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

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

Psychosocial determinants of clustering health-compromising behaviors among Saudi male adolescents.

BACKGROUND AND OBJECTIVES: To assess whether the clustering of six specific health-compromising behaviors, namely, low fruit consumption, high sweet consumption, infrequent tooth brushing, physical inactivity, fighting and smoking, varied by different psychosocial determinants such as life satisfaction, peer relationships, self-confidence, and future orientation among male adolescents in Saudi Arabia. PATIENTS AND METHODS: A representative stratified cluster random sample of 1335 Saudi Arabian male adolescents living in the city of Riyadh answered a questionnaire on health-related behaviors. Poisson regression models were constructed separately for younger (13-14-years-old) and older (17-19-years-old) adolescents to assess variations between explanatory psychosocial variables and the clustering of six health-compromising behaviors, adjusting for father's education. RESULTS: Older adolescents who perceived high levels of life satisfaction had a lower rate of clustering of multiple health-compromising behaviors compared to those reporting lower levels (RR: 1.22; 95%CI: 1.09-1.37), and the respective difference between those with high and those with middle levels of satisfaction was marginally non-significant (RR: 1.08; 95%CI: 0.98-1.19). Younger adolescents who reported that they felt "less than always" self-confident were more likely to have high clustering of health compromising behaviors compared to those who were always confident (RR: 1.08; 95%CI: 1.01-1.21). The clustering of multiple health-compromising behaviors was marginally associated with the frequency of evening meetings among older adolescents (RR: 1.03; 95%CI: 1.01-1.04 for each extra meeting), while the respective association among younger adolescents was marginally non-significant (RR: 1.02; 95%CI: 0.99-1.05). The association between clustering of health-compromising behaviors and future orientation was non-significant among both younger and older adolescents. CONCLUSIONS: Clustering of health-compromising behaviors was found to be associated with perceived life satisfaction and peer relationships among older male Saudi adolescents and with self-confidence among younger male Saudi adolescents in Riyadh.

Social Factors Associated with the Decline in Caries in Brazilian Children between 1996 and 2010.

Dental caries levels have declined in children since the 1970s in many countries. Most of the postulated main reasons for the decline are speculative and have not been rigorously evaluated. The objective of this study was to assess the relationship between some social factors and the decline in dental caries in Brazilian 12-year-old children from 1996 to 2010. Secondary analysis of national data was performed in 27 Brazilian state capitals. A panel data regression model with fixed effects and multiple linear regression were used to verify the relationship between the explanatory and the dependent variables and also the time-trend effect. The results showed that the DMFT (decayed, missing, and filled teeth) decreased by about 3% per year, and the percentage of caries-free children increased by 4.5% per year. For DMFT and percentage caries free, the results for the panel data regression showed a significant association for the Human Development Index (HDI) in the adjusted model (p = 0.010). When the overall changes over time were compared, the Gini index had a significant association with the overall change in DMFT in the final model of the multiple regression analysis (p = 0.033). Our results indicate that the maintenance of good levels of human development, which includes better education, income, and longevity, are important factors relating to improving levels of oral health in 12-year-old Brazilian children. However, to accelerate this process in cities with the worst caries situation, income inequality should be tackled.

Socioeconomic gradients in general and oral health of primary school children in Shiraz, Iran.

BACKGROUND: Health status is largely determined by socio-economic status. The general health of individuals at higher social hierarchy is better than people in lower levels. Likewise, people with higher socio-economic status have better oral health than lower socio-economic groups. There has not been much work regarding the influence of socio-economic status on the health conditions of children in developing countries, particularly in Iran. The aim of this study was to compare the oral and general health conditions of primary school children of three different socio-economic areas in the city of Shiraz, Iran. METHODS: This cross-sectional study was conducted on 335, 8- to 11-year-old primary schoolchildren in Shiraz. The children were selected by a three-stage cluster sampling method from three socio-economically different areas. Tools and methods used by the United Kingdom's Medical Research Council were used to obtain anthropometric variables as indicators of general health. The Decay, Missing, Filled Teeth (DMFT) Index for permanent teeth, dmft Index for primary teeth, the Modified Developmental Defects of Enamel (DDE) Index, the Gingival Index (GI) and the Debris Index-Simplified (DI-S) were used for oral health assessment.  RESULTS: Height (P<0.001), weight (P<0.001), and BMI (P=0.001) significantly increased as the socio-economic status of area increased. GI score (P<0.001), DI-S score (P<0.001), number of permanent teeth with DDE (P=0.008), and number of DDE lesions in permanent teeth (P=0.008) significantly decreased as the socio-economic status of area increased. DISCUSSION: Findings of this study generally confirmed that social gradients exist in both general and oral health status of the primary schoolchildren of Shiraz. The influence of socio-economic status on health condition means children have different life chances based on their socio-economic conditions. These findings emphasize the significance of interventions for tackling socio-economic inequalities in order to improve the health status of children in lower socio-economic areas.

