Investigating social inequalities in older adults' dentition and the role of dental service use in 14 European countries

Health status, care dependency and oral care utilization among older adults: a register-based study

BACKGROUND AND OBJECTIVES

The aim of the study was to examine oral care utilisation among older Danes and to describe the extent to which oral care use is associated with the co-existence of challenges relating to general health and care dependency.

MATERIALS AND METHODS

The study used registry data covering the entire population of older adults (≥65 years) in seven municipalities in Denmark (N = 178 787 individuals). Oral care services utilisation was computed from administrative data on oral care contacts up to and including 2019, including both private oral care and a municipal oral care programme (MOCP). Various registry data sources were used to compute risk factors to describe oral care utilisation across indicators of general health and care dependency.

RESULTS

Indicators for poorer health were associated with larger proportions of individuals enrolled in the MOCPs and larger proportions of non-users of any type of oral care. Higher degrees of care dependency were associated with larger proportions of individuals enrolled in MOCPs and individuals with no use of any oral care services, with the exception of nursing home residents, who comprised a lower proportion of non-users than individuals receiving at-home care. Municipal oral care mainly enrolled older adults who were nursing home residents (60% of nursing home residents were enrolled).

CONCLUSION

Our findings support existing evidence on the link between oral care utilisation and general health and frailty. While the municipal care programmes assisted in covering oral care for those with the highest level of care dependency, future preventive strategies for ensuring care continuity for older adults that are increasing in frailty may want to focus on the earlier stages of frailty and of general health deterioration.

A cross-sectional study on oral health-care habits and oral-health-related quality-of-life in marginalized persons in Copenhagen

OBJECTIVE

The aim of this cross-sectional study was to investigate the oral-health-related quality-of-life (OHRQoL) and oral health-care habits in a population of marginalized persons in Copenhagen.

MATERIALS AND METHODS

Patients attending a dental clinic for marginalized persons filled in the 14-item version of the oral-health-impact profile (OHIP-14) regarding their OHRQoLand a questionnaire on their oral health-care habits. Age, gender, smoking habits, need for general and oral health-care, and living conditions were further registered.

RESULTS

Of the 212 participants, 72% had not visited a dental clinic within the past two years and in 68% of the cases, the last dental visit was related to dental treatment. Tooth brushing at least once a day was reported by 93%. The mean OHIP-14 score in the participants was 24.9 (SD: 13.6). The most frequent problems were pain, chewing difficulties, being self-conscious, tense, and embarrassed as well as affected life. The mean OHIP-14 score was significantly higher in participants in need of general health-care (29.5, SD: 12.2) than in participants not in need of general health-care (22.8, SD: 13.9). The same applied to participants referred for dental treatment (26.1, SD: 12.7) compared to participants not being referred (20.2, SD: 15.9).

CONCLUSIONS

The OHRQoLis poor in the population with pain, chewing difficulties and aesthetic issues as the most prominent problems. The participants had low and treatment-oriented use of the dental care system. This indicates a high need for dental care in the population with a focus on including them in the dental care system.

Role of teledentistry in enabling improved oral care outcomes

Nowadays, the link between oral health and general health is clearly understood and supported by many global bodies, including the World Health Organisation. Yet, oral diseases remain prevalent worldwide, necessitating a practical approach. This opinion paper seeks to clarify the role of teledentistry as an adjunct for improving oral health when access to oral care services is one of the major concerns.While prevention is the best option, many people lack regular oral care access, missing vital maintenance for mouth and body health. Limited evidence-based education further hinders effective oral hygiene routines. This holds true for remote/rural populations, low socioeconomic groups and individuals with physical/mental disabilities which could make visiting a dental practice more difficult.We examined recent teledentistry publications, highlighting outcomes and suggesting evidence-backed oral health guidance via tailored teledentistry models. Two virtual roundtables were conducted with a global working group experienced in teledentistry and dental access barriers. This panel was made up of representatives from the UK, Belgium, Vietnam, Indonesia, Bangladesh, Ghana and Tunisia.We conclude that teledentistry effectively aids dental referrals, early disease detection, treatment planning, compliance and viability, particularly in regions with limited dental access. The advantage of teledentistry lies in expanding the reach of care. Telehealth and teledentistry are value-driven, yet larger, standardised research is needed to fully harness the potential of teledentistry in bridging underserved populations with oral care experts, ultimately fostering optimal oral health. Education on the capabilities and benefits of teledentistry should become part of the curriculum of future dental professionals and broadly leveraged on continuing education platforms.

