I N E Q U I T I E S

H E A L T H

Role of social class in caries occurrence

in 12 year olds in Turin, Italy
FABR1ZIO FAGGIANO, FRANCESCO DI STANISLAO, PATRIZIA LEMMA, GIOVANNI RENGA

Background: The objective of the study was to evaluate the social distribution of dental caries and its determinants
in the province of Turin, an area of 2,300,000 inhabitants in the north of Italy. Methods: A cross-sectional study
was carried out among a representative school-based sample of 11-12 year olds. A total of 734 (84.0% of the
starting sample) students were involved. Two questionnaires were submitted (to students and parents) and the
children received a dental examination. Dietary and hygiene indicators were calculated and the DM FT index (the
number of decayed, missing and filled teeth) was measured using methods recommended by the World Health
Organisation (WHO). The education level of the head of family was used as a proxy of social dass indicator. Univariate
and multivariate analyses were applied to obtain results. Results: Students from disadvantaged families showed: I) a
higher tendency to belong to the higher risk group for oral hygiene (RR primary school/university = 2.78); II) a
lower use of dental prevention (RR=0.40 for use of fluoride tablets and RR=0.43 for local applications of fluoride)
and iii) a higher consumption of sucrose-sweetened foods (RR=1.17%, ns) when compared with children of graduate
parents. The DMFT index was more than double among children whose parents only had a primary school education,
compared with those of graduate parents (3.2 versus 1.5). In addition, the percentage of caries-free children
increased from 16.4 to 59.1% from the lowest to the highest social group. Conclusions: Large sodal differences
are found in caries experience and in determinants of dental decay. Nevertheless, determinants of caries occurrence
seem to explain only a small fraction of inequalities.

Keywords: caries, dental decay, education, epidemiology, social class

-Social differences in health represent, at least for dedental decay and social change similar to that outlined in
veloped countries, a priority field of intervention and
ischaemic heart disease.18 The advantaged social cat1
research. In this field, the interest in studying caries
egories are most able to adopt preventive practices as far
occurrence is that
as they are demonstrated to have a favourable effect on
health, such as a decrease in sucrose consumption, im it can be considered as an early life indicator of the
provement of oral hygiene and, more recently, consump'proneness to inequality' of a specific society and
tion of fluoride. The study of these cases can help in the
the rapid evolution of the natural history of dental decay
design
of policies aimed at promoting dental health at a
in recent years among children in the industrialised
population
level reaching the whole of society. Some
world makes it particularly suitable for applying policies
other
countries,
such as Jordan19 and Uruguay,20 showed
aimed at equity and assessing their effectiveness.
no relationship with social indicators.
Furthermore, inequalities in caries occurrence is particuIn Italy, social inequalities have been reported in mortallarly unethical given that it hits primarily the 'innocent'
ity,21 ill-health,22'23 and the use of health services,23 but
population of children.
there is no published data concerning social differences
Most authors have observed an inverse association bein dental health. The aim of this study was to assess the
tween social indicators and dental health in industrialised
social
distribution of caries experience and some of its
countries: subjects from higher social classes showed a
2 7
89
determinants,
such as dietary risk and preventive praclower occurrence of caries in the USA, " UK, ' Austra10
11
12
13
tices
among
11-12
year olds in the province of Turin
lia, New Zealand, Belgium, Denmark, and Fin14
(2300,000
inhabitants
in Northern Italy).
land. On the other hand, other studies, mostly carried
out in less-developed countries, showed a direct association with social class, in particular in Hong Kong,15 MATERIALS AND METHODS
Israel16 and Greece,17 suggesting a relationship between
A cross-sectional study was carried out among a sample of
11-12 year olds within the state school system in three
* F. F*gglano', F. DI Stanlsbo', P. Lemma , G. Renga
(out of 27) local health authorities (USLs) in the prov1 Department of Public Health, University of Turin, Turin, Italy
ince of Turin. They were chosen to represent the main
Correspondence Fabrizto Fagglano, Department of Public Health,
town
(city of Turin, ^950,000 inhabitants), the suburban
University of Turin, Via Santena Sbis, 10126 Turin, Italy, tel. +39 011 6706558,
fax +39 011 6706551, e-mail: fagg.lartoOmollnette.untto.ft
area (=700,000) and the area of provincial towns
1

EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 9 1999 NO. 2

(=750,000). The reason behind the choice of these three
USLs was to give a realistic representation of the variability in economic indicators of the whole province.
Within each one of the three USLs selected, [USL VII of
the town of Turin (=100,000), Moncalieri (=77,000) and
Pinerolo (=84,000)], a given number of classes was randomly selected from the USL-specific list of the classes in
the second year of secondary school. To be statistically
significant at subgroup level, each sample size was estimated at 300 subjects. Thus 41 classes were chosen and
874 students were recruited. Seventy-seven of them
(8.8%) were not included in the study, mainly because
they were absent from school in the period when data
were collected. For 63 subjects (7.2%) at least one of the
three data collection tools was not available (seven because of their parents' refusal to participate). Twentyeight subjects could not be analysed because social class
data were inaccurate. Therefore, altogether 706 individuals were included in the analysis (80.8% of the initial
sample). The study was carried out during the period
November 1991-April 1992.
The following tools were used to collect data on dental
health status and on its determinants:
a detailed food frequency questionnaire focusing on
sugar-sweetened foods, including some questions on oral
hygiene practices, was submitted to students,
a questionnaire aimed at compiling sociodemographic
data of family members, as well as information regarding
diet and caries prevention of children and their use of
dental health services was submitted to parents and
a dental examination was carried out on the school
premises by three final-year students of the dentistry
school, supervised by a senior dentist, adopting methods
recommended by the World Health Organisation
(WHO). 2 4
In order to standardise the examination procedures, the
examiners received training after which their agreement,
tested in 20 cross-examinations, was satisfactory (K index
= 0.74 for Decayed Missing Filled Teeth, DMFT, index 25 ).
The DMFT index was used as the main outcome factor in
the study. 24 A complete report on the DMFT index and
oral health was also sent to the dentist of each pupil.
The main factors analysed in the study were as follow.
A dietary nsk indicator
A dietary risk indicator, based on children's reported
consumption of sucrose-sweetened foods (chocolate bars,
sweets, chewing gum, soft-drinks, cakes, jam and sweet
desserts), given the unreliability of most indexes aimed at
measuring the cariogenic potential of foods.26 Because it
was not appropriate to submit questions about this field
to parents for control purposes, great attention was placed
on the accuracy of this part of the children's questionnaire
and on the instructions for submission. Children under
study were also classified into three groups according to
the percentile of the daily frequency of consumption:
from zero to three times per day (lowest risk group), from
four to seven times per day (medium risk) and more than
seven times per day (highest risk).

An oral hygiene indicator

An oral hygiene indicator, calculated according to the
average weekly frequency of tooth brushing reported by
children. Subjects were grouped into three categories,
according to the percentile distribution of the average
daily frequency: three or more times per day (lowest risk
group), from 1.5 to 3 times per day (medium risk) and less
than 1.5 times per day (highest risk). To evaluate the
reliability of this variable, children's data on frequency of
tooth brushing, collected during 1 week, were compared
with data reported by parents: the reliability was considered satisfactory (68% of agreement) given the fact
that parents are prone to under-evaluate the hygiene
practices of their children.
The use of fluoride supplements
The use of fluoride supplements, of professional fluonde
applications and access to dental health services, estimated using the data of the parent's questionnaire.
The level of education of the head of the family was used
as social class indicator (university degree, ^15 years of
school education, high school 12-15 years, secondary
school 6-11 years and primary school <6 years).27 This
indicator is considered the most valid for the Italian
population. 21 ' 22 For 28 subjects no information that allowed social classification was available in the parent
questionnaire.
The DMFT index was analysed as a continuous variable,
by fitting linear regression models, 28 adjusted by age and
centre of study, using parent's education level as an independent variable. The trend for education was tested by
using models in which education was entered as a continuous variable, with the assumption of equidistance
between education levels. Confidence intervals were estimated at 95%. 2 9 For categorical variables (caries-free
status, indicator of dietary risk, oral hygiene, fluoride
supplement use, local fluoride applications and use of
dental health services), the results were provided as proportions and 95% confidence limits. The statistical
significance for trends in education was tested using the
Armitage method and the p value was shown. 30
Pupils with a DMFT of 0 were compared with those with
a DMFT of >0 by means of a logistic regression model 28
in order to check the independent effect of socioeconomic status and risk factor variables. The independent
variables in the model were education of the head of the
family, hygiene and dietary habits, while sex, age and
centre were used as confounders. The standardisation by
centre allows unbiased estimation of percentages and
ratios for the whole area under study. Results are presented
as odds ratios (ORs). Proportions of caries (DMFT >0)
attributable to parents' social class and risk factors were
estimated on the basis of ORs obtained from the logistic
regression model.
RESULTS
The average DMFT index of the population under study
was 2.66 (SD = 2.60) and the range of values was 0-16.
Table 1 presents data of caries occurring among children
of the study population according to educational level of

