Challenges in identifying indigenous peoples in population oral health surveys: a commentary.

There are currently 370 million persons identifying as indigenous across 90 countries globally. Indigenous peoples generally face substantial exclusion/marginalization and poorer health status compared with non-indigenous majority populations; this includes poorer oral health status and reduced access to dental services. Population-level oral health surveys provide data to set priorities, inform policies, and monitor progress in dental disease experience/dental service utilisation over time. Rigorously and comprehensively measuring the oral health burden of indigenous populations is an ethical issue, though, given that survey instruments and sampling procedures are usually not sufficiently inclusive. This results in substantial underestimation or even biased estimation of dental disease rates and severity among indigenous peoples, making it difficult for policy makers to prioritise resources in this area. The methodological challenges identified include: (1) suboptimal identification of indigenous populations; (2) numerator-denominator bias and; (3) statistical analytic considerations. We suggest solutions that can be implemented to strengthen the visibility of indigenous peoples around the world in an oral health context. These include acknowledgment of the need to engage indigenous peoples with all data-related processes, encouraging the use of indigenous identifiers in national and regional data sets, and mitigating and/or carefully assessing biases inherent in population oral health methodologies for indigenous peoples.

Oral diseases: a global public health challenge.

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

Ending the neglect of global oral health: time for radical action.

Oral diseases are a major global public health problem affecting over 3·5 billion people. However, dentistry has so far been unable to tackle this problem. A fundamentally different approach is now needed. In this second of two papers in a Series on oral health, we present a critique of dentistry, highlighting its key limitations and the urgent need for system reform. In high-income countries, the current treatment-dominated, increasingly high-technology, interventionist, and specialised approach is not tackling the underlying causes of disease and is not addressing inequalities in oral health. In low-income and middle-income countries (LMICs), the limitations of so-called westernised dentistry are at their most acute; dentistry is often unavailable, unaffordable, and inappropriate for the majority of these populations, but particularly the rural poor. Rather than being isolated and separated from the mainstream health-care system, dentistry needs to be more integrated, in particular with primary care services. The global drive for universal health coverage provides an ideal opportunity for this integration. Dental care systems should focus more on promoting and maintaining oral health and achieving greater oral health equity. Sugar, alcohol, and tobacco consumption, and their underlying social and commercial determinants, are common risk factors shared with a range of other non-communicable diseases (NCDs). Coherent and comprehensive regulation and legislation are needed to tackle these shared risk factors. In this Series paper, we focus on the need to reduce sugar consumption and describe how this can be achieved through the adoption of a range of upstream policies designed to combat the corporate strategies used by the global sugar industry to promote sugar consumption and profits. At present, the sugar industry is influencing dental research, oral health policy, and professional organisations through its well developed corporate strategies. The development of clearer and more transparent conflict of interest policies and procedures to limit and clarify the influence of the sugar industry on research, policy, and practice is needed. Combating the commercial determinants of oral diseases and other NCDs should be a major policy priority.

Dentist supply and children's oral health in the United States.

OBJECTIVES: We evaluated the relationship between dentist supply and children's oral health and explored heterogeneity by children's age and urbanicity. METHODS: We obtained data from the 2007 National Survey of Children's Health (>27,000 children aged 1-10 years; >23,000 children aged 11-17 years). We estimated the association between state-level dentist supply and multiple measures of children's oral health using regression analysis adjusting for several child, family, and population-level characteristics. RESULTS: Dentist supply was significantly related to better oral health outcomes among children aged 1 to 10 years. The odds of decay and bleeding gums were lower by more than 50% (odds ratio [OR]=0.46; 95% CI=0.23, 0.95) and 80% (OR=0.18; 95% CI=0.05, 0.76), respectively, with an additional dentist per 1000 population. The odds of a worse maternal rating of child's dental health on a 5-category scale from poor to excellent were lower by about 50% in this age group with an additional dentist per 1000 population (OR=0.51; 95% CI=0.29, 0.91). We observed associations only for children in urban settings. CONCLUSIONS: Dentist supply is associated with improved oral health for younger children in urban settings.

Socioeconomic position and subjective oral health: findings for the adult population in England, Wales and Northern Ireland.

