Social inequalities in tooth loss: A multinational comparison

Social Inequities in Access to Dental Care in Australian Adults over Time

INTRODUCTION

Social inequities in dental caries are reflected by both inequities in the social structures that contribute to disease severity and inequities in the provision of dental care. This study aimed to describe social differentials in the dental caries experience among Australian adults across a 13-y period and to examine if the highest magnitude of oral health inequities persisted across dental caries prevalence (decayed teeth [DT]) or its management (missing teeth [MT], filled teeth [FT]).

METHODS

Data were from 2 population-based cross-sectional surveys of Australian adult oral health conducted in 2004-2006 (National Survey of Adult Oral Health-1 [NSAOH-1], n = 5,505) and 2017-2018 (NSAOH-2, n = 5,022). In each survey, representative samples of adults were obtained through a 3-stage, stratified sample design within metropolitan and regional areas in each state/territory. Clinical outcomes included the prevalence and mean of DT, MT, FT, and DMFT. Equivalized household income was grouped into approximately quartiles from low to high.

RESULTS

Across all income quartiles, the mean DT and % DT >0 was higher in NSAOH-2 than in NSAOH-1. The increase in prevalence was highest in the third highest income group (prevalence difference [PD] = 8.4, from 24.1 to 32.5). Similarly, % MT >0 was lower in NSAOH-2 than in NSAOH-1 across all income groups, with the decrease most marked for the lowest income group (PD = -6.5, from 74.1 to 67.8). Across all income quartiles, % FT >0 was lower in NSAOH-2 than in NSAOH-1. The decrease was the most marked for the lowest income group (PD = -8.9, from 81.1 to 72.2).

CONCLUSION

The findings confirm that although oral health inequities decreased for the most extreme management outcome of dental caries (MT), inequities increased for experience of that disease (DT) and the more conservative management of dental caries (FT). For all D, M, and F components (DMFT), inequities between the lowest and highest household income groups increased from 2004-2006 to 2017-2018.

KNOWLEDGE TRANSFER STATEMENT

This study found that social inequities in oral health (experience of untreated dental caries and missing teeth) increased between the most socially advantaged and disadvantaged groups between 2004-2006 and 2017-2018. This suggests that models of dental service provision in Australia are increasingly benefitting those who can afford and access the care and who arguably need the services less than their less socially advantaged counterparts do.

A rural teledentistry care experience: a geriatric approach to assessing oral health status and treatment needs in older adults from a Mapuche community in Chile

Background

Limited attention has been given to oral health challenges faced by older Indigenous populations, especially in rural settings, where disparities exist. This study aims to assess oral health in a rural Mapuche community in southern Chile, utilizing geriatric technology support, and exploring the connection between geriatric health and oral well-being to fill a gap in this context.

Methods

A cross-sectional study was conducted involving 76 independent older adults from a rural Mapuche community who required dental care. Assessments were in a remote care setting gathering extensive data including comprehensive geriatric assessments, medical and dental conditions using a geriatric teledentistry platform (TEGO®). Statistical analysis involved descriptive analysis, logistic regression, and both multiple correspondence analysis and k-means cluster analysis.

Results

The sample comprised individuals with limited formal education and a high degree of vulnerability. Geriatric assessments unveiled cognitive deterioration, frailty, depression risk, and multimorbidity. A distribution of the DMFT index, number of remaining teeth, number of occluding pairs, number of teeth with restorative needs and other relevant clinical findings was conducted based on sociodemographic, and medical-geriatric-dental characteristics, and additionally, a Multinomial Logistic Regression Analysis of Dentition Variables in Relation to Geriatric Assessments was performed. The dental burden was substantial, with an average DMFT index of 25.96 (SD 4.38), high prevalence of non-functional dentition (89.3%), periodontal disease (83%), xerostomia (63.2%) and oral mucosal lesions (31.5%). Age, lower education, depression, daily medication number and sugary consumption frequency were associated with a decreased average number of teeth (p < 0.05). Multiple correspondence analysis and k-means cluster analysis identified 4 clusters, with the edentulous and functional dentition groups being the most distinct.

Conclusion

This study uncovers a substantial dental burden and intricate medical-geriatric conditions interlinked among Indigenous older adults in a rural Chilean Mapuche community. The implementation of a geriatric technological ecosystem in the community enabled the resolution of less complex oral health issues and facilitated remote consultations with specialists, reducing the necessity for travel to health centers. This underscores the need for innovative dental public health initiatives to address health disparities and improve the overall well-being of older Indigenous adults.

The value-for money of preventing and managing periodontitis: Opportunities and challenges

This article gives an overview of the societal and economic aspects of periodontitis and periodontal care. Despite its largely preventable nature, periodontitis is highly prevalent worldwide and imposes a substantial health and economic burden on individuals and society as a whole. The worldwide estimated direct treatment costs and productivity losses due to periodontitis (including for periodontitis-related tooth loss) amounted to US$ 186 billion and US$ 142 billion in 2019, respectively. The burden of periodontitis is particularly evident in low and disadvantaged populations. Smoking, dietary habits, and presence of systemic diseases along with social and commercial determinants are considered as risk factors for the periodontal diseases. The cost-effectiveness of preventing and managing periodontitis has been explored in several studies but it has been highlighted that there is scope for improvement in defining the methodology and quality of reporting of such studies. A recent report by The Economist Intelligence Unit examined the cost-effectiveness of interventions to prevent and manage periodontal diseases, suggesting that prevention of periodontitis through prevention of gingivitis by means of individual home care would be more cost-efficient than four other examined approaches. Future research in this field is recommended to further decipher the economic burden of periodontitis to society and to assess the value for money of alternative approaches to address periodontitis with particular emphasis on public health preventive strategies and intersectoral care approaches that address the common risk factors of periodontitis and other non-communicable diseases simultaneously.

The role of differential exposure and susceptibility to heavy drinking linking income inequalities and tooth loss: An investigation of the alcohol harm paradox using a four-way decomposition analysis

OBJECTIVES

To examine the extent to which the effect of income inequalities on tooth loss is attributable to differential exposure and susceptibility to heavy drinking in older Brazilian adults.

METHODS

We conducted a secondary analysis using data from The Brazilian Longitudinal Study of Ageing (ELSI-Brazil 2015-2016), a nationally representative sample of community-dwelling people aged 50 years and over. Causal mediation analysis based on the counterfactual outcome framework decomposed the effect of income on tooth loss mediated by heavy drinking into four components (four-way decomposition): controlled direct effect (neither mediation nor interaction), reference interaction (interaction only), mediated interaction (both mediation and interaction) and pure indirect effect (mediation only). Proportions of effect attributable to each component were calculated to estimate the differential exposure (the sum of the third and fourth components) and differential susceptibility (the sum of the second and third components) to heavy drinking.

RESULTS

The analytical sample comprised 8114 participants. After adjusting for covariates, 7.3% (95% CI: 3.8%; 10.9%) and -39.5% (95% CI: -75.8%; -3.3%) of the effects of income on tooth loss were attributable to differential exposure and susceptibility to heavy drinking, respectively, consistent with the alcohol harm paradox. When setting non-functional dentition as outcome, only the effect of differential susceptibility remained (-81.7% [95% CI: -128.2%; -35.2%]).

CONCLUSION

Our findings suggest that individuals of low-income groups appear to be more susceptible to the effects of heavy drinking on tooth loss.

Using machine learning algorithms to investigate factors associated with complete edentulism among older adults in the United States

AIMS

Edentulism is an incapacitating condition, and its prevalence is unequal among different population groups in the United States (US) despite its declining prevalence. This study aimed to investigate the current prevalence, apply Machine Learning (ML) Algorithms to investigate factors associated with complete tooth loss among older US adults, and compare the performance of the models.

METHODS

The cross-sectional 2020 Behavioral Risk Factor Surveillance System (BRFSS) data was used to evaluate the prevalence and factors associated with edentulism. ML models were developed to identify factors associated with edentulism utilizing seven ML algorithms. The performance of these models was compared using the area under the receiver operating characteristic curve (AUC).

RESULTS

An overall prevalence of 11.9% was reported. The AdaBoost algorithm (AUC = 84.9%) showed the best performance. Analysis showed that the last dental visit, educational attainment, smoking, difficulty walking, and general health status were among the top factors associated with complete edentulism.

