G Tsakos

Social Gradients in Oral and General Health

There are social gradients in general health and oral health. However, there have been few studies addressing whether similarities exist in the gradients in oral and general health in the same individuals. We set out to test, using data from NHANES III, whether there are social gradients in oral health, and whether they resemble the gradients in general health. Income, indicated by poverty-income ratio, and education gradients were examined in periodontal diseases, ischemic heart disease, and perceived oral/general health. Our analysis demonstrated consistent income and education gradients in all outcomes assessed. In the adjusted regression models, the probabilities of having poorer clinical and perceived health were attenuated, but remained significantly higher at each lower level of income and education for most outcomes. The results showed similar income and education gradients in oral and general health, implying commonalities of the social determinants of both oral and general health.

Effects of allostatic load on the social gradient in ischaemic heart disease and periodontal disease: evidence from the Third National Health and Nutrition Examination Survey

Introduction: Psychosocial stress and allostatic load have been postulated as a mechanism explaining socioeconomic inequalities in general and oral health. This study tested whether markers of allostatic load are associated with both ischaemic heart disease and periodontal disease and whether they affect education and income gradients for both conditions. Methods: Data are from the Third National Health and Nutrition Examination Survey, conducted in the United States from 1988 to 1994. Ischaemic heart disease was determined by the presence of angina or diagnosis of heart attack. Four variables were used for periodontal disease. Individual and aggregate markers of allostatic load were used. Results: Allostatic load (both aggregate and most individual markers) was associated with higher probabilities of all examined health outcomes. Adjusting for markers of allostatic load attenuated education and income gradients in both ischaemic heart disease and periodontal disease. The relationship between socioeconomic position and the examined health outcomes remained significant. Conclusion: Indicators of allostatic load were associated with ischaemic heart disease and periodontal disease and had a mediating effect partly explaining the social gradients in both diseases. The results suggest a possible common stress pathway linking socioeconomic position to both conditions.

Oral health-related quality of life and the IOTN index as predictors of children's perceived needs and acceptance for orthodontic treatment

Objective To evaluate whether the index of orthodontic treatment need (IOTN) could be improved by adding an oral health-related quality of life measure to predict both the outcome of orthodontic consultation and the childs perceived need for orthodontic treatment.Methods The sample consisted of 187 children aged 11-16 years referred to orthodontic clinics in the Bedfordshire Personal Dental Service (PDS) in the United Kingdom. The children completed a questionnaire containing the Child Perception Questionnaire (CPQ11-14), were clinically examined and completed the Child-OIDP index in face-to-face interviews. Demographic information and perceived need for orthodontic treatment were also collected. Clinical data on orthodontic treatment need was collected using the IOTN.Results 49.3% of children reported one or more oral impacts. Combining the IOTN index with either of the two oral health-related quality of life measures used in this study did not predict outcome of consultation, however it explained childrens perceived need for braces. There were some discrepancies between need according to the orthodontist and childrens perceptions.Conclusions Adding an oral health-related quality of life measure to IOTN did not influence prediction of outcome of consultation but it explained the prediction of perceived need for braces. Importantly, children with an impact were denied orthodontic treatment.

Impacts on daily performances attributed to malocclusions using the condition-specific feature of the Oral Impacts on Daily Performances Index.

OBJECTIVE To assess the prevalence, intensity, and extent of sociodental impacts attributed to malocclusions by sex, socioeconomic status, and normative orthodontic treatment need level. MATERIALS AND METHODS One thousand sixty 15- to 16-year-old adolescents without history of previous or current orthodontic treatment were randomly selected from all secondary schools in Bauru, Brazil. Interviews were done to collect information about sociodemographic variables and sociodental impacts on quality of life attributed to malocclusions using the Oral Impacts on Daily Performances Index. Adolescents were also clinically examined using the Index of Orthodontic Treatment Need. Statistical comparison by covariables was performed using chi(2) and Kruskal-Wallis tests. RESULTS The prevalence of condition-specific impacts (CSIs) was 24.6%. Among adolescents with CSIs, 52.1% reported severe or very severe intensity and 77.4% reported impacts on only one daily performance, commonly, smiling. The prevalence, intensity, and extent of CSIs differed by level of normative orthodontic treatment need but not by sex or socioeconomic status. However, among adolescents with definite normative orthodontic treatment need, 24.5% reported CSIs of severe or very severe intensity, whereas among those with moderate or slight/no need, 13.0% and 7.9%, respectively, experienced CSIs of severe or very severe intensity. CONCLUSIONS Untreated malocclusions have physical, psychological, and social consequences on quality of life of Brazilian adolescents. However, because adolescents with a definite normative orthodontic need are considered by orthodontists as in need of care, these results raise the issue of whether all these adolescents should be considered for orthodontic attention since most had no perceived impacts on performing their daily life activities.