BACKGROUND: The objective of this study was to assess socioeconomic inequalities in subjective measures of oral health in a national sample of adults in England, Wales and Northern Ireland. METHODS: We analysed data from the 2009 Adult Dental Health Survey for 8,765 adults aged 21 years and over. We examined inequalities in three oral health measures: self-rated oral health, Oral Health Impact Profile (OHIP-14), and Oral Impacts on Daily Performance (OIDP). Educational attainment, occupational social class and household income were included as socioeconomic position (SEP) indicators. Multivariable logistic regression models were fitted and from the regression coefficients, predictive margins and conditional marginal effects were estimated to compare predicted probabilities of the outcome across different SEP levels. We also assessed the effect of missing data on our results by re-estimating the regression models after imputing missing data. RESULTS: There were significant differences in predicted probabilities of the outcomes by SEP level among dentate, but not among edentate, participants. For example, persons with no qualifications showed a higher predicted probability of reporting bad oral health (9.1 percentage points higher, 95% CI: 6.54, 11.68) compared to those with a degree or equivalent. Similarly, predicted probabilities of bad oral health and oral impacts were significantly higher for participants in lower income quintiles compared to those in the highest income level (p < 0.001). Marginal effects for all outcomes were weaker for occupational social class compared to education or income. Educational and income-related inequalities were larger among young people and non-significant among 65+ year-olds. Using imputed data confirmed the aforementioned results. CONCLUSIONS: There were clear socio-economic inequalities in subjective oral health among adults in England, Wales and Northern Ireland with stronger gradients for those at younger ages.

Making the case for a new typology of dental care systems.

BACKGROUND AND RATIONALE: Dental care systems have the potential to influence population oral health and patterns of socioeconomic inequalities. Therefore, understanding the impact of the ways in which countries fund, provide, and organize their dental care services is key in the analysis of determinants of oral health. In this commentary we offer a synopsis of recent typologies of healthcare systems, based on a rapid review, and highlight that none of them fit dental care services given the separation of dental care from general healthcare provision in many countries. The paper also summarizes evidence on dental care systems as determinants of population oral health and argues why a new typology of dental care systems is needed. CHALLENGES AND WAYS FORWARD: We argue that a typology must consider institutional arrangements, structures, and processes behind the provision of dental care, and that specific dimensions/variables that inform the typology should result from a process of discussion and consensus. Some methodological considerations for developing typologies are also discussed, including the challenges in the collection and analysis of data followed by an advanced cluster analysis. Despite their limitations, typologies have evolved into an essential tool for comparing the similarities and differences of healthcare systems across countries. Therefore, a dental specific typology for health systems will be useful for researchers, policymakers, and dental professionals to characterize the provision of dentalcare services in different countries. This will also enable examining their potential role as determinants of population oral health and inequalities.

Oral health and welfare state regimes: a cross-national analysis of European countries.

Very little is known about the potential relationship between welfare state regimes and oral health. This study assessed the oral health of adults in a range of European countries clustered by welfare regimes according to Ferrera's typology and the complementary Eastern type. We analysed data from Eurobarometer wave 72.3, a cross-sectional survey of 31 European countries carried out in 2009. We evaluated three self-reported oral health outcomes: edentulousness, no functional dentition (<20 natural teeth), and oral impacts on daily living. Age-standardized prevalence rates were estimated for each country and for each welfare state regime. The Scandinavian regime showed lower prevalence rates for all outcomes. For edentulousness and no functional dentition, there were higher prevalence rates in the Eastern regime but no significant differences between Anglo-Saxon, Bismarckian, and Southern regimes. The Southern regime presented a higher prevalence of oral impacts on daily living. Results by country indicated that Sweden had the lowest prevalences for edentulousness and no functional dentition, and Denmark had the lowest prevalence for oral impacts. The results suggest that Scandinavian welfare states, with more redistributive and universal welfare policies, had better population oral health. Future research should provide further insights about the potential mechanisms through which welfare-state regimes would influence oral health.

Does subsidizing the cost of care impact on dental attendance patterns among older adults?

