Theoretical explanations for social inequalities in oral health

Association between gingival bleeding and gingival enlargement and oral health-related quality of life (OHRQoL) of subjects under fixed orthodontic treatment: a cross-sectional study

Background

There are scarce evidences that evaluated the impact of periodontal disease on oral health-related quality of life (OHRQoL) taking marginal gingival alterations into consideration. Thus, this study aimed to verify the association between OHRQoL and gingival enlargement and gingival bleeding in subjects under fixed orthodontic treatment (FOT).

Methods

330 participants under FOT for at least 6 months were examined by a single, calibrated examiner for periodontal variables and dental aesthetic index. Socio-economic background, body mass index, time with orthodontic appliances, and use of dental floss were assessed by oral interviews. OHRQoL was evaluated using the oral health impact profile (OHIP-14) questionnaire. The assessment of associations used unadjusted and adjusted Poisson regression models.

Results

Higher impacts on the OHIP-14 overall were observed in subjects who presented higher levels of anterior gingival enlargement (RR 2.83; 95% CI 2.60-3.09), were non-whites (RR 1.29; 95% CI 1.15-1.45), had household income lower than five national minimum wages (RR 1.85; 95% CI 1.30-2.61), presented body mass index > 25 (RR 1.14; 95% CI 1.01-1.29), and showed a dental aesthetic index > 30 (RR 1.32; 95% CI 1.20-1.46).

Conclusions

Anterior gingival enlargement seems to influence the OHRQoL in subjects receiving orthodontic treatment.

Social gradients in dental health among low-income mothers and their young children

For low-income mothers of children aged 3-6 years, we estimate whether social gradients exist between mothers' income, education, and employment status and mothers' perceptions of self and child dental and general health, and whether these relationships differ by racial/ethnic group. Disproportionate stratified sampling by racial/ethnic group selected 10,909 eligible children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode (web, mail, telephone) survey. Mothers' education had a strong, gradient relationship with mother ratings of self and child dental health that was not explained by other measures. Similar gradients were found for mothers' employment status and income, but some associations were no longer significant (p>.05) after adjusting for oral health beliefs and behaviors, dental insurance, and regular dental care. Associations did not differ significantly by racial/ethnic group.

Socioeconomic status and self-reported oral health in Iranian adolescents: the role of selected oral health behaviors and psychological factors

OBJECTIVES

This study investigated health inequality for self-reported oral health outcomes among adolescents. The role of oral health behaviors and psychological factors in explaining oral health inequality was investigated using the hypothesis of mediation.

METHODS

This was a cross-sectional study that used self-completed questionnaires. This study sampled 639 (315 male and 324 female) 15- to 17-year-old adolescents (second and third grade high school students) of both sexes in the city of Sanandaj in the province of Kurdistan, western Iran. Socioeconomic indicators of the study were subjective socioeconomic status, wealth index, and parental education. Oral health behaviors were measured as toothbrushing frequency, dental flossing frequency, and dental visits. Psychological factors were self-esteem, anxiety, and depression. Self-reported oral health outcomes were single item self-rated oral health and the experience of dental pain. Regression analysis was used to test four conditions for the hypothesis of mediation.

RESULTS

The results showed that the inequality is present in oral health for some pairs of relationships between socioeconomic status and oral health outcomes. Adjustment for oral health behaviors and psychological factors, individually and simultaneously, led to loss of statistical significance for some pairs of the relationships. However, adjustment for oral health behaviors and psychological factors led to only small changes in the associations between socioeconomic status and self-reported oral health outcomes.

CONCLUSIONS

This study found a graded oral health inequality, but no strong evidence to support the hypothesis that oral health behaviors and psychological factors mediate oral health inequality for self-reported oral health outcomes.

Association between dental floss use and gingival conditions in orthodontic patients

INTRODUCTION

Evidence comparing periodontal conditions in orthodontic patients who regularly use or do not use dental floss is scarce.

METHODS

The subjects were 330 patients who had been under fixed orthodontic treatment for at least 6 months. They were examined by 1 calibrated examiner for plaque and gingival indexes, probing pocket depths, clinical attachment losses, and excessive resin around brackets. Socioeconomic background, time with orthodontic appliances, and use of dental floss were assessed in interviews. Unadjusted and multiple logistic regression analyses were used to assess the associations.

