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Limited and Nongeneralizable Evidence Shows Neighborhood Contextual Factors May Be Linked to Dental Treatment but Not Untreated Caries Prevalence
The Journal of EVIDENCE-BASED DENTAL PRACTICE
ARTICLE ANALYSIS & EVALUATION // ETIOLOGY/OTHER
LIMITED AND NONGENERALIZABLE EVIDENCE SHOWS NEIGHBORHOOD CONTEXTUAL FACTORS MAY BE LINKED TO DENTAL TREATMENT BUT NOT UNTREATED CARIES PREVALENCE REVIEWER
GABRIELA DE ALMEIDA LAMARCA Are neighborhood factors associated with dental caries in the primary dentition in preschool children?
A
SORT SCORE B C
NA
SORT, Strength of Recommendation Taxonomy
LEVEL OF EVIDENCE 1 2 3 See page 11A for complete details regarding SORT and LEVEL OF EVIDENCE grading system
SOURCE OF FUNDING None.
TYPE OF STUDY/DESIGN Cross-sectional study.
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Neighbourhood Determinants of Caries Experience in Preschool Children: A Multilevel Study. Priesnitz MC, Celeste RK, Pereira MJ, Pires CA, Feldens CA, Kramer PF. Caries Res 2016;50(5):455-61.
SUMMARY Subjects A representative sample of 1110 preschool children aged from 0 to 5 years enrolled in all 31 public nurseries in the city of Canoas, Brazil, was selected. Each participant was then allocated to a neighborhood area according to his/her home address. Children with permanent teeth (n 5 197), those with past orthodontic treatment (n 5 12), and those without complete address (n 5 206) were excluded. The mean age of the sample was 3 years (standard deviation 5 1.3). No information concerning the response rate was provided.
Key Risk/Study Factor Three contextual neighborhood characteristics were investigated, including (1) Human Development Index (HDI), which is a composite measure encompassing information on income, education, and life expectancy to evaluate the social development of the area; (2) average income of the neighborhoods; and (3) rate of public primary health care units having at least 1 dentist per 10,000 inhabitants. All contextual variables were dichotomized for analytical purposes.
Main Outcome Measure J Evid Base Dent Pract 2017: [142-144] 1532-3382/$36.00 ª 2017 Elsevier Inc. All rights reserved. doi: http://dx.doi.org/10.1016/ j.jebdp.2017.03.014
142
Volume 17, Number 2
The main outcome measure was dental caries in the primary dentition of children from birth to age 5 years measured using the decayed-missing-filled tooth index, following the World Health Organization criteria for oral health surveys. Two dental caries measures were considered in the analysis: (1) number of teeth with untreated dental caries and (2) number of missing or filled teeth.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Main Results The sample included 998 children with complete data clustered in 16 official districts of the city. The mean numbers of decayed-missing-filled tooth, untreated decayed teeth, and missing/filled teeth were 1.03, 0.96, and 0.08, respectively. The prevalence of untreated decayed teeth was 24.1%, whereas 3.5% of the children had one or more missing or filled teeth. Higher income at neighborhood level increased the likelihood of having more filled or missing teeth. Nonetheless, untreated dental caries was not associated with any neighborhood factors.
Conclusions The authors concluded that there was a modest variability of contextual characteristics between neighborhoods that did not support the link between neighborhood factors and untreated dental caries. On the other hand, the present findings suggest that children living in better-off districts were more likely to have treated teeth.
COMMENTARY AND ANALYSIS A recent review of the role of social inequalities in dental caries supports the finding that low socioeconomic position is a significant predictor of dental caries when different individual social indicators are considered.1 However, the possible influence of the different characteristics of place of living, also known as contextual social factors, on the occurrence of oral diseases remains debatable despite the increase in the number of investigations during the recent decades. A crucial question in social oral epidemiology, which remains inconclusive, is whether the poor area-level social characteristics predict dental caries.2 The results of the present cross-sectional study reflect the inconsistency of previous findings to some extent. At a neighborhood level, high income increased the odds of children having access to dental treatment when measured as the number of missing and filled teeth. In contrast, none of the 3 contextual factors were related to untreated dental caries in young children. One can argue that the findings of the study might be affected, at least in part, by methodological limitations, including the cross-sectional design, small level of aggregation, similarity of the districts, and time lags between the contextual exposures and the outcomes. However, the lack of agreement about the role of contextual social inequalities on a population’s health has also been observed in different societies and for different health outcomes.3 That being said, there are certain methodological issues in the present study that must be considered when interpreting the findings. First, the levels of dental caries in children age
