London Charter on Oral Health Inequalities

To appreciate the influence of contributed determinants on dental care utilization in the context of socio-economic inequalities

BACKGROUND

To appreciate dental care utilization in ‌the context of socio-economic inequalities, it is imperative to identify sources of inequalities and evaluate the extent to which dental care utilization is still related to socio-economic status. This study aimed to quantify the influence of contributed determinants on dental care utilization in the context of socio-economic inequalities amongst adults residing in Tehran metropolis.

METHODS

In this cross-sectional community-based study, a stratified random sample of 1,510 subjects aged over 18 years was investigated by the zero-inflated Poisson analysis to measure the effect of determinants on utilization of dental care, and concentration index as well as the decomposition approach to identify the contributions of deterministic variables to the socio-economic inequality. Data was obtained by employing a phone interview survey. Individuals who were not willing or able to answer the questions in the telephone interview due to hearing or neurological problems did not participate in the interview. Dental care utilization was measured using the number of dental appointments.

RESULTS

Gender (male), oral health-related behaviors (such as brushing and dental flossing), experience of toothache, and concern about dental appearance were associated with an increased likelihood of utilizing dental care. Individuals who belonged to advanced age groups and lived alone significantly underutilized dental care. The concentration index equaling 0.05 (SE = 0.05) corroborates a pro-rich inequality. Decomposition analysis demonstrated the impact of oral health-related behaviors (i.e. dental brushing and use of dental flossing), concern about dental appearance, toothache, gender (male), insurance coverage of dental care, and smoking habit on the poor-rich gap in the dental care utilization.

CONCLUSIONS

The influence of socio-economic inequalities on dental care utilization is discernable along the entire spectrum of socio-economic status. Individuals with lower socio-economic status experience more underutilization of dental care. Community subgroups, particularly the more deprived bracket, require consideration from key stakeholders, including policymakers and health professionals for the enhancement of dental care utilization as revealed by underlying determinants.

Deep Learning-Based Recognition of Periodontitis and Dental Caries in Dental X-ray Images

Dental X-ray images are important and useful for dentists to diagnose dental diseases. Utilizing deep learning in dental X-ray images can help dentists quickly and accurately identify common dental diseases such as periodontitis and dental caries. This paper applies image processing and deep learning technologies to dental X-ray images to propose a simultaneous recognition method for periodontitis and dental caries. The single-tooth X-ray image is detected by the YOLOv7 object detection technique and cropped from the periapical X-ray image. Then, it is processed through contrast-limited adaptive histogram equalization to enhance the local contrast, and bilateral filtering to eliminate noise while preserving the edge. The deep learning architecture for classification comprises a pre-trained EfficientNet-B0 and fully connected layers that output two labels by the sigmoid activation function for the classification task. The average precision of tooth detection using YOLOv7 is 97.1%. For the recognition of periodontitis, the area under the curve (AUC) of the receiver operating characteristic (ROC) curve is 98.67%, and the AUC of the precision-recall (PR) curve is 98.38%. For the recognition of dental caries, the AUC of the ROC curve is 98.31%, and the AUC of the PR curve is 97.55%. Different from the conventional deep learning-based methods for a single disease such as periodontitis or dental caries, the proposed approach can provide the recognition of both periodontitis and dental caries simultaneously. This recognition method presents good performance in the identification of periodontitis and dental caries, thus facilitating dental diagnosis.

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.

Rapid Oral Health Deterioration in Older People-A Narrative Review from a Socio-Economic Perspective

Poor oral health is a common morbidity in old age with older adults less likely to attend dental care and more likely to have dental disease; this situation is exacerbated by older adults retaining more teeth often with complex restorations. Evidence suggests that some older adults experience rapid oral health deterioration (ROHD). While more clinical and population level evidence is needed, current evidence suggests upstream changes addressing disadvantage through the social determinants of health (SDH) may impact broader disorders such as ROHD, often occurring as older adults become dependent. The aim of this paper is to conduct a narrative review to explore the social determinants of ROHD in older adults. The social determinants of health are important in understanding oral health including ROHD. This includes the important influence of the economic determinants. We explored the SDH as relevant to oral health and ROHD including using a framework based on that of the Fisher-Owens conceptual model (for children) but adapted for older adults. Better understanding of these relationships is likely to assist in future prevention and care.

Income-related inequalities in the association of smoking with periodontitis: a cross-sectional analysis in Tokyo Metropolitan Districts

OBJECTIVE

Socio-economic status (SES) and smoking are risk factors for periodontitis; however, their interaction has not been determined. We investigated the effect of modification of SES and smoking with periodontal conditions.

MATERIALS AND METHODS

Data on the social background, smoking status, and dental examination of 1033 individuals residing in the Tokyo Metropolitan District were analyzed. The outcomes were the number of remaining teeth and the proportion of teeth with probing pocket depth (PPD) ≥ 4 mm and ≥ 6 mm. Multilevel linear and Poisson regression analyses were performed after adjusting for possible confounding factors, including SES, assessed by the average income of the residential area.

RESULTS

The mean number of remaining teeth was 24.6 ± 4.8, and the proportion of teeth with PPD ≥ 4 mm and ≥ 6 mm was 31.2 ± 28.5% and 12.2 ± 18.1%, respectively. After adjusting for confounding factors, the lowest-income population had significantly lesser teeth (coefficient: - 0.46, 95% CI - 0.89, 0.02, p = 0.039) and a higher proportion of teeth with PPD ≥ 4 mm than the highest-income population (ratio of means: 1.22, 95% CI 1.03-1.44, p = 0.013). Significant interactions were observed; income inequalities in periodontitis were significant only among current smokers.

CONCLUSION

Inequality in socio-economic status is associated with oral health inequalities. The adverse effects of smoking on periodontitis might be greater in the low-income population.

CLINICAL RELEVANCE

The low-income population, especially current smokers, had significantly more compromised oral health than the high-income population. In addition to the emphasis on smoking cessation, the promotion of universal health coverage for dental care is necessary to reduce oral health inequalities.

Inequities and oral health: A behavioural sciences perspective

OBJECTIVES

The importance of tackling ongoing dental health inequities, observed both within and across countries, cannot be overstated. Alarmingly, health inequities in some areas are widening, resulting in an urgent need to act. The objective of this commentary is to explore oral health inequities through the lens of behavioral science and discuss adapting evidence based interventions for populations experiencing health inequities.

METHOD/RESULTS

The first section of this paper aims to describe the role of health disparities and inequities within oral health, with a specific focus on behaviours. The determinants, from upstream to downstream, and the interplay between these levels of intervention are discussed. This is followed by an overview of oral health promotion interventions, again with a focus on behaviours, which could potentially improve oral health while also taking into account oral health inequities. It is essential to translate evidence-based interventions (EBIs) to populations that have the greatest burden of disease. The second section of this paper discusses the rationale for cultural adaption of EBIs, criteria to justify EBIs and considers different cultural adaptation strategies necessary for the development and testing of effective, engaging, equitable and culturally relevant interventions.

CONCLUSIONS

We conclude with future directions for the development of theory-based multi-level interventions, guided by extent evidence-based interventions, and transdisciplinary approaches to science and key stakeholders such as patients, providers and payers.

Evaluation of Mobile and Community Dental Service Use among People Experiencing Homelessness

The aim of the study was to evaluate the patterns of mobile and community dental service use among people experiencing homelessness in Bratislava, Slovakia. Data from medical records of homeless people who visited the mobile and community dental clinic from November 2012 to July 2018 have been retrospectively reviewed. The experience of providing dental services has been reported from the perspective of the dental care provider. Descriptive statistics were used for data analysis. In total, 319 patients (75.5% men) attended the clinic. Extraction of a tooth was the main dental treatment indicated in more than 80% (n = 276) of patients. A total of 363 teeth were extracted with an average number of 1.6 extracted teeth per patient. The main indications for extraction were dental caries and its sequelae (83.7%) and periodontal disease (15.2%). The patients with the need for prosthetic and conservative treatment were referred to the clinics at University Hospital; however, only 19 patients received the treatment. The barriers to accessing dental care were cost, logistic problems and individual psychological factors. We found that people experiencing homelessness in Slovakia have high needs and demands of emergency dental care and many systemic and individual barriers prevent them from accessing care. Community-based dental services are important for improving access to dental care and reducing oral health inequities.