Income- and education-based inequalities of edentulism and dental services utilization in Brazil

OBJECTIVE

Tooth loss is a worldwide public health problem affecting mainly socioeconomically disadvantaged groups. Dental services utilization may increase access to preventive actions and conservative treatment, reducing the prevalence of tooth loss. This study evaluated the income- and education-based inequalities in edentulism according to the utilization of dental services among adults and older adults in Brazil.

METHODS

Data from the National Oral Health Survey (SB Brazil, 2010) of adults (ages 35-44 years, n = 9779) and older adults (ages 65-74 years, n = 7619) were analysed. Socioeconomic indicators (SES) included education and income. The magnitude of inequality in edentulism by education and income levels was estimated by the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). The changes in the RII and SII according to the utilization of dental services were estimated. Regression models estimated the association between SES and edentulism and whether dental services utilization modified this association.

RESULTS

Higher edentulism prevalence was observed among those with lower education and income levels. The utilization of dental services changed the education-based inequality index in edentulism for adults, with percentage changes of 17.4% (RII) and 56.8% (SII). For adults with low education (0-4 years of study), the odds of edentulism were 80% (OR 0.2; 95% CI 0.1-0.6) and 90% (OR 0.1; 95% CI 0.01-0.2) lower for those who had used dental services within the preceding year and within 1-2 years compared with those who had used such services within the preceding 3 or more years, respectively.

CONCLUSION

There was a social gradient in the prevalence of edentulism in adults and older adults, and the education-based inequalities in edentulism were lower among adults reporting utilization of dental services in the preceding year.

Decomposing socioeconomic inequalities in dental caries among Chinese adults: findings from the 4th national oral health survey

OBJECTIVE

This cross-sectional study aimed to investigate socioeconomic inequalities in dental caries among adults (35 years and older) in China and explore the contributions of various factors to these inequalities.

METHODS

This study included 10,983 adults (3,674 aged 35-44 years, 3,769 aged 55-64 years and 3,540 aged 65-74 years) who participated in the 4th National Oral Health Survey (2015-2016) in China. Dental caries status was evaluated by the decayed, missing and filled teeth (DMFT) index. Concentration indices (CIs) were applied to quantify the different degrees of socioeconomic-related inequality in DMFT, decayed teeth with crown or root caries (DT), missing teeth due to caries or other reasons (MT), and filled teeth without any primary or secondary caries (FT) among adults of different age groups. Decomposition analyses were conducted to identify the determinants and their associations with inequalities in DMFT.

RESULTS

The significant negative CI indicated that DMFT for the total sample were concentrated among socioeconomically disadvantaged adults (CI = - 0.06; 95% confidence interval [CI], - 0.073 to - 0.047). The CIs for DMFT for adults aged 55-64 and 65-74 years were - 0.038 (95% CI, - 0.057 to - 0.018) and - 0.039 (95% CI, - 0.056 to - 0.023), respectively, while the CI for DMFT for adults aged 35-44 years was not statistically significant (CI = - 0.002; 95% CI, - 0.022 to 0.018). The concentration indices of DT were negative and concentrated in disadvantaged populations, while FT showed pro-rich inequalities in all age groups. Decomposition analyses showed that age, education level, toothbrushing frequency, income and type of insurance contributed substantially to socioeconomic inequalities, accounting for 47.9%, 29.9%, 24.5%,19.1%, and 15.3%, respectively.

CONCLUSION

Dental caries was disproportionately concentrated among socioeconomically disadvantaged adults in China. The results of these decomposition analyses are informative for policy-makers attempting to develop targeted health policy recommendations to reduce dental caries inequalities in China.

Behavioural intervention to promote the uptake of planned care in urgent dental care attenders: study protocol for the RETURN randomised controlled trial

BACKGROUND

People with disadvantaged backgrounds are less likely to visit the dentist for planned care, even though they have disproportionately poorer oral health. They are correspondingly more likely to experience dental problems and use urgent dental care, general practices and Accident and Emergency departments, which not only makes meeting their needs expensive, but, since these services often rely on prescriptions rather than addressing the clinical cause, can contribute to antimicrobial resistance.

