Use of Oral Health Care Services in the United States: Unequal, Inequitable—a Cross-Sectional Study

BACKGROUND: Social determinants drive disparities in dental visiting. Disparities can be measured simply by comparing outcomes between groups (inequality) but can also consider concepts of social justice or fairness (inequity). This study aimed to assess differences in dental visiting in the United States in terms of both social inequality and inequity. METHODS: Data were obtained from a cross-sectional study—the National Health and Nutrition Examination Survey (NHANES) 2015–2016, and participants were US adults aged 30+ years. The outcome of interest, use of oral health care services, was measured in terms of dental visiting in the past 12 months. Disparity was operationalized through education and income. Other characteristics included age, gender, race/ethnicity, main language, country of birth, citizenship and oral health status. To characterize existing inequality in dental service use, we examined bivariate relationships using indices of inequality: the absolute and relative concentration index (ACI and RCI), the slope index of inequality (SII) and relative index of inequality (RII) and through concentration curves (CC). Indirect standardization with a non-linear model was used to measure inequity. RESULTS: A total of 4745 US adults were included. Bivariate analysis showed a gradient by both education and income in dental visiting, with a higher proportion (> 60%) of those with lower educational attainment /lower income having not visited a dentist. The concentration curves showed pro-higher education and income inequality. All measures of absolute and relative indices were negative, indicating that from lower to higher socioeconomic position (education and income), the prevalence of no dental visiting decreased: ACI and RCI estimates were approximately 8% and 20%, while SII and RII estimates were 50% and 30%. After need-standardization, the group with the highest educational level had nearly 2.5 times- and the highest income had near three times less probability of not having a dental visit in the past 12 months than those with the lowest education and income, respectively. CONCLUSION: The findings indicate that use of oral health care is threatened by existing social inequalities and inequities, disproportionately burdening disadvantaged populations. Efforts to reduce both oral health inequalities and inequities must start with action in the social, economic and policy spheres

Periodontal disease, tooth loss and daily life in older adults in South Australia: a longitudinal study

Background: Periodontal disease is highly prevalent among older adults. The purpose of the current study was to improve the measurement of the incidence and progression of periodontal disease in older population with a high level of tooth loss, and to evaluate the relationship between daily life conditions (systemic diseases, functional limitation and cognitive impairment) and periodontal disease. Methods: Data were from the South Australian Dental Longitudinal Study (SADLS). All participants were 60+ years. Data collection started in 1991/1992 and repeated 2, 5 and 11 years later. This study investigated the measurement of periodontal disease first by the use of periodontal disease case definitions; then the calculation of individual incidence density of periodontal attachment loss (ALOSS≥ 3mm) events. The role of systemic diseases in predicting the incidence and progression of periodontal disease was estimated after adjusting for social demographic, dental characteristics and health-related behaviour covariates using Poisson regression with robust standard errors. Marginal structural models (MSMs) with stabilised inverse-probability weights were used to estimate the direct effect of functional limitations and/or cognitive impairment on the incidence and progression of periodontal disease while controlling for other risk factors such as systemic diseases and dental behaviours. Results: Of the 801 dentate participants examined at baseline (response rate: 66.5%), 596, 365 and 234 were re-examined at the 2, 5 and 11-year follow-up respectively. Large discrepancies in the prevalence of periodontal disease were found based on three different case definitions with the same population at different time points. Both the incidence and reversal of periodontal disease were associated with the number of teeth lost at baseline and across the follow-up intervals. The mean individual incidence density of ALOSS new events was 8.3 per 1,000 tooth-years with imputed missing values due to tooth loss and loss of participants to follow-up. The individual incidence density of ALOSS new events was 2 times higher in the ‘tooth loss’ groups under the different scenarios, compared to ‘no tooth loss’ group. The predictive analyses showed that among older adults who suffered from diabetes and chronic obstructive pulmonary disease (COPD), the average ALOSS events per 1,000 tooth-years was 1.3 and 1.2 times higher respectively than for those without these diseases. The estimated direct effect of people with functional limitation increased the risk of periodontal disease progression around 1.6 times, compared with those without functional limitation; people with cognitive impairment had nearly 1.7 times greater progression of periodontal disease than those who did not have cognitive impairment; and having both functional limitations and cognitive impairment raised the progression of periodontal disease to 1.8 times compared to those who did not have functional limitation or cognitive impairment. Conclusion: Individual-level incidence density of ALOSS new events was more appropriate to estimate the incidence and progression of periodontal disease in a population with a high level of tooth loss. Diabetes and COPD were risk predictors of the incidence and progression of periodontal attachment loss, and daily life (including functional limitation and/or cognitive impairment) had a direct effect on incidence and progression of periodontal disease that was not mediated by dental behaviours or systemic diseases.Thesis (Ph.D.) -- University of Adelaide, School of Dentistry, 2016

Validation of a 4-item child perception questionnaire in Australian children.

