36 (0.40)a	0–38	
Girls	684 (57.1)	9.10 (0.32)b	0–49	
Age	
15	276 (23.2)	7.67 (0.56)abc	0–36	
16	379 (31.7)	7.51 (0.31)b	0–49	
17	367 (30.7)	8.58 (0.38)cd	0–43	
18–19	175 (14.6)	10.2 (0.76)d	0–40	
Skin color*	
White	384 (33.0)	9.01 (0.40)a	0–49	
Non–white	779 (67.0)	7.90 (0.26)b	0–43	
Mother’s education*	
≤ Primary school	577 (50.2)	8.74 (0.35)a	0–49	
High school	380 (33.1)	8.20 (0.36)a	0–34	
University	192 (16.8)	6.53 (0.54)b	0–33	
Socioeconomic status*	
Low	201 (17.4)	10.35 (0.53)a	0–40	
Mid–Low	320 (27.6)	8.70 (0.45)b	0–43	
Mid–High	302 (26.1)	8.26 (0.24)b	0–38	
High	335 (29.0)	6.88 (0.47)c	0–49	
Clinical variables	
Malocclusion	
Absent (DAI ≤ 25)	293 (24.5)	7.01 (2.50)a	0–32	
Present (DAI > 25)	904 (75.5)	8.66 (0.33)b	0–49	
Gingivitis	
Absent (<10% bleeding sites)	1,031 (86.1)	8.07 (0.27)a	0–49	
Present (≥10% bleeding sites)	166 (13.9)	9.35 (0.70)a	0–37	
Traumatic dental injuries	
Absent	993 (83.0)	8.07 (0.30)a	0–49	
Present	204 (17.0)	9.10 (0.54)a	0–43	
Dental caries experience	
Absent (DMFT = 0)	641 (53.5)	6.81 (0.32)a	0–43	
Present (DMFT ≥ 1)	556 (46.4)	9.95 (0.39)b	0–49	
Underlying dentin shadow	
0	1,091 (91.1)	8.20 (0.24)a	0–49	
1–2	95 (8.0)	9.00 (1.20)a	0–43	
3–4	11 (0.9)	10.90 (3.18)a	0–36	
Total	1,197 (100)	8.24 (0,25)	0–49	
SE: standard error; DAI: Dental aesthetic index; DMFT: decayed, missing, and filled teeth index. *Missing data. **Taking into account the sampling weight. Different letters indicate statistically significant difference between categories (p < 0.05, adjusted Wald test).

The association between UDS and the overall and domain–specific OHIP–14 scores is shown in Table 2. In the unadjusted models, the presence of 1–2 UDS lesions was significantly associated with social disability, while the presence of 3–4 UDS lesions was significantly associated with psychological disability and handicap. The adjusted models, including sociodemographic and clinical variables, showed that adolescents with 1–2 UDS had a poorer OHRQoL than adolescents without UDS in the social disability domain (RR = 1.30; 95%CI: 1.02–1.64). In comparison, adolescents with 3–4 UDS lesions had a poorer OHRQoL for the physical disability (RR = 1.74; 95%CI: 1.04–2.91), psychological disability (RR = 1.72; 95%CI: 1.13–2.64), social disability (RR =1 .82, 95%CI: 1.00–3.30) and handicap domains (RR = 2.32, 95%CI: 1.24–4.34). Overall, adolescents with 1–2 UDS had an OHIP–14 score 8% higher than individuals without UDS (RR = 1.08; 95%CI: 1.01–1.17), and those with 3–4 UDS presented a more notable difference, with 35% higher mean scores than adolescents without UDS (RR = 1.35; 95%CI: 1.12–1.63). As for the other variables included in the adjusted models, all of them were significantly associated with the overall OHIP–14 score (p < 0.05).

Table 2 Association between UDS and both domain–specific and overall OHIP–14 scores among Brazilian adolescents (multilevel Poisson regression analysis).

