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  • Research article
  • Open Access
  • Open Peer Review

Inequalities in oral health among adolescents in Gangneung, South Korea

BMC Oral Health201818:68

https://doi.org/10.1186/s12903-018-0533-3

  • Received: 14 November 2017
  • Accepted: 17 April 2018
  • Published:
Open Peer Review reports

Abstract

Background

This study aims to evaluate inequality in oral health among adolescents and to explain the mechanisms of such inequalities in Gangneung, South Korea.

Methods

One thousand two hundred sixty-seven students in their first year from four vocational and three general schools participated in the baseline survey of 2011, and 84.7% of them were surveyed again in 2013. Oral examinations by the same dentist and a self-administered questionnaire were repeated during both waves. Outcome measure for oral health was the existence of untreated dental caries (DT). As socioeconomic position (SEP) indicators, school type (general vs. vocational), father’s and mother’s education, perceived economic status, and Family Affluence Scale (FAS) were measured. Variables measuring oral health related behaviours included tooth brushing frequency, frequency of eating snacks and drinking sodas, smoking, and annual visits to dental clinics. Chi-square tests and panel logistic regression were adopted to examine the associations between dental caries and SEP indicators by STATA version 15.1.

Results

Having a less educated father and attending a vocational school were significant predictors for untreated caries after controlling for SEP indicators. However, students from general schools, higher SEP by father’s education, perceived economic status, or FAS, or having non-smoking experience or annual visits to dental clinics were more likely to stay caries-free.

Conclusions

There were socioeconomic inequalities in oral health on an adolescent panel. Given that oral health status during adolescents can persist throughout the course of a person’s life, intervention to tackle such inequalities and school environments are required.

Keywords

  • Adolescent health
  • Schools
  • Socioeconomic factors

Background

Various studies have recognized that there are socioeconomic inequalities in health [13] and oral health [4, 5]. A gap exists across all levels of socioeconomic groups, especially between the highest and the lowest ones. Furthermore, such inequalities are observed throughout the course of a person’s life, from childhood to adulthood and into old age [69]. However, there are differing opinions for the existence of health inequality in a specific life stage: adolescence.

West [10, 11] suggested that adolescents exhibit dissimilar health inequality patterns when compared to other age groups because this group can be “characterised by the absence or disappearance of class variation.” To the contrary, others have claimed that findings on health equality among adolescents are the result of inappropriate measurements for socioeconomic position (SEP) indicators [12, 13]. These studies argued that commonly used SEP indicators, including education, occupation, and income levels, are not appropriate for adolescents. For example, there was a significant health gap in adolescents when using alternative SEP indicators such as the Family Affluence Scale (FAS) [14] and perceived socioeconomic status [15]. Subsequent to these debates, studies in different settings have attempted to verify both positions but a consensus stills has not been reached [1618].

Recently, there have been several longitudinal studies dealing with inequality in adolescent oral health by SEP indicators. A life-course research in cohort of New Zealand children concluded that there was an effect from childhood SEP [19]. A study from Sweden showed that there is limited effect from SEP only after considering the previous experience of caries [20]. Polk et al. [21] and Newacheck [22] also reported that there was an SEP gradient in caries experiences in the U.S. Another longitudinal study from Iowa cohort revealed that there is a gap by SEP, especially maternal educational levels [23]. However, Curtis, using the same cohort data from Iowa Fluoride Study (IFS), recently argued that ‘the role of SES in caries may not be as important as previously thought’. Meanwhile, another group of scholars have focused on school characteristics as an alternative to traditional SEP indicators [2427] or influential effectors for behaviour, especially in S. Korea [28, 29], to determine health inequalities in adolescents. Others have reported that the residential area was a socioeconomic predictor of oral health inequality among adolescents [30, 31].

In terms of oral health, adolescence is of special importance because permanent dentition is complete and parental supervision of oral health behaviours weakens. Indeed, dental caries is a unique health condition aggravating during the schooling period. On the other hand, as they are amenable by health education and highly receptive to public health programs, interventions may be effective and the effects may be long lasting.

This study aims to evaluate inequality in oral health among adolescents by various SEP indicators and to explain the mechanisms of such inequalities in Gangneung, a city in South Korea.

