Publications by authors named "Marco A Peres"

70 Publications

Challenges in identifying indigenous peoples in population oral health surveys: a commentary.

BMC Oral Health 2021 04 28;21(1):216. Epub 2021 Apr 28.

Post-Graduate Program in Public Health, Federal University of Santa Catarina, Florianópolis, Brazil.

There are currently 370 million persons identifying as indigenous across 90 countries globally. Indigenous peoples generally face substantial exclusion/marginalization and poorer health status compared with non-indigenous majority populations; this includes poorer oral health status and reduced access to dental services. Population-level oral health surveys provide data to set priorities, inform policies, and monitor progress in dental disease experience/dental service utilisation over time. Rigorously and comprehensively measuring the oral health burden of indigenous populations is an ethical issue, though, given that survey instruments and sampling procedures are usually not sufficiently inclusive. This results in substantial underestimation or even biased estimation of dental disease rates and severity among indigenous peoples, making it difficult for policy makers to prioritise resources in this area. The methodological challenges identified include: (1) suboptimal identification of indigenous populations; (2) numerator-denominator bias and; (3) statistical analytic considerations. We suggest solutions that can be implemented to strengthen the visibility of indigenous peoples around the world in an oral health context. These include acknowledgment of the need to engage indigenous peoples with all data-related processes, encouraging the use of indigenous identifiers in national and regional data sets, and mitigating and/or carefully assessing biases inherent in population oral health methodologies for indigenous peoples.
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http://dx.doi.org/10.1186/s12903-021-01455-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082663PMC
April 2021

Racism and oral health inequities; An overview.

EClinicalMedicine 2021 Apr 6;34:100827. Epub 2021 Apr 6.

Post-Graduate Program in Public Health, Federal University of Santa Catarina, Florianópolis, Brazil.

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http://dx.doi.org/10.1016/j.eclinm.2021.100827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027540PMC
April 2021

Theoretical evidence explaining the relationship between socio-demographic and psychosocial barriers on access to oral health care among adults: A scoping review.

J Dent 2021 04 11;107:103606. Epub 2021 Feb 11.

National Dental Research Institute, Oral Health ACP, Health Services and Systems Research Program, Duke-NUS Medical School, Tiong Bahru, Singapore.

Objectives: Current global models for oral health care are outdated. Out of pocket payments and exclusion from most national health systems has created a gap for access of services by socio-economically vulnerable adults. Our objective is to understand barriers to access and the causal associations between barriers to care.

Data: All study designs with a theoretical/conceptual framework to explain access and barriers among adults were included.

Sources: 6 electronic databases (PubMed, Medline (EBSCO), CINAHL, Embase, Web of Science) including grey literature searches (ProQuest) and expert consultation. The identified studies were then analysed using narrative synthesis and NVivo.

Study Selection/results: 40 studies using a theoretical framework to explain access among adults were identified. Andersen's behavioural model was most used. Cost was the primary causal factor that perpetuated the effect of other barriers. Associations were found between age and education level, cost and need, cost and dental anxiety. Study design and analysis used to identify these associations had limitations in determining causality.

Conclusion: Oral health access research is based in theory, leading to the identification of socio-demographic and psychosocial barriers and their relationships. However, a lack of explanation of causal associations persists. This review recognises the importance of understanding the cause of barriers in addition to their nature. Appropriate study designs and analysis considering the impact of time varying factors on access is required. Empirical analysis needs to focus on the role of confounders and mediators to determine causality successfully. To achieve this a theory driven causal model has been proposed.
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http://dx.doi.org/10.1016/j.jdent.2021.103606DOI Listing
April 2021

Operators matter - An assessment of the expectations, perceptions, and performance of dentists, postgraduate students, and dental prosthetist students using intraoral scanning.

J Dent 2021 02 29;105:103572. Epub 2020 Dec 29.

Faculty of Dentistry, Division of Restorative Dental Sciences, The University of Hong Kong, Hong Kong Special Administrative Region. Electronic address:

Objective: to assess the expectations, perceptions and performance of different operators with varying backgrounds and training in the use of full-arch intraoral scanning (IOS).

Methods And Materials: Dentists (DENT), postgraduate dental students (DPG), and student prosthetists (PROS) were invited to join an IOS training workshop. Participants completed a satisfactory scan of a mannikin-mounted typodont with the total scanning time (TST) recorded. They also completed anonymised pre and post-training questionnaires covering their background, and IOS expectations and experience. Statistical analysis was performed using the Mann-Whitney U, Kruskal Wallis, and chi-square tests. Open-ended questions were analysed manually and using Leximancer.

Results: Twenty-seven participants were recruited: 10 DENT; 10 PROS; and 7 DPG. Positive expectations of IOS was reported by 93 % of participants. Combined TST was 285 ± 83 s, with the PROS TST significantly longer (p < 0.05, 337 ± 79 s). Further training need was reported by 60 % of PROS and 50 % of DENT versus 14 % of DPG. Positive IOS experience was reported by 96 % of participants, 74 % perceived it to be accurate, and 63 % found it easy to use. Eighty-five percent of all participants stated that cost would influence their decision of adopting IOS in their practice.

Conclusion: Expectations and perceptions of IOS were overwhelmingly positive, irrespective of operator background and experience. Scanning performance and training needs depended on the operator's background. Cost of IOS remains a barrier to acquiring the technology.

Clinical Significance: IOS training must be customised to accommodate the needs of different operators. The cost of IOS needs revision to improve its accessibility.
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http://dx.doi.org/10.1016/j.jdent.2020.103572DOI Listing
February 2021

Association between obesity and periodontitis in Australian adults: A single mediation analysis.