Occurrence of caries and social class

the head of the family. The DMFT index showed a strong

As a separate exercise, a saturated logistic regression
tendency to be higher among lower social categories.
model was applied in order to estimate die role of the
Moreover the prevalence of caries-free children (DMFT
prevalence of both oral hygiene and dietary risk habits in
*= 0) was four times higher among advantaged families
determining social differentials (table 3). The odds ratio
than among those whose parents had attended primary
for a DMFT index of >0 was 4.21 among children of
school only (table I). Seventy-four percent of girls
parents with primary school education only, compared
(n=264) and 50.2% of boys (n=190) reported brushing
with children of parents with university education (model
their teeth more than once a day, while 12.1% of the
1). After adjustment for hygiene and dietary habits at risk
former (n=43) and 16.1% of the latter (n=61) did so only
the OR decreased to 3.82, though still remained statistonce. Oral hygiene habits seemed to present large social
ically significant (model 2).
differences to the disadvantage of lower social strata
(table 2). Students whose parent had attended primary DISCUSSION
school only were twice as likely to belong to the relatively
The results of this study do not seem to be affected by
highest risk category for oral hygiene (brushing their teeth
major biases: the response rate appears to be satisfactory
less than 1.5 times per day, on average), according to
and the reasons for non-participation does not suggest a
reported data, compared to children of parents with a
selection effect based on social class and the clinical
degree (table 2). On the other hand, the frequency of
dental examination was carried out according to WHO
consumption of sugar-sweetened products showed no
indications24 and its reliability appears to be satisfactory,
clear tendencies between social groups (table 2).
owing to die fairly good interobserver agreement. The
The use of preventive practices reported by parents' quesdata reported by parents roughly confirm information
tionnaire, such as dietary fluoride supplements and proobtained from dieir children, given parents' aptitude to
fessional fluoride applications, was more frequent among
misinterpret their children's behaviour. Moreover, the
higher social classes (table 2). Their use was twice as
sample can be considered representative of the whole
frequent among children from higher social class families
population of the same age of the three USLs under study,
than among childrenfromlower social class families. The
because it was randomly selected from die study populause of public dental health services instead of private ones
tion and the percentage of boys and girls attending private
was a feature of lower social classes (table 2). Children
schools is estimated to be lower than 5%. Given that the
whose parents had only a primary school education only
three areas selected for die study were not a random
used national health services 2.5 times more often than
sample of die USLs of the province of Turin, the study
children of parents possessing a degree.
group cannot be strictly considered a representative
Table 1 Distribution of means (and 95% confidence intervals) of the Decayed Missing Filled Teeth (DMFT) index and of the proportion
of students with no caries by educational level of the head of die family
Overall
University
n=7O6
Mean

95% Cl

Mean

2.66

235-2.97

1.49

DMFT

95% Cl
DMF=0

24.8

21.7-28.1

59.1

n-44
95% Cl
0.83-2.15
95% Cl
43.3-733

Head of the family educational level

High school
Secondary school
n=106
n-336
Mean
95% Cl
Mean
95% Cl
1.84

1.11-2.56

2.64

95% Cl
41.5

32.1-51.5

20.8

2.03-3.25
95% Cl
16.7-25.6

Primary school
n=220
Mean

95% Cl

p for
trend

3.24

2.61-3.86

<0.001

95% Cl
16.4

11.9-22.1

<0.001

All results arc standardised by centre of study, DMFT means are aUo standardised by age