OBJECTIVES: To assess whether eligibility for an age-related universal (pioneer generation [PG]) subsidy incentivises dental attendance by older Singaporeans. METHODS: Data were collected between 2018 and 2021 from in-person interviews of Singaporean adults aged 60-90 years using a questionnaire and a clinical examination. The questionnaire included details of age, gender, ethnicity, education, residential status, socio-economic status, marital status, eligibility for subsidy (community health assistance/CHAS, PG or both) and frequency of dental attendance. The clinical examination recorded number of teeth (categorized as edentulous, 1-9 teeth;10-19 teeth; ≥20 teeth). To estimate the effect of the PG subsidy on dental attendance pattern, a regression discontinuity (RD) analysis was applied using age as the assignment variable. RESULTS: A total of 1172 participants aged 60-90 years (64.2% female) were recruited, with 498 (43%) being eligible for the PG subsidy. For those eligible for PG subsidy, there was a higher proportion of regular attenders than irregular attenders (53.6% vs. 46.4%). In age adjusted RD analysis, those eligible for the PG subsidy were 1.6 (95% CI: 1.0, 2.7) times more likely to report regular attendance than their PG non-eligible counterparts. The association remained strong (OR 2.1; 95% CI: 1.1-3.7) even after further controlling for demographics, socioeconomic factors, number of teeth and eligibility for the CHAS subsidy. CONCLUSIONS: Being eligible for the PG subsidy substantially increased the odds of regular dental attendance.

The role of science communication and academic health advocacy in improving population oral health and tackling inequalities.

Oral conditions are a public health problem globally and stark oral health inequalities exist between and within countries. Yet, oral diseases are rarely considered as a health priority and evidence-informed policy generation is challenging. Science communication and health advocacy are critical in that respect. However, due to time limitations, research workload and other factors, academics are usually hindered from participating in such lengthy endeavours. Here, we make the case that 'science communication and health advocacy task forces' should be a priority at academic institutions. The two main duties of these task forces are knowledge transfer about the burden of oral conditions and patterns of inequalities, and their underlying social and commercial determinants, and advocacy and mediation between the stakeholders involved directly or indirectly in policy making. These interdisciplinary task forces, including both academics and non-academics, should collectively have skills that include (1) knowledge about oral health, dental public health and epidemiology, (2) ability to communicate clearly and coherently and make the case in both lay and scientific language terms, (3) familiarity with digital and social media platforms and ability to create visual aids, videos and documentaries, (4) good negotiation skills and (5) maintaining scientific transparency and avoiding getting involved in confrontation with political parties. In the current context, the role of the academic institutions should not only be the production of knowledge, but also the active transferability and application of this knowledge towards public benefit.

Situational diagnosis of policies in Latin American and Caribbean countries for the use of fluoride and reduction of sugar consumption.

Policy evaluation and guidance on fluoride use and sugar consumption in Latin American and Caribbean countries (LACC) may provide a scientific evidence basis for policymakers, dental professionals, civil society organizations and individuals committed to improving public oral health. A cross-sectional study was conducted to evaluate the extent of implementation of policies/guidelines on fluoride use, and sugar consumption in LACC. The study had two stages. First a questionnaire covering four major areas was developed: fluoridation of public water supplies; salt fluoridation; fluoride dentifrices, and sugar consumption. Then, the questionnaire was applied to collect data among representative participants in public oral health from LACC. Ninety-six participants from 18 LACC answered the questionnaire. One-hundred seventy documents were attached, and 285 links of websites were provided by the respondents. Implementation of policies and guidelines on water and table salt fluoridation and processed and ultra-processed food consumption were found in most countries, with some issues in the consensus and coverage. Thus, differences were identified in the extent of implementation of public oral health strategies on sugar consumption and fluoridation among the countries. There is no consensus on the policies in LACC to reduce sugar consumption and for the use of fluoride. A few policies and guidelines were applied in isolated countries, with a variety of strategies and standards. For future actions, it will be important to encourage the development of strategies and public policies within countries, and to evaluate the effectiveness of existing policies in reducing dental caries and in improving oral health in LACC.

Where are race-based oral health inequities bound? Protocol for a systematic review on interventions to tackle racial injustice in dental outcomes.

BACKGROUND: Only three literature reviews have assessed the impact of interventions on the reduction of racial inequities in general health to date; none has drawn from attempts at promoting racial oral health equity. This protocol aims to increase transparency and reduce the potential for bias of an ongoing systematic review conceived to answer the following questions: Are there any interventions to mitigate racial oral health inequities or improve the oral health of racially marginalized groups? If so, how successful have they been at promoting racial oral health equity? How do conclusions of previous reviews change by taking the findings of oral health interventions into account? METHODS: Reviewed studies must deploy interventions to reduce racial gaps or promote the oral health of groups oppressed along ancestral and/or cultural lines. We will analyze randomized clinical trials, natural experiments, pre-post studies, and observational investigations that emulate controlled experiments by assessing interactions between race and potentially health-enhancing interventions. Either clinically assessed or self-reported oral health outcomes will be considered by searching for original studies in MEDLINE, LILACS, PsycInfo, SciELO, Web of Science, Scopus, and Embase from their earliest records to March 2022. Upon examining abstracts of conference proceedings, trial registries, reports of related stakeholder organizations, as well as contacting researchers for unpublished data, we will identify studies in the grey literature. If possible, we will carry out a meta-analysis with subgroup and sensitivity analysis, including formal meta-regression, to address potential heterogeneity and inconsistency among selected studies. DISCUSSION: Conducting a systematic review of interventions to mitigate racial oral health inequities is crucial for determining which initiatives work best and under which conditions they succeed. Such knowledge will help consolidate an evidence base that may be used to inform policy and practice against persistent and pervasive racial inequities in general and oral health. SYSTEMATIC REVIEW REGISTRATION: This protocol has been registered at the International Prospective Register of Systematic Reviews, under the identification number CRD42021261450 .

