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Little is known about the health of infants born Venezuelan refugee women in Colombia. Using birth certificate data, we compared birth weight, gestational age, and Apgar scores between births to Venezuelan refugee women and Colombian women in 2016-2018 using logistic regression. We also compared number of prenatal visits and health insurance coverage. Infants born to Venezuelan refugee women were more likely to be preterm (OR=1.14 [95%CI:1.07,1.23]), extremely preterm (OR=1.71 [95%CI:1.19,2.46]), low birth weight (OR=1.30 [95%CI:1.18,1.42]), and very low birth weight (OR =1.80 [95%CI:1.45,2.23]) than infants born to Colombian women. There were no differences in Apgar scores. Most Venezuelan refugee women had no health insurance, and number of prenatal visits was half that of Colombian women. Pregnant Venezuelan refugee women face health care barriers and have worse birth outcomes than Colombian women, highlighting the need to further address health care and other socioeconomic barriers for this vulnerable population.

BackgroundWhile inequalities in oral health are documented, little is known about the extent to which they are attributable to potentially modifiable factors. We examined the role of behavioural and dental attendance pathways in explaining oral health inequalities among adults in England, Wales and Northern Ireland.MethodsUsing nationally representative data, we analysed inequalities in self-rated oral health and number of natural teeth. Highest educational attainment, equivalised household income and occupational social class were used to derive a latent socioeconomic position (SEP) variable. Pathways were dental attendance and behaviours (smoking and oral hygiene). We used structural equation modelling to test the hypothesis that SEP influences oral health directly and also indirectly via dental attendance and behavioural pathways.ResultsLower SEP was directly associated with fewer natural teeth and worse self-rated oral health (standardised path coefficients, −0.21 (SE=0.01) and −0.10 (SE=0.01), respectively). We also found significant indirect effects via behavioural factors for both outcomes and via dental attendance primarily for self-rated oral health. While the standardised parameters of total effects were similar between the two outcomes, for number of teeth, the estimated effect of SEP was mostly direct while for self-rated oral health, it was almost equally split between direct and indirect effects.ConclusionReducing inequalities in dental attendance and health behaviours is necessary but not sufficient to tackle socioeconomic inequalities in oral health.

To examine the association between changes in contextual economic factors on childhood obesity in the US. We combined data from 2003, 2007, and 2011/2012 National Surveys of Children’s Health for 129,781 children aged 10–17 with 27 state-level variables capturing general economic conditions, labor supply, and the monetary or time costs of calorie intake, physical activity, and cigarette smoking. We employed regression models controlling for demographic factors and state and year fixed effects. We also examined heterogeneity in economic effects by household income. Obesity risk increased with workforce proportion in blue-collar occupations, urban sprawl, female labor force participation, and number of convenience stores but declined with median household income, smoking ban in restaurants, and full service restaurants per capita. Most effects were specific to low income households, except for density of supercenters/warehouse clubs which was significantly associated with higher overweight/obesity risk only in higher income households. Changes in state-level economic factors related to labor supply and monetary or time cost of calorie intake may affect childhood obesity especially for children in low-income households. Policymakers should consider these effects when designing programs aimed at reducing childhood obesity.

