Association between domestic violence and oral health conditions among adolescents

This study surveyed the oral health conditions of adolescents aged 15 to 19 years and their association with exposure to domestic violence. The study sample consisted of 333 adolescents enrolled in the State School System in the city of Olinda, PE, Brazil. Sociodemographic data, information on the participant’s oral health conditions, and their history of domestic physical violence were collected. The health-related variables analyzed included self-perceived oral health, history of toothache, and the frequency of toothbrushing and visits to the dentist. The data were entered into the Epi data 3.1 and analyzed in the SPSS program 23.0 by Pearson's Chi-square or Fisher's exact tests. There was a significant association of history of toothache and domestic violence with physical aggression from the mother (P = 0.001; OR = 2.39), a relative (P = 0.001; OR = 2.41) and any family member and/or with witnessing violent acts between the parents (P = 0.011; OR = 1.88). However, no association between physical violence and self-perceived oral health or the frequency of visits to the dentist was observed. To conclude, our findings indicate that the oral health conditions of adolescents may be directly associated with domestic violence.


Introduction
Domestic violence is considered a serious public health issue, with high incidence rates in Brazilian cities (Souza et al., 2017). It is considered a multi-causal phenomenon, and may be related to family breakdown, lack of assistance to education, health and social interaction (Costa et al., 2020). According to the World Health Organization (WHO), child abuse in the domestic environment may range from neglect to severe cases involving physical force and sexual abuse (Krug et al., 2002).
Children and adolescents have less autonomy and are directly dependent on their guardian(s), which renders them more susceptible to suffer from this type of violence (Serafim et al., 2016). After the onset of the COVID-19 pandemic, the compulsory social distancing and the consequent suspension of face-to-face classes, young people were further exposed to domestic violence with direct effects on their physical health (Cluver et al., 2020). The home may often not be the safest place for those who have already experienced this type of aggression (Trajano et al. 2021), as without the social support network it is easier to keep the secret of violence at home (Fundo das Nações Unidas para a Infância [UNICEF], 2020) The Child and Adolescent Statute (ECA, in Portuguese) was created in Brazil to overcome the imbalance inherent in such a minor-family member relationship. This statute establishes guidelines for protecting minors, such as the mandatory notification by health and education professionals in suspected or confirmed cases of child abuse (Moreira et al., 2014).
However, even in the face of legislation requiring denunciation, it is still an invisible tool in the routine of these professionals (Silva et al., 2021).
The oral health conditions of adolescents may be affected by violent acts suffered or witnessed within their households. Studies have shown that caries experience is strongly associated with risk factors suggestive of neglect (Lourenço et al., 2013) and that abused children are often more neglected by their caregivers both in terms of personal hygiene and access to healthcare treatments (Montecchi et al., 2009).
Physical violence has also been associated with the occurrence of oral issues since the head and neck region is the most affected site (Souza et al., 2017), accounting for nearly 65% of the cases of domestic violence among adolescents (Matos et al., 2020).
Despite this, child abuse cases and incidents have been critically underreported in Brazil for many reasons, among which are the lack of expertise of dentists in identifying warning signs of domestic abuse and because such a topic has been unsatisfactorily addressed in undergraduate dental courses (Moreira et al., 2015). A previous study surveyed a total of 80 dentists in the city of São Paulo about any previous dental care appointment delivered to patients allegedly suffering from domestic violence. Most of the participating dentists reported never having noticed any warning signs of abuse (Carvalho et al.,

Study Design
This was a cross-sectional, descriptive, analytical, school-based study (Pereira et al., 2018) with an exploratory analysis that was part of a larger project entitled "Oral health and health risk behavior that can be modified in adolescencemonitor to prevent". The data were collected between March and August 2018.

Target Population
The study population consisted of school adolescents enrolled in the State School System in the city of Olinda, PE, Brazil, in the age group 15 to 19 years, of both sexes.

Sample Size
The sample size of this exploratory study corresponded to approximately 20% of the number of adolescents who participated in the clinical examination (n = 1,742) in the main (larger) project, totaling 333 students.

