Underlying pathways of social inequality in tooth loss: the mediating role of sugary beverages and diabetes.

BACKGROUND: Previous studies show social inequality in tooth loss, but the underlying pathways are not well understood. The aim was to investigate the mediated proportion of sugary beverages (SBs) and diabetes and the association between educational level and tooth loss, and to investigate whether the indirect effect of SBs and diabetes varied between educational groups in relation to tooth loss. METHODS: Data from 47,109 Danish men and women aged 50 years or older included in the Danish Diet, Cancer and Health Study was combined with data from Danish registers. Using natural effect models, SBs and diabetes were considered as mediators, and tooth loss was defined as having <15 teeth present. RESULTS: In total, 10,648 participants had tooth loss. The analyses showed that 3% (95% confidence interval 2-4%) of the social inequality in tooth loss was mediated through SBs and diabetes. The mediated proportion was mainly due to differential exposure to SBs and diabetes among lower educational groups. CONCLUSIONS: The findings show that SBs and diabetes to a minor degree contribute to tooth-loss inequalities. The explanation indicates that individuals in lower educational groups have higher consumption of SBs and more often suffer from diabetes than higher educational groups.

Social inequality in tooth loss, the mediating role of smoking and alcohol consumption.

OBJECTIVES: The objective of the study was to investigate the mediated proportion of smoking and alcohol consumption in the association between education and tooth loss. Further, the objective was, on the additive scale, to decompose the total effect of education on tooth loss into the direct effect of education, the natural indirect effect through smoking and alcohol consumption (differential exposure) and the mediated interaction between education, smoking and alcohol consumption on tooth loss (differential susceptibility). METHODS: The study was based on data from the Social Inequality in Cancer Cohort (SIC); a cohort constructed by seven pooled cohorts. The total study population comprised of 34 975 participants. With the use of natural effects models, we regarded smoking and alcohol consumption as intermediates; we investigated the role of smoking and alcohol consumption in mediating the effect of education on tooth loss. RESULTS: In total, 4924 participants had tooth loss defined as <15 teeth present. The results of the analyses, on the additive scale, showed 1202 (95% CI: 623-1781) additional persons with tooth loss per 10 000 persons among low compared to highly educated men. Among women, the analyses showed 1159 (95% CI: 959-1359) additional persons with tooth loss per 10 000 persons. The results, on the relative scale, showed that 11% (95% CI: 8%-15%) of the social inequality in tooth loss was jointly mediated by smoking and alcohol consumption among low-educated men. Among women with low education, the mediated proportion was 26% (95% CI: 19%-36%). CONCLUSION: Social inequality in tooth loss seems partly explained by differential exposure and differential susceptibility to smoking and alcohol consumption.

Eating disorders: experiences of and attitudes toward oral health and oral health behavior.

It is well known that early signs of eating disorders (EDs), such as dental erosion and enlarged salivary glands, may be recognized in the dental clinic. Dentists acknowledge that approaching a patient to discuss the suspicion of an ED is difficult. However, little is known about how persons with EDs experience and manage dental visits. Therefore, this study aimed to uncover knowledge, experience, and attitude of oral health and oral health behavior among persons with EDs. The study design was cross-sectional and 260 persons with EDs completed an electronic questionnaire. The participants were generally concerned about their teeth. Some participants had anxiety around having severely and irreversibly damaged teeth, and many were overly occupied with oral hygiene procedures. One-third of participants had good experiences regarding communication with a dentist, and about half of the participants wanted the dentist to address their EDs in the clinic. However, participants with less-positive experiences stated that there is a need for dentists with specialized knowledge about EDs and communication skills that emphasize an open, empathic, recognition approach from the dentist toward patients with EDs. In addition, it may be advantageous to integrate dental advice and treatment as part of the treatment of EDs in line with psychological and medical therapy.

Patterns of dental services and factors that influence dental services among 64-65-year-old regular users of dental care in Denmark.

