Evidence on Inequalities in Oral Health

Social class and deprivation

In children

There are adequate reports on the inequalities in children’s dental health. Many studies have shown that there are differences in dental caries rate in primary teeth by social class. Around 40% of toddlers in manual social class had decay compared to 16% of those in non-manual social class. Dental Health Survey reported that children attending primary school in socially deprived areas of the UK have more dental caries than those in non-deprived areas. In deprived areas, 60% of 5-year-old and 70% of 8-year-old students had dental caries compared to 40% of 5 year-olds and 55% of 8-year-olds attending schools in non-deprived areas (Watt and Sheiham, 1998). Between 1983 and 1993, dental caries decreased in all social class especially in children aged 12-15 years who are from skilled householders. Therefore, the gap between social classes was 0.9, which then widened to 1.4 (O’Berin, 1994).

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Periodontal diseases and dental trauma also vary by social classes and ethnicity of children. The proportion of children who had trauma of their teeth is much higher in low social class than in the upper classes (O’Berin, 1994). Regarding ethnicity, children who originally are from Asia or Afro Caribbean have more periodontitis than whites (Watt and Sheiham, 1998).

In adults

In adults, inequalities in oral health are less marked than in children but there are marked differences in edentulousness of adults between social classes. In 1988, the national survey found that there was a variation in social classes; for example, 14% of adults in high social classes had no natural teeth compared with 32% of low social classes (Daly et al., 2005). Adults from higher social classes, who are educated and live in urban areas, have less periodontal diseases than those in low social class, who are uneducated and live in rural areas. Besides these facts, females have less periodontal disease than males (Watt and Sheiham, 1998). Oral cancers are rare in the UK. On the other hand, in USA, social and economic instabilities, unemployment and being unmarried may increase the risk of oral cancer more than social disparities. Additionally, Males in deprived areas are more susceptible to oral cancers (Watt and Sheiham, 1998).

Amongst ethnic minorities and gender

Ethnicity as a variable could divert attention from other variables such as incomes and social classes. Females have more restorations in their teeth and less periodontitis because they tend to look after their teeth and visit a dentist regularly more than males. Although, they are more likely to be edentulous than their male counterparts (Watt and Sheiham, 1998).

National regional and districts inequalities

There are regional inequalities in oral health status in children and adults (Locker, 1993). For instance, in the UK high prevalence of dental caries exist among children who live in north east than those in other parts of England (Hind and Gregory, 1995). Inequalities are also reported in adults, 19% of women who live in southwest England are edentulous compared to 33% edentulous women in north (Todd and Lader, 1991). Johnes (2001) states that regional inequalities are mainly related to deprivation.

Determinants of oral health inequalities

Daly et al. (2005) point out that inequalities refer to differences in health and it is unrealistic to find a society in the world with same level of health. For example, old people are more likely to get diseases than the youth. This disparity is considered acceptable because they are due to unavoidable factors such as age and sex differences. On the other hand, health differences which are consequences of avoidable causes such as poverty is considered unacceptable in modern society. Watt and Sheiham (1998) emphasises that the differences in patterns of consumption of non-milk extrinsic sugar (NEMES) and fluoride toothpaste are the main causes of inequalities in oral health. Besides this, social, economic and environmental factors greatly affect the well-being of an individual’s health. Correspondingly, these factors equally determine the oral health of individuals (Marmot and Willkinson, 2003). The emphasis on similarities between determinants of oral health and general health is coherent with the US surgeon general’s review on oral health, namely, that oral health is an intrinsic part of general health (US Department of Health and Human Services, 2000).

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Socioeconomic determinants

Among rich and poor countries, those individuals who are worse off in socioeconomic terms have worse health outcomes and higher mortality rates than those who are better off. People from low socioeconomic groups are more likely to get oral diseases than those of higher SES. For example, the prevalence of chronic destructive periodontal disease is higher in individuals from low socioeconomic status (Hobbled et al., 2003). Armfield (2007) found in his study in Australia that there was a pervasive social inequality in children’s oral health in South Australia. The study also showed that there were strong relationship between socioeconomic disadvantages and high caries experiences. Socioeconomic disadvantages have many forms such as poor housing, low education level or low income. These conditions have cumulative effects on heath, and the longer people live in poor economic and social circumstances, the greater they get stressed and ill and consequently, they enjoy a less healthy life (WHO, 2003).

