Ethnic differences in oral health and use of dental services: cross-sectional study using the 2009 Adult Dental Health Survey

The Adult Dental Health Survey (ADHS) is a cross sectional study that has been conducted every ten years since 1968 [23]. It was established to provide important information about the general population’s oral health and their access to, and experience of, dental services. The information gleaned is used to plan dental services and monitor adherence to governmental targets. The most recent survey was conducted in 2009 and covered England, Wales and Northern Ireland. In contrast to the two previous surveys, Scotland did not participate. The Oxford National Health Service (NHS) Research Ethics Committee provided ethical approval for the survey to be conducted and anonymised, individual-level data are freely accessible to registered researchers via the UK Data Service.

The 2009 ADHS used a two-stage cluster sampling design. In the first stage, 253 primary sampling units were identified in England and Wales and another 15 in Northern Ireland. Within these primary sampling units, two postcode sectors were then selected from which 25 addresses were sampled to give a total sample size of 13,400 households. These 13,400 households comprised 1,150 households from each of the ten English Strategic Health Authorities (mean population 5.4 million): 1,150 from Wales (population 3.1 million) and 750 from Northern Ireland (population 1.8 million). Recruitment was not stratified by ethnic group and there was no boosted sampling of ethnic minority groups. The household response rate was 60 %. Within participating households, all adults (>16 years) were invited to participate in a face to face interview and participants with at least one natural tooth were invited to undergo a subsequent dental examination. The examination was conducted by NHS salaried dentists who attended study training over four days, undertook supervised practice examinations of volunteers, and underwent a calibration exercise. In brief, the examination included assessment of the condition of teeth surfaces, root surfaces, spaces, aesthetics and dentures, as well as a basic periodontal examination to assess the periodontal condition [24]. Full details of the dental examination are contained in the survey technical report [25]. Of the 13,509 individuals invited to participate in the 2009 ADHS, 11,380 (84 %) consented to the interview and, of the 10,457 dentate interviewees, 6,469 (62 %) underwent the subsequent dental examinations. Both the interview and examination were conducted in participants’ homes.

Data were collected during two ten week periods: October to December 2009 and January to April 2010. The self-reported data collected during the interview and included in our analyses were: sociodemographic information (age, sex, ethnic group, household tenure, number of household members, and educational qualifications (yes/no)), lifestyle (dietary sugar intake and smoking status), use (type of service provider, frequency and type of attendance) and perception of dental services, personal dental hygiene (teeth cleaning with toothpaste and toothbrush, and use of other dental hygiene products including dental floss and mouthwash), dental history (fillings, extractions, dentures and problems eating), and self-reported overall oral health. Postcode of residence was used to derive the Index of Multiple Deprivation (IMD). This is an area-based measure of socioeconomic deprivation derived from 38 indicators collected across seven domains: income, employment, health deprivation and disability, education skills and training, barriers to housing and services, crime and living environment. It is derived at the lower layer super output level which equates to a mean population of 1,600 (range 1,000 to 3,000). The IMD is used to derive quintiles for the general population and the postcode of resident of survey participants could, therefore, be used to allocate participants to a general population socioeconomic deprivation quintile.

We excluded from the study participants who did not provide information on their ethnic group and those whose ethnic group was recorded as mixed or other, because the heterogeneity within these groups would render results difficult to interpret and generalize. Pakistani and Bangladeshi groups had to be combined due to small samples sizes, as did Black African and Caribbean. Therefore the groups included in the analyses were White, Indian, Pakistani/Bangladeshi and Black. The ethnic groups were compared in terms of demographics and socioeconomic status, lifestyle risk factors, use of dental services, personal dental hygiene and self-reported oral health using χ² tests for categorical data. Missing data were imputed using imputation through chained equations using the user written “ice” module in Stata. Twenty imputed datasets were created. Logistic regression models, weighted using the ADHS provided weights, were developed for three separate outcomes available within the survey: presence of any fillings, history of any extractions and possession of fewer than 20 teeth (the recognized threshold for functional dentition) [26]. For each of these outcomes, the White group was used as the reference category. The models were run univariately and then multivariably adjusting for potential confounders (age, sex, educational qualifications, housing tenure, area socioeconomic deprivation quintile and area of residence). We then ran three further multivariable models, including additional covariates, to adjust for: potential lifestyle mediators, potential dental service mediators and both. Lifestyle mediator variables were: frequency of consumption of sweets, cakes and fizzy drinks, adding sugar to hot drinks, smoking status, frequency of teeth cleaning (≥ or < twice per day) and current use of dental hygiene products other than a manual toothbrush and toothpaste. Dental service mediators were: type of service provider (last dental service visit reported as NHS, private or other including hospital dental care), frequency of dental clinic visits (≥2 in past year, 1 in past year, 1 in past 2 years, <1 in past 2 years, or only if symptoms) and ever having had a scale and polish. All of the multivariable models produced areas under the receiver operating characteristic (ROC) of at least 76 % suggesting that the models were a good fit for the data.