OBJECTIVES: To describe the pattern of dental services provided to 64-65-year-old Danes who are regular users of dental care over a 5-year period, to analyse whether this pattern is associated with socio-demographic and/or socioeconomic factors, and if different uses of dental services are related to dental status and caries experience. Finally, to discuss the future planning of dental services aimed at the increasing population of elderly citizens. [Correction made on 21 March 2014, after first online publication: The sentence 'Data on elderly's dental service are scarce, although increased use is seen and more teeth are present in this age group.' was removed.] METHODS: A cross-sectional study of all aged 64-65 (n = 37 234) who received a dental examination in 2009 was conducted. Clinical data comprised dental services received under the National Health Insurance reimbursement scheme, dental status and DMFT. Geographical, socio-demographic and socioeconomic data derived from public registers. RESULTS: Almost all received restorations, while periodontal treatment was received by <50% during 5 years. Heavy use of dental services was dominated by periodontal services. Periodontal services were most prevalent in the capital and the most affluent areas. Relatively more extractions were related to low income and persons in least affluent areas. Total number of services was highest among women, persons with ≥20 teeth, persons living in the capital, and where the ratio user per dentist was low. CONCLUSION: For future planning of dental care for elderly, dental status, geographical and social area-based factors and to some degree gender, income, and education must be taken into consideration as all these factors seem to influence the future demand for dental services.

Calcium, vitamin D, casein and whey protein intakes and periodontitis among Danish adults.

OBJECTIVE: To investigate whether intakes of Ca, vitamin D, casein and whey are associated with periodontitis and to investigate the possibility of interactions between them. DESIGN: Cross-sectional study. An Internet-based, 267-item FFQ was used to assess dietary intake. Intakes of casein (32.0 g/d), whey proteins (9.6 g/d) and vitamin D (5.8 µg/d) were classified as within v. above the 50th percentile. Ca intake was classified as within v. below age-specific recommendations. Severe periodontitis was defined as having ≥2 inter-proximal sites with clinical attachment loss ≥6 mm (not on the same tooth) and ≥1 inter-proximal site with pocket depth ≥5 mm. Since vitamin D influences Ca absorption, models were stratified by lower and higher (<5.8 v. ≥5.8 µg/d) vitamin D intake. SETTING: Danish Health Examination Survey (DANHES) 2007-2008. SUBJECTS: Adult participants (n 3287) in the oral health study of DANHES 2007-2008. RESULTS: Intakes of Ca within recommendations (OR=0.76; 95% CI 0.58, 0.99), whey ≥9.6 g/d (OR=0.75; 95% CI 0.58, 0.97) and casein ≥32 g/d (OR=0.75 95% CI 0.58, 0.97) were associated with lower likelihood of severe periodontitis after adjustment for age, gender, education, smoking, sucrose intake, alcohol consumption, number of teeth, daily brushing, regular visits to the dentist and chronic illness, irrespective of vitamin D intake levels. Intake of vitamin D alone was not associated severe with periodontitis. CONCLUSIONS: Intakes of Ca, casein and whey protein were inversely associated with periodontitis. Consumption of foods rich in Ca, casein and whey (e.g. dairy foods) should be promoted, as they may contribute to the prevention of periodontitis. Further longitudinal studies are required to confirm these associations.

Association between dairy intake and caries among children and adolescents. results from the Danish EYHS follow-up study.

The aim of this paper was to investigate associations between the intake of dairy products and the development in caries (DMFS, decayed, missing and filled surfaces) among children/adolescents over a period of 3 and 6 years, and to investigate whether dairy intake protects against caries incidence. A total of 68.9% of the children were caries free at the age of 9 compared with 34.0% of the adolescents at the age of 15 (measured as DMFS = 0). A larger percentage of children/adolescents with a dairy intake above the mean were caries free compared with the group of children/adolescents with an intake below the mean (72.8 vs. 65.8% at age 9 and 41.1 vs. 30.7% at age 15). The results from the generalized estimation equation showed that dairy and milk intake, as well as intakes of components of dairy such as dairy calcium, whey and casein, was generally inversely associated with childhood/adolescent caries experience (measured as DMFS). With regard to caries incidence, the same inverse association was found for incidence over a period of 3 years and for incidence over 6 years, but the results were only statistically significant for the 3-year incidence and for the unadjusted models of the 6-year incidence. This study found that previous dairy intake, as well as milk intake or intake of dairy components, may be a predictor of future risk of caries measured by the DMFS count level. This relationship was inverse, meaning that a high intake of dairy products was associated with less future caries development. However, more studies on larger cohorts are needed to confirm these findings.