Poulton (2004) showed from his New Zealand’s birth cohort study that both childhood and adult socioeconomic conditions had major effects on dental health at age 26 years. Moreover, Nicolau et al. (2005) found out that there is an association between socioeconomic conditions at two periods of life and adolescence levels of oral diseases. They also concluded that Brazilian adolescents experiencing adverse socioeconomic circumstances at birth and at the age of 13 had high levels of oral diseases. In addition, they explained the strong relation between socioeconomic status and oral health status. Adverse SES at birth and during bringing up of a child with limited biological supplies reduced the chances of eating healthy food, access to dental services, and decrease the probability of taking on behaviours such as brushing of the teeth and using fluoridated toothpaste, which leads to oral diseases. Another possible explanation is that emotional deprivation and psychosocial stress in childhood cause imbalances in the immune system, which in turn affect the subject’s response to bacterial plaque leading to more oral diseases. Furthermore, adolescents who experience deprivation throughout their lives are malnourished. This results in reduction of saliva secretion, buffering capacity, calcium and immunological defence factors, which in turn makes them more prone to oral diseases (Nicolau et al., 2004).

Social gradient

The impact of socioeconomic position on the presence and seriousness of diseases is not constrained to individuals and people who live in deprivation or poverty, but exhibits at every level of the social hierarchy, causing what is known as the social gradient in health (Lopez et al., 2006). For instance, the higher frequency of periodontal diseases is not restricted to individuals at the bottom of the social hierarchy, but manifests itself as a gradient at every level of the social hierarchy.

Marmot and Wilkins (2005) argue that there is a gradient in health and it presents when relating various measures of health to measure of status. Rate of morbidity and mortality are much lower at higher ranks on the social ladder. Those in the higher ranks are healthier than those who are below them and individuals at the bottom of social hierarchy have twice the risk of illness and early death than those at the bottom. Furthermore, London Health Observatory (2007) elaborate that socioeconomic status contributes largely to an identified gradient, which is directly co-related to the level of the ladder within the socio economic gradient. For example, the prevalence of perceived oral and general health periodontal diseases and ischemic heart disease was higher at low level of poverty –income ratio and education (figure.1). Equally, gingival bleeding, pocket depth and loss of attachment were higher at lower poverty–income ratio and education level (Sabbah et al., 2007). Additionally, this study showed that income and education gradient existed in perceived oral and general health. Periodontal disease in the same person in a nationally representative sample of American adults and the differences across education levels were significant.

Researchers found out that the social structure is the main cause of the most chronic diseases. Therefore, social position is associated with generalized susceptibility to diseases rather than with a specific disease (Marmot and Wilkins, 2006). The second study relating to the social gradient of health found out that unhealthy behaviours are socially patterned and clustered together. Alcohol misuse, smoking tobacco, poor hygiene, unhealthy diet and lack of exercise co-occurred in the same people. Additionally, the clustering behaviours and the divergence of behaviour by social class manifests in adolescents (Peridou et al., 1997).

Lynch et al. (1997) states that “poor people behave poorly.” Individuals who are in lower social class are less likely to be engaged in health promoting behaviours and more likely to be involved in risk related behaviours. Those in deprived poor condition of population have high level of plaque and worse oral hygiene due to habits of not brushing the teeth and smoking.

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The extent of relative deprivation and the processes of social exclusion in a society have a major impact on the health of populations, and this applies to oral conditions. Parental socioeconomic position greatly affects the risk of dental caries in young children in both developed and developing countries (Elsa, 2009). As shown in table 1, poverty and social exclusion were found to be significantly associated with dental caries prevalence. Children living in poor households and those in socially excluded families were 2.36 times more likely to have dental caries than those in wealthier households. On the other hand, children living in poor households were 2.25 times more likely to have dental caries after accounting for social exclusion and sex (Elsa, 2009). Poverty in some region in Africa has resulted into poor nutrition that is associated with certain oral diseases such as oro-facial defects.

Psychosocial pathways

Cassel (1976) considered that psychosocial assets or recourses such as social support and social networks affect general host resistance. Cassel’s theory led to further theories such as the theory of supporting about the role of social support and coping performance on the host resistance, this theory has been applied to dental disease by Wimmer et al. (2002). He found that those who exhibited a high emotion focus and inadequate coping had even higher risks of attachment loss. So the impact of stress on periodontal diseases was regulated by adequate coping skills. Furthermore, an individual’s coping style, their belief in external vs. internal locus of control or stress, may increase the vulnerability to periodontal disease (Davis and Jenkins, 1962). In general, the results from many researchers suggest that the stressful life events increase the risk of infectious diseases and periodontal diseases.

