ORIGINAL Pereira ARTICLE et al
Caries and Oral Health Related Behaviours Among Homeless Adults from Porto, Portugal Maria de Lurdes Pereiraa/Luís Oliveirab/Nuno Lunetc Purpose: To describe caries prevalence and oral-health–related behaviours in a sample of homeless adults from the city of Porto, Portugal. Materials and Methods: Subjects attending any of two temporary shelters or two institutions that provide meal programmes were consecutively invited (n = 196); 42 (21.4%) refused to participate. Trained interviewers applied a structured questionnaire to obtain sociodemographic, behavioural, health and oral health status data. An oral examination was conducted to evaluate the past and present history of caries (Decayed Missing Filled Teeth [DMFT] index) and the presence of oral lesions. Those classified as houseless were considered for the present analysis (n = 141). The association between homelessness, sociodemographic and behavioural characteristics and oral health indexes was quantified through crude β coefficients and β coefficients adjusted for age, gender, education, nationality and duration of homelessness, as well as the respective 95% confidence intervals (CI). Results: The median age of the participants was 45 years, most were male (86.3%), reported having less than a 9thgrade education (80.1%) and were unemployed (82.1%). The median duration of homelessness was 24 months. The mean (SD) DMFT index, number of decayed, lost and filled teeth were 12.8 (7.9), 4.2 (4.4), 8.0 (7.6) and 0.6 (1.9), respectively. Older subjects and those homeless for longer periods presented higher DMFT index scores (β = 3.4, 95% CI: 0.0 to 6.8) and higher number of decayed teeth (β = 2.8, 95% CI: 0.4 to 5.2). Filled teeth were more frequent among the more educated (>9 vs ≤4 years: β = 1.6, 95% CI: 0.7 to 2.6). Conclusions: This population of homeless subjects showed poor oral health, particularly with respect to caries and missing teeth, resulting in high oral treatment needs. Key words: caries, DMFT, homeless, oral health Oral Health Prev Dent 2014;2:109-116
Submitted for publication: 13.12.11; accepted for publication: 26.02.13
doi: 10.3290/j.ohpd.a31215
H
omelessness is a complex phenomenon that is becoming more frequent worldwide due to the trends towards less favourable labor market conditions and limited public benefits (Jones et al, 2009). It is perceived as a process (rather than a
a
Professor, Department of Preventive Dentistry, Dental Medical School, University of Porto; Institute of Public Health, University of Porto (ISPUP), Porto, Portugal.
b
Assistant Professor, School of Nursing, University of Minho, Portugal; Department of Clinical Epidemiology, Predictive Medicine and Public Health, Porto University Medical School, Porto, Portugal.
c
Professor, Department of Clinical Epidemiology, Predictive Medicine and Public Health, Porto University Medical School, Porto, Portugal; Institute of Public Health, University of Porto (ISPUP), Porto, Portugal.
Correspondence: Maria de Lurdes Pereira, Faculdade de Medicina Dentária, Universidade do Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal. Tel:+351-220-901-100, Fax:+351-220901-101. Email:
[email protected]
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static phenomenon) that affects many vulnerable households at different points in their lives and consists of different housing situations: rooflessness (living on the street or in emergency shelters), houselessness (living in various types of shelters or institutions), insecure housing (living under threat of eviction or violence) or inadequate housing (living in unfit or overcrowded conditions) (Edgar, 2004). The homeless are at an increased risk of premature death (Morrison, 2009) and also experience higher levels of morbidity than the general population (Beijer and Andreasson, 2009); some of the most common health problems are related to drug dependence, alcohol abuse and mental illness (Tompkins, 2006; Fazel et al, 2008; Wright and Jones et al, 2009). High prevalences of oral diseases, namely untreated tooth decay, missing teeth, periodontal disease and oral pathology, have
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also been reported (Gibson et al, 2003; King and Gibson, 2003; De Palma et al, 2005; Conte et al, 2006; Luo and McGrath, 2006; Collins and Freeman, 2007; Chi and Milgrom, 2008; Daly et al, 2010), and the lack of regular dental care is a concern among homeless people as well. The inability of the homeless to access regular dental care is determined primarily by low economic resources and lack of health insurance (Allukian, 1995), as dental treatment is expensive and oral health care may not be perceived as a priority when compared with the satisfaction of basic needs such as food, shelter or addictive behaviours. In Portugal, the National Health Service provides universal and free access to health care. However, the number of institutions providing oral health care is relatively small and unevenly distributed across the country, which restricts the access to these specific health services. Therefore, oral health care is mainly financed by the patients, either by direct payment or through private insurance and, to a lesser extent, by the public National Health Service. Under these circumstances, homeless subjects are expected to have an even more limited access to oral health care services than the general population, and monitoring is needed to characterise their oral health status and identify unmet needs. The aim of this study was to describe the prevalence of dental caries and oral-health–related behaviours in homeless adults from the city of Porto, and their association with sociodemographic and behavioural factors.
