|Year : 2021 | Volume
| Issue : 3 | Page : 162-169
Association between social deprivation and oral health: A systematic review
Vinitha Vijayan, Manjunath P Puranik, KR Sowmya
Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||31-Dec-2020|
|Date of Decision||26-Apr-2021|
|Date of Acceptance||15-Jul-2021|
|Date of Web Publication||15-Oct-2021|
Department of Public Health Dentistry, Government Dental College and Research Institute, Fort, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Social deprivation provides a useful means of generalizing the condition of those who cannot or do not enter into ordinary forms of family and other such social relationships. The aim of this review was to evaluate the association of social deprivation with oral health. Three electronic databases (Google Scholar, MEDLINE, and Cochrane Library) were systematically searched to identify relevant studies. All the papers in English language were included without keeping any restriction for the article publication date. Review papers and those papers those were not concerned with oral diseases/oral health were excluded. Among a total of 1880 papers, 14 effective studies fulfilled the selection criteria and there was no scope for performing a meta-analysis in this area due to heterogeneity in these studies. Socially deprived adults have more dental risk behaviors, greater prevalence of dental caries, periodontitis, traumatic dental injuries, higher rates of orofacial pain, and tooth loss along with reduced dental service utilization compared to more advantaged adults. Socially deprived adults tend to suffer from poor oral health compared to socially advantaged adults suggesting the role of social deprivation in oral health inequalities. The major limitation was that most of the studies are cross sectional in nature. The studies are done across the populations considering association between various oral health variables and social deprivation using different indices which makes comparison between these studies difficult, and the indices used measured deprivation in general overlooking the social aspects of deprivation. Thus, these studies confirm the association between oral health and social deprivation.
Keywords: Deprivation, oral health, social deprivation
|How to cite this article:|
Vijayan V, Puranik MP, Sowmya K R. Association between social deprivation and oral health: A systematic review. J Indian Assoc Public Health Dent 2021;19:162-9
|How to cite this URL:|
Vijayan V, Puranik MP, Sowmya K R. Association between social deprivation and oral health: A systematic review. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Dec 6];19:162-9. Available from: https://www.jiaphd.org/text.asp?2021/19/3/162/328278
| Introduction|| |
Oral diseases remain a major public health concern throughout the world. Furthermore, these diseases have a major impact on overall health and well-being and constitute a public health burden. Moreover, socioeconomic position at different periods of life course affects chronic oral diseases. There always exists a gap between the socially advantaged and socially deprived groups.
Deprivation can be referred as the inability to meet needs, which is caused by a lack of resources of all kinds, not just financial. The term “deprivation” emerged in Britain in the 1980s from a long tradition of analyzing social inequalities in health. Deprivations are unsatisfactory and undesirable circumstances, whether material, emotional, physical, or behavioral, as recognized by a fair degree of societal consensus.
Social deprivation is the inability of individuals to participate fully in the life of their community or society. The socially deprived tend to have higher levels of ill health compared with more advantaged groups, resulting in a social gradient in health that increases with levels and durations of deprivation. Social deprivation is more closely linked to the concept of social organization, such as isolation or cohesion, individualism or cooperation, mutual assistance, and trust. They are related to mortality in the general population and premature mortality (either general or due to ischemic heart disease or other causes related to tobacco use). They vary with all forms of morbidity, from cancer to restriction of activities, and from respiratory diseases and diabetes to tooth decay. Studies have shown a tendency for deprived areas to have lower levels of dental health. Hence, this systematic review aimed to evaluate the association of social deprivation with oral health.
| Methodology|| |
This systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the reporting of this systematic review. The protocol of this systematic review was registered on the National Institutes of Health Research Database (PROSPERO: Registration number CRD42020211793).
The research question was “Are socially deprived individuals having poor oral health when compared to individuals who are less socially deprived/more advantaged?”