CONCLUSION

Findings from our study support the declining prevalence of complete edentulism in older adults in the US and show that it is possible to develop a high-performing ML model to investigate the most important factors associated with edentulism using nationally representative data.

Diabetes, periodontitis, and cardiovascular disease: towards equity in diabetes care

Type 2 diabetes and its associated cardiovascular risk is an escalating epidemic that represents a significant public health burden due to increased morbidity and mortality, disproportionately affecting disadvantaged communities. Poor glycaemic control exacerbates this burden by increasing retinal, renal, and cardiac damage and raising healthcare costs. This predicament underscores the urgent need for research into cost-effective approaches to preventing diabetes complications. An important but often overlooked strategy to improve metabolic control in diabetic patients is the treatment of periodontitis. Our aim is to assess whether the inclusion of periodontitis treatment in diabetes management strategies can effectively improve metabolic control, and to advocate for its inclusion from an equity perspective. We conducted a comprehensive review of the literature from 2000 to 2023. We analyzed the pathophysiological links between periodontitis, diabetes, and atherosclerotic cardiovascular disease, all of which have inflammation as a central component. We also examined the inequalities in health care spending in this context. Our findings suggest that incorporating routine screening and treatment of periodontitis into national health programs, with coordinated efforts between physicians and dentists, is a cost-effective measure to improve metabolic control, reduce complications and improve the overall quality of life of people with diabetes.

Dental Utilization Stratified by the Purpose of Visit: A Population-Based Study in Japan

BACKGROUND

This study aimed to provide a stratified description of dental visit utilisation by Japanese residents based on patient age, sex, prefecture, and the purpose of the visits.

METHODS

This cross-sectional study used the National Database of Health Insurance Claims of Japan to identify participants visiting dental clinics in Japan (April 2018-March 2019). Dental care utilisation by populations stratified by age, sex, and prefecture was assessed. We estimated the slope index of inequality (SII) and relative index of inequality (RII) to evaluate regional differences based on regional income and education.

RESULTS

Amongst the Japanese population, 18.6% utilised preventive dental care visits; 59,709,084 participants visited dental clinics, with children aged 5 to 9 years having the highest proportion. SII and RII were higher for preventive dental visits than those for treatments in all settings. The largest regional differences for preventive care were observed in SII of children aged 5 to 9 years and in RII of men in their 30s and women aged 80 years and older.

CONCLUSIONS

This nationwide population-based study revealed that the proportion of people utilising preventive dental care in Japan was low, with regional differences. Preventive care needs to be more easily accessible and available to improve the oral health of residents. The above findings may provide an important basis for improving policies related to dental care for residents.

Lower socio-economic status in adolescence is associated with poor oral health at an older age: Mediation by social and behavioural factors

AIM

To examine the mediators between lower socio-economic status (SES) in adolescence and oral health at an older age to uncover the underlying mechanisms of the association.

METHODS

Participants (n = 21 536) aged ≥65 years from the Japan Gerontological Evaluation Study were evaluated. The dependent variables were self-rated chewing difficulty and having ≤19 remaining teeth. The main independent variable was self-perceived SES in adolescence. The Karlson-Holm-Breen method was used for mediation analysis.

RESULTS

Mean age of the participants was 74.8 years (standard deviation = 6.4), and 51.5% were female. Overall, 5598 (26.0%) participants reported chewing difficulty and 9404 (43.7%) had ≤19 remaining teeth. Lower SES in adolescence was associated with a higher prevalence of chewing difficulty (odds ratio [OR] = 1.38, 95%confidence interval [CI] = 1.29-1.48; total effect). After controlling for mediators, OR for lower SES in adolescence was 1.22 (95%CI = 1.13-1.30; direct effect) and 1.13 (95%CI = 1.11-1.16; indirect effect). Mediators, prominently the number of teeth and income, explained 39.3% of the associations. Lower SES in adolescence increased the odds of ≤19 remaining teeth by OR = 1.23 (95% CI = 1.16-1.31; total effect). After controlling for mediators, the OR for lower SES in adolescence was 1.03 (95%CI = 0.97-1.10; direct effect) and 1.19 (95%CI = 1.16-1.23; indirect effect). Mediators, prominently educational attainment, explained 85.0% of the associations.

CONCLUSIONS

Lower SES in adolescence was associated with poor oral health at an older age through mediators. Approaches that consider social determinants from the beginning of the life course are required.

The alcohol harm paradox and tooth loss among Brazilian older adults

OBJECTIVE

To investigate whether the association between alcohol consumption and tooth loss is modified across socioeconomic positions (SEPs) in Brazilian older adults.

METHODS

We conducted a secondary analysis using data of The Brazilian Longitudinal Study of Ageing (ELSI-Brazil 2015-2016). Effect Measure Modification (EMM) analyses using multivariable Poisson regression models tested whether the association between heavy drinking and lack of functional dentition (FD) varies in magnitude and direction according to levels of Household Wealth index (HWI) and educational attainment, assessed by the Relative Excess Risk due to Interaction (RERI). Sensitivity analyses using lifetime exposure to alcohol were performed.

RESULTS

The analytical sample comprised 8078 participants. Heavy drinkers living in low-wealth households and with lower education presented 7% (95% CI: 1.01-1.14) and 36% (95% CI: 1.28-1.44) higher prevalence of lack of FD, respectively, than their counterparts, and super-additive associations were detected [RERI for HWI: 0.12 (95% CI: 0.02-0.21); RERI for educational attainment: 0.20 (95% CI: 0.09-0.30)]. The associations were also super-additive in the sensitivity analyses when controlling for abstainer reference group bias.

CONCLUSION

We suggest that alcohol consumption disproportionately impacts the prevalence of tooth loss in Brazilian older adults from lower SEP groups.

Socioeconomic inequalities in the use of dental health care among the adult population in Serbia

Objectives

The aim of this paper is to assess the association of demografic and socioeconomic determinants with utilization of dental services among Serbian adults.

Materials and methods

The study is a part of the population health research of Serbia, conducted in the period from October to December 2019 by the Institute of Statistics of the Republic of Serbia in cooperation with the Institute of Public Health of Serbia "Dr. Milan JovanovićBatut" and the Ministry of Health of the Republic of Serbia. The research was conducted as a descriptive, cross-sectional analytical study on a representative sample of the population of Serbia. For the purposes of this study, data on the adult population aged 20 years and older were used.

Results

Men were approximately 1.8 times more likely than women to not utilize dental healthcare services (OR = 1.81). The likelihood of not utilizing dental healthcare protection rises with increasing age, reaching its peak within the 65-74 age range (OR = 0.441), after which it declines. Individuals who have experienced marital dissolution due to divorce or the death of a spouse exhibit a higher probability of not utilizing health protection (OR = 1.868). As the level of education and wealth diminishes, the probability of abstaining from health protection increases by 5.8 times among respondents with an elementary school education (OR = 5.852) and 1.7 times among the most economically disadvantaged respondents (OR = 1.745). Regarding inactivity, respondents who are not employed have a 2.6-fold higher likelihood of not utilizing oral health care compared to employed respondents (OR = 2.610).

Conclusion

The results suggest that individual sociodemographic factors influence utilization of dental services by Serbian adults and confirmed the existence of socioeconomic disparities.

Association between number of remaining teeth and incident depression in a rural Chilean cohort

OBJECTIVES

Previous studies have established an association between tooth loss and depression. However, longitudinal evidence is scarce and needs to be verified in other populations. The aim of this study was to examine the longitudinal association between the number of remaining teeth and incident depression at 2- and 4-years follow-up in individuals enrolled in the Maule cohort (MAUCO) in Chile.

METHODS

This prospective study used the information of individuals, aged 38 to 74 years, excluding those with depression at baseline. The number of remaining teeth at baseline was determined in four groups: "20 or more teeth", "10 to 19 teeth", "1 to 9 teeth" and "no natural teeth". Depression was measured through the PHQ-9. Logistic regression was performed to calculate the odds ratios (OR) for incidence depression at both periods of follow-ups, adjusting for age, sex, educational attainment, diabetes mellitus II, and stressful events at follow-up. Also, we performed adjusted multinomial logistic models to analysis the association between the number of remaining teeth and depression severity.