Table 2 Distribution of die prevalence of the determinants of caries in die study population according to die head of die family's
educational level
Overall
University
n-706
%
High dietary risk
High risk for oral
hygiene
Fluoride
supplements use
Local fluoride
applications
Public services use

95% Cl

n-44
95% Cl

39.1 35.5-42.8

34.1

20.9-50.0

35.4 31.9-39.1

15.9

7.2-30.7

26.6

23.5-30.0

40.9

8.7

6.8-11.1
29.8-36.8

15.9

33.2

18.2

Head of die family educational level

High school
Secondary school
i1-106
ii=336
%
95% Cl
%
95% Cl

Primary school
ii=220
95% Cl
%

pfor
trend

42.4 33.1-52.5

38.1

32.9-43.6

40.0 33.5-46.8

0.786

31.1

22.7^0.9

33.8

28.8-39.2

43.8 37.2-50.6

0.002

26.7-56.7

41.5

32.1-51.5

28

233-33.2

16.4

11.9-22.1

<0.001

7.2-30.7
8.7-33.3

14.2

8.4-22.6

7.7

5.2-11.2

6.8

4.0-11.2

<0.001

16.0

9.9-24.7

33.3

283-38.7

44.6 38.0-51.4

<0.001

EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 9 1999 NO. 2

sample of the population of the whole province, but the
authors believe that because of the accurate choice of
areas according to their socioeconomic characteristics,
the population under study can be considered a reliable
representation of the whole province.
The first general conclusion that can be drawn is that, in
the province of Turin, the standard of caries prevalence
seems to be satisfactory, taking into account the urbanrural composition of the population understudy, since the
mean DMFT value of the study sample was lower than
that recommended by the W H O (DMFT = 3) for the age
under study. However this conclusion cannot hide the
fact that this observation represents the average of the
values of different social categories, which showed large
differences, up to four times, to the detriment of lower
ones. The prevalence of dental decay was double and the
proportion of caries-free children was four times lower
among children of lower social class families than among
those of higher social classes. This huge discrimination
against disadvantaged citizens is also more unacceptable,
from the ethical point of view, when considering that
dental care is the only health practice not covered by the
Italian National Health System. The effect of this limitation is that dentistry under the National Health Service
is of poor quality and is used 2.5 times more frequently by
disadvantaged children compared to the advantaged
ones.
But what are the determinants of these inequalities? In
the other words, what policies can be suggested to tackle
them? The major determinants of dental decay are distributed in the expected way across social strata: dental
hygiene practices, although quite satisfactory among the
whole population since the lower tertile of children
brushed their teeth, on average, 1.5 times a day, are much
more frequent among young students of the higher social
level. The same pattern of social distribution, although
much more pronounced, is evident for the other preventive practices: pupils from higher social strata reported a
more than twofold frequency of both consumption of

fluoride tablets and of local fluoride applications. In apparent contradiction with this frame, no social differences
were found in the frequency of dietary risk factors, but,
apart from the possible measurement error affecting this
indicator that could have biased the results, this observation seems to confirm the absence of any relationship
found by some other studies. ^
The finding of social differences in exposure to risk factors
could suggest that a global solution for inequity in dental
health should be to promote public health policies focusing preventive actions on lower social categories, in order
to change their habits. This solution seems too simplistic.
The logistic regression analysis presented above confirms
this: adjusted by the determinants of dental decay, ORs
for social class show a limited decrease, remaining the
more important factor explaining differences in caries
risk. Thus, the estimated proportion of dental decay attributable to social class is possibly higher (61.3%) than
that attributable to insufficient hygiene habits (13.3%)
and dietary risk factors (8.3%). Clearly this conclusion
can be partially misleading, because of misclassification
reasons stated above and also because the estimated prevalence of risk factors was measured at the same time as
the dental examination; nevertheless the difference is so
marked that it probably cannot be justified by only misclassification or bias.
Why does the risk factor adjustment not reduce the OR
associated with social class? Several factors can be associated with social variables and play a role in the aetiological pathway of dental decay.
General factors that can modify individual susceptibility
to caries, such as poor nutrition of mothers during
pregnancy and of babies during early life. Some analogies could be found with cardiovascular diseases,
where early life conditions are suggested to be a mediator
of the social class-cardiovascular risk relationship;
similar evidence came from the Whitehall study for
cancer diseases.
Differential prevalence of Streptococcus mutans.

