Use of oral health care services in the United States: unequal, inequitable-a cross-sectional study.

BACKGROUND: Social determinants drive disparities in dental visiting. Disparities can be measured simply by comparing outcomes between groups (inequality) but can also consider concepts of social justice or fairness (inequity). This study aimed to assess differences in dental visiting in the United States in terms of both social inequality and inequity. METHODS: Data were obtained from a cross-sectional study-the National Health and Nutrition Examination Survey (NHANES) 2015-2016, and participants were US adults aged 30+ years. The outcome of interest, use of oral health care services, was measured in terms of dental visiting in the past 12 months. Disparity was operationalized through education and income. Other characteristics included age, gender, race/ethnicity, main language, country of birth, citizenship and oral health status. To characterize existing inequality in dental service use, we examined bivariate relationships using indices of inequality: the absolute and relative concentration index (ACI and RCI), the slope index of inequality (SII) and relative index of inequality (RII) and through concentration curves (CC). Indirect standardization with a non-linear model was used to measure inequity. RESULTS: A total of 4745 US adults were included. Bivariate analysis showed a gradient by both education and income in dental visiting, with a higher proportion (> 60%) of those with lower educational attainment /lower income having not visited a dentist. The concentration curves showed pro-higher education and income inequality. All measures of absolute and relative indices were negative, indicating that from lower to higher socioeconomic position (education and income), the prevalence of no dental visiting decreased: ACI and RCI estimates were approximately 8% and 20%, while SII and RII estimates were 50% and 30%. After need-standardization, the group with the highest educational level had nearly 2.5 times- and the highest income had near three times less probability of not having a dental visit in the past 12 months than those with the lowest education and income, respectively. CONCLUSION: The findings indicate that use of oral health care is threatened by existing social inequalities and inequities, disproportionately burdening disadvantaged populations. Efforts to reduce both oral health inequalities and inequities must start with action in the social, economic and policy spheres.

Socioeconomic status, oral health and dental disease in Australia, Canada, New Zealand and the United States.

BACKGROUND: Socioeconomic inequalities are associated with oral health status, either subjectively (self-rated oral health) or objectively (clinically-diagnosed dental diseases). The aim of this study is to compare the magnitude of socioeconomic inequality in oral health and dental disease among adults in Australia, Canada, New Zealand and the United States (US). METHODS: Nationally-representative survey examination data were used to calculate adjusted absolute differences (AD) in prevalence of untreated decay and fair/poor self-rated oral health (SROH) in income and education. We pooled age- and gender-adjusted inequality estimates using random effects meta-analysis. RESULTS: New Zealand demonstrated the highest adjusted estimate for untreated decay; the US showed the highest adjusted prevalence of fair/poor SROH. The meta-analysis showed little heterogeneity across countries for the prevalence of decayed teeth; the pooled ADs were 19.7 (95% CI = 16.7-22.7) and 12.0 (95% CI = 8.4-15.7) between highest and lowest education and income groups, respectively. There was heterogeneity in the mean number of decayed teeth and in fair/poor SROH. New Zealand had the widest inequality in decay (education AD = 0.8; 95% CI = 0.4-1.2; income AD = 1.0; 95% CI = 0.5-1.5) and the US the widest inequality in fair/poor SROH (education AD = 40.4; 95% CI = 35.2-45.5; income AD = 20.5; 95% CI = 13.0-27.9). CONCLUSIONS: The differences in estimates, and variation in the magnitude of inequality, suggest the need for further examining socio-cultural and contextual determinants of oral health and dental disease in both the included and other countries.

Clinical oral health of Australia's rural children in a sample attending school dental services.