J Periodontol 2021 04 29;92(4):514-523. Epub 2020 Sep 29.

School of Public Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.

Background: Obesity and periodontitis are conditions with high burden and cost. This study aims to unfold the proposed pathways through which the effect of obesity in the presence of health behaviors (dental visiting behavior and diabetes) increases the risk of periodontitis?

Methods: The effect decomposition analysis using potential outcome approach was used to determine obesity-related periodontitis risk using the Australian National Survey of Adult Oral Health 2004 to 2006. A single mediation analysis for exposure, "physical-inactivity induced obesity," mediator "dental visiting behavior (a de facto measure of healthy behaviors)," outcome "periodontitis," and confounders "age, sex, household income, level of education, self-reported diabetes, alcohol-intake and smoking," was constructed for subset of 3,715 participants, aged ≥30 years. Proposed pathways were set independently for each risk factor and in synergy. The STATA 15 Paramed library was used for analysis. Sensitivity analysis was conducted to detect unmeasured confounding using non-parametric approach.

Results: The average treatment effect of physical inactivity induced obesity to periodontitis is 14%. Pathway effect analysis using potential outcomes illustrated that the effect of obesity on periodontitis that was not mediated through poor dental visiting behavior was 10%. Indirect effect of obesity-mediated through poor dental visiting behavior on periodontitis was 3%.

Conclusions: The direct effect of physical inactivity induced obesity on periodontitis was higher than the indirect effect of obesity on periodontitis through dental visiting behavior. Establishing a pathway of causal relationship for obesity and periodontitis could help in developing management strategies that focuses on mediators.
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http://dx.doi.org/10.1002/JPER.20-0044DOI Listing
April 2021

Tooth loss, denture wearing and implants: Findings from the National Study of Adult Oral Health 2017-18.

Aust Dent J 2020 06;65 Suppl 1:S23-S31

The University of Queensland, School of Dentistry, Brisbane, Queensland, Australia.

Background: We aimed to describe the prevalence of different tooth loss outcomes along with the use of dentures and implants among Australians aged 15+ years across socioeconomic and demographic groups. In addition, we performed time trend analyses of tooth loss.

Methods: Data from the National Study of Adult Oral Health 2017-18 included gender, age, residential location, household income, Socio-Economic Indexes for Areas, possession of dental insurance and pattern of dental visiting. Outcomes were complete tooth loss, inadequate dentition, average number of missing teeth, denture wearing and implants. We compared our findings with data from previous surveys carried out in 1987-88 and 2004-06.

Results: Tooth loss decreased from 14.4% in 1987-88 to 6.4% in 2004-06, and to 4.0% in 2017-18. The proportion of people with lack of functional dentition halved from 20.6% 1987-88 to 10.2% in 2017-18; the average number of teeth lost due for any reason slightly reduced from 2004-06 (6.1) to 2017-18 (5.7). Tooth loss increased with age and was higher among socioeconomically disadvantaged, uninsured and those with unfavourable pattern of dental visiting groups than in their counterparts.

Conclusions: An overall improvement in tooth retention was identified over the last decades. However, socioeconomic inequalities persist.
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http://dx.doi.org/10.1111/adj.12761DOI Listing
June 2020

Guest Editorial.

Aust Dent J 2020 06;65 Suppl 1:S3-S4

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http://dx.doi.org/10.1111/adj.12770DOI Listing
June 2020

Income at birth and tooth loss due to dental caries in adulthood: The 1982 Pelotas birth cohort.

Oral Dis 2020 Oct 26;26(7):1494-1501. Epub 2020 May 26.

Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.

Objective: To estimate the effect of income at birth on adulthood tooth loss due to dental caries in 539 adults from the 1982 Pelotas birth cohort.

Methods: Family income was collected at birth. Tooth loss was clinically assessed when individuals were aged 31. Dental visit and oral hygiene at age 25 were considered mediators. Confounders included maternal skin color, and individual's skin color, sex, and income in adulthood. Marginal structural modeling was used to estimate the controlled direct effect of income at birth on tooth loss due to dental caries that was neither mediated by the use of dental service nor oral hygiene.

Results: Forty-three percent of the individuals of low income at birth lost one/two teeth, and 23% lost three or more; among those non-poor, the prevalence was 30% and 14%, respectively. Poor individuals at birth had a 70% higher risk for missing teeth in adulthood than those non-poor. The risk of losing one/two (risk ratio 1.68) and three or more teeth (risk ratio 3.84) was also higher among those of low income at birth.

Conclusions: Economic disadvantage at birth had an effect on tooth loss due to dental caries at age 31 not mediated by individual risk factors.
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http://dx.doi.org/10.1111/odi.13373DOI Listing
October 2020

Collider bias in the association of periodontitis and carotid intima-media thickness.

Community Dent Oral Epidemiol 2020 08 3;48(4):264-270. Epub 2020 Mar 3.

School of Dentistry and Oral Health, Griffith University, Gold Coast Campus, Southport, QLD, Australia.

Objectives: This cross-sectional study tested the presence of collider bias in the relationship between periodontitis and the carotid intima-media thickness (cIMT).

Methods: Data from 480 members of the 1982 Pelotas Birth Cohort, Brazil, were used. Periodontitis at the age of 24 years was determined as the main exposure. cIMT at the age of 30 years was set as the outcome. High-sensitivity C-reactive protein (hsCRP) was considered the mediator (collider). Confounding variables included sex, income, BMI and smoking. The association between cIMT and periodontitis was tested in conventional logistic regression stratified on hsCRP levels, marginal structural modelling and sensitivity analysis for collider stratification bias.