RESULTS

The results demonstrated statistically significant higher means of plaque index, gingival index, pocket probing depth, and clinical attachment loss for nonusers of dental floss. Intragroup analyses showed higher means of these parameters in proximal sites and posterior teeth, compared with their counterparts' buccal and lingual sites and anterior teeth, respectively. After multivariate analysis, male subjects (P = 0.044) with a household income less than 5 national minimum wages (P = 0.044), and nonusers of dental floss (P = 0.000) showed higher probabilities of gingival bleeding (>30%) than did their counterparts.

CONCLUSIONS

Orthodontic patients who use dental floss regularly have somewhat better gingival conditions than those who do not use floss.

Income-related inequalities in denture-wearing by Europeans aged 50 and above

BACKGROUND

Despite its importance for the planning of future treatment needs and an optimised allocation of health care resources, only little is known about socio-economic inequalities in denture-wearing by late middle-aged and elderly generations.

OBJECTIVES

To describe income-related inequalities in denture-wearing by elderly populations residing in different European countries.

MATERIAL AND METHODS

Data from the Survey of Health, Ageing and Retirement in Europe (SHARE Wave 2) were used to assess income-related inequalities in denture-wearing by means of Concentration Indices (CI) for populations aged 50+ from 14 different European countries.

RESULTS

We could identify a significant disproportionate concentration of denture-wearing amongst the poor elderly populations in Denmark (CI = -0.3534, corresponding to the highest level of inequality), Sweden (CI = -0.3479), Switzerland (CI = -0.2013), Greece (CI = -0.1953), the Netherlands (CI = -0.1413), France (CI = -0.1339), Austria (CI = -0.0974), Czech Republic (CI = -0.0959), Belgium (CI = -0.0947), Germany (CI = -0.0762), Ireland (CI = -0.0575) and Spain (CI = -0.0482, corresponding to the lowest level of pro-poor inequality). Poland became evident as the only country in which individuals from the upper end of the income scale wear more dentures than their peers from the lower end of the income scale (CI = 0.0379). No significant income-related inequalities were observable in Italy.

CONCLUSIONS

There is considerable income-related inequality in denture-wearing by several elderly populations in Europe. Future resource planning for prosthetic care should, thus, specifically distinguish between the treatment needs of different socio-economic groups within elderly populations.

Oral health-related quality of life: what, why, how, and future implications

Despite its relatively recent emergence over the past few decades, oral health-related quality of life (OHRQoL) has important implications for the clinical practice of dentistry and dental research. OHRQoL is a multidimensional construct that includes a subjective evaluation of the individual's oral health, functional well-being, emotional well-being, expectations and satisfaction with care, and sense of self. It has wide-reaching applications in survey and clinical research. OHRQoL is an integral part of general health and well-being. In fact, it is recognized by the World Health Organization (WHO) as an important segment of the Global Oral Health Program (2003). This paper identifies the what, why, and how of OHRQoL and presents an oral health theoretical model. The relevance of OHRQoL for dental practitioners and patients in community-based dental practices is presented. Implications for health policy and related oral health disparities are also discussed. A supplemental Appendix contains a Medline and ProQuest literature search regarding OHRQoL research from 1990-2010 by discipline and research design (e.g., descriptive, longitudinal, clinical trial, etc.). The search identified 300 articles with a notable surge in OHRQoL research in pediatrics and orthodontics in recent years.

Does secondhand smoke affect the development of dental caries in children? A systematic review

This review evaluated evidence of the relationship between secondhand smoke (SHS) and dental caries in children in epidemiological studies. Relevant literature was searched and screened, and the methodological quality was assessed. The search yielded 42 citations. High-quality studies including one cohort format and 14 case-control format studies were selected. Early childhood caries was examined in 11 studies. The independent association of SHS was significant in 10 studies, and the strength was mostly weak to moderate. One study did not select SHS as a significant variable. Three studies reported decreases in the risk of previous exposure, and the association was not significant. Dose-response relationships were evident in five studies. Permanent teeth were examined in seven studies. Five studies reported significant associations, which were mostly weak. The risk of previous exposure remained similar to that of current exposure, and a dose-response relationship was not evident in one study. The overall evidence for the causal association in early childhood caries is possible regarding epidemiological studies, and the evidence of permanent teeth and the effect of maternal smoking during pregnancy were insufficient. The results warrant further studies of deciduous teeth using a cohort format and basic studies regarding the underlying mechanism.

