Longitudinal Quantiles of Frailty Trajectories Considering Death: New Insights into Sex and Cohort Differences in the Reference Curves for Frailty Progression of Older European.

BACKGROUND: Most previous studies of frailty trajectories in older adults focus on the average trajectory and ignore death. Longitudinal quantile analysis of frailty trajectories permits the definition of reference curves, and the application of mortal cohort inference provides more realistic estimates than models that ignore death. METHODS: Using data from individuals aged 65 or older (n = 25 446) from the Survey of Health, Ageing, and Retirement in Europe (SHARE) from 2004 to 2020, we derived repeated values of the Frailty Index (FI) based on the accumulation of health deficits. We applied weighted Generalized Estimating Equations to estimate the quantiles of the FI trajectory, adjusting for sample attrition due to death, sex, education, and cohort. RESULTS: The FI quantiles increased with age and progressed faster for those with the highest level of frailty (ß^a0.9 = 0.0229, p < .001; ß^a0.5 = 0.0067, p < .001; H0: ßa0.5=ßa0.9, p < .001). Education was consistently associated with a slower progression of the FI in all quantiles (ß^ae0.1 = -0.0001, p < .001; ß^ae0.5 =-0.0004, p < .001; ß^ae0.9 = -0.0003, p < .001) but sex differences varied across the quantiles. Women with the highest level of frailty showed a slower progression of the FI than men when considering death. Finally, no cohort effects were observed for the FI progression. CONCLUSIONS: Quantile FI trajectories varied by age, sex, education, and cohort. These differences could inform the practice of interventions aimed at older adults with the highest level of frailty.

Residual dentition, prosthesis type and oral health-related quality of life in Uruguayan adults.

OBJECTIVES: To investigate the association between different types of dental prostheses (and residual dentition) and oral health-related quality of life (OHRQoL). METHODS: A population-based study with a representative sample of adults and older adults in Uruguay (2010-2011). The dependent variable was the score on the oral impact on daily performance (OIDP), and the main predictor was the pattern of tooth loss and prosthesis use. Covariates included sex, age, socioeconomic status, education, missing teeth, pain and decayed teeth. Negative binomial regression was used. RESULTS: The sample comprised 762 participants. Those participants not wearing a prosthesis and with extensive tooth loss had a mean OIDP of 3.1 (95% CI = 1.6-6.2), while those wearing removable partial dentures (RPD) and having <12 missing teeth had a mean OIDP of 3.6 (95% CI = 1.3-10.0). Participants with a free-end saddle had the highest mean OIDP, at 4.9 (95% CI = 2.0-12.1). For participants with ≤12 missing teeth, any additional missing tooth was associated with an 11% higher OIDP score. Participants who wore RDPs reported fewer impacts on OHRQoL if they had extensive tooth loss or anterior tooth loss than those with a free-end saddle, or who had lost fewer teeth. CONCLUSIONS: The use of RPDs is associated with better OHRQoL. These findings may be valuable in clinical practice and prosthetic planning.

Periodontitis prevalence and associated factors: a comparison of two examination protocols / Prevalencia y factores asociados a periodontitis: comparación de dos protocolos de examen WHO

ABSTRACT The fact that there are different epidemiological definitions of periodontitis and different evaluation protocols affects the estimate of periodontitis prevalence and of the influence of associated factors. The gold standard for periodontal examination is full-mouth record assessing CAL and PD. However, there are not always sufficient human and financial resources available to apply such assessment for epidemiological surveillance systems. Aim: This study was conducted to compare different protocols and definitions of periodontitis for assessing prevalence and the impact of related factors in adult patients who requested care at the School of Dentistry, UdelaR. Materials and Method: This was a cross-sectional study of 410 subjects with a high burden of disease in terms of NCDs and periodontitis. Clinical examination evaluated PD in all teeth and CAL in the CPI sextants (WHO 2013). Four periodontitis criteria were defined based on two examination protocols (WHO 2013 and WHO 1997) and two definitions of epidemiological case. Comparisons were made taking the 2013 WHO protocol as a reference. Results: Comparison of the two examination protocols showed that prevalence was underestimated when the WHO 1997 protocol was used to define moderate-severe and severe periodontitis, by 20% and 60%, respectively. Conclusions: When the severity of periodontitis was not considered, the WHO 2013 protocol did not provide more information on what factors increase the chance of periodontitis. However, when severity was considered, the associated factors were different. Consequently, in a small population, it would be worth using the WHO 2013 protocol, which is the closest to the full-mouth gold standard criterion.

