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Early childhood caries in Switzerland: a marker of social inequalities

Early childhood caries in Switzerland: a marker of social inequalities Background: Early childhood caries (ECC) is a marker of social inequalities worldwide because disadvantaged children are more likely to develop caries than their peers. This study aimed to define the ECC prevalence among children living in French-speaking Switzerland, where data on this topic were scarce, and to assess whether ECC was an early marker of social inequalities in this country. Methods: The study took place between 2010 and 2012 in the primary care facility of Lausanne Children’s Hospital. We clinically screened 856 children from 36 to 71 months old for ECC, and their caregivers (parents or legal guardians) filled in a questionnaire including items on socioeconomic background (education, occupation, income, literacy and immigration status), dental care and dietary habits. Prevalence rates, prevalence ratios and logistic regressions were calculated. Results: The overall ECC prevalence was 24.8 %. ECC was less frequent among children from higher socioeconomic backgrounds than children from lower ones (prevalence ratios ≤ 0.58). Conclusions: This study reported a worrying prevalence rate of ECC among children from 36 to 71 months old, living in French-speaking Switzerland. ECC appears to be a good marker of social inequalities as disadvantaged children, whether from Swiss or immigrant backgrounds, were more likely to have caries than their less disadvantaged peers. Specific preventive interventions regarding ECC are needed for all disadvantaged children, whether immigrants or Swiss. Keywords: Dental health, Early childhood caries, Social inequalities, Socioeconomic background Background wellbeing and quality of life, poor self-esteem or altered Early childhood caries (ECC) is a major health concern concentration) [5–8]. worldwide [1, 2]. ECC has been defined as the presence Despite being largely preventable with good oral of one or more decayed teeth (with non-cavitated or health behaviours (e.g., regular dental visits and tooth cavitated lesions), missing teeth (due to caries) or a brushing and using fluoridated toothpaste) and nutri- filled surface on any primary tooth in a child aged tional habits (e.g., low sugar intake, limited night-time 71 months old or younger [3]. ECC is correlated with a bottle-feeding, no sharing of eating utensils and using high burden of disease [4]: previous studies have associ- fluoridated salt or water), ECC remains one of the most ated ECC with deleterious effects on other health out- common childhood diseases [6, 9–11]. ECC can be comes (e.g. poor dental health, but also pain, infection, understood as “an indicator of preventive missed op- altered eating habits or sleep disturbances), childhood portunities” [12]. development (e.g., altered cognitive development, re- duced speech development or reduced growth involving A marker of social inequalities low body weight and height) and psychological out- Social inequality is characterized by the existence of un- comes for both children and their families (e.g., altered equal opportunities, access or distribution of goods be- * Correspondence: [email protected] tween different social groups within a society [13]. ECC Life Course and Inequality Research Centre, University of Lausanne, can be seen as a marker of social inequalities because, Lausanne, Switzerland Full list of author information is available at the end of the article wherever they live in the world, disadvantaged children © 2015 Baggio et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Baggio et al. BMC Oral Health (2015) 15:82 Page 2 of 9 are more likely to develop caries than their local peers. University Hospital. The HEL is dedicated entirely to Indeed, several studies have highlighted social differ- children’s health and is the paediatric reference centre ences in the prevalence rates of ECC; disadvantaged chil- for Lausanne and its suburbs (more than 250,000 inhabi- dren also have poorer dental health [14–19]. This tants). It treats all common diseases whether medical, disadvantaged population includes children from lower surgical, psychiatric or psychosocial; life-threatening socioeconomic backgrounds, with parents who have emergencies and pathologies requiring complex tech- lower levels of education and from single-parent fam- nical support are admitted to the main Lausanne Uni- ilies. However, this population also includes children fa- versity Hospital facility. The HEL’s priorities also include cing a cultural disparity, such as their immigrant status assisting and supporting patients’ families; the institution or a language barrier [2, 8, 15–17, 20, 21]. has a strong social vocation and is rooted in the commu- nity. There were more than 53,000 paediatric consulta- ECC in Switzerland tions at the HEL in 2010 (capacity = 29 beds). About ECC prevalence and their associations with socioeco- 70 % of these patients were immigrants, and the HEL is nomic factors have been well studied worldwide, yet data also involved in the medical monitoring of children are scarce in Switzerland. Overall, dental health is de- without residency permits. scribed as improving in Switzerland [22, 23], however, Children were eligible for inclusion in the study if they dental care is not covered by the basic health insurance were between 36 and 71 months old and if their care- scheme, and patients generally have to pay for their den- giver had a minimum capacity to understand the study’s tal treatment. Two recent Swiss studies highlighted that instructions. Some were admitted to the hospital for dental care was by far the most common healthcare regular and emergency medical treatments, and others treatment to be neglected by low-income people facing were there for ambulatory care. However, they all pre- economic constraints [24, 25]. ECC might, therefore, be sented minor health problems (no severe or chronically expected to be an important marker of social inequalities ill children participated). To avoid bias, children coming in Switzerland, and some national studies have already for dental treatment were not included. A majority of highlighted the relationship between socioeconomic sta- the participants lived near Lausanne. tus and dental health [23]. Following the caregiver’s written informed consent, Despite these interesting contextual factors, only one two dentists clinically screened 856 children for ECC. previous study has reported on ECC prevalence rates in During a three-month pre-testing period, the two den- Switzerland, and this was in the German-speaking part tists individually screened a number of children for of the country. A study in Zurich, in 2003, reported that ECC, and their dental assessments were compared. 25.3 % of two- and three-year-old children presented Their scoring was calibrated, and at the end of the pre- with ECC [26]. This prevalence rate was higher than test period their convergence rate was 0.99. Examina- those reported in other European countries (e.g., tions took place in the HEL’s primary care waiting room, Norway, 11 % [18]; Great Britain, 6.8 %–12 % [27]; and although it was impossible to dry their teeth or re- Greece, 16.5 % [28]; Germany, 7.3 %–20.3 % [29]; Italy, move debris in this environment, the children’s teeth 19 % [12]; France: 18 % [30]). Only Belgium and Spain were cleaned with sterile gauze. The visual clinical reported similar ECC prevalence, of 24 % [31] and examination of the mouth was performed with the aid of 28 % [32], respectively. However, data were collected a mobile light. Only deciduous teeth were examined, from older children (five-year-olds in Belgium and and the data collected were entered into a specially de- three- to six-year-olds in Spain). Overall, except for signed table. Caregivers were also interviewed using a Norway’s, these prevalence rates were higher than the standardised questionnaire available in French, English, 11 % goal outlined in the US government’sHealthy Spanish, Albanian and Arabic—the most common lan- People 2010 agenda [33]. guages spoken by those accompanying