Title

Author(s)

The association between socioeconomic status and dental

caries in preschool children: a systematic review

Poon, Pui-lok.; .

Citation

Issued Date

URL

Rights

2011

http://hdl.handle.net/10722/145761

The author retains all proprietary rights, (such as patent rights)

and the right to use in future works.

The Association between Socioeconomic

Status and Dental Caries in Preschool
Children:
A Systematic Review
by
Dr. Poon Pui Lok
B.D.S. H.K.; F.R.A.C.D.S.; M. Paed. Dent. RCS (Edin)

A project submitted in partial fulfilment of the requirements for

the Degree of Master of Public Health
at The University of Hong Kong
August 2011

Abstract of the project entitled

The Association between Socioeconomic Status and Dental Caries in

Preschool Children: A Systematic Review
Submitted by

POON Pui Lok

for the degree of Master of Public Health
at The University of Hong Kong
in August 2011

Dental caries in preschool children is a major public health problem in both

developing and developed countries. Evidence shows that dental caries in primary
dentition is strongly related to caries in permanent dentition. Among the possible risk
factors for dental caries, socioeconomic status (SES) is at the top of the list.
The objectives of this review were to systematically identify relevant studies
from 2 electronic databases (Medline and PubMed) and to examine the consistency
and variability of the association between SES and dental caries for preschool
children. The effects of using different SES measurements, namely, individual SES
indicators and composite SES indices, to establish the association were assessed and
discussed. The quality and limitations of the studies were also highlighted.
The review showed that the major individual SES indicators with significant
effects on caries were parent/caregiver education level, income level, fathers
occupation and kindergarten tuition fees. The inverse association was found to be
significant and consistent when composite SES indices were used. However, the
review revealed that of the available SES measurement methods, including both
individual-based and area-based approaches, none was ideal. While a perfect method
has yet to be developed, the available methods are the best proxies for determining the

SES of an individual in epidemiological studies.

It is always beneficial to learn from others and so improve our own work. The
results of this review can help to generalise the association between SES and dental
caries in preschool children to the circumstances in Hong Kong, where income
inequality is one of the major social problems. It would be advisable for Hong Kong
to perform its own research in this area and establish policy directions based on the
results. These policies may include extending oral health services to the population at
an early stage and diverting more resources to less-privileged children. It is believed
that additional areas of improvement could be derived from Hong Kongs own
research in this area.

Declaration

I declare that this project represents my own work, except where due
acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a
degree, diploma or other qualifications.

Signed

............................................................................................

Poon Pui Lok

Acknowledgements

I would like to express my deepest thanks to Dr. Dennis IP for his support and
guidance in preparing this project.

My greatest gratitude also goes to all the teaching staff of the School of Public
Health for their enlightenment throughout the course.

Last but not least, many thanks to my wife, Leona, my daughter, Chloe, and my
fellow classmates for their unfailing support and encouragement at all times.

ii

Contents

Declaration ....................................................................................................................i
Acknowledgements .......................................................................................................ii
Table of Contents .........................................................................................................iii
Figure/Table..................................................................................................................vi
Abbreviations ...............................................................................................................vii

CHAPTER 1 - INTRODUCTION ........................................................................................................ 1

1.1

BACKGROUND....................................................................................................................... 1
1.1.1 Dental Caries in Preschool Children ..................................................................................... 1
1.1.2 Early Childhood Caries in Western Countries ....................................................................... 2
1.1.3 Early Childhood Caries in China and Hong Kong ................................................................ 2

1.2

COMMON RISK FACTORS FOR DENTAL CARIES ........................................................ 3

1.3

STUDY OF THE SOCIAL INEQUALITY FACTOR IN DENTAL CARIES..................... 3

1.3.1 Diagnostic Criteria and the Use of the Caries Index to Quantify the Dependent
VariableDental Caries ................................................................................................................. 4
1.3.2 Measurement of Independent Variable - Socioeconomic Status ............................................. 4
1.3.3 The Knowledge Gap ............................................................................................................... 5

1.4

AIM AND OBJECTIVES ........................................................................................................ 5

CHAPTER 2 METHOD ..................................................................................................................... 6

CHAPTER 3 RESULTS ...................................................................................................................... 7
iii

3.1

STUDY SELECTION .............................................................................................................. 7

3.2

SUMMARY OF STUDIES INCLUDED ................................................................................ 8

3.3

PREVALENCE OF DENTAL CARIES IN PRESCHOOL CHILDREN .......................... 11

3.4

INDIVIDUAL SOCIOECONOMIC STATUS VARIABLE AND THE

PREVALENCE/SEVERITY OF DENTAL CARIES IN PRESCHOOL CHILDREN ................... 11

3.4.1 Parent/Caregiver Education Level ....................................................................................... 11
3.4.2 Income Level ........................................................................................................................ 12
3.4.3 Fathers Occupation............................................................................................................. 12
3.4.4 Kindergarten Tuition Fees ................................................................................................... 13
3.5

COMPOSITE INDICES OF SOCIOECONOMIC STATUS AND THE

PREVALENCE/SEVERITY OF DENTAL CARIES IN PRESCHOOL CHILDREN ................... 13

3.5.1 Scottish Index of Multiple Deprivation Score (SIMD) ......................................................... 13
3.5.2 Social Vulnerability Index (SVI) ........................................................................................... 14
3.5.3 Neighbourhood Deprivation Score ...................................................................................... 14
CHAPTER 4 - DISCUSSION .............................................................................................................. 14
4.1

INVERSE RELATIONSHIP BETWEEN SES AND DENTAL CARIES IN

PRESCHOOL CHILDREN ................................................................................................................. 14

4.1.1 Individual SES variables ...................................................................................................... 15
4.1.2 Composite SES indices ......................................................................................................... 16
4.2

QUALITY OF THE STUDIES .............................................................................................. 16

4.3

LIMITATIONS OF THE STUDIES ..................................................................................... 17

4.3.1 Caries Diagnosis Criteria .................................................................................................... 17
4.3.2 Measurement of SES ............................................................................................................ 18
iv

4.3.3 Review Limitations ............................................................................................................... 19

CHAPTER 5 - CONCLUSION ........................................................................................................... 19
5.1.1 Implications for Future Research ......................................................................................... 20
5.1.2 The Way Forward ................................................................................................................. 21
REFERENCES ..................................................................................................................................... 22

Figure/Table

Figure 1
Flow diagram of study selection

........................................................

