Affluent neighborhoods reduce excess risk of tooth loss among the poor

Neighborhood Deprivation and Changes in Oral Health in Older Age: A Longitudinal Population-Based Study

The aim of this study was to examine the extent to which neighborhood-level socioeconomic factors (objective and perceived) are associated with poor oral health in older adults over time, independent of individual socioeconomic position. Data for this cross-sectional and longitudinal observation study came from a socially and geographically representative cohort of men aged 71 to 92 y in 2010-12 (n = 1,622), drawn from British general practices, which was followed up in 2018-19 (aged 78-98 y; N = 667). Dental measures at both times included number of teeth, periodontal pocket depth, self-rated oral health, and dry mouth. Neighborhood deprivation was based on Index of Multiple Deprivation (IMD) and a cumulative index measuring perceptions about local environment. Individual-level socioeconomic position was based on longest-held occupation. Multilevel and multivariate logistic regressions, adjusted for relevant sociodemographic, behavioral, and health-related factors, were performed to examine the relationships of dental measures with IMD and perceived neighborhood quality index, respectively. Cross-sectionally, risks of tooth loss, periodontal pockets, and dry mouth increased from IMD quintiles 1 to 5 (least to most deprived); odds ratios (ORs) for quintile 5 were 2.22 (95% confidence interval [CI], 1.41-3.51), 2.82 (95% CI, 1.72-4.64), and 1.51 (95% CI, 1.08-2.09), respectively, after adjusting for sociodemographic, behavioral, and health-related factors. Risks of increased pocket depth and dry mouth were significantly greater in quintile 5 (highest problems) of perceived neighborhood quality index compared to quintile 1. Over the 8-y follow-up, deterioration of dentition (tooth loss) was significantly higher in the most deprived IMD quintiles after full adjustment (OR for quintile 5 = 2.32; 95% CI, 1.09-4.89). Deterioration of dentition and dry mouth were significantly greater in quintile 5 of perceived neighborhood quality index. Neighborhood-level factors were associated with poor oral health in older age, both cross-sectionally and longitudinally, particularly with tooth loss, and dry mouth, independent of individual-level socioeconomic position.

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.

Oral hygiene behaviours among Australian adults in the National Study of Adult Oral Health (NSAOH) 2017-18

BACKGROUND

This paper examines oral hygiene behaviours (tooth brushing, mouthwash use and dental floss) by a range of explanatory variables.

METHODS

Explanatory variables included age, sex, region, income, area-based SES, dental insurance and visiting pattern. The data reported were collected in the interview survey in NSAOH 2017-18.

RESULTS

A higher percentage of females brushed with toothpaste at least daily (98.0%) and used floss in the last week (62.6%) than males (94.6% and 48.5% respectively). There was an income gradient in tooth brushing. Higher percentages brushed in the high income (96.8%) than middle (96.2%) and low-income tertiles (93.6%). A higher percentage of the high-income tertile (58.2%) flossed than the lower tertile (53.3%). Those with unfavourable visit patterns had lower percentages who brushed daily (92.7%) than the intermediate (96.7%) or favourable (98.2%) groups. There was a gradient in flossing by visiting, with a lower percentage flossing for the unfavourable visiting group (38.5%) than for the intermediate (52.8%) or favourable groups (67.6%).

CONCLUSIONS

Oral hygiene behaviours were associated with gender, socioeconomic status and dental visiting. A higher percentage of women brushed and flossed than men. Lower socioeconomic status and those with unfavourable visiting patterns had lower frequencies of brushing and flossing.

Contextual and individual determinants of tooth loss in adults: a multilevel study

BACKGROUND

Tooth loss represents a known marker of health inequality. The association between tooth loss and unfavorable socioeconomic conditions is evident when analyzed at an individual level. However, the effects of contextual characteristics on tooth loss need to be better investigated and understood. The objective of this study was to analyze tooth loss among Brazilian adults (35-44 years of age), in accordance with individual and contextual social characteristics.

METHODS

This was a multilevel cross-sectional study with data from 9564 adult participants from the Brazilian Oral Health Survey - SBBrasil 2010. The dependent variable was the number of lost teeth and the independent variables were grouped into structural (socioeconomic & political context) and intermediary (socioeconomic position, behavioral & biological factors, and health services) determinants. Multilevel Hierarchical Negative Binomial Regression was conducted and the Mean Ratio (MR) was estimated.