MATERIALS AND METHODS Study population A cross-sectional evaluation of homeless adults from Porto, Portugal was conducted between February and September 2009. Participants were selected among the subjects attending institutions that provide social support (e.g. food, clothes, accommodation). Initially, three of the most well-known institutions that provide social support to these populations in Porto were contacted and the people in charge of each of them were asked to identify other, similar institutions in the city. Finally, eleven local institutions were identified and their collaboration in the study was solicited. Four agreed to participate, namely, one that provides accommodation to
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homeless people (Associação dos Albergues Nocturnos do Porto – AANP), one that managed two homeless hostels (Albergue D. Margarida and Albergue de Campanhã) and two institutions that manage meal programmes (Serviço de Assistência Organizações de Maria – SAOM and Centro Social e Paróquia Nossa Senhora da Vitória – CSPNSV). Only the subjects classified as ‘houseless’ by the European Federation of Organisations Working with the People who are Homeless (FEANTSA) (Edgar, 2004) were considered for the present analyses: people who live in a place but are excluded from the legal rights of occupancy and do not have conditions to enjoy normal social relations. This includes subjects living in homeless hostels or other type of temporary accommodation (e.g. low budget hotels, bed and breakfast, pensions or similar housing paid for by social services or nongovernmental organisations) for less than six months or in transition to rehabilitation and resettlement. ‘Roofless’ people, defined as those without a shelter of any kind (sleeping rough), were also identified with this recruitment strategy and were excluded from data analysis due to their small numbers (n = 8). All participants had to be at least 18 years old and able to understand and speak Portuguese. The eligible subjects attending the institutions on the days selected for recruitment (covering all weekdays) were listed by the people in charge in each setting and consecutively invited to participate. In SAOM, only the subjects that were attending a professional course of hotel management were invited. The evaluations were conducted in the afternoons and evenings in the homeless hostels and after lunchtime and evenings in the meal programmes. Forty-two subjects refused to participate: 25 (21.5%) of those invited in the homeless hostels, 16 (45.7%) of those invited in one of the meal programme institutions (CSPNSV) and only one of those approached in the other (SAOM). A total of 146 houseless subjects underwent a faceto-face interview and were offered an oral examination. The latter was refused by 5 individuals; thus, data analysis included data from 141 participants. No statistically significant differences were observed between participants and nonparticipants regarding age (median: 45 vs 47 years, P = 0.383) or education (median: 4 vs 5 years, P = 0.637) but the proportion of women was lower among the participants (women: 12.1% vs 25.5%, P = 0.027). This study was approved by the Ethics Committee of the Hospital de S. João, Porto. All participants received oral and written information regarding the
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study purpose and procedures, and all participants gave written informed consent before being enrolled in the study.
on how to improve their oral health. Participants were referred to oral health care services when appropriate.
