The Mouth as a Site of Compound Injustices: A Structural Intersectionality Approach to the Oral Health of Working-Age US Adults.

Knowledge of and practice around health inequities have been limited by scarce investigations on intersecting forms of structural oppression, including the extent to which their effects are more severe among multiply marginalized groups. We addressed these insufficiencies by adopting a structural intersectionality approach to the study of edentulism (i.e., complete tooth loss), the dental equivalent of mortality. While individual information was gathered from approximately 200,000 adult (ages 18-64 years) respondents to the 2010 US Behavioral Risk Factor Surveillance System survey, state-level data for 2000 and 2010 were obtained from a 2021 study by Homan et al. (J Health Soc Behav. 2021;62(3):350-370) and the US Census. These 3 sources provided information on edentulism, race, sex, structural racism, structural sexism, and income inequality, in addition to multiple covariates. Analyses showed that the intersections between structural sexism and state-level income inequality and structural racism were associated with 1.4 (95% confidence interval: 1.1, 1.9) and 1.5 (95% confidence interval: 1.1, 2.2) times' increased odds of complete tooth loss, respectively. The frequency of edentulism was highest among non-Hispanic Black men residing in states with high structural racism, high structural sexism, and high economic inequality. Based on these and other findings, we highlight the importance of a structural intersectionality approach to research and policy related to health inequities in the United States and elsewhere.

Depression and anxiety among the University community during the Covid-19 pandemic: a study in Southern Brazil.

This study aimed to assess the mental health of a University community in South Brazil during the COVID-19 pandemic. A cross-sectional web-based survey was conducted between July-August 2020 through a self-administered questionnaire. All University staff and students were eligible. Depression was measured using the Patient Health Questionnaire-9 and anxiety by the Generalized Anxiety Disorder-7. To evaluate the effect of social distancing and mental health factors on outcomes, Poisson regression models with robust variance were performed, estimating Prevalence Ratios (PR) and 95% Confidence Intervals (95%CI). 2,785 individuals participated in the study. Prevalence of depression and anxiety were 39.2% (95%CI 37.3-41.1) and 52.5% (95% CI 50.6-54.4), respectively. Undergraduate students showed a higher prevalence of the outcomes. Not leaving the house routinely, mental health care, and previous diagnosis of mental illness were associated with both outcomes. Those with a previous medical diagnosis of depression had a 58% (PR 1.58; 95%CI 1.44; 1.74) and anxiety a 72% (PR 1.72; 95%CI 1.56; 1.91) greater prevalence of depression than their peers. An alarming prevalence of psychopathologies was observed. Despite the well-known benefits of social distancing to public health, it requires a surveillance on the population's mental health, especially students and those with previous mental illness diagnosis.

A multi-country survey on the impact of COVID-19 on dental practice and dentists' feelings in Latin America.

BACKGROUND: The COVID-19 pandemic has significantly influenced the routine of healthcare workers. This study investigated the impact of the pandemic on dental practice and dentists' feelings in Latin America. METHODS: A survey was conducted with dentists from 11 Spanish-speaking Latin American countries in September-December 2020. Professionals were invited by email and via an open campaign promoted on social media. The questions investigated dental care routines, practice changes, and feelings about the pandemic. Descriptive statistics were used to identify frequencies and distributions of variables. Proportions were compared using chi-square tests. RESULTS: A total of 2127 responses were collected from a sample with diverse demographic, sex, work, and education characteristics. The impact of COVID-19 was considered high/very high by 60% of respondents. The volume of patients assisted weekly was lower compared with the pre-pandemic period (mean reduction = 14 ± 15 patients). A high rate of fear to contracting the COVID-19 at work was observed (85%); 4.9% of participants had a positive COVID-19 test. The main professional challenges faced by respondents were reduction in the number of patients or financial gain (35%), fear of contracting COVID-19 (34%), and burden with or difficulty in purchasing new personal protective equipment (22%). The fear to contracting COVID-19 was influenced by the number of weekly appointments. A positive test by the dentists was associated with their reports of having assisted COVID-19 patients. The most cited feelings about the pandemic were uncertainty, fear, worry, anxiety, and stress. Negative feelings were more prevalent for professionals who did not receive training for COVID-19 preventive measures and those reporting higher levels of fear to contract the disease. CONCLUSION: This multi-country survey indicated a high impact of the pandemic on dental care routines in Latin America. A massive prevalence of bad feelings was associated with the pandemic.