RESULTS

Brazilian adults lost a mean of 7.57 (95% CI 7.1-8.1) teeth. Among the contextual variables, the number of teeth lost was higher among residents of municipalities with high and medium/low Municipal Human Development Index (MHDI) and in municipalities that did not have public water fluoridation. Among the individual variables, dental loss was higher among those who declared themselves yellow/black/brown/indigenous, were older, who had lower income, who had never visited a dentist, who had used dental services for more than a year and those whose most recent visit to the dentist was due to oral health problems. On the other hand, dental loss was lower among adults with higher education levels and males.

CONCLUSIONS

The number of missing teeth was associated with unfavorable contextual and individual conditions, which reinforces the need to reduce social inequality and guarantee regular, lifetime access to dental services.

Assessing the perceived impact of post Minamata amalgam phase down on oral health inequalities: a mixed-methods investigation

Background

Data from countries that have implemented a complete phase out of dental amalgam following the Minamata agreement suggest increased costs and time related to the placement of alternatives with consumers absorbing the additional costs. This aim of this study was to investigate the impact of a complete phase out of dental amalgam on oral health inequalities in particular for countries dependent on state run oral health services.

Methods

A mixed methods component design quantitative and qualitative study in the United Kingdom. The quantitative study involved acquisition and analysis of datasets from NHS Scotland to compare trends in placement of dental amalgam and a survey of GDPs in Yorkshire, UK. The qualitative study involved analysis of the free text of the survey and a supplementary secondary analysis of semi-structured interviews and focus groups with GDPs (private and NHS), dental school teaching leads and NHS dental commissioners to understand the impact of amalgam phase down on oral health inequalities.

Results

Time-trends for amalgam placement showed that there was a significant (p < 0.05) reduction in amalgam use compared with composites and glass ionomers. However dental amalgam still represented a large proportion (42%) of the restorations (circa 1.8 million) placed in the 2016–2017 financial year.

Survey respondents suggest that direct impacts of a phase down were related to increased costs and time to place alternative restorations and reduced quality of care. This in turn would lead to increased tooth extractions, reduced access to care and privatisation of dental services with the greatest impact on deprived populations.

Conclusion

Amalgam is still a widely placed material in state run oral health services. The complete phase down of dental amalgam poses a threat to such services and threatens to widen oral health inequalities. Our data suggest that a complete phase out is not currently feasible unless appropriate measures are in place to ensure cheaper, long-lasting and easy to use alternatives are available and can be readily adopted by primary care oral health providers.

Toothache and Non-Clinical Individual and School Factors in Five-Year-Old Children: Multilevel Analysis

Abstract The objective of the present study was to evaluate the influence of individual and contextual factors on the occurrence of toothache in five-year-old children. A cross-sectional study was conducted with 756 five-year-old children from public and private preschools in a city in the countryside of the northeast of Brazil. The sample was determined through probabilistic sampling in two stages (preschools and children). The children included could not have systematic diseases, permanent tooth or orthodontic treatment. Parents/caregivers were required to spend at least 12 hours per day with their children. The history of toothache during the life of the child was reported by parents/guardians. Socioeconomic and psychological questionnaires were completed by parents/guardians. Variables related to social context were obtained from the preschools in which the children studied and the official publications of the municipal region. Unadjusted and adjusted multilevel Poisson regression models were used to investigate the association between individual and contextual characteristics and history of toothache. The history of toothache was found for 23.8% of the children. Among the individual determinants, gender of the child, order of birth, and schooling of parent/guardian were associated with toothache in children. The individual variables remained associated with the outcome after the addition of the contextual variables to the model. The type of preschool was the contextual determinant associated with toothache in the final model. Both individual (gender, order of birth and schooling of parents/guardians) and contextual (type of preschool) determinants were associated with history of toothache in five-year-old children.

