[The Common Risk Factor Approach - An Integrated Population- and Evidence-Based Approach for Reducing Social Inequalities in Oral Health]. / Common Risk Factor Approach ­ Ein integrierter bevölkerungsbezogener und evidenzbasierter Ansatz zum Ausgleich sozialer Ungleichheiten in der Mundgesundheit.

Worldwide, non-communicable diseases including dental caries and periodontal diseases, remain a major public health problem. Moreover, there is a social gradient in health across society that runs from the top to the bottom in a linear, stepwise fashion. Health promoting behaviours become more difficult to sustain further down the social ladder. Oral health inequalities also exist in Germany. Earlier explanations of social inequalities have mainly focused on individual lifestyle factors, ignoring the broader social determinants of health and disease. Until recently, the dominant approaches to general health promotion focused on actions to reduce specific diseases, separating oral health from general health. An alternative approach is the common risk factor approach (CRFA) where risk factors common to a number of major chronic diseases, including diseases of the mouth and teeth, are tackled. The CRFA focuses on the common underlying determinants of health to improve the overall health of populations, thereby reducing social inequalities. The main implication of the CRFA for oral health policies is to work in partnership with a range of other sectors and disciplines. Oral health issues need to be integrated with recommendations to promote general health. Improvements in oral health and a reduction in oral health inequalities are more likely by working in partnership across sectors and disciplines using strategies that focus upstream on the underlying determinants of oral diseases.

Reducing Inequalities in Oral Health in the Africa and Middle East Region.

Dentistry is facing many serious challenges and threats. Addressing them will require major changes in strategy. This work outlines the extent of dental disease in the Africa and Middle East Region (AMER) and suggests strategies to reduce inequalities in oral health. The main oral health challenges in the AMER relate to controlling the relentless increase in caries with age. A very conservative estimate of population caries levels suggests that a 5-fold increase in dental personnel would be required just to treat current levels of caries. Hence, we argue that current approaches to control caries in the AMER are both ineffective and unaffordable, and a new model to promote oral health is needed. Unless determinants of noncommunicable diseases are addressed and access to evidence-based minimal intervention dental care is improved, the burden of dental disease will persist. The new oral health promotion model calls for an integrated intersectoral common risk factor approach, namely, "oral health in all policies" (OHiAP). An OHiAP framework will initiate high-level policy initiatives and intersectoral partnerships. Oral health professionals have an important advocacy role in securing the fundamental changes in health strategy needed to control the growing, unjust, and unaffordable burden of oral disease.

Impacts on quality of life related to dental caries in a national representative sample of Thai 12- and 15-year-olds.

Dental caries is generally given the highest priority in national oral health services for school-aged populations. Yet, there is no study exploring the impacts on quality of life specifically related to dental caries in national samples of school-aged children. This study assessed prevalence and characteristics of oral impacts attributed to dental caries on quality of life and compared them with overall oral health impacts. In addition, associations of oral impacts attributed to dental caries and dental caries status were investigated. A national representative sample of 1,063 12- and 811 15-year-olds completed a sociodemographic and behavioural questionnaire, and were orally examined and interviewed about oral health-related quality of life using the Child-OIDP or OIDP indexes, respectively. Associations of condition-specific impacts (CS impacts) attributed to dental caries with components of DMF were investigated using χ(2) tests and multivariate logistic regressions. CS impacts attributed to dental caries were reported by nearly half the children and such impacts accounted for half of overall oral impacts from all oral conditions. The majority of impacts were of little intensity and affected only 1-2 daily performances, particularly performances on Eating, Emotional stability and Cleaning teeth. CS impacts were significantly positively associated with number of decayed teeth, and strongly associated with severe decay.

Sociodemographic differences in oral health-related quality of life related to dental caries in thai school children.

OBJECTIVE: This study aimed to assess associations between sociodemographic and oral health behavioural factors with dental caries and oral health-related quality of life (OHRQoL) attributed to dental caries in a national representative sample of 12- and 15-year-old Thai children. METHOD: A representative subsample from the sixth Thailand National Oral Health Survey, 1,063 12-year-olds and 811 15-year-olds, completed a questionnaire on sociodemographic and behavioural information and were orally examined and interviewed about OHRQoL using the Child-OIDP or OIDP indexes. Associations of sociodemographic and behavioural factors with DMFT and Condition-Specific impacts (CS-impacts) attributed to dental caries were investigated using Chi-square tests and regressions. RESULTS: For both groups, DMFT scores were associated with gender, geographic area and recently receiving dental treatment. Geographic area was the only sociobehavioural factor independently associated with CS-impacts. Dental caries accounted for the significant associations of sugary snacks and drinks consumption with CS-impacts. Significant associations of CS-impacts with consuming crispy snacks in 12-year-olds and fizzy drinks in 15-year-olds became non-significant when DT was entered into models. CONCLUSIONS: There were considerable geographic differences in DMFT and CS-impacts attributed to dental caries among Thai children.

