- Email: [email protected]
Social support and dental visits
RESEARCH
Social support and dental visits Melanie W. Gironda, MSW, PhD; Carl Maida, PhD; Marvin Marcus, DDS, MPH; Yan Wang, MS; Honghu Liu, PhD
ormer U.S. Surgeon General Dr. C. Everett Koop stated, “You are not a healthy person unless you have good oral health.”1 Oral health is related to sustained and proactive health behavior, notably dental visits that are scheduled regularly and related to self-care. In a study comparing perceptions of selfcare among socioeconomically vulnerable versus nonvulnerable older adults, Clark and colleagues2 found that keeping medical appointments was of primary importance to participants in the vulnerable group in their perception of self-care. To understand factors that contribute to timely dental visits, Osterberg and colleagues3 conducted a study among a sample of elderly Swedish people, the results of which showed that functional ability and general health were not as important as were socioeconomic, lifestyle and social support factors. In a study of people 65 years or older conducted in the United Kingdom, McGrath and Bedi4 used “living alone” as an indicator of social support and found that this was an important predictor of a participant’s reason for the last dental visit. Hanson and colleagues5 and Rickardsson and Hanson6 measured several aspects of social support and found various associations with dental care utilization. In an intervention study testing the association between four types of social support and dental care utilization among children of Latina immigrants in North Carolina, Nahouraii and colleagues7 found that some types of social support were associated with dental care visits. Researchers generally consider social support to derive from social networks. Berkman8 defined it as “the emotional and instrumental assistance that is obtained
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ABSTRACT Background. The authors conducted a study to examine the influence of social support on dental visits among an adult population. Methods. Using 2003-2004 National Health and Nutrition Examination Survey data, the authors analyzed information pertaining to adults 40 years and older (N = 2,598) (with the exclusion of edentulous people), who represent about 108 million people in the United States. They weighted logistic regression models for dental visits, while controlling for demographic characteristics (age, race/ethnicity, sex, education, insurance, income), socioenvironmental characteristics (marital status, emotional and financial support, number of close family members and friends, years lived in the neighborhood) and physical and mental health status. Results. The study findings show that the odds of having had a timely dental visit (that is, within the preceding year), a self-care–related dental visit (that is, a visit initiated by the patient for a checkup, examination or cleaning more than one year previously but less than three years previously) or both were decreased significantly by not having had any financial help if needed and by having fewer close family members and friends. The authors did not find any association between marital status, emotional support or years lived in the neighborhood and having had a timely or self-care–related dental visit. Conclusions and Clinical Implications. Timely or self-care–related dental visits depend in part on financial support and the number of one’s close friends and family members. Clinicians should engage appropriate members of the patient’s social network to facilitate dental visits. Key Words. Dental visit; timely dental visit; selfcare–related dental visit; social support; social networks; socioeconomic. JADA 2013;144(2):188-194.
At the time this study was conducted, Dr. Gironda was an adjunct associate professor, Division of Public Health and Community Dentistry, School of Dentistry, University of California, Los Angeles. She now is an adjunct associate professor, Department of Family Medicine, School of Medicine, University of California, Irvine, 200 The City Drive South, Bldg. 200, Suite 835, Orange, Calif. 92868, e-mail [email protected]. Address reprint requests to Dr. Gironda. Dr. Maida is an adjunct professor, Division of Public Health and Community Dentistry, Division of Oral Biology and Medicine, School of Dentistry, University of California, Los Angeles. Dr. Marcus is a professor emeritus, Division of Public Health and Community Dentistry, School of Dentistry, University of California, Los Angeles. Ms. Wang is a doctoral student, Department of Biostatistics, School of Public Health, University of California, Los Angeles. Dr. Liu is a professor, Division of Public Health and Community Dentistry, School of Dentistry; Department of Biostatistics, School of Public Health; and Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles.
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RESEARCH
from people who com- TABLE 1 pose the individual’s Weighted frequency of having had a dental visit.* social network.” A common explanation DENTAL VISIT WEIGHTED STANDARD PERCENTAGE STANDARD FREQUENCY DEVIATION OF ERROR OF for the link between WEIGHTED PERCENTAGE health and social FREQUENCY support is that strong Yes 52,575,294 4,696,012 48.88 1.9526 social ties provide a No 54,994,394 4,170,712 51.12 1.9526 buffering effect from stress, reducing the TOTAL 107,569,688 7,841,482 100 —† vulnerability * Dental visit defined as timely, self-care related or both. Source: Centers for Disease Control resulting from stressand Prevention. † Not applicable. related health problems, facilitating through four waves, with its results released in adaptation and speeding recovery, as well as two-year waves. We used data from the 2003encouraging health promotion activities.8,9 In a 2004 NHANES,11 which offered the best availstudy examining social support (that is, presence of a partner) and self-care among patients able, although limited, information related to who experienced heart failure, Gallagher and dental visits and social support. For NHANES colleagues10 found that patients with a high 2003-2004, investigators selected 12,761 people level of support reported significantly better for the sample; they interviewed 10,122 of these self-care than did those with low or moderate participants (79.3 percent) and examined 9,643 levels of support. participants (75.6 percent) in a mobile examiAlthough the size of one’s social network is nation center.11 important, other aspects of supportive relationInclusion criteria. We included only adults ships, such as frequency of contact and type of 40 years and older whose interviews included available support, may be more important for social support and oral self-care–related quesdental visits. Preventing oral disease involves tions (n = 3,008), representing 120,455,464 engaging in personal health practices, including people in the U.S. population. In the analysis timely dental visits. We conducted this study to and modeling of this study, we excluded those examine the influence of social support on who were edentulous, resulting in a final timely dental visits (that is, within the presample