BackgroundHealth inequalities, including inequalities in oral health, are problems of social injustice worldwide. Evidence on this issue from low-income and middle-income countries is still needed. We aimed to examine the relationship between oral health and different dimensions of socioeconomic position (SEP) in Colombia, a very unequal society emerging from a long-lasting internal armed conflict.MethodsUsing data from the last Colombian Oral Health Survey (2014), we analysed inequalities in severe untreated caries (≥3 teeth), edentulousness (total tooth loss) and number of missing teeth. Inequalities by education, income, area-level SEP and health insurance scheme were estimated by the relative index of inequality and slope index of inequality (RII and SII, respectively).ResultsA general pattern of social gradients was observed and significant inequalities for all outcomes and SEP indicators were identified with RII and SII. Relative inequalities were larger for decay by health insurance scheme, with worse decay levels among the uninsured (RII: 2.57; 95% CI 2.11 to 3.13), and in edentulousness (RII: 3.23; 95% CI 1.88 to 5.55) and number of missing teeth (RII: 2.08; 95% CI 1.86 to 2.33) by education, with worse levels of these outcomes among the lower educated groups. Absolute inequalities followed the same pattern. Inequalities were larger in urban areas.ConclusionHealth insurance and education appear to be the main contributors to oral health inequalities in Colombia, posing challenges for designing public health strategies and social policies. Tackling health inequalities is crucial for a fairer society in a Colombian post-conflict era and our findings highlight the importance of investing in education policies and universal health care coverage.

Dental caries can be effectively managed and prevented from developing into cavitated lesions while preserving tooth structure at all levels. However, the strong correlation between caries and socioeconomic factors may compromise the efficacy of preventive strategies. The high prevalence of persistent inequalities in dental caries in Latin American and Caribbean countries (LACC) is a matter of concern. The estimates of the burden of disease in some countries in this region are outdated or absent. This paper aims to summarize and present the final recommendations of a regional Consensus for Dental Caries Prevalence, Prospects, and Challenges for LACC. This consensus is based on four articles that were written by a team of Latin American experts, reviewed by dental associations, and presented and discussed in two consensus events. The following domains were explored: epidemiology, risk factors, prevention strategies, and management of dental caries with a focus on restorative procedures. Dental caries can manifest throughout the lifespan of an individual, making it a matter of concern for infants, children, adults, and older people alike. The prevalence rates of untreated caries in deciduous and permanent teeth are high in many parts of the world, including LACCs. Previous evidence suggests that the prevalence of dental caries in 12-year-olds is moderate to high in most Latin American countries. Moreover, the prevalence of treatment needs and dental caries in the adult and elderly population can also be regarded as high in this region. The risk/protective factors (e.g., sugar consumption, exposure to fluoride, and oral hygiene) probably operate similarly in all LACCs, although variations in the interplay of these factors in some countries and within the same country cannot be ruled out. Although salt and water fluoridation programs are implemented in many countries, there is a need for implementation of a surveillance policy. There is also room for improvement with regard to the introduction of minimal intervention techniques in practice and public health programs. Dental caries is a marker of social disadvantage, and oral health promotion programs and interventions aimed at reducing the burden of dental caries in LACCs must consider the complexity of the socioeconomic dynamics in this region. There is an urgent need to promote engagement of stakeholders, policymakers, medical personnel, universities, dental associations, community members, and industries to develop regional plans that enhance the oral health agenda for LACCs. A list of recommendations has been presented to underpin strategies aimed at reducing the prevalence and severity of dental caries and improving the quality of life of the impacted LACC population in the near future.

There are currently 370 million persons identifying as indigenous across 90 countries globally. Indigenous peoples generally face substantial exclusion/marginalization and poorer health status compared with non-indigenous majority populations; this includes poorer oral health status and reduced access to dental services. Population-level oral health surveys provide data to set priorities, inform policies, and monitor progress in dental disease experience/dental service utilisation over time. Rigorously and comprehensively measuring the oral health burden of indigenous populations is an ethical issue, though, given that survey instruments and sampling procedures are usually not sufficiently inclusive. This results in substantial underestimation or even biased estimation of dental disease rates and severity among indigenous peoples, making it difficult for policy makers to prioritise resources in this area. The methodological challenges identified include: (1) suboptimal identification of indigenous populations; (2) numerator-denominator bias and; (3) statistical analytic considerations. We suggest solutions that can be implemented to strengthen the visibility of indigenous peoples around the world in an oral health context. These include acknowledgment of the need to engage indigenous peoples with all data-related processes, encouraging the use of indigenous identifiers in national and regional data sets, and mitigating and/or carefully assessing biases inherent in population oral health methodologies for indigenous peoples.