Questionnaire survey
Statistical analysis
Four interviewers surveyed participants using a structured questionnaire to obtain data on the participants’ housing status, sociodemographic situation, behaviour and oral-health–related habits. The latter included information on oral hygiene habits (frequency of toothbrushing and the use of additional dental cleaning methods), the date of the latest dental appointment, the presence of dental pain during the previous year and how it was managed and the self-perception of the participants’ oral health status. The interviewers were thoroughly trained through the conduction and observation of simulated interviews with a convenience sample of nonhomeless subjects under the supervision of the project coordinators.
The data from 141 participants who were available for oral examination were analysed. The association between homelessness, sociodemographic and behavioural characteristics and oral health indices was quantified through crude β coefficients and β coefficients adjusted for age, gender, education, nationality and duration of homelessness, as well as the respective 95% CI, as computed by multivariate linear regression analysis.
Oral examination The oral examination was performed at the temporary shelters or meal programme institutions, as applicable, by a single experienced dentist, under artificial lighting using a WHO CPI probe (WHO, 1997) and a flat-surface mouth mirror. Cotton rolls and gauze were used when needed. Caries experience was quantified using the DMFT index (sum of decayed, missing and filled teeth); complete dentition was defined as 28 teeth. Decayed, missing and filled teeth were identified using visual and tactile parameters according to the World Health Organization criteria (WHO, 1997). Caries was considered present if the tooth surfaces were irregular due to loss of hard tissue and soft to probe. Cavities and significant discolourations around restorations were also designated as carious lesions. Only the teeth lost because of caries were considered in the DMFT score calculation. The intra-examiner reliability was very high (Kappa = 0.90). The oral mucosa was inspected and the presence of any clinically meaningful abnormality recorded. The use of dentures (full or partial) was recorded. After the oral examination, the participants were informed of their oral status and advice was given
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RESULTS The median age of the participants was 45 years (range: 18 to 77 years) and less than 10% were older than 60. Most were men (87.9%), single (55.5%), reported having less than a 10th-grade education (80.1%) and were unemployed (78.8%). Participants reported being homeless for a median period of 24 months (range: 1 to 480 months) and more than 25% were homeless for at least 6 years. Approximately 75% of the participants were current smokers or daily consumers of alcoholic beverages. Roughly one-quarter of the participants had used illicit drugs in the previous year, 21.3% had been imprisoned before and two reported having prostituted themselves before. Nearly 10% reported being HIV-positive or having AIDS (Table 1). Regarding the participants’ oral health and related behaviours, nearly all participants (97%) had experienced dental caries. The mean DMFT score of the entire sample was 12.8. Missing teeth contributed to the largest component of the DMFT index (mean: 8.0) while the mean number of filled and decayed teeth was 0.6 and 4.2, respectively (Table 2). Notwithstanding the high prevalence of missing teeth, only 11.6% of the participants used dental prostheses. Suspicious oral leucoplakias were detected in two participants, but the lesions were considered nonmalignant or premalignant after further assessment by a specialist. Nearly one-third of the participants reported not having brushed their teeth in the previous week and 46% did it once daily. When asked about additional bacterial plaque control methods, only 2.8% reported use of dental floss in the previous week.
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Table 1 Sample characteristics
Table 1 Sample characteristics n (%)
n (%) Duration of homelessness
Age (years) 18–39
45 (30.8)
≤ 1 month
14 (10.0)
40–49
47 (32.2 )
2–6 months
32 (22.9)
50–59
40 (27.4)
7–12 months
17 (12.1)
> 60
14 (9.6)
1 to 5 years
40 (28.6)
≥ 6 years
37 (26.4)
Gender Male Female
124 (87.9) 17 (12.1)
Nationality Portuguese Other
124 (87.9) 17 (12.1) 19 (13.0)
Single
81 (55.5 )
Divorced/ separated
40 (27.4)
Widowed
Never
20 (14.2)
Former smoker
10 (7.1)
Current smoker
111 (78.7)
≤ 10 cigarettes /day
43 (38.7)
10 to 19 cigarettes /day
Marital status Married
Smoking
6 (4.1)
Education (years)
≥ 20 cigarettes/day
7 (6.3) 59 (53.1)
Alcohol consumption Never
26 (18.4)
Former drinker
9 (6.4)
Current drinker
106 (75.2)
Use of illicit drugs (previous year)
None
4 (2.7)
1–4
70 (48.0)
No
108 (76.6)
5–9
55 (37.7)
Yes
33 (23.4)
10–12
14 (9.6)
>12
3 (2.0)
Occupation status Employed Unemployed Retired
5 (3.4)
Yes
30 (21.3)
AIDS/HIV infection
13 (9.5)
4 (2.8)
The number of participants may be lower than 141 due to missing data. The percentages may not add up to 100% due to rounding.