size of 2,598, representing 107,569,688 ceding year), self-care–related dental visits people in the United States. (that is, initiated by the patient not by the denDependent variable. We created the selftist) or both among an adult population, while care proxy variable by combining two questions controlling for sociodemographic and physical from the survey. The first question asked parhealth characteristics. ticipants to specify about how long it had been since they had last visited a dentist. RespondMETHODS ents were instructed to include all types of denSampling and data collection. A number of tists, such as orthodontists, oral surgeons and publicly available national surveys contain oral all other dental specialists, as well as dental health information. The nationally representahygienists. The second question instructed partive National Health and Nutrition Examiticipants to indicate the main reason for their nation Survey (NHANES) is designed to assess last visit to the dentist. We dichotomized the health and nutritional status of adults and responses by using a binary measure. We children in the United States.11 The survey recorded a code of “1” for patients who had visinvolves the use of a stratified, multistage probited the dentist for a checkup, an examination ability sampling design of the civilian noninstior a cleaning within the preceding year, or who tutionalized U.S. population, with oversampling had visited the dentist on their own for a of low-income people, African Americans, Hischeckup, an examination or a cleaning more panics, people aged 12 through 19 years, and than one year previously but less than three people 60 years and older. The NHANES offers years previously; we considered these patients comprehensive dental and oral health data sets, to have had a timely dental visit, a self-care– with both self-reported and clinical examination related dental visit or both. We coded as “0” all measures. An ongoing survey since 1999, NHANES has had a substantial history of colABBREVIATION KEY. NHANES: National Health and lecting oral health data and has matured Nutrition Examination Survey. 11
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RESEARCH TABLE 2 other reasons for the last dental visit, Bivariate analysis of dental visits.* including the patient’s COVARIATE DENTAL VISIT NO DENTAL VISIT TOTAL feeling that something WEIGHTED was wrong, bothering Weighted % of Weighted % of FREQUENCY, Frequency, Participants Frequency, Participants IN MILLIONS him or her or causing in Millions in Millions pain, as well as treatAge, Years ment of a condition < 54 29.64 48.10 31.99 51.90 61.63 that a dentist discov55-64 11.17 50.39 11.00 49.61 22.17 ered at an earlier 65-74 7.36 48.87 7.70 51.13 15.07 checkup or ≥ 75 4.40 50.52 4.31 49.48 8.70 TOTAL 52.58 48.88 54.99 51.12 107.57 examination. Race/Ethnicity† Covariates. Hispanic 3.05 34.98 5.68 65.02 8.73 NHANES investigaWhite 43.31 52.50 39.19 47.50 82.50 tors collected all African 4.12 37.19 6.95 62.81 11.07 covariate data from American study participants in Other 2.09 39.76 3.17 60.24 5.26 TOTAL 52.58 48.88 54.99 51.12 107.57 the home interview. We selected specific Sex† Female 29.35 51.53 27.60 48.47 56.95 covariates for their Male 23.23 45.88 27.39 54.12 50.62 known association TOTAL 52.58 48.88 54.99 51.12 107.57 with dental visits, on Married‡ the basis of results Yes 39.72 52.73 35.60 47.27 75.33 from previous studies. No 12.75 39.87 19.24 60.13 31.99 These covariates TOTAL 52.47 48.90 54.84 51.10 107.31 include sociodemoEducation‡ graphic variables (age, Less than 9th 1.62 23.73 5.19 76.27 6.81 ethnicity, sex, educagrade 9th-11th grade 2.93 30.20 6.78 69.80 9.71 tion, insurance, High school 13.52 45.97 15.89 54.03 29.40 income), socioenvironSome college 16.06 46.80 18.26 53.20 34.32 mental variables College degree 18.35 67.71 8.75 32.29 27.09 (marital status, emoTOTAL 52.47 48.89 54.87 51.11 107.34 tional and financial Annual Family support, number of Income, $‡ close family members Refuse to 1.44 44.99 1.77 55.01 3.21 answer/missing and friends, years in data the neighborhood) and < 20,000 5.32 26.72 14.60 73.28 19.92 health status vari20,000 to 64,999 23.85 47.71 26.14 52.29 49.99 ≥ 65,000 21.96 63.74 12.49 36.26 34.45 ables (number of days TOTAL 52.58 48.88 54.99 51.12 107.57 of inactivity due to Insurance‡ poor physical or Medical and 2.87 21.50 10.46 78.50 13.33 mental health and general health status). dental No dental 16.42 46.95 18.56 53.05 34.98 We used five No medical or 32.26 57.61 23.74 42.39 56.00 dental NHANES variables to TOTAL 51.55 49.42 52.75 50.58 104.30 measure social sup* Source: Centers for Disease Control and Prevention. Some numbers have been rounded. port, as it was the † P < .05. main focus of this ‡ P ≤ .001. study: § Defined as inactive days due to poor physical or mental health during the past 30 days. Source: Centers for Disease Control and Prevention. dWhat is your current marital status? example, by paying any bills, housing costs or dCan you count on anyone to provide you hospital visits or providing you with food or with emotional support such as talking over clothes? problems or helping you make a difficult dIn general, how many close friends do you decision? have? By “close friends” I mean relatives or dIf you need some extra help financially, nonrelatives with whom you feel at ease, can could you count on anyone to help you, for 11
11
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RESEARCH TABLE 2 (CONTINUED)
edentulous, resulting in a final sample size of 2,598. The measures COVARIATE DENTAL VISIT NO DENTAL VISIT TOTAL used in our analysis WEIGHTED Weighted % of Weighted % of included demoFREQUENCY, Frequency, Participants Frequency, Participants IN MILLIONS graphics, number of in Millions in Millions years living in the Emotional neighborhood, emo† Support tional and financial Have support 50.92 50.08 50.75 49.92 101.68 support, and health Do not have 1.17 25.10 3.50 74.90 4.67 support behaviors. The Do not need 0.47 39.58 0.71 60.42 1.18 dependent variable support measured the nature TOTAL 52.56 48.88 54.97 51.12 107.53 of dental visits as Financial timely, self-care– Support‡ Have support 43.53 51.94 40.28 48.06 83.82 related or both (dental Do not have 7.79 36.59 13.51 63.41 21.30 visit = 1) and other support types of dental visits Support offered, 1.07 55.02 0.87 44.98 1.94 (dental visit = 0). not accepted TOTAL 52.39 48.94 54.66 51.06 107.05 We analyzed the data at three levels. Close Friends‡ None 1.00 34.00 1.95 66.00 2.95 First, through uniFew (1-3) 9.99 36.00 17.75 64.00 27.74 variate analysis, we Some (4-9) 25.32 53.05 22.41 46.95 47.73 calculated the mar≥ 10 16.23 56.40 12.55 43.60 28.78 ginal distribution of TOTAL 52.55 49.02 54.65 50.98 107.20 each of the outcome Years in measures, predictors Neighborhood‡ and covariates. For the Less than 1 2.47 33.08 5.00 66.92 7.47 1-2 4.45 38.37 7.15 61.63 11.60 continuous variables, 3-5 8.02 46.51 9.23 53.49 17.25 we calculated the 6-10 10.45 54.70 8.65 45.30 19.11 weighted mean, > 10 26.81 52.57 24.19 47.43 50.99 standard deviation TOTAL 52.21 49.05 54.22 50.95 106.43 and minimum and General maximum