How much of the income inequality effect can be explained by public policy? Evidence from oral health in Brazil

Longitudinal assessment of factors associated with dental caries on the first permanent molars: a prospective clinical study in Brazilian children

PURPOSE

The first molars are frequently the first permanent teeth to erupt in the oral cavity, and their premature loss can significantly affect a child's oral health. This study aimed to identify determinants of dental caries on the first permanent molars among schoolchildren.

METHODS

A longitudinal study was conducted with 122 mother-child pairs from the Brazilian city of Diamantina. The children were evaluated at three instants: first, between 1 and 3 years of age (T1), then, 3 years after the initial assessment (T2), and finally, 6 years after the initial assessment (T3). Socioeconomic data, child habits, visible plaque, and dental caries (assessed through International Caries Detection and Assessment System [ICDAS-II]) were collected at all three time points.

RESULTS

The incidence of dental caries in the first permanent molars was 70.5% and was associated with the presence of caries at T1 (RR = 1.41; 95% CI 1.08-1.84) and T2 (RR = 1.58; 95% CI 1.12-2.22). The following variables at both T1 and T2 were also significantly associated with caries incidence: a high number of income dependents (RR = 1.66; 95% CI 1.17-2.35) and low brushing frequency (RR = 1.77; 95% CI 1.27-2.46). Yet, the persistence of low brushing frequency from T2 to T3 (RR = 1.32; 95% CI 1.05-1.65) was also associated with the incidence of caries.

CONCLUSIONS

The incidence of dental caries in the first permanent molars was associated with prior caries experience, low toothbrushing frequency, and schoolchildren belonging to families with a high number of income dependents. These findings highlight the importance of early preventive interventions and socioeconomic considerations in addressing childhood dental caries.

Malocclusion: Prevalence and Determinants among Adolescents of Karachi, Pakistan

OBJECTIVES

 The aim of this study was to determine the prevalence of malocclusion and its associated demographic and clinical factors in young adolescents (13-15 years) of Karachi, Pakistan.

MATERIALS AND METHODS

 An epidemiological survey included 500 young adolescents of registered schools, madrassas (Islamic education system), and shop workers of Gulshan-e-Iqbal Town. It was a cross-sectional analytical study design. Multistage random sampling technique was used to enroll participants. The pattern of occlusion was recorded with other related features using Angle's classification. Health status was recorded through World Health Organization-guided indices (decayed, missing, and filled permanent teeth [DMFT], community periodontal index of treatment needs [CPITN], and body mass index [BMI]). The information, thus, obtained was analyzed through SPSS using the chi-squared test and regression models.

RESULTS

 Forty four percent of the participants were female, while overall estimated prevalence of malocclusion in young adolescents of Karachi was 57.4%. After adjustments, participants going to any kind of education system had less malocclusion in comparison to those who were not going to any education system (adjusted odds ratio [aOR] = 0.305, 95% confidence interval [CI] = 0.12-0.73); mother's education especially higher level (aOR = 2.02, 95% CI = 1.08-3.75) and presence of periodontal disease (aOR = 1.57, 95% CI = 1.06-2.33) were significantly associated with malocclusion.

CONCLUSION

 This study showed that the class I malocclusion is prevalent in the local community. Demographic factors like gender, age, self-reported ethnicity, and BMI did not show any significant role. Education or knowledge of parents and young adolescents does play an influential role in decreasing malocclusion. Young adolescents, who are more prone to oral health problems at an early age, would have more chances to develop occlusal discrepancies.

The mediating role of social capital in socioeconomic inequalities of oral health behaviours among Brazilian older adults

OBJECTIVES

Knowledge of the possible pathways linking socioeconomic status (SES) to oral health-related behaviours can improve the understanding of inequalities in oral health. Therefore, in this study, it was investigated whether social capital mediates the relationship between SES and oral health behaviours.

METHODS

Through a cross-sectional study, data were analysed from participants aged ≥60 years from the Brazilian National Health Survey 2019 (n = 21 575). Structural equation modelling was used to test the direct and indirect pathways from a latent variable for SES to a latent variable for oral health behaviours: daily flossing, toothbrushing frequency and the use of dental care services.

RESULTS

The maximum likelihood estimator was used for complex samples with robust standard errors, and the final model demonstrated an adequate fit. The findings demonstrated that a higher SES was directly associated with better oral health-related behaviours (standardized coefficient [SC]: 0.82; [90% CI: 0.78-0.85]) and indirectly via structural social capital (SC: 0.05; [90% CI: 0.02-0.07]). The total effect of SES on oral health-related behaviours was (SC: 0.87, [90% CI: 0.85-0.89]).

CONCLUSION

The findings demonstrate that structural social capital in older Brazilian adults might partly mediate the pathways to socioeconomic inequalities in oral health behaviours. However, there is a direct effect on oral health behaviours, reinforcing the hypothesis that SES is associated with oral health, based on paths that link income inequality to oral health.

Impact of COVID-19 pandemic on completed treatments and referrals during urgent dental visits

This ecological study assessed the impact of the COVID-19 pandemic on completed treatments (CTs) and referrals during urgent dental visits to primary health care units in Brazil, and their associations with socioeconomic, geodemographic, and pandemic index factors in Brazilian municipalities. The difference in rates of procedures 12 months before and during the pandemic was calculated. Data were extracted at baseline from health information systems of all municipalities that provided urgent dental care (n = 5,229 out of 5,570). Multiple logistic regression predicted the factors associated with referrals and CTs. The number of dental urgencies increased from 3,987.9 to 4,272.4 per 100,000 inhabitants. The rates of referrals decreased in 44.1% of the municipalities, while 53.9% had lower rates of CTs. Municipalities with a greater number of oral health teams in the primary health care system (OR = 1.52, 95%CI:1.21-1.91) and with specialized services (OR = 1.80, 95%CI:1.50-2.16) were more likely to decrease referrals during the pandemic. Higher HDI and GDP per capita were associated with a larger decrease in referrals and smaller decrease in CTs. The calamity generated by the long pandemic period resulted in a greater demand for urgent visits. Less developed and larger cities seem to have been more likely to not complete treatments during urgent visits in primary dental care units in times of calamity. Primary dental care offices in smaller and less developed municipalities should be better equipped to provide appropriate assistance and to improve the problem-solving capacity of dental services during emergencies.