responsible Thus, the present study’s aims were twofold: 1) to de- adults. The dentists also noted any relevant dental or fine ECC prevalence in French-speaking Switzerland, oral pathologies and informed caregivers of them if where data on this topic were particularly scarce; and 2) necessary. to investigate whether ECC might be a strong marker of The University of Lausanne Faculty of Biology and social inequalities in the country. Medicine’s Ethics Committee approved the study protocol. Methods Participants Sample size The study was conducted between February 2010 and The sample size was calculated in order to detect an October 2012 in the primary care facility of Lausanne odd-ratio of two between two groups—as we had no in- Children’s Hospital (HEL), a part of the Lausanne formation about the prevalence rates of socioeconomic Baggio et al. BMC Oral Health (2015) 15:82 Page 3 of 9 variables, the participants were separated at the median parent came from a developed country and ‘0’ into groups with either a lower or a higher socioeconomic otherwise. A subgroup was also created for children background. The non-exposed group (i.e., high socioeco- whose parents were both Swiss citizens. nomic background) had a prevalence rate of 10 % ECC, chosen based on the 11 % goal outlined in the US govern- Covariates ment’s Healthy People 2010 agenda [33]. For a significance Children’s age and gender were recorded. Knowledge level of 0.05, a power of 0.90 and a correction for continu- and attitudes related to dental care were assessed using: ity, each group had to include 403 participants. The mini- 1) the most recent visit to a dentist (coded ‘1’ for at least mum total sample size required to assess the associations one check-up during the previous 12 months, ‘0’ other- proposed was thus estimated to 806 participants. wise); 2) the child’s average frequency of tooth brushing (coded ‘1’ for brushing three times per day, ‘0’ otherwise); Measures 3) the caregiver’s average frequency of tooth brushing ECC. A clinical examination of the oral cavity, without (coded ‘1’ for brushing three times per day, ‘0’ otherwise); the use of X-rays, was performed to establish a dental 4) the caregiver’s presence during the child’s most recent assessment. The presence of ECC was defined as per the tooth brushing (coded ‘1’ if a caregiver was present, ‘0’ recommendations by Drury et al. [3], and coded dichot- otherwise); 5) parents in agreement about child’s tooth omously (‘1’ = presence, ‘0’ = absence). Due to the exam- brushing practices (coded ‘1’ if parents supported each ination conditions, only frank cavitation was coded 1. other, ‘0’ otherwise); 6) how the child fell asleep the pre- vious night (with water or nothing, with milk, or with a Socioeconomic background sugar-based drink); and 7) information given by the Socioeconomic background included individual-level paediatrician regarding ECC (coded ‘1’ when parents had measures: received information, ‘0’ otherwise). 1) Parents’ level of education: incomplete compulsory Statistical analyses education, compulsory education, apprenticeship ECC prevalence in Switzerland (vocational school), secondary education (high The prevalence rate of ECC and descriptive statistics for school diploma), tertiary education (university) covariates were calculated. Bivariate associations be- (for similar cut-off points, see examples in [34, 35]). tween ECC and covariates were tested using exact Fi- The highest level of education of the two parents scher tests. was used. ECC prevalence and bivariate associations for the sub- 2) Parents’ professional level: we selected three classes sample of children whose parents were both Swiss citizens from the UK’s National Statistics Socioeconomic (excluding immigrants) were additionally calculated to test Classifications [36], i.e., higher occupations (e.g., whether the relationship between ECC and socioeconomic senior manager), intermediate occupations (e.g., background was still the same, and to test whether the re- manager), lower occupations (e.g., employee, manual sult was not due only to immigration status. Analyses in- worker), and added classes that did not fit into those cluded parents’ level of education, parents’ professional above, i.e., self-employed and unemployed. The level, and family income, because literacy problems and highest professional level of the two parents was immigration were absent within this subsample. Incom- used. pleted compulsory education and unemployed were ex- 3) Family income: low family income (less than CHF cluded from the analysis because of their very low sample 4,000, i.e., around USD 4,270), medium family size. income (between CHF 4,000 and CHF 6,000, i.e., Prevalence ratios and 95 % confidence intervals were around USD 6,400), high family income (more than computed for socioeconomic variables, using the lowest CHF 6,000), or did not want to answer (for similar level (i.e., incomplete compulsory education, unemployed, cut-off points, see examples in [37]). low family income, not good French understanding, and 4) Parents’ French literacy: this was coded ‘1’ for a immigrants from countries with HDI ≥ 0.8) as the refer- good understanding and ‘0’ otherwise. ence category. A log-binomial model was run to compute 5) The 2011 United Nations human development index prevalence ratios and their significance level. (HDI) was used to assess immigration status and categorize families into two groups, i.e., immigrants Multivariate associations between ECC and socioeconomic from countries with HDI ≥ 0.8 (developed countries) background and people from Switzerland, and immigrants from Subsequently, multivariate analyses were performed. countries with HDI < 0.8 (developing countries) [38]. Logistic regressions were calculated using ECC as a Immigration status was coded ‘1’ if at least one dependent variable and socioeconomic background factors Baggio et al. BMC Oral Health (2015) 15:82 Page 4 of 9 Table 1 Descriptive statistics for demographics and covariates, as independent variables. Since the socioeconomic vari- and bivariate associations with ECC ables shared a large amount of common variance, five dif- Demographics and covariates % (N) % of ECC ferent logistic regressions were performed (parents’ level of education, parents’ professional level, family income, Gender parents’ literacy, and parents’ immigration status). Covari- Boys 55.6 (476) 25.6 ates were included as control variables (i.e., age, gender, Girls 44.4 (380) 23.7 dental check-ups, child’s frequency of tooth brushing, Dental check-up in previous 12 months caregiver’s frequency of tooth brushing, parental presence Yes 44.9 (384) 35.9 at most recent tooth brushing, parents in agreement about No 55.1 (472) 15.7 child’s tooth brushing, how the child fell asleep the previ- ous night, and information given by the paediatrician). For Child’s frequency of tooth brushing each model, a McFadden pseudo R-squared was calculated <3 times a day 74.2 (635) 23.6 to estimate the effect size of each socioeconomic variable 3 times a day 25.2 (216) 27.8 of interest. Pairwise comparisons were calculated to com- Missing 0.6 (5) - pare different levels of the categorical socioeconomic vari- Parental frequency of tooth brushing ables. The length of time that migrants had been in the < 3 times a day 65.2 (558) 29.9 country was controlled for. As the results concerning ECC were the same whether or not this confounder was in- 3 times a day 33.2 (284) 21.7 cluded, the analyses were carried out without this Missing 1.6 (14) - covariate. Parental presence at most recent tooth brushing Descriptive statistics and logistic regressions were car- Yes 86.7 (742) 22.9 ried out using Stata version 14 software. No 12.9 (110) 37.3 Missing 0.5 (4) - Results Parents in agreement on child’s tooth brushing practices ECC prevalence Yes 84.5 (723) 23.1 The children’s average age was 4.42 ± 0.88 years old. The No 14.8 (127) 34.6 prevalence rate of ECC was 24.8 %. Bivariate associations Missing 0.7 (6) - are summarized in Table 1 (demographics and covari- Way children fell asleep previous night ates) and Table 2 (socioeconomic backgrounds). With With water/nothing 72.0 (616) 26.0 regard to demographics