range. For Health‡ Excellent 30.19 58.51 21.41 41.49 51.60 categorical variables, Good 15.32 44.07 19.44 55.93 34.76 we calculated the Poor 7.00 33.11 14.15 66.89 21.15 weighted frequency TOTAL 52.51 48.85 54.99 51.15 107.51 distributions, modes Inactive Days‡§ and percentages in the None 39.23 51.76 36.57 48.24 75.80 population. We used a Less than 1 5.47 51.57 5.14 48.43 10.62 weighted bivariate week More than 1 1.96 28.88 4.83 71.12 6.80 analysis to examine week the association TOTAL 46.67 50.07 46.54 49.93 93.21 between each of the continuous or categortalk to about private matters and can call on ical outcome measures and each of the predicfor help. tors and covariates. Finally, we built weighted dHow many years have you lived in the logistic regression models for the binary cateneighborhood? gorical outcomes, adjusted for demographic Data and statistical analysis. We used characteristics such as age group, race/ nationally representative oral health data from ethnicity, sex, education and income. We used NHANES 2003-2004 for our analyses.11 This statistical software (SAS Version 9.2, SAS wave of NHANES data includes a total of Institute, Cary, N.C.) for all analyses. 10,122 participants older than 20 years, 3,008 RESULTS of whom were 40 years or older and answered both self-care–related questions and social supForty-nine percent of participants reported port questions. We excluded those who were having had a timely dental visit, a self-care– JADA 144(2)
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RESEARCH TABLE 3 related visit or both (Table 1, page 189). As expected, all Weighted logistic regression model. covariates indicated in the litCOVARIATE ESTIMATE ODDS STANDARD P VALUE erature to be associated signifRATIO ERROR icantly with dental visits were Intercept*† 1.1944 Not applicable 0.1761 < .001 statistically significant at the Demographics bivariate level (Table 2, pages Age, years 190-191). In a logistic regres(reference: ≤ 54) sion model including all statis55-64 0.1599 1.173 0.132 .226 tically significant relation65-74 0.1695 1.185 0.1551 .275 ≥ 75† 0.5281 1.696 0.1653 .001 ships at the bivariate level, Race/ethnicity the odds of having had a (reference: white) timely dental visit, a self-care– African American −0.3141 0.73 0.1634 .055 related visit or both were preHispanic −0.1106 0.895 0.3144 .725 dicted (Table 3). Other −0.2901 0.748 0.3927 .460 Sex With regard to sociodemo(reference: male) graphic characteristics, all Female† 0.4309 1.539 0.1081 < .001 bivariate relationships except Education race/ethnicity remained statis(reference: college degree) tically significant in the multiLess than 9th grade‡ −0.9579 0.384 0.32 .003 variate model. Compared with 9th-11th grade† −0.9242 0.397 0.1955 < .001 participants 54 years and High school −0.5075 0.602 0.266 .056 younger, those older than 75 Some college† −0.639 0.528 0.1381 < .001 years were significantly more Insurance (reference: medical and likely to have had a timely or dental) self-care–related dental visit No dental‡ −0.3669 0.693 0.1168 .002 during the previous year. No medical or dental† −1.0005 0.368 0.2271 < .001 Female sex significantly Income increased the odds of having Annual family income, $ had a timely or self-care– (reference: ≥ 65,000) Refuse to answer/missing 0.3489 1.418 0.5054 .49 related dental visit. The odds data of having had a timely or self‡ < 20,000 −0.687 0.503 0.1942 < .001 care–related dental visit were 20,000 to 64,999‡ −0.2696 0.764 0.1335 .043 significantly decreased for par* Represents the probability of having had more dental visits if all of the risk factors are ticipants who did not have a absent. † P ≤ .001. college degree compared with ‡ P < .05. those who had a college § Defined as inactive days due to poor physical or mental health during the past 30 days. degree. The estimated odds of Source: Centers for Disease Control and Prevention. having had a timely dental timely or self-care–related dental visits in the visit, a self-care–related dental visit or both for logistic regression model. Compared with parthose who had medical insurance but no dental ticipants who reported having had no days of insurance and for those who had no insurance inactivity as a result of physical or mental at all were 0.69 (P = .002) and 0.37 (P < .001) health issues, those reporting more than one times, respectively, the estimated odds for parweek of inactivity were significantly less likely ticipants who had both medical and dental to have had a dental visit. Similarly, compared insurance. We tested the interactions between with those who reported having excellent geninsurance status and social support with regard eral health, those who reported having poor gento having had timely or self-care–related dental eral health were significantly less likely to have visits and found that only financial support had a timely or self-care–related dental visit. exhibited a slightly significant interaction with The logistic regression model revealed a comdental insurance. The odds of having had a plex picture of the relationship between social dental visit were significantly lower for particisupport and having had timely or self-care– pants with an annual family income of less than related dental visits. We found no statistically $20,000 compared with the odds for those with significant association between marital status an annual family income of $65,000 or more. or having someone available to provide emoSelf-reported physical and mental health tional support (such as talking over problems or status also was associated significantly with 11
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found that marital status was not associated with dental visits. As Gallagher and colCOVARIATE ESTIMATE ODDS STANDARD P VALUE leagues10 reported, it is not RATIO ERROR simply the presence of a Social Support spouse that influences selfMarried (reference: yes) care, but the quality of the Not married −0.1675 0.846 0.1071 .118 relationship and the functional Emotional support support provided by the spouse (reference: have support) that matters. In a clinical setNo support −0.5439 0.58 0.2998 .07 ting, it is not enough for a No support needed 0.6299 1.877 0.7439 .397 practitioner to ask a patient if Financial support he or she has a partner or is (reference: have support) living with someone. The more No support† −0.5148 0.598 0.1453 < .001 important questions pertain to Support offered, not 0.2297 1.258 0.3002 .444 the quality of the relationship. accepted Because the NHANES data Close friends (reference: ≥ 10) set includes both relatives and Few (1-3)† −0.3698 0.691 0.1095 < .001 nonrelatives in the category of None 0.0372 1.038 0.6019 .951 “close friends,” interpreting the ‡ Some (4-9) −0.0127 0.987 0.1069 .905 significant odds ratios was Years in neighborhood (reference: > 10) challenging. It may be that Less than 1 −0.4701 0.625 0.2969 .113 among those who had only a 1-2 −0.2332 0.792 0.202 .248 few close friends or family 3-5 0.1008 1.106 0.1585 .525 members, these one, two or 6-10 0.0794 1.083 0.1819 .663 three people were less availHealth Status able or less inclined to help § Inactive days facilitate