RESUMEN La variabilidad en la definición epidemiológica de la periodontitis y los protocolos de evaluación afectan la medición de la prevalencia y su asociación con ciertos factores. Si bien, el patrón oro para el examen periodontal es el registro de boca completa, que evalúa la pérdida de inserción (CAL, por sus siglas en inglés) y profundidad de sondaje (PS, por sus siglas en inglés), los recursos no siempre están disponibles para los sistemas de vigilancia epidemiológica. Objetivo: En este estudio se compararon diferentes protocolos y definiciones de periodontitis evaluando la prevalencia y la asociación de factores relacionados en pacientes adultos que solicitaron atención en la Facultad de Odontología de la UdelaR. Materiales y Método: Los datos provienen de un estudio transversal de 410 sujetos con una elevada carga de enfermedad en términos de ENT y periodontitis. Se utilizó un examen clínico registrando PD en todos los dientes y CAL en los sextantes CPI (WHO 2013). Se definieron cuatro criterios de periodontitis basados en dos protocolos de examen y dos definiciones epidemiológicas de caso. Las comparaciones se realizaron tomando como referencia el protocolo de la OMS de 2013. Resultados: Al comparar los dos protocolos de examen, se verificó la subestimación de la prevalencia cuando se utilizó el protocolo de la OMS de 1997 para la definición de caso moderado-grave y para la periodontitis grave, siendo en el primer caso del 20% y en el segundo caso tres veces mayor que. Conclusiones: Si no se considera la gravedad de la periodontitis, el uso del protocolo de la OMS 2013 no proporciona más información sobre qué factores aumentan la probabilidad de periodontitis. Sin embargo, al analizar la gravedad, los factores asociados fueron diferentes. En consecuencia, en una población pequeña estaría justificado el esfuerzo de utilizar el protocolo de la OMS de 2013, ya que el criterio de referencia es la boca completa.

Periodontitis prevalence and associated factors: a comparison of two examination protocols.

The fact that there are different epidemiological definitions of periodontitis and different evaluation protocols affects the estimate of periodontitis prevalence and of the influence of associated factors. The gold standard for periodontal examination is full-mouth record assessing CAL and PD. However, there are not always sufficient human and financial resources available to apply such assessment for epidemiological surveillance systems. AIM: This study was conducted to compare different protocols and definitions of periodontitis for assessing prevalence and the impact of related factors in adult patients who requested care at the School of Dentistry, UdelaR. MATERIALS AND METHOD: This was a cross-sectional study of 410 subjects with a high burden of disease in terms of NCDs and periodontitis. Clinical examination evaluated PD in all teeth and CAL in the CPI sextants (WHO 2013). Four periodontitis criteria were defined based on two examination protocols (WHO 2013 and WHO 1997) and two definitions of epidemiological case. Comparisons were made taking the 2013 WHO protocol as a reference. RESULTS: Comparison of the two examination protocols showed that prevalence was underestimated when the WHO 1997 protocol was used to define moderate-severe and severe periodontitis, by 20% and 60%, respectively. CONCLUSIONS: When the severity of periodontitis was not considered, the WHO 2013 protocol did not provide more information on what factors increase the chance of periodontitis. However, when severity was considered, the associated factors were different. Consequently, in a small population, it would be worth using the WHO 2013 protocol, which is the closest to the full-mouth gold standard criterion.