Assessment of the contextual effects on the prevalence of periodontitis: a systematic review

This study reviews the influence of contextual factors on periodontitis based on a systematic search of studies recorded in the PubMed, Scopus, Web of Science, and EMBASE databases. Periodontitis was assessed by clinical attachment loss and probing depth for studies with data on the socioeconomic status (SES) of a specific area (area-level SES) or dental care service (service-level) in a catchment area among individuals aged 18 and over. Two independent reviewers performed study selection, data extraction, and assessment of methodological quality. Of the 646 articles identified, 13 were included in the systematic review, representing 101,362 individuals from five countries (USA, UK, Brazil, China, and Uruguay). A higher prevalence of periodontitis was described in lower SES neighborhoods, more deprived postcodes, and poorer provinces. Gini Index results were mixed and inconclusive. Three studies showed that higher coverage of primary dental care at the municipal level was associated with a lower prevalence of periodontitis. Contextual factors at the area-level SES and dental care service might influence periodontitis, but the existing evidence is unclear. The contextual effect is important for periodontal health and may contribute to the prevalence of periodontitis, independent of well-known risk factors and individual levels.

Social and economic capital as effect modifiers of the association between psychosocial stress and oral health

OBJECTIVES

To assess the extent of the association of psychosocial stress with oral health in an Ontario population stratified by age groups, and whether any association is modified by indicators of social and economic capital.

METHODS

We retrieved data of 21,320 Ontario adults, aged 30-74 years old, from the Canadian Community Health Survey (CCHS: 2017-2018), which is a Canada-wide, cross-sectional survey. Using binomial logistic regression models that adjusted for age, sex, education, and country of birth, we examined the association of psychosocial stress (indicated by perceived life stress) with inadequate oral health (indicated as having at least one of the following: bleeding gums, fair/poor self-perceived oral health, persistent oral pain). We assessed the effect measure modification of indicators of social (sense of belonging to the local community, living/family arrangements) and economic capital (household income, dental insurance, dwelling ownership) on the perceived life stress-oral health relationship, stratified by age (30-44, 45-59, 60-74 yrs). We then calculated the Relative Excess Risk due to Interaction (RERI) which indicates the risk that is above what would be expected if the combination of low capital (social or economic) and high psychosocial stress was entirely additive.

RESULTS

Respondents with higher perceived life stress were at a significantly higher risk of having inadequate oral health (PR = 1.39; 95% CI: 1.34, 1.44). Adults with low social and economic capital were also at an increased risk of inadequate oral health. Effect measure modification showed an additive effect of indicators of social capital on the perceived life stress-oral health relationship. This effect was evident across all three age groups (30-44, 45-59, 60-74 yrs), with the highest attributable proportion of social and economic capital indicators in the psychosocial stress-oral health relationship in older adults (60-74 yrs).

CONCLUSION

Our findings suggest an exacerbating effect for low social and economic capital in the relationship of perceived life stress with inadequate oral health among older adults.

Comprehensive metrological and content analysis of the income inequality research in health field: A bibliometric analysis

The association between income inequality in a society and the poor health status of its people has attracted the attention of researchers from multiple disciplines. Based on the ISI Web of Science database, bibliometric methods were used to analyze 546 articles related to income inequality research in health field published between 1997 and 2021. We found that the USA contributed most articles, the Harvard Univ was the most influential institution, Social Science & Medicine was the most influential journal, and Kawachi I was the most influential author; the main hotspots included the income inequality, income, health inequality, mortality, socioeconomic factors, concentration index, social capital, self-rated health, income distribution, infant mortality, and population health in 1997-2021; the cardiovascular disease risk factor, social capital income inequality, individual mortality risk, income-related inequalities, understanding income inequalities, income inequality household income, and state income inequality had been the hot research topics in 1997-2003; the self-assessed health, achieving equity, income-related inequalities, oral health, mental health, European panel, occupational class, and cardiovascular diseases had been the hot research topics in 2004-2011; the adolescent emotional problem, South Africa, avoidable mortality, rising inequalities, results from world health survey, working-age adult, spatial aggregation change, prospective study, and mental health-empirical evidence had been the hot research topics in 2012-2021; there were 11 articles with strong transformation potential during 2012-2021. The research results of this paper are helpful to the scientific understanding of the current status of income inequality research in health field.

Convergence effect of the Belt and Road Initiative on income disparity: evidence from China

The international economic effects of the Belt and Road Initiative (BRI) have received much attention, but few studies have focused on the impact of the BRI on domestic regional income disparities. Here, a theoretical framework is proposed based on the logic of public policy analysis in economic geography aiming at studying the impact of the BRI on the convergence of inter-city income disparities in China. Specifically, taking the BRI as a quasi-natural experiment, the impact of the BRI on the convergence of inter-city income disparities in 26 provinces of China is studied empirically using the difference-in-differences method. We find that the BRI has indeed contributed to the convergence of regional income disparities, and this convergence effect is continuously dynamic in its nature. The effects of trade opening and industrial structure transformation are the paths through which the BRI contributes to the convergence of income disparities. Furthermore, we find that there is significant heterogeneity in the effects of the BRI on the convergence of income disparities among cities in different provinces in China. The convergence effect of the BRI on the income disparities among cities in East China is small and insignificant, whereas it can significantly reduce the income disparities among cities in Central and West China. The research in this article has important application value for exploration of the regional income distribution effect of the BRI.