a dental visit com(reference: none) Less than 1 week 0.0867 1.091 0.2495 .728 pared with a larger group of More than 1 week‡ −0.6858 0.504 0.2375 .004 family members or friends or General health compared with no family mem(reference: excellent) bers or friends. This varying Good −0.3276 0.721 0.2276 .150 support also was reported by Poor‡ −0.4331 0.648 0.18 .016 Lim and colleagues12 in their helping make a difficult decision) and the odds study of patients’ responses to a course of of having had a dental visit. Social connection, instruction in plaque control. These authors as measured by the number of years lived in a found that gingivitis levels decreased in particineighborhood, also was not a significant prepants who had a higher number of reported disdictor of having had a timely or self-care– cussions with friends and parents, but gingivitis related dental visit in this model. On the other levels actually increased among those who hand, not having anyone to provide financial reported having had discussions with spouses. help if needed significantly decreased the odds Sabbah and colleagues13 found marital status of having had timely or self-care–related dental and number of friends, but not emotional supvisits. In addition, compared with having a port, to be associated with oral health in terms large number (10 or more) of close friends and of the extent of loss of periodontal attachment. family members, having only a few (one Engage family members and friends. through three) close friends and family memOptimal oral health depends on the timely use bers significantly decreased the odds of having of oral health services. One practical clinical had a dental visit (Table 3). intervention toward this goal is to identify and engage appropriate members of the patient’s DISCUSSION social network to facilitate timely self-care– Our study findings show that timely or selfrelated dental visits. Patients, especially older care–related dental visits were influenced by adults, often are accompanied to dental appointsome, but not all, components of social support. ments by a close family member or friend. This The relationship between social support and provides an opportunity for the dentist or a staff dental visits is affected by who is providing the member to have a brief conversation with the support and the type of support provided. We companion and acknowledge his or her role in JADA 144(2)
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supporting the patient’s oral self-care activities. Such acknowledgment of support by health care professionals sends the message that family members, friends and even the community are important to a patient’s self-care. By reviewing with patients the specific challenges related to attending dental visits and who might be able to assist them, practitioners can help patients begin to formulate their own strategies for receiving timely dental care. Gironda and Lui14 presented a sample of assessment tools appropriate for clinical settings to help practitioners determine social support needs. Ideally, the practitioner should conduct an assessment at the first patient encounter to ensure that the best possible social support is in place to facilitate timely self-care–related dental visits. Practitioners also should consider socioeconomic barriers because limited education, low income, lack of dental insurance and not having a source of financial assistance if needed significantly reduced the odds of a patient’s having had a dental visit. Study limitations. Although NHANES data were limited with regard to the number and type of social support variables, NHANES is one of the few large data sets with both social support and oral health behavior variables.11 Our ability to measure the full range of social support and to identify those who specifically provide the support was constrained by the limited number of variables and the way in which they were worded in the NHANES. For example, combining support from family members and friends into one question about the number of close friends limits our ability to interpret and translate the findings. Investigators in future studies of the relationship between social support and dental visits should use some of the well-validated measures of social support found in the literature. CONCLUSION
Timely or self-care–related dental visits depend on some, but not all, elements of one’s social
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support network. From a clinical standpoint, it may be worthwhile to identify those members of the patient’s network who either facilitate or impede timely or self-care–related dental visits. Engagement of appropriate members of the patient’s social network may help clinicians facilitate timely dental visits. ■ Disclosure. None of the authors reported any disclosures. This work was supported by grants R21DE019538 and R03DE019838 from the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md., to Dr. Liu. The authors thank the agency for its support. 1. Koop CE. Opening remarks. Am J Clin Nutr 2000;72(2 suppl): 503S. 2. Clark DO, Frankel RM, Morgan DL, et al. The meaning and significance of self-management among socioeconomically vulnerable older adults. J Gerontol B Psychol Sci Soc Sci 2008;63(5):S312-S319. 3. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand 1998;56(1):41-47. 4. McGrath C, Bedi R. Influences of social support on the oral health of older people in Britain. J Oral Rehabil 2002;29(10): 918-922. 5. Hanson BS, Liedberg B, Owall B. Social network, social support and dental status in elderly Swedish men. Community Dent Oral Epidemiol 1994;22(5 pt 1):331-337. 6. Rickardsson B, Hanson BS. Social network and regular dental care utilisation in elderly men: results from the population study “Men born in 1914”, Malmö, Sweden. Swed Dent J 1989;13(4): 151-161. 7. Nahouraii H, Wasserman M, Bender DE, Rozier RG. Social support and dental utilization among children of Latina immigrants. J Health Care Poor Underserved 2008;19(2):428-441. 8. Berkman LF. Assessing the physical health effects of social networks and social support. Annu Rev Public Health 1984;5:413-432. 9. House JS, Landis KR, Umberson D. Social relationships and health. Science 1988;241(4865):540-545. 10. Gallagher R, Luttik ML, Jaarsma T. Social support and selfcare in heart failure. J Cardiovasc Nurs 2011;26(6):439-445. 11. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. NHANES 2003-2004. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed Dec. 2, 2012. 12. Lim CS, Waite IM, Craft M, Dickinson J, Croucher R. An investigation into the response of subjects to a plaque control programme as influenced by friends and relatives. J Clin Periodontol 1984;11(7): 432-442. 13. Sabbah W, Tsakos G, Chandola T, et al. The relationship between social network, social support and periodontal disease among older Americans (published online ahead of print March 1, 2011). J Clin Periodontol 2011;38(6):547-552. doi:10.1111/j.1600051X.2011.01713.x. 14. Gironda MW, Lui A. Social support and resource needs as mediators of recovery after facial injury. Oral Maxillofac Surg Clin North Am 2010;22(2):251-259.
