Editorial - Oral health inequalities and the COVID-19 pandemic: time for action.

Over the last years, the COVID-19 pandemic has introduced a major public health crisis globally that societies have struggled to address irrespective of the approach followed. The different aspects of the crisis and how it has been handled from the point of view of social epidemiology, do not offer a positive reading. One key "message" has been that we are "all in it together". This implies a socially neutral phenomenon, yet there is clear evidence of stark socioeconomic and ethnic inequalities with disproportionate burden of the pandemic among the more deprived groups in the society (Marmot, 2020). And this has taken place in the background of already well-established health inequalities that have further increased over the last decade (Marmot et al., 2020). At the same time, addressing inequalities has been a central piece of government and societal health policy objectives.

The Brussels Statement on the Future Needs for Caries Epidemiology and Surveillance in Europe.

Following debate and discussion prompted by a focussed, day long pre-ORCA Symposium in July 2015, the Alliance for a Cavity-Free Future Pan-European Chapter, the Platform for Better Oral Health in Europe, and the European Association of Dental Public Health have agreed this statement on the future needs for caries epidemiology and surveillance in Europe. Each organisation agreed to support the planned publication of the Statement, and will make it available on their Organisation's websites and strive to implement its recommendations.

Earlier depression and later-life self-reported chewing difficulties: results from the Whitehall II study.

This study aimed to assess, whether depression in adulthood was associated with self-reported chewing difficulties at older age, and examine whether the strength of the association differed according to the number of depression episodes in earlier adult life. We used Whitehall II study data from 277 participants who completed a questionnaire in 2011. Depression was measured with the Center for Epidemiologic Studies Depression Scale (CES-D) in 2003 and 2008. The association between CES-D depression and self-reported chewing ability was assessed using regression models adjusted for some socio-demographic factors. Participants with depression at some point in their earlier adulthood had an odds ratio (95% CI) of 2·01 (1·06, 3·82) for reporting chewing difficulties in older adulthood, compared to those without depression. The respective odds ratios were 1·42 (0·66, 3·04) for individuals with depression in only one phase, but 3·53 (1·51, 8·24) for those with depression in two phases. In conclusion, while further research is required, there was an association between depression and chewing difficulty that was independent of demographic and socio-economic characteristics. Furthermore, this increased odds for chewing difficulties was primarily among adults that experienced two episodes or a prolonged period of depression.

Social inequalities in clustering of oral health related behaviors in a national sample of British adults.

OBJECTIVES: 1. To assess clustering of oral health related behaviors among a sample of British adults. 2. To determine the variation in clustering of oral health related behaviors by socioeconomic position. METHOD: We used secondary analysis of the Adult Dental Health Survey 2009 data. Health behaviors referred to smoking, tooth brushing frequency, dental visits and sugar consumption. Clustering was assessed by pairwise correlations, counts of clustering of health compromising behaviors and comparison of observed/expected ratios. Logistic regression was used to assess variation in clustering of oral health related behaviors by socioeconomic position crudely and adjusted for age, gender and self-rated oral health. RESULTS: There were weak correlations between four health behaviors. Very low prevalence of clustering was reported. Higher observed to expected ratio was observed for clustering patterns with lower prevalence. Multivariate logistic regression showed clear, strong and significant educational gradients in associations between different clustering patterns of health compromising behaviors and educational attainment. These educational gradients remained significant after adjusting for age, gender and self-reported oral health. CONCLUSION: Very clear and strong educational gradients were observed throughout patterns of clustering of oral health compromising behaviors, suggesting chances of having detrimental behavioral clustering are lower in more educated groups in population.

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.

Impact of Teeth on Social Participation: Modified Treatment Policy Approach.

