Eur J Oral Sci 2019; 127: 248–253 © 2019 The Authors.

© 2019 The Authors. Eur J Oral Sci published by John Wiley & Sons Ltd
DOI: 10.1111/eos.12609 European Journal of
Printed in Singapore. All rights reserved
Oral Sciences

Deborah A. Verlinden1,2,* ,
Socio-economic inequality in oral Sijmen A. Reijneveld2,3, Caren I.
Lanting2, Jacobus P. van Wouwe2,
health in childhood to young Annemarie A. Schuller1,2
1
Centre of Dentistry and Oral Hygiene,
University Medical Center Groningen,
adulthood, despite full dental coverage University of Groningen, Groningen;
2
Department of Child Health, the Netherlands
Organization for Applied Scientific Research
TNO, Leiden; 3Department of Health
Sciences, University Medical Center
Verlinden DA, Reijneveld SA, Lanting CI, van Wouwe JP, Schuller AA. Socio-economic Groningen, University of Groningen,
inequality in oral health in childhood to young adulthood, despite full dental coverage. Groningen, the Netherlands
Eur J Oral Sci 2019; 127: 248–253. © 2019 Eur J Oral Sci
The aim of this cross-sectional study was to assess differences in caries experience
according to socio-economic status (SES) in a health-care system with full coverage
of dental costs for children up to the age of 18 yr. In 2011 and 2014, by performing Deborah Ashley Verlinden, Centre of
hurdle negative binomial models, we obtained data on 3,022 children and young Dentistry and Oral Hygiene, University
adults aged 5, 8, 11, 14, 17, 20, and 23 yr, living in four cities in the Netherlands. Medical Center Groningen, Antonius
At all ages between 5 and 23 yr, the percentages of children with caries-free denti- Deusinglaan 1, 9713 AV Groningen,
the Netherlands
tions were lower and mean caries experience were higher in low-SES than in high-
SES participants. In 5-yr-old children with dmft > 0, mean caries experience was 3.6 E-mail: d.a.verlinden@umcg.nl
in those with low SES and 2.3 in those with high SES. In 23-yr-old participants,
these estimates were 6.8 and 4.4, respectively (P < 0.05). Low-SES children have a Key words: access to care; caries experience;
greater risk of more caries experience than high-SES children. Thus, in a system dental care; public health dentistry; youths
with full free paediatric dental coverage, socio-economic inequality in caries experi- This is an open access article under the
ence still exists. Dental health professionals, well-child care doctors and nurses, gen- terms of the Creative Commons Attribution-
eral practitioners, and elementary school teachers should collaborate to promote NonCommercial License, which permits use,
oral health at the community level, with specific targeting of low-SES families. We distribution and reproduction in any medium,
further need policy measures to curtail, at community level, the increasing availabil- provided the original work is properly cited
ity and consumption of highly processed, carbohydrate-rich foods, with particular and is not used for commercial purposes.
attention for low-SES families. Accepted for publication December 2018

Disparities in child health according to socio-economic can also result in lost school hours and affect a child’s
status (SES) are often reported. Youths in high-SES overall wellness and self-esteem (15, 16).
families generally experience better health than youths Prevention of caries in children requires adequate
in low-SES families (1). Children and young adoles- oral hygiene and a healthy diet with limited cariogenic
cents experiencing socio-economic disadvantages foods, as well as starting young with dental check-ups
encounter a wide range of health risk factors and and regular dental visits. Risk factors, on the other
adverse outcomes in adulthood (2), including increased hand, include brushing teeth less than two times a day,
risks of injury, asthma, and elevated blood pressure, as frequent consumption of cariogenic foods, skipping
well as involvement in risky health behaviours, such as breakfast, and lower parental educational level and
smoking and physical inactivity (2, 3). income (12, 17–20). Low-SES individuals have been
Dental caries experience is reportedly a strong indica- found to be more likely to have inadequate preventive
tor of socio-economic inequality in both children and oral-health behaviour (21, 22).
adults (4–11). It is the most common paediatric disease Availability of full financial coverage for costs of
(12). Among 5- to 17-yr-old individuals in the USA, dental care may also affect whether children receive
dental caries is over five times more common than dental care and the occurrence of dental caries (23).
asthma and seven times more common than hay fever However, other factors may contribute, such as low
(13). The term ‘dental caries’ refers to decay on any parental oral health literacy and limited parental lan-
surface of a tooth (14). It is characterized by a contin- guage proficiency (23, 24). Moreover, care-related barri-
uum of disease states, ranging from subclinical lesions ers may add to this (e.g. inadequate preventive services,
to cavitated lesions that extend into dentine or even care that is not culturally well adapted, and services
into the pulp. If left untreated, caries may lead to pain, that do not fully take into account low levels of oral
discomfort, infections, or tooth loss. Dental caries, and health literacy) (23, 24).
poor oral health in general, has a major impact on chil- In the Netherlands, dental care for youth is included
dren’s overall health, growth, and development. It not in the mandatory health insurance and is free of charge
only affects the ability to chew and eat properly but for children up to 18 yr of age. Research in this setting
 16000722, 2019, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12609 by Readcube (Labtiva Inc.), Wiley Online Library on [08/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Socio-economic inequality in child oral health 249