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Social support and dental visits Melanie W. Gironda, MSW, PhD; Carl Maida, PhD; Marvin Marcus, DDS, MPH; Yan Wang, MS; Honghu Liu, PhD
ormer U.S. Surgeon General Dr. C. Everett Koop stated, “You are not a healthy person unless you have good oral health.”1 Oral health is related to sustained and proactive health behavior, notably dental visits that are scheduled regularly and related to self-care. In a study comparing perceptions of selfcare among socioeconomically vulnerable versus nonvulnerable older adults, Clark and colleagues2 found that keeping medical appointments was of primary importance to participants in the vulnerable group in their perception of self-care. To understand factors that contribute to timely dental visits, Osterberg and colleagues3 conducted a study among a sample of elderly Swedish people, the results of which showed that functional ability and general health were not as important as were socioeconomic, lifestyle and social support factors. In a study of people 65 years or older conducted in the United Kingdom, McGrath and Bedi4 used “living alone” as an indicator of social support and found that this was an important predictor of a participant’s reason for the last dental visit. Hanson and colleagues5 and Rickardsson and Hanson6 measured several aspects of social support and found various associations with dental care utilization. In an intervention study testing the association between four types of social support and dental care utilization among children of Latina immigrants in North Carolina, Nahouraii and colleagues7 found that some types of social support were associated with dental care visits. Researchers generally consider social support to derive from social networks. Berkman8 defined it as “the emotional and instrumental assistance that is obtained
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ABSTRACT Background. The authors conducted a study to examine the influence of social support on dental visits among an adult population. Methods. Using 2003-2004 National Health and Nutrition Examination Survey data, the authors analyzed information pertaining to adults 40 years and older (N = 2,598) (with the exclusion of edentulous people), who represent about 108 million people in the United States. They weighted logistic regression models for dental visits, while controlling for demographic characteristics (age, race/ethnicity, sex, education, insurance, income), socioenvironmental characteristics (marital status, emotional and financial support, number of close family members and friends, years lived in the neighborhood) and physical and mental health status. Results. The study findings show that the odds of having had a timely dental visit (that is, within the preceding year), a self-care–related dental visit (that is, a visit initiated by the patient for a checkup, examination or cleaning more than one year previously but less than three years previously) or both were decreased significantly by not having had any financial help if needed and by having fewer close family members and friends. The authors did not find any association between marital status, emotional support or years lived in the neighborhood and having had a timely or self-care–related dental visit. Conclusions and Clinical Implications. Timely or self-care–related dental visits depend in part on financial support and the number of one’s close friends and family members. Clinicians should engage appropriate members of the patient’s social network to facilitate dental visits. Key Words. Dental visit; timely dental visit; selfcare–related dental visit; social support; social networks; socioeconomic. JADA 2013;144(2):188-194.
At the time this study was conducted, Dr. Gironda was an adjunct associate professor, Division of Public Health and Community Dentistry, School of Dentistry, University of California, Los Angeles. She now is an adjunct associate professor, Department of Family Medicine, School of Medicine, University of California, Irvine, 200 The City Drive South, Bldg. 200, Suite 835, Orange, Calif. 92868, e-mail [email protected]. Address reprint requests to Dr. Gironda. Dr. Maida is an adjunct professor, Division of Public Health and Community Dentistry, Division of Oral Biology and Medicine, School of Dentistry, University of California, Los Angeles. Dr. Marcus is a professor emeritus, Division of Public Health and Community Dentistry, School of Dentistry, University of California, Los Angeles. Ms. Wang is a doctoral student, Department of Biostatistics, School of Public Health, University of California, Los Angeles. Dr. Liu is a professor, Division of Public Health and Community Dentistry, School of Dentistry; Department of Biostatistics, School of Public Health; and Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles.
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from people who com- TABLE 1 pose the individual’s Weighted frequency of having had a dental visit.* social network.” A common explanation DENTAL VISIT WEIGHTED STANDARD PERCENTAGE STANDARD FREQUENCY DEVIATION OF ERROR OF for the link between WEIGHTED PERCENTAGE health and social FREQUENCY support is that strong Yes 52,575,294 4,696,012 48.88 1.9526 social ties provide a No 54,994,394 4,170,712 51.12 1.9526 buffering effect from stress, reducing the TOTAL 107,569,688 7,841,482 100 —† vulnerability * Dental visit defined as timely, self-care related or both. Source: Centers for Disease Control resulting from stressand Prevention. † Not applicable. related health problems, facilitating through four waves, with its results released in adaptation and speeding recovery, as well as two-year waves. We used data from the 2003encouraging health promotion activities.8,9 In a 2004 NHANES,11 which offered the best availstudy examining social support (that is, presence of a partner) and self-care among patients able, although limited, information related to who experienced heart failure, Gallagher and dental visits and social support. For NHANES colleagues10 found that patients with a high 2003-2004, investigators selected 12,761 people level of support reported significantly better for the sample; they interviewed 10,122 of these self-care than did those with low or moderate participants (79.3 percent) and examined 9,643 levels of support. participants (75.6 percent) in a mobile examiAlthough the size of one’s social network is nation center.11 important, other aspects of supportive relationInclusion criteria. We included only adults ships, such as frequency of contact and type of 40 years and older whose interviews included available support, may be more important for social support and oral self-care–related quesdental visits. Preventing oral disease involves tions (n = 3,008), representing 120,455,464 engaging in personal health practices, including people in the U.S. population. In the analysis timely dental visits. We conducted this study to and modeling of this study, we excluded those examine the influence of social support on who were edentulous, resulting in a final timely dental visits (that is, within the presample size of 2,598, representing 107,569,688 ceding year), self-care–related