The research hypothesis was socially deprived individuals experience poor oral health when compared to individuals who are less socially deprived/more advantaged.
| Eligibility Criteria and Search Strategy|| |
Three electronic databases (Google Scholar, MEDLINE, and Cochrane Library) were used to search for research papers. The search was restricted to English language, and the databases were searched up to 2020 March. The keywords used were the following: social deprivation AND (oral health OR mouth diseases OR dental caries OR tooth loss OR stomatitis OR gingivitis OR periodontitis OR dental care OR dental service utilization OR dental trauma OR dental fluorosis OR tooth wear OR trauma OR caries associated microorganisms). Manual searches were conducted in the reference lists of the identified papers for identification of additional relevant studies. Effective papers were manually searched for additional relevant papers (reference linkage).
| Screening and Selection|| |
All the papers regarding social deprivation and various oral diseases/conditions were considered to find the association between social deprivation and oral health for understanding whether socially deprived individuals are having poor oral health when compared to socially advantaged adults. The retrieved studies were screened for inclusion by three reviewers. Duplicate papers from the three databases were removed. The papers were selected independently by the title and abstract. Papers were excluded if were not concerned with oral diseases/oral health or were review papers. In addition, papers were also excluded if they were concerned about only area deprivation or any other forms of material deprivation) or only regarding social inequalities/social class/gradient/social determinants. Full texts of potentially effective papers were retrieved, read, and approved by the three reviewers. Disagreement between the three reviewers was resolved by discussion and consensus.
| Data Extraction|| |
Data extraction was carried out independently by the three reviewers. Data extraction forms were used to record the following information: (a) authors and year of publication, (b) country, (c) age group, (d) study design, (e) sample size, (f) oral health variable and the index for measurement, (g) oral health outcomes, and (h) measures of deprivation and summary of the main findings.
| Risk of Bias in Individual Studies|| |
The methodological quality assessment was performed by the same three researchers using JBI critical appraisal checklist for analytical cross-sectional and cohort studies. JBI of cross-sectional studies and cohort studies is made up of 8 and 11 items, respectively. Questions with “yes” answer <49% were considered studies with high risk of bias, 50%–69% as moderate risk, and more than 70% as low risk of bias. None of the studies were excluded after quality assessment. The results are described in [Table 1] and [Table 2].
|Table 1: Joanna Briggs Institute Critical Appraisal Checklist for analytical cross-sectional studies|
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|Table 2: Joanna Briggs Institute Critical Appraisal Checklist for cohort studies|
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| Results|| |
Search and selection results
The Google Scholar, MEDLINE, and Cochrane Library searches resulted in 1880 papers, of which 107 were duplicate papers [Figure 1]. The titles and abstracts of 1773 papers were screened by three independent reviewers, and a consensus was reached between reviews after discussion, resulting in the identification of potentially effective papers. A total of 57 papers were review papers pertaining to social inequalities/social class/social gradient/social determinants, etc., After retrieval of the full texts, 14 effective papers were included. No additional studies were found through reference linkage. Data extracted are summarized in [Table 3]. Among 14 effective papers, due to variations in the study populations, indexes used to measure social deprivation, and oral health outcomes, there was no scope for performing a meta-analysis in this area.
|Figure 1: Flowchart of studies on the relationship of oral health and social deprivation|
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Assessment of risk bias
The risk of bias was assessed according to the specific JBI's critical appraisal tools for cohort and cross-sectional studies. None of the studies included in this review had high risk of bias. Out of 13 cross-sectional studies, 4 studies were considered moderate quality,,, and the remainder were considered to be of low risk of bias. Only one cohort study was considered in the study and assessed as moderate quality.
| Discussion|| |
Social deprivation provides a useful means of generalizing the condition of those who do not or cannot enter into ordinary forms of family and other social relationships. Deprivation measures have a major role to play in research that examines features of people and places, and how they promote and/or damage both oral and general health. Deprivation is a complex concept, hence multiple variables must be combined rather than single variables to measure it. Indices to measure can be subjective/objective and direct/indirect and to differentiate social and material deprivation. Commonly used indicators for material deprivation are dietary indicators, physical and mental indicators, housing indicators, household facility indicators, environment indicators, and work condition indicators. Social deprivation indicators are mainly social family indicators, social support and integration indicators, and social recreational indicators.
Generally used deprivation indices are Jarman Index (1983), the DoE Indicators of Urban Deprivation (1983), the Townsend Index (1988), the Carstairs Index (1989), the LWT Breadline Britain Index (1991), and the Index of Local Conditions (DoE, 1995). Commonly used indices in dental research are the Townsend's Index of Material Deprivation, the Jarman Deprivation Score, and the Index of Multiple Deprivation (IMD).
