Oral Health Disparities in Children: A Canary in the Coalmine?

Area-Level Factors of Dental Caries in Children and Adolescents in European Neighborhoods - a Systematic Review

The WHO emphasizes the importance of taking area-level factors into account when formulating public health interventions. The aim of this systematic review was to identify which area-level factors are associated with children's dental caries in Europe and might therefore be a suitable starting point for public health interventions. We conducted a systematic review based on a search in PubMed, Web of Science, and Cochrane Library including all European studies on caries in children and their area-level factors published since the year 2000 in English or German. We included 39 studies and identified 13 area-level factors investigated in the literature: degree of urbanization, deprivation, mean housing price, gross-national product, mean level of education, unemployment proportion and income, density of supermarkets, snack bars and dental offices, health, diet, and crime. Rural residency and higher unemployment were weakly associated with poorer oral health regarding dental caries. Deprivation showed a stronger (inverse) association. For income, findings were ambiguous; studies showed associations in both directions. For the other determinants, the included studies found no association. Many studies reported associations between place of residence and children's dental caries, but the mediators on this causal path are still not clearly established. The area-level factors analyzed in this review seem to play a role, but more studies with designs that allow causal interpretation of findings are needed to establish solid robust evidence that can be used in the formulation of future health policies.

The "I" in Diversity, Equity, and Inclusion: The Challenge of Inclusivity in Dentistry

Inclusion is an essential part of diversity, equity, and inclusion. Dentistry's history has been such that the profession has experienced inclusion and exclusion, sometimes by choice and sometimes by the actions of others. This study reviews the concept of inclusion in the context of the current need to create inclusive environments for a workforce that is culturally and structurally sound to serve all patients, including the underrepresented or marginalized, in integrated health care. Additionally, this article serves as an introductory roadmap to the papers in this Dental Clinics of North America issue discussing components of inclusivity in dentistry.

Persistent oral health inequality in children-repeated cross-sectional studies in 2010 and 2019

BACKGROUND AND AIM

Children growing up in vulnerable circumstances have a higher risk of caries experience. Tracking the development of caries in relation to socioeconomic variables over time is essential for fair resource distribution to groups with higher caries risk and to even out inequalities in oral health. The aim was therefore to analyse the association between 6-year-olds´ caries prevalence and socioeconomic variables at family and residential area levels in 2010 and 2019 as well as potential differences in the association between 2010 and 2019.

METHODS

The study design is an epidemiological registry-based, repeated cross-sectional study based on caries data (grouped as 0, 1-3 and > 3 dmft) for the population of 6-year-olds in 2010 (n = 4,408, 95% coverage) and 2019 (n = 5,199, 94% coverage) in a Swedish region. Multiple socioeconomic variables for the children's families and residential areas were retrieved from official registries. Multinomial logistic regression was performed at both levels to produce models for each level and studied year.

RESULTS

The variables that explained most of the association between caries and socioeconomic variables were mainly the same over the years at both levels. At the family level, these were: maternal age when having their first child (explained most of the association in both years, at 30 and 35%, respectively); maternal age when having the child in the study group; parental employment; parental and child's migration background; maternal educational level; form of housing; and financial assistance (only 2010). At the residential area level, these were: migration background (explained most of the association both years; 82 and 52%, respectively), educational level and number of persons per household. The association between socioeconomic variables and caries was consistently stronger for severe caries (dmft > 3) than moderate (dmft 1-3). Multiple socioeconomic risk variables meant an even greater likelihood of caries.

CONCLUSION

Over the studied years, variables related to socioeconomic vulnerability continued to be associated with caries in young children growing up under socially disadvantaged circumstances. Effective efforts for families living in socially vulnerable contexts are needed to achieve good and equal oral health, as is continued follow-up to evaluate whether the goal is reached.

Socioeconomic inequalities in early childhood caries: evidence from vulnerable populations in Colombia

The Colombian Chapter of the Alliance-for-a-Cavity-Free-Future (Col-ACFF) has been conducting a health promotion and caries prevention program among young children in four vulnerable Colombian municipalities (baseline data from 2012-2014). This study aimed to quantify socioeconomic inequalities in early childhood caries (ECC) and examine the potential role of daily fluoride-toothpaste use, previous-year dental-care visit, and nutrition/diet-related aspects. The study sample included 1344 children aged 1-5 years. Inequalities in the age-standardized prevalence rates of and mean number of tooth surfaces affected by moderate/extensive (dME) and initial (dIME) caries (defined using the ICDAS-merged-epi criteria) by household income and level of education were examined using the relative index of inequality (RII) and the slope index of inequality (SII). Approximately one-third of the children included in this study exhibited dME, while 84% exhibited dIME. The majority of outcomes exhibited social gradients, and significant relative (RII) and absolute (SII) inequalities in ECC were observed. The SII estimate indicated an absolute difference of 12.4% in the prevalence of moderate/extensive carious lesions among children living in households with the lowest compared to the highest education levels [SII: 12.4; 95% confidence interval (CI): 2.7-22.1]. These children were also 6.7 times more likely to exhibit dIME compared to those living in households with higher levels of education (SII:6.73 95% CI: 4.18-9.29). Daily use of fluoride toothpastes, dental care visits in the previous year, and nutrition/diet-related factors played a limited role in ECC inequalities. In conclusion, significant ECC inequalities were observed in these vulnerable populations, highlighting the importance of upstream and downstream interventions that raise awareness among stakeholders and improve community- and individual-based practices to address this.