Variables	Unadjusted	Adjusted†	
	
RR	95%CI	p-value	RR	95%CI	p-value	
Functional limitation	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	1.16	0.91–1.48	0.24	1.12	0.87–1.44	0.39	
3–4 UDS	1.12	0.55–2.28	0.75	1.22	0.60–2.49	0.58	
Physical pain	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	1.15	1.00–1.32	0.05	1.12	0.97–1.29	0.12	
3–4 UDS	1.15	0.78–1.70	0.47	1.22	0.82–1.82	0.32	
Psychological discomfort	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	1.13	0.99–1.28	0.07	1.07	0.94–1.23	0.30	
3–4 UDS	0.91	0.61–1.37	0.66	0.94	0.62–1.42	0.76	
Physical disability	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	0.87	0.68–1.12	0.28	0.84	0.66–1.09	0.19	
3–4 UDS	1.64	1.00–2.72	0.05	1.74	1.04–2.91	0.03	
Psychological disability	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	1.10	0.92–1.31	0.29	1.06	0.88–1.27	0.54	
3–4 UDS	1.58	1.04–2.41	0.03	1.72	1.13–2.64	0.01	
Social disability	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	1.36	1.08–1.71	0.01	1.30	1.02–1.64	0.03	
3–4 UDS	1.76	0.98–3.16	0.06	1.82	1.00–3.30	0.047	
Handicap	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	1.25	0.93–1.66	0.14	1.19	0.88–1.61	0.25	
3–4 UDS	2.06	1.12–3.82	0.02	2.32	1.24–4.34	0.008	
OHIP-14	 	 	 	 	 	 	
0 UDS	1.00	 	 	 	1.00	 	
1–2 UDS	1.12	1.122–1.125	< 0.001	1.08	1.01–1.17	0.03	
3–4 UDS	1.28	1.10–1.54	0.008	1.35	1.12–1.63	0.002	
RR: Rate ratio; CI: Confidence interval; UDS: Underling dentin shadow. †Estimates are adjusted for sex, age, skin color, socioeconomic status, dental caries experience, traumatic dental injuries, malocclusion, and gingivitis. Bold numbers identify p–values < 0.05.

Discussion

This study assessed the association between UDS and OHRQoL among 15–19–year–old adolescents from southern Brazil. Our main finding was that individuals with UDS had poorer OHRQoL than those without UDS, even after adjusting for important cofactors, thus confirming the study hypothesis. To the best of our knowledge, this was the first study to assess this association.

Quality of life indicators related to oral health are fundamental for understanding and measuring the physical and psychological influence of oral diseases in aggravating individual lives, particularly, joy of living, possibility of speaking, chewing capacity, social inclusion, 20 and, more recently, happiness. 35 In the present study, we found that adolescents with UDS had higher OHIP–14 scores than those without UDS, and that the magnitude of the association was related to the number of affected teeth – the higher the number of UDS, the greater the negative association with OHRQoL. After adjusting for important sociodemographic factors and oral conditions, we found that adolescents with 1–2 UDS had 8% higher overall OHIP–14 scores, while those with 3–4 UDS had 35% higher scores. Since it is not uncommon for many adolescents to feel embarrassed to admit issues regarding their appearance, 36 this is a plausible finding. The clinical aspect of these lesions, in black, blue or gray shadows, may make adolescents feel frustrated or worried about their teeth. This concern regarding aesthetics/appearance may explain the association between UDS and both the psychological disability and social disability domains, even considering that molars are the most commonly affected teeth. 23 Adolescents with 3–4 UDS had approximately 72% higher OHIP–14 scores in the psychological disability domain than their counterparts without UDS, thus indicating that they were more likely to have difficulty relaxing, or to feel embarrassed because of tooth–related problems. As for the social disability domain, a significant gradient was observed, namely that adolescents with 1–2 UDS and those with 3–4 UDS presented 30% and 82% higher scores, respectively, than those without UDS. This means that these individuals with UDS, versus those without it, were more commonly irritated by other people, or had more difficulty performing their usual activities because of teeth–related problems. It can be speculated that even the association with the handicap domain might be related to aesthetic issues, since it involves a feeling of being less satisfied with life due to oral problems.

Although we are dealing with UDS in posterior teeth, aesthetic–related demands for restorative procedures in posterior teeth are routine in clinical practice. This clearly indicates that aesthetics in the posterior segment is a concern for some individuals. Replacement of amalgam by tooth–colored restorations for aesthetic reasons have been reported in the literature. 37,38 Similarly, Spelid et al. showed that aesthetics were important to young Norwegian and Danish patients, even in scenarios dealing with restorations in posterior teeth. 39 Their study was designed to examine how dental professionals and young patients valued three attributes of dental restorations, namely expected longevity, appearance, and risk of adverse reaction. The authors showed that young patients were willing to sacrifice longevity much more than dentists, if it meant avoiding a highly visible restoration. 39 The increasing number of studies dealing with the aesthetic properties of composite resin restorations in molars is further evidence that aesthetics matters even in posterior teeth. 40 In this sense, dental professionals should be aware that patients may seek treatment for UDS in posterior teeth because of aesthetics/appearance.

