Do Socioeconomic Conditions Explain Ethnic Inequalities in Tooth Loss among US Adults?

Objective: To assess whether there are ethnic differences in tooth loss among adult Americans aged <40 years and whether socioeconomic position attenuates these differences if they exist. Methods: Data were from the 2014 Behavioral Risk Factor Surveillance System, a health-related telephone cross-sectional survey of a nationally representative sample of US adults. Tooth loss (one tooth or more) was used as the outcome variable. Ethnicity was the main explanatory variable. Family income, education and health insurance were also used in the analysis. Logistic regression models for tooth loss were constructed adjusting for demographic (age, sex, and ethnicity), socioeconomic indicators (income and education), health insurance, dental visits, smoking and diabetes. Results: A total of 76,273 participants were included in the analysis. The prevalence of tooth loss was highest among Blacks (33.7%). Hispanics and other ethnic groups had a higher prevalence of tooth loss than Whites, 29.1% (95%CI: 27.7-30.6), 22.0% (95%CI: 20.3-23.8), and 20.8% (95%CI: 20.2-21.4), respectively. Blacks had odds ratios (OR) 1.98 (95%CI: 1.81-2.16) for tooth loss compared with Whites. After adjusting for socioeconomic positions (SEP), the relationship attenuated but remained significant with OR 1.71 (95%CI: 1.55-1.90). Conclusions: Despite recent changes in the health care system in the United States, ethnic inequalities in tooth loss still exist. Income and education partially explained ethnic differences in tooth loss among Americans aged <40 years.

Dental treatment injuries in the Finnish Patient Insurance Centre in 2000-2011.

Objective The Patient Insurance Centre in Finland reimburses patients who sustained injuries associated with medical and dental care without having to demonstrate malpractice. The aim was to analyse all dental injuries claimed through the Patient Insurance Centre over a 12-year period in order to identify factors affecting reimbursement of claims. Methods This study investigated all dental patient insurance claims in Finland during 2000-2011. The injury cases were grouped as (K00-K08) according to the International Classification of Diseases (ICD-10). Calendar year, claimant's age and gender, dental disease group and health service sector were the explanatory factors and the outcome was the decision of a claim. Multiple logistic regression modelling was used in the statistical analyses. Results The total number of decisions related to dental claims at the PIC in 2000-2011 was 7662, of which women claimed a clear majority (72%). Diseases of the pulp and periapical tissues (K04) and dental caries (K02) were the major disease groups (both 29%). Of the claims 40% were eligible for reimbursement, 27% were classified as insignificant or unavoidable injuries and 32% were rejected for other reasons. The proportion of reimbursed claims declined during the period. Patients from the private sector were more likely to be eligible for compensation than were those from the public sector (OR = 1.89, 95% CI = 1.71-2.10). Conclusions The number of dental patient insurance claims in Finland clearly rose, while the proportion of reimbursed claims declined. More claims received compensation in the private sector than in the public sector.

Associations between social inequality and tooth loss in a household sample of elderly Thai people aged ≥60 years old.

OBJECTIVE: To assess the relationship between social inequality and the number of remaining teeth in an elderly Thai population. BACKGROUND: Having twenty or more remaining teeth is an important indicator of optimal oral health in the elderly. METHODS: The data for this study were derived from the Survey of Older Persons in Thailand, conducted by the National Statistical Office, based on face-to-face interviews with people aged ≥60. The total sample was 30 427. The oral health measure was self-reported remaining number of teeth. Income, education and possession of durable goods were utilised as measures of social inequality. RESULTS: More than half of the sample (57.0%) was women. The majority (73.2%) was in the age range 60-74 years old. Less than a fifth (15.5%) had 7 or more years of education. A third earned <20 000 Thai Baht (THB) per annum (defined as poor). More than half (52.8%) of the sample had <20 remaining teeth. There was a link between social inequalities and tooth loss. In the adjusted model, elderly people, who were older than 75, who were not under a married status, had a lower level of education, had a lower income, and who did not own luxury goods, were 2.84 (CI 95% 2.66-3.03), 1.31 (CI 95% 1.21-1.41), 1.44 (CI 95% 1.34-1.56), 1.12 (CI 95% 1.13-1.29) and 1.21 (CI 95% 1.13-1.29) times more likely to have 19 or fewer teeth remaining, respectively. CONCLUSION: Social inequality is related to the number of remaining teeth in elderly Thai people.

