Assessment of the contextual effects on the prevalence of periodontitis: a systematic review

FILGUEIRAS, Leonardo Vilar; KONFLANZ, Willian; HAAS, Alex Nogueira; CELESTE, Roger Keller

doi:10.1590/1807-3107bor-2022.vol36.0125

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Systematic Review, Social/Community Dentistry • Braz. oral. res. 36 • 2022 • https://doi.org/10.1590/1807-3107bor-2022.vol36.0125 linkcopy

Assessment of the contextual effects on the prevalence of periodontitis: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study reviews the influence of contextual factors on periodontitis based on a systematic search of studies recorded in the PubMed, Scopus, Web of Science, and EMBASE databases. Periodontitis was assessed by clinical attachment loss and probing depth for studies with data on the socioeconomic status (SES) of a specific area (area-level SES) or dental care service (service-level) in a catchment area among individuals aged 18 and over. Two independent reviewers performed study selection, data extraction, and assessment of methodological quality. Of the 646 articles identified, 13 were included in the systematic review, representing 101,362 individuals from five countries (USA, UK, Brazil, China, and Uruguay). A higher prevalence of periodontitis was described in lower SES neighborhoods, more deprived postcodes, and poorer provinces. Gini Index results were mixed and inconclusive. Three studies showed that higher coverage of primary dental care at the municipal level was associated with a lower prevalence of periodontitis. Contextual factors at the area-level SES and dental care service might influence periodontitis, but the existing evidence is unclear. The contextual effect is important for periodontal health and may contribute to the prevalence of periodontitis, independent of well-known risk factors and individual levels.

Periodontitis; Residence Characteristics; Dental Care; Social Class

Publication	Sample selection (5 stars)					Comparability (2 stars)	Outcome (3 stars)	Total
	1. Representativeness of the sample: a+, random or all subjects; b+, non-random; c, selected groups; d, no description.	2. Sample size: a+, justified and satisfactory; b, not-justified.	3. No respondents: a+, comparability and response rate satisfactory; b, comparability and/or response rate unsatisfactory; c, no description.	4. Ascertainment of the exposure (risk factor): a++, validated measurement tool; b+, non-validated measurement tool, but is available or described; c, no description of measurement tool.		Subjects in outcome groups comparable: a +, study controls for most important confounder; b +, study controls for any additional confounder; c, study did not control for any confounder; d, no comparison group.	Assessment of the outcome: a++, independent blind; b++, record linkage; c+, self-report; d, no description.
							Statistical Test: a+, clearly described and appropriate; b, not described, not appropriate, or incomplete.
Borrell et al., 2006						a+	a+	a+	a++	a+ b+	a++ a+	10
Borrell et al., 2006	a+	a+		c	a++	a+ b+	b++ a+	9
Bower et al., 2007	a+	a+		a+	a++	a+ b+	b++ a+	10
Sabah et al., 2010	d	b		c	a++	a+	b++ a+	6
Hobdell et al., 2003	d	b		c	a++	a+	b++ a+	6
Celeste et al., 2011	a+	a+		a+	a++	a+ b+	a++ a+	10
Vettore et al., 2013	a+	a+		c	a++	a+ b+	a++a+	9
Chalub et al., 2016	a+	a+		c	a++	a+ b+	a++ a+	9
Dalazen et al., 2016	a+	a+		c	a++	a+ b+	a++a+	9
Sun et al., 2017	a+	a+		a+	a++	a+ b+	a++ a+	10
Valente et al., 2017	a+	a+		c	a++	a+ b+	a++a+	9
Bomfim et al., 2018	a+	a+		c	a++	a+ b+	a++a+	9
Lorenzo-Erro et al., 2018	a+	a+		a+	a++	a+ b+	a++ a+	10

