Global oral health inequalities: task group--periodontal disease

Periodontal diseases constitute one of the major global oral health burdens, and periodontitis remains a major cause of tooth loss in adults worldwide. The World Health Organization recently reported that severe periodontitis exists in 5-20% of adult populations, and most children and adolescents exhibit signs of gingivitis. Likely reasons to account for these prevalent diseases include genetic, epigenetic, and environmental risk factors, as well as individual and socio-economic determinants. Currently, there are fundamental gaps in knowledge of such fundamental issues as the mechanisms of initiation and progression of periodontal diseases, which are undefined; inability to identify high-risk forms of gingivitis that progress to periodontitis; lack of evidence on how to prevent the diseases effectively; inability to detect disease activity and predict treatment efficacy; and limited information on the effects of integration of periodontal health as a part of the health care program designed to promote general health and prevent chronic diseases. In the present report, 12 basic, translational, and applied research areas have been proposed to address the issue of global periodontal health inequality. We believe that the oral health burden caused by periodontal diseases could be relieved significantly in the near future through an effective global collaboration.     

Global oral health inequalities: task group--implementation and delivery of oral health strategies

This paper reviews the shortcomings of present approaches to reduce oral diseases and inequalities, details the importance of social determinants, and links that to research needs and policies on implementation of strategies to reduce oral health inequalities. Inequalities in health are not narrowing. Attention is therefore being directed at determinants of major health conditions and the extent to which those common determinants vary within, between, and among groups, because if inequalities in health vary across groups, then so must underlying causes. Tackling inequalities in health requires strategies tailored to determinants and needs of each group along the social gradient. Approaches focusing mainly on downstream lifestyle and behavioral factors have limited success in reducing health inequalities. They fail to address social determinants, for changing people's behaviors requires changing their environment. There is a dearth of oral health research on social determinants that cause health-compromising behaviors and on risk factors common to some chronic diseases. The gap between what is known and implemented by other health disciplines and the dental fraternity needs addressing. To re-orient oral health research, practice, and policy toward a 'social determinants' model, a closer collaboration between and integration of dental and general health research is needed. Here, we suggest a research agenda that should lead to reductions in global inequalities in oral health.     

Global oral health inequalities: oral infections-challenges and approaches

Four oral mucosal infections were identified as Global Oral Health Priorities: (a) HIV and associated viral, bacterial, and fungal infections; (b) tuberculosis; (c) NOMA; and (d) sexually transmitted diseases. Huge global inequalities exist in all four. HIV-associated infections constitute the major challenge. Oral manifestations of AIDS can be specifically diagnostic, indicating a significant role for dentists within health teams. The World Workshops in Oral Health & Disease in AIDS have identified a research program, elements of which are being implemented. Data on oral mucosal involvement in tuberculosis, syphilis, and gonorrhea are incomplete in developed countries and virtually non-existent in low- and middle-income countries, indicating the need for further epidemiological studies. Oral manifestations of tuberculosis and sexually transmitted diseases are largely associated with general health, so action programs should be integrated with agencies treating the systemic diseases. NOMA is very much in the oral health domain. It is a preventable disease associated with malnutrition and unidentified bacterial factors. Prevalence is probably grossly overestimated at present; but nevertheless it constitutes a challenge to the profession, especially in the NOMA belt. Current treatment is surgical, but plans for its eradication should be achievable. The global oral health community, especially the IADR, has a major role to play.     

National oral health survey Zimbabwe 1995: dental caries situation

Ten years after completion of the first national oral health survey, the second such survey was carried out in 1995. Application of a multi-stage sampling procedure resulted in 3,709 persons being examined according to the WHO oral health assessment form and criteria. The background variables studied were age, gender, type of location, socio-economic status. Comparison with results from major studies in other African nations are presented. It was concluded that the prevalence of dental caries in all age groups was high but that the severity was low. The prevalence of unmet treatment needs was very high with extraction as the predominant mode of treatment. The survey has shown that the vast majority of Zimbabweans are not receiving and/or are not seeking oral care.     

Global oral health inequalities: the view from a research funder

Despite impressive worldwide improvements in oral health, inequalities in oral health status among and within countries remain a daunting public health challenge. Oral health inequalities arise from a complex web of health determinants, including social, behavioral, economic, genetic, environmental, and health system factors. Eliminating these inequalities cannot be accomplished in isolation of oral health from overall health, or without recognizing that oral health is influenced at multiple individual, family, community, and health systems levels. For several reasons, this is an opportune time for global efforts targeted at reducing oral health inequalities. Global health is increasingly viewed not just as a humanitarian obligation, but also as a vehicle for health diplomacy and part of the broader mission to reduce poverty, build stronger economies, and strengthen global security. Despite the global economic recession, there are trends that portend well for support of global health efforts: increased globalization of research and development, growing investment from private philanthropy, an absolute growth of spending in research and innovation, and an enhanced interest in global health among young people. More systematic and far-reaching efforts will be required to address oral health inequalities through the engagement of oral health funders and sponsors of research, with partners from multiple public and private sectors. The oral health community must be "at the table" with other health disciplines and create opportunities for eliminating inequalities through collaborations that can harness both the intellectual and financial resources of multiple sectors and institutions.     