Number of remaining teeth and its association with socioeconomic status in South Korean adults: Data from the Korean National Health and Nutrition Examination Survey 2012-2013

Background

Socioeconomic status (SES) is associated with systemic disease and influences oral and general health. Several studies have found inequalities associated with oral health and SES. We examined the relationship between tooth loss and SES in Korean adults using data from the 2012–2013 Korean National Health and Nutrition Examination Survey. Methods: A total of 7,005 participants were included in this study. Subjects were divided into two groups depending on their total number of natural teeth: <20 and ≥20. Next, participants were divided into quartiles depending on household income and educational level. Multivariate logistic regression was used to obtain odds ratios (OR) for remaining teeth according to income and education levels.

Results

As income and education levels increased, subjects were more likely to have ≥20 remaining teeth (p-value and p-value for trend <0.001), brush their teeth more than three times per day, use extra oral products, and have regular oral-health checkups (all p<0.001). The odds of having ≥20 remaining teeth increased with increases in income and education, after adjusting for all covariates (OR = 1.493 for income Q3, OR = 1.571 for income Q4; OR = 1.763 for 10–12 years education, OR = 2.189 for ≥13years education).

Conclusion

Subjects with higher SES had more remaining teeth than subjects with lower SES. Preserving remaining teeth should be encouraged in subjects with low SES by promoting good oral-health behavior and encouraging more oral-health checkups.

Area-level income inequality and oral health among Australian adults-A population-based multilevel study

Background

A lack of evidence exists on the association between area-level income inequality and oral health within Australia. This study examined associations between area-level income inequality and oral health outcomes (inadequate dentition (<21 teeth) and poor self-rated oral health) among Australian adults. Variations in the association between area-level income inequality and oral health outcomes according to area-level mean income were also assessed. Finally, household-income gradients in oral health outcomes according to area-level income inequality were compared.

Methods

For the analyses, data on Australian dentate adults (n = 5,165 nested in 435 Local Government Areas (LGAs)) was obtained from the National Dental Telephone Interview Survey-2013. Multilevel multivariable logistic regression models with random intercept and fixed slopes were fitted to test associations between area-level income inequality and oral health outcomes, examine variations in associations according to area-level mean income, and examine variations in household-income gradients in outcomes according to area-level income inequality. Covariates included age, sex, LGA-level mean weekly household income, geographic remoteness and household income.

Results

LGA-level income inequality was not associated with poor self-rated oral health and inversely associated with inadequate dentition (OR: 0.64; 95% CI: 0.48, 0.87) after adjusting for covariates. Inverse association between income inequality and inadequate dentition at the individual level was limited to LGAs within the highest tertile of mean weekly household income. Household income gradients in both outcomes showed poorer oral health at lower levels of household income. The household income gradients for inadequate dentition varied according to the LGA-level income inequality.

Conclusion

Findings suggest that income inequality at the LGA-level in Australia is not positively associated with poorer oral health outcomes. Inverse association between income inequality and inadequate dentition is likely due to the contextual differences between Australia and other high-income countries.

Contextual socioeconomic determinants of tooth loss in adults and elderly: a systematic review

OBJECTIVE

To perform a systematic review regarding studies that investigated the association between contextual socioeconomic factors and tooth loss.

METHODS

MEDLINE, Embase, and LILACS databases were searched and no language or date restrictions were applied for this research. The search was also carried out at the Brazilian Library of Theses and Dissertations (BDTD), with the objective of seeking unpublished studies. We evaluated the bibliographical and methodological characteristics of the studies, as well as the findings.

RESULTS

We found 348 articles, out of which only 6 were included in this study after revision by 2 independent researchers. We also identified an unpublished thesis. In general, these results show that the socioeconomic context interferes in tooth loss. We found an association between the highest number of missing teeth with less favorable contextual variables, despite the weak evidence, due to the fact that all selected studies had a cross-sectional design.

CONCLUSION

We suggest the standardization of outcome formats and exposures in order to favor the comparison between studies and their quantitative analysis.

[Factors associated with dental care use among a population of Moroccan adolescents]

INTRODUCTION

Untreated dental caries are a major public health concern because of the impact on quality of life and of the high cost of dental care. Our aim was to identify factors related to dental care use among a population of urban Moroccan adolescents.

MATERIAL AND METHODS

A cross-sectional study involving adolescents in an urban area was conducted. Adolescents were recruited in high schools selected by a cluster sampling method. The studied variables were recorded through a questionnaire and oral examinations. Collected data were socio-demographic parameters, medical insurance status and oral health status using DMFT (Decayed, Missing, Filled Teeth) and SiC (Significant Caries Index) indexes. Logistic regression analysis was applied to evaluate factors associated to dental care use.

