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H E A L T H
Background: The objective of the study was to evaluate the social distribution of dental caries and its determinants
in the province of Turin, an area of 2,300,000 inhabitants in the north of Italy. Methods: A cross-sectional study
was carried out among a representative school-based sample of 11-12 year olds. A total of 734 (84.0% of the
starting sample) students were involved. Two questionnaires were submitted (to students and parents) and the
children received a dental examination. Dietary and hygiene indicators were calculated and the DM FT index (the
number of decayed, missing and filled teeth) was measured using methods recommended by the World Health
Organisation (WHO). The education level of the head of family was used as a proxy of social dass indicator. Univariate
and multivariate analyses were applied to obtain results. Results: Students from disadvantaged families showed: I) a
higher tendency to belong to the higher risk group for oral hygiene (RR primary school/university = 2.78); II) a
lower use of dental prevention (RR=0.40 for use of fluoride tablets and RR=0.43 for local applications of fluoride)
and iii) a higher consumption of sucrose-sweetened foods (RR=1.17%, ns) when compared with children of graduate
parents. The DMFT index was more than double among children whose parents only had a primary school education,
compared with those of graduate parents (3.2 versus 1.5). In addition, the percentage of caries-free children
increased from 16.4 to 59.1% from the lowest to the highest social group. Conclusions: Large sodal differences
are found in caries experience and in determinants of dental decay. Nevertheless, determinants of caries occurrence
seem to explain only a small fraction of inequalities.
-Social differences in health represent, at least for dedental decay and social change similar to that outlined in
veloped countries, a priority field of intervention and
ischaemic heart disease.18 The advantaged social cat1
research. In this field, the interest in studying caries
egories are most able to adopt preventive practices as far
occurrence is that
as they are demonstrated to have a favourable effect on
health, such as a decrease in sucrose consumption, im it can be considered as an early life indicator of the
provement of oral hygiene and, more recently, consump'proneness to inequality' of a specific society and
tion of fluoride. The study of these cases can help in the
the rapid evolution of the natural history of dental decay
design
of policies aimed at promoting dental health at a
in recent years among children in the industrialised
population
level reaching the whole of society. Some
world makes it particularly suitable for applying policies
other
countries,
such as Jordan19 and Uruguay,20 showed
aimed at equity and assessing their effectiveness.
no relationship with social indicators.
Furthermore, inequalities in caries occurrence is particuIn Italy, social inequalities have been reported in mortallarly unethical given that it hits primarily the 'innocent'
ity,21 ill-health,22'23 and the use of health services,23 but
population of children.
there is no published data concerning social differences
Most authors have observed an inverse association bein dental health. The aim of this study was to assess the
tween social indicators and dental health in industrialised
social
distribution of caries experience and some of its
countries: subjects from higher social classes showed a
2 7
89
determinants,
such as dietary risk and preventive praclower occurrence of caries in the USA, " UK, ' Austra10
11
12
13
tices
among
11-12
year olds in the province of Turin
lia, New Zealand, Belgium, Denmark, and Fin14
(2300,000
inhabitants
in Northern Italy).
land. On the other hand, other studies, mostly carried
out in less-developed countries, showed a direct association with social class, in particular in Hong Kong,15 MATERIALS AND METHODS
Israel16 and Greece,17 suggesting a relationship between
A cross-sectional study was carried out among a sample of
11-12 year olds within the state school system in three
* F. F*gglano', F. DI Stanlsbo', P. Lemma , G. Renga
(out of 27) local health authorities (USLs) in the prov1 Department of Public Health, University of Turin, Turin, Italy
ince of Turin. They were chosen to represent the main
Correspondence Fabrizto Fagglano, Department of Public Health,
town
(city of Turin, ^950,000 inhabitants), the suburban
University of Turin, Via Santena Sbis, 10126 Turin, Italy, tel. +39 011 6706558,
fax +39 011 6706551, e-mail: fagg.lartoOmollnette.untto.ft
area (=700,000) and the area of provincial towns
1
95% Cl
Mean
2.66
235-2.97
1.49
DMFT
95% Cl
DMF=0
24.8
21.7-28.1
59.1
n-44
95% Cl
0.83-2.15
95% Cl
43.3-733
1.11-2.56
2.64
95% Cl
41.5
32.1-51.5
20.8
2.03-3.25
95% Cl
16.7-25.6
Primary school
n=220
Mean
95% Cl
p for
trend
3.24
2.61-3.86
<0.001
95% Cl
16.4
11.9-22.1
<0.001
All results arc standardised by centre of study, DMFT means are aUo standardised by age
