Relationship between sense of coherence and dental attendance patterns among Brazilian adolescents

Abstract

This study aimed to investigate if sense of coherence (SOC) is associated with dental attendance (DA) patterns among Brazilian adolescent students. A cross-sectional study was conducted in the midwestern region of Brazil. A total of 2,905 adolescents aged 13 to 19 years from 14 public schools in 13 towns/cities in the state of Goiás were included in the study. Data on oral health-related behaviors and psychosocial factors were collected using self-administered questionnaires completed by students during regular school hours. The dependent variables were DA in the past year (yes/no) and the reason for DA (toothache/preventive check-up). SOC was assessed using the Antonovsky’s Orientation to Life questionnaire (SOC-13). Adjusted odds ratios (OR) and 95% confidence intervals were estimated using binary logistic regression. Results showed that 56.2% of the students had visited a dentist within the past year, most commonly for a preventive check-up (38.7%). SOC scores ranged from 13 to 91 (mean = 49.3; SD = 12.1). In the regression model adjusted for adolescents’ sociodemographic characteristics (age, sex, skin color or race, and maternal education), higher prevalence rates of DA in the past year (OR = 1.02; p < 0.001) and DA motivated by preventive check-ups (OR = 1.02; p < 0.001) were found among those with higher SOC scores. In conclusion, a significant association was found between higher SOC levels and healthier DA patterns among adolescents, regardless of socioeconomic characteristics.

Descriptors
Adolescent; Dental Health Services; Health Behavior; Oral Health; Sense of Coherence

Introduction

Dental attendance (DA), including the use of dental services and attendance patterns, is one of the major behavioral factors influencing oral health throughout life.¹,² The use of dental services is usually measured by self-reported dental visits within the past 12 months. Current evidence suggests that healthier DA patterns involve routine preventive check-ups rather than attendance prompted solely by dental emergencies. Regular DA positively influences both clinical and self-reported oral health outcomes, including lower dental caries experience, fewer missing teeth, better oral health-related quality of life, and higher self-rated oral health status.¹,²

During adolescence, individuals are susceptible to risky behaviors that can extend into adulthood, including irregular DA, that is, only visiting the dentist when experiencing an oral health problem.³,⁴ Still, the efforts to investigate, assess, and enhance oral health are mainly targeted at young children and adults. Therefore, policies, education, and research should be encouraged to address the specific oral health challenges faced by the adolescent population.⁴

Social factors are among the most relevant aspects affecting DA among adolescents. Those from lower socioeconomic backgrounds tend to exhibit less favorable DA patterns, as they frequently encounter substantial barriers to accessing dental care.⁵-⁸ In addition, psychosocial factors such as sense of coherence (SOC)⁹ may play an important role among the predisposing factors of adolescents’ oral health and related behaviors, including DA.¹⁰-¹⁵

SOC is the central psychosocial construct of the salutogenic model of health, which represents a shift from the traditional pathogenic model that is focused on disease. SOC is defined as the sense of orientation that individuals develop in life, enabling them to comprehend and manage stressful stimuli in an appropriate, meaningful, and health-promoting way.⁹ SOC develops during childhood and adolescence, shaped by familial and life experiences, oscillating during early adolescence and reaching a certain stability from late adolescence to young adulthood.⁹,¹⁶

Both parental and adolescent SOC have been investigated in terms of oral health and related behaviors during childhood and adolescence.¹⁰-¹⁴,¹⁷-²⁴ A directly proportional relationship between maternal SOC and children’s DA has been reported, that is, those children whose mothers had a higher SOC were more likely to report the use of dental services and preventive check-ups.¹⁰,¹³,¹⁷-²³

Nonetheless, the number of primary studies assessing the role of adolescents’ SOC in relation to their DA pattern remains limited.¹⁴,¹⁷,²⁰ Adolescents attending private and public schools in Brazil with a higher SOC were more likely to visit the dentist, mainly for check-ups.¹⁴ In another study of Brazilian adolescents attending public schools in socially disadvantaged areas, SOC was not associated with their use of dental services in the past 12 months.²⁰ Yet, a two-year follow-up of the same cohort showed that the decline in SOC over one year decreased the likelihood of dental services utilization in the past 12 months.¹⁷

These controversial findings in the scarce literature indicate the need for further research. In this study, we aimed to investigate whether SOC was associated with DA patterns among Brazilian adolescent students. More specifically, the aim was to assess whether adolescents with a higher SOC were more likely to visit the dentist in the past year, and whether they mainly visit the dentist for regular preventive check-ups.