RESULTS

Four hundred and fifty adolescents were included in 2012 and 2013. Three hundred and eighty seven (86%) had one untreated dental caries at least. One hundred and seventy-one (38%) had at least one filled teeth. Logistic regression analysis showed that health insurance status, parental income, gender and DMFT index were statistically significant variables associated to dental care use.

DISCUSSION

Renouncement to dental care is not only related to the lack of medical insurance. Other factors such as gender and income level seems to be as important.

Socioeconomic disadvantage and oral-health-related hospital admissions: a 10-year analysis

Objective:

The aim of this Western Australian population study was to assess the relationship of socioeconomic disadvantage and: 1) trends in hospitalisations for oral-health-related conditions over 10 years; 2) insurance status, costs and length of stay in hospital; and 3) specific conditions (principal diagnosis) patients were admitted for.

Methods:

Hospitalisation data (of oral-health-related conditions) were obtained for every episode of discharge from all hospitals in Western Australia for the financial years 1999–2000 to 2008–2009. Area based measures (using the Index of Relative Socioeconomic Disadvantage) was used to determine relationships between socioeconomic status and other variables.

Results:

The most disadvantaged in the population are being hospitalised at significantly higher rates than other groups, stay in hospital for longer, and at higher costs. This trend remained over a period of 10 years. Those least disadvantaged have the second highest rates of hospitalisation, but the likelihood of being admitted for different procedures differ between these two extremes.

Conclusions:

The importance of socioeconomic determinants of health are evident when analysing these hospitalisations. Recognition that lifestyle choices are severely restricted among the most marginalised and disadvantaged groups in the population can no longer be ignored in attempts to reduce health inequalities.

[Adult tooth loss profile in accordance with social capital and demographic and socioeconomic characteristics]

Demographic and socioeconomic conditions play an important role in tooth loss in the population, however, there is little scientific evidence regarding the influence of social capital on this outcome. The scope of this study was to describe the tooth loss profile of adults aged 35-44, who are residents of the surrounding area of the city of Belo Horizonte in the state of Minas Gerais. This cross-sectional exploratory study comprised a sample of 1,013 adults. The dependent variable was tooth loss. Exploratory variables were social capital, demographic and socioeconomic characteristics. The Chi-squared Automatic Interaction Detector (CHAID) was used to map the adult tooth loss profile which was explained by low levels of social capital (47.0%; p < 0.001), more elderly adults (60.2%; p < 0.001), and low education levels (66.3%; p = 0.022). In the high social capital group, age was the determinant factor of tooth loss, irrespective of educational level or per capita income. The conclusion, at the individual level, is that social capital as well as demographic and socio economic characteristics explained the adult tooth loss profile. Individual social capital may have attenuated the negative influence of socioeconomic factors in the population under scrutiny.

Contextual and individual indicators associated with the presence of teeth in adults

OBJECTIVE The objective of this study was to analyze whether socioeconomic conditions and the period of availability of fluoridated water are associated with the number of teeth present. METHODS This cross-sectional study analyzed data from 1,720 adults between 20 and 59 years of age who resided in Florianópolis, SC, Southern Brazil, in 2009. The outcome investigated was the self-reported number of teeth present. The individual independent variables included gender, age range, skin color, number of years of schooling, and per capita household income. The duration of residence was used as a control variable. The contextual exposures included the period of availability of fluoridated water to the households and the socioeconomic variable for the census tracts, which was created from factor analysis of the tract's mean income, education level, and percentage of households with treated water. Multilevel logistic regression was performed and inter-level interactions were tested. RESULTS Residents in intermediate and poorer areas and those with fluoridated water available for less time exhibited the presence of fewer teeth compared with those in better socioeconomic conditions and who had fluoridated water available for a longer period (OR = 1.02; 95%CI 1.01;1.02). There was an association between the period of availability of fluoridated water, per capita household income and number of years of education. The proportion of individuals in the poorer and less-educated stratum, which had fewer teeth present, was higher in regions where fluoridated water had been available for less time. CONCLUSIONS Poor socioeconomic conditions and a shorter period of availability of fluoridated water were associated with the probability of having fewer teeth in adulthood. Public policies aimed at reducing socioeconomic inequalities and increasing access to health services such as fluoridation of the water supply may help to reduce tooth loss in the future.