Reimbursement systems influence prosthodontic treatment of adult patients.

OBJECTIVE: To evaluate the influence of reimbursement system and organizational structure on oral rehabilitation of adult patients with tooth loss. MATERIALS AND METHODS: Patient data were retrieved from the databases of the Swedish Social Insurance Agency. The data consisted of treatment records of patients aged 19 years and above claiming reimbursement for dental care from July 1, 2007 until June 30, 2009. Before July 1, 2008, a proportionately higher level of subsidy was available for dental care in patients 65 years and above, but thereafter the system was changed, so that the subsidy was the same, regardless of the patient's age. Prosthodontic treatment in patients 65 years and above was compared with that in younger patients before and after the change of the reimbursement system. Prosthodontic treatment carried out in the Public Dental Health Service and the private sector was also analyzed. RESULTS: Data were retrieved for 722,842 adult patients, covering a total of 1,339,915 reimbursed treatment items. After the change of the reimbursement system, there was a decrease in the proportion of items in patients 65 years and above in relation to those under 65. Overall, there was a minimal change in the proportion of treatment items provided by the private sector compared to the public sector following the change of the reimbursement system. CONCLUSIONS: Irrespective of service provider, private or public, financial incentive such as the reimbursement system may influence the provision of prosthodontic treatment, in terms of volume of treatment.

Retaining or replacing molars with furcation involvement: a cost-effectiveness comparison of different strategies.

AIM: The comparative cost-effectiveness of retaining or replacing molars with furcation involvement (FI) remains unclear. We assessed the cost-effectiveness of retaining FI molars via periodontal treatments versus replacing them via implant-supported crowns (ISCs). METHODS: Using tooth-level Markov models, we followed a molar with FI degree I or II/III in a 50-year-old patient over his lifetime. Tooth-retaining periodontal treatments (scaling and root planing, flap debridement, root resection, guided-tissue regeneration, tunnelling) were compared with tooth replacement using ISCs. We analysed costs, time until first re-treatment and total time of tooth or implant retention. The model adopted a private payer perspective within German health care. Transition probabilities were calculated based on current evidence. Monte-Carlo microsimulations were performed, and robustness of the model and effects of heterogeneity assessed using sensitivity analyses. RESULTS: Despite requiring re-treatment later than other strategies, ISCs were the most costly therapy. Compared with most periodontal treatments, ISCs were retained for shorter time than natural teeth regardless of the degree of FI, the patients' age or risk profile (smoker/non-smoker). CONCLUSIONS: Based on available data and within its limitations, our study indicates that retaining FI molars via periodontal treatments might be more cost-effective than replacing them via ISCs. Changes in the underlying evidence or the setting might alter these results.

Applying quality assurance in real time to compliant long-term periodontal maintenance patients utilizing cost-effectiveness and cost utility.

BACKGROUND: Little work has been done on quality assurance of long-term maintenance of periodontal therapy MATERIALS/METHODS: A quality assurance model was applied to 80 patients (50 females, 30 males) with an average age of 64.3 years (SD. 8.83, range 45-91) and with 21.6 (SD. 2.65, range 16-26) maintenance years. The main elements were patients' expectations, objectives and patient-based outcomes, human and financial costs and treatment deviations. For cost-effectiveness, this group was compared with a control group of 25 patients with an average of 9.96 years not complying with maintenance therapy. RESULTS: The patients' main expectations and reasons for seeking treatment were to save teeth and a desire for better oral health. The patients had a total tooth-year loss of 3.3%. 81.3% reported improved oral health. Total treatment discounted cost was €5842. The cost of buying an extra tooth year was €20.2. Patients reported anxiety of 4.6 (SD10.5, range 0-47) and discomfort of 11.8 (SD13.2 range 0-70) for the maintenance visits on the Visual Analogue Scale (VAS). Treatment deviations showed 3.8% extreme downhill patients, 6.3% with poor oral hygiene, 3.8% reported a worsening of their oral health, 3.8% had high anxiety whereas 5.0% experienced a high level of discomfort. CONCLUSION: It is possible to apply a number of elements of a quality assurance measure to a patient population of compliant maintenance patients in real time. The results obtained compare well with previous internal and external studies. This model should be useful to patients and practitioners as well as for larger population-based studies.