We undertook additional logistic regression models in the dentate sub-group who underwent clinical examination. Because of smaller numbers of participants, we combined Indian, Pakistani and Bangladeshi participants into a single South Asian group and excluded Black participants. The two main outcomes studied were: presence of dental caries (defined as ≥1 tooth with untreated decay) and presence of periodontal pockets (defined as ≥1 pocket of ≥6 mm). As with the previous analyses, we used ADHS provided sample weights, ran the models univariately and then adjusted for confounders. We then added lifestyle and dental service mediators as covariates in two further models. The multivariable models all had areas under the receiver operator characteristic (ROC) of at least 0.63 suggesting the models did not adequately explain the variation in outcome variables observed in the dentate sub-group.

All analyses were undertaken using Stata version 14.1. Statistical significance was defined as p < 0.05. Statistical interactions could not be tested due to insufficient statistical power.

1. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:743–800.View ArticlePubMed CentralGoogle Scholar
2. Steele J, Shen J, Tsakos G, Fuller E, Morris S, Watt R, Guarnizo-Herreño C, Wildman J. The interplay between socioeconomic inequalities and clinical oral health. J Dent Res. 2015;94(1):19–26.View ArticlePubMedGoogle Scholar
3. Wu B, Liang J, Luo H, Furter R. Racial and ethnic variations in preventive dental care utilization among middle-aged and older Americans, 1999–2008. Frontiers in Public Health. 2013;1:65.View ArticlePubMedPubMed CentralGoogle Scholar
4. World Health Organisation. Sugars intake for adult and children – guideline. WHO, Geneva 2015. http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/. Accessed April 2016.
5. Rugg-Gunn AJ, Edward WM. Sugar and dental caries; a review of the evidence. Community Dent Health. 1984;8:38–53.Google Scholar
6. Toverud G. The influence of war and post-war conditions on the teeth of Norwegian school children. III. Discussions of food supply and dental condition in Norway and other European countries. Milbank Meml Fund Q. 1957;35:373–459.View ArticleGoogle Scholar
7. Gustafsson BE, Quensel CE, Lanke LS, Lundquist C, Grahnen H, Bonow BE. The Vipeholm dental caries study; the effect of different levels of carbohydrate intake on caries activity in 436 individuals observed for five years. Acta Odontol Scand. 1954;11:232–364.View ArticlePubMedGoogle Scholar
8. Scottish Intercollegiate Guidelines Network. Preventing dental caries in children at high caries risk, targeted prevention of dental caries in the permanent teeth of 6–16 year olds presenting for dental care. SIGN Publications 47. http://www.sign.ac.uk/guidelines/fulltext/47/index.html. Accessed April 2016.
9. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrititon and health: a systematic review and meta-analysis. Am J Public Health. 2007;97(4):667–75.View ArticlePubMedPubMed CentralGoogle Scholar
10. Klinge B, Norlund A. A socio-economic perspective on periodontal diseases: a systematic review. J Clin Periodontol. 2005;32(s6):314–25.View ArticlePubMedGoogle Scholar
11. Tezal M, Grossi SG, Ho AW, Genco RJ. Alcohol consumption and periodontal disease. The Third National Health and Nutrition Examination Survey. J Clin Periodontol. 2004;31:484–8.View ArticlePubMedGoogle Scholar
12. Van der Putten GJ, Vanobbergen J, De Visschere L, Schols J, de Baat C. Association of some specific nutrient deficiencies with periodontal disease in elderly people: a systematic literature review. Nutrition. 2009;25:717–22.View ArticlePubMedGoogle Scholar
13. Health and Social Care Information Centre. Statistics on Smoking – England 2015. HSCIC, 2015. http://www.hscic.gov.uk/catalogue/PUB17526/stat-smok-eng-2015-rep.pdf. Accessed April 2016.
14. Leung G, Stanner S. Diets of minority ethnic groups in the UK: influence on chronic disease risk and implications for prevention. Nutrition Bulletin. 2011;36:161–98.View ArticleGoogle Scholar
15. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye N. The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005;83(9):641–720.Google Scholar
16. The World Oral Health Report 2003. Geneva: World Health Organization; 2003 http://www.who.int/oral_health/media/en/orh_report03_en.pdf. Accessed April 2016.
17. Office for National Statistics. Ethnicity and National Identity in England and Wales 2011. www.ons.gov.uk/ons/dcp171776_290558.pdf. Accessed April 2016.
18. Watt RG, Listl S, Peres M, Heilmann A (eds). Social inequalities in oral health from evidence to action. International Centre for Oral Health Inequalities Research and Policy, London, 2015. http://media.news.health.ufl.edu/misc/cod-oralhealth/docs/posts_frontpage/SocialInequalities.pdf. Accessed April 2016.
19. Baker J, Mitchell R, Pell J. Cross-sectional study of ethnic differences in the utility of area deprivation measures to target socioeconomically deprived individuals. Soc Sci Med. 2013;85:27–31.View ArticlePubMedGoogle Scholar
20. Arevalo SP, Tucker KL, Falcon LM. Beyond cultural factors to understand immigrant mental health: Neighbourhood ethnic density and the moderating role of pre-migration and post-migration factors. Soc Sci Med. 2015;138:91–100.View ArticlePubMedGoogle Scholar
21. Reid BC, Hyman JJ, Macek MD. Race/ethnicity and untreated dental caries: the impact of material and behavioral factors. Community Dent Oral Epidemiol. 2004;32(5):329–36.View ArticlePubMedGoogle Scholar
22. Conway DI, Quarrell I, McCall DR, Gilmour H, Bedi R, Macpherson LM. Dental caries in 5-year-old children attending multi-ethnic schools in Greater Glasgow - the impact of ethnic background and levels of deprivation. Community Dent Health. 2007;24(3):161–5.PubMedGoogle Scholar
23. UK Data Service. Adult Dental Health Survey 2009. http://doc.ukdataservice.ac.uk/doc/6884/mrdoc/UKDA/UKDA_Study_6884_Information.htm. Accessed April 2016.
24. Cole E, Ray-Chaudhuri A, Vaidyanathan M, Johnson J, Sood S. Simplified basic periodontal examination (BPE) in children and adolescents: a guide for general dental practitioners. Dent Update. 2014;41(4):328–37.PubMedGoogle Scholar
25. O’Sullivan I, Lader D, Beavan-Seymour C, Chenery V, Fuller E, Sadler K. 2011. Foundation report: Adult Dental Health Survey 2009 (Technical information). http://www.hscic.gov.uk/pubs/dentalsurveyfullreport09. Accessed April 2016.
26. Newton JT, Gibbons DE, Gelbier S. The oral health of older people from minority ethnic communities in south east England. Gerodontology. 1999;16(2):103–9.View ArticlePubMedGoogle Scholar
27. Sheiham A. Impact of dental treatment on the incidence of dental caries in children and adults. Community Dent Oral Epidemiol. 1997;25(1):104–12.View ArticlePubMedGoogle Scholar
28. Sheiham A, Maizels J, Cushing A, Holmes J. Dental attendance and dental status. Community Dent Oral Epidemiol. 1985;13:304–9.View ArticlePubMedGoogle Scholar
29. Tilashalski KR, Gilbert GH, Boykin MJ, Litaker MS. Racial differences in treatment preferences: oral health as an example. J Eval Clin Pract. 2007;13(1):102–8.View ArticlePubMedGoogle Scholar
30. Cabral ED, Caldas Ade Jr F, Cabral HA. Influence of the patient's race on the dentist's decision to extract or retain a decayed tooth. Community Dent Oral Epidemiol. 2005;33(6):461–6.View ArticlePubMedGoogle Scholar
31. Celeste RK, Concalves LG, Faerstein E, Bastos JL. The role of potential mediators in racial inequalities in tooth loss: the Pro-Saude study. Community Dent Oral Epidemiol. 2013;41(6):509–16.View ArticlePubMedGoogle Scholar
32. Robinson PG, Bhavnani V, Khan FA, Newton T, Pitt J, Thorogood N, et al. Dental caries and treatment experience of adults from minority ethnic communities living in the South Thames Region, UK. Community Dent Health. 1999;17(1):41–7.Google Scholar
33. Mattin D, Smith JM. The oral health status, dental needs and factors affecting utilization of dental services in Asians aged 55 years and over, resident in Southampton. Br Dent J. 1991;170(10):369–72.View ArticlePubMedGoogle Scholar