RESULTS

In total individuals (n = 3335 at follow 1, n = 2461 at follow 2), all groups have ORs for incident depression above 1 considering 20 or more teeth as reference. In men, those with 10-19 teeth have 2.44 times higher odds of incident depression than those with 20 or more teeth (OR 2.44, CI 95% 1.33-4.50). Edentulous subjects at 4 years follow-up had 2.24 times higher odds of depression than those with more than 20 teeth (OR 2.24 CI 95%1.35-3.72). In women, the ORs (CI 95%) of incident depression were 2.56 (1.50-4.39), 1.56 (1.02-2.40) and 1.27 (0.90-1.81) for "none", "1-9", "10-19" respectively in comparison to the reference group. In edentulous individuals at baseline, the odds for each of the comparisons "mild vs no", "moderate vs no", "moderately severe vs no" and "severe vs no" were above 1, at both follow-ups.

CONCLUSION

Individuals with less than 20 teeth in the mouth could had higher odds of incident depression at 2- and 4-years follow-up, with differences between men and women. Also, in our study, edentulism was associated with increased odds of incident depression at 4-years follow-up in women, and with higher levels of severity of depressive symptoms.

Is value-based healthcare a strategy to achieve universal health coverage that includes oral health? An Australian case study

The 2021 Resolution on Oral Health by the 74th World Health Assembly supports an important health policy direction: inclusion of oral health in universal health coverage. Many healthcare systems worldwide have not yet addressed oral diseases effectively. The adoption of value-based healthcare (VBHC) reorients health services towards outcomes. Evidence indicates that VBHC initiatives are improving health outcomes, client experiences of healthcare, and reducing costs to healthcare systems. No comprehensive VBHC approach has been applied to the oral health context. Dental Health Services Victoria (DHSV), an Australian state government entity, commenced a VBHC agenda in 2016 and is continuing its efforts in oral healthcare reform. This paper explores a VBHC case study showing promise for achieving universal health coverage that includes oral health. DHSV applied the VBHC due to its flexibility in scope, consideration of a health workforce with a mix of skills, and alternative funding models other than fee-for-service.

Measuring oral health-How can the International Classification of Functioning help?

There is a need for a theoretically informed, contextualized approach to measuring oral health from a multidisciplinary perspective that goes beyond the commonly used clinical indices and sociodental measures. This commentary aims to discuss the potential for the WHO's International Classification of Functioning, Disability and Health (ICF) to provide a model for the development of indicators for oral health. It is suggested that the ICF might provide both a theoretical model and an operational classification for indicators of oral health. The ICF model states that human experience of physical, cognitive and social functioning is universal and, thus, can be described and qualified. Human function is given social and environmental context within the model at both an individual and population level. The ICF can not only capture data regarding oral health and function at the physiological level (e.g. chewing) but also at the social level (e.g. sharing meals). It is able not only to capture aspects of preventive behaviour (e.g. caring for teeth) but also aspects of social facilitation (e.g. economic self-sufficiency) or ability to fulfil a social role (e.g. remunerative employment). It also includes aspects of social environment, such as healthcare services or political, economic and legal systems. Case studies are given as examples of the potential use of the ICF in the oral health domain. Examples are also given of the first steps that have been made towards operationalization of the ICF in data collection and oral health research. The challenges of encompassing such a comprehensive model into a practical oral health measure are discussed.

Education-related inequalities in oral health among older adults: Comparing Singapore and Japan

OBJECTIVES

Oral health inequalities exist worldwide, and cross-country comparisons can provide valuable insights into country-level characteristics contributing to such inequalities. However, comparative studies in Asian countries are limited. This study examined the magnitude of education-related oral health inequalities in older adults in Singapore and Japan.

METHODS

Longitudinal data for older adults, aged ≥65 years, from the Panel on Health and Ageing of Singaporean Elderly (PHASE; 2009, 2011-2012, and 2015) and Japan Gerontological Evaluation Study (JAGES; 2010, 2013, and 2016) were used. Dependent variables were being edentate and having a minimal functional dentition (MFD; i.e. ≥20 teeth). The absolute and relative inequalities were calculated using the slope index of inequality (SII) and relative index of inequality (RII) for educational level [low (<6 years); middle (6-12 years); high (>12 years)] in each country.

RESULTS

A total of 1032 PHASE participants and 35 717 JAGES participants were included. At baseline among PHASE participants, 35.9% were edentate and 24.4% had MFD, while among JAGES participants, 8.5% were edentate and 42.4% had MFD. The prevalence of low, middle and high educational levels for PHASE was 76.5%, 18.0% and 5.5%, and for JAGES were 0.9%, 78.1% and 19.7%, respectively. Older adults in Japan had lower education-related inequalities for being edentate [for both SII (-0.53, 95% CI = -0.55 to -0.50) and RII (0.40, 95% CI = 0.33-0.48)] and for not having MFD for both SII (-0.24, 95% CI = -0.27 to -0.20) and RII (0.83, 95% CI = 0.79-0.87) compared to Singapore.

CONCLUSIONS

Education-related inequalities for being edentate and not having MFD were higher among older adults in Singapore compared to Japan.

Tooth Loss and Caries Experience of Elderly Chileans in the Context of the COVID-19 Pandemic in Five Regions of Chile

Risk factors associated with tooth loss have been studied; however, the current status of the epidemiological profiles and the impact of the pandemic on the oral health of the elderly is still unknown. This study aims to determine the experience of caries and tooth loss among elderly Chilean citizens in five regions and to identify the risk factors associated with tooth loss. The sample includes 135 participants over 60 years old assessed during COVID-19 lockdown. Sociodemographic variables such as education and RSH (Social Registry of Households) were obtained through a teledentistry platform called TEGO. The history of chronic diseases such as diabetes, obesity, depression and dental caries reported by DMFT index scores were incorporated. The statistical analysis included Adjusted Odds Ratios (ORs) to assess risk factors associated with the lack of functional dentition. Multivariate hypothesis testing was used to compare the mean equality of DMFT and its components between regions (p-value < 0.05). Individuals with RSH ≤ 40% were at higher risk of having no functional dentition with OR 4.56 (95% CI: 1.71, 12.17). The only mean difference between regions was the filled tooth component. Tooth loss was associated with multidimensional lower income, where the elderly belonging to the 40% most vulnerable population had a higher prevalence of non-functional dentition. This study highlights the importance of implementing a National Oral Health Policy that focuses on oral health promotion and minimally invasive dentistry for the most vulnerable population.

Did Dental Insurance Expansion Improve Dental Care Needs Among Korean Adults? Difference in Difference Analysis

BACKGROUND

In 2012, the Korean government expanded dental insurance for the elderly to promote improved access to dental care. We examined the causal effect of this policy on dental care needs, focusing on low-income older adults.

METHODS

We compared data before and after policy implementation using double difference (DD) and triple difference (DDD) analyses. We used the nationally representative data from the Korea National Health and Nutrition Examination Survey from 2010 and 2016-2018. Individuals aged ≥65 years were included in the treatment group, and individuals aged <65 years were included in the control group.

RESULTS

Dental insurance expansion was associated with a paradoxical increase in perceived unmet dental needs among elderly individuals (8.8 percentage points increase, 95% CI: 4.7 to 13.0). However, there were improvements in dental prosthetics outcomes (denture wearing [4.0 percentage points, 95% CI: 0.2 to 7.9] and dental implants [5.0 percentage points, 95% CI: 2.1 to 7.9]; P < 0.01). Upon analyzing low-income elderly individuals using DDD analysis, we found that the insurance expansion led to a 21.6% smaller increase in unmet dental needs among low-income adults, compared to high-income adults (95% CI, -35.0 to -8.5; P < 0.01).

CONCLUSION

Dental insurance expansion in South Korea resulted in improvements in access to dental prosthetic services overall. It also led to a smaller increase in unmet dental needs among low-income older adults, compared to high-income adults.