Methods

Study participants

The aim of this panel study was to explore inequality in untreated caries among adolescents. The city of Gangneung has eleven high schools; two in rural areas and nine in urban areas [32]. By the school types, there were six general schools, four vocational schools, and one art school. The aim of the general schools is to support students’ academic development and entry into college. By contrast, the aim of the vocational schools is to prepare students to enter the workforce directly after graduation. The one art school in this study was excluded due to its unique characteristics. First, the schools were categorized by its location as an urban or rural area. There was only one general and one vocational school in the rural area, so both of them were included. Among the other eight schools in the urban area, three vocational schools and two general schools were selected as study samples. Because they have fewer students than the general schools, all of the vocational schools were included. Two general schools were randomly selected by their close proximity to sampled vocational schools. Only first year students, 15-yr-old, were invited to participate in consideration of the follow-up survey after two years. All of the students were sixteen years old because middle school education is mandatory in South Korea, so the freshman in high school were all the same age. The research team sent the consent forms for oral examinations and surveys to students’ parents or guardians with a brief introduction. Only students who returned completed consent forms from their parents or guardians were included in the study. Among 1371 students, ninety-seven declined to participate, and seven were excluded due to incomplete answers on the questionnaires. Finally, 1267 students were enrolled into the panel.

The Institutional Review Board in Gangneung-Wonju National University Dental Hospital reviewed and approved this study (GWNUDH IRB-2011-1-3). The Gangneung Health Centre and the Gangneung Office of Education with their district offices also consented to the study and supported the administrative process.

Study variables and measurement

Outcome measure for oral health was the untreated dental caries according to the Korean National Oral Health Survey (KNOHS) standard [33], which follows the guideline established by the WHO methods for oral health survey [34]. The untreated dental caries “D” component, which includes carious teeth, filled teeth with recurrent decay, teeth with only the root left, defective filling with caries, temporary filling, and teeth with a filled tooth surfaces but with other surface decayed.

The examinations were conducted in a classroom of the surveyed schools using their table and chairs with a lightweight portable examination light. The plane mouth mirrors, periodontal probes that conform to WHO specifications, and several pairs of tweezers were supplied for the survey. The same dentist who was trained according to the Korean National Oral Health Survey (KNOHS) confirmed the students’ oral status twice in three years. To have reliable intra-examiner reliability, the dentist examined 20 students before the main study. He re-examined them one week later for calibration, and the kappa consistency was 0.91, good agreement [35]. The status transition in dental caries between 2011 and 2013 were classified as follows: 1) no to no (remained caries-free); 2) yes to no (received treatment); 3) no to yes (developed new dental caries); and 4) yes to yes (remained untreated caries).

Self-administered questionnaire surveys were administered, and items were derived from the Korean Youth Risk Behaviour Web-based Survey (KYRBWS) [36, 37] and from the guidelines in “Delivering better oral health: an evidence-based toolkit for prevention” [38]. As SEP indicators, school type (general vs. vocational), father’s and mother’s education level, perceived economic status, and FAS were measured. Father’s and mother’s education level was categorized into two groups; high school graduation or below vs. college graduation or above. The perceived economic status were re-categorised as high (high, high-middle, and middle) vs. low (middle-low and low). The FAS score was calculated by summing up dummy variables to represent the ownership of a family car, private bedroom for the student, computers, and the number of family vacations in the past year. FAS scores range from zero to nine, and students with scores larger than five were defined as ‘high’ and the others as ‘low’ group. Variable to measure oral health related behaviours included tooth brushing frequency (‘twice or more a day’ vs. ‘less than twice a day’), frequency of snacks and drinking sodas (‘less than once a day’ vs. ‘once or more a day’), smoking (‘no’ vs. ‘yes’), and annual visits of dental clinics at least once a year (‘yes’ or ‘no’).

Statistical analysis

Annual prevalence of untreated caries (decayed teeth; ‘D rate’) and proportion of status transition in dental caries over the follow-up was examined according to various SEP indicators and oral health related behaviours by chi-square tests. In order to identify independent effects of SEP variables and contributions of covariates to oral health status with considering panel design, unconditional panel logistic regression models were estimated. Data analysis was carried out using STATA version 15.1 statistical software package (StataCorp, Texas).

