The Journal of the American Dental Association
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J Am Dent Assoc, Vol 132, No 2, 216-222.
© 2001 American Dental Association
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TRENDS

Community socioeconomic status and children’s dental health



JAMES A. GILLCRIST, D.D.S., M.P.H., DAVID E. BRUMLEY, D.D.S., M.P.H. and JENNIFER U. BLACKFORD, Ph.D.

   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Although a substantial decline in dental caries has occurred among U.S. children, not everyone has benefited equally. The first-ever surgeon general’s report on oral health in America indicates that the burden of oral diseases is found in poor Americans. This study investigates the relationship between community socioeconomic status, or SES, and dental health of children.

Methods. An oral health survey of 17,256 children, representing 93 percent of children residing in 62 Tennessee communities, was conducted in public elementary schools during the 1996–1997 school year. Portable dental equipment was used for examinations, and data from each examination were entered directly into a laptop computer. The authors performed analyses of covariance to examine the relationship between community SES (low/medium/ high) and dental health, controlling for community fluoridation.

Results. Community SES was significantly related to caries experience in the primary teeth, the proportion of untreated caries in the primary and permanent teeth, dental treatment needs, dental sealants and incisor trauma. Overall, dental health was significantly worse for low-SES communities than for medium- and high-SES communities.

Conclusion. The authors conclude that all specific dental indexes used to measure children’s dental health in this study, with the exceptions of caries experience in the permanent teeth and sealant presence, were inversely related to the communities’ SES. The percentage of children with dental sealants was directly related to the community’s SES.

Practice Implications. Further improvements in oral health will necessitate that community-based preventive programs and access to quality dental care be made available to children who are identified as being at highest risk of experiencing oral disease.

Findings from national epidemiologic surveys conducted since the early 1960s provide incontrovertible evidence that a dramatic decline in dental caries has occurred in school-age children in the United States.1–10 The decline was observed initially in 1981 when the results of the National Dental Caries Prevalence Survey were published.4,5 When caries experience findings from the first and third National Health and Nutrition Examination Surveys,3,10 or NHANES I and NHANES III, covering the period of 1971–1994 are compared, it has been found that the mean number of decayed (untreated caries), missing and filled permanent teeth, or DMFT, among children 6 to 18 years of age declined 57 percent. The mean number of decayed and filled primary teeth, or dft, decreased almost 40 percent. Reductions in caries experience have occurred in the primary and permanent teeth of children of both sexes, of all races and for every age, as well as for children above and below the poverty level.3–12

This study clearly suggests that socioeconomic status is an important predictor of dental health.

Despite clear improvements in caries levels, 78 percent of American children experience dental caries by 17 years of age (Mark Macek, D.D.S., Dr.P.H., and Keith E. Heller, D.D.S., Dr.P.H., unpublished data, Oct. 15, 1999), making it the most common chronic disease of childhood.13 It is estimated that 25 percent of U.S. children 5 to 17 years of age account for approximately 80 percent of the total caries experience.8,9 An increasingly disproportionate burden of the disease is found in indigent children and those of racial or ethnic minority groups who are least able to access preventive and restorative dental services.14–16 These disparities were emphasized in the surgeon general’s report, "Oral Health in America," released in May 2000.17

One unusual aspect of this survey was that the consent procedure resulted in a response rate that was substantially higher than what typically would be observed in oral health surveys.

Early national oral health surveys of children and adolescents showed a positive relationship between socioeconomic status, or SES, and caries experience.1–3,18 More recent surveys indicate that this association has reversed.4–12,15,18–22 In fact, children who are at or below the poverty level experience a higher average number of untreated carious primary and permanent teeth than do children who are above the poverty level.11,12

From November 1996 to May 1997, public health dental staff members in Tennessee conducted a dental health survey of 5- to 11-year-old children residing in 62 communities. We developed the survey because of the need for current caries experience and treatment needs data for community-specific public health planning purposes. In this article, which is based on data collected during the survey, we examine the association between SES and specific indicators of dental health status.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Study design. The 62 communities included in the survey had stable population bases with less than a 3 percent increase in the 5- to 11-year-old population between 1990 and 1996. Almost all of the children who lived in these communities attended the one public elementary school located in each community. We examined approximately 93 percent of all of the children enrolled in the selected schools. Therefore, we considered this survey to be a census of 5- to 11-year-old children residing in each community.

We used the following criteria to select communities for inclusion in the survey: the community water system’s fluoridation status, the community’s SES, geographic location (urban or rural) within the county and number of children enrolled in kindergarten through sixth grade in public elementary schools. We obtained permission from all of the school system’s superintendents and school principals before conducting the oral health screenings.