dental visits people in the United States. (that is, initiated by the patient not by the denDependent variable. We created the selftist) or both among an adult population, while care proxy variable by combining two questions controlling for sociodemographic and physical from the survey. The first question asked parhealth characteristics. ticipants to specify about how long it had been since they had last visited a dentist. RespondMETHODS ents were instructed to include all types of denSampling and data collection. A number of tists, such as orthodontists, oral surgeons and publicly available national surveys contain oral all other dental specialists, as well as dental health information. The nationally representahygienists. The second question instructed partive National Health and Nutrition Examiticipants to indicate the main reason for their nation Survey (NHANES) is designed to assess last visit to the dentist. We dichotomized the health and nutritional status of adults and responses by using a binary measure. We children in the United States.11 The survey recorded a code of “1” for patients who had visinvolves the use of a stratified, multistage probited the dentist for a checkup, an examination ability sampling design of the civilian noninstior a cleaning within the preceding year, or who tutionalized U.S. population, with oversampling had visited the dentist on their own for a of low-income people, African Americans, Hischeckup, an examination or a cleaning more panics, people aged 12 through 19 years, and than one year previously but less than three people 60 years and older. The NHANES offers years previously; we considered these patients comprehensive dental and oral health data sets, to have had a timely dental visit, a self-care– with both self-reported and clinical examination related dental visit or both. We coded as “0” all measures. An ongoing survey since 1999, NHANES has had a substantial history of colABBREVIATION KEY. NHANES: National Health and lecting oral health data and has matured Nutrition Examination Survey. 11
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RESEARCH TABLE 2 other reasons for the last dental visit, Bivariate analysis of dental visits.* including the patient’s COVARIATE DENTAL VISIT NO DENTAL VISIT TOTAL feeling that something WEIGHTED was wrong, bothering Weighted % of Weighted % of FREQUENCY, Frequency, Participants Frequency, Participants IN MILLIONS him or her or causing in Millions in Millions pain, as well as treatAge, Years ment of a condition < 54 29.64 48.10 31.99 51.90 61.63 that a dentist discov55-64 11.17 50.39 11.00 49.61 22.17 ered at an earlier 65-74 7.36 48.87 7.70 51.13 15.07 checkup or ≥ 75 4.40 50.52 4.31 49.48 8.70 TOTAL 52.58 48.88 54.99 51.12 107.57 examination. Race/Ethnicity† Covariates. Hispanic 3.05 34.98 5.68 65.02 8.73 NHANES investigaWhite 43.31 52.50 39.19 47.50 82.50 tors collected all African 4.12 37.19 6.95 62.81 11.07 covariate data from American study participants in Other 2.09 39.76 3.17 60.24 5.26 TOTAL 52.58 48.88 54.99 51.12 107.57 the home interview. We selected specific Sex† Female 29.35 51.53 27.60 48.47 56.95 covariates for their Male 23.23 45.88 27.39 54.12 50.62 known association TOTAL 52.58 48.88 54.99 51.12 107.57 with dental visits, on Married‡ the basis of results Yes 39.72 52.73 35.60 47.27 75.33 from previous studies. No 12.75 39.87 19.24 60.13 31.99 These covariates TOTAL 52.47 48.90 54.84 51.10 107.31 include sociodemoEducation‡ graphic variables (age, Less than 9th 1.62 23.73 5.19 76.27 6.81 ethnicity, sex, educagrade 9th-11th grade 2.93 30.20 6.78 69.80 9.71 tion, insurance, High school 13.52 45.97 15.89 54.03 29.40 income), socioenvironSome college 16.06 46.80 18.26 53.20 34.32 mental variables College degree 18.35 67.71 8.75 32.29 27.09 (marital status, emoTOTAL 52.47 48.89 54.87 51.11 107.34 tional and financial Annual Family support, number of Income, $‡ close family members Refuse to 1.44 44.99 1.77 55.01 3.21 answer/missing and friends, years in data the neighborhood) and < 20,000 5.32 26.72 14.60 73.28 19.92 health status vari20,000 to 64,999 23.85 47.71 26.14 52.29 49.99 ≥ 65,000 21.96 63.74 12.49 36.26 34.45 ables (number of days TOTAL 52.58 48.88 54.99 51.12 107.57 of inactivity due to Insurance‡ poor physical or Medical and 2.87 21.50 10.46 78.50 13.33 mental health and general health status). dental No dental 16.42 46.95 18.56 53.05 34.98 We used five No medical or 32.26 57.61 23.74 42.39 56.00 dental NHANES variables to TOTAL 51.55 49.42 52.75 50.58 104.30 measure social sup* Source: Centers for Disease Control and Prevention. Some numbers have been rounded. port, as it was the † P < .05. main focus of this ‡ P ≤ .001. study: § Defined as inactive days due to poor physical or mental health during the past 30 days. Source: Centers for Disease Control and Prevention. dWhat is your current marital status? example, by paying any bills, housing costs or dCan you count on anyone to provide you hospital visits or providing you with food or with emotional support such as talking over clothes? problems or helping you make a difficult dIn general, how many close friends do you decision? have? By “close friends” I mean relatives or dIf you need some extra help financially, nonrelatives with whom you feel at ease, can could you count on anyone to help you, for 11
11
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edentulous, resulting in a final sample size of 2,598. The measures COVARIATE DENTAL VISIT NO DENTAL VISIT TOTAL used in our analysis WEIGHTED Weighted % of Weighted % of included demoFREQUENCY, Frequency, Participants Frequency, Participants IN MILLIONS graphics, number of in Millions in Millions years living in the Emotional neighborhood, emo† Support tional and financial Have support 50.92 50.08 50.75 49.92 101.68 support, and health Do not have 1.17 25.10 3.50 74.90 4.67 support behaviors. The Do not need 0.47 39.58 0.71 60.42 1.18 dependent variable support measured the nature TOTAL 52.56 48.88 54.97 51.12 107.53 of dental visits as Financial timely, self-care– Support‡ Have support 43.53 51.94 40.28 48.06 83.82 related or both (dental Do not have 7.79 36.59 13.51 63.41 21.30 visit = 1) and other support types of dental visits Support offered, 1.07 55.02 0.87 44.98 1.94 (dental visit = 0). not accepted TOTAL 52.39 48.94 54.66 51.06 107.05 We analyzed the data at three levels. Close Friends‡ None 1.00 34.00 1.95 66.00 2.95 First, through uniFew (1-3) 9.99 36.00 17.75 64.00 27.74 variate analysis, we Some (4-9) 25.32 53.05 22.41 46.95 47.73 calculated the mar≥ 10 16.23 56.40 12.55 43.60 28.78 ginal distribution of TOTAL 52.55 49.02 54.65 50.98 107.20 each of the outcome Years in measures, predictors Neighborhood‡ and covariates. For the Less than 1 2.47 33.08 5.00 66.92 7.47 1-2 4.45 38.37 7.15 61.63 11.60 continuous variables, 3-5 8.02 46.51 9.23 53.49 17.25 we calculated the 6-10 10.45 54.70 8.65 45.30 19.11 weighted mean, > 10 26.81 52.57 24.19 47.43 50.99 standard deviation TOTAL 52.21 49.05 54.22 50.95 106.43 and minimum and General maximum range. For Health‡ Excellent 30.19 58.51 21.41 41.49 51.60 categorical variables, Good 15.32 44.07 19.44 55.93 34.76 we calculated the Poor 7.00 33.11 14.15 66.89 21.15 weighted frequency TOTAL 52.51 48.85 54.99 51.15 107.51 distributions, modes Inactive Days‡§ and percentages in the None 39.23 51.76 36.57 48.24 75.80 population. We used a Less than 1 5.47 51.57 5.14 48.43 10.62 weighted bivariate week More than 1 1.96 28.88 4.83 71.12 6.80 analysis to examine week the association TOTAL 46.67 50.07 46.54 49.93 93.21 between each of the continuous or categortalk to about private matters and can call on ical outcome measures and each of the predicfor help. tors and covariates. Finally, we built weighted dHow many years have you lived in the logistic regression models for the binary cateneighborhood? gorical outcomes, adjusted for demographic Data and statistical analysis. We used characteristics such as age group, race/ nationally representative oral health data from ethnicity, sex, education and income. We used NHANES 2003-2004 for our analyses.11 This statistical software (SAS Version 9.2, SAS wave of NHANES data includes a total of Institute, Cary, N.C.) for all analyses. 