Analysis of epidemiological trends of and associated factors for tooth loss among 35- to 44-year-old adults in Guangdong, Southern China, 1995-2015: a population-based cross-sectional survey

BACKGROUND

Tooth loss is a known marker of oral and systemic health, but large-scale population-based and cross-sectional multi-year comparative studies on tooth loss have yet to be much studied in China. This study explores the changing trends in tooth loss status and the associated factors influencing the prevalence of tooth loss over the past two decades in Guangdong, Southern China.

METHODS

Data from three cross-sectional, representative oral epidemiological surveys in Guangdong Province were analyzed, including 400 in 1995, 720 in 2005, and 288 in 2015, for a total of 1408 participants. Sample selection is based on the National Census of China published by the National Bureau of Statistics. In this study, each year, the number of missing teeth (MT) and the prevalence of tooth loss (MT > 0) were calculated. Basic demographic information, socioeconomic status, caries and periodontal status, personal lifestyle factors, and dental health care behaviors were analyzed by multivariate logistic regression to estimate their associations with tooth loss. Statistical significance was evaluated with 2-sided tests with a significance level of P < 0.05.

RESULTS

This study found that the mean number of missing teeth and the prevalence of tooth loss among adults aged 35-44 years in Guangdong Province did not change significantly in the first decade (1995-2005) but decreased significantly in the second decade (2005-2015) (0.94 and 40.8% in 1995, 0.99 and 42.9% in 2005, and 0.63 and 33.3% in 2015, respectively). The mean number of MT by tooth position was highest for the first and second molars, and both were larger in the mandible than in the maxilla. In 1995, populations with low educational attainment and the presence of caries or periodontal pocket (periodontal probing depth ≥ 4 mm) were associated with a higher chance of MT > 0. In 2005, those with low educational attainment, the presence of caries, and 40-44 years old were associated with a higher chance of MT > 0. Moreover, in 2015, females, rural residents, and those with caries or periodontal pocket were associated with a higher chance of MT > 0.

CONCLUSIONS

Although tooth retention has improved recently (2005-2015) and the preventive effect of education level on tooth loss has increased over time, efforts to prevent tooth loss in adults need to be strengthened. Particular attention should be given to preventive interventions for women, rural residents, and those suffering from caries or periodontal pocket.

Changes in oral health inequalities in adults in Chile

The adult population in Chile has a high prevalence of dental caries and non-functional dentition. Fifteen years after the Health Reform, aimed to reduce health inequalities, it is necessary to analyse changes in social inequalities in oral health in Chilean adults.

METHODS

A secondary analysis of data from 2003 and 2016-2017 National Health Surveys (NHS) in Chile was performed on seven oral health outcomes in adults: prevalence of untreated caries, prevalence of severe untreated caries, number of teeth with untreated caries, prevalence of functional dentition, prevalence of edentulism, number of remaining natural teeth and utilization of dental services. Inequalities were measured with the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) by education level.

RESULTS

A decrease of caries inequalities measured with SII was observed from 2003 to 2016-17 NHS but an increase of remaining teeth inequalities was measured. The SII of the remaining teeth increased from 6.6 [95% CI = 5.0, 8.2] in 2003 to 8.8 [95% CI = 7.3, 10.3] in 2016-17. The SII of functional dentition by education increased from 29.0 [95% CI = 22.0, 36.0] in 2003 to 38.8 [95% CI = 32.6, 45.0]) in 2016-17. The utilization of dental services ≤1 year was the only outcome that showed a decrease in absolute and relative inequality, the SII was 33.9 [95% CI = 23.3, 45.6] in 2003 and 26.2 [95% CI = 16.6, 35.8] in 2016-17 and the RII decreased from 2.5 [95% CI = 1.7, 3.3] in 2003 to RII = 1.8 [95% CI = 1.4, 2.3] in 2016-17.

CONCLUSION

The increase of tooth loss inequalities in contrast to the decrease of inequalities in dental services utilization show the need to re-evaluate the current dental programmes for adults in Chile. This may include establishing a stronger oral health promotion strategy and greater dental treatment coverage focusing on avoiding tooth extractions in vulnerable social groups.

Early-life adversity and edentulism among Chinese older adults

BACKGROUND

Emerging evidence indicate the relationship between ELA with oral health problems. However, most focus on single types of adversity. The association of cumulative ELA with edentulism, the final marker of disease burden for oral health, remains unclear.

METHODS

Data came from 17,610 elderly participants in the China Health and Retirement Longitudinal Study (CHARLS). In 2014, the Life History Survey Questionnaire was utilized to evaluate the experience of threat and deprivation. Information on edentulism was evaluated through self-report from the follow-up in 2013, 2015, and 2018. By controlling for age, education, hukou residence, marital status, and disease history, logistic regression analyses were used to evaluate the relationships between distinct dimensions of ELA and risk of edentulism.

RESULTS

Nearly half (49.8%) of the 17,610 older persons (mean [SD] age at baseline: 63.6 [9.4] years) reported experiencing early adversity due to threat-related ELA, and 77.9% reported having deprivation-related ELA. ELA characterised by threat was associated with edentulism in both male and female participants. Two forms of threat-related ELA exposure were linked to a 1.65-fold and 1.73-fold higher risk for edentulism in both male (95% CI 1.23, 2.21) and female participants (95% CI 1.31, 2.29), compared to no threat-related ELA exposure. Both male (95% CI 2.34, 4.24) and female participants (95% CI 2.49, 4.56) had a 3.15-fold and 3.37-fold higher risk for edentulism when exposed to three or more threat-related ELAs.

CONCLUSION

Our findings suggest that ELA marked by threat is linked to an increased risk of edentulism. The biological pathways between different dimensions of ELA and teeth loss should be clarified by future research.

Aspirations and Worries: The Role of Parental Intrinsic Motivation in Establishing Oral Health Practices for Indigenous Children

Aboriginal and Torres Strait Islander (respectfully, subsequently referred to as Indigenous) children in Australia experience oral disease at a higher rate than non-Indigenous children. A history of colonisation, government-enforced assimilation, racism, and cultural annihilation has had profound impacts on Indigenous health, reflected in oral health inequities sustained by Indigenous communities. Motivational interviewing was one of four components utilised in this project, which aimed to identify factors related to the increased occurrence of early childhood caries in Indigenous children. This qualitative analysis represents motivational interviews with 226 participants and explores parents’ motivations for establishing oral health and nutrition practices for their children. Findings suggest that parental aspirations and worries underscored motivations to establish oral health and nutrition behaviours for children in this project. Within aspirations, parents desired for children to ‘keep their teeth’ and avoid false teeth, have a positive appearance, and preserve self-esteem. Parental worries related to child pain, negative appearance, sugar consumption, poor community oral health and rotten teeth. A discussion of findings results in the following recommendations: (1) consideration of the whole self, including mental health, in future oral health programming and research; (2) implementation of community-wide oral health programming, beyond parent-child dyads; and (3) prioritisation of community knowledge and traditions in oral health programming.

Performance of the 2017 AAP/EFP case definition compared to the CDC/AAP definition in population-based studies

BACKGROUND

Classification of the periodontal conditions is indispensable for epidemiological data in order to guide situational awareness and therapeutic strategies. The new classification of periodontal diseases and conditions introduced by the American Academy of Periodontology and the European Federation of Periodontology (AAP/EFP), however, has not yet been applied to population-based studies. The aim of the present study was to compare the prevalence of periodontitis between the AAP/EFP and the CDC/AAP classification system and to evaluate the accuracy of the new AAP/EFP classification system against the CDC/AAP case definition for population-based studies.

METHODS

Epidemiological data from two cross-sectional studies were obtained. One of them was a population-based study on Chilean adults (1.456 individuals; 35-44 years; 65-74 years) and the other one a sample of adolescents (1.070 individuals; 15-19 years) from 5 countries; Argentina, Chile, Colombia, Ecuador and Uruguay. All participants had undergone full-mouth periodontal examination by calibrated examiners. Epidemiological datasets were analyzed according to the AAP/EFP and the CDC/AAP case definitions. The accuracy of the AAP/EFP definition was examined by assessing the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating curve (ROC) using the CDC/AAP case definition as the reference standard.