To maximize the response rate, children participated in the survey without individual parental consent. If school officials deemed individual parental consent necessary specifically for this survey, we excluded these schools as a potential survey site. At the request of the examiner (D.E.B.) and the discretion of school officials, parents were notified before the survey began to give them an opportunity to exclude their children. A few children were excluded from the survey because of objections from their parents, absence from school or their unwillingness to participate.

One public health dentist, who was experienced in conducting oral health surveys, examined all of the children. Examinations were conducted at the schools using a portable dental chair and fiber-optic dental light. The diagnostic criteria for the measurement of caries experience were comparable with those originally adopted by the Caries Measurement Task Group at the Conference on Clinical Testing of Cariostatic Agents, sponsored by the American Dental Association in 1968.23 The main exception to these diagnostic criteria was that caries in this survey was diagnosed by clinical visual examination only. There was no tactile component for caries detection, and no radiographs were made.24,25

Measures. We calculated all dental health measures at the community level. We assessed dental health in primary teeth for children aged 5 to 9 years and dental health in permanent teeth for the full sample of 5- to 11-year-olds. The indexes used to gauge dental health status were mean caries experience in the primary (decayed and filled surfaces, or dfs) and permanent (decayed, missing and filled surfaces, or DMFS) teeth; proportion of untreated caries to all decayed and filled surfaces in the primary (d/dfs) and permanent (D/DMFS) teeth; percentage of children with dental treatment needs defined as restorative needs, exodontic needs or both; percentage of children with urgent treatment needs, defined as dental infection, pain, trauma or extensive carious lesions; percentage of children with a dental sealant applied to at least one permanent tooth; and percentage of children with incisor trauma, defined as visually detectable trauma to at least one permanent anterior tooth. For the dental sealant measure, only the 35 communities that had not participated in a Tennessee Department of Health, or TDH, school-based sealant program were included. There were no differences in the other dental health measures between communities participating in the TDH program and those that did not.

We established a community’s SES by determining the children’s levels of participation in the federally subsidized school lunch program at the local elementary school. The standardized eligibility guidelines developed by the U.S. Department of Agriculture for including children in the school lunch program are based on strict requirements used to determine family income, including income verification.26 Consequently, school lunch participation status serves as a reliable and valid measurement of SES and has been used as a substitute for SES in previous studies.18,19

Strict confidentiality requirements associated with participation in subsidized school lunch programs prohibited the examiner from obtaining socioeconomic information about individual children; the information, however, was obtainable at the community level in aggregate form. From 34 to 96 percent of the children participated in the school lunch program in different communities. The overall average was 63 percent, which is higher than the Tennessee average of 40 percent27 and the national average of 56 percent.28 Therefore, the communities in this sample represent a moderately low SES population.

We categorized communities as high, medium or low SES, based on subsidized school lunch program participation. Category guidelines were approximately one standard deviation from the mean, providing for an extreme-groups approach in which the majority of the sample is in the middle category. We defined high-SES communities as those with 45 percent or less of the children participating in the subsidized school lunch program, low-SES communities as those with 75 percent or more of the children participating in the subsidized school lunch program and medium-SES communities as those with 46 to 74 percent of children receiving a subsidized school lunch. Additional descriptive information provided in the table indicates that there were no significant differences in average age, sex or ethnicity by SES. There were, however, significant differences in fluoridation status by SES.

Analytic method. We used a computer software package (SAS for Windows, Version 8, SAS Institute) to conduct statistical analyses. We used analyses of covariance, or ANCOVA, to determine the relationship between SES and each dental health index, controlling for fluoridation status; ANCOVA provides a statistical method for examining the effect of an independent variable while controlling for the effect of other variables. In this sample, fluoridation status of the community was related to both SES and dental health status. By th use of an ANCOVA, the effect of fluoridation status could be controlled, allowing for a test of the effect of SES on dental health status. We used the least-squares means procedure in SAS to compute means adjusted for fluoridation status and to test for statistically significant differences among means. For all analyses, we used an {alpha} = .05 to test for statistical significance.


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Caries experience. The mean caries experience scores (dfs and DMFS) were 7.86 for primary teeth and 0.89 for permanent teeth. There was a significant effect of SES on dfs, F2,58 = 4.81, P = .01. A comparison of mean dfs and DMFS scores among SES groups is shown in Figure 1Go. For primary teeth, low-SES communities had a mean score of 9.21, which was significantly higher than scores of 7.75 and 6.40 in medium-and high-SES communities, respectively. For permanent teeth, there were no significant differences in scores among the three SES levels.