and covariates, there were sig- nificant differences in ECC prevalence rates associated With milk 24.5 (210) 21.0 with variables related to parental attitudes and behav- With sugar-based drink 2.6 (22) 22.7 iours. Children whose parents frequently brushed their Missing 0.9 (8) - own teeth, who were present at the most recent tooth Information given by pediatrician regarding ECC brushing, and who agreed on their children’s tooth- Yes 48.5 (415) 23.4 brushing practices had a lower ECC prevalence. On the No 51.3 (439) 26.0 contrary, however, information from a paediatrician was not associated with a decrease in ECC prevalence, nor Missing 0.2 (2) - was an annual visit to a dentist. Row percentages. For example: A total of 25.6 % of the boys had ECC a, b For significant Fischer’s exact test, a same subscript letter within a column Results showed higher rates of ECC among children denotes that proportions did not differ; two different subscript letters denote from lower socioeconomic backgrounds than those from that proportions differed at the 0.05 level higher ones, and this for all five variables. For example: with parents who had not completed their compulsory education, ECC = 64.3 %; but with parents with a tertiary In addition, we also computed bivariate associations of education, ECC = 15.8 % (PR = 0.25); with unemployed ECC prevalence with socioeconomic backgrounds of parents, ECC = 48.3 %; but with parents with a high pro- Swiss children with two Swiss parents (n = 457). In this fessional level, ECC = 16.0 % (PR = 0.44); in lower- group, the prevalence rate of ECC was 12.1 %, whereas income families, ECC = 42.6 %; but in higher-income the prevalence rate for immigrant children was 38.6 %. families, ECC = 12.8 % (PR = 0.33); with parents with lit- The results showed that even though ECC prevalence eracy problems, ECC = 41.7 %; but with no literacy prob- was lower, there was still an association between ECC lems: ECC = 20.4 % (PR = 0.49); and with parents from a and the socioeconomic background of the subgroup of developing country, ECC = 42.5 %; but with parents from children with two Swiss parents. Regarding parents’ level a developed country, ECC = 17.1 % (PR = 0.40). of education, children with parents with a tertiary Baggio et al. BMC Oral Health (2015) 15:82 Page 5 of 9 Table 2 Descriptive statistics for socioeconomic background and bivariate associations with ECC 1 2 Socioeconomic background % (N) % of ECC PR of ECC Parents’ level of education Incomplete compulsory education 14.6 (14) 64.3 Reference category b ** Compulsory education 15.4 (132) 31.1 0.48 [0.30-0.77] b *** Apprenticeship (vocational school) 22.4 (192) 28.1 0.44 [0.28-0.69] b ** Secondary education (high-school diploma) 18.2 (156) 31.4 0.49 [0.31-0.77] c *** Tertiary education (university) 42.1 (360) 15.8 0.25 [0.16-0.39] Missing 0.2 (2) - - Parents’ professional level Unemployed 6.8 (58) 48.3 Reference category b * Lower occupations 55.3 (473) 27.9 0.48 [0.25-0.90] c *** Intermediate occupations 16.8 (144) 17.4 0.58 [0.43-0.78] c *** Higher occupations 16.5 (141) 12.8 0.36 [0.23-0.56] b,c *** Self-employed 4.6 (39) 23.1 0.26 [0.16-0.44] Missing 0.1 (1) - Family income Low (< CHF 4,000) 18.1 (155) 42.6 Reference category b *** Medium (CHF 4,000 to CHF 6,000) 25.1 (214) 20.1 0.52 [0.38-0.71] b *** High (> CHF 6,000) 7.6 (65) 13.8 0.33 [0.17-0.61] b *** Other 15.5 (133) 18.8 0.44 [0.30-0.66] b *** Did not want to answer 33.4 (286) 22.7 0.53 [0.40-0.71] Missing 0.4 (3) - Parents’ literacy Problems 20.4 (175) 41.7 Reference category b *** No problems 79.6 (681) 20.4 0.49 [0.39-0.62] Parents’ immigration status Developing countries (HDI < 0.8) 29.7 (254) 42.5 Reference category b *** Developed countries (HDI > 0.8)/Swiss citizens 70.2 (601) 17.1 0.40 [0.32-0.51] Missing 0.1 (1) - - ECC: Early Childhood Caries; PR: Prevalence Ratio Row percentages. For example: A total of 14.6 % of the children whose parents had an incomplete compulsory education had ECC PR were computed using log-binomial models a, b, c For significant Fischer’s exact test, a same subscript letter within a column denotes that proportions did not differ; two different subscript letters denote that proportions differed at the 0.05 level * ** *** p < .05, p < .01, p < .001 education had a significant lower ECC prevalence (6.1 %, Multivariate associations of ECC with socioeconomic p < .05) in comparison with other levels (compulsory background education: 19.6 %, apprenticeship: 16.4 %, secondary Table 3 shows the adjusted estimate proportions of ECC education: 21.9 %). Regarding parents’ professional level, according to socioeconomic variables and controlling for children whose parents had a higher occupation had a covariates. All variables were significantly associated significantly lower ECC prevalence (13.6 %, p < .05) in with ECC (p < .001). The parents’ immigration status comparison with other levels (lower occupations: 20.0 %, had the highest effect size (7.74 %), whereas other socio- intermediate occupations: 14.7 %, but not with self- economic variables explained between 3.07 % and employed: 6.6 %). Finally, family income was also associ- 3.54 % of the variance in ECC. The complete models, in- ated with ECC prevalence: children with a low family cluding dental care and dietary habits, explained be- income were more likely to have ECC (24.4 %, p < .05) in tween 10.70 % and 14.96 % of the variance in ECC. comparison with other levels (medium: 13.0 %, high: As reported in the bivariate analyses, ECC was more 11.1 %, other: 11.6 %, no answer: 10.1 %). likely to occur in children from lower socioeconomic Baggio et al. BMC Oral Health (2015) 15:82 Page 6 of 9 Table 3 Logistic regressions of ECC on socioeconomic variables Socioeconomic background Adjusted estimated Likelihood Effect size for Effect size for prevalence ratio socioeconomic the test p-value variable of interest complete model Parents’ level of education < .001 3.14 % 10.70 % Incomplete compulsory education 0.61 Compulsory education 0.25 Apprenticeship (vocational school) 0.23 Secondary education (high school diploma) 0.25 Tertiary education (university) 0.13 Parents’ professional level < .001 3.74 % 11.26 % Unemployed 0.42 Lower occupations 0.23 Intermediate occupations 0.12 Higher occupations 0.10 b,c Self-employed 0.17 Family income < .001 3.35 % 10.94 % Low (< CHF 4,000) 0.36 Medium (CHF 4,000 to CHF 6,000) 0.17 High (> CHF 6,000) 0.10 Other 0.15 Did not want to answer 0.18 Parents’ literacy < .001 3.45 % 11.00 % Problems 0.37 No problems 0.17 Parents’ immigration status < .001 7.74 % 14.96 % Developing countries (HDI < 0.8) 0.40 Developed countries (HDI > 0.8) and Swiss 0.13 citizens a, b, c For significant pairwise comparisons, a same subscript letter within a column denotes that proportions did not differ; two different subscript letters denote that proportions differed at the 0.05 level Effect size measured with the McFadden pseudo R-square. The whole model included all demographics and covariates backgrounds, with adjusted estimated proportions ranging due to caries, or a filled primary tooth surface. This preva- from .36 to .61. Conversely, children from higher socio- lence rate was higher than those reported in numerous economic backgrounds were less likely to have ECC, with other European countries: from 6.8 % to 19 % [12, 18, 27– adjusted estimated proportions ranging from .10 to .17. 