Results: Conventional adjusted logistic regression analysis showed a positive association between periodontitis and cIMT (OR 1.5; 95% CI 1.1; 2.3). Stratified analysis according to the hsCRP levels revealed that the magnitude of the association was even higher among participants with hsCRP ≥ 3 mg/L (OR 2.2, 95% CI 1.1; 4.2) with 36% collider bias probability. No association between periodontitis and cIMT was found among participants with hsCRP < 3 mg/L (OR 1.3; 95% CI 0.8; 2.1). The association was not detected using marginal structural modelling (OR 1.3, 95% CI 0.8; 2.0).

Conclusions: The association between periodontitis and surrogate markers of cardiovascular disease might be induced by collider bias stratification using conventional regression analysis.
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http://dx.doi.org/10.1111/cdoe.12525DOI Listing
August 2020

Oral diseases: a global public health challenge - Authors' reply.

Lancet 2020 01;395(10219):186-187

WHO Collaborating Centre for Oral Health Inequalities and Public Health, Department of Epidemiology and Public Health, University College London, London WC1E 6BT. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(19)32997-6DOI Listing
January 2020

Ending the neglect of global oral health: time for radical action.

Lancet 2019 Jul;394(10194):261-272

WHO Collaborating Centre for Quality-Improvement, Evidence-Based Dentistry, Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York, NY, USA; New York University College of Global Public Health, New York, NY, USA.

Oral diseases are a major global public health problem affecting over 3·5 billion people. However, dentistry has so far been unable to tackle this problem. A fundamentally different approach is now needed. In this second of two papers in a Series on oral health, we present a critique of dentistry, highlighting its key limitations and the urgent need for system reform. In high-income countries, the current treatment-dominated, increasingly high-technology, interventionist, and specialised approach is not tackling the underlying causes of disease and is not addressing inequalities in oral health. In low-income and middle-income countries (LMICs), the limitations of so-called westernised dentistry are at their most acute; dentistry is often unavailable, unaffordable, and inappropriate for the majority of these populations, but particularly the rural poor. Rather than being isolated and separated from the mainstream health-care system, dentistry needs to be more integrated, in particular with primary care services. The global drive for universal health coverage provides an ideal opportunity for this integration. Dental care systems should focus more on promoting and maintaining oral health and achieving greater oral health equity. Sugar, alcohol, and tobacco consumption, and their underlying social and commercial determinants, are common risk factors shared with a range of other non-communicable diseases (NCDs). Coherent and comprehensive regulation and legislation are needed to tackle these shared risk factors. In this Series paper, we focus on the need to reduce sugar consumption and describe how this can be achieved through the adoption of a range of upstream policies designed to combat the corporate strategies used by the global sugar industry to promote sugar consumption and profits. At present, the sugar industry is influencing dental research, oral health policy, and professional organisations through its well developed corporate strategies. The development of clearer and more transparent conflict of interest policies and procedures to limit and clarify the influence of the sugar industry on research, policy, and practice is needed. Combating the commercial determinants of oral diseases and other NCDs should be a major policy priority.
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http://dx.doi.org/10.1016/S0140-6736(19)31133-XDOI Listing
July 2019

Oral diseases: a global public health challenge.

Lancet 2019 Jul;394(10194):249-260

WHO Collaborating Centre in Oral Health Inequalities and Public Health, Department of Epidemiology and Public Health, University College London, London, UK. Electronic address:

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.
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http://dx.doi.org/10.1016/S0140-6736(19)31146-8DOI Listing
July 2019

Six-year trends in dental pain and maternal education inequalities among Brazilian adolescents.

Community Dent Oral Epidemiol 2019 12 1;47(6):454-460. Epub 2019 Jul 1.

School of Dentistry, Federal University of Minas Gerais, Belo Horizonte-MG, Brazil.

Objective: To analyse trends in dental pain prevalence among Brazilian adolescent students over 6 years, focusing on inequalities by maternal education.

Methods: Data from the National Adolescent School-Based Health Survey (PeNSE) carried out in 2009 (n = 45 239), 2012 (n = 46 482) and 2015 (n = 35 592) were analysed, including ninth grade students from the 27 state capitals in Brazil who were of ages 11-17 years or older. Variables analysed were dental pain within the last 6 months (yes/no) and the following sociodemographic factors: age, sex, race, type of school and maternal schooling (years of study: ≤8; 9-11; ≥12). The prevalence of dental pain in the 3 years was compared using the Rao-Scott test. Relative and absolute measures of socioeconomic (maternal education) inequalities in dental pain were applied using the slope index of inequality (SII) and the relative concentration index (RCI).

Results: The prevalence of dental pain increased from 17.5% (95% CI = 16.9-18.2) in 2009 to 20.4% (95% CI = 19.7-21.1) in 2012, then to 21.8% (95% CI = 21.1-22.5) in 2015. All sociodemographic factors investigated were associated with dental pain in all survey years. There was an increasing proportion of the outcome in all categories of maternal education over the years studied. Absolute (SII) and relative (RCI) inequalities regarding of maternal education were found; these indicate higher levels of dental pain in the lower socioeconomic group in each study year. However, no significant changes in inequalities were found from 2009 to 2015.

Conclusions: The prevalence of dental pain increased in the 2009-2012 and 2012-2015 periods, and social inequalities were found. Higher levels of dental pain persisted in the lower maternal education group. Inequalities remained stable over time. Broader actions to reduce the existing inequalities are needed and should be a priority for public policies.
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http://dx.doi.org/10.1111/cdoe.12483DOI Listing
December 2019

Socioeconomic gradients in toothache experience among Australian adults: A time trend analysis from 1994 to 2013.