The relation between oral impacts on daily performances and perceived clinical oral conditions in primary school children in the Ugu District, Kwazulu Natal, South Africa.

UNLABELLED: Few studies have related the common oral health related quality of life (OHRQoL) impacts in children to perceived causes. OBJECTIVE: To assess the prevalence, extent and intensity of oral impacts in relation to perceived clinical conditions in primary school children in South Africa. METHODS: Cross-sectional study of a random sample of children attending 26 schools. The Child Oral Impacts on Daily Performance (Child-OIDP) index, administered through individual face-to-face interviews, was used. RESULTS: Sixty four per cent of the sample of 2610 children aged 11-13 years participated. 36.2% reported having one or more oral impacts on daily performances, 61.1% having one affected and 63.1% reporting impacts were of "very little" or "little" intensity. Eating was most commonly affected (22.8%) mainly related to decay (40%), followed by cleaning the teeth (17.2%). Toothache impacted on speaking (32.5%), whereas toothache (35.7%) and tooth decay (28.6%) influenced studying. Position of teeth impacted on smiling (19.2%), social (8.5%) and speaking (7.5%). Bleeding gums" and "tooth colour" affected cleaning teeth and smiling respectively. CONCLUSIONS: The prevalence of oral impacts on the quality of life in this South African population of schoolchildren was relatively modest, as was the extent and intensity of the impacts, affecting mainly eating, cleaning of teeth and smiling.

Global oral health inequalities: task group--implementation and delivery of oral health strategies.

This paper reviews the shortcomings of present approaches to reduce oral diseases and inequalities, details the importance of social determinants, and links that to research needs and policies on implementation of strategies to reduce oral health inequalities. Inequalities in health are not narrowing. Attention is therefore being directed at determinants of major health conditions and the extent to which those common determinants vary within, between, and among groups, because if inequalities in health vary across groups, then so must underlying causes. Tackling inequalities in health requires strategies tailored to determinants and needs of each group along the social gradient. Approaches focusing mainly on downstream lifestyle and behavioral factors have limited success in reducing health inequalities. They fail to address social determinants, for changing people's behaviors requires changing their environment. There is a dearth of oral health research on social determinants that cause health-compromising behaviors and on risk factors common to some chronic diseases. The gap between what is known and implemented by other health disciplines and the dental fraternity needs addressing. To re-orient oral health research, practice, and policy toward a 'social determinants' model, a closer collaboration between and integration of dental and general health research is needed. Here, we suggest a research agenda that should lead to reductions in global inequalities in oral health.

Using universal patterns of caries for planning and evaluating dental care.

There are universal patterns of caries, in terms of prevalence, incidence, frequency distribution and rates of progression, in permanent teeth that can be considered working rules that can be applied when planning dental care. The universal patterns are: (1) caries levels follow trend lines; therefore, knowing the caries level at one age can be used to predict the levels at later ages in that cohort by looking at the trend line for that cohort; (2) the distribution of dental caries of a population exhibits the following characteristics: as the mean DMFT increases, the percentage of caries-free individuals falls and the caries distribution widens; this changing relationship between the mean DMFT and prevalence is not limited to a subgroup of the population who already have had some caries experience; (3) there is a specific mathematical relationship between the mean DMFT and mean DMFS; (4) there is a hierarchy of caries susceptibility by tooth type and sites on teeth; for a given DMFT or DMFS, there is a specific intra-oral pattern of caries by tooth type; (5) changes in mean DMFT scores for individuals and groups are not linear, but 'stepped'; there are groupings of teeth and tooth sites that may have similar 'resistance' to caries; (6) as the mean DMFT declines, the posteruptive time for initiation of caries increases and the progression rate of caries through enamel decreases. This is true regardless of the presence of fluoride. Any improvement in dental health will cause this effect.

Income, income inequality, dental caries and dental care levels: an ecological study in rich countries.