Table 3 Logistic regression analysis using caries-free children as cases and die odiers as controls, with (model 2) and without (model 1)
adjustment for hygiene and dietary risks
Number of
cases/controls

OR

Model 1
95% CI

Model 2

OR

95% CI

Gender
272/93

Girls
Head of the family education
University

258/83

1.06

High school
Secondary school
Elementary school

62/44
266/70

1.21
3.29

184/36

4.21

Boys

Hygiene habits
Low or medium risk
High risk
Dietary habits
Low or medium risk
High risk

18/26

0.74-1.52

1
1.17

0.81-1.69

0.60-2.20
1.77-5.52

0.64-230
1.87-5.79
2.28-7.79

1.15
3.13
3.82

2.05-7.11

332/123
198/52

1
1.55

1.04-2J3

318/113
213/62

0.87-1.83

1.26

Occurrence of caries and social class

The amount of fluorides from sources not directly investigated by the present study, such as toothpaste or
enriched foods. Drinking water fluoridation is the only
major factor that cannot have played a role, given the
extremely low concentrations (<0.1 p.p.m.) in the supply of target populations.
Regardless, the results of this study support the idea that
a reduction in differences in exposure to risk factors,
through the promotion of preventive practices, can just
attenuate but not substantially reduce the social discrimination in canes experience. An alternative approach able to tackle the problem as a whole seems to be
the fluondation of drinking water.36"37 It appears to be the
only practice documented as being effective in substantially decreasing and even eliminating inequalities in
dental decay: in theory, it reaches the whole population
without social discrimination, including the more deprived strata (homeless and nomads), in the long term it
reduces the costs of prevention (fluoridation is cheaper
than individual supplementation of the infant population) and, moreover, it transfers costs from families to the
health service.
We thank Dr Anna Camerlengo, Dr Ectore Mancini and Dr Paola
Fasano for their support in the study organisation and Dr Igor
Grubessich, Dr Lucia Delsante and Dr Nadia Casciano for their
collaboration in collecting data and in performing dental examinations. We thank Hilary Martin for revising the English.

1
WHO. Health for all by the year 2000. Geneva: WHO, 1985.
2
Stadt ZM, Blum HL, Kent GW, et al. Socioeconomic status
and dental caries experience of 3911 five-year-old natives of
Contra Costa Country, California. J Public Health Dent 1967,27:2-6.
3
Anonimous. Decayed, missing and filled teeth among
youths 12-17 years. Vital & Hearth Statistics 1974,11:1-34.
4
Beck JD, Cons NC, Field HM, Walker J. The Iowa survey of
oral health: 1980. Iowa Oty: University of Iowa, 1982.
5
Clark BJ, Graves RC, Webster DB, Triol CW. Caries and
treatment patterns in children related to school lunch program
eligibility J Public Hearth Dent 1987;47:134-8.
6
Ripa LW, Leske GS, Kaufman HW. Caries prevalence,
treatment level, and sealant use related to school lunch program
participation. J Public Health Dent 1991;51:78-81.
7
Caplan DJ, Weintraub JA. The oral health burden of the
United States: a summary of recent epidemiologic studies. J Dent
Education 1993;57:853-62.
8
Attwood D, Salapata J, Blinkhorn AS. Comparison of
dental health of 12-year-old schoolchildren living in Athens and
Glasgow. Int Dent J 1990,40:117-21.
9
Provart SJ, Carmichael CL The use of an index of material
deprivation to identify groups of children at risk to dental caries
in County Durham. Commun Dent Health 1995;12:138-42.
10
Powell RN, Gilhooly JT, McKenna ER. Prevalence and
distribution of gingivitis and dental caries in children aged 6-12
years in Brisbane primary schools. Commun Dent Oral Epidemiol
1986;14:110-4.
11
Colquhoun J. Influence of social class and fluoridation on
child dental hearth. Commun Dent Oral Epidemiol 1985; 13:37-41.
12
D'Hoore W, Van Nieuwenhuysen JP. Application de la
methode des traceurs a I'evalutaion de la qualite des soins
dentaires chez 3237 ecoliers beiges (Application of an indicator
method to the quality assessment of dental care among 3237

Belgian students). Rev Epidemiol Sante Publ 1991,39:63-9.