Periodontal disease and preterm birth: Findings from the 2015 Pelotas birth cohort study.

OBJECTIVES: To verify the association between periodontal conditions and preterm birth. MATERIALS AND METHODS: This study used data from the 2015 Pelotas Birth Cohort Study, Brazil. Pregnant women expected to give birth in 2015 were interviewed and dentally examined by a trained dentist, with periodontal measures collected in all teeth, six sites per tooth. Exposure was periodontal disease. Outcomes were preterm birth (all births <37 weeks of gestational age) and early preterm birth (<34 weeks). Analysis was carried out using Poisson regression according to a directed acyclic graph. RESULTS: A total of 2,474 women participated in the study. Incidence of preterm births was 10.2% and of early preterm births was 3.5%. Frequency of gingivitis was 21.7%, and periodontitis was 14.9%. Periodontitis was associated with a risk almost two times higher of having early preterm delivery compared with healthy pregnant women (RR 1.93; 95% CI 1.09-3.43). Presence of 5+ mm periodontal pocket with bleeding on probing was also associated with higher risk for early preterm delivery. CONCLUSIONS: The association between periodontal disease in pregnancy and the occurrence of preterm delivery is sensitive to the case definitions. Periodontal disease increased the risk of early preterm delivery.

Income at birth and tooth loss due to dental caries in adulthood: The 1982 Pelotas birth cohort.

OBJECTIVE: To estimate the effect of income at birth on adulthood tooth loss due to dental caries in 539 adults from the 1982 Pelotas birth cohort. METHODS: Family income was collected at birth. Tooth loss was clinically assessed when individuals were aged 31. Dental visit and oral hygiene at age 25 were considered mediators. Confounders included maternal skin color, and individual's skin color, sex, and income in adulthood. Marginal structural modeling was used to estimate the controlled direct effect of income at birth on tooth loss due to dental caries that was neither mediated by the use of dental service nor oral hygiene. RESULTS: Forty-three percent of the individuals of low income at birth lost one/two teeth, and 23% lost three or more; among those non-poor, the prevalence was 30% and 14%, respectively. Poor individuals at birth had a 70% higher risk for missing teeth in adulthood than those non-poor. The risk of losing one/two (risk ratio 1.68) and three or more teeth (risk ratio 3.84) was also higher among those of low income at birth. CONCLUSIONS: Economic disadvantage at birth had an effect on tooth loss due to dental caries at age 31 not mediated by individual risk factors.

Effect of life-course family income trajectories on periodontitis: Birth cohort study.

AIMS: To quantify the impact of life course income trajectories on periodontitis in adulthood. MATERIALS AND METHODS: Data from the 1982 Pelotas Birth Cohort Study, Brazil, were used. Information on family income was collected at birth and ages 15, 19, 23 and 30 years. Group-based trajectory modelling was used to identify income trajectories. Periodontal measures were assessed through clinical examination at age 31. Log-Poisson regression models were used to estimate prevalence ratios (PRs) of any and moderate/severe periodontitis, as outcomes. RESULTS: Prevalence of any periodontitis and moderate/severe periodontitis was 37.3% and 14.3% (n = 539). Income trajectories were associated with prevalence of moderate/severe periodontitis. Adjusted PR in participants in low and variable income trajectory was 2.1 times higher than in participants in stable high-income trajectory. The unadjusted association between income trajectories and prevalence of any periodontitis was explained by the inclusion of behavioural and clinical variables in the model. CONCLUSIONS: Low and variable life course income increased the prevalence of moderate/severe periodontitis at age 31 years. The findings may inform programmes in identifying and targeting potentially at-risk groups during the life course to prevent periodontitis.

Emulating a target trial of intensive nurse home visiting in the policy-relevant population using linked administrative data.