Objective To examine socioeconomic inequalities in birth outcomes among infants born between 2008 and 2018 and assessed trends in inequalities during that period in Colombia, a middle-income country with high levels of inequality emerging from a long internal armed conflict. Methods Using birth certificate data in Colombia, we analysed the outcomes of low birth weight, an Apgar score Results Among the 5,433,265 full-term singleton births analysed, there was a slight improvement in the outcomes analysed over the study period (lower low-birth-weight and Apgar Conclusion The lack of a consistent improvement in the magnitude of inequalities in birth outcomes over an 11-year period is a worrying issue because it could aggravate the cycle of inequality, given the influence of birth outcomes on health, social and economic outcomes throughout the life course. The findings of our analysis emphasize the importance of policies aimed at providing access to quality education and providing a health care system with universal coverage and high levels of integration.

In this chapter, we aim to present some conceptual elements, discussion points, and research evidence about power, politics, social policies, and why these are important issues for public health in general and dental public health in particular. In the first section, we discuss the concepts of power, knowledge, epidemiology, and public health, and how they are related to each other. Some historical aspects of these concepts are also presented. Then, we introduce some ideas on how politics has been crucial in the way health/illness has been understood, analyzed, and tackled under different contexts and during distinct historical moments. Some changes in the traditional field of Public Health (Dental Public Health) are also summarized together with some characteristics of proposed alternatives documented as New Public Health and Collective Health (Collective Oral Health). Later, ideas about the theoretical basis of the influence of social policies on population oral health and inequalities are discussed, followed by a review of the evidence on the relationship between social policies and oral health (including inequalities). The closing section of the chapter presents what we think are the main challenges and steps to take forward regarding research and policy action.

“Oral health matters” was the clear and emphatic message on the front cover of The Lancet on July 20, 2019. In this single issue of The Lancet, in addition to the front cover, oral health was the focus of an editorial (The Lancet 2019), an Oral Health Series comprising 2 major papers (Peres et al. 2019; Watt et al. 2019), 2 associated commentaries (Beaglehole and Beaglehole 2019; Kearns and Bero 2019), a perspective piece on the historical origins of modern dentistry (Barnett 2019), and a profile of a dental public health researcher (Davies 2019). Never before in the 196-year history of The Lancet—one of the most prestigious medical journals in the world—has oral health been given such a high profile. This is, without doubt, a watershed moment for global oral health. It is also, however, a profoundly important opportunity for the oral and dental research community. This commentary highlights the key messages from The Lancet Oral Health Series and considers the implications for the oral and dental research agenda globally.

We greatly appreciate the comments made by Rojas-Botero et al.1 on our paper entitled “Critical reflections on the Municipal Epidemiological Resilience Index used for public policy decision-making regarding the control of the COVID-19 pandemic in Colombia”.2 We acknowledge that public health, understood as the well-being of the community, should be the focus of all our efforts as health professionals. In this sense, decision-making amid a major emergency, such as the one we are currently experiencing due to the COVID-19 pandemic, requires a balanced and calm judgment that considers both the general context and local specificities, as well as the best available scientific evidence, that is, evidence that not only supports decisions, but also prioritizes benefits over risks.

Oral health is uniquely positioned to reflect both contemporary and cumulative race-based health inequities. For example, the most common clinical measure of dental caries experience, the Decayed, Missing or Filled Teeth (DMFT) index, may be used to simultaneously present current inequities in experience of dental disease (D), as well as past exposure to inequitable treatment of that disease that is either radical (M) or conservative (F) across the life course. In so doing, this index captures the cumulative effect of racism operating at various societal levels, including race-based discrimination in dental care. Current evidence at a global level shows that: (i) racially marginalized groups often bear the greatest burden of oral diseases and; (ii) racial inequities in oral health persist over time and across space [1].