35 (24.8) 8 (5.7) 61 (43.3) 9 (6.4)
Approximately one-third claimed never having had a consultation with a dentist, and 21.1% of the remaining had had an appointment in the previous year. Nearly half the participants reported having had dental pain in the previous year and 10.9% had used nonconventional methods to control it (Table 2). Almost two-thirds of the participants rated their oral health as ‘fair’ (42.5%) or ‘good’ (19.2%) while 36.9% rated it as ‘poor’ (Table 2).
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2 (1.4)
26 (17.8) 24 (17.0)
Occasional jobs/ mendicity
Yes Imprisonment (ever)
111 (98.6)
Salary
Social insertion income
139 (98.6)
No
None
Unemployment allowance
No
115 (78.8)
Main source of income
Pension
Practice of prostitution (ever)
Table 3 presents the crude and adjusted β between DMFT index (and DMFT components) and sociodemographic characteristics of the participants. Older subjects (> 50 vs 18–39 years) had significantly higher DMFT values (adjusted β = 3.4, 95% CI: 0.0 to 6.8), a lower number of decayed teeth (adjusted β = -2.3, 95% CI: -4.3 to -0.4) and a higher number of missing teeth (adjusted β = 6.2, 95% CI: 3.0 to 9.3). Being homeless for a longer time was significantly associated with a higher
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Table 2 Oral health characterisation of the participants n (%)
Mean (SD)
Visit to dentist Never
44 (30.1)
Not in the previous year
64(46.7)
In the previous year
29 (21.1)
Dental pain (previous year) No
80 (56.7)
Yes
61 (43.3)
Treatment of dental pain (latest episode)* None
20 (43.5)
Analgesic
13 (28.3)
Antibiotic
5 (10.9)
Visit to dentist
2 (4.3)
Other †
5 (10.9)
Not specified
1 (2.2)
Toothbrushing (previous week) No
41 (29.3)
Less than once daily
34 (24.3)
Once daily
46 (32.9)
More than once and less than twice daily
15 (10.7)
At least twice daily
4 (2.9)
Perceived oral health Poor
52 (36.9)
Fair
60 (42.5)
Good
27 (19.2)
Excellent
2 (1.4)
DMFT
12.8 (7.9)
Decayed teeth
4.2 (4.41)
Missing teeth
8.0 (7.6)
Filled teeth
0.6 (1.9)
SD: Standard deviation.* Applies only to participants who reported dental pain in the past year. † Cold water, alcoholic beverage, household bleach, salt, perfume.