Table 1
Summary of included studies evaluating

...........................................

the association between SES and dental caries

in preschool children

vi

Abbreviations
BASCD
CI
d1mfs
d1mft
d3mft
dmfs
dmft
ECC
ft
ICDAS
MeSH
mt
NHANES
NIDCR
OHS
OR
ROC
sECC
SES
SIMD
STROBE
SVI
WHO

British Association for the Study of Community Dentistry

confidence interval
decayed (non-cavitated), missing, filled surfaces
decayed (non-cavitated), missing, filled teeth
decayed (cavitated), missing, filled teeth
decayed, missing, filled surfaces
decayed, missing, filled teeth (primary teeth)
early childhood caries
filled teeth
International Caries Detection and Assessment System
medical subject heading
missing teeth
National Health and Nutrition Examination Survey
National Institute of Dental and Craniofacial Research
Oral Health Survey
odds ratio
relative operating characteristic
severe early childhood caries
socioeconomic status
Scottish Index of Multiple Deprivation Score
Strengthening and Reporting of Observational Studies in Epidemiology
Social Vulnerability Index
World Health Organization

vii

CHAPTER 1 - INTRODUCTION
1.1 BACKGROUND
1.1.1 Dental Caries in Preschool Children
According to the World Health Organization (WHO), the presence of dental
caries is a public health problem for both developing and developed countries.
Approximately 60%90% of school-aged children and a vast majority of adults in
industrialised countries suffer from dental caries (1). Dental caries is defined as the
localised destruction of susceptible dental hard tissues by the acidic by-products of
the bacterial fermentation of dietary carbohydrates (2).
Early childhood caries (ECC) not only causes pain to children but also affects
their general well being as well as their growth and development. Moreover, the
difficulty in behavioural management during dental treatment for preschool children
is sometimes very frustrating to patients, parents and dentists. Quite often, general
anaesthesia is required to complete the treatments. It has been reported that oral
disease is the fourth most expensive disease treated in most industrial countries and
accounts for approximately 5%10% of the public health expenses in these countries
(1). Furthermore, studies have demonstrated that previous caries experience is a
strong predictor of future disease (3-5).
As such, finding a way to identify the causes of dental caries in early childhood
may effectively reduce childrens suffering and ultimately minimise public spending
on oral health.

1.1.2 Early Childhood Caries in Western Countries

Studies and surveys around the globe have shown that dental caries in preschool
children remains a major public health problem in western countries. In the 2005/6
survey by the British Association for the Study of Community Dentistry (BASCD),
the overall prevalence of caries among 5-year-old children in Great Britain was
39.4% (6). The Third National Health and Nutrition Examination Survey (NHANES
III) in the United States (US) found that 18.7% of 2- to 5-year-old children had at
least one untreated dental cavity during 19881994. If household income was
stratified, the prevalence of caries increased to 29.7% in the most deprived group.
Data from the same survey for 19992004 showed caries had a major impact
not only on disadvantaged groups but also on some traditionally low-risk groups of
children (7, 8).
1.1.3 Early Childhood Caries in China and Hong Kong
In China, the incidence of dental caries among 5-year-old children in 2002 was
found to be alarmingly high (76.6%) in the results of the second national survey (9).
In Hong Kong, according to the Oral Health Survey 2001 (OHS 2001) conducted by
the Department of Health (10), 51% of the surveyed preschool children suffered
from dental caries, despite the fact that universal water fluoridation has been used in
Hong Kong since 1961 (11). While the updated results from the 2011/12 Oral Health
Survey are pending, studies from the University of Hong Kong have shown that the
prevalence of dental caries for preschool children was approximately 35% in 2009
(12). This study also revealed that the severity of dental caries in this age group
varied with the childrens sociodemographic background, a finding that was also
reported by Chu et al. in their 1999 study (13).

1.2 COMMON RISK FACTORS FOR DENTAL CARIES

Although the pathogenesis of dental caries is well understood because of
multiple contributing factors in its aetiology, merely understanding the biological
background of the disease cannot effectively control it. A systematic review
examining the risk factors for dental caries in young children has shown that 20 out
of the 106 significant risk factors identified were sociodemographic factors. These
factors were preceded only by dietary factors, parental oral health and enamel
hypoplasia (14). Selwitz et al. believed that the factors implicated in caries initiation
and progression were dominated by personal and social factors, such as
sociodemographic status, education and income (2). The U.K. National Clinical
Guidelines in Paediatric Dentistry categorised dental caries risk factors into general
and local factors. Low socioeconomic status is considered one of the risk factors
with the same importance as high sugar consumption and poor oral hygiene (15).
Thus, it is worthwhile to study the relationship between social factors and dental
caries in preschool children.

1.3 STUDY OF THE SOCIAL INEQUALITY FACTOR

IN DENTAL CARIES
The social inequality factor in dental health, particularly dental caries, has been
studied and reported for decades. It is generally agreed that there is an inverse
relationship between socioeconomic status (SES) and the prevalence and severity of
dental caries. This situation is significant for children in both developing and
developed countries (16-18). According to Reisine, the inverse relationship between
SES and dental caries for children younger than 6 years of age was fairly consistent
but not as significant as the relationship in the 6- to 11-year-old age group (16). It is

conceivable that the consistency of the relationship and the magnitude of the effect
are dependent upon the accuracy of the definition and measurement of the dependent
(dental caries) and independent (SES) variables. While the relationship between
dental caries and SES has been established, consistency in measuring and comparing
the causal effect is difficult. The following section introduces some widely used
methods for the measurement of the variables, although each method has limitations.
1.3.1 Diagnostic Criteria and the Use of the Caries Index to Quantify the
Dependent VariableDental Caries
The differences between the various diagnostic criteria for caries range from
their definitions of caries to the use of dental instruments. Thus, the application of
different criteria suggests different levels of disease. Inconsistency by researchers in
applying the pre-set diagnostic criteria also introduces variation into the results.
Although the decayed, missing, filled teeth (dmft) index has been commonly
employed since 1938 (19) and has been well received in dental epidemiology as a
measurement of dental caries, its use is not without limitations, such as the
assumption that the missing and filled teeth are due to caries. Furthermore, this index
may overestimate the severity of the disease (20).
1.3.2 Measurement of Independent Variable - Socioeconomic Status
Traditionally, SES can be measured by using individual-based attributes, such
as education, occupation and income, or by using area-based composite indices,
which can be viewed as the aggregated information of the individuals in a locality
(21). Oakes and Rossi suggested that SES should be viewed as a function of material
capital, human capital and social capital. They commented that using any individual
variable as a proxy for measuring SES cannot completely reflect the social and

economic forces that affect health (22). Braveman et al. also cautioned that different
SES measures should not be assumed to be interchangeable. Standard measures,
such as years of schooling, cannot truly reflect an individuals education level or
credentials received (23). Another approach to measuring SES is to use a composite
index, which is usually composed of a large group of SES variables that are assigned
different weights. In many countries, household addresses are assigned a particular
post-code. With the information on an individuals post-code, a SES score can be
allocated to that person or family. Although composite indices, which include
multiple SES measurements, might overcome the drawbacks of individual-based
methods noted by Oakes and Rossi and might prevent recall bias caused by
questionnaires, it is questionable whether the indices ability to accurately represent
the studied individuals was validated before application (23). Thus, individuals may
be misclassified because of ecological fallacy (21).
1.3.3 The Knowledge Gap
Little has been reported in the dental literature about the variability of the
association between SES and dental diseases when using different SES
measurements in epidemiological studies in different settings. Unless proven, the
applicability of the study results to the local community remains uncertain.

1.4 AIM AND OBJECTIVES

The objectives of this study are to systematically review the literature and to
assess the consistency and variability of the association between SES and dental
caries in preschool children by using different SES measurements in different
settings. It is hoped that this review will provide scientific evidence that the results

of these studies can be applied to the local community and that new insights and
directives can be generated and translated into policies for better resource allocation
and enhanced efficiency in the provision of oral health services for the targeted
group.

CHAPTER 2 METHOD

By conducting a medical subject headings (MeSH) search using socioeconomic

factors AND dental caries, literature on the topic was identified in 2 electronic
databases, Medline and PubMed. The periods searched were limited to 19902011
for Medline and from 1 January 1990 to 30 April 2011 for PubMed. Because of time
limitations, manual searching and the gathering of unpublished reports were outside
the scope of this review.
Studies with subjects younger than 2 years and older than 5 years were
excluded, and reviews, conference papers and personal communications that were
not original studies were also excluded. Studies that were purely descriptive and
those that did not report odds ratios (OR), 95% confidence interval (CI) and/or
p-values were also excluded from this review.
Finally, inclusion criteria for the remaining studies included the relevance of the
article; at least one socioeconomic variable as the independent variable; an outcome
measure for dental caries that included the prevalence of dental caries and dental
caries indices such as dmfs, dmft or equivalent variations of the index; and studies

showing OR as the measurement of the risk due to exposure.

The results of the selected studies were synthesised, and the quality of the
studies was assessed with reference to the Strengthening and Reporting of
Observational Studies in Epidemiology (STROBE) (24, 25).
Because of the nature of this project, I was the only person who performed the
study selection for this systematic review, which might have introduced bias. As such,
when there was doubt in determining whether an article should be included, I sought
advice from my project supervisor in an attempt to minimise bias.

CHAPTER 3 RESULTS
3.1 STUDY SELECTION
There were 453 potentially relevant papers identified from the databases; of
these, 356 were excluded in the first round of examination after reviewing the titles,
keywords and abstracts. The reasons for exclusion included studies that were not
relevant to our research questions, subjects who were not preschool children or
studies that did not meet the other inclusion criteria. After in-depth examination of
the remaining papers, 15 papers remained for the review. The exclusion process is
illustrated in Figure 1.

453 potentially relevant

papers identified from
Medline and PubMed

356 papers excluded as they

were not relevant to the
research question or did not
meet the inclusion criteria

97 papers retrieved for

in-depth evaluation
82 papers excluded as they
were not relevant to the
research question or did not
meet the inclusion criteria
15 papers used for
systematic review analysis
Figure 1. Flow diagram of study selection

3.2 SUMMARY OF STUDIES INCLUDED

All studies were cross-sectional studies and were performed in both developing
and developed countries. These studies included 4 from Europe (26-29); 3 from
South America (30-32); 2 each from Asia (33, 34), Australia (35, 36) and the Middle
East (37, 38); and 1 each from Scandinavian countries (39) and the US (40). Among
the studies, 2 were works on secondary data collected by the Copenhagen Public
Dental Care Service (39) and the School Dental Service of South Australia (36). Two
more studies were national surveys conducted in Scotland (27, 28), and the rest were
studies performed on selected samples. Because some of the studies were conducted
on subjects with a wider range of ages, the actual number of subjects who met the
inclusion criterion of being 25 years old was computed. For independent variables
(SES), most researchers have included more than one SES variable, except Traebert
et al. and Ferro et al., who examined only one variable (29, 30). All studies reported
prevalence and caries index dmft (decayed, missing, filled, teeth) or dmfs (decayed,
missing, filled, surfaces) as the measures of occurrence and severity of the disease.
A summary of the included studies is presented in Table 1.