13
Petersen PE. Dental visits and self-assessment of dental
status in the adult Danish population. Commun DenJOral
Epidemiol 1983; 11:162-8.
14
Milen A, Hausen H, Heinenen OP, Paunio I. Caries in
primary dentition related to age, sex, social status and county of
residence in Finland. Commun Dent Oral Epidemiol 1981;9:83-6.
15
Wei SH, Holm AK, Tong LS, Yuen SW. Dental prevalence
and related factors in 5-year-old children in Hong-Kong. Pediatr
Dent 1993; 15:116-9.
16
Mann J, Revach A, Call R, Arwas J, Sgan-Cohen H.
Prevalence and distribution of caries in a Jerusalem adolescent
population by age, sex and family income. J Public Health Dent
1989,49:158-62.
17
Megas BF, Athanassouli TM. Dental caries prevalence in
the permanent teeth in Greek schoolchildren related to age, sex,
urbanization and social class. Commun Dental Hearth 1989;6:131-7
18
Marmot M. Coronary heart disease: rise and fall of a
modem epidemic In: Marmot M, Elliott P, editors. Coronary heart
disease epidemiology. Oxford: Oxford Medical Publ, 1992:3-19.
19
Taani DS. Dental hearth of 13-14-year-old Jordanian school
children and its relationship with socio-economic status. Int J
Paediatr Dent 1996;6:183-6.
20
Angulo M, Pivel L, Zinemanas E, Jorysz E, Krasse B. Dental
caries and microbial and salivary conditions in Uruguayan
children from t w o different socio-economic areas. Acta Odontol
Scand 1994,52:377-83.
21
Faggiano F, Lemma P, Costa G, Gnavi R, Pagnanelli F.
Cancer mortality by educational level in Italy. Cancer Causes and
Control 1995;6:311-20.
22
Faggiano F, Zanetti R, Costa G. Cancer risk and social
inequalities in Italy. J Epidemiol Commun Hearth 1994,48:447-52.
23
La Vecchia C Negri E, Pagano R, Decarli A. Education,
prevalence of disease, and frequency of health care utilisation:
the 1983 Italian national Hearth survey. J Epidemiol Commun
Hearth 1987;41:161-5.
24
WHO. Oral health surveys. Geneva: WHO, 1987.
25
Fleiss JL Statistical methods for rates and proportions.
New York: John Wiley & Sons, 1981.
26
Granath L, McHugh WD. Systematized prevention of oral
disease: theory and practice. Florida: CRC Press, 1986.
27
LJberatos P, Link BG, Kelsey JC. The measurement of social
class in epidemiology. Epidemiol Rev 1988;10:87-121.
28
Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic
research. New York: Van Nostrand Reinhold Co, 1982.
29
Gardner MJ, Altman DG. Statistics with confidence.
London: British Medical Journal, 1989.
30
Armitage P, Berry G. Statistical methods in medical
research. Oxford: Blackwell Scientific Publications, 1987.
31
Donald WL. Periodic health examination 1995 update. 2.
Prevention of dental caries. Can Medic AssocJ 1995;152:836-46.
32
Green CJ, Louie R, Wycoff SJ. Preventive dentistry dental
caries. JAMA 1989,262:3459-63.
33
Barker DJP. Mothers, babies and disease in later life.
London: BMJ Publishing Group, 1994.
34
Kaplan GA, Keil JE. Socioeconomic factors and
cardiovascular disease: a review of the literature. Circulation
1993;88:1973-98.
35
Marmot MG, Davey Smith G, Stanfield S, et al. Health
inequalities among British civil servants: the Whitehall II study.
Lancet 1991;337:1387-92.
36
Murray JJ, Breckon JA, Reynolds PJ, Tabari ED, Nunn JH.
The effect of residence and social class on dental caries
experience in 15-16-years-old children living in three towns
(natural fluoride, adjusted fluoride and low fluoride) in the North
East of England. Br Dent J 1991;171:319-22.
37
Treasure ET, Dever JG. Relationship of caries with
socioeconomic status in 14-year-old children from communities
with different fluoride histories. Commun Dent Oral Epidemiol
1994,22:226-30.
Received 10 December 1996, accepted 6 November 1998