[Income inequality and early childhood caries in Colombia: a multilevel analysis]

The association between income inequality and dental caries on early childhood in Colombia was evaluated using a multi-level analysis. We analyzed data from the latest national oral survey (2014) and information about income in absolute and relative terms on a state-level. The outcomes were caries experience, and untreated caries. A multilevel logistic regression model was used (2 levels) with children/households nested within states. Age, gender, area-level socioeconomic position (SEP), household income and health insurance regime were the level 1 explanatory variables. For level 2, variables were the Gini coefficient, Unsatisfied Basic Needs (UBN) and Gross Domestic Product (GDP). Data from 5.250 children, aged 1, 3 and 5 years were evaluated. Prevalence of caries experience and untreated caries was 36.9% and 33.0% respectively. Both outcomes showed significant associations with age, low SEP and belonging to the subsidized health insurance regime: untreated dental caries was associated with living in low and very low SEP (OR: 1.72; 95%CI 1.42, 2.07 and OR: 1.69; 95%CI 1.36, 2.09 respectively), and subsidized health insurance scheme (OR: 1.58; 95%CI 1.11, 2.24). When the Gini, GDP and UBN indicators were included in the models, no significant associations were found.

Urgent dental care in the Brazilian public health system: learning lessons from the COVID-19 pandemic for future situations

This ecological study described the effect of the COVID-19 pandemic and socioeconomic development on the use and profile of urgent dental care (UDC). UDC rates per 100,000 inhabitants before (from March to June 2019) and during (from March to June 2020) the COVID-19 pandemic in 4,062 Brazilian municipalities were compared. Data were collected from official sources. COVID-19 mortality and hospitalization rates were indicative of levels of lockdown and Human Development Index (HDI) indicated socioeconomic development. Multiple logistic regression and relative excess risk due to interaction (RERI) were used for statistical analyses. The Student t-test was used to compare changes in the profile of UDC causes and procedures in the two periods. Lower UDC rates were found in 69.1% of municipalities and were associated with higher HDI (OR = 1.20; 95%CI: 1.01; 1.42). Mortality had OR = 0.88 (95%CI: 0.73; 1.06) for municipalities with HDI < 0.70 and OR = 1.45 (95%CI: 1.07; 1.97) for municipalities with HDI > 0.70. RERI between HDI and COVID-19 was 0.13 (p < 0.05). Municipalities with greater primary health care coverage had a smaller reduction in emergency rates. Endodontic treatment and dental pain were the most frequent factors both before and during the pandemic. The percentage of UDCs due to pain and soft tissue damage, as well as temporary sealing and surgical procedures, increased. Socioeconomic variables affected UDC rates during the most restrictive period of the COVID-19 pandemic and should be considered in the planning of health actions in future emergencies.

Contextual determinants for use of dental services according to different healthcare financing systems: Andersen's model

OBJECTIVES

To explore contextual factors associated with overall dental service use, and investigate whether these factors influenced choice of the type of service according to the healthcare financing alternatives (public services; out-of-pocket services; and private health insurance), by adults and older individuals, based on the most recent Andersen's behavioural model.

METHODS

Cross-sectional study with individual data on 17,305 adults from 177 Brazilian municipalities in the National Oral Health Survey (SBBrasil 2010). Municipal-level information was obtained from health information systems and census data. Multilevel multinomial logistic regression was carried out for multivariable analysis.

RESULTS

In the previous year, 38.2% of the individuals visited the dentist; of which 21.4% used out-of-pocket spending, 11.6% used public services and 5.2% private dental insurance. Municipalities with population coverage of public primary dental care >80% had higher chances of using public services (OR = 1.28, 95%CI:1.00-1.64) than those with ≤60%, but lower chances of using private insurance (OR = 0.56, 95%CI:0.38-0.83). Municipalities with population coverage of private dental insurance > 5% had lower chances of using public services (OR = 0.62, 95%CI:0.47-0.81) than those with <1% coverage, and greater chances of using private insurance (OR = 4.33, CI:95% 2.02-9.29). These factors were not associated with out-of-pocket dental services.

CONCLUSIONS

Municipal coverage of dental services is associated with dental care use, and this is different according to the type of financing system (public or private), as they may change the individual's choice of service. A large public healthcare system may increase public service use for those with reduced access and decrease private service use.

Municipality-Level Characteristics Associated with Very Low to Good Quality of Water Fluoridation in São Paulo State, Brazil, in 2015

INTRODUCTION

Community water fluoridation (CWF) is a measure of recognized importance due to its effectiveness in preventing tooth decay at the population level. However, for the maximum benefit to be achieved, the high-quality standard of CWF must be maintained over time.

OBJECTIVE

To analyze the municipality-level characteristics associated with quality of water fluoridation in São Paulo state, Brazil.

METHODS

An ecological study was performed using official data sources on fluoride concentration surveillance in 2015. The outcome was municipalities that have not met the quality standard, identified as those with less than 80% of water samples within the optimal level for caries prevention. The independent variables were municipality-level indicators related to demographics, economics, and sanitation characteristics. Crude and adjusted prevalence ratios were estimated using Poisson regression with robust variance.

RESULTS

In total, 43.4% municipalities exhibited the outcome. Adjusted by Gini index, the prevalence ratio was 32% higher in municipalities with lower annual gross domestic product per capita. Adjusted by social responsibility index and earlier variables, the prevalence was higher in the municipalities with higher per capita expenditure on sanitation and health surveillance, where the urban population rate was lower, and with a human development index ≤0.761. Adjusted by earlier variables, the prevalence ratio was twice and 3.5 times higher for municipalities, respectively, with per capita income less than or equal to US$574 and where the type of sanitation utility was municipal and private; 50% higher in those with less than 100,000 habitants; and 20% higher in those with a chlorine concentration nonconformity rate above 0.82%.

CONCLUSIONS

To ensure high quality of CWF, additional management measures should be implemented in municipalities with less than 100,000 habitants, a higher chlorine concentration nonconformity rate, a lower per capita income, and where the type of sanitation utility was municipal or private.

KNOWLEDGE TRANSFER STATEMENT

The study showed that the quality of fluoridation was associated with municipality-level characteristics. The findings can be used by policy makers to identify and support municipalities that will need to improve fluoridation quality if they are to reach oral health goals.

Education and income-based inequality in tooth loss among Brazilian adults: does the place you live make a difference?

BACKGROUND

Socioeconomic inequalities in tooth loss might be minimized or potentialized by the characteristics of the context where people live. We examined whether there is contextual variation in socioeconomic inequalities in tooth loss across Brazilian municipalities.