Results

The characteristics of the study participants are displayed in the Table 1. At the baseline survey of 2011, the participation rate was 92.4%, and a total of 1267 students participated. The follow-up rate was 84.7% in 2013 with the drop of 194 students. Attrition was more common in vocational schools (27.3%) than general schools (7.4%). However, this did not present significant changes in the distribution of gender and SEP indicators of the sample between waves (Additional file 1: Table S1).
Table 1

The characteristics of study participants by school type in Gangneung

School location

School type

Sampled population N

Respondents in baseline 2011 (1st grade, 15-yr-old) N

Gender

Respondents in follow-up 2013 (3rd grade, 17-yr-old) N

Boys

N (%)

Girls

N (%)

Total

 

1371

1267

690(54.5)

577(45.5)

1073

Rural

 School A

General

93

88

41(46.6)

47(53.4)

71

 School B

Vocational

155

133

48(36.1)

85(63.9)

99

Urban

 School C

General

341

335

335(100.0)

 

314

 School D

General

360

343

 

343(100.0)

324

 School E

Vocational

296

242

242(100.0)

 

168

 School F

Vocational

58

58

24(41.4)

34(58.6)

45

 School G

Vocational

68

68

 

68(100.0)

52

At both waves, the students who were from vocational schools, less educated fathers, and ‘low’ groups of perceived economic status and FAS were more likely to have untreated dental caries. As for oral health behaviours, tooth brushing and annual visits were inversely associated with D rates. Smoking was strongly associated with D rates in both waves (Table 2).
Table 2

Numbers and percentages of adolescents who have untreated dental caries (D rate) by survey year in Gangneung

D rate

201l (1st grade, 15-yr-old)

N = 1267

2013 (3rd grade, 17-yr-old)

N = 1073

Total

217(17.1)

 

153(14.3)

 

Gender

 Girls

92(15.9)

 

62(12.2)

 

 Boys

125(18.1)

 

91(16.1)

 

School type

 General

94(12.3)

***

70(9.9)

***

 Vocational

123(24.6)

 

83(22.8)

 

Father’s education

 College or above

50(10.5)

***

33(7.7)

***

 High school or below

137(19.8)

 

98(17.0)

 

Mother’s education

 College or above

46(13.3)

 

31(10.3)

 

 High school or below

143(17.6)

 

101(14.4)

 

Perceived economic status

 High

145(15.6)

*

99(12.6)

**

 Low

72(21.4)

 

54(19.2)

 

FAS

 High

171(15.6)

***

115(12.5)

***

 Low

46(27.4)

 

38(26.0)

 

Frequency of tooth-brushing

 ≥2

182(16.2)

*

137(14.0)

 

 < 2

35(24.5)

 

16(17.4)

 

Frequency of eating snacks

 < 1

71(15.7)

 

118(13.4)

*

 ≥1

131(17.3)

 

35(18.9)

 

Frequency of drinking soda

 < 1

99(15.1)

 

134(13.6)

 

 ≥1

95(18.6)

 

19(21.1)

 

Smoking experience

 No

124(13.8)

***

91(12.0)

**

 Yes

93(25.3)

 

62(19.6)

 

Annual visits to dental clinic

 Yes

84(14.6)

*

55(10.7)

**

 No

133(19.2)

 

98(17.6)

 

*p < 0.05, **p < 0.01, ***p < 0.001

The odds ratios (ORs) for untreated caries were estimated after adjusting for SEP indicators only in Model 1, and SEP indicators and oral health related behaviours covariates together in Model 2 (Table 3). As for D rates, fathers’ education and school type remained significant after controlling for other SEP indicators. Even after incorporating health behaviour variables in the models, they still showed significant effects with attenuation.
Table 3

Adjusted odds ratio and 95% confidence intervals estimated from unconditional panel logistic regression models for D rate among adolescents in Gangneung (N = 2003)

D rate

Model 1†

Model 2‡

Gender

 Girls (vs. boys)

0.65(0.39–1.06)

 

0.71(0.41–1.23)

 

School type

 Vocational (vs. general)

3.10(1.79–5.35)

***

2.68(1.46–4.92)

**

Father’s education

 High school (vs. college)

2.15(1.15–4.01)

*

2.04(1.05–3.98)

*

Mother’s education

 High school (vs. college)

0.92(0.48–1.76)

 

0.86(0.43–1.73)

 

Perceived economic status

 Low (vs. high)

1.03(0.62–1.71)

 

1.05(0.61–1.81)

 

FAS

 Low (vs. high)

1.82(0.95–3.49)

 

1.80(0.88–3.64)

 

Frequency of tooth-brushing

 < 2 (vs. N ≥ 2)

  

1.42(0.72–2.83)

 

Frequency of eating snacks

 ≥1 (vs. N < 1)

  

1.64(1.00–2.70)

 

Frequency of drinking soda

 ≥1 (vs. N < 1)

  

1.13(0.66–1.95)

 

Smoking experience

 Yes (vs. no)

  

1.72(1.02–2.92)

