Social Inequalities and Access to Oral Health: Factors Associated with Dental Caries in the Riverside Children Population in the Amazon Region of Pará

ABSTRACT

Objective:  To report the prevalence of caries and its associated factors in children aged 4 to 6 years isolated on two islands in the state of Pará.

Material and Methods:  This is a cross-sectional study, involving 170 children from five schools, with clinical examinations based on WHO standards (DMFT and dmft indices) and sociodemographic questionnaires adapted from national surveys, such as SB Brazil. Caries prevalence was calculated as the proportion of children with dmft > 0, expressed as percentages with 95% confidence intervals (95% CI). Bivariate associations between caries prevalence and independent variables were assessed using the chi-square or Fisher's exact tests. Logistic regression was conducted to identify factors associated with toothache.

Results:  A prevalence of 58.82% for caries was found, with frequent dental pain; associated factors include low income (54.12% with 1-2 minimum wages) and dependence on river transport (74.12%). Logistic regression identified low income (OR = 2.34) and reliance on river transport (OR = 1.89) as significant risk factors.

Conclusion:  The need for specific interventions, professional training, and recognition of limitations in generalizing to other contexts is highlighted, with the potential to stimulate reflection in similar realities.

Keywords:
Dental Caries Susceptibility; Healthcare Disparities; Rural Population; Social Determinants of Health.

Introduction

Dental caries remains a major global public health challenge, with a particularly high prevalence in early childhood (0-6 years), a period when primary teeth are most susceptible to caries [¹]. In Brazil, epidemiological surveys, such as SB Brazil 2023, reveal significant rates of caries in children, especially in socioeconomically vulnerable populations [²]. Although these data suggest a nationwide trend of decreasing caries prevalence, emerging evidence indicates that isolated groups, such as riverside communities, may not follow this trend due to socioeconomic disparities and limited access to health services [¹,³].

From a biological perspective, dental caries is a multifactorial disease driven by the interaction between cariogenic bacteria in the dental biofilm and fermentable carbohydrates in the diet, leading to a microbial imbalance that promotes the demineralization of dental structures [⁴]. Pitts et al. [⁴] add that the production of acids during the metabolism of sugars by biofilm microorganisms leads to the progressive loss of minerals from enamel and dentin, highlighting the complex etiology of the disease. These mechanisms highlight the need for context-specific research, especially in populations with distinct dietary and environmental exposures.

Despite the well-documented incidence of dental caries, riverine populations in the Amazon region of Pará, such as those on the islands of Combu and Cotijuba, remain underrepresented in epidemiological studies [⁵]. This gap persists due to the unfavorable socioeconomic conditions and geographic barriers that limit access to health services, factors that likely exacerbate the prevalence and severity of caries in these communities [⁶].

To address this disparity, this study aims to assess the prevalence of dental caries in children living on the islands of Combu and Cotijuba (Belém, Pará, Brazil) and to identify the sociodemographic, economic, and health access factors associated with this condition. By illuminating these determinants, the data are expected to provide vital evidence for global understanding of the epidemiology of caries in marginalized communities, supporting the development of equitable oral health strategies.

Material and Methods

Ethical Clearance and Study Design

It was an observational, cross-sectional epidemiological study. It was approved by the research ethics committee of the University Center of Pará (CESUPA), under opinion number 6.622.077 and CAAE number 69641123.0.0000.5169. Informed consent was obtained via a document for children's guardians, ensuring confidentiality by anonymizing the data and providing no financial incentives. Potential risks, such as discomfort during examinations, were minimized by providing a welcoming environment, and examiners were trained to handle young children sensitively.

Participants

Inclusion criteria included children aged 4 to 6, enrolled in the schools included in the study in 2023 and 2024, with parents who confirmed informed consent and demonstrated suitable behavior for clinical evaluation. Exclusion criteria were incomplete data, non-collaborative behavior, or absence on the day of collection. The final sample consisted of 170 children, distributed across 5 schools (1 in Cotijuba, 4 in Combu), evaluated after 12 boat trips by the research team. Children with unmet dental needs were referred to local services.