METHODS

The RETURN intervention has been developed with substantial community co-production, to be delivered opportunistically in urgent dental care settings. This brief intervention is delivered by dental nurses and involves material relevant to the 'in-group' targeted. The material includes booklets relating to barriers to planned dental visiting with corresponding short video clips featuring local people and including a modelling element. Dental nurses are trained to have supportive and non-judgemental conversations, assisting patients to set personal goals and action plans, which are reinforced in a follow-up text within a few weeks. A randomised controlled trial will be undertaken in 3 types of sites: dental practices delivering urgent care (a) within working hours, (b) out of hours, and (c) in a Dental Hospital. The trial will recruit 1180 adult urgent dental care users over 12 months, who have not visited a dentist for a planned care appointment for 2 years or more and do not have a dentist who they visit for routine care. It aims to investigate the effectiveness and cost-effectiveness of the intervention and to explore whether the intervention has different effects across the socio-economic gradient. Participants will be followed up at 6, 12 and 18 months after randomisation. Co-primary outcomes are attendance at a dental practice for planned care within 12 months and self-reported oral health-related quality of life at 12 months.

DISCUSSION

This is a pragmatic trial, evaluating the effectiveness of the intervention under the usual condition in which it might be applied. Since dental practices work as independent contractors to the NHS, this brings implementation and fidelity challenges which will be explored and described in embedded qualitative work.

TRIAL REGISTRATION

ISRCTN registry identifier ISRCTN84666712. Registered 12/04/2021.

Inequality in Healthcare Utilization in Italy: How Important Are Barriers to Access?

With the ageing population, equitable access to medical care has proven to be paramount for the effective and efficient management of all diseases. Healthcare access can be hindered by cost barriers for drugs or exams, long waiting lists or difficult access to the place where the needed healthcare service is provided. The aim of this paper is to investigate whether the probability of facing one of these barriers varies among individuals with different socio-economic status and care needs, controlling for geographical variability.

METHODS

The sample for this study included 9629 interviews with Italian individuals, aged 15 and over, from the second wave (2015) of the European Health Interview Survey, which was conducted in all EU Member States. To model barriers to healthcare, two-level variance components of logistic regression models with a nested structure given by the four Italian macro-areas were considered.

RESULTS

Of the barriers considered in this study, only two were found to be significantly associated with healthcare utilization. Specifically, they are long waiting lists for specialist service accessibility (adjOR = 1.20, 95% CI (1.07; 1.35)) and very expensive exams for dental visit accessibility (adjOR = 0.84, 95% CI (0.73; 0.96)). Another important result was the evidence of an increasing north-south gradient for all of the considered barriers.

CONCLUSION

In Italy, healthcare access is generally guaranteed for all of the services, except for specialist and dental visits that face a waiting time and financial barriers. However, barriers to healthcare were differentiated by income and sex. The north-south gradient for healthcare utilization could be explained through the existing differences in organizational characteristics of the several regional healthcare services throughout Italy.

Utilização de serviços odontológicos por pacientes em tratamento oncológico

Resumo Introdução a busca por atendimento odontológico é um parâmetro importante para averiguar como os indivíduos compreendem a saúde bucal. Objetivo avaliar a utilização de serviços odontológicos e fatores associados em pacientes oncológicos em Minas Gerais, Brasil. Material e método estudo transversal, realizado com uma amostra de 441 pacientes adultos frequentadores de uma associação voluntária de apoio a pacientes oncológicos no Estado de Minas Gerais, Brasil. O desfecho foi avaliado por meio do autorrelato de consulta odontológica no último ano. As variáveis independentes incluíram condições socioeconômicas, saúde geral e relacionada ao câncer, saúde bucal e cuidados odontológicos. As associações entre o desfecho e as variáveis independentes foram testadas por meio de regressão logística bivariada e múltipla, sendo os resultados expressos por meio de odds ratio (OR) e intervalos de confiança de 95% (IC95%). Resultado a prevalência de consulta odontológica no último ano foi de 33,3%. Os indivíduos que possuem entre quatro e sete (OR: 1,80; IC95%: 1,02-3,18) e aqueles com oito ou mais anos de estudo (OR: 3,20; IC95%: 1,07-9,60) apresentaram maiores, enquanto os edêntulos (OR: 0,44; IC95%: 0,21-0,92) apresentaram menores chances de consulta odontológica no último ano, independentemente de condições socioeconômicas, saúde geral e saúde bucal. Conclusão foi baixa a procura por consulta odontológica no último ano entre os pacientes oncológicos. Além disso, houve desigualdades relacionadas à escolaridade e ao número de dentes remanescentes na utilização dos serviços. A identificação e priorização dos grupos com acesso desfavorável aos serviços são fundamentais no planejamento da prestação de cuidados odontológicos a essa população.