Evaluating the role of dental behaviour in oral health inequalities

OBJECTIVE: The aim of this study was to describe differences in dental attendance and dental self-care behaviour between socioeconomic groups and to investigate the extent to which the socioeconomic gradient in oral health was explained by these behaviours. METHODS: We used data from a representative sample of adults in Australia, surveyed by telephone interview and by self-complete questionnaire. The dependent variables were self-reported missing teeth and the social impact of oral conditions evaluated with the 14-item Oral Health Impact Profile (OHIP-14). Socioeconomic position was measured at the small-area level. We conducted bivariate analysis using one-way analysis of variance and 95% confidence intervals (95% CI) and adjusted for the effect of age. After adjusting for age, dental behavioural variables were entered individually into multivariate linear regression models. RESULTS: Data were obtained for 3678 dentate adults aged 18-91 years. Missing teeth and OHIP-14 scores followed a social gradient with poorer adults experiencing poorer outcomes. Routine dental attendance and diligent dental self-care were associated with inverse monotonic gradients in missing teeth (P < 0.05) and OHIP-14 scores (P < 0.05). Although adults living in areas with the least disadvantage had a preventive dental attendance orientation, no socioeconomic pattern was found for dental self-care. In multivariate analysis, the slope of the socioeconomic gradient [beta estimate for Index of Relative Socioeconomic Disadvantage (IRSD)] in missing teeth was not significantly attenuated by either dental attendance or dental self-care. For OHIP-14 scores, the slope of the socioeconomic gradient was significantly attenuated by dental visiting, but not by dental self-care and not by the combined effect of both behaviours. CONCLUSION: The commonly held view that the poor oral health of poor people is explained by personal neglect was not supported in this study.     

Global oral health inequalities in incidence and outcomes for oral cancer: causes and solutions

The mouth and oropharynx are among the ten most common sites affected by cancer worldwide, but global incidence varies widely. Five-year survival rates exceed 50% in only the best treatment centers. Causes are predominantly lifestyle-related: Tobacco, areca nut, alcohol, poor diet, viral infections, and pollution are all important etiological factors. Oral cancer is a disease of the poor and dispossessed, and reducing social inequalities requires national policies co-ordinated with wider health and social initiatives - the common risk factor approach: control of the environment; safe water; adequate food; public and professional education about early signs and symptoms; early diagnosis and intervention; evidence-based treatments appropriate to available resources; and thoughtful rehabilitation and palliative care. Reductions in inequalities, both within and between countries, are more likely to accrue from the application of existing knowledge in a whole-of-society approach. Basic research aimed at determining individual predisposition and acquired genetic determinants of carcinogenesis and tumor progression, thus allowing for targeted therapies, should be pursued opportunistically.     

Changing paradigms in concepts on dental caries: consequences for oral health care

Kuhn proposed in his Structure of Scientific Revolutions (1962) that the theoretical framework of a science (paradigm) determines how each generation of researchers construes a causal sequence. Paradigm change is infrequent and revolutionary; thereafter previous knowledge and ideas become partially redundant. This paper discusses two paradigms central to cariology. The first concerns the most successful caries-preventive agent: fluoride. When it was thought that fluoride had to be present during tooth mineralisation to 'improve' the biological apatite and the 'caries resistance' of the teeth, systemic fluoride administration was necessary for maximum benefit. Caries reduction therefore had to be balanced against increasing dental fluorosis. The 'caries resistance' concept was shown to be erroneous 25 years ago, but the new paradigm is not yet fully adopted in public health dentistry, so we still await real breakthroughs in more effective use of fluorides for caries prevention. The second paradigm is that caries is a transmittable, infectious disease: even one caused by specific microorganisms. This paradigm would require caries prevention by vaccination, but there is evidence that caries is not a classical infectious disease. Rather it results from an ecological shift in the tooth-surface biofilm, leading to a mineral imbalance between plaque fluid and tooth and hence net loss of tooth mineral. Therefore, caries belongs to common 'complex' or 'multifactorial' diseases, such as cancer, cardiovascular diseases, diabetes, in which many genetic, environmental and behavioural risk factors interact. The paper emphasises how these paradigm changes raise new research questions which need to be addressed to make caries prevention and treatment more cost-effective.     

Effective oral health education and promotion programs to prevent dental caries

Dental caries is nearly universal--no nation is free of this disease. Although the ability to prevent dental caries is imperfect, scientifically evaluated protective measures are available. These can substantially decrease caries when implemented and sustained, yet a large portion of the world's population, especially children, is unaided or receives outdated or unproved measures. The best individual and community protection against dental decay today is offered by the proper use of fluorides. Community water fluoridation is the most effective, practical and least expensive method. Because community water fluoridation is unavailable to many, effective alternatives must be introduced. The majority of carious lesions in children during their school years occur on occlusal surfaces. Because this surface is least protected by fluorides, adhesive sealants should be used to augment the partial protection derived from fluorides. Sound health education and health promotion activities, validated by research, form the foundation upon which prevention is organized, implemented and perpetuated.     