Data Collection

Data collection consisted of a sociodemographic questionnaire that collected information on children's and guardians' age, gender, skin color, family relationship, receipt of social benefits, access to the internet, transportation to school and to health services, household income, number of household residents, and guardians' educational level. Moreover, clinical examination of children was performed by trained and calibrated dentists in a "knee-to-knee" position at schools, using a mirror, probe, and natural light, with prior oral hygiene with a gaze soaked in distilled water to remove debris. Variables DMFT and dmft (sum of decayed, missing, and filled teeth) were measured according to the World Health Organization [⁷].

Only cavitated lesions were considered decayed. Inter-rater reliability was assessed using a Kappa coefficient ≥ 0.75, based on exclusive evaluations by three professionals certified by the Ministry of Health, who served as the gold standard at SB Brazil 2023 in Belém. Calibration between examiners occurred through initial examinations of six children, followed by discussion of disagreements, and then evaluation of 20 children aged 4 to 6 years.

Data Analysis

Collected data were entered into Microsoft Excel and analyzed using IBM SPSS software, version 26.0 (IBM Corp., Armonk, NY, USA). Caries prevalence was calculated as the proportion of children with dmft > 0, expressed as percentages with 95% confidence intervals (95% CI). Descriptive statistics of frequencies summarized sociodemographic, economic, and healthcare access variables. Bivariate associations between caries prevalence and independent variables were assessed using the chi-square or Fisher's exact tests, when appropriate. Variables with p < 0.20 in the bivariate analysis were included in the multivariate logistic regression model to identify independently associated factors, reported as odds ratios (OR) with 95% CI. Statistical significance was defined as p < 0.05. Missing data were treated by listwise deletion, with sensitivity analyses if the missingness rate exceeded 5%.

Results

The sociodemographic and economic profiles show a predominantly male population (52.94%), young (39.41% aged 4), and brown (64.69%), with high dependence on social benefits (91.18%) and river transportation (64.12% for school; 74.12% for health) (Table 1).

Table 1
Sociodemographic and economic distribution of children.

Variables	N (%)
Sex
Female	80 (47.06)
Male	90 (52.94)
Age (Years Old)
4	67 (39.41)
5	42 (24.71)
6	61 (35.88)
Skin Ccolor
White	14 (8.24)
Black	31 (18.24)
Yellow	2 (1.18)
Brown	110* (64.69)
Didn't know/didn't answer	13 (7.65)
Transportation to School
Walking	24 (14.12)
Bicycle	23 (13.53)
Motor vehicles	10 (5.88
River transportation	109* (64.12)
Others	4 (2.35)
Transportation to Health Services
Walking	10 (5.88)
Bicycle	16 (9.41)
Draft animals	6 (3.53)
Motor vehicles	9 (5.29)
River transportation	126* (74.12)
Others	3 (1.76)
History of Toothache
Yes	99* (58.23)
No	56 (32.94)
Never presented any pain/health issues	2 (1.18)
Didn't know/didn't answer	13 (7.65)

• ^*
  Statistically significant (p < 0.05).

Among the guardians, the majority are between 19 and 30 years old (59.42%), have incomplete high school education (32.35%), and have a household income of 1 to 2 minimum wages (54.12%) (Table 2). These factors were statistically significant (p<0.05), indicating associations with the prevalence of caries. The prevalence of dental caries among 170 children aged 4 to 6 years from the islands of Combu and Cotijuba, Belém, PA, was estimated at 58.82% (n=100), based on the proportion of children with DMFT/dmft > 0.

Table 2
Sociodemographic and economic distribution of guardians.

Variables	N (%)
Age (Years Old)
Up to 18	8 (4.71)
19 to 30	101* (59.42)
31 to 50	52 (30.58)
51 to 60	7 (4.12)
61 or older	2 (1.18)
Educational Level
No Schooling	4 (2.35)
Youth and Adult Education	2 (1.18)
Incomplete Elementary School	45 (26.47)
Complete Elementary School	38 (22.35)
Incomplete High School	55* (32.35)
Complete High School	26 (15.29)
Child’s Legal Guardian
Yes	154* (90.59)
No	13 (7.65)
Didn’t answer	3 (1.76)
Relationship with the Child
Grandparents	22 (12.94)
Brother/Sister	3 (1.76)
Stepmother/Stepfather	4 (2.35)
Adoptive Parent	3 (1.76)
Biological Parent	128* (75.29)
Aunt/Uncle	7 (4.12)
Neighbors/Others	3 (1.76)
Social Benefits
Yes	155* (91.18)
No	15 (8.82)
Internet Access
Yes	143* (84.12)
No	27 (15.88)
The Number of People Living in the House
Alone with a child	5 (2.94)
Two people and a child	34 (20)
More than 2 people and a child	128* (75.30)
Didn't know/didn't answer	3 (1.76)
Household income
Less than 1 Brazilian minimum wage	53 (31.18)
From 1 to 2 Brazilian minimum wages	92* (54.12)
More than 2 Brazilian minimum wages	15 (8.82)
Didn't know/didn't answer	10 (5.88)