Edentulism and Fruit and Vegetable Intake in Low-Income Adults

Poor dental status negatively relates to dietary intakes. However, this issue has not been researched among the most vulnerable groups in society. We aimed to investigate, in a national low-income sample, the association between dental status and fruit and vegetable consumption. We analyzed data on adults aged 50 years and older from the Low Income Diet and Nutrition Survey, a representative sample of deprived UK households. Considerable numbers reported difficulty eating specific foods, with significantly worse experience among edentate than dentate people. The mean daily fruits and vegetables consumption was low (256.5 g for dentate, 207.1 g for edentate). After adjustment for socio-demographic and behavioral variables, edentate individuals consumed 50.7 g (27.0, 74.3) fewer fruits/vegetables per day than the dentate. Over and above the effects of material deprivation on nutrient intake, edentulism negatively relates to eating fruits and vegetables and achieving a healthy diet in materially deprived older adults.

The Interplay between Socioeconomic Inequalities and Clinical Oral Health

Oral health inequalities associated with socioeconomic status are widely observed but may depend on the way that both oral health and socioeconomic status are measured. Our aim was to investigate inequalities using diverse indicators of oral health and 4 socioeconomic determinants, in the context of age and cohort. Multiple linear or logistic regressions were estimated for 7 oral health measures representing very different outcomes (2 caries prevalence measures, decayed/missing/filled teeth, 6-mm pockets, number of teeth, anterior spaces, and excellent oral health) against 4 socioeconomic measures (income, education, Index of Multiple Deprivation, and occupational social class) for adults aged ≥21 y in the 2009 UK Adult Dental Health Survey data set. Confounders were adjusted and marginal effects calculated. The results showed highly variable relationships for the different combinations of variables and that age group was critical, with different relationships at different ages. There were significant income inequalities in caries prevalence in the youngest age group, marginal effects of 0.10 to 0.18, representing a 10- to 18-percentage point increase in the probability of caries between the wealthiest and every other quintile, but there was not a clear gradient across the quintiles. With number of teeth as an outcome, there were significant income gradients after adjustment in older groups, up to 4.5 teeth (95% confidence interval, 2.2-6.8) between richest and poorest but none for the younger groups. For periodontal disease, income inequalities were mediated by other socioeconomic variables and smoking, while for anterior spaces, the relationships were age dependent and complex. In conclusion, oral health inequalities manifest in different ways in different age groups, representing age and cohort effects. Income sometimes has an independent relationship, but education and area of residence are also contributory. Appropriate choices of measures in relation to age are fundamental if we are to understand and address inequalities.

Oral Health and Cancer, Cardiovascular, and Respiratory Mortality of Japanese

Cardiovascular diseases, cancer, and respiratory disease are major causes of death in developed countries. No study has simultaneously compared the contribution of oral health with these major causes of death. This study examined the association between oral health and cardiovascular diseases, cancer, and respiratory mortality among older Japanese. Self-administered questionnaires were mailed to participants in the Aichi Gerontological Evaluation Study (AGES) Project in 2003. Mortality data were analyzed for 4425 respondents. Three categories of oral health were used: 20 or more teeth, 19 or fewer teeth and eat everything, 19 or fewer teeth and eating difficulty. Sex, age, body mass index (BMI), self-rated health, present illness, exercise, smoking, alcohol, education, and income were used as covariates. During 4.28 years’ follow-up, 410 people died, 159 from cancer, 108 of cardiovascular diseases, and 58 of respiratory disease. Multivariate adjusted Cox proportional hazard models showed that, compared with the respondents with 20 or more teeth, respondents with 19 or fewer teeth and with eating difficulty had a 1.83 and 1.85 times higher hazard ratio for cardiovascular disease mortality and respiratory disease mortality, respectively. There was no significant association with cancer mortality. Oral health predicted cardiovascular and respiratory disease mortality but not cancer mortality in older Japanese.

The Role of Cognitive Ability in Socio-economic Inequalities in Oral Health

Studies have postulated a role for cognitive ability in socio-economic inequalities in general health. This role has not been examined for oral health inequalities. We examined whether cognitive ability was associated with oral health, and whether it influenced the relationship between oral health and socio-economic position. Data were from the Third National Health and Nutrition Examination Survey (1988–1994), for participants aged 20–59 years. Oral health was indicated by extent of gingival bleeding, extent of loss of periodontal attachment, and tooth loss. Simple reaction time test, symbol digit substitution test, and serial digit learning test indicated cognitive ability. Education and poverty-income ratio were used as markers of socio-economic position. Participants with poorer cognitive ability had poorer oral health for all indicators. The association between oral health and socio-economic position attenuated after adjustment for cognitive ability. Cognitive ability explained part, but not all, of the socio-economic inequalities in oral health.