Association of changes in income with self-rated oral health and chewing difficulties in adults in Southern Brazil.

OBJECTIVE: To assess whether short-term changes in income (IC) in adulthood were associated with self-rated oral health (SROH) and chewing difficulties (CD). METHODS: Secondary analysis of a longitudinal study in Florianópolis, Southern Brazil (EpiFloripa); a total of 1720 adults participated in 2009 and 1223 in 2012. Logistic regression analysed the variation of SROH and CD according to short-term changes in income (IC) groups ('high income-stable', 'increased income', 'decreased income' and 'low income-stable') and adjusted for covariates (age, sex, marital status, skin colour, self-reported number of teeth and education). RESULTS: After adjusting for covariates, participants in the 'decreased income' were more likely to have poor SROH and CD than those at the 'high income-stable' group (OR: 1.78, 95% CI: 1.23, 2.58; OR: 2.76, 95% CI: 1.61, 4.74, respectively). Significant differences were also found between the 'low income-stable' and 'high income-stable' groups, but these differences were explained when adjusted for potential confounders. There were no significant differences in SROH and CD between the 'increased income' and the 'high income-stable' groups. CONCLUSIONS: Overall, SROH and CD were adversely influenced by negative changes in income during adulthood in a short period of 3 years.

Distinguishing between enamel fluorosis and other enamel defects in permanent teeth of children.

Background. The inconsistent prevalence of fluorosis for a given level of fluoride in drinking water suggests developmental defects of enamel (DDEs) other than fluorosis were being misdiagnosed as fluorosis. The imprecise definition and subjective perception of fluorosis indices could result in misdiagnosis of dental fluorosis. This study was conducted to distinguish genuine fluorosis from fluorosis-resembling defects that could have adverse health-related events as a cause using Early Childhood Events Life-grid method (ECEL). Methods. A study was conducted on 400 9-year-old children from areas with high, optimal and low levels of fluoride in the drinking water of Fars province, Iran. Fluorosis cases were diagnosed on the standardized one view photographs of the anterior teeth using Dean's and TF (Thylstrup and Fejerskov) Indices by calibrated dentists. Agreements between examiners were tested. Early childhood health-related data collected retrospectively by ECEL method were matched with the position of enamel defects. Results. Using both Dean and TF indices three out of four dentists diagnosed that 31.3% (115) children had fluorosis, 58.0%, 29.1%, and 10.0% in high (2.12-2.85 ppm), optimal (0.62-1.22 ppm), and low (0.24-0.29 ppm) fluoride areas respectively (p < 0.001). After matching health-related events in the 115 (31.3%) of children diagnosed with fluorosis, 31 (8.4%) of children had fluorosis which could be matched with their adverse health-related events. This suggests that what was diagnosed as fluorosis were non-fluoride related DDEs that resemble fluorosis. Discussion. The frequently used measures of fluorosis appear to overscore fluorosis. Use of ECEL method to consider health related events relevant to DDEs could help to differentiate between genuine fluorosis and fluorosis-resembling defects.

Changes in preschool children's OHRQoL after treatment of dental caries: responsiveness of the B-ECOHIS.