10,122 participants older than 20 years, 3,008 RESULTS of whom were 40 years or older and answered both self-care–related questions and social supForty-nine percent of participants reported port questions. We excluded those who were having had a timely dental visit, a self-care– JADA 144(2)
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RESEARCH TABLE 3 related visit or both (Table 1, page 189). As expected, all Weighted logistic regression model. covariates indicated in the litCOVARIATE ESTIMATE ODDS STANDARD P VALUE erature to be associated signifRATIO ERROR icantly with dental visits were Intercept*† 1.1944 Not applicable 0.1761 < .001 statistically significant at the Demographics bivariate level (Table 2, pages Age, years 190-191). In a logistic regres(reference: ≤ 54) sion model including all statis55-64 0.1599 1.173 0.132 .226 tically significant relation65-74 0.1695 1.185 0.1551 .275 ≥ 75† 0.5281 1.696 0.1653 .001 ships at the bivariate level, Race/ethnicity the odds of having had a (reference: white) timely dental visit, a self-care– African American −0.3141 0.73 0.1634 .055 related visit or both were preHispanic −0.1106 0.895 0.3144 .725 dicted (Table 3). Other −0.2901 0.748 0.3927 .460 Sex With regard to sociodemo(reference: male) graphic characteristics, all Female† 0.4309 1.539 0.1081 < .001 bivariate relationships except Education race/ethnicity remained statis(reference: college degree) tically significant in the multiLess than 9th grade‡ −0.9579 0.384 0.32 .003 variate model. Compared with 9th-11th grade† −0.9242 0.397 0.1955 < .001 participants 54 years and High school −0.5075 0.602 0.266 .056 younger, those older than 75 Some college† −0.639 0.528 0.1381 < .001 years were significantly more Insurance (reference: medical and likely to have had a timely or dental) self-care–related dental visit No dental‡ −0.3669 0.693 0.1168 .002 during the previous year. No medical or dental† −1.0005 0.368 0.2271 < .001 Female sex significantly Income increased the odds of having Annual family income, $ had a timely or self-care– (reference: ≥ 65,000) Refuse to answer/missing 0.3489 1.418 0.5054 .49 related dental visit. The odds data of having had a timely or self‡ < 20,000 −0.687 0.503 0.1942 < .001 care–related dental visit were 20,000 to 64,999‡ −0.2696 0.764 0.1335 .043 significantly decreased for par* Represents the probability of having had more dental visits if all of the risk factors are ticipants who did not have a absent. † P ≤ .001. college degree compared with ‡ P < .05. those who had a college § Defined as inactive days due to poor physical or mental health during the past 30 days. degree. The estimated odds of Source: Centers for Disease Control and Prevention. having had a timely dental timely or self-care–related dental visits in the visit, a self-care–related dental visit or both for logistic regression model. Compared with parthose who had medical insurance but no dental ticipants who reported having had no days of insurance and for those who had no insurance inactivity as a result of physical or mental at all were 0.69 (P = .002) and 0.37 (P < .001) health issues, those reporting more than one times, respectively, the estimated odds for parweek of inactivity were significantly less likely ticipants who had both medical and dental to have had a dental visit. Similarly, compared insurance. We tested the interactions between with those who reported having excellent geninsurance status and social support with regard eral health, those who reported having poor gento having had timely or self-care–related dental eral health were significantly less likely to have visits and found that only financial support had a timely or self-care–related dental visit. exhibited a slightly significant interaction with The logistic regression model revealed a comdental insurance. The odds of having had a plex picture of the relationship between social dental visit were significantly lower for particisupport and having had timely or self-care– pants with an annual family income of less than related dental visits. We found no statistically $20,000 compared with the odds for those with significant association between marital status an annual family income of $65,000 or more. or having someone available to provide emoSelf-reported physical and mental health tional support (such as talking over problems or status also was associated significantly with 11
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found that marital status was not associated with dental visits. As Gallagher and colCOVARIATE ESTIMATE ODDS STANDARD P VALUE leagues10 reported, it is not RATIO ERROR simply the presence of a Social Support spouse that influences selfMarried (reference: yes) care, but the quality of the Not married −0.1675 0.846 0.1071 .118 relationship and the functional Emotional support support provided by the spouse (reference: have support) that matters. In a clinical setNo support −0.5439 0.58 0.2998 .07 ting, it is not enough for a No support needed 0.6299 1.877 0.7439 .397 practitioner to ask a patient if Financial support he or she has a partner or is (reference: have support) living with someone. The more No support† −0.5148 0.598 0.1453 < .001 important questions pertain to Support offered, not 0.2297 1.258 0.3002 .444 the quality of the relationship. accepted Because the NHANES data Close friends (reference: ≥ 10) set includes both relatives and Few (1-3)† −0.3698 0.691 0.1095 < .001 nonrelatives in the category of None 0.0372 1.038 0.6019 .951 “close friends,” interpreting the ‡ Some (4-9) −0.0127 0.987 0.1069 .905 significant odds ratios was Years in neighborhood (reference: > 10) challenging. It may be that Less than 1 −0.4701 0.625 0.2969 .113 among those who had only a 1-2 −0.2332 0.792 0.202 .248 few close friends or family 3-5 0.1008 1.106 0.1585 .525 members, these one, two or 6-10 0.0794 1.083 0.1819 .663 three people were less availHealth Status able or less inclined to help § Inactive days facilitate a dental visit com(reference: none) Less than 1 week 0.0867 1.091 0.2495 .728 pared with a larger group of More than 1 week‡ −0.6858 0.504 0.2375 .004 family members or