• ^*
  Statistically significant (p < 0.05).

Clinical examinations revealed that most deciduous teeth were healthy, with the lower anterior teeth (72, 73, 81, and 82) least affected by cavitated lesions. In contrast, permanent teeth such as 14 (40% of 10 present) and 44 (33.33% of 15 present) exhibited higher rates, suggesting greater susceptibility in older children within the age range (Tables 3 and 4).

Table 3
Evaluation of deciduous teeth according to dmft criteria (per tooth).

Tooth		Decayed	Missing	Filled	Excluded	Healthy	Total
51	N	23	1	0	1	103*	128
	%	17.97	0.78	0.00	0.78	80.47	100.00
52	N	18	0	0	0	134*	152
	%	11.84	0.00	0.00	0.00	88.16	100.00
53	N	10	0	0	0	147*	157
	%	6.37	0.00	0.00	0.00	93.63	100.00
54	N	22	0	2	0	136*	160
	%	13.75	0.00	1.25	0.00	85.00	100.00
55	N	28	0	1	0	124*	153
	%	18.30	0.00	0.65	0.00	81.05	100.00
61	N	21	0	1	1	101*	124
	%	16.94	0.00	0.80	0.81	81.45	100.00
62	N	16	0	0	1	134*	151
	%	10.60	0.00	0.00	0.66	88.74	100.00
64	N	11	0	0	0	144*	155
	%	7.10	0.00	0.00	0.00	92.90	100.00
65	N	33	0	0	0	126*	159
	%	20.75	0.00	0.00	0.00	79.25	100.00
71	N	32	0	0	0	126*	158
	%	20.25	0.00	0.00	0.00	79.75	100.00
72	N	2	0	0	1	107*	110
	%	1.82	0.00	0.00	0.91	97.27	100.00
73	N	2	0	0	0	130*	132
	%	1.52	0.00	0.00	0.00	98.48	100.00
74	N	9	0	0	0	146*	155
	%	5.81	0.00	0.00	0.00	94.19	100.00
75	N	38	0	1	0	118*	157
	%	24.20	0.00	0.64	0.00	75.16	100.00
81	N	2	0	0	2	106*	110
	%	1.82	0.00	0.00	1.82	96.36	100.00
82	N	2	0	0	0	134	136
	%	1.47	0.00	0.00	0.00	98.53	100.00
83	N	8	0	0	0	148*	156
	%	5.13	0.00	0.00	0.00	94.87	100.00
84	N	41	0	1	0	112*	154
	%	26.62	0.00	0.65	0.00	72.73	100.00
85	N	34	0	1	0	120*	155
	%	21.94	0.00	0.65	0.00	77.41	100.00

• ^*
  Statistically significant (p < 0.05).

Table 4
Evaluation of permanent teeth according to DMFT criteria (per tooth).