Association between body mass index and caries among children and adolescents.

OBJECTIVE: The aim of this article was to examine the relationship between childhood caries, body mass index (BMI) and subsequent changes in BMI over 6 years, and to investigate whether these associations were modified by social class. METHODS: Data were from the European Youth Heart Study (EYHS) merged with data on caries experience from the Danish National Board of Health, (SCOR register). RESULTS: At baseline, 26.2% of the children/adolescents were caries free and 39% at follow-up. A larger percentage of normal weight children/adolescents were caries free, compared with the overweight/obese group of children/adolescents. The linear regression analysis showed that childhood caries was generally not associated with either BMI or subsequent changes in BMI. However, among children whose mothers were well educated, there was an inverse association between caries at baseline and subsequent changes in BMI over a period of 6 years, for example, a high caries experience was associated with a smaller increment in BMI, compared with the group of children with a low caries experience. No association was found for those with lower SES. CONCLUSION: An inverse association between caries and subsequent changes in BMI was found, but only among children with well-educated mothers, suggesting that high caries experience may be a marker for low future risk of overweight among the more advantaged. Associations did not appear to be significant among the less advantaged; however, numbers in this group were low, and an association may have been overlooked. Hence, more studies are needed to confirm these findings.

Intakes of calcium, vitamin D, and dairy servings and dental plaque in older Danish adults.

BACKGROUND: To investigate whether intakes of calcium and dairy-servings within-recommendations were associated with plaque score when allowing for vitamin D intakes. METHODS: In this cross-sectional study, including 606 older Danish adults, total dietary calcium intake (mg/day) was classified as below vs. within-recommendations and dairy intake as <3 vs. ≥3 servings/ d. Dental plaque, defined as the percentage of tooth surfaces exhibiting plaque, was classified as < median vs. ≥median value (9.5%). Analyses were stratified by lower and higher (≥6.8 µg/d) vitamin D intake. FINDINGS: Intakes of calcium (OR = 0.53; 95% CI = 0.31-0.92) and dairy servings (OR = 0.54; 95% CI = 0.33-0.89) within-recommendations were significantly associated with lower plaque score after adjustments for age, gender, education, intakes of alcohol, sucrose and mineral supplements, smoking, diseases, number of teeth, visits to the dentist, use of dental floss/tooth pick and salivary flow, among those with higher, but not lower, vitamin D intake. CONCLUSION: Intakes of calcium dairy-servings within-recommendations were inversely associated with plaque, among those with higher, but not lower, vitamin D intakes. Due to the cross-sectional nature of the study, it is not possible to infer that this association is causal.

Intake of dairy products in relation to periodontitis in older Danish adults.

This cross-sectional study investigates whether calcium intakes from dairy and non-dairy sources, and absolute intakes of various dairy products, are associated with periodontitis. The calcium intake (mg/day) of 135 older Danish adults was estimated by a diet history interview and divided into dairy and non-dairy calcium. Dairy food intake (g/day) was classified into four groups: milk, cheese, fermented foods and other foods. Periodontitis was defined as the number of teeth with attachment loss ≥3 mm. Intakes of total dairy calcium (Incidence-rate ratio (IRR) = 0.97; p = 0.021), calcium from milk (IRR = 0.97; p = 0.025) and fermented foods (IRR = 0.96; p = 0.03) were inversely and significantly associated with periodontitis after adjustment for age, gender, education, sucrose intake, alcohol consumption, smoking, physical activity, vitamin D intake, heart disease, visits to the dentist, use of dental floss and bleeding on probing, but non-dairy calcium, calcium from cheese and other types of dairy food intakes were not. Total dairy foods (IRR = 0.96; p = 0.003), milk (IRR = 0.96; p = 0.028) and fermented foods intakes (IRR = 0.97; p = 0.029) were associated with reduced risk of periodontitis, but cheese and other dairy foods intakes were not. These results suggest that dairy calcium, particularly from milk and fermented products, may protect against periodontitis. Prospective studies are required to confirm these findings.