METHODS

Data from the 2010 National Oral Health Survey of 9633 adults living in 157 Brazilian municipalities were used. The individual socioeconomic indicators were education and household income. At the municipal level, we used the Municipal Human Development Index (HDI) as our contextual indicator of socioeconomic status (low:< 0.699 versus high: > 0.70). The Relative (RII) and Slope (SII) Indexes of Inequality, Relative (RCI), and Absolute (ACI) Concentration Indexes were calculated to compare the magnitude of education and income-based inequalities among municipalities with low versus high HDI. Multilevel Poisson regression models with random intercepts and slopes were developed.

RESULTS

At the individual level, adults with lower education & income reported more tooth loss. The mean number of missing teeth was 9.52 (95% CI: 7.93-11.13) and 6.95 (95% CI: 6.43-7.49) in municipalities with low and high HDI, respectively. Municipalities with high HDI showed higher relative and absolute education-based inequality. For income-based inequalities, higher SII and RCI was observed in municipalities with lower HDI. A significant cross-level interaction indicated that high-education adults reported fewer missing teeth when they lived in municipalities with high HDI compared to adults with the same education level living in low HDI municipalities. For individuals with the lowest education level, there was no difference in the number of teeth between those from municipalities with high and low HDI.

CONCLUSIONS

There was a social gradient in tooth loss by education and income. Living in disadvantaged municipalities cannot overcome the risk associated with low schooling. The protective effect of higher education can be reduced when people live in disadvantaged areas.

The Relationship between Income and Oral Health: A Critical Review

In this critical review, we summarized the evidence on associations between individual/household income and oral health, between income inequality and oral health, and income-related inequalities in oral health. Meta-analyses of mainly cross-sectional studies confirm that low individual/household income is associated with oral cancer (odds ratio, 2.41; 95% confidence interval [CI], 1.59-3.65), dental caries prevalence (prevalence ratio, 1.29; 95% CI, 1.18-1.41), any caries experience (odds ratio, 1.40; 95% CI, 1.19-1.65), tooth loss (odds ratio, 1.66; 95% CI, 1.48-1.86), and traumatic dental injuries (odds ratio, 0.76; 95% CI, 0.65-0.89). Reviews also confirm qualitatively that low income is associated with periodontal disease and poor oral health-related quality of life. Limited evidence from the United States shows that psychosocial and behavioral explanations only partially explain associations between low individual/household income and oral health. Few country-level studies and a handful of subnational studies from the United States, Japan, and Brazil show associations between area-level income inequality and poor oral health. However, this evidence is conflicting given that the association between area-level income inequality and oral health outcomes varies considerably by contexts and by oral health outcomes. Evidence also shows cross-national variations in income-related inequalities in oral health outcomes of self-rated oral health, dental care, oral health-related quality of life, outcomes of dental caries, and outcomes of tooth loss. There is a lack of discussion in oral health literature about limitations of using income as a measure of social position. Future studies on the relationship between income and oral health can benefit substantially from recent theoretical and methodological advancements in social epidemiology that include application of an intersectionality framework, improvements in reporting of inequality, and causal modeling approaches. Theoretically well-informed studies that apply robust epidemiological methods are required to address knowledge gaps for designing relevant policy interventions to reduce income-related inequalities in oral health.

Adolescent and youth health policies in the Portuguese-Brazilian context: specificities and approximations

OBJECTIVE

To characterize the scientific production on adolescent health policies and programs in Brazil and Portugal in the period 2010-2017.

METHOD

This is a literature review based on the Scoping Review method. The research guidingquestion was: "How is the scientific production on adolescent health policies and programs in Brazil and Portugal characterized?"Search was carried out in October 2017 on the BVS, EBSCO and Google Scholar platforms.

RESULTS

Twenty-two studies were selected, namely, 17 Brazilian and 5 Portuguese. Seven cross-cutting thematic categories were identified, as follows: policy and program evaluation; health promotion and education; mental health; sexual and reproductive health; violence; oral health and nutritional health. We canconclude that, albeit in different social contexts, the themes reflect traditional areas of intervention of policies and programs, except for those arising from the phenomenon of structural violence, markedly present in the Brazilian reality. Also, the lack of emerging issues such as gender identities, migratory flows, and morbimortality from external causes reveal a possible care gap in policies and programs and a necessary field to be explored.

Assistência odontológica em programas sociais para populações socialmente vulneráveis na perspectiva do programa Uruguay Trabaja

Resumo Este trabalho discute características do subprograma da saúde bucal do programa Uruguai Trabaja (UT), em Montevidéu, e identifica os tratamentos odontológicos iniciados, completados e abandonados de 2008 a 2015. Por meio de análise documental, o UT é discutido a partir de dois níveis categóricos. O primeiro refere-se ao contexto macrossocial, relacionando-se à expansão da cobertura da assistência odontológica integrada nos sistemas de proteção social, enquanto o segundo se origina da observação sistemática da assistência odontológica inserida em programas de acompanhamento social. UT é um programa social anual de nove meses de duração dirigido a pessoas de 18 a 65 anos em situação de vulnerabilidade socioeconômica e desempregadas há muito tempo. Seu propósito é melhorar a empregabilidade e a integração social dos participantes. Assistência odontológica integral é um dos benefícios do programa, a qual não é disponibilizada pelo Sistema Nacional Integrado de Saúde. Dos 2.592 tratamentos odontológicos iniciados, 941 (36,3%) não chegaram ao final. Programas focalizados como o UT, enquanto dispositivos de proteção social, devem estar articulados funcionalmente a políticas sociais universais que devem responder adequadamente as necessidades da população. A saúde bucal, nesse contexto, deve ser incluída no Sistema Nacional Integrado de Saúde do Uruguai, garantindo o direito à saúde.

Socioeconomic Inequalities in the Oral Health of People Aged 15-40 Years in Kurdistan, Iran in 2015: A Cross-sectional Study

Objectives

The aim of this study was to evaluate socioeconomic inequalities in the prevalence of dental caries among an urban population.