Author, year	Country	Population sample size	Age group	Main outcome	Blinded evaluation of outcome	Sample method	Contextual level	Covariates	Total of contextual units
Borrell et al., 2006³¹	USA	5677	45–64	Severe periodontitis (PPD > 5 mm + CAL > 6 mm)	Yes	Randomized	Neighborhood-level SES	Income, education	1000 residences
Borrell et al., 2006²⁴	USA	13,09	≥1 8	Chronic periodontitis (2 sites with CAL > 4 and at least 1 site with PPD > 4 mm or more)	Yes	Randomized	Neighborhood-level SES	Race (ethnicity), income, and education	1126 census tract
Bower et al., 2007¹⁰	UK	632	≥ 16	PPD > 4 mm	Yes	Randomized	Deprivation-area level (index)^a	Age, sex, income, and social class	346 household
Sabah et al., 2010³²	UK	17	35–44	PPD> 6 mm	Yes	Randomized	Gini coefficient ratio between annual income of richest and poorest 20% of the population (20:20 ratio)	Gross domestic product (GDP) and national income (GNI)	17 countries
Hobdell et al., 2003³⁰	UK	44	35–44	PPD > 6 mm	Not described	Not described	Gini Index (1990-1999) and HDI (1992)	Sugar, manufactured cigarettes, and civil strife/instability	44 countries
Celeste et al., 2011¹⁵	Brazil	13,405	35–44	CAL > 8 mm	Yes	Randomized	Gini index (2000)	Age, sex, place of residence, last dental visit, household income	250 municipalities
Vettore et al., 2013⁷	Brazil	9564	35–44	Severe periodontal disease [at least one sextant with PPD ≥ 4 mm (CPI > 2) and at least one sextant with CAL ≥ 6 mm (CAL >1)]	Yes	Randomized	MHDI, Gini index (2000), smokers (%), and OHT/PDC	Age, sex, race, family income, years of schooling	27 municipalities
Chalub et al., 2016²⁹	Brazil	9564	35–44	Functional dentition (FD) in which FD class 6 corresponds to PPD or CAL >5 mm	Yes	Randomized	MHDI and fluoridation water supply	Gender, self-declared skin color, schooling, monthly household income, age group, self-rated treatment need, dental pain, dental appointment in the past 12 months, and dental services	177 municipalities
Dalazen et al., 2016²⁸	Brazil	7619	65–74	PPD > 6mm	Yes	Randomized	MHDI, Gini, and SB/FHS	Sex, self-reported skin color, income, and need for treatment	32 municipalities
Sun et al., 2017¹⁶	China	Adults (20,204) and older individuals (9666)	35–44	PPD and CAL > 4 mm	Yes	Randomized	Gini, dentist to population ratio, and smokers (%)	Sex, ethnicity, place of residence, education level, equivalized income, toothbrushing frequency, last dental visit, and smoking status	31 provinces
Sun et al., 2017¹⁶	China	Adults (20,204) and older individuals (9666)	65–74	PPD and CAL > 4 mm	Yes	Randomized	Gini, dentist to population ratio, and smokers (%)		31 provinces
Valente et al., 2017³³	Brazil	Adults (6011) and older individuals (2369)	35–44	Accumulated attachment loss ( AAL) using the following categories: 0-3 mm, 4-5 mm, 6-8 mm, 9-11 mm, ≥12 mm, and excluded sextant.	Yes	Randomized	Predisposing ^b (HDI and life expectancy) and Enabling b (OHT-PDC)	Age, sex, years of schooling, per capita monthly income, type of dental services, OIDP mean, dental treatment needs, time since last dental visit, and reason for last dental visit	27 municipalities
Valente et al., 2017³³	Brazil	Adults (6011) and older individuals (2369)	65–74		Yes	Randomized			27 municipalities
Bomfim et al., 2018³⁵	Brazil	2332	> 65	PPD > 6 mm	Yes	Randomized	Gini, MHDI, and fluoridation	Gender, self-declare skin color, income, and age group	178 municipalities
Lorenzo-Erro et al., 2018³⁴	Uruguay	Adults (223) and older individuals (455)	35–44	PPD and CAL > 4 mm	Yes	Randomized	Unsatisfied basic needs (UBN) ^c	Individual-SES (Sex, time since last visit), behavioral (heavy smoker, diet, drinking, and toothbrushing)	10 provinces
Lorenzo-Erro et al., 2018³⁴	Uruguay	Adults (223) and older individuals (455)	65–74	PPD and CAL > 4 mm	Yes	Randomized	Unsatisfied basic needs (UBN) ^c		10 provinces