As previously suggested in the literature, most UDS may present either no radiolucency, or radiolucency at the enamel–dentin junction, with only a few cases showing an obvious spread to dentin. 43,44 Unfortunately, radiographs of the sample cannot be obtained because of the field conditions under which epidemiological studies are conducted. However, considering the lack of an association between the OHIP–14 scores and both the functional limitation and physical pain domains, it is likely that the UDS observed in this study were not deep caries lesions, as corroborated by the literature on this topic. 43,44 Considering that most UDS present no radiographically evident spread to dentin, 43,44 and that the progression rate is low, as recently shown by our research group, 45 the indication of operatory treatment should be avoided whenever possible to avert the repetitive restorative cycle, mainly among young patients. Sharing this knowledge with patients could make them less concerned about their oral health, and ultimately improve their quality of life.

Our study was composed of a representative sample of 1,197 adolescents attending public and private schools at an undetermined school period, unlike other studies, which included only public school attendees. 20 In addition, although previous studies showed the relationship between dental caries and OHRQoL, 8 none specifically assessed UDS. Furthermore, we carried out a clinical examination protocol that included dental cleaning and drying, highly reproducible examiners, and a validated questionnaire to assess OHRQoL, thus providing methodological consistency and high internal validity. Another strength of this study was the statistical adjustment for a set of other variables that admittedly could explain the OHIP–14 scores. The lack of radiographic examination is a limitation of this study, as previously discussed. Knowledge of the radiographic presence/depth of the clinically detected UDS would help better understand the association between UDS and OHRQoL found in this study. It should also be borne in mind that this was a cross–sectional study, and that no causal relationship can be established. In conclusion, the present study showed that adolescents with UDS had poorer OHRQoL than those without UDS – the higher the number of lesions, the stronger the association.

Acknowledgments

We would like to acknowledge the support of the National Coordination of Post–graduate Education (Capes), the Brazilian Ministry of Education, and the Federal University of Santa Maria.
==== Refs
References