Sample Selection And Eligibility Criteria
High school adolescents, of both sexes, aged 15 to 19 years, regularly enrolled in the state public high school in the city of Olinda, Pernambuco, and who participated in all stages of data collection (questionnaire filling and oral examination) were considered eligible. Students with systemic health issues, any disability or dysfunction that prevented them from selffilling the questionnaire, and those whose questionnaires had 20% or more unanswered questions were excluded from the analysis.

Research Instruments
To assess the variables related to exposure to domestic violence, the Youth Risk Behavior Survey (YRBS) questionnaire was applied. This questionnaire was developed by the WHO with technical and financial assistance from the Center for Disease Control and Prevention and has already been applied in samples from approximately 100 developing countries, including Brazilian adolescents (Guedes et al., 2010). Data related to the adolescents' health status were collected, with additional questions from the instrument used in the National Schoolchildren Health Survey (PeNSE, in Portuguese), which was conducted by the Brazilian Institute of Geography and Statistics (IBGE). Some questions from the Health Behavior in School-aged Children (HBSC) tool developed by the WHO were also used to obtain information on the participants' wellbeing and self-perceived health.
To investigate their exposure to domestic violence, participating adolescents were asked whether they had suffered physical aggression from any relative, father and/or mother and, if so, the frequency of the incident, and whether they had witnessed any violent act among the adults with whom they lived. Questions addressing their oral health condition were also included, namely: history of toothache in the previous 6 months, the frequency of visits to the dentist in the previous 12 months, the frequency of toothbrushing in a period of 30 days, and how they perceived their oral health.

Data Analysis
The data were entered into the Epi data 3.1 program and analyzed statistically in the Statistical Package for the Social Sciences program (IMB / SPSS), version 23.0. Pearson's Chi-square test was used to check for a significant association between two categorical variables, or Fisher's exact test when the Chi-square test was not applicable. The strength of the association between the adolescents' oral health conditions and their degree of exposure to domestic physical violence was determined by the Odds Ratio (OR) and confidence intervals. A 5% significance level and a 95% confidence interval were considered in all statistical tests.

Ethical Considerations
This study was previously approved by the Human Research Ethics Committee at the Federal University of Pernambuco, under protocol CAAE 76609817.1.0000.5207, following Resolution No. 196/96 of the National Health Council.

Results
The final sample of 333 adolescents had a homogenous sex distribution, with males being slightly more representative (54.1%). The groups were also homogenous regarding age, with a slight predominance of adolescents aged 15 and 16 years (55.9%). Most of the participants (38.1%) reported their family income to be less than or equal to one minimum wage at the time of data collection (BRL 965.00). Less than half of the participants stated that the family was assisted by the Bolsa Família social program (44.1%). A significant number of students lived with both parents (64.9%) as compared to those living only with their father or mother (19.8%), or any relative (15.3%). Most adolescents reported that their mother's schooling was equal to or greater than 8 years (58.6%) and self-rated their skin color as brown (49.2%), followed by black (18.3%) and white (15%).
The participants' oral health conditions and related behaviors were surveyed, and the results indicated a homogeneous distribution between positive (50.2%) and negative (49.8%) self-perceived oral health. Nearly a quarter of the students (26.7%) reported an episode of toothache in the previous 6 months and most of them had not visited the dentist in the previous year (47.7%). In addition, most respondents reported a satisfactory frequency of toothbrushing (93.4%).
The degree of exposure to domestic violence most reported by the adolescents was witnessing physical violence among adult family members (44.7%), followed by having suffered physical aggression from a relative (32.3%). Concerning the violence committed by their parents, the physical aggression perpetrated by the mother (27.0%) was more frequent than that committed by the father (12.9%).
Tables 1 and 2 show that self-perceived oral health and the frequency of visits to the dentist in the previous 12 months were not associated with any type of exposure to domestic violence. (1) Pearson's Chi-square test. Source: Authors. (1) Pearson's Chi-square test. Source: Authors.
In contrast, the Table 3 show that a history of toothache was significantly associated with domestic violence committed by the adolescent's mother and relatives and/or witnessing violent acts between family members.