A Multilevel Approach on Self-Reported Dental Caries in Subjects of Minority Ethnic Groups: A Cross-Sectional Study of 6440 Adults

Regional contextual factors and dental caries using multilevel modeling related to adults in minority ethnic groups have been scantily explored. The influence of the socioeconomic context on self-reported dental caries (SRDC) in individuals of minority ethnic groups (IEG) in Colombia was studied. Data from the 2007 National Public Health Survey were collected in 34,843 participants of the population. The influence of different factors on SRDC in IEG was investigated with logistic and multilevel regression analyses. A total of 6440 individuals belonged to an ethnic group. Multilevel analysis showed a significant variance in SRDC that was smaller in IEG level than between states. Multilevel multivariate analysis also associated SRDC with increasing age, lower education level, last dental visit >1 year, unmet dental need and low Gross Domestic Product (GDP). Minority ethnic groups were at risk to report higher dental caries, where low GDP was an important variable to be considered.

Individual- and community-level social gradients of edentulousness

Background

Community-level factors as well as individual-level factors affect individual health. To date, no studies have examined the association between community-level social gradient and edentulousness. The aim of this study was to investigate individual- and community-level social inequalities in edentulousness and to determine any explanatory factors in this association.

Methods

We analyzed the data from the Japan Gerontological Evaluation Study (JAGES). In 2010-2012, 112,123 subjects aged 65 or older responded to the questionnaire survey (response rate = 66.3%). Multilevel logistic regression analysis was applied to determine the association between community-level income and edentulousness after accounting for individual-level income and demographic covariates. Then, we estimated the probability of edentulousness by individual- and community-level incomes after adjusted for covariates.

Results

Of 79,563 valid participants, the prevalence of edentulousness among 39,550 men (49.7%) and 40,013 women (50.3%) were both 13.8%. Living in communities with higher mean incomes and having higher individual-level incomes were significantly associated with a lower risk of edentulousness (odds ratios [ORs] by 10,000 USD increments were 0.37 (95% confidence interval [CI] [0.22-0.63]) for community-level and 0.85 (95% CI [0.84-0.86]) for individual-level income). Individual- and community-level social factors, including density of dental clinics, partially explained the social gradients. However, in the fully adjusted model, both community- and individual-level social gradients of edentulousness remained significant (ORs = 0.43 (95% CI [0.27-0.67]) and 0.90 (95% CI [0.88-0.91]), respectively). One standard deviation changes in community- and individual-level incomes were associated with 0.78 and 0.84 times lower odds of edentulousness, respectively. In addition, compared to men, women living in communities with higher average incomes had a significantly lower risk of edentulousness (p-value for interaction < 0.001).

Conclusions

Individual- and community-level social inequalities in dental health were observed. Public health policies should account for social determinants of oral health when reducing oral health inequalities.

The relationship between neighborhood empowerment and dental caries experience: a multilevel study in adolescents and adults

OBJECTIVE

To investigate the relationship of contextual social capital (neighborhood empowerment) and individual social capital (social support and social network) with dental caries experience in adolescents and adults.

METHODS

A population-based multilevel study was conducted involving 573 subjects, 15-19 and 35-44 years of age, from 30 census tracts in three cities of Paraíba, Brazil. A two-stage cluster sampling was used considering census tracts and households as sampling units. Caries experience was assessed using the DMFT index (decayed, missing and filled teeth) and participants were divided into two groups according to the median of the DMFT index in low and high caries experience. Demographic, socioeconomic, behaviors, use of dental services and social capital measures were collected through interviews. Neighborhood empowerment was obtained from the mean scores of the residents in each census tract. Multilevel multivariate logistic regression was used to test the relationship between neighborhood empowerment and caries experience.

RESULTS

High caries experience was inversely associated with neighborhood empowerment (OR = 0.58; 95%CI 0.33-0.99). Individual social capital was not associated with caries experience. Other associated factors with caries experience were age (OR = 1.15; 95%CI 1.12-1.18) and being a female (OR = 1.72; 95%CI 1.08-2.73).

CONCLUSION

The association between neighborhood empowerment and caries experience suggests that the perception of features of the place of residence should be taken into account in actions of oral health promotion.