Social Vulnerability Index and Dental Caries in Children: An Exploratory Study

OBJECTIVE

This retrospective cross-sectional study evaluated the association between caries outcomes in a pediatric population visiting a dental clinic and the social vulnerability index, an area-based measure capturing 4 main social determinants of health: socioeconomic status, household composition/disability, minority status/language, and housing/transportation.

METHODS

The Centers for Disease Control Social Vulnerability Index (SVI) and electronic dental record data of children (0 to 18 y) reporting a caries diagnosis at the Children's Hospital Colorado in 2020 were extracted for 9,201 children. Logistic regressions were used to test the association between SVI and the presence or absence of dental caries, adjusting for age, sex, ethnicity, and race.

RESULTS

Children with a caries diagnosis had a greater mean overall SVI percentile (62.0, standard deviation [SD] = 29.1) compared with patients without a caries diagnosis (59.1, SD = 29.8; P < 0.001). With each 10-point increase in the overall SVI percentile, having a caries diagnosis visit was 2.7% more likely compared with having a visit without a caries diagnosis (odds ratio [OR] 1.027, 95% confidence interval [CI] 1.012, 1.042; P = 0.0004). Those with an overall SVI percentile between 51 and 75 were 23% more likely to have a caries diagnosis compared with those with a percentile ≤25 (OR 1.23, 95% CI 1.07, 1.42; P = 0.003), and those with a percentile >75 were 23.6% more likely to have a caries diagnosis compared with those with a percentile ≤25 (OR 1.236, 95% CI 1.09, 1.40; P = 0.001).

CONCLUSION

Children (0 to 18 y) living in socially vulnerable environments or areas were more likely to have a caries diagnosis at their dental exam.

KNOWLEDGE TRANSFER STATEMENT

This study showed an association between social determinants of health demonstrating social vulnerability and dental caries in children. Ultimately, understanding upstream factors for children living in socially vulnerable areas could support policymakers in creating more effective policies to support socially vulnerable populations.

Application of the extended theory of planned behavior to predict dentist intention and behavior in providing caries preventive care for preschool children

BACKGROUND

Various studies show a gap between evidence-based recommendations and the preventive practice of dentists. This study aimed to create and assess an extended Theory of Planned Behavior (TPB) model on dentists' intentions to do caries preventive measures and related barriers experienced by dentists.

METHODS

A total of 362 general dentists from 34 Indonesian provinces were included in this study. A self-administered online questionnaire consisted of three sections: dentist characteristics and practice pattern, TPB questionnaire, and dentist perceived behavior regarding preventive care for pediatric patients. The questionnaire was distributed and the data was analyzed through structural equation modeling.

RESULTS

TPB's extended version is a fit and relevant model, explaining 55.3% of dentists' intentions to undertake preventive procedures and 17.8% of preventive practices. Perceived behavioral control was the most powerful predictor of intention (44.2%) and practice (8.8%), while parental barriers were the most significant barrier to provide preventive care (18.9%).

CONCLUSION

Extending the TPB by taking barriers from multiple stakeholders as a consideration has a higher predictive level for preventive practices. Each barrier should be addressed through oral health programs and policies, and dentists must be taught to overcome these barriers (through formal or continuing education) in order to maximize caries prevention strategies.

The pathways from disadvantaged socioeconomic status in childhood to edentulism in mid-to-late adulthood over the life-course

BACKGROUND

This study aimed to examine the direct and indirect pathways from childhood socioeconomic status (SES) to the prevalence of edentulism in mid-to-late age Chinese individuals using structural equation modeling (SEM).

METHODS

This study analyzed data from 17,032 mid- to-late age Chinese individuals in the 2014 and 2015 China Health and Retirement Longitudinal Study (CHARLS). Childhood SES was determined based on the parents' education and occupation, financial situation of the family, primary residence, food availability, and medical convenience. Adulthood SES was established according to educational achievements of the individuals. Edentulism is defined as the loss of all natural teeth. SEM was used to examine the statistical significance of the association between childhood SES and edentulism, mediated by childhood health, adulthood SES, and adult health.

RESULTS

Childhood SES had significant indirect (β = -0.026, p < 0.01), and total (β = -0.040, p < 0.01) effects on edentulism. It was determined that 65% of the total effect of childhood SES on edentulism was indirect, and mainly mediated by adult SES. Also, the goodness-of-fit indices of the best-fitting model were acceptable.

CONCLUSION

This study revealed that childhood health, adult health and adult SES are mediators that explain the relationship between childhood SES and edentulism. The global attention to alleviate the inequality in edentulism should focus on exploring recommendations and intervention strategies from childhood to adulthood, by considering adult SES, childhood and adult health.

Oral health surveys of Traditional Peoples and Communities in Brazil: a scoping review protocol

OBJECTIVE

The objective of this review protocol is to map the available evidence regarding all the oral health surveys of Traditional Peoples and Communities (TPCs) in Brazil.