Methods

This study was conducted among 2000 people 15-40 years of age living in Kurdistan, Iran in 2015. Using a questionnaire, data were collected by 4 trained dental students. The dependent variable was the decayed, missing, and filled teeth (DMF) index. Using principal component analysis, the socioeconomic status (SES) of families was determined based on their household assets. Inequality was measured using the concentration index; in addition, the Oaxaca analytical method was used to determine the contribution of various determinants to the observed inequality.

Results

The concentration index for poor scores on the DMF index was -0.32 (95% confidence interval [CI], -0.40 to -0.36); thus, poor DMF indices had a greater concentration in groups with a low SES (p<0.001). Decomposition analysis showed that the mean prevalence of a poor DMF index was 43.7% (95% CI, 40.4 to 46.9%) in the least privileged group and 14.4% (95% CI, 9.5 to 9.2%) in the most privileged group. It was found that 85.8% of the gap observed between these groups was due to differences in sex, parents' education, and the district of residence. A poor DMF index was less prevalent among people with higher SES than among those with lower SES (odds ratio, 0.31; 95% CI, 0.19 to 0.52).

Conclusions

An alarming degree of SES inequality in oral health status was found in the studied community. Hence, it is suggested that inequalities in oral health status be reduced via adopting appropriate policies such as the delivery of oral health services to poorer groups and covering such services in insurance programs.

Early-life socioeconomic status and malocclusion in adolescents and young adults in Uruguay

This study aims to estimate orthodontic treatment need among 15-24 year-old individuals in Montevideo, Uruguay, and the association of occlusal traits with demographic, clinical and socioeconomic factors, considering a life course approach. A cross-sectional study using data from the First National Oral Health Survey in Uruguay was conducted. A two-stage cluster procedure was used to select a sample of 278 individuals in Montevideo. Household interviews and oral examinations were performed by six dentists. Dental Aesthetic (DAI) and Decayed Missing and Filled Teeth Indices (DMFT) were used to assess orthodontic treatment need and dental caries, respectively. Early life and current socioeconomic factors were obtained from the interview. Ordinal logistic regression was used to model the DAI index. Prevalence of definite malocclusion was 20.6%, followed by severe (8.2%) and very severe (7.6%). In the adjusted analysis, individuals with untreated dental caries (OR = 1.11; 95%CI: 1.03-1.20) and those who reported a lower socioeconomic level at 6 years of age (OR = 5.52; 95%CI: 1.06-28.62) had a higher chance of being a worse case of malocclusion. Current socioeconomic position was not associated with orthodontic treatment need. Individuals aged 22-24 years (OR = 1.59; 95%CI: 1.05-2.41) had a lower chance than those aged 14-17. This study shows that orthodontic treatment need is relatively high in Uruguayan adolescents and young adults. There is a potential relationship between early life socioeconomic status and the occurrence of malocclusion in adolescents and young adults under a life course approach.

[Inequalities in dental care during the life course of young people: a cohort study]

The scope of this study was to investigate dental care from the life course perspective and its determinant factors among young people in the city of Sobral, State of Ceará, Brazil. A cohort study was conducted with waves in 2000, 2006 and 2012 with 482 young people aged between 17 and 21 years. Two outcomes were investigated: immediate dental care and the lack of dental care, based on the dental trajectory in relation to restorative treatment. Socioeconomic conditions and recourse to oral health services and actions in the three waves investigated were used as independent variables. It was found that low socioeconomic status throughout life presented itself as a risk factor for lack of dental care and the inverse effect was observed with immediate dental care. Participation in groups of teenagers was also related to dental care, as well as receiving information on oral health. This study revealed the presence of inequalities in dental care throughout the life course of the population assessed.

Income inequality and high blood pressure in Colombia: a multilevel analysis

The objective of this research was to examine the association between income inequality and high blood pressure in Colombia. Using a nationally representative Colombian sample of adults, and data from departments and municipalities, we fit sex-stratified linear and logistic multilevel models with blood pressure as a continuous and binary variable, respectively. In adjusted models, women living in departments with the highest quintile of income inequality in 1997 had higher systolic blood pressure than their counterparts living in the lowest quintile of income inequality (mean difference 4.42mmHg; 95%CI: 1.46, 7.39). Women living in departments that were at the fourth and fifth quintile of income inequality in 1994 were more likely to have hypertension than those living in departments at the first quintile in the same year (OR: 1.56 and 1.48, respectively). For men, no associations of income inequality with either systolic blood pressure or hypertension were observed. Our findings are consistent with the hypothesis that income inequality is associated with increased risk of high blood pressure for women. Future studies to analyze pathways linking income inequality to high blood pressure in Colombia are needed.

Theoretical basis and explanation for the relationship between area-level social inequalities and population oral health outcomes - A scoping review

This study was conducted to review the evidence on the association between area-level social inequalities and population oral health according to type and extent of social theories. A scoping review was conducted of studies, which assessed the association between area-level social inequality measures, and population oral health outcomes including self-rated oral health, number of teeth, dental caries, periodontal disease, tooth loss, oral health-related quality of life (OHRQoL) and dental pain. A search strategy was applied to identify evidence on PubMed, MEDLINE (Ovid), EMBASE, Web of Science, ERIC, Sociological Abstracts, Social Services Abstracts, references of selected studies, and further grey literature. A qualitative content analysis of the selected studies was conducted to identify theories and categorize studies according to their theoretical basis. A total of 2892 studies were identified with 16 included in the review. Seven types of social theories were used on 48 occasions within the selected studies including: psychosocial (n=13), behavioural (n=10), neo-material (n=10), social capital (n=6), social cohesion (n=4), material (n=3) and social support (n=2). Of the selected studies, four explicitly tested social theories as pathways from inequalities to population oral health outcomes, three used a theoretical construct, seven used theories for post-hoc explanation and two did not have any use of theory. In conclusion, psychosocial theories were used most frequently. Although theories were often mentioned, majority of these studies did not test a social theory.

Neighbourhood Determinants of Caries Experience in Preschool Children: A Multilevel Study

OBJECTIVES

To investigate the association between neighbourhood factors and decayed, missing, and filled teeth (dmft) index among preschool children.