*

Annual visits to dental clinic

 No (vs. yes)

  

1.91(1.22–3.01)

**

† Model 1: adjusted for gender, school type, father’s education, mother’s education, subjective economic status, and FAS

‡ Model 2: adjusted for gender, school type, father’s education, mother’s education, subjective economic status, FAS, frequency of tooth brushing, eating snacks, and drinking soda, smoking, and annual visits to dental clinics

*p < 0.05, **p < 0.01, ***p < 0.001. - mean VIF (=1.37) < 10

The status transition in dental caries over the follow-up is shown in Table 4. Students from general schools, in higher SEP measured by father’s education, perceived economic status, or FAS, drinking soda less than a day, without smoking experience, and to have annual visits to dental clinics were more likely to stay caries-free (p < 0.01).
Table 4

Condition transition for untreated caries over the two-year follow-up in Gangneung adolescent at 2013 (N = 1073)

 

Caries status change (from 2011 to 2013)

 

No → Noa

Yes → Nob

No → Yesc

Yes → Yesd

Total

834 (77.7)

86 (8.1)

61 (5.7)

92 (8.6)

 

Gender

 Girls

397 (78.3)

48 (9.5)

25 (4.9)

37 (7.3)

 

 Boys

437 (77.2)

38 (6.7)

36 (6.4)

55 (9.7)

 

School type

***

 General

585 (82.5)

54 (7.6)

37 (5.2)

33 (4.7)

 

 Vocational

249 (68.4)

32 (8.8)

24 (6.6)

59 (16.2)

 

Father’s education

***

 College or above

361 (84.5)

33 (7.7)

23 (5.4)

10 (2.3)

 

 High school or below

432 (74.9)

47 (8.2)

34 (5.9)

64 (11.1)

 

Mother’s education

 College or above

244 (81.1)

26 (8.6)

18 (6.0)

13 (4.3)

 

 High school or below

545 (77.8)

55 (7.9)

38 (5.4)

63 (9.0)

 

Perceived economic status

**

 High

621 (78.8)

68 (8.6)

47 (6.0)

52 (6.6)

 

 Low

209 (74.4)

18 (6.4)

14 (5.0)

40 (14.2)

 

FAS

***

 High

732 (79.2)

77 (8.3)

52 (5.6)

63 (6.8)

 

 Low

100 (68.5)

8 (5.5)

9 (6.6)

29 (19.9)

 

Frequency of tooth-brushing

 ≥2

764 (77.9)

80 (8.2)

53 (5.4)

84 (8.6)

 

 < 2

70 (76.1)

6 (6.5)

8 (8.7)

8 (8.7)

 

Frequency of eating snacks

 < 1

699 (79.1)

67 (7.6)

47 (5.3)

71 (8.0)

 

 ≥1

131 (70.8)

19 (10.3)

14 (7.6)

21 (11.4)

 

Frequency of drinking soda

**

 < 1

777 (79.0)

72 (7.3)

53 (5.4)

81 (8.2)

 

 ≥1

57 (63.3)

14 (15.6)

8 (8.9)

11 (12.2)

 

Smoking experience

***

 No

611 (80.8)

54 (7.1)

42 (5.6)

49 (6.5)

 

 Yes

223 (70.4)

32 (10.1)

19 (6.0)

43 (13.6)

 

Annual visits to dental clinic

**

 Yes

410 (79.5)

51 (9.9)

18 (3.5)

37 (7.2)

 

 No

424 (76.1)

35 (6.3)

43 (7.7)

55 (9.9)

 

aNo → No as remaining caries-free, bYes → No as being treated with fillings, cNo → Yes as developing dental caries, and dYes → Yes as remaining untreated caries

**p < 0.01, ***p < 0.001

Discussion

Our analysis of the adolescent panel in Gangneung, South Korea, verified the existence of significant differences in untreated dental caries by school type and father’s education, and in caries experience by gender and father’s education. Oral health-related behaviours attenuated but did not explain away such effects.

Differences in oral health by school type can be attributed to the fact that schools are a place where youths form a unique culture. Here, they begin to be independent from their family, spending most of the day with their peers. In a society where college graduation is the norm, vocational schools could be a symbolic representation of social disadvantages, which are related to poor health and undesirable health behaviours. There was a report that male and female students in Korean vocational schools are more likely to engage in non-conformant behaviours, including smoking, alcohol consumption, unexcused absences, running away from home, and sexual relationships, as well as to be involved in assault, harassment, and adolescent prostitution [39]. Another Korean study found that even after controlling for individual-level SEP indicators and psychological stress, students in vocational schools engaged more in risky behaviours, for example smoking and drinking, and less in health-promoting behaviours, such as tooth brushing [40, 41].