Willingness to Pay for Preventive Dental Care Amongst Older Adults

OBJECTIVE

The aims of this study were (1) to investigate willingness to pay (WTP) for preventive and curative dental care procedures and (2) to determine the factors that influence older adults' WTP for dental care.

METHODOLOGY

Older, independently living adults from Singapore aged 60 years and older and eligible for government-subsidised dental care were nonrandomly recruited for this study. Data were collected using questionnaires and a clinical examination which recorded details of caries experience, number and distribution of posterior occluding contacts, prosthodontic status, and periodontal status. Using a contingent valuation method, participants were asked to rate WTP in Singapore dollars [SGD$] for 4 aspects of care: dental fillings, dental scaling, dental extraction, and disease prevention advice. Negative binomial regression was used to assess the relationship between the predictor variables associated with WTP for dental fillings, scaling, extraction, and preventive advice.

RESULTS

The mean value of WTP for a dental filling was SGD$30.23 (SGD$31.05), for scaling was SGD$30.28 (SGD$29.46), for dental extraction was SGD$35.08 (SGD$58.54). In a multivariate model, factors associated with higher WTPfees were as follows: (1) dental filling: age (younger), level of education (higher), and frequency of dental visits (regular); (2) scaling: level of education (higher), agree that dental problems affect overall health, and frequency of dental visits (regular); (3) dental extractions: age (younger), level of education (higher), frequency of dental visits (regular), and prosthodontic status (not wearing); (4) preventive advice: age (younger), gender (male), ethnicity (Chinese), level of education (higher), marital status (married), self-perceived oral health (good), and dental visits (regular).

CONCLUSIONS

The findings of our study suggest that older adults are willing to pay most for extraction and least for preventive advice.

Inequality in dental care expenditure in Iranian households: analysis of income quintiles and educational levels

Background

Oral health is a major public health issue which affects the human life. Access to dental care is one of the important factors in maintaining oral health. This study was aimed to investigate inequality in dental care expenditure in Iranian households.

Methods

The present study is a secondary analysis of a national cross-sectional survey. The data collected from the Households Income and Expenditure Survey in 2016 and 2017. The final sample consisted of 54,354 households living in rural and urban regions of all the provinces. Inequalities in household’s dental care expenditure per capita in respect to income quintiles and educational level were measured based on the Gini coefficient and concentration index.

Results

The results showed that about 8% of households had paid for dental care during the month before sampling. The Gini coefficient value was estimated to be 0.97 and 0.96 for dental care expenditure per capita respectively in absolute and relative measure. It indicated a significant inequality in the dental expenditure among the sample households. The values of concentration index were positive and significant for all dental care subcategories in respect to the provincial and national income quintiles as well as the educational level of the head of the household.

Conclusions

Income and educational inequality in the both absolute and relative dental services expenditure of the Iranian households were in favor of higher income groups as well as higher educational level of household heads. Income inequality was higher in total dental care expenditure per capita and all its subcategories than the educational inequalities of dental expenditure. In order to reduce these inequalities, the policymakers need to pay special attention to low-income households, particularly those with low-educated heads.

Dental attendance and behavioural pathways to adult oral health inequalities

BACKGROUND

While inequalities in oral health are documented, little is known about the extent to which they are attributable to potentially modifiable factors. We examined the role of behavioural and dental attendance pathways in explaining oral health inequalities among adults in England, Wales and Northern Ireland.

METHODS

Using nationally representative data, we analysed inequalities in self-rated oral health and number of natural teeth. Highest educational attainment, equivalised household income and occupational social class were used to derive a latent socioeconomic position (SEP) variable. Pathways were dental attendance and behaviours (smoking and oral hygiene). We used structural equation modelling to test the hypothesis that SEP influences oral health directly and also indirectly via dental attendance and behavioural pathways.