Table 1. Summary of included studies evaluating the association between SES and dental caries in preschool children
Source

Age range

Sample size

No. of examiners

Calibration between
examiners

Outcome measures

Caries diagnosis
criteria

SES variables

Odds ratio (95% CI)

or (p-value)

Jin et al. 2003

(Korea)

24 59 months

268

1) prevalence
2) dmft

NIDCR

1) father education
2) mother education
3) mother
employment
4) family income

1) father education:
1.982
(0.26514.814)
2) mother
education: 1.858
(0.24614.024)
3) mother
employment: 1.142
(0.4612.829)

Traebert et al. 2009

(Brazil)

3 5 years

347

1) prevalence
2) dmft

Not mentioned

1) Maternal
schooling

1) maternal
schooling < 8: 3.22
(1.163.96)

Willems et al. 2005

(Belgium)

24 35 months

384

1) d1mfs and onward

BASCD

1) occupation status
2) education level
3) income
4) ethnicity
5) neighbourhood
deprivation score

1) neighbourhood
deprivation: 11.076
(3.99930.678)

Al-Hosani et al.
2010
(Abu Dhabi)

2 5 years

2 years = 217
4 years = 204
5 years = 219

N/A

1) prevalence
2) dmft

Not mentioned

1) level of parental
income
2) education

1) education: 0.62*
(0.450.85)
2) income: 1.56
(1.062.29)

Levin et al. 2010

(Scotland)

5 years

11417

44

1) d3mft
2) d3t
3) mt
4) ft
5) care index
6) prevalence

BASCD

SIMD score

1) most deprived:
1.02 (1.021.03)

Oliveira et al. 2008

(Brazil)

12 59 months

752 (for 2459

months)

1) prevalence
2) dmfs

WHO

1) household
crowding
2) mother education
3) father education
4) family income

1) overcrowded
household: 1.57
(1.042.36)
2) mother education
> 8 yr: 0.63*
(0.470.84)
3) father education
>8 yr: 0.64*
(0.470.88)

Bonanato et al. 2010

(Brazil)

5 years

551

1) dmft

WHO

SVI

1) low social class:

2.38 (1.683.38)

Source

Age range

Sample size

No. of examiners

Calibration between
examiners

Outcome measures

Caries diagnosis
criteria

SES variables

Odds ratio (95% CI)

or (p-value)

McMahon et al.
2010
(Scotland)
Christensen et al.
2010
(Denmark)

3 years

1711 (06/07)
2428 (07/08)

1) prevalence
2) d3mft

BASCD

SIMD score

1) most deprived:
2.9 (2.313.64)

5 years

3772

N/A

N/A

1) d3mft

WHO

1) mother education
2) family income

1) low mother
education: 1.8
(1.61.9)
2) low family
income: 1.7
(1.51.9)

Sayegh et al. 2002

(Jordan)

4 years
5 years

4 years = 569
5 years = 571

Calibrated with
an epidemiologist
who was not
involved in the
clinical examination

1) d3mft

Not mentioned

1) father occupation
2) mother education
3) kindergarten fee

1) father education :
1.5 (1.12.1)
2) kindergarten fee:
1.4 (1.11.8)

Ferro et al. 2010

(Italy)

3 5 years

1410

1) d3mft

WHO

1) occupation level

1) working class:
1.9 (1.32.8)

Du et al. 2007
(China)

3 5 years

2014

1) prevalence
2) d3mft

WHO

1) parent occupation
2) parent education

1) low mother
education: NS^

Hallet et al. 2003

(Australia)

4 5 years

2515

9 (8 dental therapist
+ 1 dentist)

Not mentioned

1) dmft
2) dmfs

BASCD

1) annual family
income

1) annual income <

$20,000: 2.1
(1.52.8)

Psoter et al. 2006

(USA)

1 4 years

2 years = 715
3 years = 947
4 years = 1152

1) d1mfs

Not mentioned

1) household
income
2) caregiver
education level

1) highest
household income:
0.5* (0.370.69)
2) highest caregiver
education level:
0.61* (0.450.82)

Armfield 2007
(Australia)

4 16 years

14209 (for 25
years)

N/A

N/A

1) dmft

Not mentioned

area-based
1) income
2) education
3) occupation
4) employment
5) housing
6) mobility

1) income: 1.51
(1.351.68)
2) education: 1.8
(1.592.04)
3) occupation: 2.07
(1.852.31)
4) unemployment:
1.35 (1.201.51)
5) public housing:
1.48 (1.311.65)
6) w/o motor
vehicle: 1.22
(1.191.56)

*OR values smaller than 1.0 indicate protective effect

^NS: Non-significant

10

3.3 PREVALENCE
OF
DENTAL
PRESCHOOL CHILDREN

CARIES

IN

The overall prevalence of dental caries in preschool children ranged from 18.5%,
reported by Willems et al. (26), to 93.8%, for 5-year-old children in Abu Dhabi
reported by Al-Hosani (37). The prevalence of caries in developed countries, such as
the US, Australia and the European countries, was lower than that in the developing
countries, such as Brazil and Jordan. Asian countries, such as Korea and China, were
in the middle of the spectrum, with caries prevalence of 56.6% and 55%, respectively.

3.4 INDIVIDUAL
SOCIOECONOMIC
STATUS
VARIABLE AND THE PREVALENCE/SEVERITY OF
DENTAL CARIES IN PRESCHOOL CHILDREN
From the results, 4 broad variables were used in the studies. The findings are
summarised below.
3.4.1 Parent/Caregiver Education Level
Because parental education level is perceived as a relatively reliable SES
estimate, 9 out of the 15 papers investigated the association between parental
education level and the prevalence of early childhood caries (ECC) and severe early
childhood caries (sECC). Except for the study in Seoul, Korea, by Jin et al., which
showed no significant association between parental education level and the prevalence
of ECC and sECC, 5 studies demonstrated a significant effect when other factors were
taken into account in multivariate logistic regression models (Table 1). Although
Armfield used area-based values rather than individual-based values for education,

11

that study demonstrated an association between the prevalence of ECC and sECC
with ORs of 1.8 (1.592.04) and 2.02 (1.732.35), respectively (36). Psoter et al.
showed that the education level of caregivers had a statistically significant protective
effect (p < 0.05) against caries in their study groups (40). The Willems, Sayegh and
Du groups showed an independent effect of parental education level on the occurrence
of dental caries in their studied groups, but the effect became insignificant when the
data were fitted into multivariate logistic regression models (26, 34, 38).
3.4.2 Income Level
Income level has also been studied widely. Willems et al. were unable to show a
statistically significant effect of income on the prevalence of caries when ethnicity
and neighbourhood deprivation were considered in the logistic regression analysis
(26). Interestingly, in Abu Dhabi, Al-Hosani and Rugg-Gunn demonstrated that when
parental education level was controlled, higher parental income was related to higher
caries prevalence (37). However, the remaining studies found that the lower the
income level, the higher the prevalence of ECC and sECC.
3.4.3 Fathers Occupation
Sayegh et al. (38) demonstrated that fathers occupation had a significant effect
on the prevalence of ECC but not sECC. The same effect of fathers occupation on
ECC was shown in the studies conducted in South Australia and Italy by Armfield and
Ferro et al. (29, 36). However, when immigration status was adjusted in the latter
group, the effect of occupation on caries became less significant: 1.4 (0.92.1) (29).
Du et al. attempted to stratify occupation into professional and non-professional
categories and demonstrated no significant effect on the prevalence of caries (34).

12

3.4.4 Kindergarten Tuition Fees

Sayegh et al. (38) was the only study to test the association between kindergarten
tuition fees and dental caries. The authors stratified kindergartens into 7 categories
according to the monthly tuition fees. This study showed that lower tuition fees had
significant effects on both the prevalence and the severity of caries, with ORs of 1.4
(1.11.8) for prevalence and 1.4 (1.11.9) for severity (38).

3.5 COMPOSITE INDICES OF SOCIOECONOMIC

STATUS AND THE PREVALENCE/SEVERITY OF
DENTAL CARIES IN PRESCHOOL CHILDREN
3.5.1 Scottish Index of Multiple Deprivation Score (SIMD)
The Scottish Index of Multiple Deprivation score (SIMD) was used in the
surveys conducted in Scotland by Levin et al. and McMahon et al. as the independent
variable in their studies (27, 28). The SIMD provided a sophisticated division of the
population into 5 quintiles, where 1 represented the most deprived and 5 represented
the least deprived (28). McMahon et al. reported that when deprivation was included
in the analysis, the prevalence of caries for 3-year-olds in Scotland increased from
25% to 33% for 2006/07 and from 26% to 32% for 2007/08. The OR for the most
deprived group was 2.9 (2.313.64). The authors also used the Relative Operating
Characteristic (ROC) curve to illustrate how the predictability (c-index) of caries
increased from 0.58 to 0.64 when the SIMD was included (28). Levin et al., who
studied urban-rural differences in caries among 5-year-old children, showed that if
deprivation was included, the odds of having caries in the remote rural model
increased to 1.02 (1.021.03). Levin et al. also remarked that deprivation might

13

explain the higher prevalence of caries in urban cities, but it was not the sole reason;
when deprivation was adjusted, the inequality in dental caries between rural and urban
areas in Scotland remained (27).
3.5.2 Social Vulnerability Index (SVI)
Bonanato et al. employed the Social Vulnerability Index (SVI) as the
measurement to categorise subjects into either high or low social class (32). They
found that oral disease outcomes were significantly higher in the lower social class
group than in the higher social class group, according to the classification based on
SVI (32).
3.5.3 Neighbourhood Deprivation Score
Willems et al. tested various individual SES variables and included the
neighbourhood deprivation score, which linked every urban address to a poverty
indicator in their study. Only this particular score showed a significant effect on ECC
with an OR of 11.076 (3.99930.678) among all the studied variables (26).

CHAPTER 4 - DISCUSSION
4.1 INVERSE RELATIONSHIP BETWEEN SES AND
DENTAL CARIES IN PRESCHOOL CHILDREN
Based on the results of the above studies, it is noted that no matter which method
is used, the results point to the same conclusion: there is an inverse relationship
between SES and dental caries among preschool children in both developing and

14

developed countries. That is, the better the SES, the lower the prevalence of dental
caries. It was also shown that the available SES measurement methods, both
individual-based and area-based approaches, were not perfect. Nevertheless, these
methods were the best available proxies to determine the SES of an individual in
epidemiological studies.

4.1.1 Individual SES variables

This review showed that most studies that have used individual SES indicators to
measure SES have demonstrated an inverse relationship between SES and dental
caries, with the exception of the studies described below.
The studies of Jin et al. and Willems et al. (26, 33) did not show significant
results for the relationship. This finding might be because both studies used small
sample sizes (268 and 384 subjects, respectively), making it difficult to arrive at the
conclusions drawn from larger sample sizes. In the study by Sayegh et al. (38), a
significant effect was shown for fathers education level but not for mothers
education level. As the study was conducted in Middle Eastern countries, where males
are the dominant figures in society as well as in the family; thus, female influence was
of less significance. It follows that mothers influence on their childrens caries
prevention behaviour is not as significant as the influence of the father.
It was also found that the classification of SES could affect a studys ability to
determine an association. For instance, although many studies in this review showed a
significant relationship between parental occupation and caries in preschool children,
Du et al.s (34) dichotomisation of occupation into professional and non-professional,
might lead to classification bias, which could subsequently hamper the effect.

15

4.1.2 Composite SES indices

The 3 studies that used composite indices as the measurement proxy for SES
unanimously showed that dental caries was related to deprivation (26-28). Armfield
used the area-based score for different SES indicators and successfully demonstrated
significant effects (36). However, caution must be used when interpreting the results
of these studies. Although Willems et al. showed a significant relationship between
the neighbourhood deprivation score and dental caries, the wide 95% CI (3.999
30.678) indicated that the sample size might be too small. In addition, the quality of
the indices used plays an important role. For example, the SIMD is more sophisticated
than the SVI and neighbourhood deprivation score because it divides the population
into finer quintiles, where 1 represents the most deprived and 5 represents the least
deprived (28). In contrast, both the SVI and the neighbourhood deprivation score
simply categorised the studied subjects into high and low social classes and deprived
or not deprived, respectively.

4.2 QUALITY OF THE STUDIES

It is difficult to comment on the overall quality of the studies included in this
review without the use of a quality rating scoring system. Reisine and Psoter provided
a score for each dimension of the studies that they reviewed to rate the quality of the
studies (16). Their categories that are applicable to the current review include study
design, recruitment, response rate, training of examiners, caries diagnosis criteria,
SES measurement and confounders adjusted for in the analysis. A more rigorous
scoring system would measure the studies against the checklist of items recommended
by the STROBE (24). In general, all of the studies clearly presented their titles,

16

backgrounds and objectives in the introduction. For the methodology, all studies used
appropriate measurement methods, performed calibrations between examiners,
reported the statistical results of the calibration and used multivariate logistic
regression to adjust for confounding factors. Among the weaknesses, not all studies
clearly stated how they arrived at the sample size, and some studies did not report the
caries diagnostic criteria that they employed. Moreover, none of the authors
commented on the generalisability of their study results. Unlike other analytical study
designs, such as cohort studies, case-control studies or even interventional studies
(which may not be applicable to this topic), cross-sectional studies only show an
association between the exposure and outcome at a particular time. As such, a definite
cause-effect relationship cannot be established, and it is difficult to effectively identify
and control confounders. The homogenous results in this review can only suggest that
SES could be a reliable risk indicator rather than a risk factor for dental caries in the
studied groups (20).

4.3 LIMITATIONS OF THE STUDIES

4.3.1 Caries Diagnosis Criteria
Different studies employed different criteria for caries diagnosis, as illustrated in
Table 1. This difference in criteria may lead to information bias. Examples of
potential issues may be whether non-cavitated lesions are included and the conditions
in which examinations are performed. The data from the Jin et al. study illustrated
how the mean dmft could be affected when non-cavitated lesions were included. The
researchers reported a 2.87 +/- 0.30 dmft index for the 36- to 47-month age group
when non-cavitated lesions were excluded; conversely, if both cavitated and

17

non-cavitated lesions were included, the dmft index increased to 5.37 +/- 0.51 (33).
Psoter et al. also included non-cavitated lesions and mentioned that shadowing in the
anterior teeth, confirmed by trans-illumination, was also counted as caries (40).
However, the researchers did not specify what kind of trans-illumination tools they
used; these tools may range from fibre-optic light to a reflection of dental light from
the dental mirror. This difference in criteria could contribute to the significant
difference in terms of the prevalence and severity of caries. At the policy level, the
need for treatment will be underestimated if only cavitated lesions are included in
surveys and studies to achieve better reliability in outcome measurement between
examiners. An integrated and widely acceptable caries detection and assessment
method should be employed in future dental epidemiological studies. Ismail et al.
developed the International Caries Detection and Assessment System (ICDAS) in
2007 (41). It is perceived by the authors as containing useful, easy to use and clearly
defined criteria for clinical visual caries detection. However, the reliability and
validity of the method is subject to further testing.
4.3.2 Measurement of SES
Lynch listed groups of individual-level and area-based measures available for
epidemiological study but did not attempt to comment on which measure was
superior (21). In the current review, several composite indices were utilised to assess
individual SES. It is argued that using a composite index to assess individual SES
might lead to ecological fallacy; for example, a person residing in the area may not
fall into the social class suggested by the index (16). Despite the inherent drawbacks,
the studies that used this approach provided more consistent results than the studies
that used traditional individual or household data as proxies. Furthermore, recall bias

18

associated with the questionnaire can be avoided by using indices. Because few
papers were included in this review, it is inconclusive whether the use of an
area-based composite index is more effective than the individual-based measures for
SES measurement.
4.3.3 Review Limitations
In addition to the limitations of the individual studies, this review may also have
different limitations. Because of limitations of time and manpower, only 2 electronic
databases were searched for English-only articles. Because this study included only
one reviewer, a selection bias may exist despite the use of objective inclusion and
exclusion criteria. Furthermore, because of the wide variability in caries diagnosis
criteria and measurements of SES, the comparability of studies in this review is
limited, and a meta-analysis to compare the study results might not be feasible.
Nonetheless, readers should consider while interpreting this review that
non-significant results do not indicate the absence of a relationship between the
explanatory variables and the outcomes (42).