RESULTS

According to the AAP/EFP, the prevalence of periodontitis in adolescents was 75.6%. The majority of the adolescents were classified either as stage I (39.2%) or stage II (28.2%). By using the CDC/AAP classification the prevalence of periodontitis in adolescents was 27.2%. The most common form of periodontitis with the CDC/AAP classification was moderate periodontitis (15.3%) followed by mild periodontitis (11.4%). The AAP/EFP revealed high sensitivity in moderate (95.7%) and severe periodontitis (100%) as well as a moderate (75%) to high specificity (92%) in moderate and severe periodontitis, respectively. The PPV was 41.6% in moderate and 5.7% in severe periodontitis while the NPV was high in both categories (moderate = 99%; severe = 100%). The AUC was 0.912 (95% CI = 0.89 - 0.93). In adults, the prevalence of periodontitis was 99% according to the AAP/EFP. The majority of adults were classified as stage IV (81.3%) whereas stage III amounted to 12.8%. By using the CDC/AAP classification, the prevalence of periodontitis in adults was 88.3% and the most common form of periodontitis was moderate periodontitis (57.2%) followed by severe periodontitis (29.7%). In adults, the AAP/EFP revealed high sensitivity in moderate (99.7%) and severe periodontitis (100%) but low specificity in both categories (moderate = 6.8%; severe = 8.3%). The PPV was 88.7% in moderate and 31.7% in severe periodontitis. The NPV was high in both categories (moderate = 76.5%; severe = 100%). The AUC was 0.573 (95% CI = 0.53 - 0.62).

CONCLUSIONS

This study revealed a clear discrepancy in the prevalence of periodontitis between the AAP/EFP and the CDC/AAP classification when using epidemiological data. The 2017 AAP/EFP classification system performs well compared to the CDC/AAP case definition in identifying adolescents with periodontitis. The AAP/EFP system seems less accurate in adults with high prevalence of periodontitis. This article is protected by copyright. All rights reserved.

Inequality and Inequity in the Use of Oral Health Services in Australian Adults

OBJECTIVE

Social determinants drive disparities in dental visiting. This study aimed to measure inequality and inequity in dental visiting among Australian adults.

METHODS

Data were obtained from the National Study of Adult Oral Health (2017 to 2018). Participants were Australian adults aged ≥30 y. The outcome of interest was dental visiting in the last 12 mo. Disparity indicators included education and income. Other sociodemographic characteristics included age, gender, Indigenous status, main language, place of birth, residential location, health card and dental insurance status, and individual's self-rated and impaired oral health. To characterize inequality in dental service use, we examined bivariate relationships using indices of inequality: the absolute and relative concentration indexes and the slope and relative indexes of inequality. Inequalities were depicted through concentration curves. Indirect standardization with a nonlinear model was used to measure inequity.

RESULTS

A total of 9,919 Australian adults were included. Bivariate analysis showed a gradient by education and income on dental visiting, with 48% of those with lowest educational attainment/income having not visited a dentist in the last 12 mo. The concentration curves showed pro-low education and pro-poor income inequalities. All measures of absolute and relative indices were negative, indicating that from the bottom to the top of the socioeconomic ladder (education and income), the prevalence of no dental visiting decreased: absolute and relative concentration index estimates were approximately 2.5% and 5.0%, while the slope and relative indexes of inequality estimates were 14% to 18% and 0.4%, respectively. After need standardization, the group with the highest education or income had almost 1.5-times less probability of not having a dental visit in the previous year than those with the lowest education or income.

CONCLUSION

The use of oral health services exhibited socioeconomic inequalities and inequities, disproportionately burdening disadvantaged Australian adults.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policy makers when planning a dental labor force in relation to the capacity of supply dental services to 1) reduce the inequality and inequity in the use of oral health services and 2) meet identified oral health needs across the Australian population, which is important for preventive dental care.

Estimation and change of edentulism among the Korean population: Korea National Health and Nutrition Examination Survey 2007-2018

OBJECTIVES

To estimate the prevalence of edentulism according to the socio-demographic variables of Korean adults between 2007 and 2018 and to analyze the trends.

METHODS

This study was conducted using raw data from the Korea National Health and Nutrition Examination Survey (KNHANES) from 2007 to 2018. Edentulism was defined as the absence of upper and lower teeth or the retained root of the missing teeth. To obtain the prevalence of edentulism, complex sample frequency analysis and regression analysis were performed according to the socio-demographic variables to represent the national population. The Korean population structure in 2005 was exploited as a standard population to calculate age-standardized edentulism.

RESULTS

The prevalence of edentulism in 2016-2018 was 9.7% in the Korean elderly, and the change of age-standardized edentulism steadily declined over time from 2007, 12.8%. In particular, it decreased by approximately 20% in the period between 2016 and 2018 compared to that in 2007 for those in their 80s. The trend of the prevalence according to gender decreased significantly in women. According to the level of education, the greatest decrease was seen in the group with the lowest education, although the prevalence itself was higher than that seen in those who were more educated.

CONCLUSIONS

The prevalence of edentulism among the older Korean population has decreased over time. However, the concern is on those with lower education and men as these groups are still at higher risk for edentulism.

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.

Insurance coverage expansion and inequalities in unmet oral healthcare needs in Korea: Repeated cross-sectional analysis, 2007-2015

OBJECTIVES

This study aimed to evaluate whether Korea's 2012 health insurance expansion of adult dental care coverage reduced income-based oral health inequalities.

METHODS

This study analysed nationally representative repeated cross-sectional data from waves IV to VI (2007-2015) of the Korean National Health and Nutrition Examination Survey. The main outcome variable is unmet dental needs due to cost, and the independent variable is household income. Further, the slope index of inequality (SII) and the relative index of inequality (RII) were calculated. Calculations were adjusted for income and stratified by age group, gender and survey period. Data from the three waves were pooled to estimate the SII and RII trend coefficients between survey years. These were tested using two-way interaction terms for each age group and gender.

RESULTS

Some changes in income-based inequality trends were identified. Relative and absolute inequalities in unmet needs (indicated by the RII and SII) decreased over time for most age groups. However, this trend was not observed for older women.

CONCLUSIONS

Income-based inequalities in unmet dental needs persisted among older women in Korea despite the insurance expansion. By contrast, after the 2012 insurance expansion, the absolute and relative inequality in unmet dental needs decreased for young and middle-aged as well as older adults.

Number of Remaining Teeth and Its Association with Educational Level in Chilean Adults: Data from the National Health Survey 2016-2017

Introduction

Several population studies have addressed oral health inequalities. Edentulism, functional dentition, and number of remaining teeth have been associated with different socioeconomic level measurements. The aim of this study was to evaluate the association between educational level and tooth loss in the Chilean population aged 15 years and above, based on the 2016-2017 National Health Survey (ENS 2016-2017). Material and Methods. The sample for this cross-sectional study comprised 5473 subjects. The main independent variable was educational level (LEL: low, MEL: medium, and HEL: high). To measure tooth loss, we considered the variables number of remaining teeth, edentulism, and functional dentition. We used logistic regressions to assess the condition of dentition according to the subject's EL. As to the number of teeth variable, linear regressions were conducted. The analyses were carried out considering the complex sampling design in SPSS 24.0.

Results

When comparing LEL subjects with HEL subjects, the adjusted difference in number of remaining teeth was 3.11 for the maxilla and 1.72 for the mandible. An individual with LEL had a 7.51 [3.50-16.10] and 6.06 [2.68-13.68] times higher risk of upper edentulism and lower edentulism than a HEL individual, respectively. Regarding functional dentition, the adjusted OR in HEL subjects was 13.33 [8.02-22.15] and in MEL subjects was 2.81 [2.03-3.87], compared to LEL results.