can clarify to which degree factors other than the costs education was coded as high SES. This decision was in
of dental care contribute to socio-economic differences accordance with the International Standard Classification
in caries experience. The research question for this for Education 2011 (28).
study was therefore: In a health-care system with full The total score of the decayed, missing, and restored
coverage of dental costs for children up to the age of teeth (DMFT) index was used to indicate level of caries
experience (29). The DMFT score represents caries experi-
18 yr, does a socio-economic difference in caries experi-
ence in permanent teeth, whereas the dmft score repre-
ence exist, based on SES? Our hypothesis was that sents that in deciduous teeth. Caries-free dentitions are
between socio-economic groups in children up to 18 yr defined in our paper as those with dmft = 0 or
of age, all of whom have free access to dental services, DMFT = 0. Caries experience was observed during a clin-
no differences in oral health would exist. ical oral examination that comprised visual inspection of
the teeth with documentation of caries lesions and any
subsequent treatment (i.e. restoration or extraction). Par-
ticipants in urgent need of treatment were advised to visit
Material and methods their dental professional.
Clinical examinations were performed by four dentists
Study population in a mobile oral health facility. During the clinical assess-
During the study period from March 2011 through Octo- ment, both permanent and deciduous teeth were evaluated,
ber 2011 and April 2014 through November 2014, children depending on the age of the participant. For children aged
and young adults aged 5–23 yr who were living in four 5 yr, only caries in deciduous teeth was included. For chil-
medium-sized cities in the Netherlands were eligible to dren aged 8 yr, caries in both deciduous and permanent
participate. These four cities (Gouda, Alphen aan den teeth was included. For children aged 11 yr or older, per-
Rijn, Breda, and Den Bosch) are typical of the Dutch pop- manent teeth were evaluated, with the exclusion of wisdom
ulation regarding age, gender, ethnicity, and marital status teeth.
(25). Random samples were drawn from the municipal To assess the quality of the clinical examinations, we
population records of each city and stratified according to determined the inter-examiner agreement for 304 partici-
age, to reach similar numbers per city per age category. pants in 2011 and 137 participants in 2014. We calculated
Sample sizes were determined based on the potential to overall Pearson correlations and intraclass correlations
detect relative differences of 30% in mean caries experi- between the two examiners, and mean outcomes of each
ence, from earlier estimates from 2005 to 2009, at an alpha examiner for dmft and DMFT. The intraclass correlation
of 0.05 with a power of 80%. This led to a required sam- coefficients were 0.92 and 0.95, respectively. Differences
ple size of about 450 children per age category (26, 27). between the two examiners in mean caries experience
In total, 13,961 children and young adults aged 5–23 yr were clinically negligible (i.e. at most 0.2 dmft and
(and their parents) received invitations to participate, DMFT).
including information about the purpose of the study.
Trained interviewers personally attempted to contact indi-
viduals who had not responded, to emphasize the impor- Data analysis
tance of the study. If the initial contact attempt failed, the First, we calculated descriptive statistics for gender, SES,
interviewer made a maximum of three additional attempts. ethnicity, toothbrushing frequency, and dental attendance
Individuals who refused to participate were asked to fill for the 5-, 8-, 11-, 14-, 17-, 20-, and 23-yr-old participants
out a non-response questionnaire with questions about in the sample. Second, we assessed mean caries experience
gender, SES, and oral health behaviour. Of the 13,961 for low-SES and high-SES children. We used Student’s
children and young adults and their parents invited to take t-tests or Mann–Whitney U-tests to assess statistical signif-
part in the study, 3,022 (23%) participated. icance, depending on the frequency distribution. Crosstabs
and chi-square tests were used for categorical variables.
Third, we assessed differences in caries experience accord-
Ethics statement ing to SES and age, using hurdle modelling. Hurdle mod-
The Central Committee on Research Involving Human els have the advantage of estimating two separate
Subjects concluded that no ethical considerations were parameters to accommodate many zero counts: one esti-
involved, as the clinical proceedings were harmless and the mate for the dichotomization of zero vs. non-zero (i.e. car-
questions not sensitive in nature. The study met all the ies-free or not); and one estimate for caries experience in
requirements of the Personal Data Protection Act (number cases of not-caries-free. As the count part had a negative
m1383077 for 2011 and number m1556571 for 2014). binomial distribution, we used a negative binomial hurdle
model (30). Hurdle analyses yield ORs for the probability
of having any caries and, in the case of those with caries,
rate ratios comparing the greater caries experience of low-
Procedure and measures
SES groups with that of high-SES groups (30). We made
Data were gathered via clinical oral examinations and a one hurdle model for caries experience in the deciduous
questionnaire. The questionnaire was completed by a par- teeth and another for caries experience in the permanent
ent for the 5-, 8-, and 11-yr-old children and by the 14-, teeth. Models were adjusted for age and age-squared
17-, 20-, and 23-yr-old subjects themselves. In this study, because the relationship between age and caries experience
SES was operationalized as the highest level of education for the count part was not linear. We performed bivariate
completed by the mother of the children aged 5, 8, and analyses using SPSS, version 22.0 (IBM, Armonk, NY,
11 yr or by the adolescent/young adult (ages 14, 17, 20, USA), and negative binomial hurdle models in R version
and 23 yr). A total of 10 or fewer years of education was 3.3.2 (R Foundation for Statistical Computing, Vienna,
coded as low SES, whereas a total of more than 10 yr of Austria).
 16000722, 2019, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12609 by Readcube (Labtiva Inc.), Wiley Online Library on [08/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
250 Verlinden et al.