Discussion
This study investigated the oral health conditions and self-perceived oral health of adolescents aged 15 to 19 years and determined their relationship with violence exposure as a risk factor. Additionally, the different types and situations of domestic violence reported by the adolescents were further described.
Our findings indicated that only a history of toothache was associated with maternal physical aggression, physical aggression from a relative, or with having witnessed violence between family members. In a previous study, Lourenço, Salgado, Amaral, Gomes, and Senra (2011) found that the main consequences in the lives of children who witnessed violence between their parents were depressive symptoms and insecurity, in addition to behavioral issues. We reasoned that the occurrence of toothache associated with physical aggression can be caused not only by parental neglect but also by the psychological trauma resulting from this stressful situation, indicating that minors are directly impacted by interparental violence.
A homogeneous distribution between positive and negative self-perceived oral health was observed in our study sample. This is in contrast with the findings of a previous study (Santos et al., 2016) carried out in the municipality of Sobral, Research, Society andDevelopment, v. 10, n. 10, e524101019132, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i10.19132 8 CE, Brazil, where 482 adolescent and young adults aged 15 to 21 years were interviewed self-rated their oral health mostly as good or excellent (adequate) (74.7%). Meanwhile, another study (Araújo et al., 2017) showed that most of the 187 adolescents aged 15 to 19 years, living in the municipalities of the Archipelago of Marajó, PA, Brazil, felt dissatisfied with their teeth.
Such variability in the findings highlights the subjectivity of self-perception, which may be related to the residence area, living and socioeconomic conditions, and even to the adolescent's emotional background.
While most of the adolescents reported a satisfactory frequency of toothbrushing in our study, the time of brushing should be examined with caution since some Brazilian parents have the habit of giving sweet snacks (Fisberg et al., 2016) to their children in the afternoon, while brushing is often performed after the lunch meal only. This may expose minors to dental caries and can be considered a neglectful act. In addition, the quality of toothbrushing also plays a direct role in the individual's oral health.
Witnessing physical aggression among family members was the most frequent experience of violence reported by the participants, followed by physical aggression from a relative and the mother. Other studies showed that mothers are the main perpetrators of physical violence against children and adolescents. This may be because they are more present physically in the lives of their children, particularly when parents are separated and the mother has the child's custody. According to Nunes and Sales (2016), this situation favors the occurrence of domestic violence incidents.
Due to the high number of cases of domestic violence in Brazil, it was necessary to establish a regulation to reduce and criminalize this type of aggression, known as the Law of Spanking. This law, which was included in the Child and Adolescent Statute in 2014, aims to prohibit the physical punishment of children and adolescents by their guardians, as explained by Pêgo, Silva, and Bastos (2015). However, corporal punishment for educational purposes has been long considered normal by society and even today it remains a common occurrence, as confirmed by our findings. Although this type of violence aims to educate the child, it can otherwise cause several issues, including severe emotional distress (Matos et al., 2020).
The cross-sectional design of our study may be considered a limitation since participants were not monitored over time and therefore other relevant information might be lacking. Moreover, this was an exploratory study with a small sample size as compared to the totality of the adolescent population. Nevertheless, the findings presented herein are substantial and provide strong evidence on the factors associated with domestic violence. This study can also contribute to dental practice by encouraging dentists to detect neglect and exposure to violence in pediatric patients.
Among the variables related to the adolescents' oral health conditions, history of toothache was significantly associated with the violence committed by the mother and some other relatives and with witnessing violence between family members.

Conclusion
In general, we conclude that there is an association between oral health conditions and exposure to domestic violence among the adolescents surveyed.
Among the variables related to the oral health conditions of adolescents, the report of toothache is significantly associated with violence perpetrated by the mother or by some other family member, as well as in the witnessing of violence among family members.
Even though it is a subject that is increasingly in evidence, it is still little explored in the dental scientific community. Therefore, it is recommended that a greater number of studies with large samples be carried out in order to obtain different reference sources and compare them in different locations, social levels and other variables. Moreover, a study on the subject is relevant during and after the pandemic of COVID-19, since several values may have changed during this time in which children and parents were more at home.