Methods

Study design, setting, and participants

We conducted a cross-sectional school-based survey. The sample consisted of high school students attending 14 federal public schools in 13 municipalities in the state of Goiás, in the midwestern region of Brazil. All schools consented to participate. Students aged between 13 and 19 years were considered eligible, and all those who were at school at the time of data collection were invited to participate. Those who agreed to participate answered a self-administered printed questionnaire in their classrooms under the supervision of a researcher. The questionnaire was designed for the survey, externally reviewed by a panel of six PhD researchers with expertise in health-related surveys and pre-tested among a group of 14 adolescent students in one public school.

Study variables

In the present analysis, the two dependent variables were binary: 1) DA in the past 12 months, at least once (no/yes); and 2) primary reason for DA among those with prior attendance (toothache/regular check-ups). DA in the past 12 months and regular visits for check-ups were considered healthier behaviors in the present analysis, in line with previous studies on adolescents.¹⁴,¹⁷,²⁰

The independent explanatory variable was the adolescents’ SOC assessed using the Orientation to Life Questionnaire (SOC-13).⁹ The SOC-13 consists of 13 items on a 7-point Likert scale with descriptive endpoints indicating the extent to which life aspects occur. The total score was obtained by summing the individual scores of all 13 items, ranging from 13 to 91, with the higher scores indicating stronger SOC.⁹ In the present study, we used the SOC-13 scale, adapted for Brazilian adolescents and widely used in previous Brazilian studies.¹⁴ The adaptation process involved adjusting an available European Portuguese version to Brazilian Portuguese.¹⁴

The independent variables analyzed as covariates were the sociodemographic characteristics of the sample: 1) sex (male/female); 2) age (in years); 3) self-reported skin color or race, considering the official classification adopted in Brazil (White, Black, Brown, Yellow (Asian descendants), and Indigenous, dichotomized into Black, Brown, Yellow, Indigenous/White); and 4) level of education of the adolescents’ mothers dichotomized into low (eight years of study or less) and high (nine years of study or more).

Statistical analysis

Descriptive statistics were calculated as absolute and relative frequencies (N; %) or mean scores with standard deviations (M; SD). Only slight deviations from normality were observed in the distribution of SOC scores, using statistical tests, Q-Q plots, histograms, and boxplots. Thus, this numerical variable was analyzed as continuous. Bivariate associations between the independent variables and the outcomes were then assessed using Pearson’s chi-square test for independent categorical variables and independent samples t-test for independent continuous variables. The statistical significance level was set at 5%. Finally, a multivariate analysis was performed using binary logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (CI) between SOC and each of the two dependent variables, adjusting for the covariates.

The cutoff point used to include variables in the unadjusted regression model was a p-value < 0.20 in bivariate analyses. Only variables statistically associated (p < 0.05) with the dependent variable were maintained in the final regression model. All analyses were performed using the IBM SPSS software.

Ethical aspects

The study protocol was approved by the Research Ethics Committee (REC) of the Federal University of Goiás (REC/UFG) (Approval N. 2142027) and the Federal Institute of Goiás (Approval N. 2556510). All students signed an informed consent form, and the REC/UFG exempted the study from obtaining parental consent for the participation of underage adolescents (Approval N. 2431088).

Results

A total of 3,034 of the 3,043 invited adolescents agreed to participate (response rate = 99.7%). Cases with missing data on DA and/or SOC were excluded, resulting in a final sample of 2,905 respondents.

Descriptive analysis (Table 1) showed that more than half of the participants were female (N = 54.1%), and the mean age was 16.01 (SD = 1.10). Regarding self-reported skin color or race, 68.3% of the participants belonged to the Black, Brown, Yellow or Indigenous group. Most mothers had a high level of education, defined as nine or more years of study (72.1%). With respect to DA, most students reported visiting a dentist in the past year (56.2%), with routine check-ups (38.7%) being their usual motivation for DA. The SOC score ranged from 13 to 91 points, and the mean SOC was 49.30 points (SD = 12.14).

Table 1
Characteristics of study participants (n = 2,905).

Variablesa	n	%
Sex (n = 2,900)
Male	1,33	45.9
Female	1,57	54.1
Color or race (n = 2,895)
Black, Brown, Yellow, Indigenous	1,977	68.3
White	918	31.7
Maternal education (years of study) (n = 2,902)
Low (≤ 8)	781	26.9
High (≥ 9)	2,019	69.5
Did not know	102	3.5
Dental attendance in the past year (n = 2,905)
Yes	1,634	56.2
No	1,271	43.8
Reason for dental attendance (n = 2,905)
Toothache	1,027	35.3
Check-ups	1,123	38.7
Did not know or remember/Never visited	755	26.0
	M	SD
Age (n = 2,892)	16.01	1.10
Sense of coherence (n = 2,905)	49.30	12.14

• M: Mean. SD: Standard deviation. ^aA smaller number of cases indicates missing data.