34. Al-Haboubi M, Klass C, Jones K, Bernabe E, Gallagher JE. Inequalities in the use of dental services among adults in inner South East London. Eur J Oral Sci. 2013;121(3):176–81.View ArticlePubMedGoogle Scholar
35. Selikowitz HS, Holst D. Dental health behavior in a migrant perspective: use of dental services of Pakistani immigrants in Norway. Community Dent Oral Epidemiol. 1986;14(6):297–301.View ArticlePubMedGoogle Scholar
36. Ong G. Periodontal reasons for tooth loss in an Asian population. J Clin Periodontol. 1996;23(4):307–9.View ArticlePubMedGoogle Scholar
37. Aspinall PJ, Mitton L. Smoking prevalence and the changing risk profiles in the UK ethnic and migrant minority populations: implications for stop smoking services. Public Health. 2014;128(3):297–306.View ArticlePubMedGoogle Scholar
38. Merelstein R. Ethnicity, gender and risk factors for smoking initiation: an overview. Nicotine Tob Res. 1999;1 Suppl 2:S39–43.View ArticleGoogle Scholar
39. Kaholokula JK, Braun KL, Kana’iaupuni S, Grandinetti A, Chang HK. Ethnic-by-gender differences in cigarette smoking among Asian and Pacific islanders. Nic Tob Res. 2006;8(2):275–86.View ArticleGoogle Scholar
40. Shetty KV, Johnson NW. Knowledge, attitudes and beliefs of adult South Asians living in London regarding risk factors and signs for oral cancer. Community Dent Health. 1999;16(4):227–31.PubMedGoogle Scholar
41. Croucher R, Islam S, Jarvis MJ, Garrett M, Rahman R, Shajahan S, et al. Oral tobacco cessation with UK resident Bangladeshi women: a community pilot investigation. Health Educ Res. 2003;18(2):216–23.View ArticlePubMedGoogle Scholar
42. Williams NJ, Whittle JG, Gatrell AC. The relationship between socio-demographic characteristics and dental health knowledge and attitudes of parents with young children. Br Dent J. 2002;193(11):651–4.View ArticlePubMedGoogle Scholar
43. Walsh TF, Srivastava RJ, Jones CV. The relationship between periodontal status and reported oral hygiene activity in a population of Asian females. Dent Health. 1989;28:3–4.Google Scholar
44. Srivastava RJ, Walsh TF, Behari SA, Glenwright HD. Periodontal disease prevalence and treatment needs of Asian females in Wolverhampton, England. Community Dent Health. 1986;3:287–96.PubMedGoogle Scholar
45. Fejerskov O, Kidd EAM. Dental caries: the disease and its clinical management. Copenhagen: Blackwell Monsgaard; 2003.Google Scholar
46. Benson PE, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS. Fluorides, orthodontics and demineralization: a systematic review. J Orthod. 2005;32(2):102–14.View ArticlePubMedGoogle Scholar
47. Summers RM, Williams SA, Curzon ME. The use of tobacco and betel quid ('pan') among Bangladeshi women in West Yorkshire. Community Dental Health. 1993;11(1):12–6.Google Scholar
48. Croucher R, Sohanpal R. Improving access to dental care in East London’s ethnic minority groups: community based qualitative study. Community Dental Health. 2006;23:95–100.PubMedGoogle Scholar
49. Newton JT, Thorogood N, Vanita B, Pitt J, Gibbons DE, Gelbier S. Barriers to the use of dental services by individuals from minority ethnic communities living in the United Kingdom: findings from focus groups. Primary Dental Care. 2001;8(4):157–61.View ArticlePubMedGoogle Scholar
50. Pearson N, Croucher R, Marcenes W, O'Farrell M. Dental service use and the implications for oral cancer screening in a sample of Bangladeshi adult medical care users living in Tower Hamlets, UK. Br Dent J. 1999;186(10):517–21.PubMedGoogle Scholar
51. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003;s1:3–24.View ArticleGoogle Scholar
52. Dhawan N, Bedi R. Transcultural oral health care: 6. The oral health of minority ethnic groups in the United Kingdom--a review. Dent Update. 2001;28(1):30–4.PubMedGoogle Scholar
53. Bhopal RS. Ethnicity, Race, and Health in Multicultural Societies: Foundations for Better Epidemiology, Public Health, and Health Care. Oxford: Oxford University Press; 2007.View ArticleGoogle Scholar