1 Borrell-Carrió F Suchman AL Epstein RM The biopsychosocial model 25 years later: principles, practice, and scientific inquiry Ann Fam Med 2004 2 6 576 582 10.1370/afm.245 15576544
2 Petersen PE Kjøller M Christensen LB Krustrup U Changing dentate status of adults, use of dental health services, and achievement of national dental health goals in Denmark by the year 2000 J Public Health Dent 2004 64 3 127 135 10.1111/j.1752-7325.2004.tb02742.x 15341135
3 Sischo L Broder HL Oral health-related quality of life: what, why, how, and future implications J Dent Res 2011 11 90 11 1264 1270 10.1177/0022034511399918 21422477
4 Xiang B Wong HM Perfecto AP McGrath CP The association of socio-economic status, dental anxiety, and behavioral and clinical variables with adolescents' oral health-related quality of life Qual Life Res 2020 09 29 9 2455 2464 10.1007/s11136-020-02504-7 32307626
5 Warren JJ Van Buren JM Levy SM Marshall TA Cavanaugh JE Curtis AM et al Dental caries clusters among adolescents Community Dent Oral Epidemiol 2017 12 45 6 538 544 10.1111/cdoe.12317 28671327
6 James SL Abate D Abate KH Abay SM Abbafati C Abbasi N et al Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 [published correction appears in Lancet. 2019 Jun 22;393(10190):e44] Lancet 2018 11 392 10159 1789 1858 https://doi.org/10.1016/S0140-6736 (18)32279-7 30496104
7 Ministério da Saúde (BR) Projeto SB Brasil 2010. Pesquisa Nacional de Saúde Bucal. Resultados Principais Brasília, DF Ministério da Saúde 2012
8 Bastos RS Carvalho ES Xavier A Caldana ML Bastos JR Lauris JR Dental caries related to quality of life in two Brazilian adolescent groups: a cross-sectional randomised study Int Dent J 2012 06 62 3 137 143 10.1111/j.1875-595X.2011.00105.x 22568738
9 Pulache J Abanto J Oliveira LB Bönecker M Porras JC Exploring the association between oral health problems and oral health-related quality of life in Peruvian 11- to 14-year-old children Int J Paediatr Dent 2016 03 26 2 81 90 10.1111/ipd.12160 25726961
10 Aimée NR van Wijk AJ Maltz M Varjão MM Mestrinho HD Carvalho JC Dental caries, fluorosis, oral health determinants, and quality of life in adolescents Clin Oral Investig 2017 06 21 5 1811 1820 10.1007/s00784-016-1964-3
11 Maia CV Mendes FM Normando D The impact of oral health on quality of life of urban and riverine populations of the Amazon: A multilevel analysis PLoS One 2018 11 13 11 e0208096 10.1371/journal.pone.0208096 30500840
12 Sfreddo CS Moreira CH Nicolau B Ortiz FR Ardenghi TM Socioeconomic inequalities in oral health-related quality of life in adolescents: a cohort study Qual Life Res 2019 09 28 9 2491 2500 10.1007/s11136-019-02229-2 31203563
13 Cadenas de Llano-Pérula M Ricse E Fieuws S Willems G Orellana-Valvekens MF Malocclusion, dental caries and oral health-related quality of life: a comparison between adolescent school children in urban and rural regions in Peru Int J Environ Res Public Health 2020 03 17 6 2038 10.3390/ijerph17062038 32204433
14 Paula JS Zina LG Jamieson L Mialhe FL The effect of caries increment on oral health-related quality of life among adolescents in Brazil: a 3-year longitudinal study Braz Oral Res 2020 34 e107 10.1590/1807-3107bor-2020.vol34.0107 32876116
15 Karki S Horváth J Laitala ML Vástyán A Nagy Á Sándor GK et al Validating and assessing the oral health-related quality of life among Hungarian children with cleft lip and palate using Child-OIDP scale Eur Arch Paediatr Dent 2021 02 22 1 57 65 10.1007/s40368-020-00525-x 32323224
16 Biazevic MG Rissotto RR Michel-Crosato E Mendes LA Mendes MO Relationship between oral health and its impact on quality of life among adolescents Braz Oral Res 2008 22 1 36 42 10.1590/S1806-83242008000100007 18425243
17 Chukwumah NM Folayan MO Oziegbe EO Umweni AA Impact of dental caries and its treatment on the quality of life of 12- to 15-year-old adolescents in Benin, Nigeria Int J Paediatr Dent 2016 01 26 1 66 76 10.1111/ipd.12162 25864531
18 Pinheiro SA Rodrigues HB Santos JT Granja GL Lussi A Leal SC et al Association of dental caries morbidity stages with oral health-related quality of life in children and adolescents Int J Paediatr Dent 2020 05 30 3 293 302 10.1111/ipd.12605 31834963
19 Severo Alves L Dam-Teixeira N Susin C Maltz M Association among quality of life, dental caries treatment and intraoral distribution in 12-year-old South Brazilian schoolchildren Community Dent Oral Epidemiol 2013 02 41 1 22 29 10.1111/j.1600-0528.2012.00707.x 22882480
20 Barasuol JC Santos PS Moccelini BS Magno MB Bolan M Martins–Júnior PA et al Association between dental pain and oral health–related quality of life in children and adolescents: a systematic review and meta–analysis Community Dent Oral Epidemiol 2020 48 4 257 263 10.1111/cdoe.12535 32383273
