Overview

The influence of socioeconomic status on health is a topic that is observed and discussed frequently within the medical field. Specifically in dentistry, despite a universal reduction in tooth decay prevalence, the numbers are still high in low socioeconomic groups.¹ This indicates that socioeconomic status is a determinant of oral health in addition to systemic health. Although social research has shed some light on health inequalities in recent times, there is still a need for increased awareness of the effect of social situations on the causation and prediction of diseases. A study reported that low level of education, monthly household income and socioeconomic status were associated with poor oral health knowledge, decreased access to oral hygiene products and dental services, higher frequency and likewise severity of tooth decay.¹ Thus, the greater prevalence of tooth decay and the associated pain and infection requires intervention from a range of healthcare professionals within the dental team, in local and central government, and through interprofessional working to tackle the problem on both an individual and community level. This article aims to discuss the effects of socioeconomic status on access to dental care, affordability, education, knowledge and barriers to dental care, success of interventions and the implications of these effects.

Socioeconomic factors 

Socioeconomic status is defined as “the absolute or relative levels of economic resources, power and prestige closely associated with wealth of an individual, community or country”.² The term is often used in the field of public health to describe the complex and cumulative way that the disadvantages of social class and wealth, and the advantages of class and wealth, affect health throughout a lifetime. In other words, socioeconomic factors are factors that are an interplay of social, economic, political, and structural processes that directly or indirectly affect health and contribute to systematic and avoidable differences in health. It encompasses various factors such as income, education, and employment status. People with low socioeconomic status are at an increased risk of developing cardiovascular diseases as well as dying from them.³ Socioeconomic factors such as education and employment can affect the health of an individual, household, and community. This is because these factors affect the affordability of medical services, housing and basic needs, access to quality health services, time, and ability to participate in health activities. They can also compound other pre-existing risk factors such as race, stress, or obesity.

Effect of socioeconomic factors on tooth decay

Many population-based studies have found a significant association between low socioeconomic status and high levels of tooth decay. Various measures of socioeconomic status, including income, education level, and occupation, are associated with different levels of oral health. For instance, a study involving Egyptian adults examined the relationship between tooth decay prevalence and various factors. They reported that risk factors including BMI, socioeconomic status, education and brushing frequency were associated with a high prevalence of tooth decay among the participants. In the study, adult participants with low levels of education, socioeconomic status and low brushing frequency had the highest number of decayed and missing teeth.⁴ Likewise, a study in Saudi reported lower levels of caries prevalent in children from higher socioeconomic groups defined by parental income and level of education.⁵ While teenagers depend more on their own socioeconomic status, children are more likely to feel the impact of their parent's status. The Royal College of Paediatrics and Child Health stated that children who live in low-income communities are at least two times more likely to have tooth decay than children from higher-income households.⁶

Poor health-seeking behaviour

Even though decay is largely preventable, individuals from these backgrounds tend to seek care only once decay has progressed to the point that it has caused pain or has become infected - known as "emergency treatment". They often prefer to consult traditional methods or family recommendations and postpone regular preventive visits to the dentist.⁷ As the decay process usually takes a few years to progress from the tooth's hard outer layer (the enamel) to the softer inner layer (dentine), individuals in higher socioeconomic groups have more of an opportunity to seek preventive treatment before decay progresses to the stage of needing invasive treatment such as fillings. Some authors suggest that this may be due to cultural values and beliefs about the source and treatment of illness.⁸ By the time an individual from a lower socioeconomic group seeks treatment, the decay is more likely to be at a stage where more complex and costly treatment is needed, if the nerve in the tooth is involved, such as root canal treatment or even tooth removal. However, these may be influenced by knowledge, income, dental insurance, access, availability, and affordability of dental services.  

Effect of educational level on tooth decay prevalence

Studies have shown that people with low educational attainment have higher tooth decay rates, and parents with higher educational levels have lower prevalence rates.¹⁰

There are multiple potential explanations for this finding. First, individuals with low educational attainment are more likely to engage in harmful health behaviours. For example, an individual with low education may be more likely to consume sugary snacks and drinks, more likely to smoke, and less likely to brush their teeth properly. Limited health literacy among this group may also contribute to a lack of awareness of the importance of maintaining good oral health and accessing appropriate preventive services. Secondly, schools are recognised as important settings for promoting children's health. It is known that oral health promotion activities delivered in educational settings help to improve children's oral health.¹¹

As a result, higher educational attainment is expected to be associated with lower tooth decay rates. This may happen because higher-educated parents are more aware of the importance of good oral health and, therefore, are more likely to encourage children to adopt health-promoting behaviours. In contrast, lower-educated parents are more likely to overlook children's oral health needs.¹⁰ Moreover, limited educational attainment is often associated with lower income and higher unemployment, and people from low socioeconomic status groups are known to experience worse oral health.⁹ Therefore, strategies aiming to tackle oral health inequalities should put more emphasis on the contribution of educational determinants.

This might involve developing public health programs that are specifically designed to target different social groups who have different levels of educational attainment. By recognising the importance of education, policymakers should look for ways to improve public awareness of the importance of oral health and promote oral health maintenance strategies. It is essential for oral health promotion activities to be focused on community and school settings, to build supportive oral health environments in which individuals can be helped to establish and maintain good oral health.