RESULTS

Lower SEP was directly associated with fewer natural teeth and worse self-rated oral health (standardised path coefficients, -0.21 (SE=0.01) and -0.10 (SE=0.01), respectively). We also found significant indirect effects via behavioural factors for both outcomes and via dental attendance primarily for self-rated oral health. While the standardised parameters of total effects were similar between the two outcomes, for number of teeth, the estimated effect of SEP was mostly direct while for self-rated oral health, it was almost equally split between direct and indirect effects.

CONCLUSION

Reducing inequalities in dental attendance and health behaviours is necessary but not sufficient to tackle socioeconomic inequalities in oral health.

Influences of behaviour and attitude on education related inequality in tooth loss: findings from Norway and Sweden over 5 years of follow- up

OBJECTIVES

Following community dwelling cohorts in Norway and Sweden from 65 to 70 years, this study aimed to answer the following questions; Is there cross country variation in educational inequality in tooth loss between the Norwegian and Swedish cohorts? Does oral health behaviours and attitudinal beliefs play a role in explaining educational inequality in tooth loss across time and cohorts?

MATERIAL AND METHODS

In 2007 and 2012 Statistics Norway administered mailed questionnaires to all individuals born in 1942 in three counties. The response rate was 58% (n = 4211) in 2007 and 54.5% (n = 3733) in 2012. In Sweden the same questionnaires were sent to the 1942 cohort in two counties. The final response rate in 2007 and 2012 were respectively, 73.1% (n = 6078) and 72.2% (n = 5697).

RESULTS

In Norway, tooth loss prevalence was 21.8% in 2007 and 23.2% in 2012. Corresponding figures in Sweden were 25.9% and 27.3%. The prevalence of tooth loss was higher among lower than higher educated participants and the gradient was significantly weaker in Sweden than in Norway. Multiple variable analyses adjusting for oral behavioural and attitudinal variables attenuated education related gradients in both cohorts.

CONCLUSION

Education related inequality in tooth loss was stronger in the Norwegian than in the Swedish cohort across the survey years. Oral behaviours and attitudinal beliefs played a role in explaining the gradients across time. This illustrates a necessity to promote oral health enhancing behaviours and attitudinal beliefs, particularly so in lower educational groups.

Income-related inequalities in unmet dental care needs in Spain: traces left by the Great Recession

BACKGROUND

Dental health is an important component of general health. Socioeconomic inequalities in unmet dental care needs have been identified in the literature, but some knowledge gaps persist. This paper tries to identify the determinants of income-related inequality in unmet need for dental care and the reasons for its recent evolution in Spain, and it inquires about the traces left by the Great Recession.

METHODS

Data from the EU-SILC forming a decade (2007-2017) were used. Income-related inequalities for three years were measured by calculating corrected concentration indices (CCI), which were further decomposed in order to compute the contribution of different factors to inequality. An Oaxaca-type decomposition approach was also used to analyze the origin of changes over time. Men and women were analyzed separately.

RESULTS

Pro-rich inequality in unmet dental care needs significantly increased over time (CCI 2007: - 0.0272 and - 0.0334 for males and females, respectively; CCI 2017: - 0.0704 and - 0.0776; p < 0.001). Inequality showed a clear "pro-cycle" pattern, growing during the Great Recession and starting to decrease just after the economic recovery began. Gender differences only were significant for 2009 (p = 0.004) and 2014 (p = 0.063). Income was the main determinant of inequality and of its variation along time -particularly for women-, followed by far by unemployment -particularly for men-; the contributions of both were mainly due to changes in elasticites.

CONCLUSIONS

The Great Recession left its trace in form of a higher inequality in the access to dental care. Also, unmet need for dental care, as well as its inequality, became more sensitive to the ability to pay and to unemployment along recent years. To broaden public coverage of dental care for vulnerable groups, such as low-income/unemployed people with high oral health needs, would help to prevent further growth of inequality.

Racial inequities in tooth loss among older Brazilian adults: A decomposition analysis

OBJECTIVE

To determine the extent to which racial inequities in tooth loss and functional dentition are explained by individual socioeconomic status, smoking status and frequency/reason for the use of dental services.

METHODS

Data came from the Brazilian Longitudinal Study of Ageing, a nationally representative sample of community-dwelling people aged 50 years and over. Tooth loss and functional dentition (ie 20+ natural teeth) were the outcomes. The main explanatory variable was self-classified race. Covariates included dental visits in the past 12 months, dental visits for check-ups only, smoking status, self-reported chronic conditions, depression and cognitive function. Logistic regression and Blinder-Oaxaca decomposition analysis were used to estimate the share of each factor in race-related tooth loss inequities.