METHODS AND ANALYSIS

The review question of the protocol is: 'What evidence is available on the oral health surveys of Traditional Peoples and Communities in Brazil?'. Observational studies that report oral health surveys of TPC in Brazil will be included. The protocol considered the Problem, Concept and Context strategy to guide data collection, as established by the Joanna Briggs Institute. The search strategy will consider Medical Subject Headings terms, synonyms and relevant free terms about epidemiological surveys in oral health and TPC in Brazil, with no limits to data, language, subject or search type, in the databases Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Literatura Latino-americana e do Caribe em Ciências da Saúde (LILACS), Scopus, Web of Science and Embase. Bibliographic searches will be updated until June 2023. The selection will be carried out by two independent, blinded reviewers, following the eligibility criteria, based on the title and abstract identified in the initial search. Potentially eligible studies will be fully read to confirm eligibility and collect relevant information. The categorisation of the studies will consider the author and year of publication, the traditional group studied, the study design, geographic location, age group, sample size, data collection method and the main oral health problem evaluated and its outcome. The data obtained and extracted will be presented in table format and text and presented using the visualisation of similarities method.

ETHICS AND DISSEMINATION

The present study does not need ethical approval. The protocol title was registered in the Open Science Framework (DOI 10.17605/OSF.IO/BQ5J3). A final article will be prepared presenting the results of the scoping review, and will be submitted for publication in a peer-reviewed journal. The findings of this review will be presented at national conferences and scientific meetings.

Time elapsed since peruvian children's last dental care and head of household educational attainment: findings from a national database

BACKGROUND

It has been documented that the parents' highest level of education has an impact on their children's access to oral health services and the frequency of their use.This study aimed to determine the association between time elapsed since peruvian children's last dental care and head of household educational attainment.

METHODS

Cross-sectional study using a database of children aged 0 to 11 years, with a final sample of 8012 participants. The dependent variable in this study was the time elapsed since last dental care and the independent variable was the head of household educational attainment. Other covariates considered were natural region, area of residence, place of residence, altitude, wealth index, health insurance coverage, sex and age. Descriptive, bivariate and multivariate statistical analyses were applied.

RESULTS

Time elapsed since last dental care in the year 2021 was 5.68 years (SD = 5.25). A hierarchical multiple linear regression analysis was performed, analyzing the variables dimensions by separate and joint models. When head of household educational attainment was analyzed, there was no statistical significance (p = 0.262); however, other models did (p < 0.05). Model 4, which addresses all dimensions, was significant (p < 0.001) with an R2% of 0.011 and constant equal to 5.788; it showed significance with place of dental care, health insurance, altitude and age.

CONCLUSIONS

No association was found between head of household educational attainment and time elapsed since last dental care; however, the latter was associated with place of care, health insurance coverage, altitude and age in Peruvian children.

Oral health research funding in relation to disease burden in Australia

BACKGROUND

This study aims to investigate and compare the major Australian government research funding schemes for oral health science with other disciplines from the burden of disease perspective.

METHODS

Major government research funding scheme outcomes were identified. An innovative index of Fair Research Funding (FRF) was developed to examine the extent to which National Health and Medical Research Council funding is aligned with the disease burden. In addition to comparing different diseases, overall governmental research funding for different areas of oral health sciences was explored.

RESULTS

Oral disorders with $15 million NHMRC grant funds (2017-2021) and FRF of 10.7 has the lowest and most inequitable amount of Australian government support in relation to disease burden. The share of oral health science in the Australian Research Council and Medical Research Future Fund was very minimal, with $3.43 and $1.88 million respectively.

CONCLUSION

Governmental research funding for oral health sciences is inequitable according to the disease burden. More dedicated oral health sciences research funding schemes are essential. Funding for prevention-focused public oral health programmes is a vital requirement towards reducing the inequalities in population oral health.

Non-utilization of oral health services and associated factors among children and adolescents: an integrative review

OBJECTIVE

To review publications exploring non-utilization of oral health services and to identify factors associated with non-utilization of oral health services among children and adolescents.

MATERIALS AND METHODS

An integrative review design was adopted. A search was conducted for research articles published during the period from 2000 to April 2021 in five databases, Medline via Ovid, Scopus, CINAHL, Cochrane Library and Web of Science. Inclusion criteria were original articles examining non-utilization of oral health services among 0-19 years old and studies published in peer-reviewed journals in English. Thematic analysis was undertaken to identify common themes. The Newcastle-Ottawa scale was used to evaluate the quality of the studies.

RESULTS

Twenty-one geographically diverse articles were included. Nineteen studies were cross-sectional, one was a prospective cohort and one a case-control study. Non-utilization of dental health services tended to be higher in children than adolescents. There were predisposing (age, gender, ethnicity, parent's level of education), enabling (family income, dental insurance) and need factors (subjective and objective oral health related parameters) that had been shown to be associated with non-utilization of dental services among children and adolescents.

CONCLUSIONS

This integrative review found predisposing, enabling and need factors to be associated with dental health service non-utilization.

Rigorous theory-based intervention research is the bold action needed to address oral health disparities and inequities

The Consensus Statement about behavioral and social sciences in oral health encourages future research to draw on testable theories that specify causal pathways that reflect the complex nature of oral health. In this commentary, we amplify the importance of explicit and well-specified theory in oral health intervention research, acknowledging that problematic use of theory has limited its utility in developing effective public health interventions. Also, we affirm the need to focus on determinants of oral health-and health inequities-most likely to drive meaningful change, and to understand the causal pathways that connect drivers of change from the individual to the global level. We view theory-based, causal mechanisms research as a powerful approach to building successful public health interventions, and suggest resources to inspire such research, including exemplary studies, methodologies, and collaborative initiatives that facilitate strong theory-based public health research.

