Social inequalities and periodontal disease: multilevel
          approach in SBBrasil 2010 survey

Vettore, Mario Vianna; Marques, Regina Auxiliadora de Amorim; Peres, Marco A

doi:10.1590/S0034-8910.2013047004422

OBJECTIVE:

To estimate the prevalence and geographical distribution of periodontal disease in the Brazilian adult population and its associations with contextual and individual social inequalities.

METHODS:

Data from adults aged 35 to 44 who participated in the 2010 Brazilian Brazilian Oral Health Survey (SBBrasil 2010) (n = 9,564) were used. The Community Periodontal Index (CPI) and clinical attachment loss (CAL) were used to define “moderate to severe” periodontal disease (CPI > 2 and CAL > 0) and “severe” periodontal disease (CPI > 2 and CAL > 1). Contextual social inequalities assessed were Human Development Index and income inequalitiy (Gini Index). Other contextual variables were integration of oral health teams in the Family Health Programme and the percentage of adult smokers. Multilevel logistic regression models for participants with complete data (n = 4,594) were used to estimate odds ratios (OR) and 95% confidence intervals (95%CI) between social inequalities and periodontal disease.

RESULTS:

The prevalence of “moderate to severe” and “severe” periodontal disease in Brazilian adults was 15.3% and 5.8%, respectively, with considerable variation across municipalities. Of the contextual variables, income inequality was independently associated with “severe” periodontal disease (OR = 3.0, 95%CI 1.5;5.9). Lower oral health teams coverage was associated with both definitions of periodontal disease whereas the percentage of smokers remained associated with “moderate to severe” periodontal disease. Older adults, brown skin color, males and those with lower family income and less schooling were more likely to both periodontal conditions.

CONCLUSIONS:

In Brazil, the prevalence of periodontal disease varied across the municipalities and according to definition of periodontal disease. Income inequality played a significant role in the occurrence of “severe” periodontal disease. Individual characteristics of social position were associated with both forms of periodontal disease.

Periodontal Diseases, epidemiology; Socioeconomic Factors; Dental Health Surveys; Oral Health; Multilevel Analysis; Health Inequalities

[TFN01t01_en] ESB/ESF: oral health care teams from the Family Health Care Strategy - Estratégia de Saúde da Família; HDI: Human Development Index.

[TFN02t01_en] ^a “moderate to severe” periodontal disease:presence of at least one sextant with pocket depth ≥ 4mm and at least one sextant with loss of periodontal attachment ≥ 4mm (Clinical Attachment Level> 0).

[TFN03t01_en] ^b “severe” periodontal disease:presence of at least one sextant with pocket depth ≥ 4 mm and at least one sextant with loss of periodontal attachment ≥ 6 mm (Clinical Attachment Level>1).

Variable	PD “moderate to severe” ^a		PD “severe” ^b

	%	95%CI	%	95%CI

Contextual

Gini index (2000)
Low	8.6	6.6;11.1	1.6	1.0;2.7
Moderate	15.6	11.8;20.5	4.8	3.2;7.1
High	13.6	10.6;17.2	4.8	3.4;6.8
HDI municipality (2000)
Low	11.9	9.2;15.4	2.9	1.7;4.8
Moderate	16.0	11.3;22.1	5.5	3.8;7.7
High	12.6	10.2;15.4	3.7	2.3;5.9
% smokers (2006)
Low	10.1	7.1;14.1	1.9	1.0;3.4
Moderate	10.6	8.5;13.2	3.5	2.4;5.1
High	18.6	13.6;24.9	6.5	4.7;8.8
Integration of OHT/FHP (2011)
Low	15.3	11.8;19.6	4.7	3.2;6.7
Moderate	9.3	7.5;11.5	3.0	2.1;4.2
High	16.9	13.4;21.1	3.4	2.3;5.1

Individual

Age (years)
35-39	10.2	8.0;12.8	2.9	1.8;4.5
≥ 40	19.1	15.0;23.9	6.0	4.3;8.3
Sex
Female	13.5	10.4;17.4	3.6	2.4;5.3
Male	14.9	11.6;19.1	5.7	3.7;8.7
Skin color
White	12.7	9.3;17.1	3.4	2.2;5.2
Yellow	26.4	5.2;70.3	10.7	1.7;44.9
Indigenous	2.3	0.5;9.3	1.2	0.2;7.2
Brown	14.8	11.7;18.4	4.8	3.4;6.8
Black	16.1	10.0;24.9	5.3	2.7;10.2
Family income (R$)
> 2,501.00	7.3	4.6;11.2	1.2	0.5;3.0
1,501.00-2,500.00	12.8	8.9;18.1	3.1	1.6;6.0
501.00-1,500.00	15.2	11.4;20.0	5.5	3.8;8.0
< 500.00	21.3	15.9;28.0	5.1	2.6;9.8
Years of schooling
> 11	6.5	3.7;11.0	1.1	0.5;2.5
9 a 11	14.2	11.0;18.2	3.7	2.2;5.9
5 a 8	16.7	12.8;21.6	6.5	4.4;9.5
0 a 4	24.7	16.1;36.0	8.1	5.2;12.6