METHODS

The sample of this cross-sectional study comprised 1,110 children (0-5 years old) clustered in 16 official neighbourhoods of Canoas city, southern Brazil. Multilevel binomial models were used to estimate the association of contextual variables at neighbourhood level (Human Development Index, average income, and public primary health care units) with two oral health outcomes: decayed teeth (dt) and missing or filled teeth (mft), after adjusting for individual variables (gender, age, maternal education, equivalent household income logarithm, household, and point of care).

RESULTS

Overall, 24.9% of the sample had dental caries experience (dmft >0), and 92.3% of the dmft was untreated caries. There was no statistical significant association (p > 0.05) of contextual characteristics with the decay component. The teeth of children living in richer areas had 2.87 (95% CI: 1.05-7.86) times more chances of being treated (mft component). Variance attributed to neighbourhood level was estimated as 5.9% (p < 0.01) and 4.1% (p = 0.17) for dt and mft, respectively, in adjusted models.

CONCLUSIONS

Intra-urban areas seem homogeneous, with small variability between neighbourhoods, having no contextual effect on untreated dental caries (dt). Contextual variables may influence treatment access (mft) through the use of dental services in preschool children.

Association between Dental Caries and Socioeconomic Factors in Schoolchildren - A Multilevel Analysis

Abstract This study aimed to assess the association between dental caries, socioeconomic individual and contextual factors in 12-years-old children. A representative sample of 1,134 children enrolled in public schools from Santa Maria, RS, Brazil, was obtained from a multistage random sampling. Four calibrated dentists examined participants at schools. Data about dental caries (DMF-T index) and dental plaque (present or absent) were assessed. Children's parents or guardians answered questions regarding their demographics and socioeconomic status. Context variables were also collected from official publications of the city. Data analyses were performed using multilevel logistic regression models. Caries prevalence in this sample (DMF-T≥1) was 49.9% (95%CI: 45.05% - 54.77%), and mean DMF-T was 1.15 (95%CI: 1.01-1.29) with 0.068 standard error. Children of the 3rd and 2nd tertile of income represented by the rich and intermediate categories, showed, respectively, a 50% (OR 0.50: CI95 % 0.35-0.71) and 39% (OR 0.61: CI95% 0.45-0.82) lower chance to present untreated caries compared with the poorest portion of the sample represented by the 1st tertile of income. Regarding the context covariates, children from lower income neighborhood presented a higher chance for having untreated dental caries compared with their counterpart (OR 1.70: CI95% 1.19 to 2.43). Inequalities in the distribution of dental caries continue affecting children from poorer socioeconomic profiles. There is need for planning public interventions for oral health promotion that take into account individual and contextual socioeconomic characteristics.

Associação entre a cobertura de equipes de saúde bucal na saúde da família e o aumento na produção ambulatorial dos municípios brasileiros, 1999 e 2011

Resumo Analisar a associação entre a cobertura populacional de equipes de saúde bucal da Estratégia Saúde da Família (ESF) e a diferença nas taxas de uso de serviços odontológicos públicos nos municípios brasileiros em 1999 e 2011. A amostra contou com 5.507 municípios nos 2 anos. Foram utilizados dados de sistemas de informação oficiais e se procedeu à regressão logística para modelar o incremento nas taxas de procedimentos. Observou-se que 85% dos municípios possuíam equipes de saúde bucal da ESF em 2011 e houve aumentos nas taxas de recursos físicos, humanos e financeiros. A produção odontológica aumentou 49,5% no período. Os municípios que incorporaram mais que 3 equipes de saúde bucal/10 mil habitantes tiveram mais chances de aumentar as taxas de procedimentos coletivos (OR = 1,61; IC95%: 1,23-2,11), preventivos (OR = 2,05; IC95%: 1,56-2,69), restaurações (OR = 2,07; IC95%: 1,58-2,71) e extrações (OR = 1,53; IC95%: 1,19-1,97), após controle por fatores sociodemográficos e relacionados à variação de recursos físicos, humanos e financeiros. A incorporação de equipes de saúde bucal à ESF parece mais efetiva para o aumento de indicadores de uso de serviços odontológicos.

Individual and contextual determinants of malocclusion in 12-year-old schoolchildren in a Brazilian city

The aim of this study was to describe malocclusion prevalence and its association with individual and contextual factors among Brazilian 12-year-old schoolchildren. This cross-sectional study included data from an oral health survey carried out in Goiânia, Brazil (n = 2,075), and data from the files of the local health authority. The data were collected through oral clinical examinations. The Dental Aesthetic Index (DAI) was used to assess occlusion. The presence of malocclusion (DAI > 25) was used as the dependent variable. The individual independent variables consisted of adolescents' sex and race and their mothers' level of schooling. The clinical variables were caries experience and presence of adverse periodontal condition (calculus and/or gingival bleeding). The contextual variables included type of school and the location of schools in the city's health districts. The Rao-Scott test and multilevel logistic regression were performed. The prevalence of malocclusion was 40.1%. In the final model, significantly higher rates of malocclusion were found among those who attended schools located in less affluent health districts and whose mothers had fewer years of education. Rates were also higher among those presenting calculus and/or gingival bleeding. Malocclusion demonstrated a high prevalence rate and the inequalities in its distribution were determined by individual and contextual factors.

As desigualdades sociais e a saúde bucal nas capitais brasileiras

ResumoApesar da melhoria das condições de vida dos brasileiros, ainda persiste um panorama de iniquidades em saúde bucal. Este estudo ecológico avaliou a relação das condições socioeconômicas e de política de saúde pública com as de saúde bucal nas capitais brasileiras. Foi realizada análise fatorial com os indicadores de condições socioeconômicas, revelando dois fatores comuns: deprivação econômica e condição sociossanitária. Em seguida, executou-se análise de regressão linear múltipla para os indicadores de saúde bucal (média CPO-D 12 anos, média de dentes perdidos e taxa de população livre de cárie) com os dois fatores em comum e a fluoretação da água de abastecimento. A análise de regressão linear múltipla para o CPO-D das capitais foi estimado pelas condições sociossanitárias e fluoretação, ajustado pela deprivação econômica; enquanto que o modelo para a média de dentes perdidos foi estimado apenas pela fluoretação e deprivação econômica, e, por fim, o modelo para a taxa da população livre de cárie nas capitais brasileiras foi estimado pela condição econômica e sociossanitária ajustadas pelo abastecimento de água fluoretada. Portanto, os resultados apontam a necessidade de ações sociais que impactem nas condições de vida da população para redução da cárie dentária.