Dental attendance and behavioural pathways to adult oral health inequalities.

BACKGROUND: While inequalities in oral health are documented, little is known about the extent to which they are attributable to potentially modifiable factors. We examined the role of behavioural and dental attendance pathways in explaining oral health inequalities among adults in England, Wales and Northern Ireland. METHODS: Using nationally representative data, we analysed inequalities in self-rated oral health and number of natural teeth. Highest educational attainment, equivalised household income and occupational social class were used to derive a latent socioeconomic position (SEP) variable. Pathways were dental attendance and behaviours (smoking and oral hygiene). We used structural equation modelling to test the hypothesis that SEP influences oral health directly and also indirectly via dental attendance and behavioural pathways. RESULTS: Lower SEP was directly associated with fewer natural teeth and worse self-rated oral health (standardised path coefficients, -0.21 (SE=0.01) and -0.10 (SE=0.01), respectively). We also found significant indirect effects via behavioural factors for both outcomes and via dental attendance primarily for self-rated oral health. While the standardised parameters of total effects were similar between the two outcomes, for number of teeth, the estimated effect of SEP was mostly direct while for self-rated oral health, it was almost equally split between direct and indirect effects. CONCLUSION: Reducing inequalities in dental attendance and health behaviours is necessary but not sufficient to tackle socioeconomic inequalities in oral health.

Explaining oral health inequalities in European welfare state regimes: The role of health behaviours.

OBJECTIVE: To assess the extent to which behavioural factors, including those related to dental care, account for oral health inequalities in different European welfare state regimes. METHODS: Data from the Eurobarometer 2009 survey were analysed. Nationally representative samples of dentate adults aged ≥45 years (n = 9979) from 21 European countries classified into the five welfare regimes (Scandinavian, Anglo-Saxon, Bismarckian, Southern, Eastern) were considered. Inequalities in no functional dentition (having <20 natural teeth) by education and occupation were identified using the Relative and Slope Indices of Inequality (RII and SII, respectively). The percentage reduction in RII and SII was calculated from regression models before and after adjustment for behaviours, first one at a time and then all together. RESULTS: Behaviours explained 21.0% (95% CI 8.7, 31.4) and 13.1% (95% CI 7.9, 33.2) of educational inequalities in no functional dentition (RII) in the Scandinavian and Eastern regimes, respectively. For occupational inequalities, the attenuations in RII in these welfare regimes were 19.3% (95% CI 7.1, 24.2) and 10.5% (95% CI 3.4, 22.5), respectively. Attenuations were weaker and nonsignificant in the Bismarckian, Anglo-Saxon and Southern regimes. Among the behaviours analysed, alcohol consumption was particularly relevant in explaining inequalities in the Scandinavian regime, and this was confirmed in sensitivity analyses through three-way cross-level interaction terms in multilevel models. Behaviours related to dental care produced similar, consistent attenuations in the Scandinavian and Eastern regimes for both socioeconomic indicators. SII findings showed a similar picture. CONCLUSION: The role of particular behaviours in explaining oral health inequalities could be heterogeneous across European welfare regimes, indicating that their importance might be influenced by the general approach to social policies.

Health insurance and education: major contributors to oral health inequalities in Colombia.