ObjectiveTo develop and validate a 4-item child oral health-related quality of life (OHRQoL) instrument that might be more amenable for uptake in large scale, multifaceted surveys of children's health and wellbeing than current, longer-form child OHRQoL instruments.MethodsData were obtained from a study of the South Australian School Dental Service population designed to investigate OHRQoL among school children aged 8-13 years in 2002-2003. The Child Perception Questionnaire (CPQ8-10 and CPQ11-14) was utilised, which comprises 25 & 37 items representing four conceptual domains: oral symptoms, functional limitations, emotional wellbeing and social wellbeing. Initially, the psychometric properties of the short form 8-item CPQ were tested in both age groups using Confirmatory Factor Analysis. The rationale was that, if the 8-item CPQ8-10 and CPQ11-14 did not display good psychometric properties, there was no reason to proceed with further shortening into 4-item versions. Following a good fit of the 8-item CPQ, items with higher factor loadings in each domain were maintained and tested in the development of a 4-item CPQ. Exploratory Factor Analysis was conducted to determine dimensionality, followed by tests for reliability and validity. Model fits were assessed using Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI) and Standardized Root Mean Square Residual (SRMR).ResultsThere were 308 children aged 8-10 years who completed CPQ8-10 and 461 children aged 11-13 years who completed CPQ11-14. For the short-form 8-item instrument, satisfactory goodness of fit was demonstrated for the two age groups, with acceptable thresholds for RMSEA, CFI, and SRMR. The four items with the highest factor loading in each domain were the same for the 8-item CPQ8-10 and CPQ11-14. and these items were selected to comprise the 4-item CPQ8-10 and CPQ11-14. The 4-item short form displayed good criterion validity, with expected score patterns found in the majority of the known groups evaluated.ConclusionsWe developed short-form 4-item CPQ8-10 and CPQ11-14 instruments that were tested in a large convenience sample of South Australian school children. The instruments demonstrated acceptable reliability and validity. Implications for practice are discussed

An intersectionality approach to Indigenous oral health inequities; the super-additive impacts of racism and negative life events.

ObjectivesIndigenous Australians experience cumulative forms of oppression. Using intersectionality as the underlying analytical framework, and with oral health as an outcome, we demonstrate how oppressions are interlinked and cannot be treated in isolation. The study aimed to quantify the cumulative effect of two forms of oppression on Indigenous Australian oral health inequities.MethodsThis observational study was conducted Feb 2018-Jan 2020. Recruitment occurred through Aboriginal Community Controlled Health Organisations in South Australia, Australia. Eligibility included identifying as Indigenous, residing in South Australia and aged 18+ years. Socio-demographic factors, health-related characteristics, experience of racism, negative life events and self-reported oral health outcomes were collected. The main outcomes were fair/poor self-rated oral health and oral health related quality of life, measured by OHIP-14. Effect-measure modification was used to verify differences on effect sizes per strata of negative life events and racism. The presence of modification was indicated by Relative Excess Risk due to Interactions (RERIs).ResultsData were obtained for 1,011 participants, median age 37 years, 66% female and 63% residing in non-metropolitan locations. Over half (52%) had experienced racism in the past 12 months and 85% had experienced one or more negative life events. Around one-third (34%) rated their oral health as fair/poor and the mean OHIP-14 score was 17. A higher proportion of participants who had experienced both racism and negative life events (46%) were male (52%), aged 37+ years (47%), resided in metropolitan locations (57%), reported difficulty paying a $100 dental bill (47%), had fair/poor self-rated oral health (54%) and higher mean OHIP-14 scores (20). The RERIs observed were 0.31 for fair/poor self-rated oral health and 0.23 for mean OHIP-14. The positive RERIs indicated a super-additive effect between racism, negative life events (effect modifier) and self-reported oral health outcomes.ConclusionThe more oppressions participants experienced, in the form of racism and negative life events, the greater the burden of poor self-reported oral health. The study is one of the first to use intersectionality as a theory to explain oral health inequities as experienced by Indigenous Australians