Community Dent Oral Epidemiol 2019 08 2;47(4):324-332. Epub 2019 May 2.

Australian Research Centre for Population Oral Health, Adelaide Dental School, The University of Adelaide, Adelaide, South Australia, Australia.

Objectives: To identify time trend pattern in toothache and to estimate whether toothache prevalence differs by socioeconomic position and residential location over time.

Methods: Data from nine successive National Dental Telephone Interview Surveys (NDTIS) from 1994 (n = 6907) to 2013 (n = 6778) performed in Australia among individuals aged 15 years or over were used. The dependent variable was toothache reported very often, often or sometimes during the previous 12 months. Independent variables were age group, household income (tertiles), insurance/cardholder status and geographical remoteness. Prais-Winsten analyses were performed, and the average annual percentage change (AAPC) for toothache prevalence was estimated.

Results: Toothache affected slightly more than 10% of the overall population in 1994 (11.6%) and 1995 (11.4%), reaching approximately one-sixth (16.2%) of individuals in 2013. Overall, there was a significant increase in toothache prevalence over time (AAPC = 2.0% [95% CI 0.7;1.34]) and in those aged 25-44 (AAPC 2.1% [95% CI 0.6;3.6]) and 45-64 (AAPC 3.4% [95% CI 1.5;5.3]) years and markedly among those in the lowest income group (AAPC 3.4% [95% CI 0.1;6.7]). All geographic locations except for remote/very remote areas had upward toothache prevalence over time. Insured status was not associated with increased toothache prevalence during the investigated period.

Conclusions: Toothache prevalence increased from 1994 to 2013 in Australian adults particularly among the lowest socioeconomic group.
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http://dx.doi.org/10.1111/cdoe.12461DOI Listing
August 2019

Area-level social development and indicators of public dental services in Southern Brazil.

Community Dent Oral Epidemiol 2019 06 25;47(3):274-280. Epub 2019 Mar 25.

Australian Research Centre for Population Oral Health (ARCPOH), The University of Adelaide, Adelaide, South Australia, Australia.

Objectives: This study aimed to test associations between a municipal social development indicator and indicators of public dental services; examine differences in the achievement of public dental services goals between fluoridated and nonfluoridated municipalities; and, quantify contribution of a municipal social development indicator in estimated mean differences in the public dental services indicators between fluoridated and nonfluoridated municipalities.

Methods: A secondary analysis of data from 293 municipal dental health services records from Southern Brazil between 2010 and 2015 was conducted. Multivariable log-binomial regression models were fitted to test the associations between municipal Human Development Index (HDI) and multiple public dental services indicators (proportion of public dental health service coverage, the proportion of tooth extraction among all clinical procedures, and monthly participation in supervised tooth brushing). Cut-off points for outcomes were based on state goals for public dental services. Blinder-Oaxaca decomposition analyses were performed to quantify the relative contribution of HDI in the differences in outcomes according to the municipal water fluoridation status.

Results: Municipalities within the lowest tertile of HDI had 66% lower prevalence of having insufficient public dental health service coverage (less than state goals)than those in the highest tertile of HDI (PR: 0.44; 95% CI: 0.24, 0.50). Municipalities with lowest HDI had nearly 30% higher prevalence of failing the state goals regarding the proportion of extraction and supervised tooth brushing (PR: 1.30; 95% CI: 1.20, 1.40 and PR: 1.34; 95% CI: 1.23, 1.45, respectively). Mean public dental health service coverage was higher in nonfluoridated municipalities than fluoridated municipalities, and municipal HDI explained 36% of the total estimated mean difference.

Conclusions: This study found associations between municipal social development and public dental services indicators in Southern Brazil. However, higher HDI was associated with lower public dental health service coverage, lower proportion of extraction and higher coverage of supervised tooth brushing [Correction added on 2 April 2019, after first online publication: In the preceding sentence, the text "but with a higher proportion of extraction and supervised tooth brushing" was changed to "lower proportion of extraction and higher coverage of supervised tooth brushing"]. Municipal HDI contributed significantly towards the gap in public dental coverage between fluoridated and nonfluoridated municipalities, favoring nonfluoridated municipalities. These findings have important policy implications for reducing oral health inequalities as it highlights the interplay between key oral health policies and their distribution according to municipal social development.
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http://dx.doi.org/10.1111/cdoe.12455DOI Listing
June 2019

Is there an association between depression and periodontitis? A birth cohort study.

J Clin Periodontol 2019 01;46(1):31-39

Graduate Program in Dentistry, Federal University of Pelotas, Pelotas, Brazil.

Aim: To investigate the association between depression and periodontitis among adults enrolled in the 1982 Pelotas Birth Cohort, Brazil.

Materials And Methods: Major depressive episode (MDE) and severity of depressive symptoms obtained in 2012 were considered the exposure of this study. In 2013, periodontitis, the outcome of interest, was clinically assessed and two different case definitions were used: the CDC/AAP and a combination of clinical attachment loss (CAL) and bleeding on probing (BOP) simultaneously. Serum levels of C-reactive protein and frequency of dental flossing were defined as mediators while confounders comprised a set of variables collected throughout the life-course of the participants. The parametric g-formula was used to test the direct, indirect and total effects of depression on periodontitis.

Results: 539 participants were clinically examined. Individuals with depressive symptoms presented higher risk of periodontitis (risk ratio [RR] 1.19). The presence of depressive symptoms was also associated with moderate/severe periodontitis (total effect RR 1.18). None of the associations was mediated by flossing or C-reactive protein levels. Finally, neither the presence of depressive symptoms nor the presence of major depression was associated with the combination of CAL+BOP.