BACKGROUND: Health inequalities, including inequalities in oral health, are problems of social injustice worldwide. Evidence on this issue from low-income and middle-income countries is still needed. We aimed to examine the relationship between oral health and different dimensions of socioeconomic position (SEP) in Colombia, a very unequal society emerging from a long-lasting internal armed conflict. METHODS: Using data from the last Colombian Oral Health Survey (2014), we analysed inequalities in severe untreated caries (≥3 teeth), edentulousness (total tooth loss) and number of missing teeth. Inequalities by education, income, area-level SEP and health insurance scheme were estimated by the relative index of inequality and slope index of inequality (RII and SII, respectively). RESULTS: A general pattern of social gradients was observed and significant inequalities for all outcomes and SEP indicators were identified with RII and SII. Relative inequalities were larger for decay by health insurance scheme, with worse decay levels among the uninsured (RII: 2.57; 95% CI 2.11 to 3.13), and in edentulousness (RII: 3.23; 95% CI 1.88 to 5.55) and number of missing teeth (RII: 2.08; 95% CI 1.86 to 2.33) by education, with worse levels of these outcomes among the lower educated groups. Absolute inequalities followed the same pattern. Inequalities were larger in urban areas. CONCLUSION: Health insurance and education appear to be the main contributors to oral health inequalities in Colombia, posing challenges for designing public health strategies and social policies. Tackling health inequalities is crucial for a fairer society in a Colombian post-conflict era and our findings highlight the importance of investing in education policies and universal health care coverage.

Situational diagnosis of policies in Latin American and Caribbean countries for the use of fluoride and reduction of sugar consumption

Abstract Policy evaluation and guidance on fluoride use and sugar consumption in Latin American and Caribbean countries (LACC) may provide a scientific evidence basis for policymakers, dental professionals, civil society organizations and individuals committed to improving public oral health. A cross-sectional study was conducted to evaluate the extent of implementation of policies/guidelines on fluoride use, and sugar consumption in LACC. The study had two stages. First a questionnaire covering four major areas was developed: fluoridation of public water supplies; salt fluoridation; fluoride dentifrices, and sugar consumption. Then, the questionnaire was applied to collect data among representative participants in public oral health from LACC. Ninety-six participants from 18 LACC answered the questionnaire. One-hundred seventy documents were attached, and 285 links of websites were provided by the respondents. Implementation of policies and guidelines on water and table salt fluoridation and processed and ultra-processed food consumption were found in most countries, with some issues in the consensus and coverage. Thus, differences were identified in the extent of implementation of public oral health strategies on sugar consumption and fluoridation among the countries. There is no consensus on the policies in LACC to reduce sugar consumption and for the use of fluoride. A few policies and guidelines were applied in isolated countries, with a variety of strategies and standards. For future actions, it will be important to encourage the development of strategies and public policies within countries, and to evaluate the effectiveness of existing policies in reducing dental caries and in improving oral health in LACC.

Do welfare regimes matter for oral health? A multilevel analysis of European countries.

While the role of political factors on population health has recently received increasing attention, relatively little is known in that respect for oral health. We aimed to assess the influence of welfare state regimes on the variation in adult oral health between European countries, building on the existing literature by using a multilevel approach. Our analysis also explored how the oral health of people with different socioeconomic position was influenced by living in five different welfare state regimes. We analysed data from the Eurobarometer survey 2009. The main outcome was no functional dentition, defined as having fewer than 20 natural teeth. Age, gender, marital status, education and occupational social class were the individual-level explanatory variables, while welfare regimes, GDP per capita and GDP annual growth were the country-level variables. Multilevel logistic regression models were fitted with individuals nested within countries. Results revealed that country-level characteristics accounted for 8.1% of the variation in oral health. Adults in all welfare regimes were more likely to have poorer oral health than their counterparts in the Scandinavian regime, with those in Eastern countries being 6.94 (95% CI: 3.62-12.67) times as likely to lack a functional dentition as adults in Scandinavian countries. The variation at country-level reduced significantly when welfare regimes were introduced into the model (from 0.57 to 0.16; 72% reduction), indicating that welfare regime explained much of the variation in the outcome among European countries. Finally, adults with less education and lower occupational level were more likely to have no functional dentition, especially in the Eastern and Bismarckian welfare regimes.

Explaining time changes in oral health-related quality of life in England: a decomposition analysis.