Trends in social inequalities in early childhood caries using population‐based clinical data

OBJECTIVE

To assess the longitudinal trends in social inequalities in early childhood caries (ECC) using collected population-based data.

METHODS

Clinical data on children were routinely collected from 2008 to 2019 in Victoria, Australia. ECC prevalence and severity (dmft) were quantified according to Indigenous status, culturally and linguistically diverse (CALD) status, concession cardholder status, geographic remoteness and area deprivation. The inverse probability weighting was used to quantify social inequalities in ECC. The weighted prevalence differences, and the ratio between the weighted prevalence of ECC and mean dmft and their 95% confidence interval, were then plotted.

RESULTS

Absolute inequalities in ECC prevalence increased for children by 7% for CALD status and cardholder status between 2008 and 2019. Likewise, absolute inequalities in ECC severity in this time period increased by 0.6 for CALD status and by 0.4 for cardholder status. Relative inequalities in ECC increased by CALD (ratio: 1.3 to 2.0), cardholder status (1.3 to 2.0) and area deprivation (1.1 to 1.3). Relative inequalities in severity increased by CALD (1.5 to 2.8), cardholder (1.4 to 2.5) or area deprivation (1.3 to 1.5). Although children with Indigenous status experienced inequalities in ECC prevalence and severity, these did not increase on the absolute (ECC: 0.1-0.1 Severity: 1.0-0.1) or relative scale (ECC ratio: 1.3-1.3 Severity ratio: 1.6-1.1).

CONCLUSIONS

Trends in inequalities in ECC were different according to sociodemographic measures. Oral health policies and interventions must be evaluated on the basis of reducing the prevalence of oral diseases and oral health inequalities between population sub-groups.

Professionals’ perspectives on how to address persistent oral health inequality among young children: an exploratory multi-stakeholder analysis in a disadvantaged neighbourhood of Amsterdam, the Netherlands

Background

Oral health promotion interventions have had limited success in reaching families in disadvantaged neighbourhoods resulting in persistent oral health inequality. This qualitative study provides insight into professionals’ perspectives on children’s poor oral health (≤ 4 years), their perceptions of the roles and responsibilities, and opportunities for child oral health promotion strategies.

Methods

Thirty-Eight professionals from different domains (community, social welfare, general health, dental care, public health, private sector) working in a disadvantaged neighbourhood in Amsterdam, the Netherlands, participated through 24 semi-structured (group) interviews. Transcripts and notes were analysed through thematic analysis.

Results

Professionals indicate that unhealthy diet, children’s non-compliance, poor parental coping, parental low oral health literacy, parent’s negative attitude, family’s daily struggles, and insufficient emphasis on childhood caries prevention in dental practices, general healthcare and social welfare organisations, underlie poor oral health. They hold parents most responsible for improving young children’s oral health, but recognise that families’ vulnerable living circumstances and lack of social support are important barriers. Interestingly, non-dental professionals acknowledge their beneficial role in child oral health promotion, and dental professionals stress the need for more collaboration.

Conclusion

A broad child-, parental-, and societal-centred educational communication strategy is perceived as promising. Professionals working within and outside the dental sector acknowledge that local and collective action is needed. This involves a better understanding of family’s complex daily reality. Furthermore, intensifying child oral health knowledge in dental practices is essential in collaboration with families, general health and social welfare organisations.

Social Epigenomics: Conceptualizations and Considerations for Oral Health

Advances in high-throughput technologies and the generation of multiomics, such as genomic, epigenomic, transcriptomic, and metabolomic data, are paving the way for the biological risk stratification and prediction of oral diseases. When integrated with electronic health records, survey, census, and/or epidemiologic data, multiomics are anticipated to facilitate data-driven precision oral health, or the delivery of the right oral health intervention to the right individuals/populations at the right time. Meanwhile, multiomics may be modified by a multitude of social exposures, cumulatively along the life course and at various time points from conception onward, also referred to as the socio-exposome. For example, adverse exposures, such as precarious social and living conditions and related psychosocial stress among others, have been linked to specific genes being switched "on and off" through epigenetic mechanisms. These in turn are associated with various health conditions in different age groups and populations. This article argues that considering the impact of the socio-exposome in the biological profiling for precision oral health applications is necessary to ensure that definitions of biological risk do not override social ones. To facilitate the uptake of the socio-exposome in multiomics oral health studies and subsequent interventions, 3 pertinent facets are discussed. First, a summary of the epigenetic landscape of oral health is presented. Next, findings from the nondental literature are drawn on to elaborate the pathways and mechanisms that link the socio-exposome with gene expression-or the biological embedding of social experiences through epigenetics. Then, methodological considerations for implementing social epigenomics into oral health research are highlighted, with emphasis on the implications for study design and interpretation. The article concludes by shedding light on some of the current and prospective opportunities for social epigenomics research applied to the study of life course oral epidemiology.

[Changes in the prevalence of decayed permanent teeth in Brazil and upper-middle income countries in the years 1990 and 2017]

The distribution of caries is uneven and strongly associated with the different socioeconomic profiles of countries. The scope of this study was to describe the changes in the prevalence of decayed permanent teeth in Brazil and in upper-middle income countries for the years 1990 and 2017. It is a descriptive study based on secondary data extracted from the Global Burden of Disease. The 53 countries included in the upper-middle income group were included. Caries prevalence estimates were collected for the years 1990 and 2017. The percentage change in prevalence was calculated between the two years. The values of the Human Development Index (HDI) for each country were also collected. The results show the trend of a reduction in the prevalence of decayed permanent teeth in Brazil and in most upper-middle income countries. The prevalence of untreated caries in Brazil was 38.17% in 1990 and 37.46% in 2017. Brazil occupies the 41st position in the ranking of the reduction in the prevalence of caries among the 53 countries evaluated. The countries that achieved the greatest reductions in the prevalence of caries were those with an improvement in their HDI. In this respect, the need to review public oral health policies is revealed, as well as a reflection on addressing the inequities present in the countries surveyed.

Effect of educational strategy combined with ART on oral health-related quality of life: a controlled clinical trial

This study aimed to assess whether complementing atraumatic restorative treatment (ART) with oral health educational strategies (OHES) improves the perception of oral health-related quality of life (OHRQoL) and clinical oral outcomes. A controlled clinical trial included 93 six- to eight-year-old students from five public schools of Piracicaba, Saltinho, and Charqueada municipalities (State of São Paulo, Brazil) divided into 3 groups (31 children each) which received: OHES (caries-free), ART (dental caries), and ART plus OHES (dental caries). OHRQoL (CPQ8-10-ISF:16), dental caries, biofilm control, and gingivitis were assessed before and 1 month after interventions by one calibrated examiner. OHES consisted of an educational interactive activity performed once a week for four weeks. Data were analyzed using mixed model ANOVA, Chi-square, and Sign tests. After 1 month of follow-up, improvement in gingivitis status, OHRQoL total score, and Functional Limitations, Emotional Well-Being and Social Well-Being domains scores were found in all groups (p < 0.05). The improvement in biofilm control was observed only in the OHES group (p < 0.001; power = 0.98), while a decrease in Oral Symptoms scores was observed only in ART+OHES group (p <0.001; power = 0.99) and a significant change in the perception of oral health was observed in the two groups that received ART (p < 0.05). In conclusion, improvement in overall OHRQoL and oral status was observed in all children, although the effect of including health educational strategies in the treatment plan was determinant for the perception of an improved oral health after restorative treatment.

Greater inequalities in dental caries treatment than in caries experience: a concentration index decomposition approach

Background

The aim of the current study was to (a) measure the socioeconomic inequalities in oral health and examine whether the inequalities are greater in disease experience or in its treatment and to (b) decompose the factors that influence oral health inequalities among the adults of Guangdong Province.