La variabilidad en la definición epidemiológica de la periodontitis y los protocolos de evaluación afectan la medición de la prevalencia y su asociación con ciertos factores. Si bien, el patrón oro para el examen periodontal es el registro de boca completa, que evalúa la pérdida de inserción (CAL, por sus siglas en inglés) y profundidad de sondaje (PS, por sus siglas en inglés), los recursos no siempre están disponibles para los sistemas de vigilancia epidemiológica. OBJETIVO: En este estudio se compararon diferentes protocolos y definiciones de periodontitis evaluando la prevalencia y la asociación de factores relacionados en pacientes adultos que solicitaron atención en la Facultad de Odontología de la UdelaR. Materiales y Método: Los datos provienen de un estudio transversal de 410 sujetos con una elevada carga de enfermedad en términos de ENT y periodontitis. Se utilizó un examen clínico registrando PD en todos los dientes y CAL en los sextantes CPI (WHO 2013). Se definieron cuatro criterios de periodontitis basados en dos protocolos de examen y dos definiciones epidemiológicas de caso. Las comparaciones se realizaron tomando como referencia el protocolo de la OMS de 2013. RESULTADOS: Al comparar los dos protocolos de examen, se verificó la subestimación de la prevalencia cuando se utilizó el protocolo de la OMS de 1997 para la definición de caso moderado-grave y para la periodontitis grave, siendo en el primer caso del 20% y en el segundo caso tres veces mayor que. CONCLUSIONES: Si no se considera la gravedad de la periodontitis, el uso del protocolo de la OMS 2013 no proporciona más información sobre qué factores aumentan la probabilidad de periodontitis. Sin embargo, al analizar la gravedad, los factores asociados fueron diferentes. En consecuencia, en una población pequeña estaría justificado el esfuerzo de utilizar el protocolo de la OMS de 2013, ya que el criterio de referencia es la boca completa.

Impacto del número de controles periódicos en la salud bucal de los pacientes atendidos en la Clínica de Odontopediatría / Impacto do número de controles periódicos na saúde bucal dos pacientes atendidos na Clínica de Odontologia Pediátrica / Impact of the number of periodic dental checkups on oral health at a university pediatric dentistry clinic

Resumen La Clínica de Odontopediatría desarrolla un modelo de atención con énfasis en promoción, educación y rehabilitación destacándose su control y mantenimiento. No hay información sobre el impacto de los controles periódicos. Objetivo: Evaluar la asociación del número de controles y la salud bucal de niños entre 5 y 10 años. Estudio transversal, descriptivo (2017-18) y retrospectivo (hasta 2014) en dos subpoblaciones: G1=controles y G2=primera vez, evaluando diferencias de piezas afectadas Resultados: 115 niños, 44 en G1 y 71 en G2. El 100% presentaron biopelícula. G1 presentó un valor significativamente menor del IPV>20% (p<0.001), de lesiones cavitadas (p<0.001). G1 con 2 o más controles el promedio de lesiones iniciales fue de 2,6 y G2 de 4,5 (p<0.001). Conclusiones: Los niños con dos o más controles presentaron mejor situación de salud bucal que quienes consultaron por primera vez. Se confirma la importancia del control programado para el mantenimiento de la salud bucal.

Resumo A Clínica de Odontologia Pediátrica desenvolve um modelo de cuidado com ênfase na promoção, educação em saúde e reabilitação destacando seu controle e manutenção. Não há informações que sustentem o impacto que os controles regulares. Objetivo: Avaliar a associação do número de controles anuais e da saúde bucal de crianças entre 5 e 10 anos. Estudo transversal e descritivo (2017-18) e retrospectiva (até 2014) em duas subpopulações: G1-controle e G2-primeira vez. Resultados: 115 crianzas: G1-44 e G2-71. 100% do de crianças apresentaram biofilme. G1 apresentou valor de IPV>20% e lesões cavitadas significativamente menor (p<0,001). G1 com 2 ou mais controles a média de lesões iniciais foi de 2,6 e no G2 4,5 (p <0,001). Conclusões: Crianças que assistem a 2 ou mais controles têm uma melhor situação de saúde bucal em comparação com aquelas que consultam pela primeira vez. Confirma-se a importância do controle programado para manutenção da saúde bucal.

Abstract The Pediatric Dentistry Clinic at the School of Dentistry, Universidad de la República, has a care model that focuses on promotion, health education and rehabilitation, and aims to support health control and maintenance. There is no information on the impact of periodic checkups. Objective: To evaluate the association between the number of checkups and oral health in children aged between 5 and 10. Cross-sectional, descriptive (2017-18) and retrospective (up to 2014) study in two subpopulations: G1 = checkups, and G2 = first visit. We evaluated the differences in the number of teeth affected. Results: The sample included 115 children: 44 in G1 and 71 in G2. All of them had biofilm. G1 presented significantly lower values regarding visible plaque index (VPI) (>20%) (p < 0.001) and cavitated lesions (p < 0.001). G1 members, who had attended two or more checkups, had 2.6 initial lesions on average, and G2 members, 4.5 (p < 0.001). Conclusions Children who had attended two or more checkups had better oral health than those seeking care for the first time. This confirms the importance of scheduled checkups for maintaining oral health.