RESULTS

The analytical sample comprised of 7126 respondents. While the prevalence of functional dentition in White Brazilians was 37% (95% CI: 33.5;40.9), it was 29% (95% CI: 26.4;31.6) among Browns and 30% (95% CI: 25.1;35.4) among Blacks. The average number of lost teeth among Whites, Browns and Blacks were 18.7 (95% CI: 17.8;19.6), 20.4 (95% CI: 19.7;21.1) and 20.8 (95% CI: 19.5;22.0), respectively. Decomposition analysis showed that the selected covariates explained 71% of the racial inequalities in tooth loss. Dental visits in the previous year and smoking status explained nearly half of race-related gaps. Other factors, such as per capita income, education and cognitive status, also had an important contribution to the examined inequalities. The proportion of racial inequities in tooth loss that was explained by dental visits (frequency and reason) and smoking status decreased from 40% for those 50-59 years of age to 22% among participants aged 70-79 years.

CONCLUSIONS

Frequency and reason for dental visits and smoking status explained nearly half of the racial inequity in tooth loss among Brazilian older adults. The Brazilian Family Health Strategy Program should target older adults from racial groups living in deprived areas.

Measuring and decomposing socioeconomic-related inequality in the use of oral health services among Chinese adults

OBJECTIVES

This study aimed to measure socioeconomic-related inequality and horizontal inequity in the use of oral health services and decompose this inequality among adults of different age groups in China.

METHODS

In total, 10 973 adults (3669 aged 35-44 years, 3767 aged 55-64 years and 3537 aged 65-74 years) who participated in the 4th National Oral Health Survey (2015-2016) in China were included. Concentration curves and the Erreygers-corrected concentration index (EI) were employed to measure socioeconomic-related inequality in the use of oral health services. Then, inequity in this utilization was measured by the horizontal inequity index (HI). Furthermore, decomposition analyses were conducted for the three groups to explain the contributions of income level, need factors (ie self-assessed oral health and evaluated oral health status), other factors (ie sex, residential location, educational attainment level and type of basic insurance) and a residual term to overall inequality in oral health service utilization.

RESULTS

The significant positive EI and HI values indicated that pro-rich inequality and inequity in oral health service utilization exist among Chinese adults. Income and type of basic medical insurance contributed the most to socioeconomic-related inequality in the use of oral health services among adults aged 55-64 and 65-74 years. However, the main driving factors of socioeconomic inequality among adults aged 35-44 years in dental care use included income, educational achievement, type of basic medical insurance and residential location. The need variables accounted for a very small proportion of overall socioeconomic-related inequality in oral health service use in all three groups.

CONCLUSIONS

Oral healthcare service utilization was disproportionately concentrated among better-off Chinese adults. The primary determinants of inequality in dental care use in different age groups provide information for policymakers to create more targeted policies to achieve equity in the oral healthcare system in China.

Early-life course factors and oral health among young Norwegian adults

OBJECTIVE

Using a national sample of young Norwegian adults, we examined whether unpleasant experience with dental care during childhood is associated with tooth loss and oral health-related quality of life in adulthood after accounting for early- and later-life socio-behavioural circumstances and dental avoidance behaviour.

METHODS

2433 individuals aged 25-35 years participated in an electronic survey. Oral quality of life was measured using the oral impact of daily performance (OIDP) inventory. Generalized linear models and negative binomial regression models were used to estimate the association of early unpleasant experiences with dental care and tooth loss and OIDP scores. Incidence rate ratio (IRR) and 95% confidence intervals (CI) were used to estimate the relative differences in prevalence of tooth loss and OIDP scores.