Table 2 Distribution of die prevalence of the determinants of caries in die study population according to die head of die family's
educational level
Overall
University
n-706
%
High dietary risk
High risk for oral
hygiene
Fluoride
supplements use
Local fluoride
applications
Public services use
95% Cl
n-44
95% Cl
39.1 35.5-42.8
34.1
20.9-50.0
35.4 31.9-39.1
15.9
7.2-30.7
26.6
23.5-30.0
40.9
8.7
6.8-11.1
29.8-36.8
15.9
33.2
18.2
Primary school
ii=220
95% Cl
%
pfor
trend
42.4 33.1-52.5
38.1
32.9-43.6
40.0 33.5-46.8
0.786
31.1
22.7^0.9
33.8
28.8-39.2
43.8 37.2-50.6
0.002
26.7-56.7
41.5
32.1-51.5
28
233-33.2
16.4
11.9-22.1
<0.001
7.2-30.7
8.7-33.3
14.2
8.4-22.6
7.7
5.2-11.2
6.8
4.0-11.2
<0.001
16.0
9.9-24.7
33.3
283-38.7
44.6 38.0-51.4
<0.001
fluoride tablets and of local fluoride applications. In apparent contradiction with this frame, no social differences
were found in the frequency of dietary risk factors, but,
apart from the possible measurement error affecting this
indicator that could have biased the results, this observation seems to confirm the absence of any relationship
found by some other studies. ^
The finding of social differences in exposure to risk factors
could suggest that a global solution for inequity in dental
health should be to promote public health policies focusing preventive actions on lower social categories, in order
to change their habits. This solution seems too simplistic.
The logistic regression analysis presented above confirms
this: adjusted by the determinants of dental decay, ORs
for social class show a limited decrease, remaining the
more important factor explaining differences in caries
risk. Thus, the estimated proportion of dental decay attributable to social class is possibly higher (61.3%) than
that attributable to insufficient hygiene habits (13.3%)
and dietary risk factors (8.3%). Clearly this conclusion
can be partially misleading, because of misclassification
reasons stated above and also because the estimated prevalence of risk factors was measured at the same time as
the dental examination; nevertheless the difference is so
marked that it probably cannot be justified by only misclassification or bias.
Why does the risk factor adjustment not reduce the OR
associated with social class? Several factors can be associated with social variables and play a role in the aetiological pathway of dental decay.
General factors that can modify individual susceptibility
to caries, such as poor nutrition of mothers during
pregnancy and of babies during early life. Some analogies could be found with cardiovascular diseases,
where early life conditions are suggested to be a mediator
of the social class-cardiovascular risk relationship;
similar evidence came from the Whitehall study for
cancer diseases.
Differential prevalence of Streptococcus mutans.
Table 3 Logistic regression analysis using caries-free children as cases and die odiers as controls, with (model 2) and without (model 1)
adjustment for hygiene and dietary risks
Number of
cases/controls
OR
Model 1
95% CI
Model 2
OR
95% CI
Gender
272/93
Girls
Head of the family education
University
258/83
1.06
High school
Secondary school
Elementary school
62/44
266/70
1.21
3.29
184/36
4.21
Boys
Hygiene habits
Low or medium risk
High risk
Dietary habits
Low or medium risk
High risk
18/26
0.74-1.52
1
1.17
0.81-1.69
0.60-2.20
1.77-5.52
0.64-230
1.87-5.79
2.28-7.79
1.15
3.13
3.82
2.05-7.11
332/123
198/52
1
1.55
1.04-2J3
318/113
213/62
0.87-1.83
1.26
The amount of fluorides from sources not directly investigated by the present study, such as toothpaste or
enriched foods. Drinking water fluoridation is the only
major factor that cannot have played a role, given the
extremely low concentrations (<0.1 p.p.m.) in the supply of target populations.
Regardless, the results of this study support the idea that
a reduction in differences in exposure to risk factors,
through the promotion of preventive practices, can just
attenuate but not substantially reduce the social discrimination in canes experience. An alternative approach able to tackle the problem as a whole seems to be
the fluondation of drinking water.36"37 It appears to be the
only practice documented as being effective in substantially decreasing and even eliminating inequalities in
dental decay: in theory, it reaches the whole population
without social discrimination, including the more deprived strata (homeless and nomads), in the long term it
reduces the costs of prevention (fluoridation is cheaper
than individual supplementation of the infant population) and, moreover, it transfers costs from families to the
health service.
We thank Dr Anna Camerlengo, Dr Ectore Mancini and Dr Paola
Fasano for their support in the study organisation and Dr Igor
Grubessich, Dr Lucia Delsante and Dr Nadia Casciano for their
collaboration in collecting data and in performing dental examinations. We thank Hilary Martin for revising the English.
1
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