Research has shown that beyond a certain level of absolute income, there is a weak relationship between income and population health. On the other hand, relative income or income inequality is more strongly related to health than absolute income in rich countries. The objective of this study was to assess the relationships of income and income inequality with dental caries and dental care levels in 35- to 44-year-old adults among rich countries. Income was assessed by gross domestic product and gross national income, income inequality by Gini coefficient and the ratio between the income of the richest and poorest 20% of the population, dental caries by DMFT and dental care levels by the care, restorative and treatment indices. Pearson and partial correlation were used to examine the relationships between income, income inequality, caries experience and dental care. Income measures were not related to either dental caries or dental care levels. However, income inequality measures were inversely and significantly related to number of filled teeth, DMFT, care index and restorative index, but not to number of decayed or missing teeth. It is concluded that DMFT scores were higher in more equal countries and may be explained by greater levels of restorative care in those countries.

Impacts on daily performances attributed to malocclusions by British adolescents.

The aim of this study was to assess the prevalence of condition-specific impacts on daily performances attributed to malocclusion in British adolescents. Two hundred 16- to 17-year-old adolescents were randomly selected from 957 children attending a public college in London, UK. During interviews, participants provided information about demographic variables and socio-dental impacts on quality of life attributed to malocclusions, using the Condition-Specific form of the Oral Impacts on Daily Performances (CS-OIDP) index. Adolescents were also clinically examined using the Index of Orthodontic Treatment Need. Statistical comparison by covariates was performed using chi-squared test and chi-squared test for trends. The prevalence of oral impacts on daily performances attributed to any oral condition was 26.5% whereas the prevalence of CS-OIDP attributed to malocclusion was 21.5%. There was no statistically significant difference by sex, age, ethnicity or orthodontic treatment status of schoolchildren in the prevalence of CS-OIDP attributed to malocclusion (P >/= 0.243 for all cases). However, there was a linear trend for the prevalence of CS-OIDP attributed to malocclusion, by level of normative orthodontic treatment need (P = 0.042). The prevalence of such impacts increased from 16.8% for adolescents with no/slight need for orthodontic treatment, to 31.7% for those with definite need for orthodontic treatment. Although findings support the idea that malocclusion has physical, psychological and social effects on quality of life of these adolescents, the inconsistencies in findings between the self-reports of impacts of malocclusion and the assessment of normative needs highlight the shortcomings of using only clinical indexes to estimate orthodontic treatment needs.

The relationship between periodontitis and preterm low birthweight.

There is no consensus about the influence of periodontal disease on preterm low birthweight. The objective was to investigate the relationship between periodontal disease and preterm low birthweight. A case-control study with 542 post partum women aged over 30 yrs was conducted. Three groups of cases were compared with non-preterm and non-low-birthweight control individuals (n = 393): low birthweight (n = 96), preterm (n = 110), and preterm and low birthweight (n = 63). Periodontal clinical parameters and covariates were recorded. Periodontal disease levels were higher in control individuals than in cases. The extent of periodontal disease did not increase risk of preterm low birthweight according to 15 measures of periodontal disease. Mean periodontal pocket depth and frequency of periodontal sites with clinical attachment level > or = 3 mm in preterm low birthweight cases were lower than in control individuals. Periodontal disease was not more severe in women with preterm low birthweight babies.

The relationship between periodontal disease and preterm low birthweight: clinical and microbiological results.

BACKGROUND AND OBJECTIVE: Findings on the effect of periodontal disease on preterm low birthweight are inconclusive. The objective of this study was to compare periodontal clinical measures and the levels and proportions of 39 bacterial species in subgingival biofilm samples in puerperal women with preterm low birthweight and nonpreterm low birthweight. MATERIAL AND METHODS: A case-control study with 116 postpartum women over 30 years of age was conducted. Four case groups of subjects with preterm and/or low birthweight [preterm (n = 40), low birthweight (n = 35), preterm and/or low birthweight (n = 50) and preterm and low birthweight (n = 25)] were compared with normal nonpreterm low-birthweight controls (n = 66). Periodontal clinical parameters of dental plaque, calculus, bleeding on probing, periodontal pocket depth and clinical attachment level were recorded. Covariates included socio-demographic and anthropometric characteristics, smoking, alcohol consumption, obstetric history, prenatal care and diseases during pregnancy. Two subgingival biofilm samples per women were analyzed for 39 bacterial species using a checkerboard DNA-DNA hybridization technique. RESULTS: The mean periodontal pocket depth was significantly higher in nonpreterm low-birthweight controls than in subjects in the preterm low birthweight, preterm and/or low birthweight, and preterm and low-birthweight groups. Clinical attachment level measures were not different between all pairs of cases and control groups. Groups did not differ with respect to the mean proportions of different microbial complexes. The mean counts of Treponema socranskii were lower in all case groups compared with the control group. CONCLUSION: Maternal periodontal microbiota and clinical characteristics of periodontal disease were not associated with having preterm low-birthweight babies.

Antibodies to periodontal pathogens and coronary artery calcification in type 1 diabetic and nondiabetic subjects.