OBJECTIVE: To examine the association between children's clinical oral health status and their residential location using the latest available data (2009) and to ascertain whether poor oral health among rural children is related to being Indigenous, having less access to fluoridated water or being of lower socioeconomic status (SES), than children from urban areas. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANT: Data were collected on 74, 467 children aged 5-12 years attending school dental services in Australia (data were not available for Victoria or New South Wales). MAIN OUTCOME MEASURES: Clinical oral health was determined by the mean number of permanent teeth with untreated caries, missing and filled permanent teeth, and the mean decayed, missing and filled permanent teeth index (DMFT) of 8 to 12-year-old-children and the mean number deciduous teeth with untreated caries, missing and filled deciduous teeth, and the mean decayed, missing and filled deciduous teeth index (dmft) of 5-10-year-olds. RESULTS: The multivariable models that included coefficients on whether the child was Indigenous, from an area with fluoridated water and SES, were controlled for age and sex. The mean DMFT of 8-12-year-old children and the mean dmft of 5-10-year-old-children were significantly higher in rural areas compared with urban centres after accounting for Indigenous status, fluoridated water and SES. CONCLUSION: Children's oral health was poorer in rural areas than in major city areas.

Socioeconomic and psychosocial correlates of oral health.

BACKGROUND: It has been proposed that psychosocial variables are important determinants of oral health outcomes. In addition, the effect of socioeconomic factors in oral health has been argued to work through the shaping of psychosocial stressors and resources. This study therefore aimed to examine the role of psychosocial factors in oral health after controlling for selected socioeconomic and behavioural factors. METHODS: Logistic and generalised linear regression analyses were conducted on self-rated oral health, untreated decayed teeth and number of decayed, missing and filled teeth (DMFT) from dentate participants in a national survey of adult oral health (n = 5364) conducted in 2004-2006 in Australia. RESULTS: After controlling for all other variables, more frequent dental visiting and toothbrushing were associated with poorer self-rated oral health, more untreated decay and higher DMFT. Pervasive socioeconomic inequalities were demonstrated, with higher income, having a tertiary degree, higher self-perceived social standing and not being employed all significantly associated with oral health after controlling for the other variables. The only psychosocial variables related to self-rated oral health were the stressors perceived stress and perceived constraints. Psychosocial resources were not statistically associated with self-rated oral health and no psychosocial variables were significantly associated with either untreated decayed teeth or DMFT after controlling for the other variables. CONCLUSION: Although the role of behavioural and socioeconomic variables as determinants of oral health was supported, the role of psychosocial variables in oral health outcomes received mixed support.

Effect of oral health literacy on self-reported tooth loss: A multiple mediation analysis.

BACKGROUND: This study aims to investigate the mediating pathways of oral health literacy (OHL) and oral health-related behaviours on the relationship between education and self-reported tooth loss among Australian adults. METHODS: Data used for studying the effects of mediating pathways are from the National Dental Telephone Interview Survey 2013, a random sample survey of Australian adults aged 18+ years. To study the mediating effects, we use counterfactual-based analysis. To decompose the effect of multiple mediator's alternate, to natural effect, methods such as interventional effects have been proposed. In this paper, we use these approaches to decompose the effect between education, OHL and oral health-related behaviours on self-reported tooth loss. Sensitivity analysis was performed for unmeasured confounding with multiple mediators. RESULTS: Data were available for 2936 Australian adults. The prevalence of persons with ≥12 self-reported tooth loss was approximately 15%. The average total causal effect from the low education group was nearly 150%, and the interventional indirect effect through OHL and the dependence of oral health-related behaviours on OHL to more than 12 missing teeth were 20% and 120%, respectively, higher than in the high education group. Sensitivity analysis indicated if the difference in the prevalence of unmeasured confounder is as big as 6% the direct effect and the indirect effect remains as observed. CONCLUSIONS: An additional two-fifths reduction on having more than 12 missing teeth for Australian adults with lower education level could be achieved if the proportion of lower OHL was decreased and optimal dental behaviours were increased.

Risk factors for impaired oral health among 18- to 34-year-old Australians.