30]. ECC was particularly prevalent among young children living in French-speaking Switzerland, even though dental Discussion health in the country has been described as improving [23]. This study aimed to provide the ECC prevalence among One reason may be that Switzerland has a high immigration children living in French-speaking Switzerland and to as- rate—the highest among European countries [39, 40]. In sess whether socioeconomic background had a signifi- 2010, the proportion of immigrants in Switzerland was cant influence on the risk of ECC, as it does in other 23 %, far higher than the second highest proportion, in countries. In other words, ECC was tested to ascertain Germany, with 11.9 % of immigrants [41]. Many studies whether it was an early marker of social inequalities. have reported that migrants have higher ECC prevalence, in- cluding in Switzerland [26]. Indeed, the prevalence rate of ECC prevalence in French-speaking Switzerland ECC for the subsample of children whose parents were both The prevalence rate of ECC in the children examined, from Swiss was only 12.7 %, although this result was still higher 36 to 71 months old, was unexpectedly high: 24.8 % had at than that reported by Menghini et al. [26], who calculated a least one decayed primary tooth, a primary tooth missing prevalence rate of ECC of 7.5 % among Swiss children. Baggio et al. BMC Oral Health (2015) 15:82 Page 7 of 9 ECC as a marker of social inequalities and the importance In order to remove the influence of Switzerland’s par- of immigration status ticularly significant immigrant population on ECC The present study highlighted social inequalities related prevalence, we also tested the association between ECC to dental health. As socioeconomic background is a and the socioeconomic background of children whose multi-dimensional phenomenon, including several sources parents were both Swiss. Although the prevalence rate of social differences, we used multi-component indica- of ECC in this subsample was much lower than that re- tors [16]. The effects of social differences are often ported for the entire cohort, the association with disad- investigated using geographical measures, focusing on vantaged backgrounds remained. Thus, children of Swiss disadvantaged areas or deprived communities [42]. parents with a lower socioeconomic status (lower family However, this approach does not capture the entire income, lower level of education, lower occupations) extent of inequalities [42], and studies dealing with were more likely to have ECC than their more advan- individual-level measures are needed [16, 31]. The re- taged peers. ECC remained a marker of social inequal- sults presented here show that in French-speaking ities for Swiss citizens, especially of harsh social Switzerland, ECC is significantly related to socioeco- inequalities affecting vulnerable populations [12]. The nomic background, with both a higher proportion and high ECC prevalence, even among disadvantaged Swiss prevalence ratio of ECC among disadvantaged chil- children, may reflect economic difficulties and a result- dren. This result is in line with those reported in pre- ant renunciation of healthcare [24, 25]. Menghini et al. vious studies in other countries [2, 8, 15–17, 20, 21]. [26] recommended specific preventive interventions for Disadvantaged children included those whose parents immigrants because they had the higher prevalence rate had not completed primary education (61 % presented of ECC. The results of our study show that disadvan- with ECC after controlling for covariates) or were un- taged Swiss children should also be included in such employed (41 %), those from lower-income families preventive programs. (36 %), those whose parents had literacy problems or faced a language barrier (37 %), and those whose par- Preventing ECC ents came from a developing country (40 %). ECC is a preventable disease, so early interventions The most important effect size was related to the par- should be made to identify high-risk children and thus ents’ immigration status: this explained twice as much of avoid it. A simple way to provide families with informa- the percentage of variance of ECC as other socioeco- tion about ECC is to help paediatricians and other pro- nomic variables. Thus, immigration may be a major con- fessionals caring for children to recognize the risks of tributing factor to ECC in Switzerland, a country with a ECC [46]. Moreover, since good parental practises re- high immigration rate. These results were in accordance garding oral health were associated with lower preva- with the high ECC prevalence among immigrants in lence rates of ECC, preventive intervention should also Zurich, in German-speaking Switzerland, (38.5 %) re- target parents (e.g., their own oral health and the im- ported by Menghini et al. [26]. Immigrants may have dif- portance they give to their children’s oral health). ferent ideas and beliefs about oral health, infant feeding practises and oral health awareness [43]. Previous epi- Limitations demiological studies and clinical surveys have suggested This study had some limitations. Firstly, its cross- links between race/ethnicity and oral health status [44], sectional nature did not allow us to draw any causal however, the specific actual cultural beliefs and values paths between ECC and factors associated with it. Sec- that influence decisions or practices regarding oral ondly, the use of a self-administered questionnaire for health are seldom reported. Further research into immi- caregivers may have induced either a response or recall grants’ cultural beliefs and their associations with their bias. Finally, generalising these results to the whole behaviours and practices surrounding oral health and country should be done with caution since the sample seeking dental care would provide information helpful in was based on children living in western Switzerland who designing future preventive and treatment programmes. had consulted a paediatrician in a primary care hospital. Butani et al. [44] suggested that qualitative research Moreover, the patients visiting the HEL included a high would be suitable for this purpose, providing valuable in- proportion of immigrants (70 %), and even though the formation towards understanding cultural beliefs related HEL is the paediatric reference centre for Lausanne and to oral health and helping to explore cultural reasons for its suburbs, our results may reflect the large number of seeking or delaying dental care. They also suggested that immigrants who came to the HEL. Europeans make up a community-based participatory approach [45] would the majority of immigrants in Lausanne and its suburbs help to involve community members, understand cul- (in 2011, 83 % of immigrants were from Europe, 72 % tural beliefs and practises, and implement appropriate from the European Union [47]). In 2010, at 30.5 %, the interventions. canton of Vaud (where Lausanne is located) had one of Baggio et al. BMC Oral Health (2015) 15:82 Page 8 of 9 the highest immigration rates in the country [48], Author details Life Course and Inequality Research Centre, University of Lausanne, whereas it was 23 % for Switzerland as a whole [41]. Lausanne, Switzerland. Private practice, University of Lausanne, Lausanne, Our results may, therefore, be representative of the par- Switzerland. Vulnerable Population Unit, Department of Ambulatory Care ticularities of this part of western Switzerland. Indeed, and Community Medicine, University of Lausanne & Lausanne University Hospital, Lausanne, Switzerland. Children’s Hospital, Lausanne University the ECC prevalence was similar to one reported among Hospital, Lausanne, Switzerland. Stomatology and Dentistry Unit, Lausanne children living in Zurich, allowing the authors to be University Hospital, Lausanne, Switzerland. confident about the representativeness of the results. Received: 13 May 2015 Accepted: 13 July 2015 Again, with regards to the sample, children consulting for dental healthcare problems were excluded. This could have had an impact on the findings in two ways: References children who consulted for ECC problems could have 1. Tinanoff N, Reisine S. Update on early childhood caries since the Surgeon been those whose lack of dental hygiene had let caries General's Report. Acad Pediatr. 2009;9(6):396–403. go too far (perhaps from families of a lower socioeco- 2. Colak H, Dulgergil CT, Dalli M, Hamidi MM. 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Oral health-related cultural beliefs for four • Inclusion in PubMed, CAS, Scopus and Google Scholar racial/ethnic groups: Assessment of the literature. BMC Oral Health. 2008;8(1):26. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Oral Health Springer Journals

Early childhood caries in Switzerland: a marker of social inequalities

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Springer Journals
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Copyright © 2015 by Baggio et al.