The cost-effectiveness of supportive periodontal care: a global perspective.

AIM: To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care. MATERIAL AND METHODS: SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years. RESULTS: SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time. CONCLUSION: SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

[Preventive strategies in prosthetic dentistry]. / Präventionsorientierte Strategien in der prothetischen Zahnmedizin.

Despite the success in preventing oral diseases, the prevalence of tooth loss in the German population remains high and increases with age. Today, the advances in prosthetic dentistry allow necessary tooth replacement following preventive strategies-after considering benefits and risks. Modern treatment options improve the overall prognosis of the stomatognathic system and the quality of life of the affected patients significantly. Hereby, adverse iatrogenic effects can be minimized or even completely avoided by extending the traditional treatment spectrum, e.g., using adhesively fixed restorations and implant-supported restorations, and refraining from placing restorations that are unnecessary from the medical point of view. Generally, patients benefit greatly from prosthetic treatment and the achieved health gain is remarkably high. It encompasses not only the recovery of the impaired oral functions but also extends to the whole human organism, including nutrition, digestion, musculoskeletal system, as well as mental and social well-being.

Post-trial costs, clinical outcomes, and dental service utilization after a randomized clinical trial for caries control among Finnish adolescents.

The aim of this study was to assess post-trial treatment costs, clinical outcomes [decayed, missing or filled surfaces (DMFS) scores], and utilization of dental services among adolescents who had participated in a randomized clinical trial (RCT) in Pori, Finland, in 2001-2005. At baseline the children were 11-12 yr of age and had had at least one active initial caries lesion. The children in the experimental group (n = 250) had been exposed to multiple measures for caries control, while those in the control group (n = 247) had received standard dental care. During the post-trial period (2005-2008), all participants received the standard dental care offered in public dental clinics in Pori. In both groups the costs of treatment procedures and outcomes for the post-trial period were calculated for each adolescent. Information from patient records was available for 487 adolescents (former experimental n = 246, control n = 241). The mean total costs per adolescent were lower and the clinical outcome was better among the former experimental-group participants. The differences in mean costs between the groups were statistically significant for preventive and restorative procedures. The utilization of dental services was significantly more regular among the former experimental-group participants.

Association between dental consultation and oral health status among male Japanese employees.

OBJECTIVE: To investigate the association between dental consultation and oral health status among male Japanese employees. METHODS: The participants were 3351 male employees who received a workplace oral health examination conducted at the ages of 35, 40, 45, 50, 55, and 59 years before retirement in conjunction with an annual health checkup. Data on dental expenditures were collected from health insurance claims. The number of dental visits and dental care expenses, alone or in combination, were used as indices of the dental consultation status for the analyses. The effects of dental consultation status on oral health status (number of total teeth, number of decayed teeth, and periodontal status) were analyzed using multivariate multinomial logistic regression analyses adjusted for confounders. RESULTS: Multivariate analyses revealed that the odds ratio (OR) for 20-27 teeth (losing 1-8 teeth) was significantly higher (OR 1.4, 95% confidence interval (CI) 1.1-1.7) in those who had a high number of dental visits and high dental care expenses than in those who did not have a dental visit. By contrast, the ORs for ≤19 teeth (losing ≥9 teeth), having ≥3 decayed teeth, or having a periodontal pocket ≥6 mm were significantly lower (OR 0.2, 95% CI 0.1-0.6; OR 0.5, 95% CI 0.3-0.6; OR 0.7, 95% CI 0.5-1.0, respectively) in those who had fewer dental visits and lower dental care expenses. CONCLUSIONS: These results imply that the dental consultation status is associated with oral health status among male employees.