OBJECTIVES: The objective of this study was to determine risk factors for a summary measure of oral health impairment among 18- to 34-year-olds in Australia. METHODS: Data were from Australia's National Survey of Adult Oral Health, a representative survey that utilized a three-stage, stratified, clustered sampling design. Oral health impairment was defined as reported experience of toothache, poor dental appearance, or food avoidance in the last 12 months. Multivariate Poisson regression models were used to evaluate effects of sociodemographic characteristics, self-perceived oral health, dental service utilization, and clinical oral disease indicators on oral health impairments. Effects were quantified as prevalence ratios (PR). RESULTS: The estimated percent of 18- to 34-year-olds with oral health impairment was 42.4 [95 percent confidence interval (CI) 37.7-47.2]. In the multivariate model, oral health impairment was associated with untreated dental decay (PR 1.38, 95 percent CI 1.13-1.68) and presence of periodontal pockets 4 mm+ (PR 1.29, 95 percent CI 1.03-1.61). In addition to those clinical indicators, greater prevalence of oral health impairment was associated with trouble paying a $100 dental bill (PR 1.37, 95 percent CI 1.12-1.68), usually visiting a dentist because of a dental problem (PR 1.46, 95 percent CI 1.15-1.86), reported cost barriers to dental care (PR 1.46, 95 percent CI 1.16-1.85), and dental fear (PR 1.43, 95 percent CI 1.18-1.73). CONCLUSIONS: Oral health impairment was highly prevalent in this population. The findings suggest that treatment of dental disease, reduction of financial barriers to dental care, and control of dental fear are needed to reduce oral health impairment among Australian young adults.

An introduction to oral health inequalities among Indigenous and non-Indigenous populations.

This overview revealed that substantial oral health inequalities exist between Indigenous and non-Indigenous child and adult populations in the United States, Canada, Brazil, Australia and New Zealand, with evidence suggesting that these inequalities are increasing. Despite the marked differences in geography, culture, language and history experienced by these groups, it is notable how similar the oral health inequalities were. A number of reasons are discussed in the paper.

Use of the Dental Electronic Health Record for Research: Assessing Demographic and Oral Health Characteristics Data for Clinic Patients.

Dental schools in the United States increasingly emphasize community-based practice targeting underserved populations. However, the impact on target populations remains largely undocumented. East Carolina University School of Dental Medicine (ECU SoDM) developed an integrated electronic health record database that aggregates patient data from all clinics in the ECU SoDM system and enables longitudinal assessment of the impact of clinical care on oral health outcomes. The aim of this study was to analyze the demographic and oral health characteristics data for eligible patients from June 2012 to March 2016. Data from 28,029 eligible patients were included. Except for expected variations in racial composition, the demographic data were similar across ECU SoDM clinics and indicated that the patient population represents a geographically diverse sample of outpatients. The mean decayed, missing, and filled teeth (DMFT) index was elevated in this population. Among the trends identified across subgroups were higher DMFT index in older patients and lower DMFT index for individuals of Hispanic or Latino ethnicity. Although the percentage of patients with dental caries overall rose steadily with age, the percentage with untreated dental caries generally fluctuated around 33%±5% without age-related trends. These data provide a baseline for evaluating changes over time and the impact of oral health care introduced to areas served by the ECU SoDM. These findings highlight the need for access to care and support the ECU SoDM's core mission.

Obesity and Periodontal Outcomes: A Population-Based Cohort Study in Brazil.