Methods

A cross-sectional study was conducted among 35- to 44-year-old and 65- to 74-year-old adults in Guangdong Province. All participants underwent oral health examinations and answered questionnaires about their oral health. We measured the concentration indices of the DMFT and its separate components, namely, decayed teeth (DT), missing teeth (MT), and filled teeth (FT), to explore the inequalities in oral health status; then, we analysed its decomposition to interpret the factors that influence the inequalities.

Results

The results showed that significant inequality was concentrated on FT (CI =  0.24, 95% CI = 0.14/0.33, SE = 0.05). The concentration indices for the DMFT (CI =  0.02, 95% CI =  0.02/0.06, SE = 0.02) and MT (CI =  0.02, 95% CI 0.03/0.08, SE = 0.03) were small and close to zero, while the concentration for DT (CI =  − 0.04, 95% CI =  − 0.01/0.02, SE = 0.03) was not statistically significant. The results from the decomposition analysis suggested that a substantial proportion of the inequality was explained by household income, high education level, regular oral examination and type of insurance (5.1%, 12.4%, 43.2%, − 39.6% (Urban Employee Basic Medical Insurance System) and 34.5% (New-Type Rural Medical Collaboration System), respectively).

Conclusions

The results indicated greater inequalities in dental caries than in caries experience. Among the included factors, household income, high education level, and regular oral health examinations had the greatest impact on the inequalities in the number of FT. In addition, the current medical insurance systems, including the Urban Employee Basic Medical Insurance System, Urban Resident Basic Medical Insurance System, and the New-Type Rural Medical Collaboration System, have not been effectively used in oral treatment. Policy-making and the implementation of interventions for tackling socioeconomic oral health inequalities should focus on reducing the burden of treatment and providing greater access to dental care for low-income groups. Welfare policies are skewed towards rural areas and low-income people.

Incorporation of Storytelling as a Method of Oral Health Education among 3-6-year-old Preschool Children

Purpose

To find the effectiveness of storytelling as a method of oral health education among 3–6-year-old preschool children.

Design

A non-randomized experimental pre–post study design.

Setting

Preschools located in urban Bengaluru.

Subjects

Two hundred, 3–6 years, preschool children.

Intervention

An age-appropriate story with oral health messages was delivered using hand puppets during the storytelling session in preschool.

Measures

A self-administered 11-item picture-based, closed-ended questionnaire assessed children's knowledge and attitude at baseline and post-intervention. A 1-week audit sheet to monitor the brushing, eating, and mouth rinsing pattern was administered for the parents to measure the change in behavior post-intervention.

Analysis

Change in KAP mean scores was assessed using the “Wilcoxon Sign Rank test” at p < 0.05. “Cohen's d” was used to calculate the “Effect size”.

Results

Significant improvement was observed in mean KAP score (pre 7.52 ± 1.95 post 8.60 ± 1.55, p = 0.0001) with effect size 0.2. There was a significant increase in the knowledge and attitude and practice score, knowledge (pre 2.97 ± 1.02, post 3.63 ± 0.78, p = 0.0001, effect size: 0.3), attitude (2.27 ± 0.81, 2.77 ± 0.60, p = 0.000, effect size: 0.3), and practice (2.04 ± 1.07, 2.28 ± 0.60, p = 0.0001, effect size: 0.1).

Conclusion

The storytelling method was effective in improving the oral health-related KAP of children aged 3–6 years.

Significance

This study attempts to inculcate good oral hygiene practices at a very early stage by targeting 3–6-year-old preschool children. Storytelling being humankind's oldest form of teaching and motivating change, can not only address the prevailing oral disease burden but also the oral health inequality by reaching out to every community.

How to cite this article

Shruti T, Govindraju HA, Sriranga J. Incorporation of Storytelling as a Method of Oral Health Education among 3–6-year-old Preschool Children. Int J Clin Pediatr Dent 2021;14(3):349–352.

The prevalence of dental caries and associated factors among secondary school children in rural highland Vietnam

BACKGROUND

To determine the prevalence of dental caries in primary and permanent teeth and identify factors associated with dental caries among secondary school children in rural highland Vietnam.

METHODS

This was a cross-sectional study that included 1985 secondary schoolchildren. Dental examination was performed at school using World Health Organization criteria. Data collection on demographic characteristics and knowledge, attitude, and practices related to dental caries was conducted by interviewing children. Descriptive and inferential statistics using a multivariate logistic regression model were applied.

RESULTS

Prevalence of caries in primary and permanent teeth was 41.1 and 68.9 %, respectively. Prevalence of caries in primary teeth in the age group 11-12 years old (59.4 %) was significantly higher than in children in the age group of 13-14 years (27.8 %; p < 0.01). Factors associated with dental caries in primary teeth were age group of 11-12 years, belonging to the Jarai ethnic group, and having inadequate knowledge or attitude related to dental caries. Factors associated with dental caries in permanent teeth were having insufficient knowledge, attitude, and practices related to dental caries.

CONCLUSIONS

The prevalence of dental caries in primary and permanent teeth was high among secondary school children in Vietnam's rural highlands. It is recommended that interventions focus on younger secondary school children and the Jarai minority ethnic group, and that interventions should emphasize improving knowledge, attitudes, and practices related to dental caries.

Population-Based Prevalence of Oral Conditions as a Basis for Planning Community-Based Interventions: An Epidemiological Study From Rural Burkina Faso

Objectives: The purpose of the present study was to: (i) provide timely data on dental caries and periodontal conditions in rural Burkina Faso; (ii) identify the oral health practices carried out in this population, and (iii) to prioritize evidence-based interventions at the community level. Methods: Leaning on WHO recommendations for oral health epidemiological studies, clinical examinations and questionnaire-based surveys were conducted in two different age groups (adolescents: 15-19 years old; adults: 35-44 years old) in the health district of Nouna, Burkina Faso. Caries and tooth status were assessed according to the DMFT Index. The periodontal status was assessed by a modified Community Periodontal Index on all teeth present and measuring the level of attachment-loss of six index teeth. Questionnaire items specifically included utilization of oral health care and oral health behaviors. Results: The prevalence of untreated caries was 38% in adolescents and 73% in adults. In terms of periodontal health, 21% of adolescents and 61% of adults had an attachment loss ≥4 mm. Ninety seven percent of adolescents had not attended a dentist in the previous year and 78% of adults had never seen a dentist in their life. About one third of adolescents and adults cleaned their teeth less often than once per day with equal proportions of toothbrushes and traditional chewing sticks made of tree branches. Fluoride toothpaste was used by <10% of study participants. Almost half of the examined people reported to drink a sugar-sweetened beverage at least once a day. Conclusions: Dental caries and periodontitis are highly prevalent in rural Burkina Faso. These findings highlight the key relevance of epidemiological data for identifying people's oral health needs as basis for developing, testing, and implementing oral health interventions and programs. Special emphasis should be put on the design and evaluation of community-based interventions.

Public transport access to NHS dental care in Great Britain

Objective Access to transport is a common barrier to oral health. Greater dependence on public transport has shown delayed oral healthcare, lack of usual source of care and greater unmet health needs. This study examined the spatial accessibility of the population of Great Britain to public transport in providing access to oral healthcare.Methods A total of 8,791 dental practices in Great Britain were identified and geocoded. There were 10,444 rail, metro and light rail stops and 348,961 bus and tram stops. Geographic information systems were utilised to integrate the dental practice locations and public transport points to respective census tracts of each nation containing population data, deprivation measures, and classification of rural and urban areas.Results Almost all dental clinics in Great Britain were located within 400 m of bus and tram stops or 800 m of a rail, metro or light rail stop. Similarly, in Scotland and England, 92% lived within any public transport (within 400m of bus and tram stops or 800m of a rail, metro or light rail stop), and in Wales, 84.2% lived within any public transport stop. However, only 75.1%, 79.6% and 60.4% of the population of Scotland, England and Wales had access to a high-frequency bus stop, respectively. In Scotland, England and Wales, 40.7%, 33.7% and 38.3% of rural residents did not have access to any public transport and only 4.9%, 7.5% and 14.6% of the rural residents had access to an optimal bus stop, respectively. In Wales, 19.5% of older adults do not have access to a bus stop.Conclusion Some transport-disadvantaged groups do not have adequate access to public transport services. There is a compelling need to address public transport integration with oral health facilities to ensure equality in accessing integral services.

