Desde la Declaración del Milenio hasta la formulación de objetivos e indica-

The results of this study provided important information on the association between social determinants, oral health and school performance in a statistical analysis model that simultaneously included socioeconomic factors and oral clinical variables. It should be highlighted that although socioeconomic factors remained in the final regression model, the presence of caries remained strongly associated with children in the case group (with a mean of final scores below the sample mean). This finding reinforces the evidence of the impact of oral diseases, particularly dental caries, on poor school performance in the children, in conjunction with factors related to the social determinants of health.

There seems to be an complex mechanism by which oral health affects school performance. These associations may be mediated by the impact that oral alterations have on the functional and psychosocial aspects of children and adolescents, and that affects their systemic health, self-esteem and cognitive aspects. Thus, oral health interferes with psychosocial aspects of the schoolchildren, which, in turn, impacts on their daily activities, including their school performance. 24.25 _{This fact was corroborated by the study of Piovesan et al.}19_, which verified that oral health-related quality of life was an important variable associated with a number of higher school days missed and lower school performance. Thus, oral problems can cause deterioration in all quality of life domains which, in turn, can worsen the academic performance of adolescents.

Furthermore, the main highlight of this study was that in spite of carious lesions being treated during the school year, schoolchildren who presented the disease at the beginning of the academic year (2011) showed a lower median school performance compared with children without caries lesions. This demonstrated that even after treatment, the experience of active disease continued to be an important risk indicator for poor school performance. Complementary to the findings of this research, another research found that school performance was an important risk indicator for the existence of need for dental treatment, even when controlling for other factors of deprivation such as family income and parental

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education.4,9-11,27 _{Therefore, it can be used as an important variable for the non-} clinical prioritization of schoolchildren who should receive treatment in dental care programs.

In regard to the socioeconomic factors involved in school performance, Seirawam et al.15_{, in a study with students of Los Angeles Country Public Schools,} found associations between socioeconomic characteristics of schoolchildren, toothache in the last six months and poor school performance. In the present study, we found associations of the variables gender and family income with poor school performance. Piovesan et al.19 _{also found that these same socioeconomic} characteristics were associated with the performance of schoolchildren aged 12 years, measured by the test score in Portuguese. Blumenshine et al.14 _conducted telephone interviews with the parents of schoolchildren and also concluded that socioeconomic parameters were related to poor school performance. However, this investigation advances by including other socioeconomic factors in the analysis model, which were not assessed together in the aforementioned studies. Here, we also found that the mother´s education, number of residents in the house and with whom the child lives (father and mother or others) were also associated with school performance, which advances our knowledge about the variables involved in this scenario.

Certainly, the family is considered an important variable for the school performance of children and adolescents.28 _{Özmert et al.}2 _{in their study, found} associations between mother´s education and school performance of their schoolchildren, explaining the impact of mother´s education on the child’s cognitive development.

Considering the results of the present study, it is evident that actions involving the sectors of education and health are essential to improve school performance and absenteeism, since the socioeconomic factors and oral health conditions were identified as risk indicators for poor performance in schoolchildren. Therefore, one realizes the importance of interdisciplinary public policy, including health, education and social programs13,29 _{that focus on the social determinants of}

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health with the aim of impacting on general6 _{and oral health, thus improving the} quality of life as well the school performance of children and adolescents.10,19,20

Furthermore, this study emphasizes the importance of schoolchildren having access to dental care programs at school, so that the damage caused by oral diseases does not impact their quality of life and school performance, and lead to psychological problems and possible consequences in their adult life, as pointed out by Kumar et al.30 _{Therefore, where possible, these programs should direct} their actions to preventing the onset and development of oral diseases, because children without diseases had more chance of obtaining the best mean scores at school.

This study has some limitations. The fact that it was a case-control and not a cohort study did not allow us to investigate the risk factors and causal relationships for better or worse school performance over time and after dental treatment. Additionally, the sample consisting of children coming only from peripheral public schools participating of PAS, which does not allow us to make inferences of our findings for children of all socioeconomic levels. The absence of a single and standardized test to evaluate school performance in every school can also be considered a limitation, although the type of evaluation in public schools be like.

In conclusion, socioeconomic factors and the presence of caries lesions, even if treated, were risk indicators for poor school performance.