Income-related inequalities in dental service utilization by Europeans aged 50+

The purpose of this study was to describe income-related inequalities in dental service utilization by the elderly populations residing in different European countries. We used data from the Survey of Health, Ageing, and Retirement in Europe (SHARE Wave 2), which contains information on utilization of dental services by 33,358 individuals aged 50+ years from 14 different countries. We assessed income-related inequalities in dental attendance and preventive and/or operative dental treatment by means of Concentration Indices (CI) and Slope Indices of Inequality (SII). We could identify a disproportionate concentration of access to treatment among the rich elderly populations in all 14 countries (relative inequality according to CI), as well as significantly higher access to treatment by individuals located in the highest in relation to the lowest income group for all countries except Italy and the Czech Republic (absolute inequality according to SII). Such differential utilization appears mainly attributable to inequalities in preventive dental visits, either alone or in combination with operative treatment. Persons' oral health status explains substantial proportions of absolute but not of relative inequalities. Overall, there is considerable income-related inequality in dental service utilization by several elderly populations residing in Europe. More research is needed to identify the exact causes of such disparities.

Can type of school be used as an alternative indicator of socioeconomic status in dental caries studies? A cross-sectional study

Background

Despite the importance of collecting individual data of socioeconomic status (SES) in epidemiological oral health surveys with children, this procedure relies on the parents as respondents. Therefore, type of school (public or private schools) could be used as an alternative indicator of SES, instead of collecting data individually. The aim of this study was to evaluate the use of the variable type of school as an indicator of socioeconomic status as a substitute of individual data in an epidemiological survey about dental caries in Brazilian preschool children.

Methods

This study followed a cross-sectional design, with a random sample of 411 preschool children aged 1 to 5 years, representative of Catalão, Brazil. A calibrated examiner evaluated the prevalence of dental caries and parents or guardians provided information about several individual socioeconomic indicators by means of a semi-structured questionnaire. A multilevel approach was used to investigate the association among individual socioeconomic variables, as well as the type of school, and the outcome.

Results

When all significant variables in the univariate analysis were used in the multiple model, only mother's schooling and household income (individual socioeconomic variables) presented significant associations with presence of dental caries, and the type of school was not significantly associated. However, when the type of school was used alone, children of public school presented significantly higher prevalence of dental caries than those enrolled in private schools.

Conclusions

The type of school used as an alternative indicator for socioeconomic status is a feasible predictor for caries experience in epidemiological dental caries studies involving preschool children in Brazilian context.

Sense of coherence and oral health status in an adult Swedish population

OBJECTIVE

To investigate sense of coherence in relation to oral health status in an adult Swedish population in order to better understand the determinants of positive oral health-promoting behavior and differences in oral health.

MATERIAL AND METHODS

A stratified random sample of 910 individuals from Jönköping, Sweden aged 20, 30, 40, 50, 60, 70 and 80 years was obtained. The investigation used the Swedish short version of the Sense of Coherence (SOC) questionnaire comprising 13 items and a self-report questionnaire to elicit demographic information. In addition, a clinical and radiographic oral examination was performed.

RESULTS

A total of 525 individuals, 261 men and 264 women, consented to participate in the study. Bivariate analysis revealed that higher mean SOC scores were statistically significantly associated with more decayed and filled surfaces (DFS) and filled surfaces (FS), fewer decayed surfaces (DS), fewer teeth with calculus and periodontal health. Multivariate analysis showed that higher SOC scores represented a predictor of fewer occurrences of a periodontal probing pocket depth of ≥4 mm and a lower risk of plaque in different regression models.

CONCLUSIONS

Higher SOC scores may be a protective determinant of plaque and periodontal disease, indicating an association between SOC and oral health.