Conclusions: A positive association between depressive symptoms and periodontitis and moderate/severe periodontitis was found. MDE was not associated with periodontitis.
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http://dx.doi.org/10.1111/jcpe.13039DOI Listing
January 2019

How Should We Evaluate and Use Evidence to Improve Population Oral Health?

Dent Clin North Am 2019 01 29;63(1):145-156. Epub 2018 Oct 29.

Main Arts Building, Bangor University, Bangor, UK.

Generating and implementing evidence-based policy is an important aim for many publicly funded health systems. In dentistry, this is based on the assumption that evidence-based health care increases the efficiency and effectiveness of interventions to improve oral health at a population level. This article argues that a linear logic model that links the generation of research evidence with its use is overly simplistic. It also challenges an uncritical interpretation of the evidence-based paradigm and explores approaches to the evaluation of complex interventions and how they can be embedded into policy and practice to improve oral health at a population level.
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http://dx.doi.org/10.1016/j.cden.2018.08.009DOI Listing
January 2019

Metabolic syndrome and periodontitis: A structural equation modeling approach.

J Periodontol 2019 06 7;90(6):655-662. Epub 2018 Dec 7.

School of Dentistry and Oral Health, Griffith University, Gold Coast, Queensland, Australia.

Background: This study aimed to investigate the association between metabolic syndrome (MetS) and periodontitis among young adults, and also to compare results using observed and latent variables for MetS and periodontitis.

Methods: Data from the 1982 Pelotas Birth Cohort, Brazil, were used. Metabolic syndrome at the age of 23 years was measured using clinical and biochemical analysis and set as the main exposure. Periodontitis at the age of 31 years was clinically measured and set as the outcome. Confounding variables included sex and maternal education, assessed at birth, family income at 23 years, and smoking status at the age of 23 and 30 years. Factor analyses (exploratory and confirmatory) were performed to define latent variables for MetS and periodontitis. In addition, both conditions were also defined as categorical observed variables. The association between MetS and periodontitis was tested in structural equation models.

Results: Two latent periodontal variables were identified: "initial" and "advanced" periodontitis, while one latent variable was identified for MetS. Metabolic syndrome is positively associated with "advanced" (coefficient 0.11; P value < 0.01), but not with "initial" (coefficient -0.01; P value = 0.79) periodontitis. When MetS and periodontitis were set as observed variables in the structural equation models, no association was found irrespective of the criteria used for periodontitis classification.

Conclusions: There was a positive association between metabolic syndrome and "advanced" periodontitis, when the multiple dimensions of both diseases were accounted in latent variables. Nevertheless, when MetS and periodontitis were treated as observed variables, no association was detected irrespective of the criteria used for periodontitis classification.
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http://dx.doi.org/10.1002/JPER.18-0483DOI Listing
June 2019

Prediction models for the incidence and progression of periodontitis: A systematic review.

J Clin Periodontol 2018 12 25;45(12):1408-1420. Epub 2018 Nov 25.

Australian Research Centre for Population Oral Health, the University of Adelaide, Adelaide, South Australia, Australia.

Aims: To comprehensively review, identify and critically assess the performance of models predicting the incidence and progression of periodontitis.

Methods: Electronic searches of the MEDLINE via PubMed, EMBASE, DOSS, Web of Science, Scopus and ProQuest databases, and hand searching of reference lists and citations were conducted. No date or language restrictions were used. The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist was followed when extracting data and appraising the selected studies.

Results: Of the 2,560 records, five studies with 12 prediction models and three risk assessment studies were included. The prediction models showed great heterogeneity precluding meta-analysis. Eight criteria were identified for periodontitis incidence and progression. Four models from one study examined the incidence, while others assessed progression. Age, smoking and diabetes status were common predictors used in modelling. Only two studies reported external validation. Predictive performance of the models (discrimination and calibration) was unable to be fully assessed or compared quantitatively. Nevertheless, most models had "good" ability to discriminate between people at risk for periodontitis.

Conclusions: Existing predictive modelling approaches were identified. However, no studies followed the recommended methodology, and almost all models were characterized by a generally poor level of reporting.
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http://dx.doi.org/10.1111/jcpe.13037DOI Listing
December 2018

Influence of maternal characteristics and caregiving behaviours on children's caries experience: An intergenerational approach.

Community Dent Oral Epidemiol 2018 10 30;46(5):435-441. Epub 2018 Jul 30.

Graduate Program in Dentistry, Federal University of Pelotas, Pelotas, Brazil.

Objectives: This study adopted an intergenerational approach, aiming to answer the following research questions: (a) Are maternal oral health-related behaviours and oral health associated with dental caries in preschool children?; (b) Do maternal caregiving behaviours mediate the association between maternal oral health-related behaviours and dental caries in preschool children.

Methods: Children aged 5 years, enrolled in the 2004 Pelotas (Brazil) Birth Cohort, were investigated (n = 1303). Children were dentally examined using WHO criteria to assess the number of decayed, missing and filled surfaces (dmfs), and their mothers were interviewed. Standardized direct, indirect and total effects of maternal characteristics (frequency of toothbrushing, dental anxiety, the pattern of dental attendance, self-perception about oral health and self-reported dental caries) on maternal caregiving behaviours and children's dmfs were assessed using path analysis.