Social capital and oral health

Social determinants have always been an important element of the oral health. It has been seen that social aspects like the organizations and relations influence the health of population. A new domain named social capital has come up into limelight which refers to "features of social organization, such as trust, norms and networks that can improve the efficacy of society by facilitating coordinated actions". The bonds between individuals, both in intimate relationships and in voluntary associations have been claimed to have health promoting effects. Oral health can never be segregated from general health as they are bidirectional in their relationship. Therefore determinants of general health and its promotion are interlinked with that of oral health. So, this review tries to figure out the effects of social capital on various aspects of oral health.

Social determinants of dental treatment needs in Brazilian adults

BACKGROUND

The chronic cumulative nature of caries makes treatment needs a severe problem in adults. Despite the fact that oral diseases occur in social contexts, there are few studies using multilevel analyses focusing on treatment needs. Thus, considering the importance of context in explaining oral health related inequalities, this study aims to evaluate the social determinants of dental treatment needs in 35-44 year old Brazilian adults, assessing whether inequalities in needs are expressed at individual and contextual levels.

METHODS

The dependent variables were based on the prevalence of normative dental treatment needs in adults: (a) restorative treatment; (b) tooth extraction and (c) prosthetic treatment. The independent variables at first level were household income, formal education level, sex and race. At second level, income, sanitation, infrastructure and house conditions. The city-level variables were the Human Development Index (HDI) and indicators related to health services. Exploratory analysis was performed evaluating the effect of each level through calculating Prevalence Ratios (PR). In addition, a three-level multilevel modelling was constructed for all outcomes to verify the effect of individual characteristics and also the influence of context.

RESULTS

In relation to the need for restorative treatment, the main factors implicated were related to individual socioeconomic position, however the city-level contextual effect should also be considered. Regarding need for tooth extraction, the contextual effect does not seem to be important and, in relation to the needs for prosthetic treatment, the final model showed effect of individual-level and city-level. Variables related to health services did not show significant effects.

CONCLUSIONS

Dental treatment needs related to primary care (restoration and tooth extraction) and secondary care (prosthesis) were strongly associated with individual socioeconomic position, mainly income and education, in Brazilian adults. In addition to this individual effect, a city-level contextual effect, represented by HDI, was also observed for need for restorations and prosthesis, but not for tooth extractions. These findings have important implications for the health policy especially for financing and planning, since the distribution of oral health resources must consider the inequalities in availability and affordability of dental care for all.

Social oral epidemi(olog)(2) y where next: one small step or one giant leap?

Since the early 1990s, there has been heated debate critically reflecting on social epidemiology. Yet, very little of this debate has reached oral epidemiology. This is no more noticeable than in the field of oral health inequalities. One of the significant achievements of social oral epidemiology has been the persistent documentation of social patterning of oral disease. Nevertheless, where social oral epidemiology has fallen down is going beyond description to explaining these patterns. Thinking how and in what way things happen, not just in relation to oral health inequalities but also more broadly, requires a more creative approach which links to scholarship outside of dentistry, including the work from critical epidemiologists to that within the social sciences. The aim of this review study is to provide a critical commentary on key aspects of more general epidemiological debates in order to inform and develop social oral epidemiology theory and methodology. In the first section, 'Where are we now?', six key debates are reflected upon: (i) analysis of variance versus analysis of causes, (ii) the fallacy of independent effects, (iii) black box thinking, (iv) theory and the understanding of mechanisms, (v) individualization of risk and (vi) the meaning of 'social'. In the second section, 'Where to next?' we draw on a number of fundamental issues from within the social science literature in order to highlight possible channels of future inquiry. Our overriding goal throughout is to facilitate a critical engagement in order to improve understanding and generate knowledge in relation to population oral health.