Income Inequality and Use of Dental Services in 66 Countries

This study explored the association between income inequality and use of dental services and the role that investment in health care plays in explaining that association. We pooled individual-level data from 223,299 adults, 18 years or older, in 66 countries, who participated in the World Health Organization (WHO) World Health Surveys with country-level data from different international sources. Income inequality was measured at the national level using the Gini coefficient, and use of dental services was defined as having received treatment to address problems with mouth and/or teeth in the past year. The association between the Gini coefficient and use of dental services was examined in multilevel models controlling for a standard set of individual- and country-level confounders. The individual and joint contributions of 4 indicators of investment in health care were evaluated in sequential modeling. The Gini coefficient and use of dental services were inversely associated after adjustment for confounders. Every 10% increase in the Gini coefficient corresponded with a 15% lower odds of using dental services (odds ratio: 0.85; 95% confidence interval: 0.70-0.99). The association between the Gini coefficient and use of dental services was attenuated and became nonsignificant after individual adjustment for total health expenditure, public expenditure on health, health system responsiveness, or type of dental health system. The 4 indicators together explained 80% of the association between the Gini coefficient and use of dental services. This study suggests that more equal countries have greater use of dental services. It also supports the mediating role of investment in health care in explaining that association.

The influence of normative and subjective oral health status on schoolchildren's happiness

Background

Traditional methods to measure oral health based on clinical standards are limited because they do not consider psychosocial and functional aspects of oral health. It has been recommended that these measures need to be supplemented by data obtained from patients regarding their individual perceptions on oral health-related quality of life (OHRQoL). Happiness is a multidimensional construct comprising both emotional and cognitive domains, and has been defined as “the degree to which an individual judges the overall quality of his or her life as a whole favorably”. It has been associated with several health outcomes, including oral health. The aim of this study was to assess the impact of oral health conditions, oral health-related quality of life (OHRQoL), and socioeconomic factors on the subjective happiness of Brazilian adolescents.

Methods

A cross-sectional study was conducted in 2012 on a representative sample of 12-year-old schoolchildren in Santa Maria-RS, Brazil. The data were collected through dental examinations and structured interviews. The participants underwent an evaluation aimed at detecting dental caries, traumatic dental injuries, malocclusion, and gingival bleeding. They also completed the Brazilian versions of the Child Perceptions Questionnaire-short form (CPQ11–14 – ISF: 16) and the Subjective Happiness Scale (SHS), which was our outcome variable. Socioeconomic conditions were evaluated through a questionnaire that was completed by the participants’ parents. Poisson regression analysis was used to determine the association between the explanatory variables and the outcome. Moreover, a correlation analysis was performed to determine the relationship between the SHS scores and the overall and domain scores of the CPQ11–14 –ISF: 16.

Results

A total of 1,134 children were evaluated. Unadjusted analyses showed that happiness was associated with socioeconomic indicators, the use of dental services, clinical status, and scores on the OHRQoL measure. After adjustment, household overcrowding (RR: 0.96; 95% CI: 0.93-0.98), dental caries (RR: 0.98; 95% CI: 0.97-0.99), malocclusion (RR: 0.98; 95% CI: 0.96-0.99), and the severity associated with the CPQ11-14 (RR: 0.95; 95% CI: 0.93-0.97) still showed a significant association with lower levels of the mean SHS score.

Conclusions

Happiness is influenced by oral conditions, socioeconomic status, and OHRQoL.

[Inequalities in untreated dental caries prevalence in preschool children in Brazil]

OBJECTIVE

To evaluate the influence of social inequalities of individual and contextual nature on untreated dental caries in Brazilian children.

METHODS

The data on the prevalence of dental caries were obtained from the Brazilian Oral Health Survey (SBBrasil 2010) Project, an epidemiological survey of oral health with a representative sample for the country and each of the geographical micro-regions. Children aged five (n = 7,217) in 177 municipalities were examined and their parents/guardians completed a questionnaire. Contextual characteristics referring to the municipalities in 2010 (mean income, fluorodized water and proportion of residences with water supply) were supplied by the Fundação Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics). Multilevel Poisson regression analysis models were used to assess associations.

RESULTS

The prevalence of non-treated dental caries was 48.2%; more than half of the sample had at least one deciduous tooth affected by dental caries. The index of dental caries in deciduous teeth was 2.41, with higher figures in the North and Northeast. Black and brown children and those from lower income families had a higher prevalence of untreated dental caries. With regards context, the mean income in the municipality and the addition of fluoride to the water supply were inversely associated with the prevalence of the outcome.

CONCLUSIONS

Inequalities in the prevalence of untreated dental caries remain, affecting deciduous teeth of children in Brazil. Planning public policies to promote oral health should consider the effect of contextual factors as a determinant of individual risk.

Income inequality, disinvestment in health care and use of dental services

OBJECTIVE

To explore the interrelationships between income inequality, disinvestment in health care, and use of dental services at country level.

METHODS

This study pooled national estimates for use of dental services among adults aged 18 years or older from the 70 countries that participated in the World Health Survey from 2002 to 2004, together with aggregate data on national income (GDP per capita), income inequality (Gini coefficient), and disinvestment in health care (total health expenditure and dentist-to-population ratio) from various international sources. Use of dental services was defined as having had dental problems in the last 12 months and having received any treatment to address those needs. Associations between variables were explored using Pearson correlation coefficients and linear regression.

RESULTS

Data from 63 countries representing the six WHO regions were analyzed. Use of dental services was negatively correlated with Gini coefficient (Pearson correlation coefficient -0.48, P < 0.001) and positively correlated with GDP per capita (0.40, P < 0.05), total health expenditure (0.45, P < 0.001), and dentist-to-population ratio (0.67, P < 0.001). The association between Gini coefficient and use of dental services was attenuated but remained significant after adjustments for GDP per capita, total health expenditure, and dentist-to-population ratio (regression coefficient -0.36; 95% CI -0.57, -0.15).