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  		Figure 1. Mean caries experience in primary and permanent teeth by community socioeconomic status.

 
Proportion of untreated dental caries. The mean proportion of untreated dental caries was 25 percent for primary teeth and 7 percent for permanent teeth. Figure 2Go shows the mean proportion of untreated dental caries for primary and permanent teeth by community SES. There was a significant effect of SES on the d/dfs ratio, F2,58 = 20.93, P = .0001. The mean d/dfs ratio was significantly different for all levels of SES. The mean d/dfs ratio was highest for low-SES communities (36 percent) and lowest for high-SES communities (17 percent).



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  		Figure 2. Proportion of untreated caries in primary and permanent teeth by community socioeconomic status.

 
There also was a significant effect of SES on the D/DMFS ratio, F2,58 = 10.08, P = .0002. The mean D/DMFS ratio was significantly different for all SES levels. The D/DMFS ratio of 11 percent for low-SES communities was higher than the D/DMFS ratio of 7 percent for medium-SES communities and the D/DMFS ratio of 4 percent for high-SES communities. In addition, medium-SES communities had a significantly higher D/DMFS compared with high-SES communities. Thus, the treatment of dental caries in both primary and permanent teeth was significantly related to SES.

Treatment needs. We determined each child’s need for dental treatment. The average dental treatment needs by community SES are presented in Figure 3Go. Overall, 36 percent of children had treatment needs, with almost 11 percent having urgent treatment needs. Overall treatment needs differed significantly by SES, F2,58 = 22.83, P = .0001, and we found significant differences between all SES levels. Low-SES communities had the highest treatment needs at 49 percent. For medium-SES communities, the treatment need was 34 percent, which was higher than the 26 percent treatment need found in high-SES communities.



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  		Figure 3. Percentage of children with dental treatment needs by community socioeconomic status.

 
Urgent treatment needs also differed significantly by SES, F2,58 = 17.20, P = .0001. Sixteen percent of children in low-SES communities had urgent treatment needs, while 8 percent of children in medium-SES communities and 5 percent in high-SES communities had urgent treatment needs.

Sealant status. In the 35 communities that did not participate in a TDH sealant program, 18 percent of children had sealant on at least one permanent tooth. There were significant differences in sealant status by SES group, F2,58 = 4.56, P = .02. In Figure 4Go, the percentage of children with dental sealants by community SES is presented. The 11 percent of children with sealants in low-SES communities was significantly different from that of both medium-SES communities (18 percent) and high-SES communities (22 percent). There was no statistical difference in percentages between medium- and high-SES communities. Since we did not include more than one-half of the communities (mostly low-SES) in our analyses, these findings represent a conservative estimate of the effect of SES on this measure of preventive care.



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  		Figure 4. Percentage of children with dental sealants by community socioeconomic status.

 
Incisor trauma in permanent teeth. Incisor trauma was present in 7 percent of children in the communities. There were significant effects of SES on incisor trauma, F2,58 = 3.60, P = .03. The percentage of children with incisor trauma for each community SES is shown in Figure 5Go. The percentage of children with incisor trauma was lower for high-SES (5 percent) and medium-SES (6 percent) communities than for low-SES communities (8 percent). Thus, children from low-SES communities were most likely to have trauma to their permanent anterior teeth.



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  		Figure 5. Percentage of children with incisor trauma by community socioeconomic status.

 

   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
This study clearly suggests that SES is an important predictor of dental health. Regardless of the specific design, measurement or sample population, studies conducted after 1980 have consistently shown an inverse relationship between SES and dental caries in children.18–21 Findings from NHANES III10 showed a 38 percent lower mean dft score for 6- to 10-year-old children who are above the poverty level compared with 6- to 10-year-old children who are at or below the poverty level. Mean DMFT scores for 6- to 11-year-old children, however, showed no difference based on poverty level. Results of the current study showed a 31 percent lower mean dfs score for 5- to 9-year-olds and a 14 percent lower mean DMFS score for 5- to 11-year-olds residing in high-SES communities compared with children in the same age categories living in low-SES communities.

We found that community SES was significantly related to all specific dental indexes used to measure children’s dental health in this study, except for DMFS. We expected an SES effect on DMFS. It is likely that SES affects caries experience for the permanent teeth as well; however, the effect may be seen only in adolescents and adults after the permanent teeth have been exposed to the environment for a longer period.30

One unusual aspect of this survey was that the consent procedure of parental notification vs. individual parental consent resulted in a response rate that was substantially higher than what typically would be observed in oral health surveys. This fact is critical, because it has been our experience that children with the highest caries levels and greatest treatment needs generally are those least likely to return individual consent forms and participate in health surveys. We do not recommend that a census be conducted in lieu of probability sampling. In this particular study, data collection was just one aspect of a large dental health project involving all 5- to 11-year-olds in these communities.