Oral health, oral pain, and visits to the dentist: neighborhood influences among a large diverse urban sample of adults

The objective of this study was to assess the association between oral health and individual-level characteristics as well as both socioeconomic position (SEP) and service provision characteristics at the neighborhood level. Multilevel logistic analysis was undertaken of data from the Neighbourhood Effects on Health and Well-being Study in Toronto comprising 2,412 participants living in 47 neighborhoods and 87 census tracts. Three oral health outcomes were investigated: last dental visit, self-rated oral health, and self-rated oral pain. Results indicated that SEP was significantly associated with no dental visits in the last year, poor self-rated oral health, and experiencing oral pain after adjusting for age, gender, and immigrant status. Lack of dental insurance was associated with no visits to the dentist in the last year and poor self-rated oral health; however, no association was observed with oral pain. In adjusted regression models, few neighborhood level variables were significantly associated with dental visits and self-rated oral health and no neighborhood variables were associated with oral pain. Based on these results, SEP appears to be important in evaluating oral health outcomes. While insignificant in this study, neighborhood factors are important when considering the impact of service provision on oral health.

Social capital and dental pain in Brazilian northeast: a multilevel cross-sectional study

BACKGROUND

There is limited evidence on possible associations between social determinants and dental pain. This study investigated the relationship of neighborhood and individual social capital with dental pain in adolescents, adults and the elderly.

METHODS

A population-based multilevel study was conducted involving 624 subjects from 3 age groups: 15-19, 35-44 and 65-74 years. They were randomly selected from 30 census tracts in three cities in the State of Paraíba, Brazil. A two-stage cluster sampling was used considering census tracts and households as sampling units. The outcome of study was the presence of dental pain in the last 6 months. Information on dental pain, demographic, socio-economic, health-related behaviors, use of dental services, self-perceived oral health and social capital measures was collected through interviews. Participants underwent a clinical examination for assessment of dental caries. Neighborhood social capital was evaluated using aggregated measures of social trust, social control, empowerment, political efficacy and neighborhood safety. Individual social capital assessment included bonding and bridging social capital. Multilevel logistic regression was used to test the relationship of neighborhood and individual social capital with dental pain after sequential adjustment for covariates.

RESULTS

Individuals living in neighborhoods with high social capital were 52% less likely to report dental pain than those living in neighborhoods with low social capital (OR = 0.48, 95% CI = 0.27-0.85). Bonding social capital (positive interaction) was independently associated with dental pain (OR = 0.88, 95% CI = 0.80-0.91). Last dental visit, self-perceived oral health and number of decayed teeth were also significantly associated with dental pain.

CONCLUSIONS

Our findings suggest that contextual and individual social capital are independently associated with dental pain.

Reduction of social inequalities in utilization of dental care in Brazil from 1998 to 2008

OBJECTIVE

To analyze access to and utilization of dental care services in Brazil.

METHODS

We used data from the 2003 and 2008 Brazilian National Household Surveys, which we compared to data from the 1998 survey. We investigated access and utilization variables at ages three, six, nine, 12, 15, and 19 years in the first (Q1) and fifth (Q5) quintiles of per capita family income. All analyses took into account the complex sampling strategy.

RESULTS

The proportion of subjects that had never seen a dentist decreased during the period (18.7% in 1998, 15.9% in 2003 and 11.7% in 2008). There was an important reduction in the absolute difference in failure to use dental care services after age nine years between Q1 and Q5 from 1998 to 2008, which decreased to about half its value at 15 (30.3 percentage points - pp to 16.1 pp) and 19 years (20.4 pp to 9.9 pp). Q5/Q1 ratios for recent dental appointments fell across all age groups, especially between zero and six years (Q5/Q1 from 3.2 to 2.6); utilization of the National Health Care System for dental care increased in Q1 and Q5, with a reduction in the Q1/Q5 ratio of approximately 20%. Use of the National Health Care System for dental care increased by approximately 8% in Q1 and 35% in Q5 between 2003 and 2008.

CONCLUSIONS

There have been considerable advances in terms of reducing inequalities in access to, and increasing the utilization of, dental care services in Brazil between 1998 and 2008. However, inequality between social groups remains substantial.