BACKGROUND AND OBJECTIVE: The aim of this study was to examine whether serum immunoglobulin G (IgG) levels to Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans are higher in type 1 diabetic patients than in controls and are associated with coronary artery calcification, a measure of atherosclerosis. MATERIAL AND METHODS: One-hundred and ninety nine type 1 diabetic patients (mean age 38 +/- 4 years) and 201 age- and gender-matched nondiabetic subjects had coronary artery calcification, as measured by electron beam computed tomography. Serum IgG levels to P. gingivalis W50 and to A. actinomycetemcomitans HK1651 whole cells were measured by enzyme-linked immunosorbent assay. RESULTS: A similar proportion of diabetic patients (29%) and controls (31%, p = 0.7) had elevated serum IgG to periodontal bacteria, defined as being above the median antibody level for both microorganisms. Elevated antibody levels were associated with higher systolic blood pressure (p = 0.02) and an increased odds of coronary artery calcification in all subjects combined (odds ratio = 1.7, p = 0.047) and in diabetic subjects examined separately (odds ratio = 2.01, p = 0.027). Association of serum IgG levels with coronary artery calcification was independent of social class, lipids and antibody levels to other microorganisms, but not systolic blood pressure (odds ratio = 1.4, p = 0.1 on adjustment for blood pressure). There was no association between serum IgG level and vascular endothelial function. CONCLUSION: Elevated levels of serum IgG to P. gingivalis and A. actinomycetemcomitans are associated with coronary artery atherosclerosis. This may reflect a direct role for periodontal infection or a role for the host response to infection in coronary atherosclerosis, particularly in patients with type 1 diabetes.

Relationship between height and dental caries in adolescents.

Taller stature is associated with better health status. The objective of this study was to test the hypothesis that taller Brazilian adolescents have lower levels of caries experience. Data were collected through questionnaires, clinical examinations for oral health and anthropometric measures from a cross-sectional study conducted in Goiânia, Brazil, on 664 randomly selected 15-year-old schoolchildren. Variables analyzed were adolescents' caries experience (DMFT and DMFS index) as outcome variables, height as an explanatory variable and social class, school performance, exposure to fluoride, frequency of sugar consumption and pattern of dental attendance as possible confounders. Polytomous ordered regression was used in the data analysis. A decreased risk of having higher DMFT levels was found among taller adolescents in quintile 3 (OR = 0.63, CI 0.40-0.99) and in the highest quintile (OR = 0.54, CI 0.35-0.82), while an increased risk was found among those from low social class compared with those from high social class (OR = 1.45, CI 1.10-1.91) and those who had at least one school failure compared with those who had never failed (OR = 1.57, CI 1.17-2.10). A decreased risk of having higher DMFS levels was found among the tallest adolescents (OR = 0.55, CI 0.36-0.83), while an increased risk was found among those from low social class compared with those from high social class (OR = 1.57, CI 1.20-2.07) and those who had at least one school failure compared with those who had never failed (OR = 1.66, CI 1.24-2.23). The hypothesis that taller adolescents have lower levels of caries experience was confirmed in the sample of the present study.

Comparison of ranking dental status using the Significant Caries Index and the Significant Filled and Sound-Teeth Index.

OBJECTIVE: The objective was to test whether the ranking of countries was different using the SFS-T (Significant Filled Sound-Teeth Index) or the Significant Caries Index (SIC). METHOD: This study compared the country rankings using the SiC and the SFS-T indices in 12 year olds in a range of countries. The SFS-T is the one-third of the population with the lowest filled or sound teeth and is a measure of functional status. We used the SiC and DMFT data from the WHO database for 12 year olds. SFS-T index values were estimated for the 12 year olds for 16 countries. RESULTS: The ranking by SiC index scores was lower for developed countries than for developing countries. CONCLUSIONS: These findings suggest that it may be more useful to use the SFS-T index than the SiC index in studies comparing dental status between countries.

Time absent from school due to dental conditions and dental care in Thai schoolchildren.

OBJECTIVES: To assess the number of school hours missed for dental reasons per 1,000 grade 5 primary school children in 1 school year and compare dentally related school absences with those related to medical and social reasons. METHODS: A longitudinal study using a multistage sampling technique was carried out on a sample of 1,211 children attending schools in Lampang province, Thailand. Data on absence were collected from daily school attendance records for 1 year and from children and parents questionnaires and school dental clinic records. Clinical examinations were done using the World Health Organization criteria. RESULTS: A total of 1,158 children (response rate: 95.7 percent) aged 9 to 13 years were examined and returned completed questionnaires. Their caries level was relatively low (DMFT 1.4 +/- 1.7). The children (22.5 percent) reported school absence for any dental reason. The mean number of hours of school absence per year for dental care was 434 hours per 1,000 children (613 hours per 1,000 children when dental screening was included). Among those who actually missed school for dental reasons, the numbers of hours missed were 1,923 hours per 1,000 children. CONCLUSIONS: The level of school absence for dental-related conditions and care was low per child but cumulatively was considerable. The time missed because of dental reasons was substantially less than the time missed because of other health and social reasons.