Impact of adopting different socioeconomic indicators in older adults' oral health research

This study aimed to evaluate the influence of choosing different socioeconomic status indicators in research regarding older adults' oral health. This is a cross-sectional study that analyzed baseline data from the Brazilian Longitudinal Study on Aging (ELSI-Brazil). The outcomes were edentulism (n = 9,073) and self-reported oral health (n = 9,365). The following socioeconomic indicators were assessed: individual income, per capita household income, and wealth index. Poisson regression analysis with robust variance was performed to estimate prevalence ratios (PR), with their respective 95% confidence intervals (CI), after adjusting for socioeconomic and oral health behavior variables. Absolute inequality measures were also estimated. The individual income indicator was not statistically associated with the results after adjustments. When using per capita household income indicator, individuals in the richest quintile showed a 12% lower prevalence of poor self-reported oral health [PR: 0.88 (CI: 0.78-0.98)], relative to the poorest, and there was no association with edentulism. When the wealth index was chosen, there was a 22% lower prevalence of edentulism [PR: 0.78 (CI: 0.64-0.94)] and 15% lower prevalence of self-reported poor oral health [PR: 0.85 (CI: 0.78-0.93)] in individuals of the richest quintile, both relative to the poorest quintile. Regarding absolute inequality measures, for edentulism, the wealth index showed the highest absolute inequality. When considering self-reported oral health, per capita household income showed the greatest absolute inequality. Despite scientific challenges and the difficulty of socioeconomic indicator metrics, further investments in its development are critical to measure, promote, and improve population oral health.

A disability-based exploration of psychosocial barriers and enablers to accessing dental services for people with clinically severe obesity: A qualitative study

This qualitative study aimed to explore psychosocial barriers and enablers to accessing dental services for people with clinically severe obesity (PwCSO). Eight focus groups were conducted by one researcher with 40 adult participants at the Adult Healthy Weight Clinic within a hospital-based obesity service. Thematic analysis of focus group transcripts was performed to reveal insights relating to how PwCSO experience dental care and view oral health. A total of 11 participants were male, 29 female, all between the ages of 23 to 74 (mean age of 50). The body mass index of participants ranged from 31.6 to 84.6 kg/m² . The results highlighted four key themes, including "disempowerment to act to improve oral health", "weight-related stigma and discrimination", "unpredictability of the dental environment" and a "lack of tailored services for PwCSO". A number of subthemes were identified, which reflect the six categories of barriers to access from the disability literature: availability, affordability, acceptability, accommodation, accessibility and appropriateness. These were explored to further appreciate the unique psychosocial considerations for this group. This study concluded that PwCSO face significant barriers to accessing dental services across all six categories highlighted in the disability literature. The study findings provide valuable patient-based information regarding the psychosocial barriers to accessing dental services, which are relevant for all healthcare professionals. The study reflected an increased need for promotion of the dentist's role in obesity management and obesity-related dental training, including familiarization with the biopsychosocial domains of obesity to reduce weight related stigma and discrimination, as an area for further study. The findings also guide the design of Specialized Bariatric Dental Services in the future, with a focus on enablers to access.

Oral health academics' conceptualisation of health promotion and perceived barriers and opportunities in dental practice: a qualitative study

BACKGROUND

Oral diseases place a significant burden on individual and population health. These diseases are largely preventable; health promotion initiatives have been shown to decrease the disease rates. However, there is limited implementation of health promotion in dentistry, this could be due to a number of factors; the ethos and philosophy of dentistry is focused on a curative, individualised approach to oral diseases, confusion around health promotion as a concept. Oral health academics are well placed to implement health promotion, training of these professionals needs to include prevention, as training influences dental practice. However, there is a little understanding about how oral health academics (dental professionals who educate dental and oral health students) view health promotion. The aim of this exploratory study is to understand how oral health academics conceptualise health promotion and perceive the barriers and possible opportunities for health promotion implementation in dental practice.

METHODS

Nominal group technique (NGT), a highly structured face-to-face meeting, was conducted with 24 oral health academics to explore how they conceptualize health promotion and the barriers and opportunities for health promotion in practice. An additional 4 questions were emailed to oral health educators after the NGT meeting to gather additional data, 6 oral health academics were involved. The data was analyzed using thematic analysis.

RESULTS

Three board themes were identified: "Knowledge, ideas and concepts of health promotion", "Challenges to health promotion", "Opportunities for health promotion practice". The oral health academics in this study discussed health promotion in a holistic way, however, health education and behaviour change were mentioned more than other aspects of health promotion. The structure of dental practice specifically the curative approach that underpins dentistry and the lack of funding, and value placed on health promotion could act as a challenge to health promotion being implemented in practice. There has been a shift towards prevention in dentistry, however the participants acknowledge there needs to be a change in the curative culture of the profession. Collaboration with other health professionals and using a common risk factor approach were the identified opportunities for health promotion practice.

CONCLUSIONS

Oral health academics have a holistic understanding of health promotion, but still focus more on behavioural approaches which is common within dentistry. For a change to occur in health promotion practice a change in the structure, curative approach and funding model of dentistry is required. Collaboration with other health professionals is an opportunity to be capitalised on. Training of future dental professionals is the perfect place to start to implement the changes and opportunities for health promotion presented in this paper.

Stressed-Out Oral Immunity: A Gateway From Socioeconomic Adversity to Periodontal Disease

OBJECTIVE

It has been suggested that adverse socioeconomic conditions "get under the skin" by eliciting a stress response that can trigger periodontal inflammation. We aimed to a) estimate the extent to which socioeconomic position (SEP) is associated with periodontal disease (PD) and proinflammatory oral immunity, and b) determine the contribution of psychosocial stress and stress hormones to these relationships.

METHODS

In this cross-sectional study (n = 102), participants (20-59 years old) completed financial and perceived stress questionnaires and underwent full-mouth periodontal examinations. SEP was characterized by annual household income and educational attainment. Cortisol, a biological correlate of chronic stress, was assessed in hair samples. Oral immunity was characterized by assessing oral inflammatory load and proinflammatory oral neutrophil function. Blockwise Poisson and logistic regression models were applied.

RESULTS

Compared with lower SEP, individuals in the middle- and higher-income categories had a significantly lower probability of PD (incidence rate ratio [IRR] = 0.5 [confidence interval {CI} = 0.3-0.7] and IRR = 0.4 [95% CI = 0.2-0.7]) and oral inflammatory load (IRR = 0.6 [95% CI = 0.3-0.8] and IRR = 0.5 [95% CI = 0.3-0.7]) and were less likely to have a proinflammatory oral immune function (odds ratio [OR] = 0.1 [95% CI = 0.0-0.7] and OR = 0.1 [95% CI = 0.0-0.9]). PD and oral immune parameters were significantly associated with financial stress and cortisol. Adjusting for financial stress and cortisol partially attenuated the socioeconomic differences in PD to IRR = 0.7 (95% CI = 0.5-0.8) and IRR = 0.6 (95% CI = 0.5-0.7) for the middle- and higher-income categories, respectively. Similar results were observed for proinflammatory immunity (OR = 0.2 [95% CI = 0.0-1.8] and OR = 0.3 [95% CI = 0.0-2.3]).

CONCLUSION

These findings suggest that psychosocial stress may contribute to a proinflammatory immunity that is implicated in PD pathobiology and provide insight into social-to-biological processes in oral health.

Changes in income-related inequalities in oral health status in Ontario, Canada

OBJECTIVES

Oral health inequalities impose a substantial burden on society and the healthcare system across Canadian provinces. Monitoring these inequalities is crucial for informing public health policy and action towards reducing inequalities; however, trends within Canada have not been explored. The objectives of this study are as follows: (a) to assess trends in income-related inequalities in oral health in Ontario, Canada's most populous province, from 2003 to 2014, and (b) to determine whether the magnitude of such inequalities differ by age and sex.