BACKGROUND: Populations willing to participate in randomized trials may not correspond well to policy-relevant target populations. Evidence of effectiveness that is complementary to randomized trials may be obtained by combining the 'target trial' causal inference framework with whole-of-population linked administrative data. METHODS: We demonstrate this approach in an evaluation of the South Australian Family Home Visiting Program, a nurse home visiting programme targeting socially disadvantaged families. Using de-identified data from 2004-10 in the ethics-approved Better Evidence Better Outcomes Linked Data (BEBOLD) platform, we characterized the policy-relevant population and emulated a trial evaluating effects on child developmental vulnerability at 5 years (n = 4160) and academic achievement at 9 years (n = 6370). Linkage to seven health, welfare and education data sources allowed adjustment for 29 confounders using Targeted Maximum Likelihood Estimation (TMLE) with SuperLearner. Sensitivity analyses assessed robustness to analytical choices. RESULTS: We demonstrated how the target trial framework may be used with linked administrative data to generate evidence for an intervention as it is delivered in practice in the community in the policy-relevant target population, and considering effects on outcomes years down the track. The target trial lens also aided in understanding and limiting the increased measurement, confounding and selection bias risks arising with such data. Substantively, we did not find robust evidence of a meaningful beneficial intervention effect. CONCLUSIONS: This approach could be a valuable avenue for generating high-quality, policy-relevant evidence that is complementary to trials, particularly when the target populations are multiply disadvantaged and less likely to participate in trials.

The independent and joint contribution of objective and subjective socioeconomic status on oral health indicators.

OBJECTIVES: The understanding of how subjective socioeconomic status (SSS) relates to objective socioeconomic status (OSS), and how both conditions act together in oral health outcomes is still unclear. This study aims to test the independent and joint association between OSS and SSS with oral health, to assess the role of socioeconomic status discrepancies, and to evaluate the role of SSS in the association between OSS and oral health. METHODS: Data from 1140 adults from a population-based study in Southern Brazil were used. We applied diagonal reference models DRM to disentangle the effects of OSS (education) and SSS (MacArthur Scale) to oral health outcomes. The outcomes were functional dentition clinically evaluated (FD ≥20 teeth) and self-reported oral health SROH. We also examined the discrepancy between OSS and SSS to oral health indicators and the effect measure modification (EMM) of SSS on the association between OSS and oral health. RESULTS: Subjective socioeconomic status and OSS contributed equally to SROH, while OSS explained a substantially higher amount of FD than SSS (0.85 vs 0.15). An EMM of SSS was found on the association between OSS and fair/poor SROH, with a relative excess risk due to interaction (RERI) of 1.08. Less evidence of EMM was found for FD (RERI = 0.14). Individuals with lower SSS and OSS had four times the risk of the outcomes than the reference group. CONCLUSIONS: Adults with concordant lower SSS and OSS have a worse oral health than those with concordant higher status. There was evidence that the association between OSS and SROH is modified by SSS.

Is the association between social support and oral health modified by household income? Findings from a national study of adults in Australia.

OBJECTIVE: To investigate whether the association between social support and oral health outcomes is modified by levels of household income. METHODS: Data were from the National Study of Adults Oral Health (NSAOH 2004-06), a nationally representative study comprising n = 3619 adults in Australia. Effect measure modification (EMM) analysis was adopted to verify whether the association between social support and poor/fair self-rated oral health, lack of a functional dentition (<21 teeth) and low Oral Health Related Quality of Life (OHRQoL; measured using OHIP-14) varies according to levels of income. Poisson regressions adjusted for age, sex, education, country of birth, main language spoken at home and remoteness were used to estimate prevalence ratios (PR) for oral health outcomes for each stratum of social support (overall, family, friends and significant other) and income (effect modifier). We then computed the Relative Excess Risk due to Interaction (RERI), which represents the risk that is over what would be expected if the combination of low social support and low income was entirely additive. Sensitivity analyses for different cut-offs of household income were performed. RESULTS: Adults with lower levels of social support had a 2.1, 1.2 and 1.9 times higher prevalence of fair/poor self-rated oral health, <21 teeth and poor OHRQoL respectively. The RERIs observed were 0.98 (95% CI -0.01; 1.96) for poor/fair self-rated oral health; 0.52 (95% CI -0.06; 1.10) for lack of a functional dentition and 0.50 (95% CI -0.16; 1.15) for poor OHRQoL. For all outcomes and all individual domains of social support, the positive RERIs indicated that the joint association of low social support and low household income surpassed the sum of their separate associations with objective and subjective oral health indicators. CONCLUSION: Individuals with lower levels of social support had poorer oral health than those with high levels of social support, although this association was small for the outcome <21 teeth. The association between social support and poor oral health indicators is modified by levels of household income. Hence, the provision of social support had a stronger association with the oral health of low-income participants, suggesting that socioeconomically disadvantaged individuals would mostly benefit from a social support intervention.