Despite the fact that the dental diseases levels of the overall population have declined in recent decades, there remains a problem in certain demographic groups with high levels of social deprivation. Compared with more advantaged adults, deprived adults have more dental risk behaviors, greater prevalence of dental caries and periodontitis, and higher rates of tooth loss.
Fourteen studies have reported the relationship between social deprivation and oral health. Most of the studies were cross sectional in study design and one was a cohort study. Out of these cross sectional studies, majority of them were retrospective studies.,,,,,,, Studies are done in Australia, Sweden, England,,,,,, Brazil, Scotland,, London, and the United Kingdom., These studies evaluated the association between social deprivation with dental caries,,,,,, water fluoridation,,, dental trauma,, tooth loss, dental service utilization,, and orofacial pain. Out of 14 studies, 11 were related to children or adolescents. This could be attributed to ease of conducting research among children/adolescents who are considered captive population and are often reflected as a major social investment. Since dental caries is the most prevalent condition in young individuals, most of the studies are pertaining to social deprivation and dental caries.
Studies have measured social deprivation using indices like Jarman Index,,,,, IMD,,, Deprivation Category (DEPCAT),, postcodes,, Department of the Environment Index, level of education and family income, area. The oral health variables included were dental caries (Decayed, Missing, and Filled Teeth [DMFT];, dmft;, and International Caries Detection and Assessment System [ICDAS]), dental fluorosis (TF score,), traumatic dental injury, dental erosion, caries-associated microorganisms, dental service utilization,, tooth loss, and orofacial pain.
The qualitative synthesis of the evidence with respect to the research question “Are socially deprived individuals having poor oral health when compared to individuals who are less socially deprived/more advantaged?” is presented thematically in terms of social deprivation and its association with numerous variables such as sociodemographic profile, dental caries, water fluoridation, dental erosion, dental trauma, tooth loss, orofacial pain, and NHS dental service utilization.
Sociodemographic profile and social deprivation
None of the studies considered relationship between age and gender with social deprivation. Among deprived adults, individuals with current smoking habits had higher prevalence of tooth loss when compared to former smokers/never smoked individuals. Oral health behaviors such as age started to brush, brushing frequency, amount, weight, type of toothpaste amount of toothpaste, and rinsing behavior were not associated with social deprivation., The tooth brushing frequency was less among deprived individuals when compared to nondeprived adults. Rinsing behavior was found to be lower in nonfluoridated area (deprived) when compared to fluoridated area. The interaction of fluoridation and brushing teeth twice daily resulted in reduced risk of tooth wear in children residing in less deprived fluoridated areas. Nutritional preferences were not taken into consideration in any of the studies. These studies reflect suboptimal oral health behaviors among deprived individuals suggesting association between social deprivation and oral health.
Social deprivation and dental caries
Dental caries is the most common noncommunicable disease worldwide. Studies are performed in Brazil, England,,, Scotland, and Sweden to find out association between social deprivation and dental caries. Indexes used to measure deprivation were IMD, Care Need Index (CNI), Jarman Index,, and DEPCAT, DMFT,, dmft, and ICDAS were used to determine dental caries. The study population comprised children and adolescents of age groups: 1–4 years, 3–19 years, 5 years,, 6–12 years, and 11–13 years. The prevalence of dental caries was more in socially deprived individuals when compared to affluent individuals,,, in majority of studies. The association between decay and social deprivation has supported the principle of targeting enhanced capitation payments for the dental registration of children from deprived areas.
When controlling for caries, one study found an association between social deprivation and the isolation frequency of yeasts when the children were 1 and 2 years old, whereas lactobacilli were associated when the infants were 3 and 4 years old.
In a study conducted in Sweden study, the socially deprived children had more caries and filled teeth/surfaces when compared to the affluent population. Most deprived children were more likely to report dental caries than affluent. The CNI was significantly higher for socially deprived individuals than the more affluent population. Difference in the diet pattern and the oral hygiene behaviors were the major risk factors mediating the association between social deprivation and dental caries.