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

Oral diseases are a major global public health problem affecting over 3·5 billion people. However, dentistry has so far been unable to tackle this problem. A fundamentally different approach is now needed. In this second of two papers in a Series on oral health, we present a critique of dentistry, highlighting its key limitations and the urgent need for system reform. In high-income countries, the current treatment-dominated, increasingly high-technology, interventionist, and specialised approach is not tackling the underlying causes of disease and is not addressing inequalities in oral health. In low-income and middle-income countries (LMICs), the limitations of so-called westernised dentistry are at their most acute; dentistry is often unavailable, unaffordable, and inappropriate for the majority of these populations, but particularly the rural poor. Rather than being isolated and separated from the mainstream health-care system, dentistry needs to be more integrated, in particular with primary care services. The global drive for universal health coverage provides an ideal opportunity for this integration. Dental care systems should focus more on promoting and maintaining oral health and achieving greater oral health equity. Sugar, alcohol, and tobacco consumption, and their underlying social and commercial determinants, are common risk factors shared with a range of other non-communicable diseases (NCDs). Coherent and comprehensive regulation and legislation are needed to tackle these shared risk factors. In this Series paper, we focus on the need to reduce sugar consumption and describe how this can be achieved through the adoption of a range of upstream policies designed to combat the corporate strategies used by the global sugar industry to promote sugar consumption and profits. At present, the sugar industry is influencing dental research, oral health policy, and professional organisations through its well developed corporate strategies. The development of clearer and more transparent conflict of interest policies and procedures to limit and clarify the influence of the sugar industry on research, policy, and practice is needed. Combating the commercial determinants of oral diseases and other NCDs should be a major policy priority.

We thank Jean-Noel Vergnes and Marco Mazevet for their interest in our Series paper on the global public health challenge of oral diseases,1 and we thank Himmatrao and Pramodini Bawaskar for sharing their experience of oral health in India.

Objective To assess the association between children's oral health and academic performance using the most recent US national data, a decade after the last assessment using similar previous data. Study design Data from the 2016-2017 National Survey of Children's Health for 45 711 children aged 6-17 years were analyzed. Children's oral health measures were indicators of specific oral health problems and parent-rated oral health. Academic performance measures included problems at school and missing school days. Regression models were employed adjusting for relevant demographic, socioeconomic, and health characteristics and state effects. Analyses also were conducted stratifying by child's age, sex, household income, and type of health insurance. Results We found significant associations across all the evaluated academic outcomes and oral health measures. Children with oral health problems were more likely to have problems at school (OR 1.56, 95% CI 1.32-1.85), miss at least 1 school day (OR 1.54, 95% CI 1.28-1.85), and miss more than 3 or 6 school days (OR 1.39, 95% CI 1.20-1.61 and OR 1.39, 95% CI 1.14-1.69; respectively). These associations were generally larger when using the child's oral health rating. Poor oral health was consistently related to worse academic performance across age, sex, household income, and health insurance type subgroups. Conclusions Children's oral health status continues to be strongly linked to their academic outcomes. This evidence highlights the need for broad population-wide policies and integrated approaches to reduce academic deficits and promote children's health and development, of which oral health is an important component.

OBJECTIVE: To assess the extent to which behavioural factors, including those related to dental care, account for oral health inequalities in different European welfare state regimes. METHODS: Data from the Eurobarometer 2009 survey were analysed. Nationally representative samples of dentate adults aged ≥45 years (n = 9979) from 21 European countries classified into the five welfare regimes (Scandinavian, Anglo-Saxon, Bismarckian, Southern, Eastern) were considered. Inequalities in no functional dentition (having