Child oral health and preventive dental service access among children with intellectual disabilities, autism and other educational additional support needs: A population‐based record linkage cohort study

OBJECTIVE

Inequalities in child oral health are a global challenge and the intersection of socioeconomic factors with educational additional support needs (ASN), including children with intellectual disabilities or autism, have thus far received limited attention in relatively small clinical studies. We aimed to address this evidence gap by investigating oral health and access to preventive dental services among children with ASN compared to the general child population.

METHODS

Cohort study linking data from six Scotland-wide health and education databases compared: dental caries experience and tooth extraction via general anaesthetic; receipt of school-based dental inspection; access to primary care and hospital dental services; and access to the Childsmile national oral health improvement programme between children with a range of ASN (intellectual disabilities, autism, social and other) and their peers for the school years 2016/17-2018/19 (n = 166 781).

RESULTS

Children with any ASN had higher rates of caries experience than those with no ASN, however, after adjustment for socioeconomic deprivation, sex, year, and school type only those with a social or other ASN remained at increased risk. Rates of tooth extraction under general anaesthesia in hospital were higher among children with intellectual disabilities (aRR = 1.67;95% CI = [1.16-2.37]). School-based dental inspection access improved for children with intellectual disability and/or autism from 2016/17 onwards, although higher rates of child refusal on the day were observed in these groups (no ASN refusal: 5.4%; intellectual disability: 35.8%; autism: 40.3%). Children with any ASN were less likely to attend primary dental-care regularly, and in those who attended, children with intellectual disability or autism were less likely than their peers to receive prevention (fluoride varnish, oral-hygiene instruction, or dietary advice). Childsmile nursery-supervised toothbrushing programme access among children with any ASN was similar to children with no ASN and children with intellectual disability (aRR = 1.27;95% CI = [1.12-1.45]) or autism (aRR = 1.32;95% CI = [1.19-1.45]) were more likely to receive support from Childsmile dental health support worker.

CONCLUSIONS

We have identified inequalities in oral health and dental care for children with different ASN in Scotland with both a greater burden of disease among some groups and higher complexity of care; compounded by reduced and variable access to preventive dental services. Further efforts are needed to develop and improve preventive care pathways for children with ASN and integrate oral health to wider healthcare systems for these children to mitigate against oral health inequalities.

Early Childhood Caries in a Preschool-based Sample in Northeast Italy: Socioeconomic Status and Behavioral Risk Factors

Aim

To assess the relationship among caries and age, gender, immigrant condition, socioeconomic status (SES), and a behavioral risk factor (toothbrushing) in a sample of 3-5-year-old children.

Materials and methods

We performed a random cross-sectional survey from January to December 2017, carrying out clinical examinations to estimate the decayed, missing, and filled teeth (dmft) score. Parents filled in a questionnaire reporting their education level (SES) and the daily frequency of children's toothbrushing. The multivariate analysis assessed the association between caries occurrence and the independent variables. The dmft score was assessed by zero-inflated negative binomial regression (ZINBR).

Results

Out of 1,441 children in the sample, 357 (26.0%) presented at least one caries-affected tooth. Caries risk significantly increased with age and irregular toothbrushing, and it was significantly higher in children with lower SES levels. We modeled caries risk by means of ZINBR. The degree of caries experience increased in children from lower SES positions, immigrant status, and of older age; regular toothbrushing (twice a day) is a predicting factor to belong to the "zero caries" group.

Conclusion

Dental caries represent a significant burden in preschool children and can be regarded as an early marker of social disadvantage.

Clinical significance

The confirmation of the earliest preventive approach as the only chance to grant a "caries free" dentition in all ages and the first target for a pediatric dentist.

How to cite this article

Ferro R, Besostri A, Olivieri A, et al. Early Childhood Caries in a Preschool-based Sample in Northeast Italy: Socioeconomic Status and Behavioral Risk Factors. Int J Clin Pediatr Dent 2022;15(6):717-723.

Polyzwitterion Manipulates Remineralization and Antibiofilm Functions against Dental Demineralization

Biomineralization technology has become a trend for the arrest and prevention of dental caries. In particular, the bioactivity and ability to release large amounts of Ca²⁺ and PO₄^3- ions make amorphous calcium phosphate (ACP) for hard tissue remineralization are highly desired. However, the instability of ACP limits its clinical application. Under continuous bacterial challenge in the oral cavity, the currently developed ACP-based remineralization system lacks the ability to inhibit bacterial adhesion and biofilm formation. Here, a dual-functional nanocomposite with antibiofilm and remineralization properties was designed by combining zwitterionic poly(carboxybetaine acrylamide) (PCBAA) and ACP. The resulting nanocomposite was stable in solution for at least 3 days without any aggregation. The PCBAA/ACP nanocomposite exerted a significant inhibitory effect on the adhesion and biofilm formation of Streptococcus mutans and exhibited bactericidal activities under acidic conditions resulting from bacteria. Moreover, compared with fluoride, this nanocomposite demonstrated superior effects in promoting the remineralization of demineralized enamel and the occlusion of exposed dentinal tubules in vivo and in vitro. The present work provides a theoretical and experimental basis for the use of the PCBAA/ACP nanocomposite as a potential dual-functional agent for arresting and preventing caries.

Effects of the COVID-19 Pandemic on Children’s Oral Health and Dental Care Use

Background

The COVID-19 pandemic led to early restrictions on access to oral health care and social distancing requirements. The authors examined the early effects of the COVID-19 pandemic on children’s oral health and access to oral health care in the United States.