There was no significant difference by gender in untreated dental caries. It is contrary to the findings in the 2012 Korean National Oral Health Survey, which showed higher prevalence of decayed teeth among girls by 10.6% [42]. Martinez-Mier and Zandona [43] argued that caries is multifactorial disease attributable to diverse factors, including genetic and hormonal factors as well as cultural influences, behavioural, and dietary practices. Kawamura and colleagues attributed the better oral health of girls to more frequent tooth brushing and their desires to possess healthy teeth [44]. It was suggested that their concern for good oral health motivates them to visit dental clinics for treatment more often than males. Indeed, we found that students who visited dental clinics more regularly had a reduced likelihood of having untreated caries; adolescents who visited the dental clinic more regularly to receive treatment had less untreated caries.

It is noteworthy that father’s education but not mother’s education was a strong predictor of oral health in Korean adolescents. This is contrary to the report that mothers play an important role in the child development of oral health [45]. First, the cut-off level of mother’s education might be inappropriate to capture the differences; in fact, only 30% of students in the panel had mothers who had graduated college, which means that the ‘low’ education group consisted of heterogeneous individuals, resulting in non-differential misclassification. Second, although parents’ education level is associated with health literacy and awareness and thereby children’s behaviours and service utilisation [46], parental influence wanes during transitional developmental periods [47]. Children have a desire to be similar with their friends, and such desires become stronger in older adolescents [48]. Therefore, mother’s education might have little impact on the oral health and behaviours of adolescents in this panel. Along the same line, in our study, father’s education as surrogate marker of household material conditions might be a better indicator of cultural and behavioural resources than mother’s education. In Korea, fathers are generally family breadwinners, and there is a clear correlation between fathers’ education and family economic status. As a mid-sized semi-urban city, Gangneung provides less job opportunities. In this context, father’s education could surpass other SEP indicators in representing household socioeconomic conditions.

The oral health behaviours of the study panel improved during the follow-up. For instance, the prevalence of eating less snacks went from under 37.5% at baseline to 82.7% at the second wave. Students exhibiting healthier behaviours increased dramatically in terms of oral health; they brushed teeth more and consumed less snacks and soda. All of this generally contributes to better oral health [4951], and indeed D rates with untreated caries in our panel declined over time.

This study has some limitations. First, although differential sample attrition between general and vocational schools did not bring out differences in the distribution of socioeconomic factors among students, we cannot be sure that there was no systematic difference in oral health-related behaviours between participants and dropouts. Second, we could not fully explain why the strong effect of father’s education persisted even after controlling for oral health-related behaviours. Third, because the panel was composed of high-school students only, it was hard to conduct follow-ups after their graduation. In order to examine long-term effects of oral health and related behaviours in adolescents, it would thus be necessary to expand the panel range to primary school students as they begin to formulate health behaviours.

Conclusion

We found socioeconomic inequalities in oral health based on an adolescent panel from Gangneung. Given that poor oral health and undesirable oral health-related behaviours during the adolescent period could last throughout a person’s lifetime [52], there should be an immediate intervention to tackle such inequalities and school environments.

Declarations

Acknowledgements

This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2011-0011208). The authors thank to the Gangneung Health Centre and the Gangneung Office of Education for supporting the administrative process.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

All authors contributed extensively to the work presented in this paper. SH has made substantial contributions to conception and design, acquisition of data, and interpretation of data; JI has been involved in analysis and interpretation of data and drafting the manuscript; MH has been revising it critically for important intellectual content; and All authors have given final approval of the version to be published. Each author have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics approval and consent to participate

The research team sent the consent forms for oral examinations and surveys to students’ parents/guardians with a brief introduction. Only students who returned completed consent forms from their parents/guardians were included in the study.

The Institutional Review Board in Gangneung-Wonju National University Dental Hospital reviewed and approved this study (GWNUDH IRB-2011-1-3).

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Department of Preventive Dentistry, College of Dentistry, Gangneung-Wonju University, 120 Gangneungdaehag-ro, Gangneung City, Gangwon Province, 25457, South Korea
(2)
Center for Health Equity Research, People’s Health Institute, 36 Sadangro 13-gil, 2nd floor, Dongjak-gu, Seoul, 07004, South Korea
(3)
Department of Preventive and Social Dentistry, College of Dentistry, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea

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