Intake of dairy calcium and tooth loss among adult Danish men and women.

OBJECTIVE: To investigate whether gender differences in tooth loss are influenced by caries risk and sources of dietary calcium intake. METHODS: This was a cohort study that included 432 Danish adults (30-60 y old) with information on dietary calcium intake in 1982 and 1983 and tooth loss from 1987 and 1988 through 1993 and 1994. Total calcium intake, estimated by a 7-d food record or a a diet history interview, was divided into dairy and non-dairy forms of calcium. RESULTS: In men, a 10-fold increase in dairy calcium intake was significantly associated with a decreased risk of tooth loss (incidence-rate ratio 0.32, 95% confidence interval 0.15-0.68) even after an adjustment for tooth count in 1987 and 1988, age, education, and civil status (model 1), smoking, alcohol consumption, sucrose intake, and use of vitamin and/or mineral supplements (model 2), time since last dental visit and the presence of oral dryness (model 3), and a high Lactobacillus count (model 4). In women, dairy calcium was not statistically associated with tooth loss in the crude and adjusted models (models 1 to 3). However, the association became highly significant once the Lactobacillus count was included in model 4 (incidence-rate ratio 0.25, 95% confidence interval 0.09-0.73). Non-dairy calcium was not associated with tooth loss in men and women in the fully adjusted models. CONCLUSION: Dietary calcium intake, particularly calcium from dairy products, seems to protect against loss of teeth in adult men and women. The previous gender differences found in the relation between calcium intake and tooth loss may be the result of differences in the caries risk between genders.

Low calcium intake is related to increased risk of tooth loss in men.

Our aim was to investigate the association between calcium (Ca) intake and number of teeth and tooth loss. The Danish Monica (Monitoring Trends and Determinants in Cardiovascular Disease) study is a prospective observational study from 1982-83 to 1993-94. The study population included 1602 adults (30-60 y) with information on dietary Ca intake and number of teeth and a subset of 511 participants with information on tooth loss from 1987-88 to 1993-94. Ca intake less than the recommendations, estimated by a 7-d food record or a diet history interview in 1982-83, was more frequent among females (55%) than males (45%; P < 0.001). Low Ca intake was associated with low number of teeth (1-25 vs. 26-32 teeth) in males [odds ratio (OR) = 1.57 (95% CI = 1.10-2.29)] and females [OR = 1.44 (95% CI = 1.10-2.05)] after adjustment for age, education, smoking, alcohol and sucrose consumption, subjective oral dryness, and time since last dental care visit. The reference group (26-32 teeth) and edentulous participants did not significantly differ. A Ca intake below recommendations was significantly associated with increased risk of subsequent tooth loss in males [incidence-rate ratio = 1.70 (95% CI = 1.15-2.48)]. There was no association in women. Ca intake below recommendations was significantly associated with fewer teeth in both sexes. However, there was a significant, negative association between Ca intake below recommendations and tooth loss in males only. Given the high percentage of individuals with Ca intake below recommendations, consumption of foods rich in Ca should be promoted to preserve oral health.

Consumption of dental services among adults in Denmark 1994-2003.

The purpose of the present study was to measure the consumption of dental services among adults in Denmark and to analyze at what level socio-demographic/socio-economic factors influence dental attendance and oral examinations. A sample of 10% of the total population of 18 yr or older was randomly drawn from a population register, based on a cross-sectional design. Information on the use of dental services was retrieved from public registers along with data on gender, age-group, regions, ethnicity, education, marital status, and income. In addition, a cohort of persons was drawn from the sample in 1999 including only persons who were registered as residents in Denmark from 1999 to 2003. Over time, an increase in the number of dental visits and oral examinations was found among persons older than 45 yr, whereas a decrease was observed in the younger age-groups. Logistic regression analysis was applied to determine the effect of various variables on the experience of dental visits and oral examinations, and relatively high odds for dental attendance and oral examinations was found for the following: younger adults; women; married persons; high income; high education; and persons of Danish origin. The present dental healthcare system does not yet seem to have established mechanisms to address social inequalities in the consumption of dental services.