Tooth		Decayed	Missing	Filled	Excluded	Healthy	Total
11	N	0	0	0	3	39*	42
	%	0.00	0.00	0.00	7.14	92.86	100.00
12	N	0	0	0	1	17*	18
	%	0.00	0.00	0.00	5.56	94.44	100.00
13	N	1	0	0	2	10*	13
	%	7.69	0.00	0.00	15.38	76.92	100.00
14	N	4	0	0	1	5	10
	%	40.00	0.00	0.00	10.00	50.00	100.00
15	N	2	0	0	4	11	17
	%	11.76	0.00	0.00	23.53	64.71	100.00
16	N	6	0	0	110	42	158
	%	3.80	0.00	0.00	69.62	26.58	100.00
17	N	0	0	0	161	8	169
	%	0.00	0.00	0.00	95.27	4.73	100.00
21	N	0	0	1	5	40*	46
	%	0.00	0.00	2.17	10.87	86.96	100.00
22	N	1	0	0	2	16*	19
	%	5.26	0.00	0.00	10.53	84.21	100.00
23	N	1	0	0	3	11	15
	%	6.67	0.00	0.00	20.00	73.33	100.00
24	N	1	1	0	1	8	11
	%	9.09	9.09	0.00	9.09	72.73	100.00
25	N	1	0	0	3	8	12
	%	8.33	0.00	0.00	25.00	66.67	100.00
26	N	5	0	1	117	37	160
	%	3.13	0.00	0.63	73.13	23.13	100.00
27	N	0	0	0	160	9	169
	%	0.00	0.00	0.00	94.67	5.33	100.00
31	N	0	0	0	2	58*	60
	%	0.00	0.00	0.00	3.33	96.67	100.00
32	N	0	0	0	3	35*	38
	%	0.00	0.00	0.00	7.89	92.11	100.00
33	N	0	1	0	3	11	15
	%	0.00	6.67	0.00	20.00	73.33	100.00
34	N	2	1	1	2	7	13
	%	15.38	7.69	7.69	15.38	53.85	100.00
35	N	2	0	0	2	10	14
	%	14.29	0.00	0.00	14.29	71.43	100.00
36	N	10	1	0	110	41	162
	%	6.17	0.62	0.00	67.90	25.31	100.00
37	N	0	0	0	161	8	169
	%	0.00	0.00	0.00	95.27	4.73	100.00
41	N	0	0	0	57	3	60
	%	0.00	0.00	0.00	95.00	5.00	100.00
42	N	0	0	0	1	33*	34
	%	0.00	0.00	0.00	2.94	97.06	100.00
43	N	0	1	0	1	12	14
	%	0.00	7.14	0.00	7.14	85.71	100.00
44	N	5	1	0	2	7	15
	%	33.33	6.67	0.00	13.33	46.67	100.00
45	N	3	1	0	3	8	15
	%	20.00	6.67	0.00	20.00	53.33	100.00
46	N	11	1	0	104	45	161
	%	6.83	0.62	0.00	64.60	27.95	100.00
47	N	2	0	0	161	5	168
	%	1.24	0.00	0.00	100.00	3.11	104.35

• ^*
  Statistically significant (p < 0.05).

Moreover, a multivariate logistic regression analysis confirmed that household income (OR = 2.34, 95% CI: 1.21-4.52) and river transportation to health services (OR = 1.89, 95% CI: 1.03-3.45) are independent factors associated with toothache (Table 5).

Table 5
Factors Associated with Toothache (Multivariate Logistic Regression).

Variable	Odds Ratio (OR)	Confidence Interval (95%)	p-value
Family Income (1-2 minimum wages)	2.34	1.21 - 4.52	<0.05
Health Transport - River	1.89	1.03 - 3.45	<0.05

Discussion

The results of the present study reveal a dental caries prevalence of 58.82% among children aged 4 to 6 years on the islands of Combu and Cotijuba, reflecting a high disease burden in riverside communities in the Amazon region of Pará. This high prevalence reflects the vulnerability of these communities, in line with regional data such as SB Brazil 2023, which indicated an average of 2.97 for the dmft index in 5-year-old children in the interior of the northern region of Brazil, higher than the national average (2.14) and that of Brazilian interior regions (2.22) [²]. This conclusion aligns with the literature, which indicates that caries is one of the most prevalent oral health conditions globally, with a 2017 prevalence of 29.4% for untreated caries in permanent teeth [⁸].

The consequences of caries are significant, as they can cause oral pain, difficulty in swallowing food, sleep disturbances, and changes in behavior and social relationships for children [⁹]. Furthermore, caries can affect children's growth, and severe early childhood caries can further impact oral health-related quality of life in preschoolers and their families, as parents only register an oral health problem when it becomes evident or manifests as pain [¹⁰].

