Contextual and individual determinants of tooth loss in adults: a multilevel study

Abstract

Background: Tooth loss represents a known marker of health inequality. The association between tooth loss and unfavorable socioeconomic conditions is evident when analyzed at an individual level. However, the effects of contextual characteristics on tooth loss need to be better investigated and understood. The objective of this study was to analyze tooth loss among Brazilian adults (35-44 years of age), in accordance with individual and contextual social characteristics. Methods: This was a multilevel cross-sectional study with data from 9564 adult participants from the Brazilian Oral Health Survey-SBBrasil 2010. The dependent variable was the number of lost teeth and the independent variables were grouped into structural (socioeconomic & political context) and intermediary (socioeconomic position, behavioral & biological factors, and health services) determinants. Multilevel Hierarchical Negative Binomial Regression was conducted and the Mean Ratio (MR) was estimated. Results: Brazilian adults lost a mean of 7.57 (95% CI 7.1-8.1) teeth. Among the contextual variables, the number of teeth lost was higher among residents of municipalities with high and medium/low Municipal Human Development Index (MHDI) and in municipalities that did not have public water fluoridation. Among the individual variables, dental loss was higher among those who declared themselves yellow/black/brown/indigenous, were older, who had lower income, who had never visited a dentist, who had used dental services for more than a year and those whose most recent visit to the dentist was due to oral health problems. On the other hand, dental loss was lower among adults with higher education levels and males. Conclusions: The number of missing teeth was associated with unfavorable contextual and individual conditions, which reinforces the need to reduce social inequality and guarantee regular, lifetime access to dental services.

Systematic Review of the Literature on Dental Caries and Periodontal Disease in Socio-Economically Disadvantaged Individuals

“…Considering the number of residual teeth as an outcome, low income was found to be a risk factor of tooth loss. This concept was expressed as the average number of teeth per capita (23.4 SD2.6 vs. 26.7 SD 1.1, p < 0.01; 36,506 participants) [ 151 , 152 ], as the average difference in number of teeth (MD −0.279 [−3.48 to −2.10] p < 0.05; 5084 participants) [ 153 ] and, in addiction, as the probability of having a reduced number of teeth in terms of mean ratio (MR 0.93 [0.93–0.94], p < 0.001; 9564 participants) [ 154 ] or risk ratio (RR0.79 [95% CI 0.75–0.83], p < 0.05) [ 155 ]. The prevalence of severe tooth loss (<10 remaining teeth) also appeared to be conditioned by a low level of education, with similar scores in both men (OR 2.71 [95% CI 2.27–3.24], p < 0.001) and women (OR 3.00 [95% CI 2.31–3.90], p < 0.001) as reported in a study involving 34,975 participants [ 156 ].…”

“…In terms of the number of residual teeth, low-income people were more likely to show fewer teeth than control group individuals (24.48 SD 0.05 vs. 21.81 SD 0.13, p < 0.001; 36,026 participants) [ 152 ]. This increased tooth loss was also expressed in terms of mean difference (MD −0.69 [–1.22 to –0.15], p < 0.05) [ 153 ] and of higher probability (mean ratio 1.97, [CI 1.76–2.20], p < 0.001; 9564 participants) [ 154 ].…”

Individual- and City-Level Socioeconomic Factors and Tooth Loss among Elderly People: A Cross-Level Multilevel Analysis

“…Other research on social inequalities of tooth loss has used different methodological approaches to assess contextual socioeconomic conditions. Some studies have used a single measure of income inequality (e.g., Gini Index) [10,13], while another assessed the relationship between multiple contextual measures and tooth loss at the same time [12,14,15]. Due to possible similarities between the different area-level socioeconomic status measures, one study used component analysis to extract a single factor in order to aggregate different measures of socioeconomic status avoiding multicolinearity [11].…”

“…The relationship between HDI, tooth loss and completed denture need has been shown [12,14,15]. Chalub et al observed that the prevalence rates of four definitions of functional dentition were greater among adults living in cities with very high HDI (≥ 0.800) than those from very low, low and medium (≤ 0.699) HDI [12].…”

“…The possible role of contextual and individual socioeconomic inequalities on tooth loss among adults has been explored. Overall, these studies reported that adults living in socially deprived regions and in areas with higher levels of income inequality had a greater likelihood of having fewer natural teeth than those living in better-off regions [10][11][12][13][14]. However, studies exploring whether contextual social inequalities may influence tooth loss among elderly people are scarce [15].…”