Variable	Variance ^a	MOR ^b	β	Standard error	OR	95%CI

Contextual

Gini index (2000)	0.236 (0.080) ^**	1.6
Moderate			0.315	0.246	1.4	0.9;2.2
High			0.238	0.271	1.3	0.8;2.2
HDI municipality (2000)	0.256 (0.085) ^**	1.6
Moderate			-0.137	0.247	0.9	0.5;1.4
Low			0.013	0.235	1.0	0.4;1.6
% smokers (2006)	0.196 (0.069) ^**	1.5
Moderate			0.238	0.229	1.3	0.8;2.0
High			0.562	0.244	1.8	1.1;2.8 ^*
Integration of OHT/FHP (2011)	0.154 (0.058) ^**	1.5
Moderate			-0.725	0.214	0.5	0.3;0.7 ^*
High			-0.333	0.217	0.7	0.5;1.1

Individual

Age (years)					1
35-39					1.5	1.3;1.8 ^*
≥ 40
Sex					1
Female					1.3	1.1;1.5 ^*
Male
Skin colour					1
White					1.5	1.2;1.8 ^*
Brown					1.5	1.1;2.0 ^*
Black
Household income (R$)					1
> 2,501.00					2.0	1.4;2.7 ^*
1,501.00-2,500.00					2.4	1.9;3.2 ^*
501.00-1,500.00					3.1	2.2;4.3 ^*
< 500.00
Years of schooling
> 11					1
9 a 11					2.4	1.9;3.1 ^*
5 a 8					3.6	2.7;4.6 ^*
0 a 4					4.2	3.1;5.7*

Variable	Variance ^a	MOR ^b	β	Standard Error	OR	95%CI

Contextual

Gini index (2000)	0.350 (0.142) ^*	1.8
Moderate			0.592	0.342	1.8	0.9;3.5
High			0.723	0.367	2.1	1.0;4.2 ^*
HDI Municipality (2000)	0.473 (0.175) ^**	1.9
Moderate			0.032	0.360	1.0	0.5;2.1
Low			0.367	0.348	1.4	0.7;2.9
% smokers (2006)	0.495 (0.181) ^**	2.0
Moderate			0.118	0.370	1.1	0.5;2.3
High			0.224	0.397	1.3	0.6;2.7
Integration of OHT/FHP (2011)	0.340 (0.139) ^*	1.7
Moderate			-0.597	0.339	0.6	0.3;1.1
High			-0.231	0.337	0.8	0.4;1.5

Individual

Age (years)
35-39					1
≥ 40					2.0	1.5;2.7 ^*
Sex
Female					1
Male					1.3	1.0;1.7 ^*
Skin color
White					1
Brown					1.8	1.3;2.6 ^*
Black					2.1	1.3;3.4 ^*
Family income (R$)
> 2,501.00					1
1,501.00-2,500.00					2.2	1.2;4.1 ^*
501.00-1,500.00					3.4	2.0;5.8 ^*
< 500.00					4.3	2.3;8.0 ^*
Years of schooling
> 11					1
9 to 11					2.8	1.6;4.7 ^*
5 to 8				₢	4.9	2.9;8.3 ^*
0 to 4					8.4	4.9;4.7 ^*

Variable	“Moderate to severe” periodontal disease ^a				“Severe” periodontal disease ^b

	Model 1		Model 2		Model 1		Model 2

	OR	95%CI	OR	95%CI	OR	95%CI	OR	95%CI

Contextual (2 ^nd level)
Gini index (2000)
Moderate	−	−	−	−	1.7	1.0;3.2	1.8	1.0;3.2
High	−	−	−	−	2.3	1.2;4.3*	3.0	1.5;5.9*
% smokers (2006)
Moderate	1.4	1.0;2.9	1.4	1.0;2.1	−	−	−	−
High	1.7	1.1;2.5*	1.9	1.3;2.8*	−	−	−	−
Integration of OHT/FHP (2011)
Moderate	0.5	0.3;0.7*	0.6	0.4;0.9*	0.5	0.3;0.9*	0.4	0.2;0.8*
High	0.8	0.5;1.1	0.7	0.4;0.9*	0.8	0.5;1.5	0.9	0.5;1.7
Individual (1 ^st level)
Age (years)
35-39			1				1
≥ 40			1.6	1.4;1.9*			2.0	1.5;2.7*
Sex
Female			1				1
Male			1.3	1.1;1.6*			1.2	0.9;1.7
Skin color
Whithe			1				1
Brown			1.3	1.1;1.6*			1.6	1.1;2.3*
Black			1.1	0.8;1.5			1.6	1.0;2.5
Family income (in reais )
> 2,500.00			1				1
1,501.00 - 2,500.00			1.7	1.3;2.4*			1.8	0.9;3.5
500.00 - 1,500.00			1.8	1.3;2.5*			2.2	1.2;4.1*
≤ 500.00			2.2	1.5;3.3*			2.7	1.3;5.4*
Years of schooling
> 11			1				1
9 to 11			2.1	1.6;2.8*			2.1	1.2;3.7*
5 to 8			3.0	2.3;4.1*			3.5	2.0;6.1*
0 to 4			3.4	2.4;4.7*			5.3	3.0;9.9*
Variance at city level (Ωμ (Standard error) ^c	0.107 (0.044)*		0.102(0.044)*		0.236 (0.110)*		0.101(0.044)*
MOR ^d	1.4		1.4		1.6		1.6

Brasil

Brasil

Social inequalities and periodontal disease: multilevel approach in SBBrasil 2010 survey

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS: