Role of Socioeconomic and Behavioral Factors
Introduction
At group and population level, socioeconomic factors, particularly educational levels, are emerging as the most important external factors related to dental caries today.
History has clearly shown a relationship between social characteristics and dental disease patterns and, in particular, how social changes have influenced those patterns.
Wartime, urbanization, and industrialization, to mention a few, have affected caries prevalence. Most often, we think of social class when we talk about social factors.
There are various classifications of social class, usually based on the income of the head of the household and the length and type of education.
The links between social class and dental caries have been demonstrated in many studies (Antoft et al, 1988; Beal, 1989; Holm et al, 1975; Koch and Martinsson, 1970; Milen, 1987; Schwarz, 1985; Zadik, 1978). Throughout the 20th century, in temperate and industrialized countries, caries prevalence in primary teeth has been found to increase with decreasing socioeconomic status. In contrast, during the first half of the century, caries experience in permanent teeth was more prevalent in the highest social class, but the situation is now reversed (Milen and Tala, 1986). In most tropical and developing countries, on the other hand, caries prevalence has been reported to increase with increasing socioeconomic status (for review, see Enwonwu, 1981).
Social factors are closely linked to behavioral factors, and a great number of behaviors, particularly health behaviors, are characteristic and distinctive for each social class. Other indicators have also been used, for example, which newspaper the household reads, whether the family has a car, the number of households with no bath, the absence of an inside toilet, shared toilet facilities, residents per room, and similar factors. With such information, geographic areas can be ranked separately for each variable. A combination of variables gives a clear indication of the most and least advantaged areas: these appear at opposite ends of the scale. Such a system is valid for extremes, such as high-risk groups, but less reliable for the middle ranges.
Palmer and Pitter (1988) used such a classification and clearly demonstrated wide variations in caries status and treatment levels in 8-year-old English children from different social backgrounds. Socially disadvantaged children had a much higher level of dental caries than did their more socially advantaged contemporaries. The potential number of social and behavioral indicators of deprived or disadvantaged groups or individuals is enormous; such indicators must be chosen with care, with special reference not only to relevance to a given society but also to the changing nature of these indicators with time.
The Korner Report (Department of Health and Social Security [DHSS], 1982)
recently questioned the validity of social class as a health-related variable and set up
an inquiry to study alternatives. Sarll et al (1984) have studied the advantages and
limitations of a composite indicator, A Classification Of Residential Neighborhoods
(ACORN), a system based on census statistics, in terms of its use in planning dental
services. In the industrial area in the north of England they found that the
socioeconomic ACORN analyses effectively identified differences in caries
prevalence. Data collection was simple, and a high proportion of subjects could be
classified. In addition, the ACORN classification, relying on postal address, avoided
the need for questions about occupation and economic circumstances, which may be
particularly difficult in studies of children.
The national survey of children’s dental health in the United Kingdom (Todd and
Dodd, 1985) disclosed regional inequalities in dental health: Children living in
England had the least dental caries, and those in Northern Ireland had the most. The
findings showed that, at the national level, where a child lives is a more important
factor than social class in determining caries experience.