Work, income and education

Work is an essential element to consider as a social determinant of health. It determines the income levels, affects self-esteem and the type of employment may influence an individual’s health. Stress at work plays an important role in contributing to large differences in health. Besides this, Abegg et al. (1999) found a relationship between levels of flexibility of working time and tooth brushing: more flexibility of working time lead to increased tooth cleaning frequency and lower dental plaque. Therefore, work plays an important role in maintaining oral health.

Income is another important determinant of variation in health condition (Naidoo and Wills, 2006). Armfield (2007) argues that income has an impact on oral health through either a direct effect on the material conditions necessary for biological survival or through an effect on social involvement and the chance to control life circumstances. For example, a new study by Sabbah shows the relation between income and periodontal diseases.

Education, on the other hand, prepares children’s lives by enabling them to attain knowledge to live full and healthy lives and plays a role in educating people with regard to the use of services (Armfield, 2007). Studies have proved that low achievers are more likely to have worse oral health behaviours and are 2.3 times more likely to have a high level of oral diseases (Nicolau, 2007)

Lifestyle and behaviours

The aspects of a person’s behaviour, lifestyle, emotional reaction and psychological status can influence his or her dietary manners, physical activity, personal hygiene and habits such as drinking alcohol and cigarette smoking. These increase the risk of diseases and injuries (Sheiham, 2006). Lifestyle plays a very important role in determining the oral well-being of an individual (Sisson, 2007). The daily activities undertaken by an individual, which determine his or her lifestyle, can have great impact on his or her oral health. The two common lifestyle habits of cigarette smoking and alcohol misuse have been attributed to several diseases such as oral cancer and periodontal diseases. In addition, chewing betel quid is another example of unhealthy habit, as it is carcinogenic to the human body and is one of the major risk factors of oral cancer. This habit is very popular among Asian ethnic minorities residing in the UK. In addition, Yemen and some East African countries such as Somalia, Ethiopia and Djibouti consume extensively khat leaves that cause oral cancer (Wamakulasuirya, 2009).

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Social conditions influence these behaviours. People respond to stress and adverse circumstances by practicing these behaviours (Blane, 1985). Therefore, the lifestyle of clustering of behaviours can be shown as ‘the manner in which social groups translate their objective situation into patterns of behaviours’ (Dean, 1988). Those in poor conditions have unhealthy behaviours, which affect their immune system and thereby their resistance to disease (Blane, 1985). Watt and Sheiham (1998), state that the severity and prevalence of periodontal diseases are associated to behaviours such as tooth brushing and smoking. Additionally, they mentioned that social classes are strongly associated with these behaviours. Individuals belonging to low social class are less likely to brush their teeth or use oral cleaning aids and are more likely to smoke and drink alcohol than those of high social class.

Environmental determinants

Poor housing, malnourishment and poverty can influence an individual’s health. Housing conditions affect the health of people. For example, overcrowded, cold, damp housing contribute to infection, stress and respiratory diseases. In addition, traumas of children are associated with lack of play space in the house (Naidoo and Wills, 2006). Sociologists have emphasized that places shape peoples’ lives and affect behaviour and concepts of risk (Bartley et al., 1998). These environmental determinants of health and behaviour are undoubted. For instance, a person’s past social events are recorded into the physiology and pathology of his or her body. Therefore, people’s health carries the marks of the positions they occupy in the social hierarchy. Moreover, Brunner and Marmot (1999) have created models of pathways of biological response to environment, and they have noticed that when people change their environment, the risk for disease changes.

Adequate food supply and good diet are central for promoting oral health. Lack of food and vitamins lead to malnourishment, which in turn lead to oral diseases such as oral cancer. For example, Vitamin A and C are considered to have a protective effect for oral cancer (Smith, 1979).

The above-mentioned determinants are just some of the socioeconomic factors that implicate on the oral health of an individual. The studies of these determinants effects on oral health have been very limited. Newton and Bower (2005) argue that this is attributed to lack of a theoretical framework that puts into consideration the social processes and how their role within the causal pathways leads to oral health complications. However, their study points out that there is a strong relation between the causal pathway and the society’s structure. This is facilitated by the psychosocial and other behaviours characteristics of individuals within the society. In echoing this position, Sisson (2007) posits that controlling social inequalities within oral health has become a great challenge because of limited understanding by health professionals; social health determinants ought to have the first hand priority and consideration for any substantial achievement in this endeavour to be realised.