Development and evaluation of an index of eating difficulty for older southern Chinese people.

The objectives of this study were to develop and evaluate the validity and reliability of a new index to assess difficulty in eating certain foods among older southern Chinese people. The Index of Eating Difficulty (IED) was developed using a Guttman scaling analysis. After two pilot studies in which subjects were asked to grade 39 typical, frequently eaten Chinese foods, 10 of the 39 foods were selected and divided into five groups based on their texture and frequency of being eaten by older people. In the main study, 1229 Chinese generally healthy subjects aged 55 years and above, attending routine health checks in the Check-up Centre of the First Affiliated Hospital of Guangxi Medical University, Nanning of Guangxi province, China were interviewed to psychometrically test the index. Content, face and criterion validity, coefficients of reproducibility and scalability and test-retest reliability were tested. For criterion validity, the index was significantly associated with three other established eating difficulty measures, namely, general eating difficulty, dissatisfaction with chewing ability and oral impact on daily performances eating scores (P < 0.001 for all tests). The coefficients of reproducibility and scalability were 0.99 and 0.89, respectively. Weighted kappa for test-retest reliability was 0.89. The present results indicate that the IED is a valid and reliable measure to be used among older southern Chinese people.

Numbers of natural teeth, diet, and nutritional status in US adults.

Evidence that dental status affects diet is equivocal. The hypothesis of this study was that diet was affected by dental status. The objective was to assess the relationship between numbers of teeth and diet and nutritional status in US adult civilians without prostheses. We examined 6985 NHANES (1988-1994) participants. Data included socio-economics, demographics, dental status, and diet and nutritional status. Dietary data were obtained from food frequency questionnaires and 24-hour dietary recall. Serum levels of beta carotene, folate, and vitamin C were measured with isocratic high-performance liquid chromatography. The population was classified by numbers of teeth. Covariance and Satterthwaite F-adjusted statistical comparisons were made between tooth groupings and the fully dentate population. Multilinear regression models adjusted for covariates. People with fewer than 28 teeth had significantly lower intakes of carrots, tossed salads, and dietary fiber than did fully dentate people, and lower serum levels for beta carotene, folate, and vitamin C. Dental status significantly affects diet and nutrition.

Social gradients in oral and general health.

There are social gradients in general health and oral health. However, there have been few studies addressing whether similarities exist in the gradients in oral and general health in the same individuals. We set out to test, using data from NHANES III, whether there are social gradients in oral health, and whether they resemble the gradients in general health. Income, indicated by poverty-income ratio, and education gradients were examined in periodontal diseases, ischemic heart disease, and perceived oral/general health. Our analysis demonstrated consistent income and education gradients in all outcomes assessed. In the adjusted regression models, the probabilities of having poorer clinical and perceived health were attenuated, but remained significantly higher at each lower level of income and education for most outcomes. The results showed similar income and education gradients in oral and general health, implying commonalities of the social determinants of both oral and general health.

The prevalence and severity of dental pain in 14-15 year old Brazilian schoolchildren.

OBJECTIVE: To assess the prevalence and severity of dental pain and associated factors in Brazilian schoolchildren. METHODS: The study was a cross-sectional survey conducted in Recife, Brazil. The data were collected through questionnaires, personal interviews and clinical dental examinations of a random sample of 14-15 years old schoolchildren. The prevalence of dental pain and its characteristics were recorded using standard measures of pain. Dental caries, dental trauma and dental plaque were assessed using WHO criteria. Multiple logistic and ordinal polytomous regression were used to assess which factors were associated with the dental pain outcomes. RESULTS: 1,052 individuals participated in the study. The prevalence of reported toothache in schoolchildren in the last six months was 33.6% (31.1-36.8, 95% CI). The fully adjusted regression models showed a significant relationship between lower social class, later birth order, failure at school and attendance at the dentist only when in trouble with both the prevalence and severity of dental pain. The major predictor of the prevalence and severity of pain was pattern of dental attendance (p<0.001). CONCLUSIONS: The prevalence of toothache in 14-15 years old schoolchildren was high. The major predictor of the prevalence and severity of pain was the pattern of dental attendance.