BACKGROUND: The aim of this study is to investigate the effects of abdominal and general obesity on periodontal outcomes in a population-based cohort of Brazilian adults. METHODS: Abdominal and general obesity were assessed in the years 2009 (n = 1,720) and 2012 (n = 1,222). For abdominal obesity, a dichotomous variable was created: 1) eutrophic/lost weight or 2) obese/gained weight. For general obesity, a categorical variable was created: 1) eutrophic/lost weight; 2) gained weight; or 3) obese. Periodontal outcomes were percentage of teeth with bleeding on probing (BOP) and combination of BOP and attachment loss (AL). Hypertension was set as the mediator. Marginal structural models (MSMs) were used to estimate the controlled direct effect of obesity on periodontal outcomes. RESULTS: Periodontal data were presented from 1,066 participants. The total effect model showed those with general obesity in the cohort period presented higher risk of unfavorable periodontal outcomes (rate ratio [RR]: 1.45 for AL and BOP in different teeth; RR: 1.84 for AL and BOP in the same tooth). Estimates from MSMs revealed an effect of general obesity on AL and BOP in different teeth (RR: 1.44). No effect of general obesity was noted on the percentage of BOP. Total effect of abdominal obesity increased risk of AL and BOP in different teeth (RR: 1.47), AL and BOP in the same tooth (RR: 2.77), and percentage of BOP (RR: 1.49). In a MSM, those with abdominal obesity presented greater risk of AL and BOP in the same tooth (RR: 2.16) and percentage of BOP (RR: 1.37). CONCLUSION: Abdominal obesity has a direct effect on unfavorable periodontal outcomes in MSMs.

Social inequalities in tooth loss: A multinational comparison.

OBJECTIVES: To conduct cross-national comparison of education-based inequalities in tooth loss across Australia, Canada, Chile, New Zealand and the United States. METHODS: We used nationally representative data from Australia's National Survey of Adult Oral Health; Canadian Health Measures Survey; Chile's First National Health Survey Ministry of Health; US National Health and Nutrition Examination Survey; and the New Zealand Oral Health Survey. We examined the prevalence of edentulism, the proportion of individuals having <21 teeth and the mean number of teeth present. We used education as a measure of socioeconomic position and measured absolute and relative inequalities. We used random-effects meta-analysis to summarize inequality estimates. RESULTS: The USA showed the widest absolute and relative inequality in edentulism prevalence, whereas Chile demonstrated the largest absolute and relative social inequality gradient for the mean number of teeth present. Australia had the narrowest absolute and relative inequality gap for proportion of individuals having <21 teeth. Pooled estimates showed substantial heterogeneity for both absolute and relative inequality measures. CONCLUSIONS: There is a considerable variation in the magnitude of inequalities in tooth loss across the countries included in this analysis.

Estimating the effects of maternal education on child dental caries using marginal structural models: The Longitudinal Study of Indigenous Australian Children.

OBJECTIVE: To estimate the effect of mothers' education on Indigenous Australian children's dental caries experience while controlling for the mediating effect of children's sweet food intake. METHODS: The Longitudinal Study of Indigenous Children is a study of two representative cohorts of Indigenous Australian children, aged from 6 months to 2 years (baby cohort) and from 3.5 to 5 years (child cohort) at baseline. The children's primary caregiver undertook a face-to-face interview in 2008 and repeated annually for the next 4 years. Data included household demographics, child health (nutrition information and dental health), maternal conditions and highest qualification levels. Mother's educational level was classified into four categories: 0-9 years, 10 years, 11-12 years and >12 years. Children's mean sweet food intake was categorized as <20%, 20-30%, and >30%. After multiple imputation of missing values, a marginal structural model with stabilized inverse probability weights was used to estimate the direct effect of mothers' education level on children's dental decay experience. RESULTS: From 2008 to 2012, complete data on 1720 mother-child dyads were available. Dental caries experience for children was 42.3% over the 5-year period. The controlled direct effect estimates of mother's education on child dental caries were 1.21 (95% CI: 1.01-1.45), 1.03 (95% CI: 0.91-1.18) and 1.07 (95% CI: 0.93-1.22); after multiple imputation of missing values, the effects were 1.21 (95% CI: 1.05-1.39), 1.06 (95% CI: 0.94-1.19) and 1.06 (95% CI: 0.95-1.19), comparing '0-9', '10' and '11-12' years to > 12 years of education. CONCLUSION: Mothers' education level had a direct effect on children's dental decay experience that was not mediated by sweet food intake and other risk factors when estimated using a marginal structural model.