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Dentistry; Dentistry; Oral and Maxillofacial Surgery
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1472-6831
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10.1186/s12903-015-0066-y
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26198542
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Abstract

Background: Early childhood caries (ECC) is a marker of social inequalities worldwide because disadvantaged children are more likely to develop caries than their peers. This study aimed to define the ECC prevalence among children living in French-speaking Switzerland, where data on this topic were scarce, and to assess whether ECC was an early marker of social inequalities in this country. Methods: The study took place between 2010 and 2012 in the primary care facility of Lausanne Children’s Hospital. We clinically screened 856 children from 36 to 71 months old for ECC, and their caregivers (parents or legal guardians) filled in a questionnaire including items on socioeconomic background (education, occupation, income, literacy and immigration status), dental care and dietary habits. Prevalence rates, prevalence ratios and logistic regressions were calculated. Results: The overall ECC prevalence was 24.8 %. ECC was less frequent among children from higher socioeconomic backgrounds than children from lower ones (prevalence ratios ≤ 0.58). Conclusions: This study reported a worrying prevalence rate of ECC among children from 36 to 71 months old, living in French-speaking Switzerland. ECC appears to be a good marker of social inequalities as disadvantaged children, whether from Swiss or immigrant backgrounds, were more likely to have caries than their less disadvantaged peers. Specific preventive interventions regarding ECC are needed for all disadvantaged children, whether immigrants or Swiss. Keywords: Dental health, Early childhood caries, Social inequalities, Socioeconomic background Background wellbeing and quality of life, poor self-esteem or altered Early childhood caries (ECC) is a major health concern concentration) [5–8]. worldwide [1, 2]. ECC has been defined as the presence Despite being largely preventable with good oral of one or more decayed teeth (with non-cavitated or health behaviours (e.g., regular dental visits and tooth cavitated lesions), missing teeth (due to caries) or a brushing and using fluoridated toothpaste) and nutri- filled surface on any primary tooth in a child aged tional habits (e.g., low sugar intake, limited night-time 71 months old or younger [3]. ECC is correlated with a bottle-feeding, no sharing of eating utensils and using high burden of disease [4]: previous studies have associ- fluoridated salt or water), ECC remains one of the most ated ECC with deleterious effects on other health out- common childhood diseases [6, 9–11]. ECC can be comes (e.g. poor dental health, but also pain, infection, understood as “an indicator of preventive missed op- altered eating habits or sleep disturbances), childhood portunities” [12]. development (e.g., altered cognitive development, re- duced speech development or reduced growth involving A marker of social inequalities low body weight and height) and psychological out- Social inequality is characterized by the existence of un- comes for both children and their families (e.g., altered equal opportunities, access or distribution of goods be- * Correspondence: [email protected] tween different social groups within a society [13]. ECC Life Course and Inequality Research Centre, University of Lausanne, can be seen as a marker of social inequalities because, Lausanne, Switzerland Full list of author information is available at the end of the article wherever they live in the world, disadvantaged children © 2015 Baggio et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Baggio et al. BMC Oral Health (2015) 15:82 Page 2 of 9 are more likely to develop caries than their local peers. University Hospital. The HEL is dedicated entirely to Indeed, several studies have highlighted social differ- children’s health and is the paediatric reference centre ences in the prevalence rates of ECC; disadvantaged chil- for Lausanne and its suburbs (more than 250,000 inhabi- dren also have poorer dental health [14–19]. This tants). It treats all common diseases whether medical, disadvantaged population includes children from lower surgical, psychiatric or psychosocial; life-threatening socioeconomic backgrounds, with parents who have emergencies and pathologies requiring complex tech- lower levels of education and from single-parent fam- nical support are admitted to the main Lausanne Uni- ilies. However, this population also includes children fa- versity Hospital facility. The HEL’s priorities also include cing a cultural disparity, such as their immigrant status assisting and supporting patients’ families; the institution or a language barrier [2, 8, 15–17, 20, 21]. has a strong social vocation and is rooted in the commu- nity. There were more than 53,000 paediatric consulta- ECC in Switzerland tions at the HEL in 2010 (capacity = 29 beds). About ECC prevalence and their associations with socioeco- 70 % of these patients were immigrants, and the HEL is nomic factors have been well studied worldwide, yet data also involved in the medical monitoring of children are scarce in Switzerland. Overall, dental health is de- without residency permits. scribed as improving in Switzerland [22, 23], however, Children were eligible for inclusion in the study if they dental care is not covered by the basic health insurance were between 36 and 71 months old and if their care- scheme, and patients generally have to pay for their den- giver had a minimum capacity to understand the study’s tal treatment. Two recent Swiss studies highlighted that instructions. Some were admitted to the hospital for dental care was by far the most common healthcare regular and emergency medical treatments, and others treatment to be neglected by low-income people facing were there for ambulatory care. However, they all pre- economic constraints [24, 25]. ECC might, therefore, be sented minor health problems (no severe or chronically expected to be an important marker of social inequalities ill children participated). To avoid bias, children coming in Switzerland, and some national studies have already for dental treatment were not included. A majority of highlighted the relationship between socioeconomic sta- the participants lived near Lausanne. tus and dental health [23]. Following the caregiver’s written informed consent, Despite these interesting contextual factors, only one two dentists clinically screened 856 children for ECC. previous study has reported on ECC prevalence rates in During a three-month pre-testing period, the two den- Switzerland, and this was in the German-speaking part tists individually screened a number of children for of the country. A study in Zurich, in 2003, reported that ECC, and their dental assessments were compared. 