friends or General health compared with no family mem(reference: excellent) bers or friends. This varying Good −0.3276 0.721 0.2276 .150 support also was reported by Poor‡ −0.4331 0.648 0.18 .016 Lim and colleagues12 in their helping make a difficult decision) and the odds study of patients’ responses to a course of of having had a dental visit. Social connection, instruction in plaque control. These authors as measured by the number of years lived in a found that gingivitis levels decreased in particineighborhood, also was not a significant prepants who had a higher number of reported disdictor of having had a timely or self-care– cussions with friends and parents, but gingivitis related dental visit in this model. On the other levels actually increased among those who hand, not having anyone to provide financial reported having had discussions with spouses. help if needed significantly decreased the odds Sabbah and colleagues13 found marital status of having had timely or self-care–related dental and number of friends, but not emotional supvisits. In addition, compared with having a port, to be associated with oral health in terms large number (10 or more) of close friends and of the extent of loss of periodontal attachment. family members, having only a few (one Engage family members and friends. through three) close friends and family memOptimal oral health depends on the timely use bers significantly decreased the odds of having of oral health services. One practical clinical had a dental visit (Table 3). intervention toward this goal is to identify and engage appropriate members of the patient’s DISCUSSION social network to facilitate timely self-care– Our study findings show that timely or selfrelated dental visits. Patients, especially older care–related dental visits were influenced by adults, often are accompanied to dental appointsome, but not all, components of social support. ments by a close family member or friend. This The relationship between social support and provides an opportunity for the dentist or a staff dental visits is affected by who is providing the member to have a brief conversation with the support and the type of support provided. We companion and acknowledge his or her role in JADA 144(2)
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supporting the patient’s oral self-care activities. Such acknowledgment of support by health care professionals sends the message that family members, friends and even the community are important to a patient’s self-care. By reviewing with patients the specific challenges related to attending dental visits and who might be able to assist them, practitioners can help patients begin to formulate their own strategies for receiving timely dental care. Gironda and Lui14 presented a sample of assessment tools appropriate for clinical settings to help practitioners determine social support needs. Ideally, the practitioner should conduct an assessment at the first patient encounter to ensure that the best possible social support is in place to facilitate timely self-care–related dental visits. Practitioners also should consider socioeconomic barriers because limited education, low income, lack of dental insurance and not having a source of financial assistance if needed significantly reduced the odds of a patient’s having had a dental visit. Study limitations. Although NHANES data were limited with regard to the number and type of social support variables, NHANES is one of the few large data sets with both social support and oral health behavior variables.11 Our ability to measure the full range of social support and to identify those who specifically provide the support was constrained by the limited number of variables and the way in which they were worded in the NHANES. For example, combining support from family members and friends into one question about the number of close friends limits our ability to interpret and translate the findings. Investigators in future studies of the relationship between social support and dental visits should use some of the well-validated measures of social support found in the literature. CONCLUSION
Timely or self-care–related dental visits depend on some, but not all, elements of one’s social
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support network. From a clinical standpoint, it may be worthwhile to identify those members of the patient’s network who either facilitate or impede timely or self-care–related dental visits. Engagement of appropriate members of the patient’s social network may help clinicians facilitate timely dental visits. ■ Disclosure. None of the authors reported any disclosures. This work was supported by grants R21DE019538 and R03DE019838 from the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md., to Dr. Liu. The authors thank the agency for its support. 1. Koop CE. Opening remarks. Am J Clin Nutr 2000;72(2 suppl): 503S. 2. Clark DO, Frankel RM, Morgan DL, et al. The meaning and significance of self-management among socioeconomically vulnerable older adults. J Gerontol B Psychol Sci Soc Sci 2008;63(5):S312-S319. 3. Osterberg T, Lundgren M, Emilson CG, Sundh V, Birkhed D, Steen B. Utilization of dental services in relation to socioeconomic and health factors in the middle-aged and elderly Swedish population. Acta Odontol Scand 1998;56(1):41-47. 4. McGrath C, Bedi R. Influences of social support on the oral health of older people in Britain. J Oral Rehabil 2002;29(10): 918-922. 5. Hanson BS, Liedberg B, Owall B. Social network, social support and dental status in elderly Swedish men. Community Dent Oral Epidemiol 1994;22(5 pt 1):331-337. 6. Rickardsson B, Hanson BS. Social network and regular dental care utilisation in elderly men: results from the population study “Men born in 1914”, Malmö, Sweden. Swed Dent J 1989;13(4): 151-161. 7. Nahouraii H, Wasserman M, Bender DE, Rozier RG. Social support and dental utilization among children of Latina immigrants. J Health Care Poor Underserved 2008;19(2):428-441. 8. Berkman LF. Assessing the physical health effects of social networks and social support. Annu Rev Public Health 1984;5:413-432. 9. House JS, Landis KR, Umberson D. Social relationships and health. Science 1988;241(4865):540-545. 10. Gallagher R, Luttik ML, Jaarsma T. Social support and selfcare in heart failure. J Cardiovasc Nurs 2011;26(6):439-445. 11. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. NHANES 2003-2004. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed Dec. 2, 2012. 12. Lim CS, Waite IM, Craft M, Dickinson J, Croucher R. An investigation into the response of subjects to a plaque control programme as influenced by friends and relatives. J Clin Periodontol 1984;11(7): 432-442. 13. Sabbah W, Tsakos G, Chandola T, et al. The relationship between social network, social support and periodontal disease among older Americans (published online ahead of print March 1, 2011). J Clin Periodontol 2011;38(6):547-552. doi:10.1111/j.1600051X.2011.01713.x. 14. Gironda MW, Lui A. Social support and resource needs as mediators of recovery after facial injury. Oral Maxillofac Surg Clin North Am 2010;22(2):251-259.
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