BACKGROUND: Oral health-related quality of life (OHRQoL) measures should be tested for responsiveness to change if they are to be used as outcomes in randomized clinical trials. AIM: To assess the responsiveness of the Brazilian ECOHIS (B-ECOHIS) to dental treatment of dental caries. METHODS: One hundred parents of 3- to 5-year-old children completed the B-ECOHIS prior to their children's treatment and 7-14 days after completion of treatment. The post-treatment questionnaire also included a global transition judgment that assessed parent's perceptions of change in their children's oral health following treatment. Change scores, longitudinal construct validity, standardized effect sizes (ES) and standardized response mean (SRM) were calculated. RESULTS: Improvements in children's oral health after treatment were reflected in mean pre- and post-treatment B-ECOHIS scores. They declined considerably significantly from 17.4 to 1.6 (P < 0.0001), as did the individual domain scores (P < 0.0001). There were significant differences in the pre- and post-treatment scores of children who reported little improvement (P < 0.0001) as well as in those who reported large improvements (P < 0.0001). The ES and SRM based on change scores mean for total scores and for categories of global transitions judgments were large. CONCLUSIONS: Dental treatment resulted in significant improvement of the preschool children's OHRQoL. The B-ECOHIS is responsive.

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

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

The different effects of neighbourhood and individual social capital on health-compromising behaviours in women during pregnancy: a multi-level analysis.

BACKGROUND: This study assessed clustering of three health-compromising behaviours and explored the association of neighbourhood and individual social capital with simultaneous health-compromising behaviours and patterns of those behaviours in women in the first trimester of pregnancy (baseline) and during the second and third trimesters of pregnancy (follow-up). METHODS: A longitudinal study was conducted on a representative sample of women recruited in antenatal care units grouped in 46 neighbourhoods from Brazil. Neighbourhood-level measures (social capital and socioeconomic status), individual social capital (social support and social networks) and socio-demographic variables were collected at baseline. Smoking, alcohol consumption and inadequate diet were assessed at baseline and follow-up. Clustering was assessed using an observed to expected ratio method. The association of contextual and individual social capital with the health-compromising behaviours outcomes was analyzed through multilevel multivariate regression models. RESULTS: Clustering of the three health-compromising behaviours as well as of smoking and alcohol consumption were identified at both baseline and follow-up periods. Neighbourhood social capital did not influence the occurrence of simultaneous health-compromising behaviours. More health-compromising behaviours in both periods was inversely associated with low levels of individual social capital. Low individual social capital predicted smoking during whole pregnancy, while high individual social capital increased the likelihood of stopping smoking and improving diet during pregnancy. Maintaining an inadequate diet during pregnancy was influenced by low individual and neighbourhood social capital. CONCLUSIONS: Three health-compromising behaviours are relatively common and cluster in Brazilian women throughout pregnancy. Low individual social capital significantly predicted simultaneous health-compromising behaviours and patterns of smoking and inadequate diet during pregnancy while low neighbourhood social capital was only relevant for inadequate diet. These findings suggest that interventions focusing on reducing multiple behaviours should be part of antenatal care throughout pregnancy. Individual and contextual social resources should be considered when planning the interventions.

The association of depression and anxiety with dental caries and periodontal disease among Finnish adults.

OBJECTIVE: To explore the association of depression and anxiety with two oral health outcomes, dental caries and periodontal disease and assess possible mediators for any of the associations. METHODS: Secondary analysis of the Finnish Health 2000 Survey. Depression was assessed with Beck's Depression Inventory and anxiety with Composite International Diagnostic Interview. Number of decayed teeth included carious lesions reaching dentine; periodontal disease was number of teeth with periodontal pockets of 4 mm or deeper. Third molars were excluded. The association of mental disorders and oral health was tested in regression models adjusted for confounders and potential mediators. RESULTS: Depression was associated with number of decayed teeth only among 35- to 54-year-olds. The association between anxiety and the number of decayed teeth was not statistically significant. Depression and periodontal pocketing were not significantly associated. CONCLUSION: Depression was significantly associated with number of decayed teeth only among participants aged 35-54 old and not with other age groups. Neither depression nor anxiety was significantly related to periodontal disease.

Household expenditure for dental care in low and middle income countries.