25.3 % of two- and three-year-old children presented Their scoring was calibrated, and at the end of the pre- with ECC [26]. This prevalence rate was higher than test period their convergence rate was 0.99. Examina- those reported in other European countries (e.g., tions took place in the HEL’s primary care waiting room, Norway, 11 % [18]; Great Britain, 6.8 %–12 % [27]; and although it was impossible to dry their teeth or re- Greece, 16.5 % [28]; Germany, 7.3 %–20.3 % [29]; Italy, move debris in this environment, the children’s teeth 19 % [12]; France: 18 % [30]). Only Belgium and Spain were cleaned with sterile gauze. The visual clinical reported similar ECC prevalence, of 24 % [31] and examination of the mouth was performed with the aid of 28 % [32], respectively. However, data were collected a mobile light. Only deciduous teeth were examined, from older children (five-year-olds in Belgium and and the data collected were entered into a specially de- three- to six-year-olds in Spain). Overall, except for signed table. Caregivers were also interviewed using a Norway’s, these prevalence rates were higher than the standardised questionnaire available in French, English, 11 % goal outlined in the US government’sHealthy Spanish, Albanian and Arabic—the most common lan- People 2010 agenda [33]. guages spoken by those accompanying responsible Thus, the present study’s aims were twofold: 1) to de- adults. The dentists also noted any relevant dental or fine ECC prevalence in French-speaking Switzerland, oral pathologies and informed caregivers of them if where data on this topic were particularly scarce; and 2) necessary. to investigate whether ECC might be a strong marker of The University of Lausanne Faculty of Biology and social inequalities in the country. Medicine’s Ethics Committee approved the study protocol. Methods Participants Sample size The study was conducted between February 2010 and The sample size was calculated in order to detect an October 2012 in the primary care facility of Lausanne odd-ratio of two between two groups—as we had no in- Children’s Hospital (HEL), a part of the Lausanne formation about the prevalence rates of socioeconomic Baggio et al. BMC Oral Health (2015) 15:82 Page 3 of 9 variables, the participants were separated at the median parent came from a developed country and ‘0’ into groups with either a lower or a higher socioeconomic otherwise. A subgroup was also created for children background. The non-exposed group (i.e., high socioeco- whose parents were both Swiss citizens. nomic background) had a prevalence rate of 10 % ECC, chosen based on the 11 % goal outlined in the US govern- Covariates ment’s Healthy People 2010 agenda [33]. For a significance Children’s age and gender were recorded. Knowledge level of 0.05, a power of 0.90 and a correction for continu- and attitudes related to dental care were assessed using: ity, each group had to include 403 participants. The mini- 1) the most recent visit to a dentist (coded ‘1’ for at least mum total sample size required to assess the associations one check-up during the previous 12 months, ‘0’ other- proposed was thus estimated to 806 participants. wise); 2) the child’s average frequency of tooth brushing (coded ‘1’ for brushing three times per day, ‘0’ otherwise); Measures 3) the caregiver’s average frequency of tooth brushing ECC. A clinical examination of the oral cavity, without (coded ‘1’ for brushing three times per day, ‘0’ otherwise); the use of X-rays, was performed to establish a dental 4) the caregiver’s presence during the child’s most recent assessment. The presence of ECC was defined as per the tooth brushing (coded ‘1’ if a caregiver was present, ‘0’ recommendations by Drury et al. [3], and coded dichot- otherwise); 5) parents in agreement about child’s tooth omously (‘1’ = presence, ‘0’ = absence). Due to the exam- brushing practices (coded ‘1’ if parents supported each ination conditions, only frank cavitation was coded 1. other, ‘0’ otherwise); 6) how the child fell asleep the pre- vious night (with water or nothing, with milk, or with a Socioeconomic background sugar-based drink); and 7) information given by the Socioeconomic background included individual-level paediatrician regarding ECC (coded ‘1’ when parents had measures: received information, ‘0’ otherwise). 1) Parents’ level of education: incomplete compulsory Statistical analyses education, compulsory education, apprenticeship ECC prevalence in Switzerland (vocational school), secondary education (high The prevalence rate of ECC and descriptive statistics for school diploma), tertiary education (university) covariates were calculated. Bivariate associations be- (for similar cut-off points, see examples in [34, 35]). tween ECC and covariates were tested using exact Fi- The highest level of education of the two parents scher tests. was used. ECC prevalence and bivariate associations for the sub- 2) Parents’ professional level: we selected three classes sample of children whose parents were both Swiss citizens from the UK’s National Statistics Socioeconomic (excluding immigrants) were additionally calculated to test Classifications [36], i.e., higher occupations (e.g., whether the relationship between ECC and socioeconomic senior manager), intermediate occupations (e.g., background was still the same, and to test whether the re- manager), lower occupations (e.g., employee, manual sult was not due only to immigration status. Analyses in- worker), and added classes that did not fit into those cluded parents’ level of education, parents’ professional above, i.e., self-employed and unemployed. The level, and family income, because literacy problems and highest professional level of the two parents was immigration were absent within this subsample. Incom- used. pleted compulsory education and unemployed were ex- 3) Family income: low family income (less than CHF cluded from the analysis because of their very low sample 4,000, i.e., around USD 4,270), medium family size. income (between CHF 4,000 and CHF 6,000, i.e., Prevalence ratios and 95 % confidence intervals were around USD 6,400), high family income (more than computed for socioeconomic variables, using the lowest CHF 6,000), or did not want to answer (for similar level (i.e., incomplete compulsory education, unemployed, cut-off points, see examples in [37]). low family income, not good French understanding, and 4) Parents’ French literacy: this was coded ‘1’ for a immigrants from countries with HDI ≥ 0.8) as the refer- good understanding and ‘0’ otherwise. ence category. A log-binomial model was run to compute 5) The 2011 United Nations human development index prevalence ratios and their significance level. (HDI) was used to assess immigration status and categorize families into two groups, i.e., immigrants Multivariate associations between ECC and socioeconomic from countries with HDI ≥ 0.8 (developed countries) background and people from Switzerland, and immigrants from Subsequently, multivariate analyses were performed. countries with HDI < 0.8 (developing countries) [38]. Logistic regressions were calculated using ECC as a Immigration status was coded ‘1’ if at least one dependent variable and socioeconomic background factors Baggio et al. BMC Oral Health (2015) 15:82 Page 4 of 9 Table 1 Descriptive statistics for demographics and covariates, as independent variables. Since the socioeconomic vari- and bivariate associations with ECC ables shared a large amount of common variance, five dif- Demographics and covariates % (N) % of ECC ferent logistic regressions were performed (parents’ level of education, parents’ professional level, family income, Gender parents’ literacy, and parents’ immigration status). Covari- Boys 55.6 (476) 25.6 ates were included as control variables (i.e., age, gender, Girls 44.4 (380) 23.7 dental check-ups, child’s frequency of tooth brushing, Dental check-up in previous 12 months caregiver’s frequency of tooth brushing, parental presence Yes 44.9 (384) 35.9 at most recent tooth brushing, parents in agreement about No 55.1 (472) 15.7 child’s tooth brushing, how the child fell asleep the previ- ous night, and information given by the paediatrician). For Child’s frequency of tooth brushing each model, a McFadden pseudo R-squared was calculated <3 times a day 74.2 (635) 23.6 to estimate the effect size of each socioeconomic variable 3 times a day 25.2 (216) 27.8 of interest. Pairwise comparisons were calculated to com- Missing 0.6 (5) - pare different levels of the categorical socioeconomic vari- Parental frequency of tooth brushing ables. The length of time that migrants had been in the < 3 times a day 65.2 (558) 29.9 country was controlled for. As the results concerning ECC were the same whether or not this confounder was in- 3 times a day 33.2 (284) 21.7 cluded, the analyses were carried out without this