Bivariate analysis indicated that higher SOC was associated with adolescents reporting DA in the past year (p < 0.001) (Table 2). Higher SOC was also associated with DA motivated by check-ups (p < 0.001) (Table 3). Among the covariates, skin color/race was associated with DA in the past year, while maternal education was associated with both outcomes (p < 0.05).

Table 2
Bivariate analysis of factors associated with dental attendance in the past year among Brazilian adolescents (n = 2,905).

Variablesa	Dental attendance in the past year
	Yes	No	p-value*
	n (%)	n (%)
Sex (n = 2,900)
Male	756 (56.8)	574 (43.2)	0.548
Female	875 (55.7)	695 (44.3)
Color or race (n = 2,895)
Black, brown, yellow, indigenous	1,081 (54.7)	896 (45.3)	0.013
White	547 (59.6)	371 (40.4)
Maternal education (years of study) (n = 2,800)
Low (≤ 8)	401 (51.3)	380 (48.7)	0.001
High (≥ 9)	1,182 (58.5)	837 (41.5)
	M (SD)	M (SD)	p-value**
Age (n = 2,892)	16.02 (1.10)	16.01 (1.11)	0.804
Sense of coherence (n = 2,905)	50.40 (11.85)	47.90 (12.37)	< 0.001

• M: Mean. SD: Standard deviation. ^aA smaller number of cases in the covariates indicates missing data and, in the case of maternal education, missing data and responses of “I don’t know”. *Pearson’s chi-square test. **Independent samples t-test. Bold values indicate statistical significance.

Table 3
Bivariate analysis of factors associated with the reason for dental attendance among Brazilian adolescents (n = 2,150).

Variablesa	Reason for dental attendance
	Check-ups	Toothache	p-value*
	n (%)	n (%)
Sex (n = 2,147)
Male	538 (54.5)	450 (45.5)	0.066
Female	585 (50.5)	574 (49.5)
Color or race (n = 2,143)
Black, brown, yellow, indigenous	739 (51.8)	689 (48.2)	0.542
White	380 (53.1)	335 (46.9)
Maternal education (years of study) (n = 2,077)
Low (≤ 8)	238 (41.2)	339 (58.8)	<0 .001
High (≥ 9)	847 (56.5)	653 (43.5)
	M (SD)	M (SD)	p-value**
Age (n = 2,142)	15.99 (1.12)	16.08 (1.08)	0.077
Sense of coherence (n = 2,150)	51.22 (12.01)	48.53 (11.81)	< 0.001

• M: Mean. SD: Standard deviation. ^aA smaller number of cases in the covariates indicates missing data and, in the case of maternal education, missing data and responses of “I don’t know”. *Pearson’s chi-square Test. **Independent samples t-test. Bold values indicate statistical significance.

In the regression analyses (Table 4), SOC remained statistically associated with both dependent variables. After adjusting for the adolescents’ sociodemographic characteristics, an increase in SOC raised the likelihood of DA in the past year (OR = 1.02; p < 0.001) and DA for check-ups (OR = 1.02; p < 0.001), in comparison with no visit in the past year and DA only in case of toothache, respectively. Maternal education also remained associated with both dependent variables. In other words, compared with adolescents whose mothers had a high level of education, those whose mothers had a low level of education were less likely to report DA in the past year (OR = 0.77; p = 0.002) and less likely to report DA primarily for routine check-ups (OR = 0.56; p < 0.001). Additionally, in comparison with White adolescents, those who were not White (Black, Brown, Yellow, or Indigenous) were less likely to report DA in the past year (OR = 0.84; p < 0.05).

Table 4
Logistic regression analysis of the association between sense of coherence and dental attendance among Brazilian adolescent students.

Model 1	Dental attendance in the past year – Yes (N=2,792)
	Unadjusted OR (95%CI)	p-value*	Adjusted OR (95%CI)	p-value *
Sense of coherence	1.017 (1.011–1.024)	<.001	1.017 (1.011–1.023)	<0.001
Color or race
Black, brown, yellow, indigenous	.817 (.695–.960)	.014	.839 (.712–.987)	0.035
White	1		1
Maternal education (years of study)
Low (≤ 8)	.748 (.634–.883)	.001	.767 (.649–.907)	0.002
High (≥ 9)	1		1
Model 2	Reason for dental attendance–Check-ups (N=2,067)
Sense of coherence	1.019 (1.012–1.027)	<.001	1.018 (1.011–1.026)	< 0.001
Age	.927 (.857–1.002)	.056
Sex
Male	1.187 (.998–1.412)	.053
Female	1
Maternal education (years of study)
Low (≤ 8)	.540 (.444–.656)	<.001	.552 (.453–.672)	< 0.001
High (≥ 9)	1		1

• *Wald test. Bold values indicate statistical significance.