Since the sampled communities represented a moderately low-SES population, the SES differences reported here probably are more conservative than estimates expected from a full range of SES communities. In this restricted range, the differences still were consequential and imply that even within a socioeconomic category the degree of affluence has an effect on dental health.

One limitation of this study was that the sample did not include a sufficient proportion of minority children to allow us to examine the relationship of SES, race and dental caries. Antithetically, the ability to remove race as a factor, while demonstrating significant differences in dental health based on SES alone, is notable.

What is it about lower SES that results in poor dental health? Although we did not measure it in this study, SES probably is related to one or more intervening variables often referred to as "barriers to care" that have a direct effect on dental health. Patient barriers to dental care have long been recognized; they include economic, geographic, educational, cultural, social and psychological (anxiety and fear of pain) barriers.30

Having a low income, the high price of dental services and lack of dental insurance coverage play major roles in patients’ use of dental services. Children from low-income families are less likely than children from higher-income families to have access to and to use dental services.31 Even when the financial barrier is removed, only a small proportion of low-income children who theoretically have access to dental services (by virtue of eligibility for early and periodic screening, diagnosis and treatment under Medicaid) ever receive such services.32

It is reasonable to assume that children from low-income families also are less likely to have benefited from preventive products and services, such as dental sealants, dietary fluoride supplements, professionally applied topical fluoride gels, fluoride varnishes and dentifrices.18,19,33 This study demonstrated that a substantially smaller percentage of children in low SES communities had a protective dental sealant applied to their permanent teeth compared with children in high SES communities.

There is little argument that a more equitable distribution of public health finances is a necessary first step for reducing economic barriers. Authorities estimate that only 0.5 percent of Medicaid expenditures fund children’s dental care.13,32 Increased reimbursements that encourage substantial participation of private dentists in publicly funded programs may help eliminate economic barriers and improve access.34,35 Findings, however, suggest that increased reimbursements alone do not translate into proportional increases in use by beneficiaries.13

Strategies for eliminating or overcoming other barriers also are crucial. Active involvement of stakeholders in both the private and public sectors of a community is necessary to make this happen. It has been demonstrated that county and regional health councils have been extremely effective in helping solve health problems at the local level.36 Unfortunately, oral health services have been perceived as discretionary or optional, and oral health proponents generally have been unsuccessful in convincing consumers, legislators, health policy-makers and program administrators about the importance of oral health to general health and well-being.35


   CONCLUSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
This study revealed that children from low-SES communities had worse dental health than did children from high-SES communities. They had higher dental caries experience, higher dental treatment needs, a higher prevalence of incisor trauma and a lower prevalence of dental sealants. Classification of a community’s SES by the level of participation of its children in the federally subsidized school lunch program makes it possible to determine the risk of developing dental caries and sustaining dental injury. Knowing the caries experience, socioeconomic distribution of caries and treatment needs of a population is beneficial in planning, implementing and evaluating programs to facilitate access to preventive and clinical dental care. In times of fierce competition for limited resources, it provides justification for public health officials to use resources where they will have the greatest effect on reducing dental disease and injury.

Dental caries is a preventable and treatable disease. This study corroborates the results from other studies that have shown dental disparities among children based on SES. Now that the national health focus is on oral health, these studies take on greater relevance. The surgeon general’s report, supported by a body of evidence that underscores existing disparities, should serve as a catalyst for mobilization and change. There is a fundamental need to make a stronger case in support of oral health services for all children, especially disenfranchised children who suffer the greatest burden of oral diseases.


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  		TABLE DEMOGRAPHIC PROFILE OF EAST TENNESSEE COMMUNITIES BY SOCIOECONOMIC STATUS.

 


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  		Dr. Gillcrist is the director, Oral Health Services, Tennessee Department of Health, Cordell Building, 5th Floor, 425 5th Ave., North Nashville, Tenn. 37247. Address reprint requests to Dr. Gillcrist.

 


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  		Dr. Brumley is the South Central Regional oral health director, Tennessee Department of Health, Columbia.

 


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  		Dr. Blackford is the director, Information Systems and Research, Vanderbilt Mental Health Center, Vanderbilt University, Nashville, Tenn.

 


   REFERENCES
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
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