Missing 1.6 (14) - covariate. Parental presence at most recent tooth brushing Descriptive statistics and logistic regressions were car- Yes 86.7 (742) 22.9 ried out using Stata version 14 software. No 12.9 (110) 37.3 Missing 0.5 (4) - Results Parents in agreement on child’s tooth brushing practices ECC prevalence Yes 84.5 (723) 23.1 The children’s average age was 4.42 ± 0.88 years old. The No 14.8 (127) 34.6 prevalence rate of ECC was 24.8 %. Bivariate associations Missing 0.7 (6) - are summarized in Table 1 (demographics and covari- Way children fell asleep previous night ates) and Table 2 (socioeconomic backgrounds). With With water/nothing 72.0 (616) 26.0 regard to demographics and covariates, there were sig- nificant differences in ECC prevalence rates associated With milk 24.5 (210) 21.0 with variables related to parental attitudes and behav- With sugar-based drink 2.6 (22) 22.7 iours. Children whose parents frequently brushed their Missing 0.9 (8) - own teeth, who were present at the most recent tooth Information given by pediatrician regarding ECC brushing, and who agreed on their children’s tooth- Yes 48.5 (415) 23.4 brushing practices had a lower ECC prevalence. On the No 51.3 (439) 26.0 contrary, however, information from a paediatrician was not associated with a decrease in ECC prevalence, nor Missing 0.2 (2) - was an annual visit to a dentist. Row percentages. For example: A total of 25.6 % of the boys had ECC a, b For significant Fischer’s exact test, a same subscript letter within a column Results showed higher rates of ECC among children denotes that proportions did not differ; two different subscript letters denote from lower socioeconomic backgrounds than those from that proportions differed at the 0.05 level higher ones, and this for all five variables. For example: with parents who had not completed their compulsory education, ECC = 64.3 %; but with parents with a tertiary In addition, we also computed bivariate associations of education, ECC = 15.8 % (PR = 0.25); with unemployed ECC prevalence with socioeconomic backgrounds of parents, ECC = 48.3 %; but with parents with a high pro- Swiss children with two Swiss parents (n = 457). In this fessional level, ECC = 16.0 % (PR = 0.44); in lower- group, the prevalence rate of ECC was 12.1 %, whereas income families, ECC = 42.6 %; but in higher-income the prevalence rate for immigrant children was 38.6 %. families, ECC = 12.8 % (PR = 0.33); with parents with lit- The results showed that even though ECC prevalence eracy problems, ECC = 41.7 %; but with no literacy prob- was lower, there was still an association between ECC lems: ECC = 20.4 % (PR = 0.49); and with parents from a and the socioeconomic background of the subgroup of developing country, ECC = 42.5 %; but with parents from children with two Swiss parents. Regarding parents’ level a developed country, ECC = 17.1 % (PR = 0.40). of education, children with parents with a tertiary Baggio et al. BMC Oral Health (2015) 15:82 Page 5 of 9 Table 2 Descriptive statistics for socioeconomic background and bivariate associations with ECC 1 2 Socioeconomic background % (N) % of ECC PR of ECC Parents’ level of education Incomplete compulsory education 14.6 (14) 64.3 Reference category b ** Compulsory education 15.4 (132) 31.1 0.48 [0.30-0.77] b *** Apprenticeship (vocational school) 22.4 (192) 28.1 0.44 [0.28-0.69] b ** Secondary education (high-school diploma) 18.2 (156) 31.4 0.49 [0.31-0.77] c *** Tertiary education (university) 42.1 (360) 15.8 0.25 [0.16-0.39] Missing 0.2 (2) - - Parents’ professional level Unemployed 6.8 (58) 48.3 Reference category b * Lower occupations 55.3 (473) 27.9 0.48 [0.25-0.90] c *** Intermediate occupations 16.8 (144) 17.4 0.58 [0.43-0.78] c *** Higher occupations 16.5 (141) 12.8 0.36 [0.23-0.56] b,c *** Self-employed 4.6 (39) 23.1 0.26 [0.16-0.44] Missing 0.1 (1) - Family income Low (< CHF 4,000) 18.1 (155) 42.6 Reference category b *** Medium (CHF 4,000 to CHF 6,000) 25.1 (214) 20.1 0.52 [0.38-0.71] b *** High (> CHF 6,000) 7.6 (65) 13.8 0.33 [0.17-0.61] b *** Other 15.5 (133) 18.8 0.44 [0.30-0.66] b *** Did not want to answer 33.4 (286) 22.7 0.53 [0.40-0.71] Missing 0.4 (3) - Parents’ literacy Problems 20.4 (175) 41.7 Reference category b *** No problems 79.6 (681) 20.4 0.49 [0.39-0.62] Parents’ immigration status Developing countries (HDI < 0.8) 29.7 (254) 42.5 Reference category b *** Developed countries (HDI > 0.8)/Swiss citizens 70.2 (601) 17.1 0.40 [0.32-0.51] Missing 0.1 (1) - - ECC: Early Childhood Caries; PR: Prevalence Ratio Row percentages. For example: A total of 14.6 % of the children whose parents had an incomplete compulsory education had ECC PR were computed using log-binomial models a, b, c For significant Fischer’s exact test, a same subscript letter within a column denotes that proportions did not differ; two different subscript letters denote that proportions differed at the 0.05 level * ** *** p < .05, p < .01, p < .001 education had a significant lower ECC prevalence (6.1 %, Multivariate associations of ECC with socioeconomic p < .05) in comparison with other levels (compulsory background education: 19.6 %, apprenticeship: 16.4 %, secondary Table 3 shows the adjusted estimate proportions of ECC education: 21.9 %). Regarding parents’ professional level, according to socioeconomic variables and controlling for children whose parents had a higher occupation had a covariates. All variables were significantly associated significantly lower ECC prevalence (13.6 %, p < .05) in with ECC (p < .001). The parents’ immigration status comparison with other levels (lower occupations: 20.0 %, had the highest effect size (7.74 %), whereas other socio- intermediate occupations: 14.7 %, but not with self- economic variables explained between 3.07 % and employed: 6.6 %). Finally, family income was also associ- 3.54 % of the variance in ECC. The complete models, in- ated with ECC prevalence: children with a low family cluding dental care and dietary habits, explained be- income were more likely to have ECC (24.4 %, p < .05) in tween 10.70 % and 14.96 % of the variance in ECC. comparison with other levels (medium: 13.0 %, high: As reported in the bivariate analyses, ECC was more 11.1 %, other: 11.6 %, no answer: 10.1 %). likely to occur in children from lower socioeconomic Baggio et al. BMC Oral Health (2015) 15:82 Page 6 of 9 Table 3 Logistic regressions of ECC on socioeconomic variables Socioeconomic background Adjusted estimated Likelihood Effect size for Effect size for prevalence ratio socioeconomic the test p-value variable of interest complete model Parents’ level of education < .001 3.14 % 10.70 % Incomplete compulsory education 0.61 Compulsory education 0.25 Apprenticeship (vocational school) 0.23 Secondary education (high school diploma) 0.25 Tertiary education (university) 0.13 Parents’ professional level < .001 3.74 % 11.26 % Unemployed 0.42 Lower occupations 0.23 Intermediate occupations 0.12 Higher occupations 0.10 b,c Self-employed 0.17 Family income < .001 3.35 % 10.94 % Low (< CHF 4,000) 0.36 Medium (CHF 4,000 to CHF 6,000) 0.17 High (> CHF 6,000) 0.10 Other 0.15 Did not want to answer 0.18 Parents’ literacy < .001 3.45 % 11.00 % Problems 0.37 No problems 0.17 Parents’ immigration status < .001 7.74 % 14.96 % Developing countries (HDI < 0.8) 0.40 Developed countries (HDI > 0.8) and Swiss 0.13 citizens a, b, c For significant pairwise comparisons, a same subscript letter within a column denotes that proportions did not differ; two different subscript letters denote that proportions differed at the 0.05 level Effect size measured with the McFadden pseudo R-square. The whole model included all demographics and covariates backgrounds, with adjusted estimated proportions ranging due to caries, or a filled primary tooth surface. This preva- from .36 to .61. Conversely, children from higher socio- lence rate was higher than those reported in numerous economic backgrounds were less likely to have ECC, with other European countries: from 6.8 % to 19 % [12, 18, 27– adjusted estimated proportions ranging from .10 to .17. 