Social participation prevents social isolation and loneliness among older adults while having numerous positive effects on their health and well-being in rapidly aging societies. We aimed to estimate the effect of retaining more natural teeth on social participation among older adults in Japan. The analysis used longitudinal data from 24,872 participants in the Japan Gerontological Evaluation Study (2010, 2013, and 2016). We employed a longitudinal modified treatment policy approach to determine the effect of several hypothetical scenarios (preventive scenarios and tooth loss scenarios) on frequent social participation (1 = at least once a week/0 = less than once a week) after a 6-y follow-up. The corresponding statistical parameters were estimated using targeted minimum loss-based estimation (TMLE) method. Number of teeth category (edentate/1-9/10-19/≥20) was treated as a time-varying exposure, and the outcome estimates were adjusted for time-varying (income, self-rated health, marital status, instrumental activities of daily living, vision loss, hearing loss, major comorbidities, and number of household members) and time-invariant covariates (age, sex, education, baseline social participation). Less frequent social participation was associated with older age, male sex, lower income, low educational attainment, and poor self-rated health at the baseline. Social participation improved when tooth loss prevention scenarios were emulated. The best preventive scenario (i.e., maintaining ≥20 teeth among each participant) improved social participation by 8% (risk ratio [RR] = 1.08; 95% confidence interval [CI], 1.05-1.11). Emulated tooth loss scenarios gradually decreased social participation. A hypothetical scenario in which all the participants were edentate throughout the follow-up period resulted in a 11% (RR = 0.89; 95% CI, 0.84-0.94) reduction in social participation. Subsequent tooth loss scenarios showed 8% (RR = 0.92; 95% CI, 0.88-0.95), 6% (RR = 0.94; 95% CI, 0.91-0.97), and 4% (RR = 0.96; 95% CI, 0.93-0.98) reductions, respectively. Thus, among Japanese older adults, retaining a higher number of teeth positively affects their social participation, whereas being edentate or having a relatively lower number of teeth negatively affects their social participation.

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.

Impact of Dental Diseases on Quality-Adjusted Life Expectancy in US Adults.

Comparing the burden of dental conditions to other health outcomes provides useful insight for public policy. We aimed to estimate quality-adjusted life expectancy (QALE) loss due to dental conditions in the US adult population. Social inequalities in QALE loss by dental conditions were also examined. Data from 3 cross-sectional waves of the National Health and Nutrition Examination Survey (NHANES waves 2001 to 2002, 2003 to 2004, and 2011 to 2012) were pooled and analyzed. The average age of study participants ( n = 9,445) was 48.4 y. Disutility scores were derived from self-rated health and the numbers of physically unhealthy days, mentally unhealthy days, and days with activity limitation, employing a previously published algorithm. The associations between the disutility scores and the numbers of decayed teeth, missing teeth, and periodontitis were examined by multiple linear regression stratified by age groups (20-39, 40-59, and ≥60 y), adjusted for other covariates (age, sex, wave fixed effect, educational attainment, smoking, and diabetes). The QALE loss due to dental conditions at the age of 20 was estimated using life tables. Decayed and missing teeth, but not periodontitis, were associated with a larger disutility score. The coefficient for decayed teeth was larger among the older population, whereas that of missing teeth was smaller among them. The estimated QALE loss was 0.43 y (95% confidence interval [CI], 0.28-0.59), which reached 5.3% of QALE loss (8.15 y; 95% CI, 8.03-8.27) due to overall morbidity. There were clear social gradients in QALE loss by dental conditions across the life course, and people with high school or less education had 0.32 y larger QALE loss in total compared with people with college or more education. This study suggests that improvements in people's dental health may yield substantial gains in population health and well-being. The necessity of more comprehensive public health strategies is highlighted.

Minimally invasive non-surgical vs. surgical approach for periodontal intrabony defects: a randomised controlled trial.

BACKGROUND: Periodontal intrabony defects are usually treated surgically with the aim of increasing attachment and bone levels and reducing risk of progression. However, recent studies have suggested that a minimally invasive non-surgical therapy (MINST) leads to considerable clinical and radiographic defect depth reductions in intrabony defects. The aim of this study is to compare the efficacy of a modified MINST approach with a surgical approach (modified minimally invasive surgical therapy, M-MIST) for the treatment of intrabony defects. METHODS: This is a parallel-group, single-centre, examiner-blind non-inferiority randomised controlled trial with a sample size of 66 patients. Inclusion criteria are age 25-70, diagnosis of periodontitis stage III or IV (grades A to C), presence of ≥ 1 'intrabony defect' with probing pocket depth (PPD) > 5 mm and intrabony defect depth ≥ 3 mm. Smokers and patients who received previous periodontal treatment to the study site within the last 12 months will be excluded. Patients will be randomly assigned to either the modified MINST or the M-MIST protocol and will be assessed up to 15 months following initial therapy. The primary outcome of the study is radiographic intrabony defect depth change at 15 months follow-up. Secondary outcomes are PPD and clinical attachment level change, inflammatory markers and growth factors in gingival crevicular fluid, bacterial detection, gingival inflammation and healing (as measured by geometric thermal camera imaging in a subset of 10 test and 10 control patients) and patient-reported outcomes. DISCUSSION: This study will produce evidence about the clinical efficacy and potential applicability of a modified MINST protocol for the treatment of periodontal intrabony defects, as a less invasive alternative to the use of surgical procedures. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03797807. Registered on 9 January 2019.