Salud Bucal y Enfermedades no transmisibles en pacientes de un centro de enseñanza universitaria del área Salud, Montevideo-Uruguay. Parte 2 / Saúde bucal e doenças não transmissíveis em pacientes de uma instituição de ensino superior, Montevidéu, Uruguai 2016. Parte 2 / Oral health and noncommunicable diseases in patients at a higher education institution. Montevideo, Uruguay. Part 2

Resumen Las enfermedades no transmisibles (ENT) comparten factores de riesgo conductuales y metabólicos con las enfermedades bucales. Ambas representan también un problema de salud pública. Objetivo: determinar la prevalencia de caries, paradenciopatías y pérdida dentaria en personas que demandan atención en la facultad de odontología de la udelar. Metodos: se relevó una muestra de los pacientes de la facultad de odontología, que respondieron un cuestionario sobre características sociodemográficas y hábitos vinculados a factores de riesgo comportamentales, se les realizaron mediciones antropométricas, de presión arterial, de glicemia capilar y un examen bucal. Resultados: fueron encuestados 602 individuos, el cpod promedio fue de 16, la prevalencia de caries no tratada fue de 72,8 % y la prevalencia de periodontitis 42,9 %. Conclusiones: Se recomienda la instalación de un programa preventivo-asistencial conjunto entre Facultad de Odontología y área salud de la UDELAR que integre la promoción y prevención de las enfermedades bucales y las no transmisibles.

Resumo As doenças não transmissíveis (DCNT) compartilham fatores de risco comportamentais e metabólicos com as doenças bucais. Ambos também representam um problema de saúde pública. Objetivo: determinar a prevalência de cárie, paradenciopatias e perda de dente em pessoas que exigem atenção na faculdade de odontologia da udelar. Métodos: foram avaliados 602 adultos, que responderam a um questionário sobre características sociodemográficas e hábitos relacionados a fatores de risco comportamentais, medidas antropométricas, pressão arterial, glicemia capilar e realização de exame oral. Resultados: foram pesquisados ​​602 indivíduos com média de 16 cáries, prevalência de cárie não tratada de 72,8% e prevalência de periodontite de 42,9%. Conclusões: Recomenda-se a instalação de um programa de cuidados preventivos conjuntos entre a Faculdade de Odontologia e a área da saúde da UDELAR que integre a promoção e prevenção das doenças bucais e não transmissíveis.

Abstract Noncommunicable diseases (NCDs) share behavioral and metabolic risk factors with oral diseases. Both are also public health issues. Objective: To determine the prevalence of caries, gum conditions, and tooth loss in patients treated at UdelaR's School of Dentistry. Methods: A sample of individuals treated at the School of Dentistry answered a questionnaire on sociodemographic characteristics and habits related to behavioral risk factors. Anthropometric measurements, blood pressure, and capillary blood glucose were recorded, and an oral exam was performed. Results: Six hundred and two individuals were surveyed. The average DMFT was 16, the prevalence of untreated caries, 72.8%, and the prevalence of periodontitis, 42.9%. Conclusions: We recommend implementing a joint preventive-care program run by the School of Dentistry and the health area of UDELAR that integrates the promotion and prevention of oral and noncommunicable diseases.

Salud Bucal y Enfermedades no transmisibles en pacientes de un centro de enseñanza universitaria, Montevideo-Uruguay. Parte 1 / Saúde bucal e doenças não transmissíveis em pacientes de uma instituição de ensino superior, Montevidéu, Uruguai 2016. Parte 1 / Oral Health and Non communicable Diseases in patients of a higher education institution, Montevideo, Uruguay 2016. Part 1

Resumen Las enfermedades no transmisibles (ENT) comparten factores de riesgo conductuales y metabólicos con las enfermedades bucales y ambas representan un problema de salud pública. Objetivo: Determinar la prevalencia ENT y sus factores de riesgo conductuales y metabólicos en personas que concurrieron a la Facultad de Odontología de la Universidad de la República. Metodos: Estudio transversal en el que se aplicó un cuestionario sobre características sociodemográficas y hábitos vinculados a factores de riesgo comportamentales. Se realizaron mediciones antropométricas, de presión arterial y glicemia capilar. Resultados: Fueron encuestados 602 individuos Conclusiones: En función de las prevalencias elevadas de varios factores de riesgo, se recomienda la instalación de un programa preventivo-educativo en las salas de espera de la Facultad.