CHAPTER 5 - CONCLUSION
Over the past decades, reviews have demonstrated an inverse relationship
between SES and oral diseases, particularly dental caries (16, 43, 44). In this review,
which focused on preschool children, the results also point in the same direction: SES
is associated with dental caries. In addition, the current review suggests that the
inverse association between SES and dental caries in preschool children is not

19

affected by different SES measures in different settings. These findings echo the
WHOs suggestion of the causal chains of exposure leading to disease and
implications for intervention (44). SES can be viewed as the distal cause of dental
caries. Sociocultural risk factors may include education, occupation, income, ethnicity,
lifestyle and social network support (45). Thus, dental caries prevention strategies
should be targeted at the population level while considering the above-mentioned SES
attributes.
5.1.1 Implications for Future Research
Ecological studies have demonstrated that there is a strong correlation between
the mean dmft index of 5- to 6-year-olds and the Gini coefficient (46). Thus, when the
social gradient is steep, even in rich countries, dental caries inequality is still a major
public health challenge. As such, additional studies should focus on wealthy areas
where the Gini coefficient is high (e.g., Hong Kong). In a city such as Hong Kong,
where income inequality is large, the results of such research may produce new
insights into the situation and may indicate future policy directions. Efforts should
also be made to study the possible behavioural and other factors that explain the
effects of SES on the prevalence and severity of dental caries (16, 47). Finally, many
researchers are still searching for the best SES measurement proxy, and this issue
warrants additional resources and funding. A recent study has suggested that the type
of school (e.g., public, private or subsidised) can be used as an alternative indicator
for SES in the Brazilian context (48). The generalisability of this theory to other
places is subject to further investigation.

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5.1.2 The Way Forward

From a life course perspective, biological elements can combine with social
factors, leading to the longitudinal accumulation of disadvantages (49). To control
dental caries in the entire population, strategies should be developed that take a
socioeconomic and political perspective towards dental caries in early life. Resources
should be utilised to mitigate social gradients for the entire population, and more
targeted approaches should be applied to deprived groups, in an approach that
Marmot and Bell described as proportionate universalism (17). Perhaps it is time to
consider expanding the service of the School Dental Care Service, which currently
covers only primary school children in Hong Kong, to preschool children as well.
Moreover, intensive oral health education and promotion should be made available to
the poor. This may require a multi-sectoral approach in which leaders not only have
the ability to translate evidence into policy but also possess the political will to put
theory into practice. It is most important, however, to bridge the gap between what is
known by the scientists and what is perceived and implemented by the health
authorities (50).

21

REFERENCES

1. Petersen P, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global

burden of oral diseases and risks to oral health. Bulletin of the World Health
Organization. 2005(83):661-9.
2. Selwitz R, Ismail A, Pitts N. Dental caries. The Lancet. 2007;369:51-9.
3. Widmer R, Mekertichian K. A contemporary approach to the art and science of
caries risk assessment. Ann Roy Australas Coll Dent Surg. 1996;13:119-26.
4. Wandera A, Bhakta S. Caries prediction and indicators using a pediatric risk
assessment
teaching
tool.
Journal
of
Dentistry
for
Children.
2000;November-December:408-12.
5. Li Y, Wang W. Predicting Caries in Permanent Teeth from Caries in Primary
Teeth: An Eight-year Cohort Study. Journal Of Dental Research. 2002;81(8):561-6.
6. Pitts N, Boyles J, Nugent Z, Thomas N, Pine C. The dental caries experience of
5-year-old children in Great Britain (2005/6). Surveys co-ordinated by the British
Association for the Study of Community Dentistry. Community Dental Health.
2007(24):59-63.
7. Vargas C, Crall J, Schneider D. Sociodemographic Distribution of Pediatric
Dental Caries: NHANES III, 1988-1994. JADA. 1998;129:1229-38.
8. Dye B, Arevalo O, Vargas C. Trends in pediatric dental caries by poverty status
in the United States, 1988-1994 and 1999-2004. International Journal of Paediatric
Dentistry. 2010(20):132-43.
9. Wang H, Petersen P, Bian J, Zhang B. The second national survey of oral health
status of children and adults in China. Int Dent J. 2002;52(4):283-90.
10. Oral Health Survey 2001
[6th
June
2011];
Available
from:
http://www.dh.gov.hk/english/pub_rec/pub_rec_lpoi/files/ohse3.pdf.
11. Davies W, Corbert E, Chiu G. Dentistry's development in Hong Kong. Int Dent J.
1997;47:137-41.
12. Lo E, Loo E, Lee C. Dental health status of Hong Kong preschool children.
Hong Kong Dent J. 2009(6):6-12.
13. Chu C, Fung D, Lo E. Dental caries status of preschool children in Hong Kong.
BDJ. 1999;187:616-20.
14. Harris R, Nicoll A, Adair P, Pine C. Risk factors for dental caries in young

22

children: a systematic review of the literature. Community Dental Health. 2004;21

(Supplement):71-85.
15. Shaw L. U.K. National Clinical Guidelines in Paeiatric Dentistry: Prevention of
dental caries in children. International Journal of Paediatric Dentistry. 1997;7:267-72.
16. Reisine S, Psoter W. Socioeconomic Status and Selected Behavioral
Determinants as Risk Factors for Dental Caries. Journal of Dental Education.
2001;65(10):1009-16.
17. Marmot M, Bell R. Social Determinants and Dental Health. Advances in
Dental Research. 2011;23(2):201-6.
18. Edelstein B. The Dental Caries Pandemic and Disparities Problem. BMC Oral
Health. 2006;6((Suppl I)):S2.
19. Klein H, Palmer C, Knutson J. Studies on dental caries. I. Dental status and
dental needs of elementary school children. Public Health Reports. 1938;53:751-65.
20. Burt B. How useful are cross-sectional data from surveys of dental caries.
Community Dentistry And Oral Epidemiology. 1997;25:36-41.
21. Lynch J, Kaplan G. Socioeconomic Position. In: Berkman L, Kawachi I, editors.
Social Epidemiology: Oxford University Press; 2000. p. 13-30.
22. Oakes J, Rossi P. The measurement of SES in health research: current practice
and steps toward a new approach. Social Science & Medicine. 2003;56:769-84.
23. Braveman P, Cubbin C, Egerter S, Chideya S, Marchi K, Metzler M, et al.
Socioeconomic Status in Health Research: One size does not fit all. JAMA.
2005;294(22):2879-88.
24. Elm E, Altman D, Egger M, Pocock S, Gotzsche P, Vandenbroucke J. The
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
Statement: guidelines for reporting observational studies. Bulletin of the World Health
Organization. 2007;85:867-72.
25. Vandenbroucke J, Elm E, Altman D, Gotzsche P, Mulrow C, Pocock S, et al.
Strengthening the Report of Observational Studies in Epidemiology (STROBE):
Explanation and Elaboration. PLoS Medicine. 2007;4(10):1628-54.
26. Willems S, Vanobbergen J, Martens L, De Maeseneer J. The independent impact
of household- and neighborhood-based social determinants on early childhood caries:
a cross-sectional study of inner-city children. Family & Community Health.
2005;28(2):168-75.
27. Levin KA, Davies CA, Douglas GVA, Pitts NB. Urban-rural differences in dental
caries of 5-year old children in Scotland. Social Science & Medicine (1982).
2010;71(11):2020-7.
28. McMahon AD, Blair Y, McCall DR, Macpherson LMD. The dental health of