This study assessed the extent of household catastrophic expenditure in dental health care and its possible determinants in 41 low and middle income countries. Data from 182,007 respondents aged 18 years and over (69,315 in 18 low income countries, 59,645 in 15 lower middle income countries and 53,047 in 8 upper middle income countries) who participated in the WHO World Health Survey (WHS) were analyzed. Expenditure in dental health care was defined as catastrophic if it was equal to or higher than 40% of the household capacity to pay. A number of individual and country-level factors were assessed as potential determinants of catastrophic dental health expenditure (CDHE) in multilevel logistic regression with individuals nested within countries. Up to 7% of households in low and middle income countries faced CDHE in the last 4 weeks. This proportion rose up to 35% among households that incurred some dental health expenditure within the same period. The multilevel model showed that wealthier, urban and larger households and more economically developed countries had higher odds of facing CDHE. The results of this study show that payments for dental health care can be a considerable burden on households, to the extent of preventing expenditure on basic necessities. They also help characterize households more likely to incur catastrophic expenditure on dental health care. Alternative health care financing strategies and policies targeted to improve fairness in financial contribution are urgently required in low and middle income countries.

Treatment needs and skill mix workforce requirements for prosthodontic care: a comparison of estimates using normative and sociodental approaches.

BACKGROUND: The traditional measure for assessing dental treatment needs and workforce requirements based solely on normative need (NN) has major shortcomings. The sociodental approach (SDA) to assess needs overcomes some of the shortcomings as it combines normative and subjective needs assessments and also incorporates behavioural propensity (Sheiham and Tsakos 2007). The objective of this study was to estimate and compare prosthodontic treatment needs and workforce requirements, using the normative and the sociodental approaches for different skill mix models. METHODS: A cross-sectional study was conducted on 732 university employees aged 30-54 years. Normative prosthodontic need was assessed using the WHO (1997) method. The SDA includes NN and also considers oral impacts, measured through the OIDP index, and behavioural propensity. Estimates of prosthodontic need and dental workforce requirements using the two methods were compared using McNemar and Wilcoxon Signed Rank test respectively. The dental workforce required for prosthodontic treatment based on NN and SDA approaches were then compared using different workforce skill mix models. RESULTS: The proportion of subjects needing prosthodontic treatment was lower by more than 90% when the SDA was used compared to NN. The number of dentists required for prosthodontic treatment per 100,000 people were 98.8 using NN compared to 2.49 using SDA. Using a skill mix approach, the requirements for dentists per 100,000 people decreased slightly when more denture procedures were delegated to dental therapists. CONCLUSION: There were very much lower levels of prosthodontic treatment needs and workforce requirements when using the sociodental approach compared to normative methods.

Socially unequal improvements in dental caries levels in Brazilian adolescents between 2003 and 2010.

OBJECTIVES: Although there are numerous reports on socioeconomic inequalities in dental caries, few studies have focused on whether improvements in dental status have been accompanied by changes in socioeconomic inequalities in caries. The objective of this study was to assess whether declines in caries between 2003 and 2010 were associated with reductions in inequalities in dental caries in adolescents. METHODS: Data on dental caries in adolescents aged 15-19 were used from the Brazilian National Oral Health surveys conducted in 2003 (n = 16 833) and 2010 (n = 5445). The dependent variables were Decayed, Missing and Filled Teeth (DMFT) index and the percentage caries free. Household income and educational level were independent variables. Differences between surveys for DMFT and caries free were calculated, and measurement of inequality was performed using the Slope Index of Inequality (SII) and Relative Index of Inequality (RII). RESULTS: Both DMFT and percentage caries free showed significant differences in absolute (SII) and relative (RII) inequalities between the two surveys for both education and income. The SII for DMFT rose from 0.54 to 2.01 and from 1.44 to 3.67 for income and education, respectively. For caries free, these values were 3.64-19.40 and 5.06-22.93. Regarding to RII, a similar trend has been found. CONCLUSIONS: Despite the overall reduction in DMFT and an increase in caries free, there were increases in both income and education-related inequalities in caries in Brazilian adolescents. The findings on caries differ from those for other health conditions in Brazil, where there have been reductions in inequalities.

Claims that periodontal treatment reduces costs of treating five systemic conditions are questionable.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Am J Prev Med 2014; 47(2):166-74 REVIEWER: Aubrey Sheiham, BDS, PhD, DHC PURPOSE/QUESTION: Did periodontal treatment reduce the medical costs and inpatient hospitalizations during the 5 years after periodontal treatment in individuals with five systemic medical diseases or conditions, namely, type 2 diabetes; coronary artery disease; cerebral vascular disease; rheumatoid arthritis; and pregnancy? SOURCE OF FUNDING: Industry: United Concordia Companies, Inc. TYPE OF STUDY/DESIGN: Retrospective cohort study LEVEL OF EVIDENCE: Level 3: Other evidence STRENGTH OF RECOMMENDATION GRADE: Not applicable.