RESULTS

Adjusting for early-life characteristics only, the prevalence of tooth loss was 1.42 (IRR = 1.42, 95% CI: 1.24-1.64) and 1.96 (IRR = 1.96, 95% CI: 1.70-2.26) times higher among individuals who reported unpleasant experiences a few times or several times, than in individuals who did not report unpleasant experiences with dental care in childhood. Adjusting further for educational level, smoking and tooth brushing attenuated the relative differences (IRR = 1.40, 95% CI: 1.22-1.62 and IRR = 1.88, 95% CI: 1.62-2.17, respectively). Lastly, when adjusting for dental avoidance behaviour, the prevalence of tooth loss was 1.29 (IRR = 1.29, 95% CI: 1.11-1.50) and 1.58 (IRR = 1.58, 95% CI: 1.32-1.88) times higher among individuals who reported unpleasant experiences a few times or several times than in those who did not. Corresponding associations of early unpleasant experience with OIDP were (IRR = 1.41 95% CI: 1.22-1.63) and (IRR = 1.69, 95% CI: 1.42-2.01) when adjusting for early-life characteristics, and (IRR = 1.39, 95% CI: 1.20-1.60) and (IRR = 1.51, 95% CI: 1.27-1.80) when adjusting for education, smoking and tooth brushing. When adjusting for dental avoidance behaviour, the association of early unpleasant experience with OIDP became nonsignificant.

CONCLUSION

Unpleasant dental care experiences during childhood are associated with poor oral health in adulthood, independent of later-life socio-behavioural characteristics including negative dental care seeking. This highlights the importance of tailoring regular contacts with dental healthcare services in childhood to build confidence in children and thus has implications for healthcare policy.

Education-Related Inequalities in Dental Services Use among Older Adults in 23 Countries

This study aimed to measure the magnitude of education-related inequalities in the use of dental services among older adults (aged 50 y or older) from a sizable multicountry sample of 23 upper-middle- and high-income countries. This study used cross-sectional data from nationally representative surveys of people aged 50 y and over. Countries included in the Health and Retirement Study surveys were the following: Brazil, China, South Korea, Mexico, United States, Austria, Belgium, Croatia, Czech Republic, Denmark, Estonia, France, Germany, Greece, Italy, Israel, Luxembourg, Poland, Portugal, Slovenia, Spain, Sweden, and Switzerland. The dependent variable was the use of dental services, based on the self-report of having had a dental visit within the previous year, except for the United States and South Korea, which used 2-y recall periods. Educational level was used as the measure of socioeconomic position and was standardized across countries. Multivariate logistic regression modeling was used to evaluate the factors associated with the use of dental services, and the magnitude of education inequalities in the use of dental services was assessed using the slope index of inequality (SII) to measure absolute inequalities and the relative index of inequality for relative inequalities. The pooled prevalence of the use of dental services was 31.7% and ranged from 18.7% in China to 81.2% in Sweden. In the overall sample, the absolute difference in the prevalence of use between the lowest and highest educational groups was 20 percentage points. SII was significant for all countries except Portugal. Relative educational inequalities were significant for all countries and ranged from 3.2 in Poland to 1.2 in Sweden. There were significant education-related inequalities in the use of dental care by older adults in all countries. Monitoring these inequalities is critical to the planning and delivery of dental services.

Dental expenditure, progressivity and horizontal inequality in Chinese adults: based on the 4th National Oral Health Epidemiology Survey

Background

The financial burden of oral diseases is a growing concern as the medical expenses rise worldwide. The aim of this study was to investigate the dental expenditure, analyze its progressivity and horizontal inequality under the general health finance and insurance system, and identify the key social determinants of the inequality for Chinese adults.

Methods

A secondary analysis used the data of 13,464 adults from the 4th National Oral Health Epidemiological Survey (NOHES) in China was undertaken. The dental expenditure was collected and divided into out-of-pocket and health insurance payments. Horizontal inequality index and Kakwani index were used to analyze the horizontal inequality and progressivity, respectively. The decomposition model of the concentration index was set up to explore the associated socioeconomic determinants.

Results

The results showed that a mean dental expenditure per capita of Chinese adults was $20.55 (95% Confidence Interval-CI: 18.83,22.26). Among those who actually used dental service, the cost was $100.95 (95%CI: 93.22,108.68). Over 90% of dental spending was due to out-of-pocket expenses. For self-reported oral health, the horizontal inequality index was − 0.1391 and for the decayed tooth (DT), it was − 0.2252. For out-of-pocket payment, the Kakwani index was − 0.3154 and for health insurance payment it was − 0.1598. Income, residential location, educational attainment, oral hygiene practice, self-reported oral health, age difference were the main contributors to the inequality of dental expenditure.

Conclusion

Dental expenditure for Chinese adults was at a lower level due to underutilization. The ratio of payments of dental expenditure and utilization was disproportional, whether it was out-of-pocket or insurance payment. Individuals who were more in need of oral care showed less demand for service or not required service in time. For future policy making on oral health, it is worth the effort to further promote the awareness of the importance of oral health and utilization of dental service.