How do state-level racism, sexism, and income inequality shape edentulism-related racial inequities in contemporary United States? A structural intersectionality approach to population oral health.

OBJECTIVE: Research on racial oral health inequities has relied on individual-level data with the premise being that the unequal distribution of dental diseases is an intractable problem. We address these insufficiencies by examining the relationships between structural racism, structural sexism, state-level income inequality, and edentulism-related racial inequities according to a structural intersectionality approach. METHODS: Data were from two sources, the 2010 survey of the U.S. Behavioral Risk Factor Surveillance System, and Patricia Homan et al.'s (2021) study on the health impacts from interlocking systems of oppression. While the first contains information on edentulism from a large probabilistic sample of older (65+) respondents, the second provides estimates of racism, sexism, and income inequality across the US states. Taking into account a range of individual characteristics and contextual factors in multilevel models, we determine the extent to which structural forms of marginalization underlie racial inequities in edentulism. RESULTS: Our analysis reveals that structural racism, structural sexism, and state-level income inequality are associated with the overall frequency of edentulism and the magnitude of edentulism-related racial inequities, both individually and intersectionally. Coupled with living in states with both high racism and sexism (but not income inequality), the odds of edentulism were 60% higher among non-Hispanic Blacks, relative to Whites residing where these structural oppressions were at their lowest. CONCLUSIONS: These findings provide evidence that racial oral health inequities cannot be disentangled from social forces that differentially allocate power and resources among population groups. Mitigating race-based inequities in oral health entails dismantling the multifaceted systems of oppression in the contemporary U.S. society.

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 .

Intersectionality, racial discrimination and oral health in Australia.

BACKGROUND: There is a dearth of studies on the extent to which perceived racial discrimination shapes oral health. Following an intersectional perspective, we estimated the prevalence of perceived racial discrimination in Australia, its association with oral health impairment, and examined whether this association was more severe among low socioeconomic status (SES) groups. METHODS: Data came from the 2013 National Dental Telephone Interview Survey (N = 2798), a population-based study of Australian adults. Multivariable Poisson regression models were estimated to test the relationship between perceived racial discrimination and self-reported oral health impairment, as well as to investigate whether the magnitude of this association was greater among low-SES respondents. Relative Excess Risks due to Interaction (RERI) were used to indicate the presence of potentially large discrimination effects within low-SES strata. RESULTS: Racial discrimination in the past 12 months was reported by 11.5% of all participants. Australians reporting racial discrimination had 1.4 (95% CI 1.1, 1.7) times the prevalence of impaired oral health. The association between perceived racial discrimination and oral health impairment was stronger among low-SES groups. The RERI was 0.55, indicating a super-additive Effect Measure Modification (EMM) by income on the additive scale. Similar results were observed with the EMM analyses by educational attainment. CONCLUSION: Our findings indicate that perceived racial discrimination, as a specific form of widespread inequality, is associated with higher frequencies of oral health impairment among Australian adults. We also suggest that socially marginalized groups bear a greater burden of the oral health effects of racial discrimination.

The vicious cycle of dental fear at age 31 in a birth cohort in Southern Brazil.