Effort and costs of tooth preservation in supportive periodontal treatment in a German population.

OBJECTIVES: Assessment of effort (number of visits) and costs of tooth preservation 10 years after initiation of anti-infective therapy. MATERIAL AND METHODS: Data of 98 patients who had received active periodontal treatment 10 years ago by the same examiner were analysed to gather information on effort and costs of supportive periodontal therapy (SPT). Clinical examination, interleukin-1 (IL-1) polymorphism test, smoking, search of patients' files (i.e. initial diagnosis), as well as a questionnaire on medical history and socioeconomic data were performed. Statistical analysis was performed using multivariate linear regression analysis. RESULTS: During 10 years of SPT patients had 14.8+/-7.4 visits. Number of visits was statistically significantly higher for individuals with a mean plaque control record >or=24 %. The number of subgingival scalings per tooth ranged from 0 to 14 (mean: 1.17). On tooth level several confounders could be identified: tooth type, initial bone loss, furcation involvement, abutment status, and previous regenerative surgery (p

Cost-effectiveness of an experimental caries-control regimen in a 3.4-yr randomized clinical trial among 11-12-yr-old Finnish schoolchildren.

The aim of this study was to assess the cost-effectiveness of an experimental caries-control regimen in a randomized clinical trial (RCT) conducted in Pori, Finland, in 2001-2005. Children (n = 497) who were 11-12 yr of age and had at least one active initial caries lesion at baseline were studied. The children in the experimental group (n = 250) were offered an individually designed patient-centered regimen for caries control. The children in the control group (n = 247) received standard dental care. Furthermore, the whole population was exposed to continuous community-level oral health promotion. Individual costs of treatment procedures and outcomes (DMFS increment score) for the follow-up period of 3.4 yr were calculated for each child in both groups. The incremental cost-effectiveness ratio was euro 34.07 per averted DMF surface. The experimental regimen was more effective, and also more costly. However, the total costs decreased year after year, and for the last 2 yr the experimental regimen was less expensive than the standard dental care. The experimental regimen would probably have been more cost-effective than standard dental care if the follow-up period had been longer, the regimen less comprehensive, and/or if dental nurses had conducted the preventive procedures.

Prospective cohort of adult oral health in Piracicaba, SP, Brazil.

OBJECTIVE: To describe the methodological aspects of a Prospective Cohort Study of adult oral health in Piracicaba, Brazil. RESULTS: This Prospective Cohort Study evaluated adults (20-64 years old) between the years of 2011 and 2015, in Piracicaba, São Paulo, Brazil. The main objective was to evaluate the risk factors for tooth loss in adults. Data were collected at households and selected via probabilistic sampling, through clinical examination of caries, considering as variables the decayed, missing and filled permanent teeth index, need for caries treatment, periodontal disease (Community Periodontal Index and Periodontal Attachment Loss), use and need for dental prosthesis, and presence of visible biofilm. A questionnaire about demographic, socioeconomic and health habits, use of dental services, self-perceived quality of life (Oral Health Impact Profile-14) and health literacy (14-item Health Literacy Scale) was also employed. In 2011, 248 adults participated, and in 2015, 143 (follow-up rate = 57.7%). Despite the follow-up sample loss, most sociodemographic characteristics remained in the participant sample: for example, women (72.0%) (p = 0.534), family income between R$545,00 and R$1090,00 (63.9%) (p = 0.920), above 11 years of education (53.1%) (p = 0.200) and belonging to middle class (67.1%) (p = 0.909).

Does psychological stress mediate social deprivation in tooth loss?