Conclusions

LEL was associated with a significant tooth loss in the Chilean population. Subjects with LEL obtained a lower mean of number of remaining teeth and higher prevalence of edentulism and nonfunctional dentition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Concern with dental appearance and associated factors among the elderly of two southern Brazilian cities

Aim: This study aimed to evaluate the prevalence of concern with dental appearance (DA) and associated factors among the elderly of two southern Brazilian cities. Methods: A cross-sectional study was conducted in the cities of Cruz Alta and Veranópolis, Brazil. Oral health examination and a structured questionnaire were applied. Questions from the PCATool-SB Brasil tool and the Questionnaire about Teeth Appearance, both validated to Brazilian samples, were used. The collected independent variables were: sex, age, ethnicity, education level, marital status, retirement, health problem, use of medication, smoking exposure, alcohol exposure, access to the dentist, toothbrushing frequency, use of dental floss, edentulism, use of and need for dental prosthesis. Concern with DA was dichotomized into yes/no. Associations between dependent and independent variables were assessed by Chi-square or Mann-Whitney tests. Moreover, uni- and multivariate analyses were conducted by Poisson regression with robust variance. Level of significance was established as p<0.05. Results: The prevalence of concern with DA was 18.8% (n=107). The prevalence ratio (PR) of concern with DA decreased 5.8% for each year increase (PR:0.942; 95% confidence interval [95%CI]:0.911–0.973). Elderly without access to the dentist in the last 12 months presented 62.5% (p=0.006) higher PR of concern with DA when compared to those with access to dental care. Dentate elderly showed 219% higher PR for concern with DA (PR:2.197; 95%CI:1.364–3.539) in comparison to edentulous individuals. Conclusion: Prevalence of concern with DA was low and associated with demographics, access to dental care and edentulism.

Demonstration of high value care to improve oral health of a remote Indigenous community in Australia

Background

The oral health of Indigenous children in remote communities is much worse than other population groups in Australia. Providing and maintaining an oral health service is challenging due to the remoteness of communities, the associated high cost, and the low retention of clinical staff. An annual preventive intervention delivered by fly-in clinicians may be a more cost-effective way to manage this problem. In this analysis we estimate the cost-effectiveness of an annual professional intervention for the prevention of dental caries in children of a remote Indigenous community in Far North Queensland.

Methods

A cost-effectiveness analysis was conducted based on an annual preventive intervention protocol. This included treating all dental decay in those with disease, applying fissure sealants, a disinfectant swab, fluoride varnish and providing oral hygiene instructions and dietary advice to all participating school children. This study included an intervention group and a natural comparison group and both groups were followed-up for 2 years after the initial preventive intervention. A Markov model was built to assess the cost-effectiveness of the intervention compared with the usual care. Costs of treatment from the Queensland Department of Health were used and effectiveness was measured as quality-adjusted life years (QALYs) with the CHU-9D. One-way and probabilistic sensitivity analyses were conducted to identify key drivers and quantify uncertainty.

Results

The preventive intervention was found to be highly cost-effective. The incremental cost per QALY gained was AU$3747. Probability of new caries and seeking treatment were identified as the main drivers of the model. In probabilistic sensitivity analysis intervention was cost effective in 100% of simulations.

Conclusion

An annual preventive intervention for remote Indigenous communities in Australia is a highly cost-effective strategy to prevent dental caries and improve the quality of life of children.

Dental caries is associated with severe periodontitis in Chilean adults: a cross-sectional study

BACKGROUND

The co-occurrence of caries and periodontitis and a possible association is still a matter of debate. Thus, the aim of the study was to determine the co-occurrence of caries and periodontitis in Chilean adults.

METHODS

Evaluation of periodontal and dental status in 994 adults (35-44 years old) based on the First Chilean National Examination Survey 2007-2008. The prevalence of caries was defined as the percentage of participants with one or more teeth with untreated caries by using the D component of the DMFT index (DT ≠ 0). The prevalence of periodontitis was determined using standard case definitions for population-based surveillance of periodontitis described by the CDC-AAP.

RESULTS

Individuals with caries had an approximately 40% higher prevalence of severe (29.3% vs 20.8%, p < 0.05) and a 13% higher prevalence of total periodontitis (89.3% vs 78.4%, p < 0.05) than those without caries. Ordinal logistic regression revealed a positive association between periodontitis and the number of teeth with caries (DT ≠ 0; 3 or 4 teeth with caries: OR 1.74; CI = 1.12-2.29 p < 0.05; 5 or more teeth with caries: OR 2.47; CI = 1.66-3.67 p < 0.01).

CONCLUSION

Dental caries is associated with the severity and prevalence of periodontitis in Chilean adults. Individuals with 3 or more teeth with untreated caries are more likely to suffer from periodontal disease.

Income inequality and social gradients in children's height: a comparison of cohort studies from five high-income countries

BACKGROUND

Health and well-being are better, on average, in countries that are more equal, but less is known about how this benefit is distributed across society. Height is a widely used, objective indicator of child health and predictor of lifelong well-being. We compared the level and slope of social gradients in children's height in high-income countries with different levels of income inequality, in order to investigate whether children growing up in all socioeconomic circumstances are healthier in more equal countries.

METHODS

We conducted a coordinated analysis of data from five cohort studies from countries selected to represent different levels of income inequality (the USA, UK, Australia, the Netherlands and Sweden). We used standardised methods to compare social gradients in children's height at age 4-6 years, by parent education status and household income. We used linear regression models and predicted height for children with the same age, sex and socioeconomic circumstances in each cohort.

RESULTS

The total analytic sample was 37 063 children aged 4-6 years. Gradients by parent education and household income varied between cohorts and outcomes. After adjusting for differences in age and sex, children in more equal countries (Sweden, the Netherlands) were taller at all levels of parent education and household income than children in less equal countries (USA, UK and Australia), with the greatest between-country differences among children with less educated parents and lowest household incomes.

CONCLUSIONS

The study provides preliminary evidence that children across society do better in more equal countries, with greatest benefit among children from the most disadvantaged socioeconomic groups.

Cost-effectiveness of implant-supported dental prosthesis compared to conventional dental prosthesis

OBJECTIVE

To conduct a cost-effectiveness analysis of alternatives for rehabilitation treatment of mandibular edentulism in the context of the Brazilian Unified Health System (implant-supported total dental prosthesis versus conventional total dental prosthesis).

METHODS

A Markov model was developed to capture long-term clinical and economic outcomes. The model’s population was comprised of a hypothetical cohort of 1,000,000 patients, aged 55 years, with total mandibular edentulism and without medical contraindications for performing surgical procedures. The adopted analysis perspective was that of the Brazilian Unified Health System. Based on the proposed model, we calculated cost – in BRL, and effectiveness – measured by quality-adjusted prosthesis year (QAPY). The time horizon of the analysis was 20 years.

RESULTS

Considering a 5% discount in costs and effects, the incremental cost-effectiveness ratio of implant-supported total dental prostheses compared to conventional total dental prosthesis (BRL 464.22/QAPY) was lower than the willingness to pay threshold adopted in the model (BRL 3,050.00/QAPY).

CONCLUSIONS

The results of this economic analysis showed that the rehabilitation of mandibular edentulous patients by implant-supported total prosthesis is very cost-effective when compared to conventional complete prosthesis, considering the cost-effectiveness limits employed.

Influence of an Alternative Implant Design and Surgical Protocol on Primary Stability

The purpose of thisin vitrostudy was to evaluate the influence of a new proposal of implant design and surgical protocol on primary stability in different bone densities. Four groups were tested (n=9): G1 - tapered, cone morse, Ø 4.3 mm x 10 mm in length (Alvim CM); G2 - experimental tapered; G3 - cylindrical, cone morse, Ø 4.0 mm x 11 mm in length (Titamax CM) and G4 - experimental cylindrical. The experimental implants were obtained from a design change in the respective commercial models. The insertion was performed in polyurethane (PU) blocks 0.24 g/cm3(20 pcf) and 0.64 g/cm3(40 pcf), according to different surgical protocols. The primary stability was measured by means of insertion torque (IT) and pullout test. Data were analyzed by ANOVA, Tukey's test (α=0.05) and Pearson's correlation. For IT and pullout, conventional and experimental implants showed no difference between them when inserted in the 20 pcf PU (p>0.05). In the 40 pcf PU, the modified implants exhibited greater IT (p<0.05) and lower pullout (p<0.05) compared to the respective conventional models. The implant design tested associated with the surgical protocol, positively influenced primary stability in higher density bones.

Validity of the self-reported number of teeth in Chilean adults

Background

Clinical dental evaluations are considered complex and costly measurements that epidemiological surveillance studies of multiple simultaneous chronic diseases currently require, for example National Health Surveys (ENS). Accordingly, simpler and more affordable methods need to be validated. The aim of this study was to assess the validity of the self-report on the total number of teeth in the general Chilean adult population.