Which life course model better explains the association between socioeconomic position and periodontal health?

AIM: To assess whether the relationship between socioeconomic position (SEP) and periodontal health fitted the Critical Period or the Social Mobility life course models. METHODS: A nationally representative sample of 5570 Korean adults from KNHANES IV study. Log-binomial regression models adjusting for adulthood or childhood socioeconomic (SES) variables was used to assess independent effects of socioeconomic differences for childhood, adulthood and period of transition from child to adult in periodontal health. RESULTS: In the Critical Period model, poorer periodontal status was associated with SES disadvantage in adulthood and not predicted by SES disadvantage in childhood. For the intergenerational Social Mobility model, prevalence of current periodontal disease was only different for females aged 30-39 and 40-49 years, after adjustment. Prevalence of periodontal disease in females was highest in the downwardly mobile group. CONCLUSIONS: The Critical Period model was better at explaining association between socioeconomic position and periodontal health, such as the adulthood socioeconomic variables (SEP), had a stronger effect than childhood factors on periodontal disease. The Social Mobility model explained more of the variation in the association between SEP and periodontal health among women than among men.

Periodontal treatment needs and workforce requirements: comparisons between the normative and sociodental approaches using different skill mix models.

OBJECTIVES: Assessment of dental treatment needs has predominantly been based on the normative approach, despite its numerous limitations. The sociodental approach is a more rational method of needs assessment as it incorporates broader concepts of health and needs and behavioural propensity. This study compares estimates of periodontal dental treatment needs and workforce requirements for different skill mixes using normative and sociodental approaches among a sample of adults in Malaysia. METHODS: A cross-sectional study was carried out on 732 Malaysian adults aged 30-54 years. Subjects' normative and sociodental needs for periodontal treatment were assessed using WHO criteria, an oral health-related quality of life measure (the Oral Impacts on Daily Performances index), and behavioural propensity measures for toothbrushing and smoking behaviour. The proportion of subjects requiring periodontal treatment and the numbers of dentists and dental therapists required to treat them using the normative and sociodental approach were compared using different skill mix models. RESULTS: The estimates of need for periodontal treatment using the sociodental approach were 90% lower than the respective estimates using the normative need method. Overall, 14.43 dentists would be required per 100 000 people using the normative approach compared to 2.32 for the sociodental approach. When skill mix models were used, the number of dentists required decreased by almost 70% when more periodontal procedures were delegated to dental therapists. CONCLUSIONS: Using the sociodental approach resulted in much lower estimates of dental need and workforce requirements for periodontal treatment than using the normative method. Using dental therapists markedly reduced the numbers of dentists needed for periodontal treatment.

Patterns of clustering of six health-compromising behaviours in Saudi adolescents.

BACKGROUND: Clustering of multiple health-compromising behaviours is associated with an increased risk of various chronic diseases. There are few studies on patterns of clustering of multiple health-compromising behaviours in adolescents. Therefore, the aim of this study is to assess how six health-compromising behaviours, namely, low fruit consumption, high sweet consumption, less frequent tooth brushing, low physical activity, physical fighting and smoking, cluster among Saudi male adolescents. METHODS: A representative stratified cluster random sample of 1,335 Saudi Arabian male adolescents living in Riyadh city answered a questionnaire on health-related behaviours. Hierarchical Agglomerative Cluster Analysis (HACA) was used to identify cluster solutions of the six health-compromising behaviours. RESULTS: HACA suggested two broad and stable clusters for the six health-compromising behaviours. The first cluster included low fruit consumption, less frequent tooth brushing and low physical activity. The second cluster included high sweets consumption, smoking and physical fighting. CONCLUSIONS: The six health-compromising behaviours clustered into two conceptually distinct clusters among Saudi Arabian male adolescents, one reflecting non-adherence to preventive behaviours and the second undertaking of risk behaviours. Clustering of health behaviours has important implications for health promotion.