METHODS

Data representative of the Ontario population aged 12 years and older were sourced from the Canadian Community Health Survey (CCHS) cycles 2003 (n = 36,182), 2007/08 (n = 36,430) and 2013/14 (n = 41,258). Income-related inequalities in poor self-reported oral health (SROH) were measured using the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) and compared across surveys. All analyses were sample-weighted and performed with STATA 15.

RESULTS

The prevalence of poor SROH was stable across the CCHS cycles, ranging from 14.1% (2003 cycle) to 14.8% (2013/14 cycle). SII estimates did not change (18.7-19.0), while variation in RII estimates was observed over time (2003 = 3.85; 2007/08 = 4.47; 2013/14 = 4.02); differences were not statistically significant. SII and RII were lowest among 12- to 19-year-olds and gradually higher among 20- to 64-year-olds. RII was slightly higher among females in all survey years.

CONCLUSION

Absolute and relative income-related inequalities in SROH have persisted in Ontario over time and are more severe among middle-aged adults. Therefore, oral health inequalities in Ontario require attention from key stakeholders, including governments, regulators and health professionals.

Associations between Individual-level and Area-level social disadvantage and oral health behaviours in Australian adolescents

BACKGROUND

Oral health behaviours are significant determinants of oral health. There is evidence that socioeconomic position influences oral health behaviours, but little is known about this association during adolescence. This study aims to investigate the association between social disadvantage (individual and area level) and oral health behaviours among Australian adolescents.

METHODS

This study utilized data from the Longitudinal Study of Australian Children (LSAC). The sample consisted of 2877 adolescents. Exposure measures were area-level social disadvantage (Socioeconomic Indexes for Areas) and parent-reported household income from Wave 5. Outcomes, measured in Wave 6, were three different adolescent-reported oral health behaviours: frequency of brushing, consumption of sugar-sweetened beverages (SSB) and dental visits. Associations between quintiles of each exposure and each oral health behaviour were tested by fitting multivariable logistic regression models.

RESULTS

Household income and area-level disadvantage were associated with dental visits and brushing frequency. Associations between social disadvantage and consumption of SSBs were less apparent, with only the least disadvantaged adolescents having lower odds of consumption of SSBs compared to the most disadvantaged group.

CONCLUSION

Individual and area-level socioeconomic factors are associated with dental visits, and frequency of brushing.Broad population-based strategies must be adopted to reduce intake of SSBs, however, targeted strategies are needed among more disadvantaged populations to address infrequent toothbrushing and irregular dental visits among adolescents.

Effect of Copayment on Dental Visits: A Regression Discontinuity Analysis

Despite their prevalence and burdens, oral diseases are neglected in universal health coverage. In Japan, a 30% copayment (out of pocket) by the user and a 70% contribution by Japan’s universal health insurance (JUHI) are required for dental and medical services. From the age of 70 y, an additional 10% is offered by JUHI (copayment, 20%; JUHI, 80%). This study aimed to investigate the effect of cost on dental service use among older adults under the current JUHI system. A regression discontinuity quasi-experimental method was used to investigate the causal effect of the JUHI discount policy on dental visits based on cross-sectional data. Data were derived from the 2016 Japan Gerontological Evaluation Study. This analysis contained 7,161 participants who used JUHI, were aged 68 to 73 y, and responded to questions regarding past dental visits. Analyses were controlled for age, sex, number of teeth, and equalized household income. Mean ± SD age was 72.1 ± 0.79 y for the discount-eligible group and 68.9 ± 0.78 y for the noneligible group. During the past 12 mo, significantly more discount-eligible participants had visited dental services than noneligible participants (66.0% vs. 62.1% for treatment visits, 57.7% vs. 53.1% for checkups). After controlling for covariates, the effect of discount eligibility was significant on dental treatment visits (odds ratio [OR], 1.36; 95% CI, 1.32 to 1.40) and dental checkups (OR, 1.49; 95% CI, 1.44 to 1.54) in the regression discontinuity analysis. Similar findings were observed in triangular kernel-weighted models (OR, 1.38 [95% CI, 1.34 to 1.44]; OR, 1.52 [95% CI, 1.47 to 1.56], respectively). JUHI copayment discount policy increases oral health service utilization among older Japanese. The price elasticity for dental checkup visits appears to be higher than for dental treatment visits. Hence, reforming the universal health coverage system to improve the affordability of relatively inexpensive preventive care could increase dental service utilization in Japan.

Behavioral Sciences in the Promotion of Oral Health

The importance and value of behavioral sciences in dentistry have long been recognized, and their contribution to dental education, research, clinical practice, and oral health policy has been significant over the past half century. Over time behavioral sciences have expanded our understanding of oral health beyond "disease" to a broader biopsychosocial concept of oral health. This in turn has led dentistry away from a focus of "treatment" to oral health "care," notably in the new millennium. Key oral health behaviors have been identified for more than half a century: the importance of diet, oral hygiene, dental services, and other factors. Various behavioral models and theories have been proposed, particularly since the 1970s, providing useful frameworks with sound psychological basis to help understand the paths of oral health behaviors. These models draw on theories of self-efficacy, motivation, counseling, and "behavior change." Since the 1980s, there has been a greater understanding that these behaviors often share a common pathway with the etiology of other diseases (common risk factors). Furthermore, the relationship between individual factors and the broader environmental factors has been increasingly emphasized since the 1990s, leading to a united call for action in addressing oral health inequalities. Within the past decade, there are useful examples of models, frameworks, and techniques of behavior change with respect to oral health, involving planning, prompting, encouraging, goal setting, and/or motivating. In particular, there is a growing interest and use of motivational interviewing. Likewise, behavioral therapies, such as cognitive behavioral therapy, are increasingly being employed in dental practice in the management of dental anxiety, pain, and psychosomatic dental and oral problems, with promising results. Recommendations are outlined for future directions for behavioral sciences in the promotion of oral health.

Uso de serviços odontológicos públicos entre idosos brasileiros: uma análise multinível

Resumo Avaliou-se, entre idosos brasileiros, se o uso dos serviços odontológicos provenientes do Sistema Único de Saúde (SUS) é equânime. Utilizaram-se dados individuais de exames conduzidos por profissionais calibrados do levantamento nacional de saúde bucal (2010) e dados contextuais originários do DATASUS e do IBGE. A variável dependente foi o tipo de serviço utilizado: SUS e Outros. Foram conduzidas análises multiníveis através de regressão logística (α = 5%) (OR/IC 95%), através do SPSS 24.0. Participaram 6.303 idosos, a prevalência do uso no SUS foi de 30%, os fatores contextuais associados foram o acesso a banheiro e a água encanada (1,54/1,19-2,00) e o índice de cuidados odontológicos (1,41/1,10-1,81); já os individuais: idade (0,77/0,66-0,90), anos de estudo (1,83/1,53-2,20), renda familiar (2,57/2,20-3,01), motivo da última consulta (0,75/0,60-0,93), no de dentes cariados (1,26/1,08-1,48), no de dentes obturados (0,63/0,54-0,74), uso de próteses (2,23/1,91-2,59), dor de dente (1,36/1.11-1,67), autopercepção da necessidade de tratamento odontológico (1,20/1,12-1,51) e da necessidade de próteses (1,38/1,20-159). O uso no SUS tem sido equânime, porém é preciso organizar o processo de trabalho, viabilizando tal uso de forma regular e preventiva buscando a universalidade e a integralidade.

Why UK dental education should take a greater interest in the behavioural and social sciences

Recent moves by public health academics and social scientists for increased recognition of the behavioural and social sciences (BeSS) in medical education in the UK have put the role and place of the BeSS in dental education back on the curricular agenda. Behavioural and social sciences have been a component of the UK dental curriculum since 1990 but, to our knowledge, have only been reviewed once, in 1999. The aim of this article is to reignite a discussion about the role and place of BeSS in dental education in the UK. It reiterates the benefits of BeSS to dental education and dentistry in general, while remaining cognisant of the implicit and explicit barriers that can conspire to side-line their contribution to dental education. This paper concludes by making renewed calls for more integration of BeSS into the dental undergraduate curriculum as well as sectoral recognition for its contribution to the advancement of dental education and the professional development of dentists.