23

three-year-old children in Greater Glasgow, Scotland. British Dental Journal.

2010;209(4):E5-E.
29. Ferro R, Cecchin C, Besostri A, Olivieri A, Stellini E, Mazzoleni S. Social
differences in tooth decay occurrence in a sample of children aged 3 to 5 in
North-East Italy. Community Dental Health. 2010;27:163-6.
30. Traebert J, Guimaraes L, Durante E, Serratine A. Low Maternal Schooling and
Severity of Dental Caries in Brazilian Preschool Children. Oral Health Prev Dent.
2009;7:39-45.
31. Oliveira LB, Sheiham A, Bnecker M. Exploring the association of dental caries
with social factors and nutritional status in Brazilian preschool children. European
Journal Of Oral Sciences. 2008;116(1):37-43.
32. Bonanato K, Pordeus I, Moura-Leite F, Ramos-Jorge M, Vale M, Paiva S. Oral
Disease and Social Class in a Random Sample of Five-year-old Preschool Children in
a Brazilian City. Oral Health Prev Dent. 2010;8:125-32.
33. Jin B-H, Ma D-S, Moon H-S, Paik D-I, Hahn S-H, Horowitz AM. Early
childhood caries: prevalence and risk factors in Seoul, Korea. Journal Of Public
Health Dentistry. 2003 2003 Summer;63(3):183-8.
34. Du M, Luo Y, Zeng X, Alkhatib N, Bedi R. Caries in preschool children and its
risk factors in 2 provinces in China. Quintessence International (Berlin, Germany:
1985). 2007;38(2):143-51.
35. Hallet K, O'Rourke P. Social and behavioural determinants of early childhood
caries. Australian Dental Journal. 2003;48(1):27-33.
36. Armfield J. Socioeconomic Inequalities in Child Oral Health: A comparison of
Discrete and Composite Area-Based Measures. Journal Of Public Health Dentistry.
Spring 2007;67(2):119-25.
37. Al-Hosani E, Rugg-Gunn A. Combination of low parental educational attainment
and high parental income related to high caries experience in pre-school children in
Abu Dhabi. Community Dentistry And Oral Epidemiology. 1998;26(1):31-6.
38. Sayegh A, Dini EL, Holt RD, Bedi R. Caries in preschool children in Amman,
Jordan and the relationship to socio-demographic factors. International Dental Journal.
2002;52(2):87-93.
39. Christensen L, Twetman S, Sundby A. Oral health in children and adolescents
with different socio-cultural and socio-economic backgrounds. Acta Odontologica
Scandinavica. 2010;68:34-42.
40. Psoter W, Pendrys D, Morse D, Zhang H, Mayne S. Associations of
Ethnicity/Race and Socioeconomic Status with Early Childhood Caries Patterns.
Journal Of Public Health Dentistry. Winter 2006;66(1):23-9.

24

41. Ismail A, Sohn W, Tellez M, Amaya A, Sen A, Hason H, et al. The International
Caries Detection and Assessment System (ICDAS): an integrated system for
measuring dental caries. Community Dent Oral Epidemiology. 2007;35:170-8.
42. Liberati A, Altman D, Tetzlaff J, Mulrow C, Gotzsche P, Ioannidis J, et al. The
PRISMA statement for reporting systematic reviews and meta-analyses of studies that
evaluate health care interventions: explanation and elaboration. Journal of Clinical
Epidemiology. 2009;62:e1-e34.
43. Hobdell M, Oliveita E, Bautista R, Myburgh N, Lalloo R, Narendran S, et al.
Oral diseases and socio-economic status (SES). BDJ. 2003;194(2):91-6.
44. Petersen PE. Sociobehavioural risk factors in dental caries - international
perspectives. Community Dentistry And Oral Epidemiology. 2005;33(4):274-9.
45. Petersen P. The World Oral Health Report 2003: continuous improvement of oral
health in the 21st century- the approach of the WHO Global Oral Health Programme.
Community Dentistry And Oral Epidemiology. 2003;31(Suppl. 1):3-24.
46. Bernabe E, Hobdell M. Is income inequality related to childhood dental caries in
rich countries. JADA. 2010(141):143-9.
47. Hamasha A-H, Warren J, Levy S, Broffitt B, Kanellis M. Oral Health Behaviors
of Children in Low and High Socioeconomic Status Families. Pediatric Dentistry.
2006;28:310-5.
48. Piovesan C, Padua M, Ardenghi T, Mendes F, Bonini G. Can type of school be
used as an alternative indicator of socioeconomic status in dental caries studies? A
cross-sectional study. BMC Medical Research Methodology. 2011;11:37-42.
49. Blane D. The life course, the social gradient, and health. In: Marmot M,
Wilkinson R, editors. Social Determinants of Health. 2 Ed ed: Oxford University
Press; 2006. p. 54-77.
50. Sheiham A, Alexander D, Cohen L, Marinho V, Moyses S, Petersen P, et al.
Global Oral Health Inequalities: Task Group- Implementation and Delivery of Oral
Health Strategies. Advances in Dental Research. 2011;23(2):259-67.

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