Changes in Area-level Socioeconomic Status and Oral Health of Indigenous Australian Children.

OBJECTIVE: Dental diseases have shown to be influenced by area-level socioeconomic status. This study aims to assess the effects of change in area-level SES on the oral health of Australian Indigenous children. METHODS: Data were collected from a national surveillance survey for children's dental health at two points of time (2000-2002/2007-2010). The study examines caries experienced by area-level SES and whether changes in area-level SES (stable-high, upwardly-mobile, downwardly-mobile and stable low) affects caries experience. RESULTS: Dental caries in both the deciduous and permanent dentition increased significantly among Indigenous children during the study period. In stable low-SES areas, the experience of decayed, missing and overall dmft/DMFT in both dentitions was highest compared with other groups at both Time 1(2.15 vs 1.61, 1.77, 1.87 and 0.86 vs 0.55, 0.67, 0.70 respectively) and Time 2 (3.23 vs 2.08, 2.17, 2.02 and 1.49 vs 1.18, 1.21 respectively). CONCLUSION: A change in area-level SES was associated with experience of dental disease among Indigenous Australian children.

Changes in Area-level Socioeconomic Status and Oral Health of Indigenous Australian Children.

OBJECTIVE: Dental diseases have shown to be influenced by area-level socioeconomic status. This study aims to assess the effects of change in area-level SES on the oral health of Australian Indigenous children. METHODS: Data were collected from a national surveillance survey for children's dental health at two points of time (2000-2002/2007-2010). The study examines caries experienced by area-level SES and whether changes in area-level SES (stable-high, upwardly-mobile, downwardly-mobile and stable low) affects caries experience. RESULTS: Dental caries in both the deciduous and permanent dentition increased significantly among Indigenous children during the study period. In stable low-SES areas, the experience of decayed, missing and overall dmft/DMFT in both dentitions was highest compared with other groups at both Time 1(2.15 vs 1.61, 1.77, 1.87 and 0.86 vs 0.55, 0.67, 0.70 respectively) and Time 2 (3.23 vs 2.08, 2.17, 2.02 and 1.49 vs 1.18, 1.21 respectively). CONCLUSION: A change in area-level SES was associated with experience of dental disease among Indigenous Australian children.

A screening model for oral cancer using risk scores: development and validation.

OBJECTIVE: A study was conducted to develop and validate a screening model using risk scores to identify individuals at high risk for developing oral cancer in an Indian population. METHODS: Life-course data collected from a multicentre case-control study in India were used. Interview was conducted to collect information on predictors limited to the time before the onset of symptoms or cancer diagnosis. Predictors included statistically significant risk factors in the multivariable model. A risk score for each predictor was derived from respective odds ratios (OR). Discrimination of the final model, risk scores and various risk score cut-offs was examined using the c statistic. The optimal cut-off was determined as the one with good area under curve (AUC) and high sensitivity. Predictive ability of the regression model and cut-off risk score was determined by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Models were validated from a bootstrap sample. RESULTS: Smoking, chewing quid and/or tobacco, alcohol, a family history of upper aero-digestive tract cancer, diet and oral hygiene behaviour were the predictors. Risk scores ranged from 0 to 28. Area under the receiver operating characteristic (ROC) curve for risk scores was good (0.866). The sensitivity (0.928) and negative predictive value (0.927) were high, while specificity (0.603) and positive predictive value (0.607) were low for a risk score cut-off of 6. CONCLUSION: A risk score model to screen for individuals with high risk of oral cancer with satisfactory predictive ability was developed in the Indian population. Validation of the model in other populations is necessary before it can be recommended to identify subgroups of the population to be directed towards more extensive clinical evaluation.

Measuring the oral health of populations.