BACKGROUND: Oral diseases are highly prevalent and impact on oral health-related quality of life (OHRQoL). However, time changes in OHRQoL have been scarcely investigated in the current context of general improvement in clinical oral health. This study aims to examine changes in OHRQoL between 1998 and 2009 among adults in England, and to analyse the contribution of demographics, socioeconomic characteristics and clinical oral health measures. METHODS: Using data from two nationally representative surveys in England, we assessed changes in the Oral Health Impact Profile-14 (OHIP-14), in both the sample overall (n=12 027) and by quasi-cohorts. We calculated the prevalence and extent of oral impacts and summary OHIP-14 scores. An Oaxaca-Blinder type decomposition analysis was used to assess the contribution of demographics (age, gender, marital status), socioeconomic position (education, occupation) and clinical measures (presence of decay, number of missing teeth, having advanced periodontitis). RESULTS: There were significant improvements in OHRQoL, predominantly among those that experienced oral impacts occasionally, but no difference in the proportion with frequent oral impacts. The decomposition model showed that 43% (-4.07/-9.47) of the decrease in prevalence of oral impacts reported occasionally or more often was accounted by the model explanatory variables. Improvements in clinical oral health and the effect of ageing itself accounted for most of the explained change in OHRQoL, but the effect of these factors varied substantially across the lifecourse and quasi-cohorts. CONCLUSIONS: These decomposition findings indicate that broader determinants could be primarily targeted to influence OHRQoL in different age groups or across different adult cohorts.

Austin Powers bites back: a cross sectional comparison of US and English national oral health surveys.

OBJECTIVE: To compare oral health in the US and England and to assess levels of educational and income related oral health inequalities between both countries. DESIGN: Cross sectional analysis of US and English national surveys. SETTING: Non-institutionalised adults living in their own homes. PARTICIPANTS: Oral health measures and socioeconomic indicators were assessed in nationally representative samples: the Adult Dental Health Survey 2009 for England, and the US National Health and Nutrition Examination Survey 2005-08. Adults aged ≥25 years were included in analyses with samples of 8719 (England) and 9786 (US) for analyses by education, and 7184 (England) and 9094 (US) for analyses by income. MAIN OUTCOME MEASURES: Number of missing teeth, self rated oral health, and oral impacts on daily life were outcomes. Educational attainment and household income were used as socioeconomic indicators. Age standardised estimates of oral health were compared between countries and across educational and income groups. Regression models were fitted, and relative and absolute inequalities were measured using the relative index of inequality (RII) and the slope index of inequality (SII). RESULTS: The mean number of missing teeth was significantly higher in the US (7.31 (standard error 0.15)) than in England (6.97 (0.09)), while oral impacts were higher in England. There was evidence of significant social gradients in oral health in both countries, although differences in oral health by socioeconomic position varied according to the oral health measure used. Consistently higher RII and SII values were found in the US than in England, particularly for self rated oral health. RII estimates for self rated oral health by education were 3.67 (95% confidence interval 3.23 to 4.17) in the US and 1.83 (1.59 to 2.11) in England. In turn, SII values were 42.55 (38.14 to 46.96) in the US and 18.43 (14.01 to 22.85) in England. CONCLUSIONS: The oral health of US citizens is not better than the English, and there are consistently wider educational and income oral health inequalities in the US compared with England.

Socioeconomic inequalities in oral health in different European welfare state regimes.

BACKGROUND: There is very little information about the relationship between welfare regimes and oral health inequalities. We compared socioeconomic inequalities in adults' oral health in five European welfare-state regimes: Scandinavian, Anglo-Saxon, Bismarckian, Southern and Eastern. METHODS: Using data from the oral health module of the Eurobarometer 72.3 survey, we assessed inequalities in two self-reported oral health measures: no functional dentition (less than 20 natural teeth) and edentulousness (no natural teeth). Occupational social class, education and subjective social status (SSS) were included as socioeconomic position indicators. We estimated age-standardised prevalence rates, ORs, the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). RESULTS: The Scandinavian regime showed the lowest prevalence rates of the two oral health measures while the Eastern showed the highest. In all welfare regimes there was a general pattern of social gradients by occupational social class and education. Relative educational inequalities in no functional dentition were largest in the Scandinavian welfare regime (RII=3.81; 95% CI 2.68 to 5.42). The Scandinavian and Southern regimes showed the largest relative inequalities in edentulousness by occupation and education, respectively. There were larger absolute inequalities in no functional dentition in the Eastern regime by occupation (SII=42.16; 95% CI 31.42 to 52.89) and in the Southern by SSS (SII=27.92; 95% CI 17.36 to 38.47). CONCLUSIONS: Oral health inequalities in adults exist in all welfare-state regimes, but contrary to what may be expected from theory, they are not smaller in the Scandinavian regime. Future work should examine the potential mechanisms linking welfare provision and oral health inequalities.