Methods

A substudy was conducted on ENS 2016–2017 participants. A stratified random sample of 101 of them was subjected to a telephone questionnaire. This information was then compared with the results obtained from the oral examination performed by a trained nurse during a home visit. Spearman correlations, intraclass correlation coefficients and the Bland-Altman method were used to analyse the data.

Results

In men, the average number of teeth recorded during the oral examination coincided with the number of teeth in the self-report (22 teeth). In women, the total teeth average was 18 and 19 teeth according to the examination and self-report, respectively. For the total number of participants, a strong and significant Spearman correlation was obtained (ρ = 0.93); in men and women, the Spearman correlation observed was also strong and significant (ρ = 0.90 and ρ = 0.96 respectively). The value of the intraclass correlation coefficient indicated a significant concordance (CCI = 0.96) in both men and women (CCI = 0.93 and 0.98 respectively). A tendency to greater correlation was observed as the number of teeth decreased.

Conclusions

The number of teeth self-reported by the subjects in this study correlated with the number of teeth recorded in the clinical examination. Self-report is a valid method to determine the number of teeth in national health surveys.

Impact of oral health on Australian urban Aboriginal and Torres Strait Islander families: a qualitative study

BACKGROUND

The oral health of a child not only impacts the physical well-being of the child, but can have quality of life implications for parents and families as they endeavour to provide care and support their child's oral health needs. Within Australia, Aboriginal and Torres Strait Islander children are thought to experience a disproportionate burden of poor oral heath compared to non-Indigenous children. Despite the prevalence of oral health challenges, there are limited qualitative studies investigating the oral health experiences of families. The objective of the study was to explore 'from the perspective of urban, Aboriginal and Torres Strait Islander parents and carers' the impact child oral health has on families.

METHODS

Yarning circles and face-to-face interviews were used to document the experiences of (N = 20) parents of urban, Aboriginal and Torres Strait Islander children. Participants were recruited from an Aboriginal-owned and operated primary health clinic in northern Brisbane, Australia and through word of mouth. Information collected was transcribed and analysed thematically. Codes and themes were confirmed by the researcher and two participants.

RESULTS

The findings indicate that oral health is an important issue for urban Indigenous families and maintaining oral health to a desired standard is having emotional, physical and financial impacts. Themes identified were financial concerns, worry about the future and juggling multiple priorities, all of which were inter-related and cyclical.

CONCLUSIONS

Families in this study have demonstrated that with the current policy arrangements, oral health is impacting their quality of life, contributing to stress, financial challenges and at times affecting their physical health. To address these challenges, oral health education and promotion needs a multidisciplinary approach that reaches families before children are school-aged.

The Causal Effect of Education on Tooth Loss: Evidence From United Kingdom Schooling Reforms

Associations between education and oral health have frequently been reported, but until now there has been no causal evidence. Exploiting exogenous variation in the duration of schooling due to 1947 and 1972 reforms in mandatory schooling in the United Kingdom, we examined the causal relationship between education and tooth loss in older age. We conducted a cross-sectional study using data from waves 3 (2006-2007), 5 (2010-2011), and 7 (2014-2015) of the English Longitudinal Study of Ageing. We used a 2-stage least squares instrumental variable approach and included 5,667 respondents (average age = 67.8 years; 44.4% were men) in the analyses, of whom 819 (14.5%) had no teeth. The schooling reforms increased the duration of education by an average of 0.624 years (95% confidence interval: 0.412, 0.835). For respondents born within ±6 years of the pivotal cohorts, a 1-year increment of education causally reduced the probability of edentulism by 9.1 (95% confidence interval: 1.5, 16.8) percentage points. The effects were stronger for the 1947 reform than for the 1972 reform. Results were robust to broadening of the cohort bandwidth and functional form of the cohort trend. The findings suggest that investment in education produces improved oral health later in life.

Neo-Marxian social class inequalities in oral health among the South Korean population

AIM

The aims of this study were to examine inequalities in periodontitis and tooth loss among South Korean adults using the Wright's Neo-Marxian social class (NMSC) indicator and to assess the impact of material, psychosocial, health behavioural and workplace environmental factors in the association of social class with oral health.

METHODS

This study used the data from the 4th Korea National Health and Nutrition Examination Survey with 6710 participants aged 19-54 years old. Participants were classified into 12 social class positions based on the Wright's social class map. Healthy gum and absence of tooth loss were the health outcomes. Mediating factors were material (M), psychosocial (PS), health behavioural (HB) and workplace environmental (WPE) factors. A series of logistic regressions were performed to analyse the data. Odds ratio (OR) and 95% confidence interval (CI) were used to report the results.

RESULTS

For the absence of periodontal pockets status, expert supervisors were the healthiest periodontal group among the social classes (OR = 2.15 95% CI 1.59-2.90) in the age and gender adjusted model. For the absence of tooth loss, skilled workers had the highest OR for absence of tooth loss (OR = 1.64 95% CI 1.31-2.05) in the age- and gender-adjusted model. For absence of periodontal pockets, the explanatory power of the M factor was the highest in all social class positions except for nonskilled supervisors followed by the HB factor. Additionally, the absence of tooth loss had a fairly similar pattern. The explanatory power of the M factor was the highest in all social class positions except for the petty bourgeoisie (highest: HB) and nonskilled supervisors (highest: WPE) followed by the HB and WPE factors.

CONCLUSION

There were nongradient oral health inequalities among the South Korean population according to the NMSC. Oral health promotion programmes that focus on changing the socioeconomic environment and health behaviours should be implemented.

Macroeconomic changes and trends in dental care utilization in Estonia and Lithuania in 2004-2012: a repeated cross-sectional study

BACKGROUND

The aim of this study was to assess trends and inequalities in dental care utilization in Estonia and Lithuania in relation to large-scale macroeconomic changes in 2004-2012.

METHODS

Data on 22,784 individuals in the 20-64 age group were retrieved from nationally representative cross-sectional surveys in 2004, 2006, 2008, 2010 and 2012. Age- and sex-standardized prevalence estimates of past 12-month dental visits were calculated for each study year, stratified by gender, age group, ethnicity, educational level and economic activity. Multivariable logistic regression analysis was used to assess the independent effect of study year and socioeconomic status on dental visits.

RESULTS

The age- and sex-standardized prevalence of dental visits in the past 12 months was 46-52% in Estonia and 61-67% in Lithuania. In 2004-2008, the prevalence of dental visits increased by 5.9 percentage points in both countries and fell in 2008-2010 by 3.8 percentage points in Estonia and 4.6 percentage points in Lithuania. In both countries the prevalence of dental care utilization had increased slightly by 2012, although the increase was statistically insignificant. Results from a logistic regression analysis showed that these differences between study years were not explained by differences in socioeconomic status or oral health conditions. Women, the main ethnic group (only in Estonia), and higher educated and employed persons had significantly higher odds of dental visits in both countries, but the odds were lower for 50-64 year olds in Lithuania.

CONCLUSIONS

In European Union countries with lower national wealth, the use of dental services is sensitive to macroeconomic changes regardless of the extent of public coverage, at the same time, higher public coverage may not relate to lower inequalities in dental care use.

Tooth loss is a complex measure of oral disease: Determinants and methodological considerations

OBJECTIVES

Counts of missing teeth or measures of incident tooth loss are gaining attention as a simple way to measure dental status in large population studies. We explore the meaning of these metrics and how missing teeth might influence other measures of dental status.

METHODS

An observational study was performed in 2 contrasting adult populations. In total, 62 522 adult participants were available with clinically assessed caries and periodontal indices from the Swedish arm of the Gene-Lifestyle Interactions and Dental Endpoints Study (GLIDE) and the Korea National Health and Nutrition Examination Survey (KNHANES) in the Republic of Korea. Longitudinal measures of tooth loss were available for 28 244 participants in GLIDE with median follow-up of 10.6 years.