OBJECTIVES: This longitudinal study assessed the prevalence of dental fear in adulthood and the association with socio-economic, behavioural and clinical variables. Also, the existence of a vicious cycle of dental fear was tested. METHODS: A random sample of adults (n = 535) from the 1982 Pelotas Birth Cohort, Brazil, was selected. Socio-economic data, behavioural characteristics and clinical variables were collected during different cohort waves. Oral health data were collected at ages 15, 24 and 31 years old, using questionnaires and oral examination. Dental fear (the outcome) was assessed by the question: 'Are you afraid of going to the dentist?', with possible responses: dichotomized into 'No' or 'A little/Yes/A lot'. Exposure variables were as follows: dental visit in the last years (at the ages 15 and 31); caries experience (DMFT ≥ mean) at the ages 15 and 31; the trajectory of caries prevalence from 15 to 31 years old; dental pain in the last six months in the two ages evaluated; and self-rated oral health at age 31. Several multivariable Poisson regression models were used to investigate the association between each of the exposure variables and dental fear. RESULTS: Dental fear prevalence was 22.1%, and it was more prevalent among non-white individuals and females. After controlling for potential confounders, dental fear was more likely to be reported by those individuals who had dental pain or a higher prevalence of dental caries at the age 15. Dental fear was also associated with a worse trajectory of dental caries, negative self-rated oral health at age 31 and with not having visited the dentist in the last year (at the age 31). Results supported the proposed vicious cycle of dental fear. CONCLUSIONS: Dental fear in adulthood was related to exposures occurring across the lifecourse. Also, it was possible to observe the occurrence of the vicious cycle of dental fear in the 1982 Pelotas Birth Cohort. Therefore, preventive measures during different periods of the life course are required to prevent dental fear and adulthood.

The role of cognitions in short-term temporal changes in dental fear among Australian adults.

OBJECTIVES: To determine if temporal changes in dental fear over a 4-month period are predicted by changed cognitive vulnerability-related perceptions of going to the dentist. METHODS: Australian adults (n = 484) completed mailed questionnaires at baseline and follow-up, containing measures of dental fear, cognitive vulnerability-related perceptions, dental services received, and possible aversive experiences during the study period. Change in dental fear was the main outcome measure, categorized as decreased (Fear- ), unchanged (Fear0 ), and increased (Fear+ ). RESULTS: Across the study period, 15.5 percent of people had Fear- , 73.4 percent had Fear0 , and 11.1 percent had Fear+ . In a multinomial logistic regression, after controlling for participant gender, income, time since last dental visit at baseline, dental fear at baseline and experiencing an aversive event, increased vulnerability-related perceptions were significantly associated with Fear+ (OR = 2.83, P < 0.001) while decreased vulnerability-related perceptions were associated with Fear- (OR = 0.17, P < 0.001). CONCLUSIONS: This study found, across a relatively short 4-month period, that increased vulnerability-related perceptions of visiting the dentist predicted increased dental fear while decreased vulnerability-related perceptions predicted decreased dental fear. More appropriate study designs, such as longitudinal designs, and longer follow-up periods are needed to determine the possible causal nature of these associations.

The magnitude of Indigenous and non-Indigenous oral health inequalities in Brazil, New Zealand and Australia.

OBJECTIVE: To compare the magnitude of relative oral health inequalities between Indigenous and non-Indigenous persons from Brazil, New Zealand and Australia. METHODS: Data were from surveys in Brazil (2010), New Zealand (2009) and Australia (2004-06 and 2012). Participants were aged 35-44 years and 65-74 years. Indigenous and non-Indigenous inequalities were estimated by prevalence ratios (PR) and their corresponding 95% confidence intervals (CI), adjusting for sex, age and income. Outcomes included inadequate dentition, untreated dental caries, periodontal disease and the prevalence of "fair" or "poor" self-rated oral health in Australia and New Zealand, and satisfaction with mouth/teeth in Brazil (SROH). RESULTS: Irrespective of country, Indigenous persons had worse oral health than their non-Indigenous counterparts in all indicators. The magnitude of these ratios was greatest among Indigenous and non-Indigenous Australians, who, after adjustments, had 2.77 times the prevalence of untreated dental caries (95% CI 1.76, 4.37), 5.14 times the prevalence of fair/poor SROH (95% CI 2.53, 10.43). CONCLUSION: Indigenous people had poorer oral health than their non-Indigenous counterparts, regardless of setting. The magnitude of the relative inequalities was greatest among Indigenous Australians for untreated dental decay and poor SROH.