Resumo As doenças não transmissíveis (DNT) compartem fatores de risco comportamentais e metabólicos com as doenças bucais, as duas representam um problema de saúde pública. Objetivo: Determinar a prevalência DNT e os fatores de risco comportamentais e metabólicos em pessoas que concorreram à Faculdade de Odontologia da Universidade da República. Métodos: Foi realizado um estudo transversal, onde foi aplicado um questionário relativo às características sociodemográficas e hábitos ligados com fatores de risco comportamentais. Se realizaram medições antropométricas, de pressão arterial e glicemia capilar. Resultados: Foram pesquisados 602 indivíduos. Constatou-se uma alta prevalência de inatividade física, ingestão problemática de álcool, consumo excessivo de sal, hipertensão e diabetes. Estes valores foram acima dos encontrados a nível nacional. Conclusão: Dada a alta prevalência encontrada de vários fatores de risco, recomenda-se a instalação de um programa educacional-preventivo nas salas de espera da Faculdade.

Summary Non-communicable diseases (NCD) share behavioral and metabolic risk factors with oral diseases and both represent a public health problem. Objective: to find out the prevalence of NCD and its behavioral and metabolic risk factors in people who attend at College of Odontology of the University of the Republic. Methods: A Cross-sectional study was conducted and a questionnaire related to socio-demograhic characteristics and habits linked to behavioral risk factors was applied. Anthropometric measurements of arterial pressure and capillary glucose were taken, Results: The final sample were 602 individuals. A high prevalence of physical inactivity, problematic alcohol intake, excessive salt consumption, hypertension and diabetes was found. These figures were larger than those found at the national level. Conclusions: Due to the high prevalence of various risk factors, the installation of a preventive-educational program in the waiting rooms of the Faculty is recommended.

Prevalence of temporomandibular disorders and bruxism in Uruguay. Part I

Objectives: To determine the prevalence of bruxism and TMD in two populations in Uruguay: the capital city, Montevideo, and outside Montevideo. Method: A cross-sectional study was conducted throughout the country with stratified multistage sampling. Results: The variables selected and analyzed in this first paper were: degree of mouth opening, muscle pain, TMJ clicking, parafunctional wear facets, headache, history of joint noise, feeling of clenching during sleep and self-perception of stress. The following global prevalence rates were found: TMD: 55%, with at least one symptom, it being more prevalent in Montevideo (57%) than outside Montevideo (53%); with at least one sign: 44%, it also being more prevalent in Montevideo (47%) than outside Montevideo (41%). As for active bruxism, regarding the feeling of clenching during sleep, a prevalence of 30.72% was found in Montevideo and 23.19% outside Montevideo, while being or having been a bruxer in the assessment of the parafunctional wear facets had a prevalence of 71.95% in Montevideo and 62.17% outside Montevideo. Conclusions: With this survey, we found a high prevalence of TMD and bruxism in the Uruguayan population and encourage the development of collective prevention and treatment actions.

The role of contextual and individual factors on periodontal disease in Uruguayan adults.

The present study aimed at understanding the relationship between periodontitis and socio-contextual and individual determinants of health. Data from "The First Uruguayan Oral Health Survey, 2011", which included 223 and 455 individuals with 35-44 and 65-74 years old respectively, were used. A stratified, multistage cluster sampling design was adopted (cities with ≥ 20.000 residents). Periodontitis was assessed using the modified Community Periodontal Index (CPI) and clinical attachment loss (CAL) (periodontal pocket and CAL ≥ 4 mm). Independent variables included contextual socioeconomic status (SES) measured by proportion of houses with Unsatisfied Basic Needs (UBN) and individual demographic and behavioral factors. Logistic regression multilevel models were generated. Living in contexts with a higher UBN was associated with higher odds for periodontitis in both age groups, even when adjusting for individual level variables (odds ratio [OR] = 1.51, 95%CI = 1.42-1.60 and 1.31, 95%CI = 1.21-1.42, respectively). Being male or heavy smoker increased the odds of periodontitis in this population for both age groups. Social structure impacts periodontal disease by modifying individual socioeconomic situations: in better socioeconomic context, UBN acts increasing the protector role of socioeconomic situation but in a poverty context the role is attenuated. Conclusions for this study are that periodontitis varies across contextual socio-demographic groups being higher in the population with a lower SES, challenging health authorities to integrate oral health into national non-communicable diseases programs.