Oral health inequalities associated with socioeconomic status are widely observed but may depend on the way that both oral health and socioeconomic status are measured. Our aim was to investigate inequalities using diverse indicators of oral health and 4 socioeconomic determinants, in the context of age and cohort. Multiple linear or logistic regressions were estimated for 7 oral health measures representing very different outcomes (2 caries prevalence measures, decayed/missing/filled teeth, 6-mm pockets, number of teeth, anterior spaces, and excellent oral health) against 4 socioeconomic measures (income, education, Index of Multiple Deprivation, and occupational social class) for adults aged ≥21 y in the 2009 UK Adult Dental Health Survey data set. Confounders were adjusted and marginal effects calculated. The results showed highly variable relationships for the different combinations of variables and that age group was critical, with different relationships at different ages. There were significant income inequalities in caries prevalence in the youngest age group, marginal effects of 0.10 to 0.18, representing a 10- to 18-percentage point increase in the probability of caries between the wealthiest and every other quintile, but there was not a clear gradient across the quintiles. With number of teeth as an outcome, there were significant income gradients after adjustment in older groups, up to 4.5 teeth (95% confidence interval, 2.2-6.8) between richest and poorest but none for the younger groups. For periodontal disease, income inequalities were mediated by other socioeconomic variables and smoking, while for anterior spaces, the relationships were age dependent and complex. In conclusion, oral health inequalities manifest in different ways in different age groups, representing age and cohort effects. Income sometimes has an independent relationship, but education and area of residence are also contributory. Appropriate choices of measures in relation to age are fundamental if we are to understand and address inequalities.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved. Objective: Very few studies have analysed the relationship between political factors and oral health inequalities, and only one study has compared the magnitude of inequalities in oral health-related quality of life (OHRQoL) across welfare state regimes. This study aimed to compare socioeconomic inequalities in oral impacts on daily life among 21 European countries with different welfare state regimes (Scandinavian, Anglo-Saxon, Bismarckian, Southern, and Eastern). Methods: We analysed data from the Eurobarometer 72.3, a survey carried out in 2009 among adults in European countries. Inequalities in oral impacts by education, occupational social class and subjective social status (SSS) were estimated by means of age-standardized prevalence rates, odds ratios (ORs), the relative index of inequality (RII) and the slope index of inequality (SII). Results: Educational inequalities in the form of social gradients were observed in all welfare regimes. The Scandinavian and Southern welfare regimes also showed gradients for all SEP measures. There were not significant differences in the magnitude of relative inequalities (RII) across welfare state regimes. Absolute educational inequalities were largest in the Anglo-Saxon welfare regime (SII = 17.57; 95% CI: 7.80-27.33) and smallest in the Bismarckian (SII = 3.32; 95% CI: -2.18 to 8.83). Conclusions: A significant difference in the magnitude of inequalities across welfare regimes was found for absolute educational inequalities but not for relative inequalities. Welfare state regimes may influence the relationship between knowledge-related resources and oral impacts on daily life.

Objectives. We measured racial/ethnic inequalities in US children’s dental health and quantified the contribution of conceptually relevant factors. Methods. Using data from the 2007 National Survey of Children’s Health, we investigated racial/ethnic disparities in selected child dental health and preventive care outcomes. We employed a decomposition model to quantify demographic, socioeconomic, maternal health, health insurance, neighborhood, and geographic effects. Results. Hispanic children had the poorest dental health and lowest preventive dental care utilization, followed by Black then White children. The model explanatory variables accounted for 58% to 77% of the disparities in dental health and 89% to 100% of the disparities in preventive dental care. Socioeconomic status accounted for 71% of the gap in preventive dental care between Black children and White children and 55% of that between Hispanic children and White children. Maternal health, age, and marital status; neighborhood safety and social capital; and state of residence were relevant factors. Conclusions. Reducing US children’s racial/ethnic dental health disparities—which are mostly socioeconomically driven—requires policies that recognize the multilevel pathways underlying them and the need for household- and neighborhood-level interventions.