Impact of socioeconomic and clinical factors on child oral health-related quality of life (COHRQoL)

PURPOSE

Child oral health-related quality of life (COHRQoL) has been increasingly assessed; however, few studies appraised the influence of socioeconomic status on COHRQoL in developing countries. This study assessed the relationship of COHRQoL with socioeconomic backgrounds and clinical factors.

METHODS

This study followed a cross-sectional design, with a multistage random sample of 792 schoolchildren aged 12 years, representative of Santa Maria, a southern city in Brazil. Participants completed the Brazilian version of the Child Perceptions Questionnaire (CPQ(11-14)), their parents or guardians answered questions on socioeconomic status, and a dental examination provided information on the prevalence of caries, dental trauma and occlusion. The assessment of association used hierarchically adjusted Poisson regression models.

RESULTS

Higher impacts on COHRQoL were observed for children presenting with untreated dental caries (RR 1.20; 95% CI 1.07-1.35) and maxillary overjet (RR 1.19; 95% CI 1.02-1.40). Socioeconomic factors also associated with COHRQoL; poorer scores were reported by children whose mothers have not completed primary education (RR 1.30; 95% CI 1.17-1.44) and those with lower household income (RR 1.13; 95% CI 1.02-1.26).

CONCLUSION

Poor socioeconomic standings and poor dental status have a negative impact on COHRQoL; reducing health inequalities may demand dental programmes and policies targeting deprived population.

Behavioral Pathways Explaining Oral Health Disparity in Children

Policymakers’ understanding of and ability to reduce health disparities are pivotal for health promotion worldwide. This study aimed to verify the behavioral pathways leading to oral health disparities. Oral examinations were conducted for 1782 randomly selected preschoolers (3-6 yrs), and 1576 (88.4%) participants were followed up after 12 months. Parents were surveyed on their knowledge (K), attitude (A), and practices (P) regarding their children’s oral health homecare (infant feeding, diet, and oral hygiene) and dental attendance. Structural equation modeling substantiated the links between specific KAs and corresponding practices, while generic KA did not affect practices. KAP pathways partly explained the ethnic and socio-economic disparities in oral health. Deprivation had a direct effect (not mediated by KA) on dental attendance, but not on oral health homecare. Ethnicity directly influenced oral health homecare practices, but not dental attendance. These behavioral pathways, furthering our understanding of health disparity, may have practical implications for health promotion and policy-making.

Is income inequality related to childhood dental caries in rich countries?

BACKGROUND

The aim of this study was to assess the correlates of income and income inequality with dental caries in a sample of all countries, as well as in rich countries alone.

METHODS

In this ecological study, the authors analyzed national data on income, income inequality and dental caries from 48 countries. Of them, 22 were rich countries (according to World Bank criteria). The authors determined income by gross national income (GNI) per capita (formerly known as gross national product) and income inequality by the Gini coefficient (a measure of income inequality on a scale between 0 and 1). They assessed dental caries according to the decayed, missing, filled teeth (dmft) index in 5- to 6-year-old children. The authors used Pearson and partial correlation coefficients to examine the linear associations of income and income inequality with dental caries.

RESULTS

GNI per capita, but not the Gini coefficient, was inversely correlated with the dmft index in the 48 countries. However, the results showed an opposite pattern when analyses were restricted to rich countries (that is, the dmft index was significantly correlated with the Gini coefficient but not with GNI per capita).

CONCLUSION

These findings support the income inequality hypothesis that beyond a certain level of national income, the relationship between income and the population's health is weak. Income inequality was correlated more strongly with dental caries than was income in rich countries.

CLINICAL IMPLICATIONS

Among rich countries, income inequality is a stronger determinant of childhood dental caries than is absolute income.