Methods

Using nationally representative data from the National Survey of Children’s Health, the authors compared several measures of children’s oral health and oral health care use early during the pandemic in 2020 with 1 year earlier. Logistic (multinomial or binary) regression models were estimated, adjusting for several child and household covariates and state fixed effects. Similar comparisons were estimated for 2019 relative to 2018 to evaluate prepandemic trends.

Results

Children in 2020 were 16% (relative risk ratio, 0.84; 95% CI, 0.75 to 0.93) less likely to have excellent dental health as perceived by parents and 75% (relative risk ratio, 1.75; 95% CI, 1.14 to 2.67) more likely to have poor dental health than in 2019. In addition, children in 2020 had higher risk of bleeding gingivae (odds ratio, 1.46; 95% CI, 1.16 to 1.85). The likelihood of having a dental visit in the past 12 months was 27% (odds ratio, 0.73; 95% CI, 0.65 to 0.82) lower in 2020, including lower likelihood for preventive visits. The differences between 2020 and 2019 were observed across demographic and socioeconomic subgroups. There were no such differences between 2019 and 2018.

Conclusions

There was a widespread decline in children’s oral health status and access to oral health care early during the COVID-19 pandemic.

Practical Implications

Prompt policies and oral health campaigns are needed to counter the pandemic effects and increase timely access to dental services.

Child-, Family-, and Community-Level Facilitators for Promoting Oral Health Practices among Indigenous Children

Despite the preventive nature of oral diseases and their significance for general wellbeing, poor oral health is highly prevalent and has unfavourable ramifications for children around the world. Indigenous children in Australia experience disproportionate rates of early childhood caries compared to their non-Indigenous counterparts. Therefore, this paper aims to collate parental experiences and generate an understanding of facilitators for Indigenous childhood oral health. This project aggregated stories from parents of Indigenous children across South Australia who were participants in an early childhood caries-prevention trial. This paper explores facilitators for establishing oral health and nutrition behaviours for Indigenous children under the age of three through reflexive thematic analysis. Fisher-Owens' conceptual model for influences on children's oral health is utilised as a framework for thematic findings. Child-level facilitators include oral hygiene routines and regular water consumption. Family-level facilitators include familial ties, importance of knowledge, and positive oral health beliefs. Community-level facilitators include generational teaching, helpful community resources, and holistic health care. Recommendations from findings include the following: exploration of Indigenous health workers and elder participation in oral health initiatives; inclusion of Indigenous community representatives in mainstream oral health discussions; and incorporation of child-level, family-level, and community-level facilitators to increase support for efficacious oral health programs.

Influence of socioeconomic status on oral disease burden: a population-based study

Background

Dental caries is associated with Biological, behavioral, socioeconomic, and environmental factors; however, socioeconomic status is a distal determinant of dental caries development that modulates exposure to risk and protective factors. This study aimed to analyze the socioeconomic factors associated with the concentration of oral diseases in a population-based study in Brazil.

Methods

This is a quantitative, analytical, cross-sectional study based on secondary data from the SB São Paulo 2015 epidemiological survey. A total of 17,560 subjects were included. The concentration of oral disease in the population was estimated by the oral disease burden (ODB) variable. The ODB consists of four components: dental caries; tooth loss; need for dental prosthesis and periodontal condition. Thus, the total score on the ODB could vary between 0 and 4, with the highest score indicating the worst possible situation. ODB was analyzed in multivariate negative binomial regression, and multivariate binary logistic regression analysis. The following factors were included as independent variables: age group, skin color, socioeconomic factors, family income and Oral Impact on Daily Performance (OIDP).

Results

In the sample, 86.9% had no minimum ODP component. Negative multivariate binomial regression showed a statistically significant relationship (p < 0.005) between ODB and all variables analyzed (skin color, family income, education, OIDP results and age range). The adjusted multivariate binary logistic regression showed that the individuals most likely to have at least one component of ODB were nonwhite (25.5%), had a family income of up to R$ 1500.00/month (19.6%), had only completed primary education (19.1%), and reported that their oral health had an impact on their daily activities (57.6%). Older adults individuals were two times more likely than adolescents to have an ODB component.

Conclusions

ODB is associated with factors related to social inequality. Adults and older adults individuals had the highest cumulative number of ODB components.

Dental Visits for Autistic Children: A Qualitative Focus Group Study of Parental Perceptions

INTRODUCTION

Patient groups who pose behavioral challenges during dental attendance may be offered more restricted dental treatment options. Unsuccessful participation with dental visit tasks and demands has been commonly reported for autistic children.

OBJECTIVES

This study aimed to examine parental perceptions of difficulties associated with dental attendance and oral care for autistic children and young adults, to highlight reported challenges and potential adaptations, and to identify interventions that will encourage positive experiences of dental attendance.

METHODS

Qualitative data were gathered through 2 focus groups with parents of primary school and secondary school pupils with autism, interviewed in separate groups. Questions about parents' perceptions of dental attendance and oral care were asked. The groups were audio-recorded and transcribed verbatim. The transcripts were analyzed and initial codes generated. Development of subthemes and themes followed a process of thematic analysis.

RESULTS

Parental perceptions, which confirmed data from other studies, included the need for understanding and training, awareness of sensory issues, recognition of the individuality of autistic traits, time and clarity for communication, and factors affecting the confidence of parents to advocate in the clinical environment. Focus group participants identified the critical value of empathizing with an autistic perspective and highlighted the importance of positive oral health messages. They also noted the lack of understanding regarding the complexity of altering self-imposed, ritualistic dietary regimes and attempting to enact good dental preventive habits for their children.