CONCLUSION

This study shows an inverse relationship between income inequality and use of dental services. Of the two indicators of disinvestment in health care assessed, only dentist-to-population ratio was associated with income inequality and use of dental services.

Análise da produção ambulatorial em municípios com e sem centros de especialidades odontológicas no Brasil em 2010

O objetivo foi descrever a produção de serviços especializados em municípios brasileiros com e sem Centros de Especialidades Odontológicas (CEO) e estudar fatores associados. Para a coleta de dados, foram consultados: o Departamento de Informática do SUS, dados do Atlas de Desenvolvimento Humano do Brasil e do Instituto Brasileiro de Geografia e Estatística. Utilizou-se regressão binominal negativa inflada de zeros para modelar taxas de procedimentos de endodontia, atenção básica, periodontia e cirurgia. Após controle por fatores sociodemográficos, os municípios com CEO apresentaram taxas maiores do que os sem, exceto para taxas de atenção básica. No modelo final, com variáveis de estrutura dos serviços, os municípios com CEO do tipo III tiveram uma taxa de procedimentos de endodontia 2,08 (IC95%: 1,26; 3,44) vezes maior que sem CEO. Das variáveis de estrutura, mais gastos em saúde e maiores taxas de dentistas no SUS estavam consistentemente associados a maiores taxas de quaisquer procedimentos. Os CEO parecem ter um efeito positivo na produção municipal de procedimentos especializados, particularmente para a taxa de procedimentos de endodontia, e esse efeito não é explicado por variáveis de estrutura.

Social determinants of health and dental caries in Brazil: a systematic review of the literature between 1999 and 2010

OBJECTIVE: To review epidemiological studies conducted in Brazil that investigated the distribution of dental caries according to socioeconomic status and demographic characteristics. METHODS: The systematic review included articles published between 1999 and 2010 available in six bibliographic sources, without any other restriction. We analyzed the bibliometric and methodological characteristics of the studies, and the direction and statistical significance of associations tested. RESULTS: Of the 1,128 references identified, 67 were incorporated into this study. There was a higher percentage of publications in the last two years and most of the studies were conducted in the South and Southeast of the country with a young population. The cross-sectional design, using a complex sampling procedure, was the most commonly adopted. The DMFT and dmft indexes were the most commonly used to measure dental caries, while sex/gender, income, education, race/skin color and type of school were the most common socioeconomic exposures. CONCLUSIONS: Most studies identified a high rates of dental caries among the poorest, least educated, black and brown and female individuals. A more detailed methodological and theoretically sound study of the relationship between dental caries and socioeconomic conditions is needed.

Associations between Caries among Children and Household Sugar Procurement, Exposure to Fluoridated Water and Socioeconomic Indicators in the Brazilian Capital Cities

The objective of this ecological study was to investigate the association between caries experience in 5- and 12-year-old Brazilian children in 2010 and household sugar procurement in 2003 and the effects of exposure to water fluoridation and socioeconomic indicators. Sample units were all 27 Brazilian capital cities. Data were obtained from the National Surveys of Oral Health; the National Household Food Budget Survey; and the United Nations Program for Development. Data analysis included correlation coefficients, exploratory factor analysis, and linear regression. There were significant negative associations between caries experience and procurement of confectionery, fluoridated water, HDI, and per capita income. Procurement of confectionery and soft drinks was positively associated with HDI and per capita income. Exploratory factor analysis grouped the independent variables by reducing highly correlated variables into two uncorrelated component variables that explained 86.1% of total variance. The first component included income, HDI, water fluoridation, and procurement of confectionery, while the second included free sugar and procurement of soft drinks. Multiple regression analysis showed that caries is associated with the first component. Caries experience was associated with better socioeconomic indicators of a city and exposure to fluoridated water, which may affect the impact of sugars on the disease.

Epidemiology of dental caries: when structure and context matter

The widespread expansion of the sugar market drove dental caries prevalence to high levels in several regions of the world. On the other hand, the dissemination of fluoride use is one of the reasons for caries decline at the end of the 20th century. However, caries remains one of the most prevalent non-communicable chronic diseases in human beings, and an important cause of pain and dental loss, which lead to school and work absenteeism affecting individuals' daily activities and emotional stability. The decline in caries has important implications for research, human resources and oral healthcare. The aim of this study was to summarize the changes in dental caries occurrence in the population, and bring to light the latest research on the role of non-biological determinants in caries distribution.

The relationship between levels of income inequality and dental caries and periodontal diseases

The objective of this study was to evaluate the association between income inequality at a lagged time of 2 and 11 years with two short latency outcomes (untreated dental caries and gingivitis) and two long latency outcomes (edentulism and periodontal attachment loss > 8mm). We used data from the Brazilian oral health survey in 2002-2003. Our analysis included 13,405 subjects aged 35-44 years. Different lagged Gini at municipal level were fitted using logistic and negative binomial multilevel analyses. Covariates included municipal per capita income, equivalized income, age, sex, time since last dental visit and place of residence (rural versus urban). Crude estimates showed that only untreated dental caries was associated with current and lagged Gini, but in adjusted models only current Gini remained significant with a ratio of 1.19 (95%CI: 1.09-1.30) for every ten-point increase in the Gini coefficient. We conclude that lagged Gini showed no association with oral health; and current income Gini was associated with current dental caries but not with periodontal disease.

Income Inequality and Tooth Loss in the United States

This study explored the relationship between state income inequality and individual tooth loss among 386,629 adults in the United States who participated in the 2008 Behavioral and Risk Factor Surveillance System. Multilevel models were used to test the association of the state Gini coefficient with tooth loss after sequential adjustment for state- (median household income) and individual-level confounders (sex, age, race, education, and household income), as well as state- (percent receiving fluoridated water and dentist-to-population ratio) and individual-level mediators (marital status and last dental visit). The state Gini coefficient was significantly associated with tooth loss even after adjustment for state- and individual-level confounders and potential mediators (Odds Ratio, 1.17; 95% Confidence Interval, 1.05 to 1.30). This study provides support for the relationship between state income inequality and individual tooth loss in the United States.