Validation of the health literacy in dentistry scale in brazilian adults

To perform cross-cultural adaptation and validation of the Health Literacy Dental scale (HeLD) in Brazilian adults. The HeLD instrument was translated and cross-culturally adapted to the Brazilian Portuguese language to create longer (HeLD-29) and shorter (HeLD-14) versions. The reliability and validity of these versions were assessed in a sample of 603 adults living near six primary care units in the city of Piracicaba, Sao Paulo, Brazil. Both versions of HeLD demonstrated high internal reliability, acceptable convergent validity and discriminant validity. However, the confirmatory factor analysis showed that only HeLD-14 demonstrated satisfactory goodness of fit. There were associations between HeLD-14 scores and social demographic characteristics, general and oral health and oral health-related behaviours. Higher scores were observed for the total HeLD-14 and/or individual components of HeLD-14 among women, ethnic white subjects, those with high educational attainment, those with higher income, those reporting toothbrushing twice or more daily, regular dental attenders, those who usually attended for dental care for a check-up, those with excellent or very good self-ratings of general health, those with excellent or very good self-ratings of oral health, and those without tooth extraction and oral health impact. The Brazilian version of HeLD-14 was demonstrated to be a reliable and valid instrument for measuring broad aspects of oral health literacy in the adult Brazilian population702116126COORDENAÇÃO DE APERFEIÇOAMENTO DE PESSOAL DE NÍVEL SUPERIOR - CAPESnão te

Social inequality in dental caries and changes over time among Indigenous and non‐Indigenous Australian children

Abstract Objective: This paper describes and compares magnitudes of socioeconomic (SES) inequalities in oral health among Indigenous and non‐Indigenous children over a 10‐year period. Methods: We analysed annual oral health survey data from NSW, NT and SA. Data were extracted for time period 1 (2000–2002, N=215,317) and time period 2 (2007–2010, N=34,495). Oral health outcomes were untreated decayed deciduous teeth (dt) and cumulative dental caries experience (dmft). Postcode‐level Socioeconomic Index for Areas was used to assess SES. Age standardisation and complex survey weights were used. Indices of socioeconomic inequality in health (Slope Index of Inequality, Relative Index of Inequality, Absolute and Relative Concentration Index) were used to quantify inequality in dental caries and its changes over time. Results: Oral health outcomes deteriorated in both Indigenous and non‐Indigenous populations over time. Indigenous children experienced higher levels of disease at both times. Untreated dt increased in both populations. The cummulative disease (dmft) increased at higher rate among children in low‐SES areas in both populations. Over time, there was an increase in socioecononomic inequalities in dmft in all children and in dt in non‐Indigenous children. Conclusion: Area‐level socioeconomic inequality in child oral health has widened due to deterioration in low‐SES children

Provision of Dental Care to Indigenous South Australians and Impacts on Improved General Health: Study Protocol

Background: Indigenous South Australians carry a disproportionate burden of dental diseases, with approximately 80 percent of Indigenous adults having both periodontal disease and dental caries. The chronic inflammatory nature of many dental conditions means there are widespread systemic impacts, particularly on type 2 diabetes, chronic kidney disease and cardiovascular disease. Evidence suggests there are barriers experienced by Indigenous South Australians in accessing timely and culturally safe dental care. This study aims to: (1) elicit the views of Indigenous South Australians regarding their perspectives of what comprises culturally safe dental care; (2) provide such dental care and; (3) assess any changes in both oral and general health using point-of-care testing following receipt of timely, comprehensive and culturally safe dental care. Methods/Design: This mixed-methods study will involve qualitative interviews and an intervention without randomisation. The qualitative component will comprise seeking perspectives of Indigenous South Australians regarding what culturally safe dental care means for them. For the intervention component, participants will take part in oral epidemiological examinations at baseline and 12-month follow-up (after receipt of dental care), which will include collection of saliva, plaque and calculus, as well as completion of a self-report questionnaire. The primary outcome measures—changes in type 2 diabetes (HbA1c), cardiovascular disease (CRP) and chronic kidney disease (ACR)—will be obtained by blood/urine spot from a finger prick/urine collection at baseline and 12-month follow-up via point-of-care testing. Results: Participant recruitment will commence in July 2022. The first results are expected to be submitted for publication one year after recruitment begins. Discussion: The project will have a number of important outcomes, including increased understanding of what culturally safe dental care means for Indigenous South Australians, the delivery of such care, and empirical evidence of how culturally safe dental care leads to better prognosis for chronic diseases linked with poor oral health. This will be important for health services planning, especially in the Aboriginal Community Controlled Health Organisation sector, where the management of dental diseases in a culturally safe manner for better chronic disease outcomes is currently insufficiently understood, planned and budgeted for

Development and validation of an HPV infection knowledge assessment scale among Aboriginal and Torres Strait Islander Peoples