Appropriate oral health promotion approaches and policies

The previous parts of this essay have shown that oral health determinants are fundamental aspects liable for consideration when combating oral diseases and complications. It is therefore, a prerequisite that before any strategy is made to reduce the inequality in oral health, the societies socioeconomic, environmental and cultural factors are put into consideration. Treatment services and dental health education will never eradicate the underlining causes of oral diseases (Royal Commission, 1979). Many effective reviews have been conducted to assess the effect of educational approach. All these reviews have shown that dental health education alone does not produce long-term behavioural changes (Watt and Shieham, 1998). Therefore, public health strategies should tackle the underlying determinants of oral health through adoption of appropriate approaches such as a common risk factors approach, preventive lifestyle and upstream approaches. In both developed and developing countries, a common risk approach is very effective in achieving significant oral health gains (Sheiham and Watt, 2000).

The common risk factor approach recognizes that chronic diseases share a set of common factors. The fundamental basis of this approach is the importance of focusing attention on changing a small number of factors that have a major impact on many numbers of diseases at a lower cost, greater efficiency, and effectiveness than diseases specific approach. For example, smoking, alcohol, stress, hygiene and exercise are linked to a wide range of diseases such as cancers; heart diseases and diabetes. Therefore, changing these factors will minimize the risk of these chronic diseases as well as oral diseases such as periodontal disease and oral cancer (Watt and Sheiham, 1998). Additionally, one of the principles of health promotion is to work on the entire population, not only on a disease specific to a particular risk group, which is one of the major benefits of this approach. The improvement in general will be evident in the health of the whole population and in groups at high risks. This thereby reduces social inequalities. Besides, the common risk approach is a very appropriate strategy in countries with shortage of oral health personnel because it provides a rational for partnership working. The potential benefits of such a strategy are far greater than isolated intervention (Watt and Sheiham, 1998).

Furthermore, Rose (1992) describes two basic types of preventive approach: the whole population and risk group approach. The risk group approach has two subdivisions: target-population and high-risk approach. The target population approach works on groups of the population that are at greater risk compared to the whole population. Then “A” variation of intervention can be applied: clinical, environmental or developing individual skills. For instance, schools can be identified and action taken to introduce fluoride toothpaste and brushing scheme to the system. On the other hand, high-risk approach focuses on individuals who are at a high risk and screening test has identified them. After the process of identification, preventive support is offered to them. For example, patients who have received irradiation of their salivary glands are susceptible to dental caries, so clinical intervention programme will be applied to prevent them from developing dental caries. However, in the population approach, public health measures are applied to the population to reduce the risk in the whole population. Water fluoridation is a good example of this approach. Everyone on the centralized water supply receives the intervention so that compliance is not a problem. In prevention of oral disease, a combination of whole population and high-risk approach is the best strategy (Rose, 1992).

Lifestyle approach is another strategy in dental public health. People’s behaviours are enmeshed within the social, economic, environmental circumstances. In addition, lifestyles and behaviour have a great influence on oral health. For that reason, it is important to understand the broader context, which determines the patterns of behaviour. For instance, tooth brushing, dietary patterns and visiting the dentist. All these habits are influenced by socioeconomic and environmental factors as well as political measures (Dahlgren, 1993). Therefore, public health strategies should aim at changing the social determinants and efforts should be directed at the underlying determinants of the causes (Rose, 1992). Smoking, for instance, is one of the major risk factors of periodontal disease. Therefore, in order to decrease the rate of smoking, we should understand the social causes of such a habit. Particularly in rich countries, there is a social gradient in smoking: the lower the socioeconomic position, the higher the rate of smoking (Marmot, 2006). Watt (2007) argues that narrowly focused lifestyle intervention methods, which fails to acknowledge and address the underlying social determinants of health inequalities, are victims of blaming nature.

In addition to all the above approaches, upstream approach is another strategy that aims at controlling the source of the problems. Since political, socioeconomic and environmental factors can enhance or impair the oral health, efforts should be directed towards these determinants that cause oral health inequalities in societies (McKinlay, 1974). This puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of health consequences of their decisions and to accept their responsibility for health. Upstream approach suggests that the clinical dentistry focuses on downstream (sick people) without going further, and examines what is making them sick. Tackling the underlying causes of the cases is what the “upstream approach” is all about (McKinley, 1974).

Ottawa Charter for Health promotion

Health promotion policy merges diverse but favourable approaches including legislation, fiscal measures, taxation and organizational change. A harmonized action causes changes to health, income and social policy that foster greater fairness. Collaborative action exists to ensure safer and healthier goods and services, healthier public services and cleaner, more pleasant environment (WHO, 1986). In 1986, Ottawa Charter outlined five principles, which can be adopted to provide a framework to describe remedies and therefore reduce the oral health inequalities.