CONCLUSIONS

Analysis of data from parent focus groups provided a greater understanding of the needs and responsivity required for successful dental visits for autistic children and young adults. A range of potential interventions was identified and incorporated within a model of needs. Interventions based on Partnership Working, System Change, and Training of Dental Staff could be effective in reducing challenges posed by dental attendance for many children with autism.

KNOWLEDGE TRANSFER STATEMENT

Sensory sensitivities, communication difficulties, comorbid intellectual disability, and dental anxiety are barriers to successful participation during dental attendance for autistic children. This research proposes that interventions supporting Partnership Working, System Change, and Training of Dental Staff can reduce challenges posed by dental attendance. The model of interventions developed as part of this project can be used by oral care teams to help reduce barriers and improve the success of dental visits for autistic children.

Determinants of caries experience and the impact on the OHRQOL of 6-year-old Libyan children: a cross-sectional survey

Objective

The current study aimed to assess the caries experience and associated factors and its impact on the oral health-related quality of life (OHRQoL) among 6-year-old Libyan children.

Methods

A cross-sectional survey including 706 six-year-old children was conducted in 2017 in Benghazi, Libya. Data were collected through a self-administered questionnaire assessing socioeconomic status and oral health behaviours, and the Arabic version of the Early Childhood Oral Health Impact Scale (A-ECOHIS) to assess the OHRQoL. Clinical examination assessed caries experience at tooth level (dmft) and the number of decayed, missing due to caries and filled teeth (dt, mt and ft). Poisson regression analysis was performed to determine the association between dmft scores and the independent predictors. Linear regression analysis was conducted for ECOHIS scores with the children’s gender, SES and OHB. The statistical significance was set to ≤  0.05.

Results

Data were available for 706 children. Caries prevalence (dt) and dmft of ≥ 1 were 69.1% and 71% respectively. The mean ± SD dmft score was 3.23 ± 3.32. There was a significant and direct association between dmft scores and daily consumption of sugary snacks (B = 1.27, P = 0.011) and a significant inverse association with teethbrushing twice daily (B = 0.80, P = 0.041). There was a significant and direct association between A-ECOHIS and dmft (B = 1.14, P ≤ 0.001) and a significant and inverse association between A- ECOHIS and high and intermediate family income compared to low income (B = −3.82, P = 0.0001 and B = −2.06, P = 0.028).

Conclusions

6-year-old Libyan children had a relatively high caries experience an untreated decay with impact on OHRQoL. Social disparities, sugar consumption patterns and oral hygiene practices were associated with high caries experience.

Caries Prevalence Associated with Oral Health-Related Behaviors among Romanian Schoolchildren

Oral health-related behaviors and living conditions play an important role in general and oral health. This study aimed to evaluate caries prevalence and severity in schoolchildren residing in rural and urban areas of Romania, and to correlate these with oral health-related behaviors. An estimation of the required sample size was conducted (sampling error of ±3% at a 95% confidence level), followed by the stratification of administrative units and then the selection of 49 schools. The Hurdle approach was used to analyze the dataset, requiring two sets of analyses for each outcome variable: a multilevel binary model to predict prevalence, and a multilevel Poisson analysis using only non-zero values. The mean and standard deviation (SD) for the dentinal caries index was 4.96 (5.33). Girls were more likely to have non-zero restoration codes (β = 0.14, SE = 0.08, p < 0.05). Low education levels of each parent were associated with an increased likelihood of having non-zero carious tooth surfaces (β = 0.23, SE = 0.06, p = 0.01; β = 0.22, SE = 0.06, p < 0.01). The presence of cavities was predicted by the consumption of carbonated soft drinks (β = 0.19, SE = 0.07, p < 0.01), candies (β = 0.13, SE = 0.06, p < 0.01), sweetened milk (β = 0.12, SE = 0.06, p < 0.05), tea (β = 0.16, SE = 0.08, p < 0.05), or cocoa (β = 0.13, SE = 0.06, p < 0.05). Furthermore, the non-zero values of the dentinal caries index were more likely in rural schools (β = -0.37, SE = 0.11, p < 0.01), and a negative association between the county development index and the fillings/restorations index (β = -0.01, SE = 0.01, p < 0.05) was also established. The outcome of this research highlights that the presence of caries (dentinal caries index) in Romanian schoolchildren is influenced by their socioeconomic background, as well as their specific consumption behaviors.

Do social inequalities persist in the distribution of dental caries in adolescents from Maranhão? Contributions of a population-based study

This study aimed to analyze the association of socioeconomic factors with the prevalence of dental caries in adolescents from São Luís, Maranhão, Brazil, to answer whether social inequalities persist in distributing this disease. This is a cross-sectional study nested in a prospective cohort. We included 2,413 adolescents aged 18-19 years evaluated in the 2016 second follow-up. The outcome was teeth with untreated dental caries (yes or no) assessed by the DMFT index. Socioeconomic and demographic characteristics were the independent variables. Descriptive statistical and Poisson regression analyses were performed, calculating crude and adjusted prevalence ratios (PRs) (alpha=5%). Belonging to economic classes C (PR=1.23; 95% CI: 1.11-1.37) or D-E (PR=1.48; 95% CI: 1.32-1.65), being married/living with a partner (PR=1.22; 95% CI: 1.07-1.39), having separated parents (PR=1.11; 95% CI 1.03-1.19) and a greater number of people in the household (PR=1.05; 95% CI: 1.03-1.07) were associated with a higher prevalence of dental caries. Social inequalities in adolescent oral health persist despite the implementation of the National Oral Health Policy. The current health care model should seek to reorient health education strategies, targeting them at vulnerable populations.