Differences of oral health conditions between adults and older adults: A census in a Southern Brazilian city.

AIM: To assess differences in the oral diseases/conditions between adults and older adults. METHODS: A cross-sectional study was carried out with all adults and older adults in Luzerna, South Brazil (n = 569). Clinical data included use of and need for dental prostheses; number of decayed, missing and filled teeth; and temporomandibular disorder. Differences between adults and older adults were evaluated using χ(2) -tests. Associations between independent variables and the use of and need for dental prostheses were determined using Poisson regression analyses (P < 0.05). RESULTS: Increased number of decayed, missing and filled teeth, use of and need for dental prostheses, higher use of complete dentures, and fewer temporomandibular disorder signs and symptoms were observed in older adults. After adjustments, lower social class (P = 0.001) and unmarried status (P = 0.05) were associated with greater need for prosthetic rehabilitation. Women (P = 0.02), older individuals (P < 0.001) and those of lower socioeconomic status (P = 0.001) had a higher risk of using prostheses. CONCLUSION: A significant difference of oral conditions between adults and older adults was observed. The frequency of use of and need for dental prostheses was higher for older adults, although they had reported lower frequency of temporomandibular disorder. Women, married and individuals of higher socioeconomic status showed better oral health conditions. Geriatr Gerontol Int 2016; 16: 1014-1020.

Theoretical basis and explanation for the relationship between area-level social inequalities and population oral health outcomes - A scoping review.

This study was conducted to review the evidence on the association between area-level social inequalities and population oral health according to type and extent of social theories. A scoping review was conducted of studies, which assessed the association between area-level social inequality measures, and population oral health outcomes including self-rated oral health, number of teeth, dental caries, periodontal disease, tooth loss, oral health-related quality of life (OHRQoL) and dental pain. A search strategy was applied to identify evidence on PubMed, MEDLINE (Ovid), EMBASE, Web of Science, ERIC, Sociological Abstracts, Social Services Abstracts, references of selected studies, and further grey literature. A qualitative content analysis of the selected studies was conducted to identify theories and categorize studies according to their theoretical basis. A total of 2892 studies were identified with 16 included in the review. Seven types of social theories were used on 48 occasions within the selected studies including: psychosocial (n=13), behavioural (n=10), neo-material (n=10), social capital (n=6), social cohesion (n=4), material (n=3) and social support (n=2). Of the selected studies, four explicitly tested social theories as pathways from inequalities to population oral health outcomes, three used a theoretical construct, seven used theories for post-hoc explanation and two did not have any use of theory. In conclusion, psychosocial theories were used most frequently. Although theories were often mentioned, majority of these studies did not test a social theory.

Are there universal restorative composites for anterior and posterior teeth?

OBJECTIVE: This retrospective, longitudinal clinical study investigated the longevity up to 20 years of posterior restorations placed with 3 universal composites (Charisma, Herculite XR, Z100) and of anterior restorations placed with 2 universal composites (Charisma, Herculite XR). METHODS: Records from 90 patients were retrieved from a private practice (374 posterior, 219 anterior restorations). Clinical evaluation was performed by the FDI criteria. Survival analysis was assessed using Kaplan-Meier method and Log-Rank test, and factors associated with failure by multivariate Cox regression with shared frailty. RESULTS: In the first 10 years, almost 95% of the restorations were satisfactory, showing increased failure thereafter. Charisma showed the most failures in anterior and posterior areas. Annual failure rates varied between 0.3% and 2.5%, with slightly better performance for anterior restorations. Fracture (posterior) and aesthetics (anterior) were the main reasons for failure. CLINICAL SIGNIFICANCE: Differences were observed between restorative materials with different properties, but these became apparent only after more than 10 years of clinical service. The present study provides evidence that in a patient group with low caries risk, anterior and posterior restorations placed with universal composites may have excellent long-term clinical performance.