Adjusting for confounding by neighborhood using a proportional odds model and complex survey data

In social epidemiology, an individual's neighborhood is considered to be an important determinant of health behaviors, mediators, and outcomes. Consequently, when investigating health disparities, researchers may wish to adjust for confounding by unmeasured neighborhood factors, such as local availability of health facilities or cultural predispositions. With a simple random sample and a binary outcome, a conditional logistic regression analysis that treats individuals within a neighborhood as a matched set is a natural method to use. The authors present a generalization of this method for ordinal outcomes and complex sampling designs. The method is based on a proportional odds model and is very simple to program using standard software such as SAS PROC SURVEYLOGISTIC (SAS Institute Inc., Cary, North Carolina). The authors applied the method to analyze racial/ethnic differences in dental preventative care, using 2008 Florida Behavioral Risk Factor Surveillance System survey data. The ordinal outcome represented time since last dental cleaning, and the authors adjusted for individual-level confounding by gender, age, education, and health insurance coverage. The authors compared results with and without additional adjustment for confounding by neighborhood, operationalized as zip code. The authors found that adjustment for confounding by neighborhood greatly affected the results in this example.

Dentistry and population approaches for preventing dental diseases

Dental professionals are expected to engage in oral disease prevention, but their tools limit the approach to chair side activities based on the common notion that the major dental diseases, dental caries, gingivitis and periodontitis, are behavioural diseases shaped by individual lifestyles. However, lifestyles also have causes and individual behaviours reflect cultural norms, expectations and opportunities that are socio-economically determined and structurally maintained. Importantly, the effects of the societal and socio-economic determinants reach way above their influences as individual attributes, and effective approaches to the prevention and control of oral diseases are aligned with this causal chain. Unfortunately, the ethos and philosophy of dentistry is focused to a downstream, patient-centred, curative and rehabilitative approach to oral diseases. Whilst such services are needed to care for those who have already suffered the consequences of oral diseases, they do not influence population oral health. A more balanced distribution of efforts and resources along the whole range of intervention points from the downstream curative to the upstream structural healthy policy approaches is required if appropriate, evidence-based, effective, cost-effective, sustainable, equitable, universal, comprehensive and ethical delivery of health care, including oral health care, is the goal. The implementation of healthy policies and sound approaches to population oral health will require substantial commitment and political will on the part of the public and their elected officials.

The association between individual and contextual factors and functional dentition status among adults in Rio Grande do Sul State, Brazil: a multilevel study

Functional dentition plays an important role in maintaining masticatory function, which is closely related to the number of teeth present in the mouth. The objective of this study was to investigate the association between individual and contextual factors and functional dentition (defined as the presence of at least 20 teeth) in Brazilian adults. This was a multilevel cross-sectional population-based study with a two-level structure and a total sample of 10,407 adults from 84 municipalities (counties). The exposures at both levels were demographic, socioeconomic, and oral health treatment-related. Multivariate analyses showed that higher prevalence rates of functional dentition were associated (p < 0.01) with municipalities having higher mean income and fluoridated water supply and with individuals living in urban areas, younger adults, males, those with more schooling and higher income, those that reported having visited the dentist in the previous 12 months, and those with access to information on prevention. The findings suggest that research on tooth loss and functional dentition should take different socioeconomic factors into account.

Income Inequality and Tooth Loss in the United States

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

Contextual and individual assessment of dental pain period prevalence in adolescents: a multilevel approach

BACKGROUND

Despite evidence that health and disease occur in social contexts, the vast majority of studies addressing dental pain exclusively assessed information gathered at individual level.

OBJECTIVES

To assess the association between dental pain and contextual and individual characteristics in Brazilian adolescents. In addition, we aimed to test whether contextual Human Development Index is independently associated with dental pain after adjusting for individual level variables of socio-demographics and dental characteristics.

METHODS

The study used data from an oral health survey carried out in São Paulo, Brazil, which included dental pain, dental exams, individual socioeconomic and demographic conditions, and Human Development Index at area level of 4,249 12-year-old and 1,566 15-year-old schoolchildren. The Poisson multilevel analysis was performed.

RESULTS

Dental pain was found among 25.6% (95%CI = 24.5-26.7) of the adolescents and was 33% less prevalent among those living in more developed areas of the city than among those living in less developed areas. Girls, blacks, those whose parents earn low income and have low schooling, those studying at public schools, and those with dental treatment needs presented higher dental-pain prevalence than their counterparts. Area HDI remained associated with dental pain after adjusting for individual level variables of socio demographic and dental characteristics.

CONCLUSIONS

Girls, students whose parents have low schooling, those with low per capita income, those classified as having black skin color and those with dental treatment needs had higher dental pain prevalence than their counterparts. Students from areas with low Human Development Index had higher prevalence of dental pain than those from the more developed areas regardless of individual characteristics.