Background Oral diseases are highly prevalent and impact on oral health-related quality of life (OHRQoL). However, time changes in OHRQoL have been scarcely investigated in the current context of general improvement in clinical oral health. This study aims to examine changes in OHRQoL between 1998 and 2009 among adults in England, and to analyse the contribution of demographics, socioeconomic characteristics and clinical oral health measures. Methods Using data from two nationally representative surveys in England, we assessed changes in the Oral Health Impact Profile-14 (OHIP-14), in both the sample overall (n=12 027) and by quasi-cohorts. We calculated the prevalence and extent of oral impacts and summary OHIP-14 scores. An Oaxaca-Blinder type decomposition analysis was used to assess the contribution of demographics (age, gender, marital status), socioeconomic position (education, occupation) and clinical measures (presence of decay, number of missing teeth, having advanced periodontitis). Results There were significant improvements in OHRQoL, predominantly among those that experienced oral impacts occasionally, but no difference in the proportion with frequent oral impacts. The decomposition model showed that 43% (–4.07/–9.47) of the decrease in prevalence of oral impacts reported occasionally or more often was accounted by the model explanatory variables. Improvements in clinical oral health and the effect of ageing itself accounted for most of the explained change in OHRQoL, but the effect of these factors varied substantially across the lifecourse and quasi-cohorts. Conclusions These decomposition findings indicate that broader determinants could be primarily targeted to influence OHRQoL in different age groups or across different adult cohorts.

Objective To assess the effects of dental health on school performance and psychosocial well-being in a nationally representative sample of children in the US. Study design We analyzed data from the 2007 National Survey of Children's Health for 40 752-41 988 children. The effects of dental problems and maternal-rated dental health on school performance and psychosocial well-being outcomes were evaluated using regression models adjusting for demographic, socioeconomic, and health characteristics. Results Dental problems were significantly associated with reductions in school performance and psychosocial well-being. Children with dental problems were more likely to have problems at school (OR = 1.52; 95% CI: 1.37-1.72) and to miss school (OR = 1.42; 95% CI: 1.23-1.64) and were less likely to do all required homework (OR = 0.76; 95% CI: 0.68-0.85). Dental problems were associated with shyness, unhappiness, feeling of worthlessness, and reduced friendliness. The effects of dental problems on unhappiness and feeling of worthlessness were largest for adolescents between 15 and 17 years. Conclusion Preventing and treating dental problems and improving dental health may benefit child academic achievement and cognitive and psychosocial development.

Objective To compare oral health in the US and England and to assess levels of educational and income related oral health inequalities between both countries. Design Cross sectional analysis of US and English national surveys. Setting Non-institutionalised adults living in their own homes. Participants Oral health measures and socioeconomic indicators were assessed in nationally representative samples: the Adult Dental Health Survey 2009 for England, and the US National Health and Nutrition Examination Survey 2005-08. Adults aged ≥25 years were included in analyses with samples of 8719 (England) and 9786 (US) for analyses by education, and 7184 (England) and 9094 (US) for analyses by income. Main outcome measures Number of missing teeth, self rated oral health, and oral impacts on daily life were outcomes. Educational attainment and household income were used as socioeconomic indicators. Age standardised estimates of oral health were compared between countries and across educational and income groups. Regression models were fitted, and relative and absolute inequalities were measured using the relative index of inequality (RII) and the slope index of inequality (SII). Results The mean number of missing teeth was significantly higher in the US (7.31 (standard error 0.15)) than in England (6.97 (0.09)), while oral impacts were higher in England. There was evidence of significant social gradients in oral health in both countries, although differences in oral health by socioeconomic position varied according to the oral health measure used. Consistently higher RII and SII values were found in the US than in England, particularly for self rated oral health. RII estimates for self rated oral health by education were 3.67 (95% confidence interval 3.23 to 4.17) in the US and 1.83 (1.59 to 2.11) in England. In turn, SII values were 42.55 (38.14 to 46.96) in the US and 18.43 (14.01 to 22.85) in England. Conclusions The oral health of US citizens is not better than the English, and there are consistently wider educational and income oral health inequalities in the US compared with England.