The Biology of Social Adversity Applied to Oral Health

Biological embodiment is a concept derived from Engel's biopsychosocial model to health, theorized as the process by which adverse social exposures trigger neuroendocrine and immune responses, leading to disease and/or increased disease susceptibility. This critical review discusses the biopsychosocial model as applied to oral health and its relevance to oral health policy while deciphering some of the pathobiological processes underlying social adversity. In periodontal disease, for example, such processes can occur via the activation of the hypothalamic-pituitary-adrenal axis and the consequent release of the chronic stress hormone cortisol. The latter contributes to a proinflammatory immune state that increases the risk for periodontal inflammation. Recent research shows that cortisol relates to an elevated oral inflammatory load, demonstrated as hyperactive neutrophils that are pivotal to periodontal tissue damage. Consistent with the biopsychosocial model, this relationship is amplified in those of lower income and higher financial stress. Similarly, among children from lower socioeconomic backgrounds, cortisol is linked to a higher cariogenic bacterial load. Such findings implicate the stress pathway as key in the oral pathogenic process, particularly under social/socioeconomic adversity. Collectively, this work emphasizes the importance of addressing social factors in alleviating oral disease burden and reducing the social gaps therein.

Oral health-related quality of life among 11-12 year old indigenous children in Malaysia

BACKGROUND

Poor oral health among Malaysian indigenous Orang Asli (OA) children may impact on their daily performances.

AIM

To assess the oral health status, related behaviours, and oral health-related quality of life (OHRQoL) among OA children in Cameron Highlands (CH), Malaysia, and to identify the predictor(s) for poor OHRQoL.

DESIGN

This was a cross-sectional study involving 249, 11-12 year old OA children from 4 OA primary schools in CH. The children completed a self-administered questionnaire comprising information on socio-demographics, oral health-related behaviours, and the Malay Child Oral Impacts on Daily Performances (Malay Child-OIDP) index followed by an oral examination. Data were entered into the SPSS version 23.0 software. Non-parametric tests and multiple logistic regression were used for data analysis.

RESULTS

The response rate was 91.2% (n = 227/249). The prevalence of caries was 61.6% (mean DMFT = 1.36, mean dft = 1.01) and for gingivitis was 96.0%. Despite the majority reported brushing their teeth ≥ 2x/day (83.7%) with fluoride toothpaste (80.2%), more than two-thirds chewed betel nut ≥ 1/day (67.4%). Majority of the children (97.8%) had a dental check-up once a year. Nearly three-fifths (58.6%) reported experiencing oral impacts on their daily performances in the past 3 months (mean score = 5.45, SD = 8.5). Most of the impacts were of "very little" to "moderate" levels of impact intensity with 90.2% had up to 4 daily performances affected. Most of the impacts were on eating (35.2%), cleaning teeth (22.0%) and relaxing activities (15.9%). Caries in primary teeth is associated with oral impacts among the OA children.

CONCLUSIONS

The 11-12 year old OA children in Cameron Highland had high prevalence of caries and gingivitis with the majority chewed betel nut regularly. Caries in primary teeth is associated with poor OHRQoL. Future programmes should target younger age group children to promote positive oral hygiene practices, reduce caries, and improve quality of life.

The impact of a prospective 4-year longitudinal school intervention for improving oral health and oral health inequalities in primary schoolchildren in Flanders-Belgium

BACKGROUND

Oral diseases and socio-economic inequalities in children are a persisting problem.

AIM

To investigate the 4-year longitudinal impact of an oral health promotion programme on oral health, knowledge, and socio-economic inequalities in primary schoolchildren.

DESIGN

The intervention was carried out between 2010 and 2014 within a random sample of Flemish primary schoolchildren (born in 2002). It consisted of an annual oral health education session. ICDAS/DMFT, care level, knowledge scores, and plaque index were used as outcome variables. Being entitled to a corrective policy measure was used as social indicator. Mixed model analyses were conducted to evaluate changes over time between intervention and control group and between higher and lower social subgroups.

RESULTS

A total of 1058 participants (23.8%) attended all four sessions. The intervention had a stabilizing effect on the number of decayed teeth and increased knowledge scores. No statistically different effect on the two social groups could be demonstrated. Socio-economic inequalities were present both at T₀ and T₄ .

CONCLUSION

The oral health promotion programme had a positive impact on oral health knowledge and stabilized the number of decayed teeth. No impact on inequalities could be demonstrated, although a higher dropout rate in children with a lower social status was seen.

The Relationship between Income and Oral Health: A Critical Review

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

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.

What factors are associated with dental general anaesthetics for Australian children and what are the policy implications? A qualitative study

BACKGROUND

Dental general anaesthetics undertaken on young children are amongst the most common of all potentially preventable hospitalisations of children in Australia. They are costly for families and the community and entail some risk. The aim of the study was to explore the views of stakeholders about factors associated with children's dental general anaesthetics in Victoria, Australia and to identify policy implications.

METHODS

Interviews with stakeholders were used to develop a framework of factors. Interview data were subject to qualitative analysis, informed by Interpretative Phenomenological Analysis.

RESULTS

Eight themes that encompassed 30 main factors were identified through focused discussions with 16 stakeholders. While the safety of dental general anaesthetics has improved and mortality rates are low, side effects are common. Push factors for children's dental general anaesthetics include a perceived greater 'child-focus'; preferred models of care; low oral health literacy; parent guilt; convenience; and some dentists reluctance to treat high needs children in the clinic. Factors that may decrease the prevalence of dental general anaesthetics include: prevention of dental caries; using alternative approaches; an appropriate workforce mix; enhancing oral health literacy; and development of guidelines.

CONCLUSION

The prevalence of hospitalisation of children to treat dental caries is increasing. Many factors influence the prevalence of paediatric dental general anaesthetics - relating to the child, parent, oral health professional, financial impact, health risk, and accessibility to facilities. There are quality of care and convenience benefits but also high costs and possible health risks. Family, workforce and health system factors have been identified that could decrease the prevalence of paediatric dental general anaesthetics.

Inequalities in dental caries in children within the UK: Have there been changes over time?

OBJECTIVES

To examine any change over time in the association between deprivation and caries experience between 2003 and 2013 in a nationally representative sample of UK children.

METHODS

Data from UK Children's Dental Health Surveys, 2003 and 2013, were used. The target population was 5-, 8-, 12- and 15-year-olds. A total of 9604 children in 2003 and 9866 in 2013 were included in the surveys. Outcome variables were any active caries, caries experience and total number of carious teeth. Family socio-economic position (SEP) or deprivation level was measured at school level using eligibility for free school meals (FSM) to identify children from low-income families. Incidence rate ratios (IRR) and pooled standardized incidence rates ratios were calculated to measure dichotomous outcome variables by year, age group and status of deprivation. The study continuous outcome was modelled using a zero-inflated Poisson regression while the dichotomous outcomes were modelled using logistic regressions. The multivariable analyses were run by age groups accounting for year, sex and deprivation status.

RESULTS

The percentage of those identified as deprived was significantly higher in 2013 (35.8% in 2013 vs 26.0% in 2003, P < 0.001). Among both deprived and non-deprived children, the prevalence of any active caries significantly dropped over the years, observed in all age groups. Comparing 2013 with 2003 and accounting for sex, deprivation level, "any active caries," "any caries experience" and "total number of carious teeth" significantly dropped were observed in all age groups. Comparing the years, the association of deprivation with caries outcomes mostly remained the same or decreased. This decrease was predominantly seen in "any caries experience." Only among the 5-year-olds, did the association between deprivation and total number of carious teeth over the years significantly increase. For all age groups, the likelihood of "any active caries" and "total number of carious teeth" by deprivation remained the same comparing the two points in time: 2003 and 2013. However, irrespective of year, deprivation was significantly associated with caries observed in all age groups.