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.

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.

Psychometric properties and the prevalence, intensity and causes of oral impacts on daily performance (OIDP) in a population of older Tanzanians.

BACKGROUND: The objective was to study whether a Kiswahili version of the OIDP (Oral Impacts on Daily Performance) inventory was valid and reliable for use in a population of older adults in urban and rural areas of Tanzania; and to assess the area specific prevalence, intensity and perceived causes of OIDP. METHOD: A cross-sectional survey was conducted in Pwani region and in Dar es Salaam in 2004/2005. A two-stage stratified cluster sample design was utilized. Information became available for 511 urban and 520 rural subjects (mean age 62.9 years) who were interviewed and participated in a full mouth clinical examination in their own homes. RESULTS: The Kiswahili version of the weighted OIDP inventory preserved the overall concept of the original English version. Cronbach's alpha was 0.83 and 0.90 in urban and rural areas, respectively, and the OIDP inventory varied systematically in the expected direction with self-reported oral health measures. The respective prevalence of oral impacts was 51.2% and 62.1% in urban and rural areas. Problems with eating was the performance reported most frequently (42.5% in urban, 55.1% in rural) followed by cleaning teeth (18.2% in urban, 30.6% in rural). More than half of the urban and rural residents with impacts had very little, little and moderate impact intensity. The most frequently reported causes of impacts were toothache and loose teeth. CONCLUSION: The Kiswahili OIDP inventory had acceptable psychometric properties among non-institutionalized adults 50 years and above in Tanzania. The impacts affecting their performances were relatively common but not very severe.

The impact of oral conditions on children in England, Wales and Northern Ireland 2013.

Background The 2013 Children's Dental Health survey is the fifth in a series of national surveys.Aim To summarise key findings on oral health perceptions, oral symptoms, and the impacts of oral conditions on the daily life of children and their families.Methodology A representative sample of children (aged 5, 8 12 and 15 years) and their parents in England, Wales and Northern Ireland completed relevant questionnaires.Results Oral symptoms, even more profound ones such as toothache, were prevalent among all age groups. Overall, 58% of 12- and 45% of 15-year-olds reported at least one oral impact in the past three months. The most prevalent oral impact was feeling embarrassed to smile or laugh, followed by difficulty eating. These symptoms and oral impacts were disproportionately high among children eligible for free school meals. Furthermore, one fifth to one third of parents reported that their children's oral conditions had some impact on their family life.Conclusion Oral symptoms were common and oral conditions had a negative impact on the quality of life of large proportions of children. There were clear and marked socioeconomic inequalities, with considerably worse oral health perceptions and higher levels of oral impacts among the more deprived children.

Differences by age and sex in general dental practitioners' knowledge, attitudes and behaviours in delivering prevention.

PURPOSE: To assess sex and age differences in NHS dentists' knowledge, attitudes and behaviours in providing preventive care. MATERIALS AND METHODS: A cross-sectional questionnaire survey was conducted with dentists working in North London, UK. RESULTS: The sample displayed limited knowledge in certain key aspects of prevention, but expressed generally positive attitudes towards preventive care. More female and younger dentists reported that a child should attend the dentist before the age of 3 years (p = 0.03 and p = 0.04, respectively). No other differences in knowledge or attitudes were found by age and sex. The majority of the sample reported routinely providing oral hygiene (95.7%), diet (85.4%) and smoking cessation advice (76.7%), but provision of alcohol advice was much less common (38%). A significantly higher proportion of younger dentists were more likely to give diet advice (p = 0.03) and smoking cessation support (p = 0.009) than their older colleagues. Female dentists were more likely to provide fissure sealants (p = 0.04), diet advice (p = 0.02) and smoking cessation support (p = 0.03). The main perceived barriers were related to organisational factors including insufficient remuneration (86.3%), lack of time (84%) and poor patient compliance (66%). There were no significant differences in perceived barriers by sex, but younger dentists were significantly more likely to identify poor patient compliance as a barrier (p = 0.02). CONCLUSION: Although dentists in this study may lack some core preventive knowledge, many expressed very positive attitudes towards prevention and reported to be routinely offering a range of preventive measures. Younger and female dentists tended to engage more frequently in preventive activities.

Burden of poor oral health in older age: findings from a population-based study of older British men.