Progress and challenges in potential access to oral health primary care services in Brazil: A population-based panel study with latent transition analysis

OBJECTIVE

Compared indicators of potential access to oral health services sought in two cycles of the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB), verifying whether the program generated changes in access to oral health services.

METHODS

Transitional analysis of latent classes was used to analyze two cross-sections of the external evaluation of the PMAQ-AB (Cycle I: 2011-2012 and Cycle II: 2013-2014), identifying completeness classes for a structure and work process related to oral health. Consider three indicators of structure (presence of a dental surgeon, existence of a dental office and operating at minimum hours) and five of the work process (scheduling every day of the week, home visits, basic dental procedures, scheduling for spontaneous demand and continuation of treatment). Choropleth maps and hotspots were made.

RESULTS

The proportion of elements that had one or more dentist (CD), dental office and operated at minimum hours varied from 65.56% to 67.13 between the two cycles of the PMAQ-AB. The number of teams that made appointments every day of the week increased 8.7% and those that made home visits varied from 44.51% to 52.88%. The reduction in the number of teams that reported guaranteeing the agenda for accommodating spontaneous demand, varying from 62.41% to 60.11% and in the continuity of treatment, varying from 63.41% to 61.11%. For the structure of health requirements, the predominant completeness profile was "Best completeness" in both cycles, comprising 71.0% of the sets at time 1 and 67.0% at time 2. The proportion of teams with "Best completeness" increased by 89.1%, the one with "Worst completeness" increased by 20%, while those with "Average completeness" decreased by 66.3%.

CONCLUSION

We identified positive changes in the indicators of potential access to oral health services, expanding the users' ability to use them. However, some access attributes remain unsatisfactory, with organizational barriers persisting.

Oral Health Inequalities among Indigenous and Non-Indigenous Children

INTRODUCTION

Our ability to address child oral health inequalities would be greatly facilitated by a more nuanced understanding of whether underlying disease experience or treatment opportunities account for a larger share of differences between social groups. This is particularly relevant in the context of population subgroups who are socially marginalized, such as Australia's Indigenous population. The decayed, missing, and filled (dmf) surfaces index is at once a reflection of dental caries experience (d) and its management (m and f).

OBJECTIVES

To 1) describe socioeconomic inequalities in dental caries experience and its management among Indigenous and non-Indigenous children and 2) compare these inequalities using absolute and relative measures.

METHODS

Data were from the Australian National Child Oral Health Study 2012-2014. Absolute and relative income inequalities were assessed for overall dmfs and its individual components (ds, ms, fs) using adjusted means and health disparity indices (Slope Index of Inequality [SII] and Relative Index of Inequality [RII]).

RESULTS

Mean dmfs among Indigenous children aged 5 to 10 y was 6.4 (95% confidence interval [CI], 5.4-7.4), ranging from 2.3 in the highest to 9.1 in the lowest income group. Mean dmfs among non-Indigenous children was 2.9 (95% CI, 2.8-3.1), ranging from 1.9 in the highest to 4.2 in the lowest income group. Age- and gender-adjusted social gradients for Indigenous children were evident across all dmfs components but were particularly notable for ds (SII = -4.6, RII = -1.7) and fs (SII = -3.2, RII = -1.5). The social gradients for non-Indigenous children were much lower in magnitude: ds (SII = -1.8, RII = -1.6) and fs (SII = -0.7, RII = -0.5).

CONCLUSION

Our findings suggest that socioeconomic disadvantage may translate into both higher disease experience and increased use of dental services for both Indigenous and non-Indigenous groups, with the social gradients being much more amplified among Indigenous children.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study demonstrate the magnitude of disparities in dental caries among children by population groups in Australia. Our results suggest that the relationship between socioeconomic disadvantage and poor oral health is more deleterious among Indigenous than non-Indigenous children. Tackling upstream determinants of health might not only affect population patterns of health and disease but also mitigate the overwhelming racial inequalities in oral health between Indigenous and non-Indigenous Australians.

Disparities in Access to Oral Health Care

In the United States, people are more likely to have poor oral health if they are low-income, uninsured, and/or members of racial/ethnic minority, immigrant, or rural populations who have suboptimal access to quality oral health care. As a result, poor oral health serves as the national symbol of social inequality. There is increasing recognition among those in public health that oral diseases such as dental caries and periodontal disease and general health conditions such as obesity and diabetes are closely linked by sharing common risk factors, including excess sugar consumption and tobacco use, as well as underlying infection and inflammatory pathways. Hence, efforts to integrate oral health and primary health care, incorporate interventions at multiple levels to improve access to and quality of services, and create health care teams that provide patient-centered care in both safety net clinics and community settings may narrow the gaps in access to oral health care across the life course.

Dentists' Adoption of Silver Diamine Fluoride among 1- to 5-Year-Old Children in North Carolina

BACKGROUND

A natural experiment was conducted to observe the adoption of silver diamine fluoride (SDF) by Medicaid-enrolled dentists in North Carolina (NC). The purpose of this study was to describe the sociocontextual and community health characteristics where dentists adopted SDF, determine the association between SDF use and general anesthesia (GA) use, and examine the changes in GA utilization following implementing SDF reimbursement.