21 Ismail AI Sohn W Tellez M Amaya A Sen A Hasson H et al The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries Community Dent Oral Epidemiol 2007 06 35 3 170 178 10.1111/j.1600-0528.2007.00347.x 17518963
22 Marquezan PK Alves LS Damé-Teixeira N Maltz M Zenkner JE Prevalence and risk indicators for underlying dentin shadows among 12-year-old southern Brazilian schoolchildren Braz Oral Res 2021 11 35 e105 10.1590/1807-3107bor-2021.vol35.0105 34816894
23 Marquezan PK Comim LD Oliveira Racki DN Nora ÂD Alves LS Amaral Zenkner JE Prevalence, extent, risk indicators, and intraoral distribution of underlying dentin shadows (ICDAS 4) among 15-19-year-old South Brazilian adolescents J Conserv Dent 2022 25 6 630 635 10.4103/jcd.jcd_324_22 36591590
24 Slade GD Derivation and validation of a short-form oral health impact profile Community Dent Oral Epidemiol 1997 08 25 4 284 290 10.1111/j.1600-0528.1997.tb00941.x 9332805
25 Oliveira BH Nadanovsky P Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form Community Dent Oral Epidemiol 2005 08 33 4 307 314 10.1111/j.1600-0528.2005.00225.x 16008638
26 Baker SR Testing a conceptual model of oral health: a structural equation modeling approach J Dent Res 2007 08 86 8 708 712 10.1177/154405910708600804 17652196
27 Maltz M Barbachan e Silva B Carvalho DQ Volkweis A Results after two years of non-operative treatment of occlusal surface in children with high caries prevalence Braz Dent J 2003 14 1 48 54 10.1590/S0103-64402003000100009 12656465
28 O'Brien M Children's dental health in the United Kingdom London Her Majesty's Station Off 1994
29 Ainamo J Bay I Problems and proposals for recording gingivitis and plaque Int Dent J 1975 12 25 4 229 235 1058834
30 World Health Organization Oral health surveys: basic methods 4th Geneva World Health Organization 1997
31 Associação Brasileira de Estudos Populacionais Critério de classificação econômica brasileira São Paulo Associação Brasileira de Estudos Populacionais 2015
32 Jenny J Cons NC Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale Aust Dent J 1996 02 41 1 43 46 10.1111/j.1834-7819.1996.tb05654.x 8639114
33 Trombelli L Farina R Silva CO Tatakis DN Plaque-induced gingivitis: case definition and diagnostic considerations J Clin Periodontol 2018 06 45 S20 Suppl 20 S44 S67 10.1111/jcpe.12939 29926492
34 Sheiham A Oral health, general health and quality of life Bull World Health Organ 2005 09 83 9 644 16211151
35 Tuchtenhagen S Ortiz FR Ardenghi TM Antunes JL Oral health and happiness in adolescents: A cohort study Community Dent Oral Epidemiol 2021 04 49 2 176 185 10.1111/cdoe.12589 33135221
36 Colussi PR Hugo FN Muniz FW Rösing CK Oral Health-Related Quality of Life and Associated Factors in Brazilian Adolescents Braz Dent J 2017 28 1 113 120 10.1590/0103-6440201701098 28301028
37 Pouralibaba F Joulaei M Kashefimehr A Pakdel F Jamali Z Esmaeili A Clinical evaluation of reasons for replacement of amalgam restorations in patients referring to a dental school in iran J Dent Res Dent Clin Dent Prospect 2010 4 2 56 59 10.5681/joddd.2010.015
38 Al-Asmar AA Ha Sabrah A Abd-Raheam IM Ismail NH Oweis YG Clinical evaluation of reasons for replacement of amalgam vs composite posterior restorations Saudi Dent J 2023 03 35 3 275 281 10.1016/j.sdentj.2023.02.003 37091274
39 Espelid I Cairns J Askildsen JE Qvist V Gaarden T Tveit AB Preferences over dental restorative materials among young patients and dental professionals Eur J Oral Sci 2006 02 114 1 15 21 10.1111/j.1600-0722.2006.00282.x 16460336
40 Miletic V Marjanovic J Veljovic DN Stasic JN Petrovic V Color stability of bulk-fill and universal composite restorations with dissimilar dentin replacement materials J Esthet Restor Dent 2019 09 31 5 520 528 10.1111/jerd.12529 31580013
41 Batista GR Borges AB Zanatta RF Pucci CR Torres CR Esthetical properties of single-shade and multishade composites in posterior teeth Int J Dent 2023 09 2023 7783321 10.1155/2023/7783321
42 Mahrous AI Salama AA Shabaan AA Abdou A Radwan MM Color stability of two different resin matrix ceramics: randomized clinical trial BMC Oral Health 2023 09 23 1 665 10.1186/s12903-023-03364-6
43 Bertella N Moura S Alves LS Damé-Teixeira N Fontanella V Maltz M Clinical and radiographic diagnosis of underlying dark shadow from dentin (ICDAS 4) in permanent molars Caries Res 2013 47 5 429 432 10.1159/000350924 23712062
44 Marquezan PK Alves LS Dalla Nora A Maltz M Zenkner JEA Radiographic pattern of underlying dentin lesions (ICDAS 4) in permanent teeth Clin Oral Investig 2019 10 23 10 3879 3883 10.1007/s00784-019-02818-y
45 Marquezan PK Alves LS Comim LD Zenkner JE Underlying dentin shadows (ICDAS 4) in occlusal surface of permanent teeth have low progression rate after 1-2 years Caries Res 2023 57 5-6 584 591 10.1159/000533155 37562363