Persistent but narrowing oral health care inequalities in Canada from 2001 through 2016

BACKGROUND

Similar to the United States, inequality in oral health care use is longstanding in Canada. It remains unclear whether this inequality is improving or worsening. In this study, the authors report on income-related inequality in dental visits in Canada and across its provinces over time and interprovincial inequality in dental visits among Canadian provinces.

METHODS

The authors used 7 nationally representative health surveys of the Canadian population and collected data from 2001 through 2016. The magnitude of income-related inequality was measured using the slope index of inequality and relative index of inequality. Interprovincial inequality was examined using a number of indexes including the Theil index.

RESULTS

Income-related inequality in dental visits was present in all survey years, with people in higher income groups reporting higher dental visit prevalence rates. However, results from the slope index of inequality and relative index of inequality showed a steady decline, meaning there was a decrease in the magnitude of inequality over time. Absolute and relative inequality decreased by 7.2% and 22.9% from 2000 through 2016, respectively. A similar decline was observed across most Canadian provinces. Interprovincial differences in dental visits also decreased over time.

CONCLUSIONS

There appears to be persistent but narrowing income-related inequality in dental visits in Canada and across its provinces over time. In addition, it appears that Canadian provinces are becoming more equal in terms of dental services use.

PRACTICAL IMPLICATIONS

Narrowing income-related inequality in dental visits in Canada is promising, suggesting a more equal distribution of dental visits. However, unequal use of dental services remains an issue affecting the Canadian population.

Persistent Socioeconomic Inequality in Child Dental Caries in England despite Equal Attendance

INTRODUCTION

Despite a decline in the prevalence of dental caries among children in England and ongoing arrangements for the provision of free dental care up to the age of 18 y, there is limited information on the pattern and trend of socioeconomic inequalities in dental caries and dental attendance.

METHODS

We estimated the magnitude of deprivation-related inequalities for dental caries and dental attendance in young children, using publicly available data and 2 regression-based summary measures of inequalities: slope index of inequality and relative index of inequality.

RESULTS

We found no significant absolute or relative inequalities in dental attendance across English areas in the past decade, while there were persistent absolute and relative inequalities in dental caries. Socioeconomic inequalities in dental caries decreased between 2007 and 2012; thereafter, the relative inequalities increased.

CONCLUSIONS

The apparent widening inequality in child dental caries in England despite equal access to dental care is a challenge for policy makers.

KNOWLEDGE TRANSFER STATEMENT

While caries prevalence among English children has declined over the past decade, there has been an increase in socioeconomic inequalities in oral health despite there being no inequality in dental attendance. This has implications for the development of oral health strategy and planning dental services.

Socioeconomic status, oral health and dental disease in Australia, Canada, New Zealand and the United States

BACKGROUND

Socioeconomic inequalities are associated with oral health status, either subjectively (self-rated oral health) or objectively (clinically-diagnosed dental diseases). The aim of this study is to compare the magnitude of socioeconomic inequality in oral health and dental disease among adults in Australia, Canada, New Zealand and the United States (US).

METHODS

Nationally-representative survey examination data were used to calculate adjusted absolute differences (AD) in prevalence of untreated decay and fair/poor self-rated oral health (SROH) in income and education. We pooled age- and gender-adjusted inequality estimates using random effects meta-analysis.

RESULTS

New Zealand demonstrated the highest adjusted estimate for untreated decay; the US showed the highest adjusted prevalence of fair/poor SROH. The meta-analysis showed little heterogeneity across countries for the prevalence of decayed teeth; the pooled ADs were 19.7 (95% CI = 16.7-22.7) and 12.0 (95% CI = 8.4-15.7) between highest and lowest education and income groups, respectively. There was heterogeneity in the mean number of decayed teeth and in fair/poor SROH. New Zealand had the widest inequality in decay (education AD = 0.8; 95% CI = 0.4-1.2; income AD = 1.0; 95% CI = 0.5-1.5) and the US the widest inequality in fair/poor SROH (education AD = 40.4; 95% CI = 35.2-45.5; income AD = 20.5; 95% CI = 13.0-27.9).

CONCLUSIONS

The differences in estimates, and variation in the magnitude of inequality, suggest the need for further examining socio-cultural and contextual determinants of oral health and dental disease in both the included and other countries.