Inequalities in Oral Health of the Elderly Rising to the Public Health Challenge

From both a public health and a social justice perspective, older adults are an increasingly important age group, partly due to the universal demographic transition toward an aging society. From an oral health perspective, this is complemented by an oral health transition, whereby current cohorts of older adults are very different from their predecessors, each new cohort having a much lower proportion of edentate, while the dentate tend to keep more teeth into older age. That pattern may lead to increased treatment needs (Petersen et al., 2010). Poor oral health is particularly important in older people, since risk factors and oral diseases have accumulated throughout their life course. Indeed, oral health affects general health and quality of life in older people. There is abundant evidence highlighting the important influence of oral health on diet and nutrition (Nowjack-Raymer and Sheiham, 2003; Walls and Steele, 2004; Moynihan, 2007). In addition, oral health status has been independently associated with mortality and disability. Moreover, oral diseases and tooth loss have a significant negative impact on the quality of life and well-being of people and affect them not only functionally, but also psychologically and socially (Gerritsen et al., 2010). Dental treatment also places a considerable economic burden on individuals and society, since oral diseases are costly to treat. A paper in this issue (Listl, 2011) demonstrates clear and mostly consistent inequalities by income in dental services utilization among older adults in Europe. As expected, higher income groups have higher levels of access to dental care in national samples in 14 European countries. This paper provides a useful foundation for considering the importance of inequalities in this age group and their consequences for oral health and dental care. An important contribution of this study relates to the finding that these inequalities were evident in, and primarily attributable to, preventive dental care, with more affluent people benefiting from prevention more than those in lower income groups. Furthermore, dental status did not seem to explain relative inequalities in dental service utilization. If we combine the findings from this study with the evidence that groups in a higher socio-economic position have better oral health status than their more disadvantaged counterparts (Locker, 2000; Sabbah et al., 2007; Bernabe and Marcenes, 2011), it seems that, compared with those higher up in the social hierarchy, older people in lower socio-economic position groups face a double disadvantage: worse oral health and more limited access to services that could potentially improve their oral health and quality of life. Looking at the broader perspective, there is an urgent need to address inequalities in oral health—rather than only dental services—and to put more emphasis on the social determinants of health. Health inequalities are a major political and public health issue, as stressed by the recent WHO Commission on Social Determinants (Commission on Social Determinants of Health, 2008), and they also bring excessive financial burden to society (Marmot Review, 2010). The most striking finding about health inequalities is that they tend to take the form of a social gradient, whereby people in each lower socio-economic position category have successively worse levels of health and die earlier than those who are better off (Marmot, 2001). Therefore, explaining the determinants of the social gradient in oral health will provide useful guidance for oral health promotion interventions on inequalities. Different pathways have been proposed to link socio-economic position with oral health outcomes (Newton and Bower, 2005). Dental services and attendance are factors that could contribute to oral health inequalities. Focusing on the role of health care services by increasing the effectiveness and efficiency of clinical care is essential for the provision of state-of-the-art evidencebased care. But such services alone have only “modest effects on the health of the population in the absence of an ecologic, population-based approach to health improvement” (Institute of Medicine, 2011). Moreover, health behaviors are relevant and important, but can only partly explain the social gradients in health (Lantz et al., 1998). This implies that improving the health behaviors of the more disadvantaged groups in society will not eliminate health inequalities. Therefore, it is equally important that other pathways, such as the role of psychosocial factors, also be explored. Furthermore, recent innovative methodological developments in the field of social epidemiology have enabled researchers to look at and partition the effects on health of factors that operate at different levels, such as the individual and the community. The study by Listl (2011) has presented European data, but the issue of health inequalities is global. Since inequalities have detrimental consequences for the health of the population, it is important that both the oral health research and the public health communities act promptly to address oral health inequalities. In DOI: 10.1177/0022034511407072

Relationship between clinical dental status and eating difficulty in an old Chinese population

This study investigated the relationship between clinical dental status and eating difficulty in a sample of older Chinese people in Guangxi, China. Sample was selected from people aged 55 years and older who had routine annual health check-ups at a large hospital health centre. The sample consisted of 1,196 dentate people who had clinical oral examinations and face-to-face interviews. Different measures, namely the Index of Eating Difficulty, dissatisfaction with chewing ability and ease of eating certain foods were used to measure eating difficulty. Multiple logistic regression analysis showed that after controlling for the effects of age, sex, occupation, self-assessed social class and self-perceived general health, increased eating difficulty was significantly related with having fewer teeth, fewer posterior and anterior occluding pairs of teeth (both natural teeth only and natural plus replaced teeth), more unfilled posterior spaces, more unfilled anterior spaces, mobile teeth, decayed teeth and roots. In conclusion, clinical dental status was strongly related with eating difficulty in a sample of older Chinese dentate people.