RESULTS

In longitudinal analysis, hazard for tooth loss was associated with baseline dental status (previous tooth loss, periodontal status and caries status) and socio-demographic variables (age, smoking status and highest educational level). Analysis of cross-sectional data suggested that indices of caries exposure were not independent of periodontal status. The strength and direction of association varied between groups, even for measures specifically intended to avoid measuring tooth loss. Individuals with impaired periodontal health (community periodontal index [CPI] 3 or higher in any sextant) had higher standardized decayed and filled surfaces (DFS; number of DFS divided by total number of tooth surfaces) in GLIDE (incidence risk ratio [IRR] 1.05 [95% CI: 1.04, 1.07], but lower standardized DFS in KNHANES (IRR: 0.95 [0.92, 0.98]) than individuals with better periodontal health (CPI <3 in all sextants).

CONCLUSIONS

Incident tooth loss is a complex measure of dental disease, with multiple determinants. The relative importance of dental caries and periodontal disease as drivers of tooth loss differs between age groups. Measures of dental caries exposure are associated with periodontal status in the studied populations, and these associations can be population-specific. Consideration of the study-specific properties of these metrics may be required for valid inference in large population studies.

Do Patients With More Education Receive More Subsidized Dental Care? Evidence From a Natural Experiment Using the Introduction of a School Reform in Norway as an Instrumental Variable

BACKGROUND

In Norway, for several dental conditions, a substantial part of treatment costs are reimbursed by the National Insurance Scheme. Ideally, the probability of receiving subsidized dental care (SDC) should be independent of social determinants of health, such as education, so that dental services are accessible to everyone independent of their social status.

OBJECTIVE

The main objective of this study was to estimate the causal effect of education on the probability of receiving SDC in the adult Norwegian population.

RESEARCH DESIGN

During the period 1960-1972, all municipalities in Norway were required to increase the number of compulsory years of education from 7 to 9 years. This education reform was used to create exogenous variation in the education variable. Since municipalities implemented the reform at different times, we have both cross-sectional and time series variation in the reform instrument. Thus we were able to estimate the effect of education on the probability of receiving SDC by controlling for municipality fixed effects and trend variables.

SUBJECTS

This study included all Norwegian adults, born during the period of 1947-1958.

MEASURES

Information about education (number of years), whether the individuals had received SDC, place of residence (municipality) was collected.

RESULTS

The probability of receiving SDC was found to increase by 2 percentage points per additional year of education.

CONCLUSION

People with the most resources benefit the most from a universal welfare scheme that is addressed to reach everybody. We suggest providing information about the subsidy scheme in a way that is easily available and understandable to all individuals, independent of their level of education.

Trends in Dental Implant Use in the U.S., 1999-2016, and Projections to 2026

Dental implants have become an increasingly popular treatment choice for replacing missing teeth. Yet, little is known about the prevalence and sociodemographic distribution of dental implant use in the United States. To address this knowledge gap, we analyzed data from 7 National Health and Nutrition Examination Surveys from 1999 to 2016. We estimated dental implant prevalence among adults missing any teeth for each survey period overall as stratified by sociodemographic characteristics. We calculated absolute and relative differences from 1999-2000 to 2015-2016 and fit logistic regression models to estimate changes over time. We also used multivariable logistic regression to estimate independent associations of sociodemographic covariates with the presence of any implant. We projected the proportion of patients treated with dental implants into the year 2026 under varying assumptions of how the temporal trend would continue. There has been a large increase in the prevalence of dental implants, from 0.7% in 1999 to 2000 to 5.7% in 2015 to 2016. The largest absolute increase in prevalence (12.9%) was among individuals 65 to 74 y old, whereas the largest relative increase was ~1,000% among those 55 to 64 y old. There was an average covariate-adjusted increase in dental implant prevalence of 14% per year (95% CI, 11% to 18%). Having private insurance (vs. none or public insurance) or more than a high school education (vs. high school or less) was each associated with a 2-fold increase in prevalence, with an almost 13-fold (95% CI, 8 to21) increase for older adults. Dental implant prevalence projected to 2026 ranged from 5.7% in the most conservative scenario to 23% in the least. This study demonstrates that dental implant prevalence among US adults with missing teeth has substantially increased since 1999. Yet access overall is still very low, and prevalence was consistently higher among more advantaged groups.

The Challenge of Evaluating the Oral Health Status of Older Persons in Latin America

Knowledge Transfer Statement: This article provides an overview of the oral health status of older people from Latin American countries and the emergence of recent gerodontology research initiatives within the region.

An oral epidemiological comparison of Chinese and New Zealand adults in 2 key age groups

OBJECTIVES

To use recent national survey data to compare dentition status and oral diseases in China and New Zealand (NZ), with a particular focus on differences by sex and education level.

METHODS

We undertook secondary analysis of representative data from oral health surveys conducted in 2009 in Sichuan (China) and NZ. Both surveys had an oral examination component and collected detailed demographic data. Socioeconomic position in this analysis was represented by the highest level of education completed. Participants were allocated to 1 of 3 comparable ordinal categories of years of education (primary, middle or tertiary). Analyses used survey weights.

RESULTS

The proportion of Chinese who had been educated to only primary level was 3 times higher than that among their NZ counterparts, and the proportion with a tertiary education was correspondingly lower. In the 35-44 age group, the dentate proportions were similar, although the mean number of teeth was higher in China than in NZ. There were substantial differences in dental caries experience, with the mean DMFT in NZ being almost 3 times that observed in China. New Zealanders had more filled teeth, but the prevalence of 1+ missing teeth was lower. Periodontitis was more common in the NZ sample than in the Chinese one, although the extent of bleeding on probing was almost 3 times higher among the latter. For the 65-74 age group, there were significant differences in dentition status, with greater tooth retention among Chinese people. There were also significant differences in dental caries experience, with Chinese 65- to 74-year-olds having more decayed teeth but fewer filled or missing teeth, and lower DMFT scores, on average. Periodontal health was better among the New Zealanders. There were notable differences by sex and education level.

CONCLUSIONS

The differences observed in this study provide strong support for using broader sociocultural models of oral health.

Some Malocclusion Traits Significantly Reduce Quality of Life Among Adults

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Malocclusion traits and oral health-related quality of life in Finnish adults. Masood M, Suominen AL, Pietila T, Lahti S. Community Dent Oral Epidemiol 2017;45:178-88.

SOURCE OF FUNDING

Finnish Dental Society Apollonia and the Finnish Dental Association TYPE OF STUDY/DESIGN: Cross-sectional study.

New Zealand's School Dental Service over the Decades: Its Response to Social, Political, and Economic Influences, and the Effect on Oral Health Inequalities

New Zealand’s School Dental Service (SDS) was founded in 1921, partly as a response to the “appalling” state of children’s teeth, but also at a time when social policy became centered on children’s health and welfare. Referring to the Commission on Social Determinants of Health (CSDH) conceptual framework, this review reflects upon how SDS policy evolved in response to contemporary constraints, challenges, and opportunities and, in turn, affected oral health. Although the SDS played a crucial role in improving oral health for New Zealanders overall and, in particular, children, challenges in addressing oral health inequalities remain to this day.

Supported by New Zealand’s Welfare State policies, the SDS expanded over several decades. Economic depression, war, and the “baby boom” affected its growth to some extent but, by 1976, all primary-aged children and most preschoolers were under its care. Despite SDS care, and the introduction of water fluoridation in the 1950s, oral health surveys in the 1970s observed that New Zealand children had heavily-filled teeth, and that adults lost their teeth early. Changes to SDS preventive and restorative practices reduced the average number of fillings per child by the early 1980s, but statistics then revealed substantial inequalities in child oral health, with Ma¯ ori and Pacific Island children faring worse than other children.

In the 1990s, New Zealand underwent a series of major structural “reforms,” including changes to the health system and a degree of withdrawal of the Welfare State. As a result, children’s oral health deteriorated and inequalities not only persisted but also widened. By the beginning of the new millennium, reviews of the SDS noted that, as well as worsening oral health, equipment and facilities were run-down and the workforce was aging. In 2006, the New Zealand Government invested in a “reorientation” of the SDS to a Community Oral Health Service (COHS), focusing on prevention. Ten years on, initial evaluations of the COHS appear to be mostly positive, but oral health inequalities persevere. Innovative strategies at COHS level may improve oral health but inequalities will only be overcome by the implementation of policies that address the wider social determinants of health.