Measuring inequalities in the distribution of dental caries

Abstract – Objectives: To evaluate different measurements of prevalence and inequality in the distribution of dental caries as to their partial collinearity, and ability in expressing associations with the supply of fluoridated tap water, indices of socioeconomic status and provision of dental services. Methods: The DMFT, the Significant Caries (SiC) Index, the proportions of children with high- (DMFT ≥ 4) and rampant- (DMFT ≥ 7) caries experience, caries-free children (DMFT = 0), the Gini coefficient and the Dental Health Inequality Index (DHII) were the dental outcomes appraised in a sample comprising 18 718 oral examination records for 11- and 12-year-old schoolchildren in 131 towns of the state of São Paulo, Brazil. Spatial data analysis assessed the association between aggregate figures of dental indices and several covariates. Results: The DMFT, the SiC Index and the proportions of children with high- and rampant-caries experience presented strong linear associations (Pearson r near or higher than 0.95), and an analogous profile of correlation with indicators of socioeconomic status, dental services and access to fluoride tap water. The same was observed for the DHII, the Gini coefficient and the proportion of caries-free children. These observations involve the perception of variables in each set as interchangeable tools for ecological studies assessing factors influencing, respectively, prevalence levels and inequality in the distribution of dental disease. Conclusion: An improved characterization of the skewed distribution of caries experience demands the concurrent estimation of figures of prevalence and inequality in dental outcomes. This strategy may contribute to the design of socially appropriate programmes of oral health promotion.     

"摩梭人"龋病流行状况及口腔保健知识的调查

目的 :本调查旨在了解“摩梭人”龋患情况及对龋病相关知识的认识。方法 :选择“摩梭人”886人 ,男 389人 ,女 4 97人。口腔专业人员进行问卷和口腔内检查 ,用WHO(1997)口腔健康调查表 ,记录每户家庭内受检者的龋、失、补牙数 (DMFT)以及对龋病相关知识的认识。采用龋均 (XDMFT)和患龋率 (cariesprevalencerate)来描述受检人群龋病的严重程度。结果 :调查发现龋病常在家族中流行 ,该人群的龋患率为 4 8% ,龋均为 4 .9。其中女性的患龋率明显高于男性 (P <0 .0 0 1)。女性龋均为 6 .95± 0 .5 ,患龋率 86 .9% ;男性龋均为 1.6 5± 0 .3,患龋率为 11.4 % ,男女之间每天刷牙及饮食习惯无明显差异。调查群体大部分缺乏对龋病病因及如何预防等知识的认识。结论 :“摩梭人”口腔卫生状况很差 ,龋患情况较严重 ,龋病的发生有明显的性别特征。在该地区应积极开展防龋工作 ,重视口腔卫生保健知识宣传教育工作 ,提高“摩梭人”的口腔自我保健意识。     

Latino oral health: A research agenda toward eliminating oral health disparities

BACKGROUND: The Hispanic population has become the largest minority group in the United States, resulting in an increase in oral health care demands. Developing a research agenda and promoting collaboration on Latino oral health issues are crucial. METHODS: The Hispanic Dental Association and the University of Puerto Rico, School of Dentistry, San Juan, convened a workshop of health care providers and other experts to examine the current state of Hispanic oral health research and identify gaps in existing data and research methods. Participants were asked to break out into small groups to discuss research priorities. RESULTS: The participants discussed the following research areas: population-based studies, social and behavioral sciences, health promotion and communications, gene-environment interactions, and research training and workforce development. Participants emphasized the importance of understanding variations among subgroups within the Hispanic population in the development of future studies. CONCLUSIONS: Participants recommended collaborative research studies to advance existing oral disease prevention and oral health promotion efforts, with a stronger focus on the development of a multidisciplinary pipeline of researchers participating in Latino oral health research to address the growing needs of this population. Practice Implications. Building an infrastructure for research training and workforce development would supply researchers with the necessary tools to develop new studies that could affect the overall oral health of the Latino population. The translation and dissemination of these research findings will benefit clinicians by leading to a better understanding of new trends and specific population needs, as well as appropriate targeted interventions.     

Social inequalities in dental health

The analysis of social inequality is one of the predominant concerns of sociology. Inequalities in general health or utilization of health care services are nearly universal. The purpose of the paper is to describe inequalities in dental health in Denmark. Recent empirical findings are reviewed. Longitudinal data on the number of adults with few or no teeth left show remarkable differences between low and high social classes in 1976 and 1986. Among the younger individuals some reduction in the social differences has been observed over time. This was ascribed to the establishment of a public child dental health service. The level of dental caries and unmet treatment need is higher among workers than officials. Studies of industrial workers also indicate that dental illness or diseases are induced by environmental working factors. The association between health-related behavior and dental health status has been demonstrated as well as the effects of social network relations and lifestyle. Finally, theoretical explanations of the inequalities in dental health are outlined: artefact explanations, theories of natural or social selection, materialist or structuralist explanations, and cultural/behavioral explanations. Arguments for the relevance of the materialist/structuralist and the cultural/behavioral approaches are given and a combined model on dental health is presented. The practical implications of the various models are discussed.