Availability and access to quality dental services 

Another important aspect of the availability of dental services is the maldistribution of dentists. Wealthier urban areas tend to have a higher dentist-to-population ratio than poorer rural areas. Tudor Hart termed the “inverse care law” to describe the tendency of availability of quality health services to vary inversely with the need for them in the population it serves.¹² This was coined in 1971 but is still the case in many communities and countries today. For example, this was investigated by researchers in India where there still exists a gap between available resources and the demand for dental care.¹³ The relative lack of dentists in rural and low-income areas puts residents in these areas at a disadvantage in terms of access to preventive and routine dental care. This phenomenon reflects one of the underlying problems associated with the availability of dental services in that there is still a lack of proper and effective dental services strategies and policies that could help relieve the status quo of the inequalities in oral health among different socioeconomic groups.

Affordability of quality dental services 

Some dental treatments, especially extensive procedures like a root canal or dental implants, can cost a lot. For instance, in the US, affordability is a significant barrier to dental care access with a huge percentage of people being uninsured and having to pay out of pocket despite being medically insured. Dental coverage is optional under the Affordable Care Act. In 2022, it was reported that twelve states provided emergency treatments only to recipients of Medicaid and three states provided no dental coverage. When compared with their developing countries, the US has the least amount of dental coverage for adults.¹⁴ Another Canadian study stated that respondents reported shunning dental treatment due to high costs. The respondents with low incomes and no dental coverage were four times more likely to avoid dentists due to cost and about 2.5 times more likely to refuse dental treatment recommended by a professional.¹⁵

Barriers causing disparities in dental care

An insignificant sense of duty regarding oral cleanliness and dental visits, and a distinction in dental wellbeing recognition in guardians from various financial foundations, exists and adds to the hole in dental disease rates. Families with higher livelihoods frequently express a more elevated level of dental well-being mindfulness and a more grounded commitment to forestalling depressions contrasted with those with lower livelihoods.¹⁶ Current evidence can't seem to consider wide scale if language hindrances and cultural affectability in dental wellbeing administrations likewise add to the hole in dental illness rates, however, it is recommended there is a connection. Among minority populaces, it is accepted that various societies may have fluctuated inclinations for the sort of dental therapies and social contrasts in the worthiness of various prophylaxes, and athleticism dental medicines.⁷ Such social elements and inclinations have the potential to affect dental assistance usage and result in various degrees of oral well-being and the predominance of dental maladies among various racial, ethnic, and financial gatherings.

Public health interventions 

Oral health education initiatives are also crucial in preventing tooth decay. These initiatives aim to raise public awareness through tailored messaging and education. Nonprofit organisations like the Oral Health Foundation and the National Children's Oral Health Foundation often carry out national oral health education campaigns. Digital media and social networks provide channels for more engaging and interactive oral health education, using various content formats such as video clips, webinars, blogs, and e-learning modules. Oral health education initiatives in schools and local communities help promote healthy behaviours and create supportive oral health environments. By empowering individuals to make healthy choices and influencing the social determinants that impact oral health, these initiatives can significantly reduce tooth decay across a population.

School-based dental sealant programs are another effective public health intervention to prevent tooth decay, especially in children. Dental sealants are thin, protective coatings that can be applied to the chewing surfaces of back teeth. Placing dental sealants in children has

been shown to reduce tooth decay in the grooves of teeth by more than 80%.¹⁷ School-based dental sealant programs involve a licensed dental provider coming to a school to screen children for cavities, apply sealants to cavity-prone teeth, and provide oral health education. These programs allow many children to receive preventive treatments at school without imposing a financial burden on their families or the difficulties of transportation and time off from work that parents may face.

Some common public health interventions used to prevent tooth decay include community oral health programs, school-based dental sealant programs, and oral health education initiatives. Community oral health programs typically provide prevention and education services in local community centres, schools, public health offices, and mobile dental vans. These programs offer a range of free or reduced-price dental services, such as dental screenings, fluoride varnish treatments, dental sealants, and oral health education. By bringing prevention services to where people live, eat, work, and learn, community oral health programs help reduce barriers to regular dental care. Public health interventions focus on preventing and managing diseases, increasing health awareness, and ensuring equal access to healthcare services.

These interventions target large populations and aim to have a significant impact on health outcomes. When it comes to addressing tooth decay, public health interventions often involve interdisciplinary efforts with health professionals, community leaders, educators, and policymakers. These efforts aim to educate the public, raise awareness about the importance of oral health, and address disparities in access to dental care.

Summary 

This article discussed how socioeconomic factors are strongly interrelated with the prevalence of tooth decay. According to studies highlighted earlier, the lowest prevalence of tooth decay, both in male and female adults, is found in the group of high socioeconomic status. Also, the results of these studies showed that the prevalence of tooth decay increased with a decrease in income.

Further to this, research indicates that there is a negative relationship between the level of education and the prevalence of tooth decay. In fact, those who had a high level of education showed a lower level of tooth decay when compared to the low-education group. These studies highlight the need to refine future planning and policies for public oral health promotion. For example, if a government wants to implement a program for oral health in a certain area, the knowledge that access to dental care has a significant effect on tooth decay can be used to argue that part of the resources should be allocated to increase the accessibility to dental care, particularly among the lower socio-economic group.

Finally, it is hoped that dentists would advise their patients, as patient education has always been deemed important to achieve positive health outcomes. It is suggested that future studies can incorporate other dimensions of socioeconomic status in the research, for example, occupation and place of living, and further investigate how each different element of socioeconomic status may affect tooth decay. Also, studies can be undertaken in different countries and compare their findings to this current study to obtain a more complete view of the impact of socioeconomic status on tooth decay prevalence globally. In addition, research considering different ethnic groups is warranted because different ethnic groups may have different cultural practices that may show an effect on oral health and ultimately lead to different tooth decay prevalence.