Results having caries, children with low SES and older children
had, on average, more caries experiences than did chil-
Table 1 shows the characteristics of the participants. Of dren with high SES and younger children, respectively.
all participants, 46% were male and 39% had a low We found a difference in caries experience, according
SES. to SES, in a health-care system with full coverage of
Table 2 shows caries experience in deciduous and dental costs for children up to the age of 18 yr. Epi-
permanent teeth and mean caries experience according demiological research in the Netherlands reported den-
to age and SES. For all age groups, except 11-yr-old tal check-up rates of around 95% for children with low
children, the percentage of subjects with caries-free SES and high SES from ages 4 to 16 yr (31). Moreover,
teeth was lower for those with low SES than for those in our sample, we also found that most participants in
with high SES (P < 0.05). We observed mean dmft (or all age groups visited dental professionals yearly. Nev-
DMFT) scores to be higher in low-SES children than ertheless, socio-economic differences in caries experi-
in high-SES children. ence existed, which may be explained in several ways:
Table 3 shows ORs and rate ratios (RRs) for the by client-related factors; by professional-related factors;
association of SES and age with caries experience in or by the organization of care.
children aged 5 and 8 yr and children aged 14 yr and With respect to client-related factors, children from
older. Children with low-SES had higher odds of low-SES groups have been shown to have a greater risk
dmft > 0 or DMFT > 0 than children with high SES. of unfavourable preventive oral health behaviour than
Low-SES children with dmft > 0 or DMFT > 0 had their high-SES counterparts, resulting in the gradient
(on average) more caries experience than did children found in caries experience (21, 22, 32–34). Low-SES
with high SES, teens, and young adults. The odds of households consume larger quantities of highly pro-
dfmt > 0 or DFMT > 0 increased with age. The same cessed carbohydrate-rich foods (because such foods are
held for the mean number of caries experiences. Older inexpensive) than do high-SES households (35). There
children had higher odds of dmft > 0 or DMFT > 0 is a lack of regulation in the production, availability,
than did younger children. Older children with and pricing of junk food and sugar-sweetened bev-
dmft > 0 or DMFT > 0 had more caries experience erages. Another client-related factor is that parents with
than did younger children. We found no statistically low SES may have lower oral health literacy than par-
significant interaction of SES with age. ents with high SES and consequently have limited
potential to teach their children how to perform opti-
mal dental care. In the matter of professional-related
Discussion factors, not all dental professionals may have the skills
to promote oral health behaviour effectively among
At all ages between 5 and 23 yr, children with low SES parents with low SES, or to solve the challenges associ-
were less likely to have caries-free teeth and had, on ated with lower levels of oral health literacy (36, 37).
average, more caries experiences. The absolute differ- Concerning factors related to the organization of care,
ence in caries experience between those with low SES clear guidelines for oral health promotion and preven-
and those with high SES was greatest among 23-yr-old tion are not yet available. Without guidelines, dental
subjects. Children with low SES and older children had professionals may be insufficiently informed about the
higher odds for dmft > 0 or DMFT > 0 than children recommendations to train parents how to keep their
with high SES and younger children. Also, when childrens’ teeth healthy and children to keep their own
teeth healthy, and the methods to achieve this.
Table 1 Our findings of differences in caries experience
between participants with low SES and high SES are in
Characteristics of participants according to age category line with those of studies completed in Switzerland,
Age category (yr) Brazil, Denmark, Australia, Los Angeles County
(USA), Norway, and southern China (4–8, 10, 11, 38).
5 8 11 14 17 20 23
These findings indicate the socio-economic inequality in
n oral health in children in multiple countries, despite dif-
Variable 302 363 453 619 434 438 413 ferent dental-coverage systems.
In a Dutch system with full dental coverage, we found
Characteristics inequalities in caries experience according to SES in par-
Male gender 54.9 54.0 49.8 46.5 43.3 39.3 35.7 ticipants from the ages of 5 yr through 23 yr. In Den-
Low socio- 40.3 38.8 40.8 41.0 38.8 34.7 36.9
economic status
mark, socio-economic inequality was still found to exist
Mother with 83.1 87.8 88.9 85.0 82.4 85.3 83.7 in dental health, even though almost all children and
Dutch ethnicity adolescents attended a free public dental service (6).
Oral health behaviour Moreover, according to DARMAWIKARTA et al. (39),
Toothbrushing 73.9 85.4 82.1 80.6 71.3 73.3 72.6 among urban Canadian children who had been to a den-
twice daily tist, those in low-income families were more likely to
Dental check-up 78.2 87.1 89.7 84.0 82.9 67.1 65.6
have dental caries. Findings from a study conducted in
every 6 months
North Carolina showed that low-income children with
Values are given as %. extended dental coverage had less dental caries
 16000722, 2019, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eos.12609 by Readcube (Labtiva Inc.), Wiley Online Library on [08/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Socio-economic inequality in child oral health 251