number of decayed teeth (≥ 6 years vs < 1 month: adjusted β = 2.8, 95% CI: 0.4 to 5.2). The number of filled teeth was higher in more educated individuals (>9 vs ≤4 years: adjusted β = 1.6, 95% CI: 0.7 to 2.6). Being an immigrant was significantly associated with a higher score in the DMFT index (adjusted β = 4.7, 95% CI: 0.8 to 8.9), higher number of decayed teeth (adjusted β = 2.7, 95% CI: 0.4 to 5.2) and lower number of filled teeth (adjusted β = -1.9, 95% CI: -2.8 to -1.0). Vol 12, No 2, 2014
DISCUSSION The present study showed unfavourable oral indices and oral-health–related behaviours in a population of houseless persons from Porto. The high mean values of decayed and missing teeth correspond to important unmet needs regarding oral health education and treatment of both acute and chronic conditions. This study is the first to provide data on the oral health of the homeless in Portugal. However, there are some limitations that must be acknowledged, especially regarding the sampling procedures and its implications in the external validity of the findings. The conduction of epidemiological research on homeless populations is challenging due to the difficulties in recruiting representative samples and gaining the confidence of the potential participants. These difficulties were partially overcome by recruiting the participants in different types of institutions that provide support to homeless subjects, namely charitable organisations that afford shelter or meal programmes. National data about homelessness prevalence in Portugal are scarce, but based on data provided by several organisations that provide social support, the Institute of Social Security published a report that estimates 2242 to 8718 people experienced homelessness between the period of 2004 and 2005, and 16% of these cases were reported in the district of Porto (the city of Porto is the largest in this region, representing approximately 16% of the population of the district; ISP, 2005). However, there may be some overlap of data presented because the same situations of homelessness may be supported by more than one institution (ISP, 2005). Taking this information into account, the population of homeless people in the city of Porto can be estimated to range between 270 and 1050 and our sample may include at least 13.5% of the homeless (ISP, 2005). In the present study, there was very little overlap between the samples obtained in each setting, with only two participants attending two different institutions, reflecting the fact that the institutions were very different in the objectives and populations served. Although the institutions selected for the study were not a random sample, the main criterion for not including other institutions was the fact they did not reply to the research team’s request by the date set in the study’s time line. Within each institution, the procedures for selection of the potential participants are reproducible and are not expected to introduce additional biases. Unfortunately, most
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Table 3 Crude and adjusted b coefficients for the association between sociodemographic characteristics and DMFT index and DMFT index compounds DMFT
DMFT compounds Decayed
Missing
Filled
Crude β (95% CI)