Prevalencia de signos y síntomas de trastornos témporomandibulares en una población joven al inicio del tratamiento por drogodependencia / Prevalence of signs and symptoms of temporomandibular disorders in a young population at the beginning of treatment for drug dependence

Introducción: El consumo de drogas puede constituir un agente etiológico de trastornos témporomandibulares (TTM), lo cual debe ser tenido en cuenta al momento del diagnóstico y en la elaboración de un plan de tratamiento. Objetivo: Estimar la prevalencia de signos y síntomas de TTM en una población con dependencia a las drogas al inicio del régimen de internación y analizar posibles factores asociados. Material y método:Fue un estudio descriptivo y transversal, que incluyó pacientes consecutivos al inicio del tratamiento por consumo problemático de drogas. Participaron 135 pacientes internados en el Portal Amarillo y examinados por un investigador calibrado. Se solicitó consentimiento informado al participante y/o su representante legal. Resultados: La prevalencia de participantes con uno o más signos actuales de TTM fue de 29,7% y con uno o más síntomas actuales de TTM fue de 68,8%. La prevalencia de síntomas actuales de TTM presentó asociación significativa con autopercepción de estrés (p=.03), consumo de mate (p=.03) y de alcohol (p=.03). Conclusiones: La prevalencia de síntomas de TTM en una población en tratamiento por dependencia a las drogas es elevada respecto a la población general. Esto debe ser tenido en cuenta a la hora de desarrollar políticas de prevención y tratamiento.

Introduction: Drug consumption may be an etiological agent of temporomandibular disorders (TMD) which should be considered when diagnosing a patient and developing a treatment plan. Objective: To estimate the prevalence of TMD signs and symptoms in a drug-dependent population at the beginning of their admission, and to analyze possible associated factors. Materials and methods: This was a descriptive cross-sectional study that included patients at the beginning of treatment for problematic drug use. We studied 135 subjects admitted to Portal Amarillo, Uruguay. The patients were examined by a calibrated researcher. Informed consent was requested from each participant and/or their legal representative. Results: The prevalence of subjects with one or more current TMD signs was 29.7%, and those with one or more current TMD symptoms accounted for 68.8%. The prevalence of current TMD symptoms showed a significant association with self-perceived stress (p=.03), mate consumption (p=.03) and alcohol consumption (p=.03). Conclusions: The prevalence of current TMD symptoms in the population under treatment for drug dependence is high compared to the general population. This should be considered when developing prevention and therapeutic strategies.

The role of contextual and individual factors on periodontal disease in Uruguayan adults

Abstract The present study aimed at understanding the relationship between periodontitis and socio-contextual and individual determinants of health. Data from "The First Uruguayan Oral Health Survey, 2011", which included 223 and 455 individuals with 35-44 and 65-74 years old respectively, were used. A stratified, multistage cluster sampling design was adopted (cities with ≥ 20.000 residents). Periodontitis was assessed using the modified Community Periodontal Index (CPI) and clinical attachment loss (CAL) (periodontal pocket and CAL ≥ 4 mm). Independent variables included contextual socioeconomic status (SES) measured by proportion of houses with Unsatisfied Basic Needs (UBN) and individual demographic and behavioral factors. Logistic regression multilevel models were generated. Living in contexts with a higher UBN was associated with higher odds for periodontitis in both age groups, even when adjusting for individual level variables (odds ratio [OR] = 1.51, 95%CI = 1.42-1.60 and 1.31, 95%CI = 1.21-1.42, respectively). Being male or heavy smoker increased the odds of periodontitis in this population for both age groups. Social structure impacts periodontal disease by modifying individual socioeconomic situations: in better socioeconomic context, UBN acts increasing the protector role of socioeconomic situation but in a poverty context the role is attenuated. Conclusions for this study are that periodontitis varies across contextual socio-demographic groups being higher in the population with a lower SES, challenging health authorities to integrate oral health into national non-communicable diseases programs.