CONCLUSION

In the UK, the prevalence of active dental caries and caries experience has decreased in the period between 2003 and 2013. Similarly, the likelihood of having dental caries by deprivation in 2013 was predominantly lower than that observed in 2003.

Variables associated with the oral impact on daily performance of adults in the state of São Paulo: A population-based study

OBJECTIVE

This study aimed to assess the oral impact on daily performance and its association with sociodemographic characteristics, tooth pain, need for prosthesis, and periodontal disease of adults in the state of São Paulo, Brazil.

METHODS

This was a cross-sectional epidemiological study with secondary data obtained from the Oral Health Conditions Project- 2015 conducted in 163 municipalities in the state of São Paulo with the participation of 17,560 individuals. This study evaluated adults in the age-range between 35-44 years (n = 5,855), selected by means of probabilistic cluster sampling in two stages. The outcome variable was the OIDP (Oral Impacts on Daily Performances), obtained by using this instrument to assess daily activities (eating, speaking, oral hygiene, relaxation, sports practice, smile, study/work, social contact, and sleep). The independent variables were collected and grouped into three blocks: Block 1 (sex, age group, and ethnic group); Block 2 (household income and education); and Block 3 (tooth pain, need for prosthesis, bleeding, calculus, and periodontal pockets). A hierarchical multiple logistic regression analysis was performed considering the complex cluster sampling plan. Each observation was assigned a specific weight, depending on the location, which resulted in weighted frequencies adjusted for the effect of outlining.

RESULTS

the female sex (p<0.0001), ethnic group black/mulatto (p<0.0001), low household income (p = 0.0112), up to 8 years of education (p<0.0001), tooth pain (p<0.0001), presence of bleeding (p<0.0001), and presence of periodontal pockets (p<0.0001) had greater oral impact on daily performance.

CONCLUSION

sociodemographic characteristics, tooth pain, and presence of periodontal disease were associated with oral impact on daily performance of the adult population in the state of São Paulo, Brazil.

Oral healthcare systems for an ageing population: concepts and challenges

Oral healthcare systems (OHCS) are designed to maintain the health and function through Communication (Health promotion and education), Prevention, Assessment and Diagnosis, and Treatment. The complexity of these OHCS functions for the ageing are described utilizing the spectrum of dependency of the Seattle Care Pathway framework. Barriers and disparities which challenge the development of OHCS for the ageing can be universal but often vary between developed and developing countries. Recognizing that oral diseases are largely preventable, strategies to improve OHCS must be targeted locally, nationally, and internationally at oral health policy, education, research, and clinical care.

Identifying common factors of functioning, participation and environment amongst adults requiring specialist oral health care using the International Classification of Functioning, disability and health

INTRODUCTION

Persons unable to access oral health care in the conventional primary health care setting suffer from inequalities in oral health, particularly in terms of unmet dental need. The International Classification of Functioning, disability and health (ICF) is designed to look beyond medical diagnosis and to describe individuals or populations in terms of their ability to function and participate in a social environment. The objective of the study was to describe an adult population requiring specialist oral health care using the ICF and to identify common factors of functioning, participation and environmental context.

METHOD

The ICF Checklist for Oral Health was completed for 246 participants from five specialist dental services in five countries (mean age 36 ±16.44 years; 16-92). 'Developmental disability' and 'Medically compromised' groups were identified (72% and 28%).

RESULTS

Participants presented with oral disease (92%) and dysfunction (66% impaired chewing). 33 ICF items were affected in over 50% of participants in both groups. Impaired body functions included 'ingestion functions', 'energy and drive functions' and 'emotional functions'. Participation was restricted for "Acquiring, keeping and terminating a job", "Intimate relationships", "Handling stress and psychological demands", "Economic self-sufficiency", "Carrying out a daily routine", "Recreation and leisure", "Community life" and "Looking after one's health". In the environment domain, "Support and relationships" and "Attitudes" were rated as facilitators. Environmental barriers reported for over 25% of the whole group were related to "Services, systems and policies" including, health, social security, general support, transportation, and labour and employment.

DISCUSSION AND PERSPECTIVES

Common aspects of functioning, participation and environment were found amongst a heterogeneous population of adults attending specialist dental services, alongside poor oral health and function. The ICF may be used to describe populations that suffer inequality in oral health in order to develop services that effectively target those in need of additional means.

Structural Determinants and Children's Oral Health: A Cross-National Study

Much research on children's oral health has focused on proximal determinants at the expense of distal (upstream) factors. Yet, such upstream factors-the so-called structural determinants of health-play a crucial role. Children's lives, and in turn their health, are shaped by politics, economic forces, and social and public policies. The aim of this study was to examine the relationship between children's clinical (number of decayed, missing, and filled teeth) and self-reported oral health (oral health-related quality of life) and 4 key structural determinants (governance, macroeconomic policy, public policy, and social policy) as outlined in the World Health Organization's Commission for Social Determinants of Health framework. Secondary data analyses were carried out using subnational epidemiological samples of 8- to 15-y-olds in 11 countries ( N = 6,648): Australia (372), New Zealand (three samples; 352, 202, 429), Brunei (423), Cambodia (423), Hong Kong (542), Malaysia (439), Thailand (261, 506), United Kingdom (88, 374), Germany (1498), Mexico (335), and Brazil (404). The results indicated that the type of political regime, amount of governance (e.g., rule of law, accountability), gross domestic product per capita, employment ratio, income inequality, type of welfare regime, human development index, government expenditure on health, and out-of-pocket (private) health expenditure by citizens were all associated with children's oral health. The structural determinants accounted for between 5% and 21% of the variance in children's oral health quality-of-life scores. These findings bring attention to the upstream or structural determinants as an understudied area but one that could reap huge rewards for public health dentistry research and the oral health inequalities policy agenda.

Reducing Potentially Preventable Dental Hospitalizations of Young Children: A Community-Level Analysis

An increasing number of Australians are being admitted to hospitals and day procedure centers to have dental treatment under a dental general anesthetic (DGA). Children younger than 2 y are having DGAs. These operations are costly and, although there have been improvements in safety, are not without risk. Most DGAs in children are to treat dental caries and have been defined as potentially preventable dental hospitalizations (PPDHs). This article reports on an analysis of the impact of access to community water fluoridation (CWF), availability of oral health professionals (OHPs), and socioeconomic status (SES) on PPDHs of 0- to 4-y-olds in 2012–2013 in Victoria, Australia. Data on these variables were obtained at the community (postcode) level. From the negative binomial multivariate analysis, each of the 3 independent variables was independently significantly associated with PPDHs at the postcode level. Children residing in postcodes without CWF on average had 59% higher rates than those with access (incident rate ratio [IRR], 1.59; P < 0.0001), children in postcodes with the lowest level of availability of OHPs had 65% higher rates than those with the highest access (IRR, 1.65; P < 0.0001), and children living in the most disadvantaged SES quintiles had 57% higher rates than children in the most advantaged quintiles (IRR, 1.57; P < 0.0001). There was a stepwise social gradient by SES quintile. In analysis of access to CWF and SES status, children without access to CWF had 86% higher PPDH rates than children with access (IRR, 1.86; P < 0.0001). In summary, no access to CWF, poor availability of OHPs, and lower SES status were independently associated with higher PPDH rates among 0- to 4-y-olds in Victoria at the postcode level. The study highlights the importance of considering 3 interacting factors—access to CWF, access to OHPs, and SES—in efforts to reduce PPDH rates in young children.

Knowledge Transfer Statement: Extending access to water fluoridation, increasing the availability of dental services, and raising disadvantaged families’ socioeconomic status are each likely to decrease the rate of dental general anesthetics in young children.