Background: An increased incidence of Human Papillomavirus (HPV) infection and its related cancers has been observed in recent years. Correct knowledge about HPV infection can lead to a significant decrease in transmission and a subsequent increase in vaccine uptake. Awareness and behavioural perception towards HPV infections are critical for improving HPV vaccination rates among Aboriginal and/or Torres Strait Islander Peoples. However, to the best of our knowledge, there has been no instrument designed to measure knowledge about HPV infection that is culturally appropriate and validated among Aboriginal and/or Torres Strait Islander People. Aim: To address this research gap, this paper aims to examine the psychometric properties of the HPV Knowledge Tool (HPV-KT) in an Indigenous population sample from South Australia. Methodology: Data from 747 Indigenous Australian Adults who participated in the 12-month follow-up of the HPV and Oropharyngeal Carcinoma in Indigenous Australians Study was utilised for this study. The psychometric properties examined included1) dimensionality and item redundancy; (2) network loadings; (3) model fit; (4) criterion validity; and (5) reliability. The network model was estimated using the Graphical Least Absolute Shrinkage and Selector Operator (GLASSO). Evaluation of the HPV-KT (10 items) dimensionality and item redundancy was conducted within the framework of Exploratory Graph Analysis (EGA). Reliability was evaluated with the McDonald’s Omega (ω) coefficient. Results: After the exclusion of two items, the HPV-KT exhibited good psychometric properties for Aboriginal and/or Torres Strait Islander Peoples. The two dimensions of “General HPV Knowledge” and “Commonness of HPV” were identified. The dimension of “Commonness of HPV” displayed poor reliability, so a sum score for this subscale is not recommended (i.e. the items can still be used individually) The network model of the 7-item HPV-KT was fitted in the validation sample and model fit was adequate (x2 (7) = 17.17, p < 0.016; CFI = 0.980; TLI = 0.94; RMSEA = 0.063, 90% CI = 0.025–0.010). Furthermore, the reliability of the “General HPV Knowledge” subscale (ω = 0.76, 95% CI: 0.72–0.79), while the reliability of the “Commonness of HPV” subscale (ω = 0.58, 95% CI0.58–0.88) was poor. Conclusion: The HPV-KT was adapted for an Aboriginal and/or Torres Strait Islander population and is readily available for future use in Australia. The addition of items assessing specifications of HPV infection, natural history and behaviour will improve the reliability and usability to assess the level of accurate knowledge about HPV infection. Future studies should investigate the possibility of developing new items for the dimension ‘Commonness of HPV’

The Indigenous Australian Human Papillomavirus (HPV) Cohort Study 2, Continuation for 5 to 10 Years: Protocol for a Longitudinal Study

BackgroundHuman papillomavirus (HPV) infection, a common sexually transmitted disease, is associated with cancers of the cervix, vulva, vagina, penis, anus, and head and neck. Oropharyngeal squamous cell carcinoma (OPSCC; throat cancer) is a type of cancer involving the head and neck area that is rapidly increasing across the globe. There are higher rates of OPSCC among Indigenous populations relative to non–Indigenous Australian populations, although the HPV-attributable fraction remains unknown. For the first time at a global level, we plan to extend an Indigenous Australian adult cohort to monitor, screen, and ultimately prevent HPV-associated OPSCC and to undertake extensive cost-effectiveness modelling around HPV vaccination. ObjectiveThis study aims to (1) extend follow-up to a minimum of 7 years post recruitment to describe the prevalence, incidence, clearance, and persistence of oral HPV infection; and (2) conduct clinical examinations of the head and neck, oral cavity, and oropharynx and collect saliva samples for early-stage OPSCC testing. MethodsWe will continue to implement a longitudinal design for the next study phase, where we will ascertain the prevalence, incidence, clearance, and persistence of oral HPV infection at 48, 60, and 72 months; undertake clinical examinations/saliva assessments to detect early-stage OPSCC; and refer for treatment. The primary outcome measures are changes in oral HPV infection status, biomarker measures of early HPV-related cancer, and clinical evidence of early-stage OPSCC. ResultsParticipant 48-month follow-up will commence in January 2023. The first results are expected to be submitted for publication 1 year after 48-month follow-up begins. ConclusionsOur findings have potential to change the way in which OPSCC among Australian Indigenous adults is managed, with desired impacts including cost-savings on expensive cancer treatments; improved nutritional, social, and emotional outcomes; and improved quality of life for both Indigenous adults and the Indigenous community more broadly. Continuing a large, representative Indigenous adult cohort to track oral HPV infection and monitor early OPSCC is essential to yield critical information to include in the management armamentarium of health and well-being recommendations for Australia’s First Nations. International Registered Report Identifier (IRRID)PRR1-10.2196/4459