Social deprivation and water fluoridation
Three studies were performed to find out the relationship between social deprivation and water fluoridation among children in England.,, Two studies employed cross-sectional study design., While the third-one used results from British Dental Survey. One study used IMD while the other two used Jarman Index, to measure deprivation. Thylstrup–Fejerskov Index was used to measure fluorosis in these studies.,, Subjects in the most underprivileged wards without water fluoridation tended to have less fluorosis than those in the more privileged wards with water fluoridation suggesting high amount of fluoride concentration in the fluoridated regions. Subjects in the fluoridated area had significantly less caries experience than the nonfluoridated area., There was an increase in mean DMFT with increasing deprivation for both the fluoridated and nonfluoridated populations suggestive of a positive association between social deprivation and dental caries., In two studies, social gradient between caries and deprivation appeared to be lower in the fluoridated population compared to the nonfluoridated population, particularly when considering caries into dentin, demonstrating a reduction in inequalities of oral health for the most deprived individuals in the population., This is suggestive of the role of water fluoridation in the reduction of social class gradient.,
Social deprivation and dental erosion
The interaction of fluoridation and brushing teeth twice daily resulted in reduced risk of tooth wear in children residing in less deprived fluoridated areas. Affluent districts are more likely to have smooth surface wear compared with children in fluoridated districts.
Social deprivation and dental trauma
Traumatic dental injury is a public health issue because of its occurrence among young patients., Two studies were performed to find out the relationship between traumatic dental injury and social deprivation in children., One was a retrospective analysis done in Scotland and the other was a cross-sectional study in London. Social deprivation was measured by the Carstairs DEPCAT and the Jarman Index. An overcrowded household (indicator of social deprivation) tended to increase the likelihood of traumatic dental injuries whereas deprivation level had no effect on incidence of dental injury has also been reported. The association between gender and dental trauma was also found to be inconclusive because one study showed a significantly high prevalence of injury in males while the other study was not able to find any difference between genders and social deprivation.
Social deprivation and tooth loss
Retention of fewer than 20 teeth is considered tooth loss. In a cross-sectional study in Australia, deprived adults experienced higher levels of psychological stress, risk behavior, and retention of <20 teeth whereas coping had a protective effect against tooth loss. The causes of tooth loss are attributed to social-behavioral circumstances and disease risk factors which acted as mediators in the association between social deprivation and tooth loss.
Social deprivation and orofacial pain
A cross-sectional study demonstrated that orofacial pain had significant impacts on daily life and was higher among adults living in the most deprived areas compared with their counterparts living in the least deprived areas of the UK. However, orofacial pain did not mediate the relationship between deprivation and impacts on daily life.
Social deprivation and NHS dental service utilization
Two studies were performed to understand the relationship between social deprivation and NHS dental service utilization in which one was conducted among older adults using IMD while the other was performed among children using the Department of the Environment Index of local conditions and the Jarman Underprivileged Area Score. The most deprived older adults showed an increased provision of NHS dental care with regard to routine examinations, prevention, extractions, and upper acrylic dentures. However, for permanent fillings and more complex restorative treatment (endodontics, bridges, crowns, inlays, and veneers), the relationship appeared to be an inverse one. Dental visits were less frequent and symptom driven among deprived individuals when compared to nondeprived adults. Hence, the dental service utilization was less among older age adults, and the treatment relationship with social deprivation was complex. Registration and lapse rates were significantly associated with social deprivation confirming that there is an inverse “dental” care law for children in England.
Most of the studies are cross sectional in nature that determined the relationship between social deprivation and oral health. The studies are done across the populations considering association between various oral health variables and social deprivation using different indices which makes comparison between these studies difficult. The indices used measured deprivation in general overlooking the social aspects of deprivation.
| Conclusion|| |
Studies have shown higher prevalence of dental caries, periodontal disease and tooth loss, dental trauma, and dental erosion with few dental restorations coupled with reduced dental service utilization in socially deprived individuals. Differences in oral health behaviors among the affluent and deprived also exist. Studies conducted to date suggest a link between social deprivation and oral health and demonstrate the relatively poor oral health experience of individuals living in areas of deprivation. Since majority of the studies have high quality, low risk of bias, consistency of results, good precision, and directness of evidence, it may be concluded that there is moderate-to-high evidence to substantiate the association of social deprivation with oral health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]