OBJECTIVES: This article provides a conceptual base for population oral health measurement and argues that problems associated with particular indices are subject to the basic issues of knowing what to measure and the level of measurement required to address the object of study and provide clear information about the health of the population as a whole. METHODS: Alternative approaches to caries measurement are presented using data from South Australian children attending the school dental services during 2007. RESULTS: While threshold selection of case definitions depicted different profiles of the same population, the inclusion of non-cavitated lesions did not alter the general disease profile of the population. CONCLUSIONS: The types of measures used depend on the purpose, nature of the data, and conceptualization of the phenomenon, and should continually refer to the population level. In population oral health, controversies surrounding outcome measures, such as caries indices, are moving away from addressing core issues to narrowing mechanistic views. Fundamental deliberations should include the valuation of health states, clearly defining health and disease and distinguishing between disease, determinants and the impacts of disease.

Language and literacy relate to lack of children's dental sealant use.

OBJECTIVES: This study aimed to determine the percent of California's third grade public school children lacking sealants by child and family factors and to measure social disparities for lacking sealants. METHODS: The study analyzed data from the California Oral Health Needs Assessment (COHNA) 2004-2005, a complex stratified cluster sample of children (n = 10,450) from 182 randomly selected public elementary schools in California. The dependent variable was absence of sealants in first permanent molars. The independent variables included child race/ethnicity; socio-economic position (SEP) measured as child's participation in the free or reduced-price lunch program at the individual and school level; acculturation measured as language spoken at home and school level percent of English language learners; and parent functional health literacy measured as correctly following questionnaire instructions. Absolute differences and health disparity indices (i.e. Slope Index of Inequality, Relative Index of Inequality-mean, Absolute Concentration Index) were used to measure absolute and relative disparities. RESULTS: The percent of children lacking sealants was high in all racial/ethnic groups; no child or school level SEP differences in lacking sealants were seen, but significant differences existed by acculturation (child and school level) and parental functional health literacy. CONCLUSIONS: NonEnglish language and poor parental functional health literacy are potential barriers that need to be addressed to overcome disparities in sealant utilization.

Predictors of untreated dental decay among 15-34-year-old Australians.

OBJECTIVES: To determine predictors of untreated dental decay among 15-34-year-olds in Australia. METHODS: Data were from Australia's National Survey of Adult Oral Health, a representative survey that utilized a three-stage, stratified clustered sampling design. Models representing demographic, socioeconomic, dental service utilization and oral health perception variables were tested using multivariable logistic regression to produce odds ratios. RESULTS: An estimated 25.8% (95% CI 22.4-29.5) of 15-34-year-old Australians had untreated dental decay. After controlling for other covariates, those who lived in a location other than a capital city had 2.0 times the odds of having untreated dental decay than their capital city-dwelling counterparts (95% CI 1.29-3.06). Similarly, those whose highest level of education was not a university degree had 2.1 times the odds of experiencing untreated dental decay (95% CI 1.35-3.31). Perceived need of extractions or restorations predicted untreated coronal decay, with 2.9 times the odds for those who perceived a treatment need over those with no such treatment need perception (95% CI 1.84-4.53). Participants who experienced dental fear had 2.2 times the odds of having untreated dental decay (95% CI 1.38-3.41), while those who reported experiencing toothache, orofacial pain or food avoidance in the last 12 months had 1.9 times the odds of having untreated dental decay than their counterparts with no such oral health-related quality-of-life impact (95% CI 1.20-2.92). The multivariate model achieved a 'useful' level of accuracy in predicting untreated decay (area under the ROC curve = 0.74; sensitivity = 0.63; specificity = 0.73). CONCLUSIONS: In the Australian young adult population, residential location, education level, perceived need for dental care, dental fear, toothache, orofacial pain or food avoidance together were predictors of untreated dental decay. The prediction model had acceptable specificity, indicating that it may be useful as part of a triage system for health departments wishing to screen by means of a questionnaire for apparently-dentally healthy 15-34-year-olds.