Adjusted β (95% CI)*
Crude β (95% CI)
Adjusted β (95% CI)*
Crude β (95% CI)
Adjusted β (95% CI)*
Crude β (95% CI)
Adjusted β (95% CI)*
18–39
reference
reference
reference
reference
reference
reference
reference
reference
40–49
1.8 (-1.5 to 5.0)
1.1 (-2.2 to 4.5)
-1.9 (-3.7 to 0.0)
-2.4 (-4.3 to -0.5)
4.0 (0.9 to 7.0)
3.8 (0.7 to 7.0)
-0.3 (-1.1 to 0.4)
-0.3 (-1.0 to 0.4)
3.8 (0.7 to7.0)
3.4 (0.0 to 6.8)
-1.6 (-3.3 to 0.2)
-2.3 (-4.3 to -0.4)
6.0 (3.1 to 8.9)
6.2 (3.0 to 9.3)
-0.4 (-1.2 to 0.3)
-0.3 (-1.1 to 0.4)
reference
reference
reference
reference
reference
reference
reference
reference
-0.6 (-4.6 to 3.4)
-1.2 (-5.2 to 2.8)
0.1 (-2.1 to 2.4)
-0.2 (-2.4 to 2.1)
0.2 (-3.6 to 4.1)
-0.4 (-4.1 to 3.3)
-0.9 (-1.9 to .01)
-0.6 (-1.5 to 0.2)
Age
> 50 Gender Male Female
Education (years) ≤4
reference
reference
reference
reference
reference
reference
reference
reference
5–9
-2.0 (-4.8 to 0.8)
-0.9 (-3.8 to 2.1)
-0.9 (-2.5 to 0.7)
-1.5 (-3.2 to 0.1)
-1.6 ( -4.3 to 1.1)
0.4 (-2.3 to 3.1)
0.4 (-0.2 to 1.0)
0.2 (-0.0 to 0.8)
>9
-0.3 (-4.5 to 3.8)
0.8 (-3.6 to 5.2)
-1.0 (-3.4 to 1.3)
-0.0 (-2.3 to 0.4)
-1.8 (-5.8 to 2.3)
-0.8 (-5.0 to 3.2)
2.3 (1.4 to 3.3)
1.6 (0.7 to 2.6)
reference
reference
reference
reference
reference
reference
reference
reference
4.1 (0.1 to 8.1)
4.7 (0.8 to 8.9)
2.8 (0.6 to 5.0)
2.7 (0.4 to 5.2)
3.8 (-0.0 to 7.6)
3.9 (-0.0 to 7.8)
-2.5 (-3.3 to -1.6)
-1.9 (-2.8 to -1.0)
reference
reference
reference
reference
reference
reference
reference
reference
2–6 months
4.6 (-0.3 to 9.6)
0.32 (-0.9 to 1.5)
0.07 (-2.7 to 2.9)
0.7 (-2.0 to 3.5)
4.2 (-0.4 to 9.0)
4.5 (-0.1 to 9.0)
0.3 (-0.9 to 1.5)
-0.2 (-1.3 to 0.8)
7–12 months
3.7 (-1.8 to 9.2)
-2.2 (-1.5 to 1.1)
0.2 (-2.9 to 3.4)
0.4 (-2.6 to 3.5)
3.7 (-1.6 to 9.1)
2.8 (-2.3 to 8.0)
-0.2 (-1.5 to 1.1)
0.0 (-1.2 to 1.2)
1–5 years
0.8 (-3.9 to 5.5)
-0.6 (-1.7 to 0.6)
0.6 (-2.1 to 3.3)
1.2 (-1.5 to 4.3)
0.9 (-3.7 to 5.4)
-0.1 (-4.6 to 4.4)
-0.5 (-1.7 to 0.6)
-0.6 (-1.2 to 1.1)
≥6 years
4.9 (5.6 to 13.9)
-0.6 (-1.8 to 0.5)
1.0 (-1.7 to 5.6)
2.8 (0.4 to 5.2)
4.5 (0.0 to 9.1)
2.0 (-2.6 to 6.7)
-0.6 (-0.0 to 0.5)
-0.3 (-2.8 to 1.0)
Nationality Portuguese Other
Duration of homelessness ≤ 1 month
* Adjusted β coefficients derived from models including age, gender, education, nationality and duration of homelessness. CI: confidence interval. Results presented in bold indicate statistically significant associations.
of the subjects refusing to participate also refused to answer a short questionnaire to characterise the refusals and no comparison between these two groups was possible. The instrument used for data collection was designed specifically for the present study, mostly based on instruments used by our group in other investigations of the general population. Unfortunately, no formal validation of the questionnaire or
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assessment of test-retest reliability could be conducted due to the small number of homeless people and the difficulties in gaining their trust to participate in an epidemiological study. Although this may limit the validity of our findings, we believe that our results are still useful, since to our knowledge, this the first assessment of issues related to the oral health of these hard-to-reach populations in Portugal.