Author, year	Country	Age group	Area-level SES	OR	95% CI	r	p-value
Borrell et al., 2006³¹	USA	45–64	Neighborhood-level SES
			High	1
			Medium	1.10	0.90-1.30*
			Low	1.10	0.80-1.30*
	USA	≥ 18	High	1
			Medium	1.63	1.23-2.17*
			Low	1.73	1.29-2.32*
Lorenzo-Erro et al., 2018³⁴	Uruguay	35–44	Province-level SES
			Greater area-level (score1)	1
			Lower area-level (score 2)	1.51	1.42-1.60
		65–74	Greater area-level (score 1)	1
		65–74	Lower area-level (score 2)	1.31	1.21-1.42
Bower et al., 2007¹⁰	UK	≥ 16	Postcode-level SES
			Least deprived area-level (score 1)	1
			Most deprived area-level (score 7)	7.60	0.48-119.2*
Sabah et al., 2010³²	UK	35–44	Country-level SES (Gini/HDI)
			Gini coefficient/GDP	-	-	0.55	0.03
			Gini coefficient/GNI	-	-	0.53	0.03
			20:20/GDP	-	-	0.62	0.01
			20:20/GNI	-	-	0.61	0.01
Hobdell et al., 2003³⁰	UK	35–44	Gini Index ( 1990-1999)	-	-	0.25	<0.01
Hobdell et al., 2003³⁰	UK	35–44	HDI (1992)	-	-	0.23	<0.01
Celeste et al., 2011¹⁵	Brazil	35–44	Municipal- or province-level Gini/HDI
Celeste et al., 2011¹⁵	Brazil	35–44	Gini (2000; every 10 points)	0.99	0.69-1.44
Vettore et al., 2013⁷	Brazil	35–44	Gini (lower)	1
			Gini (middle)	1.80	1.00-3.20
			Gini (upper)	3.00	1.50-5.90
Chalub et al., 2016²⁹	Brazil	35–44	MHDI (<0.70)	1
			MHDI (0.70-0.79)	1.16	0.99-1.37
			MHDI (>0.80)	1.42	1.16-1.75
Dalazen et al., 2016²⁸	Brazil	65–74	Gini (lower)	1
			Gini (middle)	1.02	0.68-1.55
			Gini (upper)	0.64	0.41-1.00
			MHDI (<0.7)	1
			MHDI (>0.7)	1.09	0.64-1.88
Sun et al., 2017¹⁶	China	35–44	Gini coefficient (%)	0.97	0.87-1.08
Sun et al., 2017¹⁶	China	65–74	Gini coefficient (%)	0.98	0.92-1.05
Valente et al., 2017³³	Brazil	35–44	Predisposing (HDI/Life expectancy)	0.93^PR	0.87-0.99
Valente et al., 2017³³	Brazil	65–74	Predisposing (HDI/Life expectancy)
Bomfim et al., 2018³⁵	Brazil	> 65	Gini (lower)	1
			Gini (middle)	0.75	0.39-1.40
			Gini (upper)	0.90	0.50-1.65
			MHDI (<0.7)	1
			MHDI (0.70-0.79)	1.13	0.18-6.94
			MHDI (>0.80)	0.53	0.07-1.91

Author, year	Country	Age group	Service level	OR	95%CI
Vettore et al. , 2013⁷	Brazil	35–-44	Municipal coverage of primary dental care
			(OHT/PDC)
			<25%	1	-
			25-50%	0.40	0.20–0.80*
			>50%	0.90	0.50–1.70
Dalazen et al., 2016²⁸	Brazil	65–74	<25%	1	-
			25-50%	0.62	0.44–0.89**
			>50%	0.58	0.37–0.92
Valente et al., 2017³³	Brazil	35–44	Enabling (OHT-PDC)	0.99^PR	0.98–0.99*
Valente et al., 2017³³	Brazil	65–74	Enabling (OHT-PDC)	0.99^PR	0.98–0.99*
Bomfim et al., 2018³⁵	Brazil	> 65	<25%	1
			25-50%	0.80	0.39–1.63
			>50%	0.97	0.49–1.91
Sun et al., 2017¹⁶	China	35–44	Province level dental services coverage
		35–44	Dentist/population ratio ^a	0.81	0.69–0.95*
		65–74	Dentist/population ratio ^a	0.86	0.78–0.95**

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[TFN1] PPD: periodontal probing depth; CAL: clinical attachment loss. a) The deprivation-level index is based on four factors in the postcode sector: level of overcrowding in households; male unemployment; the proportion of social classes IV and V; and the proportion of persons in private households with no car. The index consists of seven categories (Depcat 1=least deprived to Depcat 7=most deprived). b) Predisposing was composed of HDI (human developed index) and life expectancy, while enabling was composed of population coverage by primary dental care and oral health care teams into primary care (OHT/PDC). In both dimensions of Anderson´s model, those contextual variables show a high correlation by Spearman´s and are tested by principal component analysis (PCA). c) Unsatisfied basic needs (UBN) was performed to measure socioeconomic deprivation using six dimensions as contextual variables: housing and minimum domestic, household equipment, sanitation facilities, access to education, electricity, and clean drinking water. The absence of one of these dimensions is considered a positive or lower case.