The impact of educational level on oral health-related quality of life in older people in London

There are socioeconomic inequalities in oral health, but the relationship between education and oral health-related quality of life (OHRQoL) among older adults has not been adequately studied. This study assessed whether there is an educational gradient in OHRQoL among older people in London. We employed secondary analysis of baseline data (n = 1,090) from a randomized controlled trial of health-risk appraisal on community-dwelling non-disabled people 65 yr of age and older, registered with three group medical practices in suburban London. Multiple linear regressions were used to analyze the association between OHRQoL [measured using the Geriatric Oral Health Assessment Index (GOHAI)] and education, adjusted for age, gender, pension status, and denture wearing. Overall, 30.6% reported low levels of OHRQoL. Eating discomfort was the most frequent problem (24% reported 'often/always'), while concerns about appearance were also prevalent. Significant variations in OHRQoL existed between socioeconomic groups. In adjusted analyses, there was a clear education gradient in OHRQoL, with worse perceptions at each lower level of education. Low educational level has an independent negative impact on OHRQoL in older people, which is not explained by differences in income or in denture wearing between educational groups. Policies targeting lower educated groups should be complemented with whole-population strategies for the reduction of oral health inequalities.

Poverty, social exclusion and dental caries of 12-year-old children: a cross-sectional study in Lima, Peru

BACKGROUND

Socioeconomic differences in oral health have been reported in many countries. Poverty and social exclusion are two commonly used indicators of socioeconomic position in Latin America. The aim of this study was to explore the associations of poverty and social exclusion with dental caries experience in 12-year-old children.

METHODS

Ninety families, with a child aged 12 years, were selected from 11 underserved communities in Lima (Peru), using a two-stage cluster sampling. Head of households were interviewed with regard to indicators of poverty and social exclusion and their children were clinically examined for dental caries. The associations of poverty and social exclusion with dental caries prevalence were tested in binary logistic regression models.

RESULTS

Among children in the sample, 84.5% lived in poor households and 30.0% in socially excluded families. Out of all the children, 83.3% had dental caries. Poverty and social exclusion were significantly associated with dental caries in the unadjusted models (p = 0.013 and 0.047 respectively). In the adjusted model, poverty remained significantly related to dental caries (p = 0.008), but the association between social exclusion and dental caries was no longer significant (p = 0.077). Children living in poor households were 2.25 times more likely to have dental caries (95% confidence interval: 1.24; 4.09), compared to those living in non-poor households.

CONCLUSION

There was support for an association between poverty and dental caries, but not for an association between social exclusion and dental caries in these children. Some potential explanations for these findings are discussed.

Factors associated with caregivers' perception of children's health and oral health status: a study of 6- to 36-month-olds in Uganda

BACKGROUND

The impact of oral diseases on quality of life of children and their families has not been thoroughly investigated.

AIM

Focusing on Ugandan infants aged 6-36 months and their caregivers, this study examined the degree to which clinical and psychosocial factors were associated with caregivers' overall evaluation of their children's oral health and health status.

DESIGN

Eight hundred and sixteen children were examined for dental caries and anthropometric status in 2007. A questionnaire was completed by the caregivers.

RESULTS

Poor child oral health was reported by 40.2% and 17.5% of caregivers who reported their children's health as, respectively, poor and good. Having the least family wealth [odds ratio (OR) = 1.9] and reporting distressed family activities (OR = 2.3) were associated with higher odds of reporting poor child oral health, whereas being a rural resident (OR = 0.4) and reporting no symptoms during tooth eruption (OR = 0.3) were associated with lower odds. Perception of poor child oral health (OR = 2.8) and having the least family wealth (OR = 1.7) were associated with higher odds of reporting poor child health status, whereas no stunting was associated with lower odds (OR = 0.5).

CONCLUSION

The results support the growing recognition of oral health as a predictor of health and well-being in early childhood.

The different effects of vertical social capital and horizontal social capital on dental status: a multilevel analysis

Few studies distinguish between the effects of different forms of social capital on health and of those that do none use physical indicators of health as an outcome variable. The objective of this study was to determine whether vertical and horizontal social capital had different associations with dental status of elderly Japanese. In this cross-sectional study, self-administered questionnaires were mailed to elderly individuals living in 25 Japanese communities in 2003. Data from 5560 respondents (49.9%, 72.9+/-6.0 years) included information on social capital, numbers of remaining teeth, health behaviors, physical and mental health, and socioeconomic status. Vertical social capital was defined as participating in groups which encouraged hierarchical relations and horizontal social capital as participating in groups of equals. A multilevel logistic regression analysis was conducted to assess the association between social capital and number of remaining teeth (< or = 19 teeth or > or = 20 teeth). The prevalence of people with 19 or less teeth was 70.7%. Univariate analysis showed significant beneficial associations between individual horizontal social capital and number of remaining teeth. After adjusting for individual- and community-level covariates in multilevel analysis, community-level horizontal social capital still showed beneficial association. Compared to respondents living in highest horizontal social capital areas, those living in lowest horizontal social capital areas had a 1.25 times higher odds ratio for having 19 or less teeth. Individual-level horizontal social capital also showed beneficial effects on number of remaining teeth. Community- and individual-level vertical social capital did not show significant associations with dental status. The results suggest that horizontal social capital, not vertical social capital, has beneficial effects on numbers of remaining teeth in older Japanese adults.