Investigating societal determinants of oral health-Opportunities and challenges in multilevel studies

The high prevalence of oral diseases and the persistent nature of socioeconomic inequalities in oral health outcomes across societies presents a significant challenge for public health globally. A debate exists in epidemiology on the merits of investigating population variations in health and its determinants over studying individual health and its individual risk factors. The choice of analytical unit for health outcomes at the population level has policy implications and consequences for the causal understanding of population-level variations in health/disease. There is a lack of discussion in oral epidemiology on the relevance of studying population variations in oral health. Evidence on the role of societal factors in shaping variations in oral health at both the individual level and the population level is also mounting. Multilevel studies are increasingly applied in social epidemiology to address hypotheses generated at different levels of social organization, but the opportunities offered by multilevel approaches are less applied for studying determinants of oral health at the societal level. Multilevel studies are complex as they aim to examine hypotheses generated at multiple levels of social organization and require attention to a range of theoretical and methodological aspects from the stage of design to analysis and interpretation. This discussion study aimed to highlight the value in studying population variations in oral health. It discusses the opportunities provided by multilevel approaches to study societal determinants of oral health. Finally, it reviews the key methodological aspects related to operationalizing multilevel studies of societal determinants of oral health.

Obesity and caries in four-to-six year old English children: a cross-sectional study

Background

Obesity and caries are common conditions in childhood and can have significant implications on children’s wellbeing. Evidence into their association remains conflicting. Furthermore, studies examining the ssociation between obesity and caries commonly focus on individual-level determinants. The present study aimed to examine the association between obesity and caries in young English children and to determine the impact of deprivation and area-level characteristics on the distribution of the two conditions.

Methods

This was a cross-sectional study among children in Plymouth city aged four-to-six years. Anthropometric measurements included weight and height (converted to Body Mass Index centiles and z-scores), and waist circumference. Caries was assessed by using the sum of the number of teeth that were decayed, missing or filled. A questionnaire was used to obtain information on children’s demographic characteristics, oral hygiene, and dietary habits. The impact of deprivation on anthropometric variables and caries was determined using Linear and Poisson regression models, respectively. Multiple logistic regression was used to assess the association between different anthropometric measures and caries. Logistic regression models were also used to examine the impact of several demographic characteristics and health behaviours on the presence of obesity and caries.

Results

The total sample included 347 children aged 5.10 ± 0.31 (mean ± SD). Deprivation had a significant impact on caries and BMI z-scores (p < 0.05). Neither BMI- nor waist circumference z-scores were shown to be significantly associated with dental caries. Among the neighbourhood characteristics examined, the percentage of people dependent on benefits was found to have a significant impact on caries rates (p < 0.05). Household’s total annual income was inversely related to caries risk and parental educational level affected children’s tooth brushing frequency.

Conclusions

No associations between any measure of obesity and caries were found. However, deprivation affected both obesity and caries, thus highlighting the need to prioritise disadvantaged children in future prevention programmes.

Effect of risk-based payment model on caries inequalities in preschool children assessed by geo-mapping

Background

To describe, with aid of geo-mapping, the effects of a risk-based capitation model linked to caries-preventive guidelines on the polarization of caries in preschool children living in the Halland region of Sweden.

Methods

The new capitation model was implemented in 2013 in which more money was allocated to Public Dental Clinics surrounded by administrative parishes inhabited by children with increased caries risk, while a reduced capitation was allocated to those clinics with a low burden of high risk children. Regional geo-maps of caries risk based on caries prevalence, level of education and the families purchasing power were produced for 3-6-year-old children in 2010 (n = 10,583) and 2016 (n = 7574). Newly migrated children to the region (n = 344 in 2010 and n = 522 in 2016) were analyzed separately. A regional caries polarization index was calculated as the ratio between the maximum and minimum estimates of caries frequency on parish-level, based on a Bayesian hierarchical mapping model.

Results

Overall, the total caries prevalence (dmfs > 0) remained unchanged from 2010 (10.6%) to 2016 (10.5%). However, the polarization index decreased from 7.0 in 2010 to 5.6 in 2016. Newly arrived children born outside Sweden had around four times higher caries prevalence than their Swedish-born peers.

Conclusions

A risk-based capitation model could reduce the socio-economic inequalities in dental caries among preschool children living in Sweden. Although updated evidence-based caries-preventive guidelines were released, the total prevalence of caries on dentin surface level was unaffected 4 years after the implementation.

Electronic supplementary material

The online version of this article (10.1186/s12903-017-0470-6) contains supplementary material, which is available to authorized users.

Waiting room time: An opportunity for parental oral health education

OBJECTIVES

The UBC Children's Dental Program (CDP) has provided free dental treatments to underserved low-income children, but its preventive component needs to be enhanced. The study aims were: 1) to develop a "waiting-room based" dental education program engaging caregivers of these children, and 2) to assess the program's feasibility, acceptability and effectiveness.

METHODS

In preparation, a situational analysis (SA) included structured interviews with caregivers, and with various stakeholders (e.g., dental students, instructors, health authority) involved in the CDP program. Based on the SA, caregiver-centered education was designed using an interactive power point presentation; after the presentation, each caregiver set personalized goals for modifying his/her child's dental behaviours. Evaluation of the program was done with follow-up telephone calls; the program's effectiveness was assessed by comparing before/after proportions of caregivers brushing their child's teeth, children brushing teeth in the morning and evening, children eating sugar-containing snacks, and children drinking sugar-containing drinks.

RESULTS

The program proved to be easy to implement (feasible) and the recruitment rate was 99% (acceptable). The follow-up rate was 81%. The SA identified that the caregivers' knowledge about caries etiology and prevention was limited. All recruited caregivers completed the educational session and set goals for their family. The evaluation demonstrated an increase in caregiver-reported short-term diet and oral self-care behaviours of their children.

CONCLUSION

A dental education program engaging caregivers in the waiting room was a feasible, acceptable and promising strategy for improving short-term dental behaviours of children.

Inequalities in oral health: Understanding the contributions of education and income

OBJECTIVE

To quantify the extent to which income and education explain gradients in oral health outcomes.

METHODS

Using data from the Canadian Community Health Survey (CCHS 2003), binary logistic regression models were constructed to examine the relationship between income and education on self-reported oral health (SROH) and chewing difficulties (CD) while controlling for age, sex, ethnicity, employment status and dental insurance coverage. The relative index of inequality (RII) was utilized to quantify the extent to which income and education explain gradients in poor SROH and CD.

RESULTS

Income and education gradients were present for SROH and CD. From fully adjusted models, income inequalities were greater for CD (RIIinc = 2.85) than for SROH (RIIinc = 2.75), with no substantial difference in education inequalities between the two. Income explained 37.4% and 42.4% of the education gradient in SROH and CD respectively, whereas education explained 45.2% and 6.1% of income gradients in SROH and CD respectively. Education appears to play a larger role than income when explaining inequalities in SROH; however, it is the opposite for CD.

CONCLUSION

In this sample of the Canadian adult population, income explained over one third of the education gradient in SROH and CDs, whereas the contribution of education to income gradients varied by choice of self-reported outcome. Results call for stakeholders to improve affordability of dental care in order to reduce inequalities in the Canadian population.

How does the social "get under the gums"? The role of socio-economic position in the oral-systemic health link

OBJECTIVES

To evaluate the extent of association between systemic inflammation and periodontal disease in American adults, and to assess whether socio-economic position mediated this relationship.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES IV) (2001-2010). Systemic inflammation was defined by individual and aggregate (cumulative inflammatory load) biomarkers (C-reactive protein, white blood cell counts, neutrophil counts, and neutrophil:lymphocyte ratio). Loss of attachment and bleeding on probing were used to define periodontal disease. Poverty:income ratio and education were indicators of socio-economic position. Covariates included age, sex, ethnicity, smoking, alcohol, and attendance for dental treatment. Univariate and multivariable logistic regressions were constructed to assess the relationships of interest.

RESULTS

In a total of 2296 respondents, biomarkers of systemic inflammation and cumulative inflammatory load were significantly associated with periodontal disease after adjusting for age, sex, and behavioural factors. Socio-economic position attenuated the association between markers of systemic inflammation and periodontal disease in the fully adjusted model.

CONCLUSION

Socio-economic position partly explains how systemic inflammation and periodontal disease are coupled, and may thus have a significant role in the mechanisms linking oral and non-oral health conditions. It is of critical importance that the social and living conditions are taken into account when considering prevention and treatment strategies for inflammatory diseases, given what appears to be their impactful effect on disease processes.