Analyzing the dmft indices for the interior of the Northern region, using data from SB Brazil 2010 and 2023, it is possible to observe a reduction in the average through the years, from 3.73 to 2.97 [²,¹¹]. However, this study showed that the prevalence of caries in riverside children remains high, which may be explained by the high social and economic vulnerability of riverside communities, where factors such as geographic isolation, low family income (54.12% with 1-2 minimum wages) and dependence on river transport (74.12% for access to health) amplify the risk of preventable diseases, as highlighted by [⁸,¹²].

Clinical analysis revealed that permanent teeth, such as 14 (40%) and 44 (33.33%), had higher caries rates than deciduous teeth, which were mostly healthy. This pattern suggests that as children reach older ages within the 0-12 years age range, exposure to risk factors, such as diets rich in sugar and inadequate oral hygiene, corroborates findings by Andrysiak-Karmińska et al. [¹³].

Furthermore, the association between caries and socioeconomic factors, such as family income (OR = 2.34, 95% CI: 1.21-4.52) and river transportation (OR = 1.89, 95% CI: 1.03-3.45), reinforces the influence of structural barriers on the prevalence of the disease, a phenomenon also observed in other Amazon communities, where limited access to dental services is a recurring challenge [¹⁴].

The persistence of high prevalence may be attributed to structural barriers that go beyond education, such as geographic isolation and low income, which limit access to regular dental care and consistent oral hygiene practices [⁶]. This scenario is particularly worrying in riverine populations, where dependence on river transport deters the continuity of interventions, as identified in this study.

The consequences of tooth decay observed in other Amazon studies are also relevant to this study. Oral pain, reported by 33.8% of children in Ecuador, impacts eating and sleeping habits, increasing the risk of malnutrition [¹⁵], an effect that may be present in children from Combu and Cotijuba, given the high rate of reported toothache. Furthermore, childhood caries affects family quality of life, with associations between children's caries and that of caregivers, creating an intergenerational cycle of oral health problems, as observed in Claverito, Peru [¹⁶]. The relationship between caries and obesity, reported in Manaus, where obese children had a higher experience of caries [¹⁷], is an aspect that deserves future investigation in the context of Pará.

The results of this study indicate that children in areas of high social vulnerability, such as riverside communities, still face a significant burden of untreated caries. This reinforces the need for specific strategies for these populations, going beyond health education [¹⁸-²⁰]. Oral health promotion, as suggested by So et al. [¹⁵], should be combined with structural interventions, such as the deployment of mobile oral health units to overcome geographical barriers and the expansion of social programs that address social determinants, including family income and access to basic services.

As limitations of this study, the authors highlight the non-probabilistic sampling used due to logistical challenges in accessing isolated communities, which prevents generalizing the results to all riverside communities in the Amazon. Due to the cross-sectional nature of this study, it is not possible to establish a cause-and-effect relationship; it can only be inferred that family income and river transport use are risk factors for toothache in children. Despite the epidemiological survey of DFMT/dmft indexes, this study sought to analyze it beyond the average mean number of decayed, missing, and filled teeth, providing a descriptive analysis of each permanent and deciduous tooth, which made it possible to perceive the progression of caries through a different perspective from age and identified the greater susceptibility to caries in the permanent teeth of riverside children. Therefore, future studies should investigate the role of river transport as a barrier to healthcare access for these populations, as well as the impact of social programs and oral health on the quality of life of riverside communities.

Conclusion

The study reveals a public health problem, as it found a high prevalence of dental caries among young children in riverside communities in Pará, which represents pain, discomfort, and potential long-term setbacks in the physical and academic development of these children. This finding appears to be linked to poverty, geographic isolation, and inadequate access to dental care, all of which require urgent attention. Therefore, public policies and health care strategies must be implemented, including mobile dental units and oral health education programs adapted to the specificities of these communities. Only through targeted approaches will it be possible to mitigate inequalities in oral health and ensure that all children, regardless of socioeconomic and geographic context, have access to healthy development.

• Financial Support
  None.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

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Edited by

• Academic Editor:
  Alessandro Leite Cavalcanti

Publication Dates

• Publication in this collection
  06 July 2026
• Date of issue
  2026

History

• Received
  16 May 2025
• Reviewed
  15 Nov 2025
• Accepted
  19 Nov 2025