Discussion

This study evaluated the association between SOC scores and DA patterns among Brazilian adolescent students. Considering that a strong SOC in this age group is generally associated with healthier oral health-related behaviors,¹⁰-¹⁵ we hypothesized that higher SOC would be associated with a healthier DA pattern, indicated by at least one dental visit in the past year and regular dental visits for check-ups. This study contributes to complementing and strengthening the current knowledge on this issue, given the limited and controversial evidence in the literature.¹⁴,¹⁷,²⁰

Our findings revealed that adolescents with a higher SOC were more likely to have visited a dentist in the past year and were usually motivated by regular check-ups. These findings corroborate those of the first study investigating the association between SOC and DA among adolescent students.¹⁴ In contrast, another study showed no statistical association between these variables.²⁰Although these cross-sectional studies were conducted in Brazil, other methodological aspects may contribute to the conflicting results. For example, the previous study reporting contrasting findings was carried out among socially disadvantaged schoolchildren,²⁰ while the other study included students from diverse socioeconomic backgrounds,¹⁴ as in the present study.

Taken together, the current and previous findings suggest that a strong SOC may indicate greater oral health awareness among adolescents. Therefore, strengthening their SOC as a psychosocial resource may be a good strategy to improve DA at this stage of life. Adolescents with a high SOC tend to have a more positive perception of their oral health and may be more capable of managing their available resources to address concerns about their dental appearance or oral symptoms, which are common in this age group. This is known as ‘manageability’.⁹,¹⁷ A two-year cohort study found a deterioration of adolescents’ DA patterns when their SOC declined.¹⁷ Also, SOC is an important psychosocial resource related to healthier patterns of DA among adults.²⁵-²⁸

The present study did not investigate the SOC of adolescents’ parents or guardians. Nevertheless, students whose mothers had a higher level of education exhibited a better DA pattern. Given that a high level of education may be a proxy for higher socioeconomic status, which is associated with a higher SOC,²⁹ it is reasonable to presume that maternal SOC also contributed to the healthier DA pattern of adolescents, as reported in previous studies.¹⁰,¹³-¹⁵,¹⁷,²⁰-²⁴Importantly, in addition to receiving free education in public schools, Brazilian adolescents are entitled to free dental services.

Regarding individual sociodemographic characteristics, those adolescents who self-identified as White were more likely to have visited a dentist in the past year than those belonging to other racial or skin color groups. Furthermore, a high level of maternal education played a protective role against an unhealthy DA pattern. These findings reflect persistent social inequalities in oral health worldwide over the past decades, and underscore the need for concerted action to address them and promote equity in oral health.³⁰

Some limitations of this study should be acknowledged. The data are representative only of adolescents attending public schools. Notably, this study and previous studies on adolescents’ SOC and their DA patterns were carried out in Brazil, an upper middle-income country. Therefore, the findings cannot be generalized to other socioeconomic and geographic contexts. Furthermore, as this was a cross-sectional study, no causal relationships can be established between the studied variables, nor can it be concluded that higher SOC among adolescents resulted in healthier DA patterns. Notable strengths of this study include its methodological rigor, strong internal validity, and large sample size. In addition, this study adds knowledge to the currently limited evidence base.

The current findings indicate that SOC may be a psychosocial ally in promoting adolescents’ motivation to adopt healthier DA patterns. Of note, school-based interventions designed to enhance SOC have proven to be effective in promoting oral health among children and adolescents.³¹ Therefore, interventions aimed at improving SOC may be combined with oral health education to empower and inform adolescents about healthy vs. risky behaviors, improving their understanding and encouraging their orientation towards regular preventive dental visits.

Conclusions

High SOC was associated with a healthier DA pattern, even among adolescents whose characteristics indicated greater social vulnerability. Those with a higher SOC were more likely to report having visited a dentist in the past year and seeking dental care mainly for routine check-ups.

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• Data availability:
  The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
• Financial support:
  Fundação de Amparo à Pesquisa do Estado de Goiás (Fapeg), Goiás, Brasil (public call 04/2017), and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) (Finance Code 001).

Edited by

• Editor-in-Chief:
  Lucianne Maia

• Associate Editor:
  Mauro Henrique Abreu

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Publication Dates

• Publication in this collection
  20 Mar 2026
• Date of issue
  2026

History

• Received
  6 May 2025
• Accepted
  7 Aug 2025
• Received
  10 Oct 2025