METHODS

NC Medicaid initiated SDF reimbursement in 2016 for children ages 1 to 5 y. This cross-sectional time series study used aggregate NC Medicaid claims, including geographic data, from 2014 to 2018. All dentists who provided GA and/or SDF to children ages 1 to 5 y were included. County health ranking data described social and community health indicators. Descriptive statistics, spatial data techniques, and multivariable methods were used.

RESULTS

From 2016 to 2018, the number of dentists using SDF increased from 35 to 258, or 637%, whereas the number of dentists using GA increased from 179 to 211, or 17%. SDF utilization spread outward from areas of good social and health indicators to areas of poorer indicators. SDF utilization increased from 0.35 to 0.65 per 1,000 children, whereas GA utilization decreased from 2.57 to 2.47 per 1,000 children. GA utilization was positively associated with SDF utilization and poorer county health ranking but did not change before and after SDF implementation.

CONCLUSION

Early adopters of SDF in NC practiced in areas with positive social and community health indicators. Over time, SDF was adopted in resource-poor communities. It remains too early to determine the public health impacts of SDF treatment on GA utilization.

KNOWLEDGE TRANSFER STATEMENT

Policy makers and clinicians can use the results of this study to develop geographically targeted interventions that could lead to clinically and cost-effective public health programs.

Nursing Students’ Assessment and Parent Reports of Their Children’s Oral Health Behaviors as Predictors of Tooth Decay Risk—A Cross-Sectional, Correlational Study

Aim:

The aim of this study is to evaluate the relationship between children’s tooth decay risk score and a dental examination and parent reports of oral health practices.

Materials and Methods:

A cross-sectional correlational study utilizing data from an oral health assessment was performed by undergraduate nursing students and parents completed the permission forms.

Results:

Four hundred and fifty-six children received an oral health assessment. None of the percentages were found to be at high risk for tooth de cay and 21% were referred for further evaluation and dental treatment. Twenty-seven % of parents reported that their child was not being seen by a dentist and 49% reported that they had not established recommended tooth brushing practices in early childhood. In this analysis, the physical examination measures accounted for a significant amount of risk: R2 = 0.55, F(5,317) = 7.62, P < .00. The parent report measures offered little predictive power beyond the examination: R2 = 0.029, F(7,310) = 3.01, P = .00.

Conclusions:

These findings identify a need for a broader perspective to inform oral risk assessment and interventions to address oral health disparities. A social determinant of health framework would improve nursing students’ competency to identify children in need of early intervention. Oral health promotion at the family and community level would improve the preventive oral health practices.

Inequalities in Caries Experience Among Mongolian Children

Although inequalities in dental caries have been well-reported, there is only one Mongolian study on the association between socioeconomic status (SES) and caries experience, which was published ten years ago. This study aimed to determine the dental health status of Mongolian children living in urban and suburban areas of Ulaanbaatar city and examine its association with income and parental educational attainment. An oral examination was conducted by dentists and caries were measured as deft/DMFT indices. A questionnaire including demographic characteristics and socioeconomic status was completed by their parents or caregiver. Parental educational attainment and household income were used as the measures of SES. The relative index of inequality (RII) and slope index of inequality (SII) were employed to examine the association between SES on deft and DMFT after adjusting for covariates. Dental caries prevalence (those with deft/DMFT > 0) was 89.3% among the total number of participants. The mean deft/DMFT values for age groups 1-6, 7-12, and 13-18 were 5.83 (SD = 4.37, deft), 5.77 (SD = 3.31, deft/DMFT), and 3.59 (SD = 2.69, DMFT), respectively. Rather than residence area and parental educational attainment, significant caries experience inequality was observed in relation to income (RII 0.65 95%, CI 0.52 to 0.82, SII -2.30, 95% CI -4.16 to -0.45). A prevention strategy for lower socioeconomic groups and building integrated oral health surveillance to monitor epidemiological trends for further evaluation of its progress is necessary.

Oral diseases: a global public health challenge

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

Children's Oral Health and Academic Performance: Evidence of a Persisting Relationship Over the Last Decade in the United States

OBJECTIVE

To assess the association between children's oral health and academic performance using the most recent US national data, a decade after the last assessment using similar previous data.

STUDY DESIGN

Data from the 2016-2017 National Survey of Children's Health for 45 711 children aged 6-17 years were analyzed. Children's oral health measures were indicators of specific oral health problems and parent-rated oral health. Academic performance measures included problems at school and missing school days. Regression models were employed adjusting for relevant demographic, socioeconomic, and health characteristics and state effects. Analyses also were conducted stratifying by child's age, sex, household income, and type of health insurance.

RESULTS

We found significant associations across all the evaluated academic outcomes and oral health measures. Children with oral health problems were more likely to have problems at school (OR 1.56, 95% CI 1.32-1.85), miss at least 1 school day (OR 1.54, 95% CI 1.28-1.85), and miss more than 3 or 6 school days (OR 1.39, 95% CI 1.20-1.61 and OR 1.39, 95% CI 1.14-1.69; respectively). These associations were generally larger when using the child's oral health rating. Poor oral health was consistently related to worse academic performance across age, sex, household income, and health insurance type subgroups.

CONCLUSIONS

Children's oral health status continues to be strongly linked to their academic outcomes. This evidence highlights the need for broad population-wide policies and integrated approaches to reduce academic deficits and promote children's health and development, of which oral health is an important component.