30]. ECC was particularly prevalent among young children living in French-speaking Switzerland, even though dental Discussion health in the country has been described as improving [23]. This study aimed to provide the ECC prevalence among One reason may be that Switzerland has a high immigration children living in French-speaking Switzerland and to as- rate—the highest among European countries [39, 40]. In sess whether socioeconomic background had a signifi- 2010, the proportion of immigrants in Switzerland was cant influence on the risk of ECC, as it does in other 23 %, far higher than the second highest proportion, in countries. In other words, ECC was tested to ascertain Germany, with 11.9 % of immigrants [41]. Many studies whether it was an early marker of social inequalities. have reported that migrants have higher ECC prevalence, in- cluding in Switzerland [26]. Indeed, the prevalence rate of ECC prevalence in French-speaking Switzerland ECC for the subsample of children whose parents were both The prevalence rate of ECC in the children examined, from Swiss was only 12.7 %, although this result was still higher 36 to 71 months old, was unexpectedly high: 24.8 % had at than that reported by Menghini et al. [26], who calculated a least one decayed primary tooth, a primary tooth missing prevalence rate of ECC of 7.5 % among Swiss children. Baggio et al. BMC Oral Health (2015) 15:82 Page 7 of 9 ECC as a marker of social inequalities and the importance In order to remove the influence of Switzerland’s par- of immigration status ticularly significant immigrant population on ECC The present study highlighted social inequalities related prevalence, we also tested the association between ECC to dental health. As socioeconomic background is a and the socioeconomic background of children whose multi-dimensional phenomenon, including several sources parents were both Swiss. Although the prevalence rate of social differences, we used multi-component indica- of ECC in this subsample was much lower than that re- tors [16]. The effects of social differences are often ported for the entire cohort, the association with disad- investigated using geographical measures, focusing on vantaged backgrounds remained. Thus, children of Swiss disadvantaged areas or deprived communities [42]. parents with a lower socioeconomic status (lower family However, this approach does not capture the entire income, lower level of education, lower occupations) extent of inequalities [42], and studies dealing with were more likely to have ECC than their more advan- individual-level measures are needed [16, 31]. The re- taged peers. ECC remained a marker of social inequal- sults presented here show that in French-speaking ities for Swiss citizens, especially of harsh social Switzerland, ECC is significantly related to socioeco- inequalities affecting vulnerable populations [12]. The nomic background, with both a higher proportion and high ECC prevalence, even among disadvantaged Swiss prevalence ratio of ECC among disadvantaged chil- children, may reflect economic difficulties and a result- dren. This result is in line with those reported in pre- ant renunciation of healthcare [24, 25]. Menghini et al. vious studies in other countries [2, 8, 15–17, 20, 21]. [26] recommended specific preventive interventions for Disadvantaged children included those whose parents immigrants because they had the higher prevalence rate had not completed primary education (61 % presented of ECC. The results of our study show that disadvan- with ECC after controlling for covariates) or were un- taged Swiss children should also be included in such employed (41 %), those from lower-income families preventive programs. (36 %), those whose parents had literacy problems or faced a language barrier (37 %), and those whose par- Preventing ECC ents came from a developing country (40 %). ECC is a preventable disease, so early interventions The most important effect size was related to the par- should be made to identify high-risk children and thus ents’ immigration status: this explained twice as much of avoid it. A simple way to provide families with informa- the percentage of variance of ECC as other socioeco- tion about ECC is to help paediatricians and other pro- nomic variables. Thus, immigration may be a major con- fessionals caring for children to recognize the risks of tributing factor to ECC in Switzerland, a country with a ECC [46]. Moreover, since good parental practises re- high immigration rate. These results were in accordance garding oral health were associated with lower preva- with the high ECC prevalence among immigrants in lence rates of ECC, preventive intervention should also Zurich, in German-speaking Switzerland, (38.5 %) re- target parents (e.g., their own oral health and the im- ported by Menghini et al. [26]. Immigrants may have dif- portance they give to their children’s oral health). ferent ideas and beliefs about oral health, infant feeding practises and oral health awareness [43]. Previous epi- Limitations demiological studies and clinical surveys have suggested This study had some limitations. Firstly, its cross- links between race/ethnicity and oral health status [44], sectional nature did not allow us to draw any causal however, the specific actual cultural beliefs and values paths between ECC and factors associated with it. Sec- that influence decisions or practices regarding oral ondly, the use of a self-administered questionnaire for health are seldom reported. Further research into immi- caregivers may have induced either a response or recall grants’ cultural beliefs and their associations with their bias. Finally, generalising these results to the whole behaviours and practices surrounding oral health and country should be done with caution since the sample seeking dental care would provide information helpful in was based on children living in western Switzerland who designing future preventive and treatment programmes. had consulted a paediatrician in a primary care hospital. Butani et al. [44] suggested that qualitative research Moreover, the patients visiting the HEL included a high would be suitable for this purpose, providing valuable in- proportion of immigrants (70 %), and even though the formation towards understanding cultural beliefs related HEL is the paediatric reference centre for Lausanne and to oral health and helping to explore cultural reasons for its suburbs, our results may reflect the large number of seeking or delaying dental care. They also suggested that immigrants who came to the HEL. Europeans make up a community-based participatory approach [45] would the majority of immigrants in Lausanne and its suburbs help to involve community members, understand cul- (in 2011, 83 % of immigrants were from Europe, 72 % tural beliefs and practises, and implement appropriate from the European Union [47]). In 2010, at 30.5 %, the interventions. canton of Vaud (where Lausanne is located) had one of Baggio et al. BMC Oral Health (2015) 15:82 Page 8 of 9 the highest immigration rates in the country [48], Author details Life Course and Inequality Research Centre, University of Lausanne, whereas it was 23 % for Switzerland as a whole [41]. Lausanne, Switzerland. Private practice, University of Lausanne, Lausanne, Our results may, therefore, be representative of the par- Switzerland. Vulnerable Population Unit, Department of Ambulatory Care ticularities of this part of western Switzerland. 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Oral health-related cultural beliefs for four • Inclusion in PubMed, CAS, Scopus and Google Scholar racial/ethnic groups: Assessment of the literature. BMC Oral Health. 2008;8(1):26. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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