birth to 5 years were assessed between 2010 and 2011, and at least 2 contextual variables (average income and HDI) were for the year 2000. It is unclear to which year the access to primary health care data refers. Thus, the 10-year interval between neighborhood characteristic measures and dental caries assessment in young children suggests the contextual factors were assessed 5 years before participants’ birth. Second, dental caries in young children is greatly influenced by parental attitudes, mainly those related to children’s sugar consumption and use of fluoride toothpaste. However, although meaningful confounders were considered in the multilevel analysis, parental behavior was not assessed. Third, all children had access to a fluoridated water supply since birth. Water fluoridation is recognized as an effective public health policy to reduce oral health inequities in areas with high social inequities. This may explain the lack of association between neighborhood factors and untreated dental caries. Other public policies that have an impact on the distribution of dental caries, such as oral health promotion programs and health policies in the local nurseries, may have also influenced the results. Fourth, the contextual measures considered indicative of social conditions vary from relatively simple single-item asset-based measures (eg, average income) to composite measures combining distinct variables (eg, HDI). The former measures have been criticized because single-item measures may be insufficient to address the different dimensions of the contextual phenomenon.4 Finally, it is unclear whether the contextual measures were used as alternatives to social inequalities or were posited as the pathways that link social inequalities and dental caries. Similar to previous research on the influence of area-level social factors and oral health, there was no theoretical basis for selecting the contextual social indicators. The adoption and clear specification of a social theory is paramount to understand the underlying mechanisms between social conditions and oral health. In conclusion, although young children are considered the most susceptible population group with respect to environmental factors and many studies have demonstrated an association between poor socioeconomic conditions and dental caries, the current findings do not support a possibly harmful effect of neighborhood characteristics on untreated dental caries in children. However, the results reinforce the importance of contextual social conditions on the inequalities related to access to dental care. Evidence regarding the influence of contextual social determinants on oral health from a single cross-sectional study conducted in a city with a high level of income inequality should be interpreted with caution and must not be generalized to other communities.
June 2017
143
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Further studies on the link between contextual factors and dental caries in young children are needed.
REFERENCES 1. Schwendicke F, Dorfer CE, Schlattmann P, Foster Page L, Thomson WM, Paris S. Socioeconomic inequality and caries: a systematic review and meta-analysis. J Dent Res 2015;94:10-8. 2. Singh A, Harford J, Watt RG, Peres MA. The role of theories in explaining the association between social inequalities and population oral health: a scoping review protocol. JBI Database System Rev Implement Rep 2015;13:30-40.
144
Volume 17, Number 2
3. Wilkinson RG, Pickett KE. Income inequality and population health: a review and explanation of the evidence. Soc Sci Med 2006;62:1768-84. 4. Locker D. Deprivation and oral health: a review. Community Dent Oral Epidemiol 2000;28:161-9.
REVIEWER Gabriela de Almeida Lamarca, DDS, MSc, PhD Centre of Studies, Policies and Information on Social Determinants of Health, National School of Public Health, Oswaldo Cruz Foundation, Manguinhos, Rio de Janeiro, Brazil, [email protected]
ARTICLE ANALYSIS & EVALUATION // ETIOLOGY/OTHER
LIMITED AND NONGENERALIZABLE EVIDENCE SHOWS NEIGHBORHOOD CONTEXTUAL FACTORS MAY BE LINKED TO DENTAL TREATMENT BUT NOT UNTREATED CARIES PREVALENCE REVIEWER
GABRIELA DE ALMEIDA LAMARCA Are neighborhood factors associated with dental caries in the primary dentition in preschool children?
A
SORT SCORE B C
NA
SORT, Strength of Recommendation Taxonomy
LEVEL OF EVIDENCE 1 2 3 See page 11A for complete details regarding SORT and LEVEL OF EVIDENCE grading system
SOURCE OF FUNDING None.
TYPE OF STUDY/DESIGN Cross-sectional study.
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Neighbourhood Determinants of Caries Experience in Preschool Children: A Multilevel Study. Priesnitz MC, Celeste RK, Pereira MJ, Pires CA, Feldens CA, Kramer PF. Caries Res 2016;50(5):455-61.
SUMMARY Subjects A representative sample of 1110 preschool children aged from 0 to 5 years enrolled in all 31 public nurseries in the city of Canoas, Brazil, was selected. Each participant was then allocated to a neighborhood area according to his/her home address. Children with permanent teeth (n 5 197), those with past orthodontic treatment (n 5 12), and those without complete address (n 5 206) were excluded. The mean age of the sample was 3 years (standard deviation 5 1.3). No information concerning the response rate was provided.
Key Risk/Study Factor Three contextual neighborhood characteristics were investigated, including (1) Human Development Index (HDI), which is a composite measure encompassing information on income, education, and life expectancy to evaluate the social development of the area; (2) average income of the neighborhoods; and (3) rate of public primary health care units having at least 1 dentist per 10,000 inhabitants. All contextual variables were dichotomized for analytical purposes.