Table 2
Percentages of Dutch children and young adults with caries experience in deciduous or permanent teeth, and mean caries experience
(SD) of them, according to age and SES (2011–2014).

Age category (yrs) and tooth type

a b
5 8 11 14 17 20 23
n
Variable 295 363 448 619 420 438 401

dmft > 0 or DMFT > 0 (%)

Low SES 42.9* 56.7* 25.5* 21.3 53.5* 66.9* 75.0* 89.2*
High SES 29.5 48.6 13.5 18.9 38.1 52.9 70.3 77.9
Mean caries experience (SD) when dmft > 0 or DMFT > 0
Low SES 3.6 (2.6)* 4.3 (2.6)* 1.7 (0.8) 2.0 (1.2) 3.3 (2.8)* 4.1 (3.6) 5.4 (4.3)* 6.8 (5.4)*
High SES 2.3 (1.7) 3.1 (2.1) 1.8 (0.9) 1.7 (1.1) 2.3 (1.6) 3.3 (2.6) 4.4 (3.9) 4.4 (3.2)
a
In this age group, caries experience in the 20 deciduous teeth only.
b
In this age group, caries experience in deciduous and permanent teeth as present.
*Statistically significant different from high SES group (P < 0.05).

Table 3
Association of socio-economic status (SES) and age with caries experience in deciduous and permanent teeth of children (5 and 8 yr
of age) and young adults (14 yr of age and older): findings of Hurdle models

Deciduous teeth Permanent teeth†

OR for dmft > 0 RR for caries OR for DMFT > 0 RR for caries
Variable (95% CI) experience (95% CI) (95% CI) experience (95% CI)

SES (Low vs. High) 1.66 (1.13–2.14)** 1.55 (1.32–2.08)*** 1.75 (1.41–2.16)*** 1.47 (1.29–1.68)***
Centred age (per yr) 1.15 (1.14–1.51)*** 1.31 (1.02–1.29)* 1.22 (1.18–1.27)*** 1.11 (1.08–1.15)***
Centred age2† 1.00 (0.98–1.01) 0.99 (0.98–1.00)*
Centred age 9 SES 0.93 (0.74–1.14) 0.92 (0.79–1.09) 0.99 (0.93–1.06) 1.01 (0.97–1.04)

Age squared was significant, meaning that the association between age and caries experience for the count part was not lineair. Therefore
age-squared was used in the count model for a better fit.
*P < 0.05, **P < 0.01, ***P < 0.001.
†
We included a quadratic term for centred age to achieve a better fit of the data with the model. RR, rate ratio.

experience than children in Medicaid (40). These findings for children, socio-economic differences in caries experi-
indicate that although free dental services are important ence may persist nonetheless (Fig. 1).
The findings of this study should be considered in light
of its strengths and limitations. The strengths include the
large sample of children and young adults shown to be
representative of the Dutch population of 5- to 23-yr-old
subjects with respect to background variables (26, 41).
Moreover, the dental examinations were carried out by
trained professionals with satisfactory interexaminer
agreement. There are also some limitations. Given the
low response rate of 23%, selection bias may have
affected our findings. In our study, the inclusion of par-
ticipants stopped when the required number was
reached, slightly increasing non-response rates but less
likely causing bias. Non-response analyses indicated why
people were unwilling to participate. The most frequent
reasons were lack of interest, lack of time, and anxiety,
with (in particular) the last item in this list potentially
resulting in bias. Moreover, selection bias is less likely as
the demographic characteristics of the sample were very
similar to those of the general population. A second limi-
Fig. 1. Cumulative frequency distribution of the percentage of tation may be that we assessed SES only according to
teeth with caries. One-hundred percent teeth with caries expe- educational level and not by using other measures, such
rience is equivalent to 20 teeth with caries experience for age as income or occupation. Asking about educational level
5 yr, and 28 teeth with caries experience for age 23 yr. has the advantage of a high response, particularly in
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252 Verlinden et al.

contrast to asking about income; moreover, in the dearth of clear guidelines for preventive dental care in
Netherlands, educational level has been found to be the children. Community-based interventions to decrease the
most sensitive indicator of SES (42). socio-economic differences and to improve oral health
Our finding, of large absolute differences according may include enhancing oral health literacy and improv-
to SES in all age groups in a country with a system of ing parental knowledge, skills, and self-efficacy in
full dental coverage, suggests a need for additional pre- relation to preventive oral-health behaviour. Better col-
ventive efforts. The disease of dental caries is pre- laboration between paediatric primary care, elementary
ventable (43). One way to prevent it is to change schools, and preventive dental care may help motivate
unfavourable oral health behaviours, such as tooth- parents to brush their child’s teeth twice a day, to let
brushing less than twice daily and frequent consump- their child drink water, and to limit their child’s con-
tion of cariogenic food and drinks. Interventions to sumption of highly processed carbohydrate-rich foods.
reach children to prevent caries experience may include Moreover, we need policy measures to curtail, at com-
enhancing oral health literacy, as well as improving munity level, the increasing availability and consumption
parental knowledge, skills, and self-efficacy in relation of highly processed, carbohydrate-rich foods, which par-
to preventive oral health behaviour, both early in life ticularly affects low-SES families. Further research is
and thereafter. needed on the effectiveness of such interventions and on
In this study, differences in mean caries experience the degree to which they reach low-SES children. This
between children with low SES and high SES were may reduce child dental morbidity in a major way.
already present in 5-yr-old participants, despite full
dental coverage. One could hypothesize that children Acknowledgements – We wish to thank Dr. Paula van Dommelen
receive preventive dental care too late. To minimize for her contribution to the statistical analyses, Ineke van Kempen
for her skilled assistance during the data collection and Dr. Erik
socio-economic differences, community-based interven- Vermaire for his useful suggestions.
tions aimed at improving the oral health of children
and young adults should start early in life – as early as
the age of 6 months when the first tooth erupts (44, Conflicts of interest – The authors declare no conflicts of interest.
45). To reach all children, better integration of preven-
tive dental care in well-child care, paediatric primary
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