Correspondence |
Dental filling as an indicator of socio-economic status
Caroline S. Drugan
Bristol Directorate for Public Health King Square House King Square Bristol BS2 8EE
Martin C. Downer
Honorary Professor 1 Middlecroft Stapleton Shrewsbury SY5 7EA
Sirs,
We read with interest the article on the association of self-reported violence at home and health in primary school pupils in West London.1 We note the authors state that ‘There was no direct measure of socioeconomic status, so the report of dental filling was used as the best available proxy’. Later, in their results, they purport to show ‘health outcomes significantly associated with exposure to violence at home, after adjusting for socioeconomic status as measured by dental filling’. Finally, in the discussion, they note that they were ‘unable to control rigorously for socioeconomic status as such data were not collected. However, adjustment using a proxy measure resulted in virtually unchanged effect sizes’.
The authors’ admission of their inability to control rigorously for socioeconomic status is somewhat of an under-statement because the proxy measure used was invalid and unreliable as a dependable indicator of socioeconomic status. There are several reasons for this apart from the obvious ones of recall bias allied to the fact that no time frame as to when the child attended a dentist was evidently implied in the question. Thus, dental filling, or more accurately the receipt of restorative dental treatment, as a factor on its own outside the context of the child’s overall dental decay experience, as conventionally measured by decayed, missing (extracted) or filled teeth (abbreviated to dmft in the primary and DMFT in the permanent dentition), has only an indirect relationship with socioeconomic status. As a general background, mean dmft experience in young children has been low and relatively stable for at least two decades2,3 with only 13 per cent of dmft currently residing in the ‘filled’ component.3 At the same time, dental decay is not evenly distributed within the child population. For example, 50 per cent of 5-year-old dmft in an area of relatively high disease experience was found to occur in some 20 per cent of children; those with the highest decay experience tending to reside in more deprived localities.4 However, this refers to overall decay experience and not merely ‘dental filling’.
In general, children of high socioeconomic status are more likely to attend the dentist regularly and are therefore more likely to be exposed to dental treatment. Yet at the same time they are less likely to have suffered dental decay as their diet will probably include relatively infrequent intakes of sugary snacks. They are therefore less likely to require and receive restorative dental treatment. On the other hand, children from deprived backgrounds are less likely to attend a dentist regularly and more likely to attend only when prompted by pain. The 1993 survey of children’s dental health,5 for example, found that although 96 per cent of 8-year-old children had been to a dentist, this varied by social class ranging from 2 per cent non-attenders for groups I, II and III non-manual to 6 per cent for groups IV and V. Moreover, parents in groups IV and V may opt for dental extraction rather than restoration as the treatment of choice for their children. A further relevant factor is that children in age groups 8–11 years are in what is known as the mixed dentition stage. Whether any remaining decayed primary teeth are filled or not is also a matter of the dentist’s preferred treatment option given that most of these teeth will soon be shed naturally.
Overall measures of decay experience, expressed as dmft/DMFT, are known to be related to socioeconomic status. Tickle et al.6 demonstrated a strong relationship between dmft and deprivation at ward level. However, measures of deprivation accounted for only 51 per cent of the variability of dmft in a ward. Clearly, ‘dental filling’ in isolation would account for much less. In view of this, we believe that the use of dental filling as a proxy measure for socioeconomic status is severely flawed and invalidates any notion that this variable was controlled for in the author’s multivariate analysis as presented in the article.
Yours faithfully
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References |
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 TOP References |
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- Stewart G, Ruggles R, Peacock J. The association of self-reported violence at home and health in primary school pupils in west London. J Publ Hlth 2004; 26: 19–23.
- Downer MC. Caries experience and sucrose availability: an analysis of the relationship in the United Kingdom over 50 years. Community Dent Hlth 1999; 16: 18–20.
- Pitts NB, Boyles J, Nugent ZJ, Thomas N, Pine CM. The dental caries experience of 5-year-old children in England and Wales. Surveys coordinated by the British Association for the Study of Community Dentistry in 2001/2002. Community Dent Hlth 2003; 20: 45–54.
- Tickle M. The 80:20 phenomenon: help or hindrance to planning caries prevention programmes? Community Dent Hlth 2002; 19: 39–42.
- O’Brien M. Children’s dental health in the United Kingdom 1993. London: Office of Population Censuses and Surveys, 1994.
- Tickle M, Kay E, Worthington H, Blinkhorn A. Predicting population dental disease experience at a small area level using census and health service data. J Public Hlth Med 2000; 22: 368–374.
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