Results: Mean dmfs was 4.1 (95% CI 3.6;4.5). Maternal oral health-related behaviours had no direct effect on children's dental caries: child dental attendance pattern partially mediates the effect of maternal dental attendance pattern on dental caries (87.8%; P < 0.05) and partially mediates the effect of maternal dental anxiety (39.9%; P < 0.001). Child frequency of toothbrushing mediates 28.0% (P < 0.001) of the effect of maternal frequency of toothbrushing on dental caries.

Conclusions: Socioeconomic factors directly influenced children's caries experience, whereas maternal oral health-related behaviours had no direct effect. It was observed an indirect effect of maternal dental anxiety and dental attendance pattern on children's dental caries mediated by caregiving behaviours, such as child dental attendance pattern and frequency of toothbrushing.
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http://dx.doi.org/10.1111/cdoe.12406DOI Listing
October 2018

Investigating societal determinants of oral health-Opportunities and challenges in multilevel studies.

Community Dent Oral Epidemiol 2018 08 20;46(4):317-327. Epub 2018 Feb 20.

Australian Research Centre for Population Oral Health (ARCPOH), Adelaide Dental School, The University of Adelaide, Adelaide, SA, Australia.

The high prevalence of oral diseases and the persistent nature of socioeconomic inequalities in oral health outcomes across societies presents a significant challenge for public health globally. A debate exists in epidemiology on the merits of investigating population variations in health and its determinants over studying individual health and its individual risk factors. The choice of analytical unit for health outcomes at the population level has policy implications and consequences for the causal understanding of population-level variations in health/disease. There is a lack of discussion in oral epidemiology on the relevance of studying population variations in oral health. Evidence on the role of societal factors in shaping variations in oral health at both the individual level and the population level is also mounting. Multilevel studies are increasingly applied in social epidemiology to address hypotheses generated at different levels of social organization, but the opportunities offered by multilevel approaches are less applied for studying determinants of oral health at the societal level. Multilevel studies are complex as they aim to examine hypotheses generated at multiple levels of social organization and require attention to a range of theoretical and methodological aspects from the stage of design to analysis and interpretation. This discussion study aimed to highlight the value in studying population variations in oral health. It discusses the opportunities provided by multilevel approaches to study societal determinants of oral health. Finally, it reviews the key methodological aspects related to operationalizing multilevel studies of societal determinants of oral health.
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http://dx.doi.org/10.1111/cdoe.12369DOI Listing
August 2018

Area-level income inequality and oral health among Australian adults-A population-based multilevel study.

PLoS One 2018 24;13(1):e0191438. Epub 2018 Jan 24.

Australian Research Centre for Population Oral Health (ARCPOH), Adelaide Dental School, The University of Adelaide, Adelaide, Australia.

Background: A lack of evidence exists on the association between area-level income inequality and oral health within Australia. This study examined associations between area-level income inequality and oral health outcomes (inadequate dentition (<21 teeth) and poor self-rated oral health) among Australian adults. Variations in the association between area-level income inequality and oral health outcomes according to area-level mean income were also assessed. Finally, household-income gradients in oral health outcomes according to area-level income inequality were compared.

Methods: For the analyses, data on Australian dentate adults (n = 5,165 nested in 435 Local Government Areas (LGAs)) was obtained from the National Dental Telephone Interview Survey-2013. Multilevel multivariable logistic regression models with random intercept and fixed slopes were fitted to test associations between area-level income inequality and oral health outcomes, examine variations in associations according to area-level mean income, and examine variations in household-income gradients in outcomes according to area-level income inequality. Covariates included age, sex, LGA-level mean weekly household income, geographic remoteness and household income.

Results: LGA-level income inequality was not associated with poor self-rated oral health and inversely associated with inadequate dentition (OR: 0.64; 95% CI: 0.48, 0.87) after adjusting for covariates. Inverse association between income inequality and inadequate dentition at the individual level was limited to LGAs within the highest tertile of mean weekly household income. Household income gradients in both outcomes showed poorer oral health at lower levels of household income. The household income gradients for inadequate dentition varied according to the LGA-level income inequality.

Conclusion: Findings suggest that income inequality at the LGA-level in Australia is not positively associated with poorer oral health outcomes. Inverse association between income inequality and inadequate dentition is likely due to the contextual differences between Australia and other high-income countries.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191438PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5783384PMC
February 2018

Oral health-related behaviours do not mediate the effect of maternal education on adolescents' gingival bleeding: A birth cohort study.

Community Dent Oral Epidemiol 2018 04 27;46(2):169-177. Epub 2017 Nov 27.

Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.

Objectives: To test whether maternal education has a direct effect on gingival bleeding in adolescents aged 12 and to assess whether oral health behaviours over time mediate that association.

Methods: Two oral health studies nested in the 1993 Pelotas (Brazil) birth cohort study were carried out in participants aged 6 (n = 359) and 12 years (n = 339). The proportion of teeth with bleeding on probing (BOP) and the median number of teeth with gingivitis at age 12 were recorded. Maternal education at birth was the exposure. Toothbrushing frequency and dental visit at ages 6 and 12 years were investigated as mediators of the association between maternal education at birth and gingival bleeding. Time-varying family income through childhood and adolescence was included as later confounder. Paternal education was taken as baseline confounder. The controlled direct effect (CDE) of maternal education at child's birth on gingival bleeding at age 12 was estimated using marginal structural models (MSM). Additionally, path analysis was employed to estimate standardized direct, indirect and total effects of maternal education at birth on gingival bleeding.

Results: Adjusted analyses using MSM showed that adolescents whose mothers had <8 years of education had 3.82 higher risk of having teeth with gingival bleeding above the median (rate ratio RR 3.82; 95% CI: 1.68-8.19). Low maternal education doubled the proportion of gingival bleeding at age 12 not mediated by dental visit and toothbrushing frequency (RR 1.99; 95% CI: 1.52-2.60). Path analysis revealed that maternal education had a direct effect on gingival bleeding independently of the mediators.