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Given the sampling procedures adopted in the present study, predominantly houseless subjects were evaluated, according to the FENTEASA definition (Edgar, 2004); thus, our conclusions may only apply to this subset of the homeless population from Porto. The houseless population is easier to contact than other homeless people because they remain for longer periods in the same location and have access to homeless assistance services that can refer them to institutions that provide health and oral care when needed. However, it should be considered that homelessness is not a static phenomenon. Most of these individuals experience different types of homelessness over time and, at least to some extent, our results are likely to reflect the oral health among roofless people. A survey conducted in San Francisco (USA) showed that 88% of the roofless had used either a shelter or institutions that provide meal programmes in the previous 30 days (White et al, 1997). The comparison of the present results from those obtained in other settings is naturally dependent on the characteristics of the subjects evaluated. This study showed a large predominance of men, which is consistent with previous observations in other studies. In studies conducted in London and Stockholm (De Palma et al, 2005; Daly et al, 2010) the percentage of men was 73% and 75%, respectively. The sample evaluated in the present investigation was predominantly under 49 years old, and less than 10% of the participants were older than 60 years, which may reflect an increased mortality among the homeless population (Morrison, 2009) or the institutionalisation of the older homeless population in nursing homes, as previously observed in Boston (O’Connell et al, 2004). A high percentage of individuals had spent time in prison and used illicit drugs in the previous year, probably reflecting the fact that drug abuse and criminal behaviour share risk factors with homelessness (Kemp et al, 2006). We found a very high prevalence of tobacco and alcohol use. It has been stated that cigarette smoking and alcohol use/abuse are common habits among homeless people (Fischer and Breakey, 1991; Connor et al, 2002; Snyder and Eisner, 2004; Baggett and Rigotti, 2010; Gomez et al, 2010). Although regular consumption of alcohol and tobacco are known risk factors for the development of mucosal oral lesions, only a small percentage (2%) of oral mucosal lesions needed to be referred to a specialist to exclude malignancy or premalignancy. These results are also in accord-
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ance with other authors who reported low prevalence of oral mucosal lesions in homeless people (Collins and Freeman, 2007; Daly et al, 2010). The DMFT index in the homeless population of Porto is in agreement with previous observations in homeless populations from other countries (De Palma et al, 2005; Conte et al, 2006; Collins and Freeman, 2007; Daly et al, 2010). In our study, the scores for missing teeth were approximately 12 times higher than for filled teeth, suggesting that extraction prevails over restoration when these patients receive oral care. This may reflect negligence regarding oral health behaviours, as well as economic difficulties that preclude the treatment of teeth before they reach levels of destruction that are incompatible with restoration. Older subjects and those being homeless for longer periods had an increased experience of dental caries, as described elsewhere (Luo and McGrath, 2006; Collins and Freeman, 2007). As expected, aging was also associated with an increased number of missing teeth (Felton, 2009). Despite the high scores for missing teeth, suggesting prosthetic needs, only 12% of the participants had a dental prosthesis. These high rates of unmet prosthetic treatment needs are also consistent with observations in other surveys that reported a high prevalence of oral prosthetic treatment needs among the homeless population (De Palma et al, 2005; Conte et al, 2006; Daly et al, 2010). Educational level significantly affects the number of filled teeth, being higher in more educated individuals. This may reflect a previous access to dental care and also the fact that more years of education may increase oral dental health literacy and consequently a demand for conservative dental care. Regular dental care is important to maintaining good oral health and periodic consultations with a dentist may somehow contribute to improving oral health. Although 50% of the participants reported having had dental pain in the last year, only half of these consulted the dentist in the same period, considerably less than the 46% reported by the general population (Directorate General Communication, 2009), reflecting the low demand for dental care in this homeless population. It has been suggested (Kemp et al, 2006) that homeless people are a special group for dental care due to the difficult access to dental treatment among this population. In a survey conducted in New Jersey (USA), one-third of the homeless population studied did not know where to seek dental care if they needed it (Conte et al, 2006).
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Immigrants currently have difficulties finding employment and do not have any social or family relations in Portugal, which in turn makes them more vulnerable to homelessness and consequently less access to dental care, which may explain the higher values in DMFT scores observed. We found that about 50% of participants do not have regular oral hygiene habits; furthermore, the use of additional methods of bacterial plaque removal was very low. These results show that the homeless populations under study failed to practice primary preventive measures on a daily basis.
CONCLUSION The current study showed that oral morbidity is high in the homeless of Porto, particularly with respect to untreated caries and missing teeth, in accordance with the very low levels of basic oral hygiene behaviours. These findings suggest the need to implement strategies that facilitate access to dental treatment with a preventive and curative perspective. This can be accomplished by developing a health care system for the homeless population that includes and maximises the use of the resources already in place to support this population, taking into account their various problems, such as length of homelessness, lack of monetary resources, medical conditions, drug abuse and immigration status.
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Oral Health & Preventive Dentistry