It is unclear which theoretical dimension of psychological stress affects health status. We hypothesized that both distress and coping mediate the relationship between socio-economic position and tooth loss. Cross-sectional data from 2915 middle-aged adults evaluated retention of < 20 teeth, behaviors, psychological stress, and sociodemographic characteristics. Principal components analysis of the Perceived Stress Scale (PSS) extracted 'distress' (a = 0.85) and 'coping' (a =0.83) factors, consistent with theory. Hierarchical entry of explanatory variables into age- and sex-adjusted logistic regression models estimated odds ratios (OR) and 95% confidence intervals [95% CI] for retention of < 20 teeth. Analysis of the separate contributions of distress and coping revealed a significant main effect of coping (OR = 0.7 [95% CI = 0.7-0.8]), but no effect for distress (OR = 1.0 [95% CI = 0.9-1.1]) or for the interaction of coping and distress. Behavior and psychological stress only modestly attenuated socio-economic inequality in retention of < 20 teeth, providing evidence to support a mediating role of coping.

The cost-effectiveness of adding fluorides to milk-products distributed by the National Food Supplement Programme (PNAC) in rural areas of Chile.

OBJECTIVE: This paper assesses the cost-effectiveness of a community dental caries prevention programme, targeting pre-school children living in non-fluoridated rural areas of Chile. BASIC RESEARCH DESIGN: The results of a community trial to measure the effects of using fluoridated powdered milk and milk-cereal to prevent dental caries, together with the cost of running the programmeme, were used to determine its cost-effectiveness when compared to the status-quo alternative. In the experimental community, fluoridated milk products were given to approximately 1,000 children aged between six months and six years, using the standard National Complementary Feeding Programme available in Chile. The control group received the milk products only. Dental caries status was recorded at the beginning and end of the programme in both communities using WHO criteria. The costs that would be incurred by such a programme, using a societal perspective, were identified and measured. RESULTS: Children who received fluoridated products had significantly lower mean levels of dental caries than those who had not. This improvement was achieved with a yearly cost of RCH (1999) $1,839.75 per child (1 US$ = RCH (1999) $527.70). On average, this programme resulted in a net societal savings of RCH (1999) $2,695.61 per diseased tooth averted after four years when compared to the control group. CONCLUSIONS: While the analysis has inherent limitations as a result of its reliance on a range of assumptions, the findings suggest that there are important health and economic benefits to be gained from the use of fluoridated milk products in non-fluoridated rural communities in Chile.

Prosthodontics, care utilization and oral health-related quality of life.

The main aim of this thesis was to study the impact of oral health and oral prostheses on oral health-related quality of life (OHRQOL) in an adult Swedish population. Additional aims were to study social inequalities in oral health, attitudes towards the cost for dental care and dental care utilization. The study base was 1294 responses to a questionnaire from a random sample of 1974 persons aged 50-75 years, all of whom were resident in the County of Skine, Sweden. There was an association between impaired dental conditions and poor social conditions. Low dental care utilization covaried with impaired dental conditions and with stating a perceived need to obtain dental care but with no possibility to obtain it because of a cost barrier. In factor analysis, three factors captured 22 variables that aimed to measure OHRQOL. The constituent variables were summed into three index variables interpreted as oral health impact on everyday activities, on a psychological dimension and on oral function. The three variables were set as dependent variables in regression models with the independent variables social attributes, individual attributes, dentures, number of teeth and dental care attitudes. The models were run in three steps taking into account the interaction between the type of denture and the number of remaining teeth. The number of remaining teeth was more important than the type of denture when explaining OHRQOL. The type of replacement, in terms of fixed or removable denture, was less important for those with few or no remaining teeth, than for all others. OHRQOL was also explained by general health in relation to age peers as well as by varying attitudes towards dental care costs. Statistically significant interactions were observed between the number of remaining teeth and the type of denture when explaining OHRQOL. As a whole the thesis shows that social and dental conditions and cost for dental care play a great role for dental care utilization as well as for OHRQOL. Prosthodontics has an important role, where type of replacement interacts with tooth loss in its effect on QOL.

Cost-effectiveness of Different Post-retained Restorations.