Conclusions: The pattern of oral health behaviours does not explain the association between mother's education and adolescent's gingival bleeding. Individual-based approaches focused on oral health-related behaviours tend to fail to prevent gingival bleeding.
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http://dx.doi.org/10.1111/cdoe.12350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5887883PMC
April 2018

Effect of life-course family income trajectories on periodontitis: Birth cohort study.

J Clin Periodontol 2018 04 12;45(4):394-403. Epub 2018 Mar 12.

Australian Research Centre for Population Oral Health (ARCPOH), Adelaide Dental School, The University of Adelaide, Adelaide, SA, Australia.

Aims: To quantify the impact of life course income trajectories on periodontitis in adulthood.

Materials And Methods: Data from the 1982 Pelotas Birth Cohort Study, Brazil, were used. Information on family income was collected at birth and ages 15, 19, 23 and 30 years. Group-based trajectory modelling was used to identify income trajectories. Periodontal measures were assessed through clinical examination at age 31. Log-Poisson regression models were used to estimate prevalence ratios (PRs) of any and moderate/severe periodontitis, as outcomes.

Results: Prevalence of any periodontitis and moderate/severe periodontitis was 37.3% and 14.3% (n = 539). Income trajectories were associated with prevalence of moderate/severe periodontitis. Adjusted PR in participants in low and variable income trajectory was 2.1 times higher than in participants in stable high-income trajectory. The unadjusted association between income trajectories and prevalence of any periodontitis was explained by the inclusion of behavioural and clinical variables in the model.

Conclusions: Low and variable life course income increased the prevalence of moderate/severe periodontitis at age 31 years. The findings may inform programmes in identifying and targeting potentially at-risk groups during the life course to prevent periodontitis.
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http://dx.doi.org/10.1111/jcpe.12845DOI Listing
April 2018

Higher experience of caries and lower income trajectory influence the quality of restorations: A multilevel analysis in a birth cohort.

J Dent 2018 01 21;68:79-84. Epub 2017 Nov 21.

Graduate Program in Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, RS, Brazil.

Objectives: This study aimed to evaluate the quality of posterior restorations (amalgam or composite) placed in adults from a birth cohort and its association with clinical and socioeconomic determinants experienced during their life course.

Methods: A representative sample (n=539) of all 5914 births occurring in Pelotas (Brazil) in 1982 was prospectively investigated. Quality of posterior restorations (satisfactory or unsatisfactory) was assessed at 31 yrs-old, using modified USPHS criteria. Trained and calibrated dentists performed clinical examination. Explanatory variables included demographic and socioeconomic, oral health and dental service utilization patterns during the life course. Tooth related variables (type of tooth, material, size of cavity) were also analyzed. Untreated caries and socioeconomic status were assessed by group-based trajectories analyses. Multilevel Regression models were used to determine factors associated with restoration outcomes.

Results: In total 2123 restorations (53% composite) were evaluated of which 107 (5%) were assessed as failed. The main reasons for failure were tooth/restoration fracture (50.5%) and secondary caries (30.7%). Failures in posterior restorations showed a significant association with socioeconomic aspects (lower tertile of income at age 30 - prevalence ratio (PR) 2.21 [95% CI 1.19-4.09]), clinical variables (trajectory of higher untreated caries - PR 2.11 [95% CI 1.23-3.61]) and also with tooth-related factors (Restorations involving three or more surfaces - PR 5.51 [95% CI 3.30-9.19]) after adjustment for each other.

Conclusions: These findings suggest that, although tooth-related variables have an important role in restoration longevity, patient-related factors, such as socioeconomic variables and untreated caries are also associated with failure and should be taken into account when evaluating longevity of posterior restorations.

Clinical Significance: This was the first study assessing long-term trajectory of untreated caries, showing an association between higher experience of caries during the life-course and unsatisfactory restorations. The findings suggest that individual related factors should be considered when planning treatment and in future research evaluating the longevity of dental restorations.
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http://dx.doi.org/10.1016/j.jdent.2017.11.009DOI Listing
January 2018

Childhood socioeconomic conditions and teeth in older adulthood: Evidence from SHARE wave 5.

Community Dent Oral Epidemiol 2018 02 19;46(1):78-87. Epub 2017 Sep 19.

Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany.

Objectives: Dental diseases are the most common chronic diseases worldwide. Healthy teeth are vital for quality of life, particularly diet and nutrition. However, little information exists to inform health policymakers about potentially long-lasting influences of early-life conditions. The purpose of this study was to investigate the relation between early-life socioeconomic conditions and number of natural teeth at age 50 and above.

Methods: Analyses were conducted on cross-sectional data from the Survey of Health, Ageing and Retirement in Europe (SHARE wave 5), which includes information on 41 560 respondents aged 50 years or older from 14 European countries and Israel. Using SHARE life history information, a series of regression models (OLS, Tobit) were estimated to analyse the relationship between socioeconomic conditions in earlier life and the number of teeth at age 50+.

Results: Childhood socioeconomic background was associated with the number of natural teeth at age 50 and above, even after controlling for current determinants of oral health. Respondents who had had more than 25 books in their childhood household had a mean 1.4 (95% CI: 1.2-1.5) more teeth than respondents with fewer books. Respondents who reported poor financial conditions during childhood had a mean 0.6 (95% CI: 0.3-0.9) fewer teeth than respondents who reported better financial conditions in childhood.