Oral health of early head start children: a qualitative study of staff, parents, and pregnant women

OBJECTIVES

We explored the oral health knowledge, attitudes, and activities of Early Head Start (EHS) staff members, parents, and pregnant women, along with their suggestions related to future oral health educational interventions targeting EHS children.

METHODS

Nine focus groups were conducted with EHS staff, parents, and pregnant women. Audiotapes of sessions were transcribed and entered into ATLAS.ti 5.0 for coding and analysis.

RESULTS

Attitudes about the importance of children's oral health among parents and pregnant women were mixed. Staff members voiced responsibility for children's oral health but frustration in their inability to communicate effectively with parents. Parents in turn perceived staff criticism regarding how they cared for their children's oral health. Gaps were noted in the oral health activities of EHS programs. Participants expressed confusion regarding the application of Head Start oral health performance standards to EHS. The need for culturally sensitive, hands-on oral health education was highlighted.

CONCLUSIONS

Tailored, theory-based interventions are needed to improve communication between EHS staff and families. Clear policies on the application of Head Start oral health performance standards to EHS are warranted. Educational activities should address the needs and suggestions of EHS participants.

What a difference a place makes: dental attendance and self-rated oral health among adults in three counties in Norway

Through a multilevel approach, the study explores the relationships of dental attendance and self-rated oral health (SROH) to individual and structural factors among adults in Norway. The individual factors include various socio-demographic characteristics. The structural ones are population density and dentist density. The sample was recruited from three counties that represent three different combinations of population density and dentist density. There were significant differences in both dental attendance and SROH between the counties. The findings support the theory of a structural explanation of the observed differences and indicate evidence of supplier-suppressed demand. Access to dental services could be improved either by regulating the supply side of dentistry or by compensating patients for travel costs incurred in accessing dental services.

The Effects of Social Class and Dental Attendance on Oral Health

The relationship between socio-economic status (SES) and oral health is well-established. We investigated whether the association between SES and the number of sound teeth in adults is explained by dental attendance patterns, in turn determined by the effect of SES on barriers to dental attendance. Data on 3817 participants from the 1998 Adult Dental Health Survey in the UK were analyzed. Using structural equation modeling, we found a model with 4 factors (aging, SES, attendance-profile, and barriers-to-dental-attendance) providing an adequate fit to the covariance matrix of the 9 covariates. The final model suggests that the association between SES and the number of sound teeth in adults in the UK is partially explained by the pathway [SES → barriers-to-dental-attendance → dental-attendance-profile → number-of-sound-teeth]. A direct relationship, SES → number-of-sound-teeth, is also significant.

Inequalities in oral health practices and social space: an exploratory qualitative study

This study analyzed the oral health practices and access to dental care of individuals according to their position in social space. The rationale was based on the hypothesis that different positions in social space may imply different habitus, in the sense conferred by Bourdieu. Such dispositions would influence practical behavior, choices and preferences in general and in this context, dental care. Twenty-two semi-structured interviews were carried out with individuals, as part of a multiple case study carried out in two municipalities in the state of Bahia, Brazil. Differences were found between the two study groups both with respect to actions of personal care and in seeking and using dental services. This, in addition to poor material and living conditions, and difficult access to restorative dental work in the public sector, may explain part of the pattern of tooth loss found in the adult Brazilian population. The adoption of effective communicative and educational actions by health professionals should be stimulated. However, the structural dimension of the social determinants requires transformations in the structures that generate the perceptions and practices of agents. The study discusses the implications of these data to public dental policies that are focused on reducing these inequalities.