Main Outcome Measure J Evid Base Dent Pract 2017: [142-144] 1532-3382/$36.00 ª 2017 Elsevier Inc. All rights reserved. doi: http://dx.doi.org/10.1016/ j.jebdp.2017.03.014
142
Volume 17, Number 2
The main outcome measure was dental caries in the primary dentition of children from birth to age 5 years measured using the decayed-missing-filled tooth index, following the World Health Organization criteria for oral health surveys. Two dental caries measures were considered in the analysis: (1) number of teeth with untreated dental caries and (2) number of missing or filled teeth.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Main Results The sample included 998 children with complete data clustered in 16 official districts of the city. The mean numbers of decayed-missing-filled tooth, untreated decayed teeth, and missing/filled teeth were 1.03, 0.96, and 0.08, respectively. The prevalence of untreated decayed teeth was 24.1%, whereas 3.5% of the children had one or more missing or filled teeth. Higher income at neighborhood level increased the likelihood of having more filled or missing teeth. Nonetheless, untreated dental caries was not associated with any neighborhood factors.
Conclusions The authors concluded that there was a modest variability of contextual characteristics between neighborhoods that did not support the link between neighborhood factors and untreated dental caries. On the other hand, the present findings suggest that children living in better-off districts were more likely to have treated teeth.
COMMENTARY AND ANALYSIS A recent review of the role of social inequalities in dental caries supports the finding that low socioeconomic position is a significant predictor of dental caries when different individual social indicators are considered.1 However, the possible influence of the different characteristics of place of living, also known as contextual social factors, on the occurrence of oral diseases remains debatable despite the increase in the number of investigations during the recent decades. A crucial question in social oral epidemiology, which remains inconclusive, is whether the poor area-level social characteristics predict dental caries.2 The results of the present cross-sectional study reflect the inconsistency of previous findings to some extent. At a neighborhood level, high income increased the odds of children having access to dental treatment when measured as the number of missing and filled teeth. In contrast, none of the 3 contextual factors were related to untreated dental caries in young children. One can argue that the findings of the study might be affected, at least in part, by methodological limitations, including the cross-sectional design, small level of aggregation, similarity of the districts, and time lags between the contextual exposures and the outcomes. However, the lack of agreement about the role of contextual social inequalities on a population’s health has also been observed in different societies and for different health outcomes.3 That being said, there are certain methodological issues in the present study that must be considered when interpreting the findings. First, the levels of dental caries in children age
birth to 5 years were assessed between 2010 and 2011, and at least 2 contextual variables (average income and HDI) were for the year 2000. It is unclear to which year the access to primary health care data refers. Thus, the 10-year interval between neighborhood characteristic measures and dental caries assessment in young children suggests the contextual factors were assessed 5 years before participants’ birth. Second, dental caries in young children is greatly influenced by parental attitudes, mainly those related to children’s sugar consumption and use of fluoride toothpaste. However, although meaningful confounders were considered in the multilevel analysis, parental behavior was not assessed. Third, all children had access to a fluoridated water supply since birth. Water fluoridation is recognized as an effective public health policy to reduce oral health inequities in areas with high social inequities. This may explain the lack of association between neighborhood factors and untreated dental caries. Other public policies that have an impact on the distribution of dental caries, such as oral health promotion programs and health policies in the local nurseries, may have also influenced the results. Fourth, the contextual measures considered indicative of social conditions vary from relatively simple single-item asset-based measures (eg, average income) to composite measures combining distinct variables (eg, HDI). The former measures have been criticized because single-item measures may be insufficient to address the different dimensions of the contextual phenomenon.4 Finally, it is unclear whether the contextual measures were used as alternatives to social inequalities or were posited as the pathways that link social inequalities and dental caries. Similar to previous research on the influence of area-level social factors and oral health, there was no theoretical basis for selecting the contextual social indicators. The adoption and clear specification of a social theory is paramount to understand the underlying mechanisms between social conditions and oral health. In conclusion, although young children are considered the most susceptible population group with respect to environmental factors and many studies have demonstrated an association between poor socioeconomic conditions and dental caries, the current findings do not support a possibly harmful effect of neighborhood characteristics on untreated dental caries in children. However, the results reinforce the importance of contextual social conditions on the inequalities related to access to dental care. Evidence regarding the influence of contextual social determinants on oral health from a single cross-sectional study conducted in a city with a high level of income inequality should be interpreted with caution and must not be generalized to other communities.
June 2017
143
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Further studies on the link between contextual factors and dental caries in young children are needed.
REFERENCES 1. Schwendicke F, Dorfer CE, Schlattmann P, Foster Page L, Thomson WM, Paris S. Socioeconomic inequality and caries: a systematic review and meta-analysis. J Dent Res 2015;94:10-8. 2. Singh A, Harford J, Watt RG, Peres MA. The role of theories in explaining the association between social inequalities and population oral health: a scoping review protocol. JBI Database System Rev Implement Rep 2015;13:30-40.
144
Volume 17, Number 2
3. Wilkinson RG, Pickett KE. Income inequality and population health: a review and explanation of the evidence. Soc Sci Med 2006;62:1768-84. 4. Locker D. Deprivation and oral health: a review. Community Dent Oral Epidemiol 2000;28:161-9.
REVIEWER Gabriela de Almeida Lamarca, DDS, MSc, PhD Centre of Studies, Policies and Information on Social Determinants of Health, National School of Public Health, Oswaldo Cruz Foundation, Manguinhos, Rio de Janeiro, Brazil, [email protected]