Building healthy public policy

Legislative policy passed at either national or local level can have a very great impact on health by providing social environment that improves oral health (Watt and Sheiham, 1998). An example of this is cutting down of non-extrinsic milk sugar (NEMS) consumption in terms of frequency and the amount taken. This will be achieved through a national food policy, supported by regional and local initiatives. Such policies need government support to facilitate legislation, fiscal measures, educational and organizational polices. The things to include in such a policy would be nutritional guidelines on the content of nursery school meals and strict guidelines for food in residential houses. Product labelling of (NEMS) content of all products would be needed, as well as supermarkets providing a wide range of low and no sugar products. In Brazil, for example, food polices in state nurseries reduced sugars consumption and improved the nutritional quality of the diet (Rodriquez et al., 1999). A similar policy has been applied in the UK in nurseries children in care and residential places (Caroline walker trust, 1995). Unfortunately, unhealthy food is cheaper than healthy food such as the European Union subsidy. A policy on reduction of the prices of healthy products and increase the prices of unhealthy products will make the healthy choices the easier choices and unhealthy choices the more difficult (Milio, 1986).

Creating supportive environment

Fluoridation of public water supplies is a proven public health measure, which has shown the capacity to reduce caries, particularly among socially deprived communities. Studies conducted in the UK and Australia have shown that water fluoride provides benefits for all social classes, especially to children in lower social class (Slade et al., 1996). Moreover, exemption of value added tax on fluoride toothpaste would facilitate and increase the utilisation of the product particularly among people in deprived areas who are susceptible to caries. This policy is very important because fluoride is the reason for the dramatic decline in caries in the past 20 years (Watt and Sheiham, 1998).

Additionally, health-promoting school is an initiated programme by WHO and it is aimed at achieving a healthy lifestyle through providing supportive environments for the whole school population. It offers safe and health enhancing social and physical environment. Efforts such as school nutrition action groups (SNAG) or school meals campaign are initiatives which provide students with a cheap and appealing nutritious foods and drinks within school canteens and vending machines. Dental professionals should always seek to develop cooperation with oral health providers to create a healthy lifestyle to people.

Developing personal skills

Health education can provide knowledge and awareness on issues concerning oral health. Traditional health education was based upon the theory that acquiring new knowledge (K) would alter attitudes (A) and lead to change in behavioural (B), the so-called KAB model. This simplistic representation (K→A→B) of human behaviour rarely exists in the real world (Daly et al., 2005). Health professionals have focused largely on giving their clients information in an attempt to change their behaviour. Such an approach has however been unsuccessful at securing long-term changes in behaviour (Sprod et al., 1996). Additionally, Sheiham (1999) argue that one importance of health education is helping patients to have confidence in their abilities and to care for their own, otherwise known as self-empowerment. More recently, oral health education has extended its aims to include the development of oral health skills. For example, in Scotland the children have the highest level of caries. To tackle this issue, a randomized controlled trial was taken to examine the efficacy of a supervised tooth brushing in a group of Scottish children. The new feature of this study was that mothers volunteered to supervise tooth brushing. The results of this study showed a significant reduction in caries in the test group as compared with the controls. Teachers, mothers and local authority all can help in educating their students or children about oral health (Watt, 2005).

Reorienting oral health services

Dental care system will play an important role in reducing oral health inequalities if the activity of the system goes beyond the provision of clinical services and the local oral health strategies, which include equity, and targeting of recourses to areas of greatest need. In this regard, population programmes aimed at preventing caries, such as fissure sealant, targeting schoolchildren with high dmft/DMFT indexes are very effective preventive measures that should be encouraged.

Another important issue regarding dental care services is equal access to people in certain localities, those with disabilities, the older as well as the socially disadvantage people. Clinics and health care centres are more in areas where the need for such services is minimal while a few health centres exist in deprived areas where they are mostly needed. Tudor-Hart ‘inverse care law’ describes this situation (Daly et al., 2002). Prescription of free sugar medicines to children can enhance caries reduction. Therefore, it is imperative that medical and pharmaceutical professionals together with pharmaceutical industry understand this and consequently prescribe sugar free medicines to children.

Strengthen community action

This approach recognizes the strengths and capabilities that collective actions can do in fostering healthier conditions for poor communities. In Newcastle and Tyneside, for example, the oral health promotion program is using community link to improve the oral health of poor areas (Watt, 2005). Another example of community development activities and services is the national child oral health demonstration childsmile, which began in Scotland in January 2006. It involves the free distribution of toothpaste and toothbrushes to every child in Scotland on at least six occasions during their first five years. Additionally this programme is focused on children in socioeconomically deprived areas (Shaw, 2009).

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