OBJECTIVES: Evidence of the extent of poor oral health in the older UK adult population is limited. We describe the prevalence of oral health conditions, using objective clinical and subjective measures, in a population-based study of older men. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: A representative sample of men aged 71-92 years in 2010-2012 from the British Regional Heart Study, initially recruited in 1978-1980 from general practices across Britain. Physical examination among 1660 men included the number of teeth, and periodontal disease in index teeth in each sextant (loss of attachment, periodontal pocket, gingival bleeding). Postal questionnaires (completed by 2147 men including all participants who were clinically examined) included self-rated oral health, oral impacts on daily life and current perception of dry mouth experience. RESULTS: Among 1660 men clinically examined, 338 (20%) were edentulous and a further 728 (43%) had <21 teeth. For periodontal disease, 233 (19%) had loss of attachment (>5.5 mm) affecting 1-20% of sites while 303 (24%) had >20% sites affected. The prevalence of gingival bleeding was 16%. Among 2147 men who returned postal questionnaires, 35% reported fair/poor oral health; 11% reported difficulty eating due to oral health problems. 31% reported 1-2 symptoms of dry mouth and 20% reported 3-5 symptoms of dry mouth. The prevalence of edentulism, loss of attachment, or fair/poor self-rated oral health was greater in those from manual social class. CONCLUSIONS: These findings highlight the high burden of poor oral health in older British men. This was reflected in both the objective clinical and subjective measures of oral health conditions. The determinants of these oral health problems in older populations merit further research to reduce the burden and consequences of poor oral health in older people.

The Interplay between socioeconomic inequalities and clinical oral health.

Oral health inequalities associated with socioeconomic status are widely observed but may depend on the way that both oral health and socioeconomic status are measured. Our aim was to investigate inequalities using diverse indicators of oral health and 4 socioeconomic determinants, in the context of age and cohort. Multiple linear or logistic regressions were estimated for 7 oral health measures representing very different outcomes (2 caries prevalence measures, decayed/missing/filled teeth, 6-mm pockets, number of teeth, anterior spaces, and excellent oral health) against 4 socioeconomic measures (income, education, Index of Multiple Deprivation, and occupational social class) for adults aged ≥21 y in the 2009 UK Adult Dental Health Survey data set. Confounders were adjusted and marginal effects calculated. The results showed highly variable relationships for the different combinations of variables and that age group was critical, with different relationships at different ages. There were significant income inequalities in caries prevalence in the youngest age group, marginal effects of 0.10 to 0.18, representing a 10- to 18-percentage point increase in the probability of caries between the wealthiest and every other quintile, but there was not a clear gradient across the quintiles. With number of teeth as an outcome, there were significant income gradients after adjustment in older groups, up to 4.5 teeth (95% confidence interval, 2.2-6.8) between richest and poorest but none for the younger groups. For periodontal disease, income inequalities were mediated by other socioeconomic variables and smoking, while for anterior spaces, the relationships were age dependent and complex. In conclusion, oral health inequalities manifest in different ways in different age groups, representing age and cohort effects. Income sometimes has an independent relationship, but education and area of residence are also contributory. Appropriate choices of measures in relation to age are fundamental if we are to understand and address inequalities.

Prevalence of impacts of dental and oral disorders and their effects on eating among older people; a national survey in Great Britain.

OBJECTIVE: The objective was to assess the prevalence, in a British population aged 65 years and older, of oral health related impacts and the effects they had on the quality of daily life and in particular on eating. METHODS: 753 free living and 202 institutionalised subjects aged 65 years and over, participating in the oral health survey of the British National Diet and Nutrition Survey (NDNS), had a dental examination and interview. Data on the impact of dental and oral disorders on the activities of daily living based upon the modified Oral Impacts on Daily Performance (OIDP) indicator were collected. RESULTS: 17% of the free living edentate participants reported that their mouth affected their pattern of daily living on a regular basis. Oral impacts levels were lowest in dentate subjects with the greatest number of teeth. For the dentate, the most common oral impacts were on eating and speaking. Impacts relating to emotional stability, sleeping, relaxing, carrying out physical activity and social contact were very infrequent, but were severe when they did occur. Among those with an impact on eating, 25% said it was severe and 42% had the impact nearly every day or in a spell of 3 or more months. Oral impacts were more prevalent among the institution sample, particularly the dentate. The impacts were associated with the inability or difficulty to eat a range of 16 common foods. CONCLUSION: This survey has shown that the oral status of older people fairly frequently affects the quality of life of older people, and in particular, the ability to eat several common types of foods.