OBJECTIVES: Dentists can choose between metal and fiber post systems to provide post-retained restorations. The risk of tooth loss and other complications differs between different post systems, as do the initial treatment costs. We aimed to assess the cost-effectiveness of (1) cast metal (MC), (2) preformed metal (MP), (3) glass fiber (GF), and (4) carbon fiber (CF) post-retained restorations. METHODS: A mixed public-private payer's perspective within German healthcare was taken. Risks of complications were extracted from systematic reviews. Costs were estimated by using fee items and 2016 material costs. A Markov model was constructed to follow up an endodontically treated molar receiving a post-retained crown in an initially 50-year-old patient during his lifetime. Monte Carlo microsimulations were performed to assess lifetime costs and tooth retention time. RESULTS: MPs were least costly (€692€), retaining teeth for 26.7 years. GFs were more costly (€745€), retaining teeth for 27.6 years. MCs were minimally more effective but also more costly than GFs (€774€). CFs were less effective and most expensive (€825€, 26.7 years). For payers willing to invest more than €60€ per tooth retention year, GF was cost-effective. Payers willing to invest an additional €670€ found MC to be cost-effective. These findings were found robust in sensitivity analyses. CONCLUSIONS: For payers not willing to invest additional money for longer tooth retention, MP seemed most suitable to retain restorations. For payers with additional willingness to pay, GF seemed suitable, retaining teeth for longer. MC was only cost-effective under very high willingness to pay. CF is not recommendable on the basis of their cost-effectiveness.

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.

Social inequalities in adult oral health in 40 low- and middle-income countries.

OBJECTIVE: This study evaluated social inequalities in adult oral health across several low- and middle-income countries. METHODS: We used data from 40 countries that participated in the World Health Surveys. Participants' socio-economic position was assessed using the wealth index. Oral health was assessed using two perceived measures, namely total tooth loss and whether they had any problems with their mouth and/or teeth during the last 12 months (perceived needs). Absolute and relative wealth inequalities in oral health were measured using the slope index of inequality (SII) and the relative index of inequality (RII), respectively, after adjusting for participants' sex, age and education. RESULTS: There were wealth inequalities in total tooth loss and perceived needs in most countries. However, significant monotonic gradients were found in 21 countries for total tooth loss and in 18 countries for perceived needs. Two distinctive patterns of social inequality in oral health were found across countries using the RII and the SII. For total tooth loss, pro-rich inequality was found in 25 countries (significant RII/SII in eight countries) and pro-poor inequality was found in 15 (significant RII/SII in three countries). For perceived needs, pro-poor inequality was found in 26 countries (significant RII/SII in six countries) and pro-rich inequality was found in 14 (significant RII/SII in five countries). CONCLUSIONS: The well-documented social gradient in adult oral health favouring the rich was not present in all low- and middle-income countries. Pro-poor inequalities in total tooth loss, and particularly in perceived dental-treatment needs, were observed in some countries.

Variation and change in the meaning of oral health related quality of life: a 'grounded' systems approach.

Changes in concepts of health and disease have led to increased interest in health related quality of life in medicine. Quality of life measures tend to treat quality of life as a stable construct that can be measured externally. They do not consider people's differing expectations and assume that what quality of life means to people is stable over time. This paper reports on a study which aimed to find out how measures of oral health related quality of life (OHRQoL) vary between and change within individuals. Longitudinal semi-structured open-ended interviews were carried out with twenty people with socially noticeable broken, decayed or missing teeth who were or were not seeking dental treatment. The data were collected and analysed using the iterative processes of grounded systems theory based on Glaserian (Theoretical Sensitivity, The Sociology Press, Mill Valley, CA, 1978) grounded theory and Luhmann's (Social Systems, Stanford University, Stanford, 1984) social systems theory. During the data analysis it emerged that participants' were adopting positions on seven dimensions of oral health relating to the positions that people would adopt with respect norm, attribution, trust, accessibility, commodity, authenticity, and character. The core distinction that accommodated people's varying positions was that people constructed their own margins of relevance of oral health. The margins of relevance indicated a variable from a hypothetical extreme of 'super-relevant' to the other extreme of 'not relevant'. The margins of relevance could shift, meaning that assessments of quality of life would vary. Oral health related quality of life is therefore defined as the cyclical and self-renewing interaction between the relevance and impact of oral health in everyday life.