Conclusion: These findings substantiate the association between socioeconomic conditions in the early years of life and tooth retention to older adulthood and highlight the long-lasting relation between childhood living conditions and oral health through the lifecourse.
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http://dx.doi.org/10.1111/cdoe.12332DOI Listing
February 2018

The magnitude of Indigenous and non-Indigenous oral health inequalities in Brazil, New Zealand and Australia.

Community Dent Oral Epidemiol 2017 10 16;45(5):434-441. Epub 2017 May 16.

Australian Research Centre for Population Oral Health, Adelaide Dental School, The University of Adelaide, Adelaide, SA, Australia.

Objective: To compare the magnitude of relative oral health inequalities between Indigenous and non-Indigenous persons from Brazil, New Zealand and Australia.

Methods: Data were from surveys in Brazil (2010), New Zealand (2009) and Australia (2004-06 and 2012). Participants were aged 35-44 years and 65-74 years. Indigenous and non-Indigenous inequalities were estimated by prevalence ratios (PR) and their corresponding 95% confidence intervals (CI), adjusting for sex, age and income. Outcomes included inadequate dentition, untreated dental caries, periodontal disease and the prevalence of "fair" or "poor" self-rated oral health in Australia and New Zealand, and satisfaction with mouth/teeth in Brazil (SROH).

Results: Irrespective of country, Indigenous persons had worse oral health than their non-Indigenous counterparts in all indicators. The magnitude of these ratios was greatest among Indigenous and non-Indigenous Australians, who, after adjustments, had 2.77 times the prevalence of untreated dental caries (95% CI 1.76, 4.37), 5.14 times the prevalence of fair/poor SROH (95% CI 2.53, 10.43).

Conclusion: Indigenous people had poorer oral health than their non-Indigenous counterparts, regardless of setting. The magnitude of the relative inequalities was greatest among Indigenous Australians for untreated dental decay and poor SROH.
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http://dx.doi.org/10.1111/cdoe.12307DOI Listing
October 2017

Prediction of Periodontitis Occurrence: Influence of Classification and Sociodemographic and General Health Information.

J Periodontol 2017 08 31;88(8):731-743. Epub 2017 Mar 31.

Australian Research Center for Population Oral Health, School of Dentistry, The University of Adelaide, Adelaide, SA, Australia.

Background: Prediction of periodontitis development is challenging. Use of oral health-related data alone, especially in a young population, might underestimate disease risk. This study investigates accuracy of oral, systemic, and socioeconomic data on estimating periodontitis development in a population-based prospective cohort.

Methods: General health history and sociodemographic information were collected throughout the life-course of individuals. Oral examinations were performed at ages 24 and 31 years in the Pelotas 1982 birth cohort. Periodontitis at age 31 years according to six classifications was used as the gold standard to compute area under the receiver operating characteristic curve (AUC). Multivariable binomial regression models were used to evaluate the effects of oral health, general health, and socioeconomic characteristics on accuracy of periodontitis development prediction.

Results: Complete data for 471 participants were used. Periodontitis classifications with lower thresholds yielded superior predictive power. Calculus, pocket, or bleeding presence at age 24 years separately presented fair accuracy. Accuracy increased using multivariable models; for example, the Beck et al. classification AUC from 0.59 to 0.75 combining proportion of teeth with calculus, bleeding, or pocket with income; number of lost teeth; sex; education; people living in the house; prosthetic needs; or number of decayed, missing, or filled teeth (DMFT). Proportion of teeth with pocket, bleeding, or calculus; number of DMFT; toothbrushing frequency; blood pressure; sex; and income were most frequently associated.

Conclusions: Choice of classification might have an impact on accuracy to predict periodontitis occurrence. Regardless of the classification, predictive value for development of periodontitis in young adults might be increased by combining periodontal information, sociodemographic information, and general health history.
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http://dx.doi.org/10.1902/jop.2017.160607DOI Listing
August 2017

Having fewer than 21 teeth associated with poorer general health among South Australians.

J Public Health Dent 2017 Jun 13;77(3):216-224. Epub 2017 Feb 13.

Flinders Health Economics Group & Palliative Care Clinical Studies Collaborative, Flinders University, Adelaide, Australia.

Objective: To explore whether having less than 21 teeth is associated with poorer general health in a representative population sample of South Australians.

Methods: Data were from a cross-sectional state-based survey, conducted from September to December 2013. Complete data were available for 2,908 participants (58 percent response rate). General health-related quality of life (HrQOL), as measured by the EuroQol instrument (EQ-5D-5L), was the main outcome measure. Total disutility scores were calculated, with the five individual EQ-5D dimensions then dichotomized into "no problems" and "at least one problem." The main explanatory variable was self-reported missing teeth, as assessed by having <21 teeth versus 21+ teeth in a questionnaire.

Results: Overall, disutility was low (0.09) (ranges from 0 to 1, with high scores indicating poorer general health). In multivariable analysis, total disutility was positively associated with older age, lower annual household income, lower levels of physical activity, being a current tobacco smoker, receiving mental health treatment and <21 teeth. When individual dimensions were considered, missing teeth remained significantly associated with mobility problems (PR 1.26, 95 percent CI 1.06, 1.50) and pain/discomfort (PR 1.16, 95 percent CI 1.06, 1.27).

Conclusions: Missing teeth was associated with poor general health status as measured by EQ-5D-5L disutility. The relationship was especially evident with respect to mobility and pain/discomfort. The findings emphasize the importance of oral health as predictors of general health.
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http://dx.doi.org/10.1111/jphd.12200DOI Listing
June 2017