Does the Financial and Educational Status of the Patients Play a Role in Tooth Extraction?

doi:10.21203/rs.3.rs-1654106/v1

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Research Article

Does the Financial and Educational Status of the Patients Play a Role in Tooth Extraction?

https://doi.org/10.21203/rs.3.rs-1654106/v1

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Backgrounds

The purpose of this study was to establish the relationship between educational status, family income, social inequality, and the Human Development Index (HDI) with the need for tooth extraction.

Methods

The authors conducted a 3,964 patients retrospective cohort, from 2007 to 2017, assessing gender, age, hometown, family income, general health data, educational level, extracted teeth, and cause of the extraction.

Results

Females were predominant in a 1.5:1 ratio. The average number of removed teeth was 2.27 per patient. Third molar extraction was correlated with wealthier patients (p = .01), while poorer patients opted for the removal of other functional teeth. Neither social inequality nor human development promoted a correlation between which teeth were removed. Uneducated and poorly educated were related to the removal of other teeth, molars, and anterior teeth, rather than third molars (p = .032). Educated ones, with a college education and high school, preferably remove their third molar, without any other loss of permanent teeth (p = .006).

Conclusion

Wealthy and educated patients are aware of oral health promotion programs, and usually seek elective treatment, especially third molars extractions, while the poor and uneducated are demanding treatment for functional teeth removal, worsening chewing, and aesthetics.

During the twenty century, there was an increased interest in the health impact on humanity, and oral health relevance was not forgotten though. Tooth loss due to caries or other periodontal diseases has diminished, however even in rich countries a substantial proportion of the population undergoes dental removal every year, with a considerable impact on the perceived quality of life ^1–3. Broad Nationals studies conducted on the Brazilian population revealed that the rate of missing teeth decayed from 22.5–16.3% of the adults, from 1986 to 2010, possibly due to the improvement of the socioeconomic conditions, especially formal education and improved public health services ².

The more relevant causes of early removal of permanent teeth are well-known, and dental caries (36%-55.3%), periodontal diseases (24.8%-23.1%), trauma (0.8%-4.4%), orthodontic treatment (2.5%-7.2%) are the most recognized among others ^4,5. These factors are closely related to the increase in age expectancy, gender discrepancies, cultural values, interest in dental care, diet, schooling, and social-economic status ^6–10.

Tooth loss may cause serious harmful alterations to oral function, the morphology of the facial bones, especially the mandible, diet quality, social interaction, employment opportunities, and even cognitive capacities, as tooth loss-related dementia has been previously reported ^4,5. Adults who have lost 5 or more teeth may face difficulty chewing, which is a pivotal point in a dietary change, opting for soft and less nutritional food ⁴. Early edentulism could be directly related to an increased risk of chronic coronary arterial disease, diabetes, hypertension, stroke, kidney failure, and even malignancy ⁴.

This study has the proposal to establish the relationship between educational status, family income, social inequality, and the Human Development Index (HDI) with the indication for tooth extraction.

Study Design

This study is a retrospective cohort focused on the analysis of medical records, in a 10-years span from 2007 to 2017. The study and all the researchers respected the World Medical Association Helsinki Declaration. The guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement were followed by the authors.

Study Population

The study sample included all patients that had removed at least one tooth in a 10-years span from 2007 to 2017. A total of 3,964 participants who received the instructions of an informed and consent term, at the time of the surgical procedure, had their medical records included in this study. Patients who had medical records with missing data on one or more variables were excluded from the study.

Data Collection

All the medical records were individually collected by the evaluators, in a safe bunker, to avoid data exposure, in a strict data protection protocol.

From records, the variables extracted were: gender, age, marital status, hometown, family income, general health data, educational level, extracted teeth, and cause of the extraction.

The family income data was collected using the minimum wage in Brazil, in American Dollar (USD), as the base of comparison. The patients were divided into three groups, by the income range. Group F1, with family income inferior to US$500/month, Group F2, with family income between US$ 500 to US$ 1000/month, and Group F3, with family monthly income greater than US$1000.

The Gini Index and HDI were obtained by using the hometown and the latest data provided by the Brazilian Government, in the 2019 census. The Gini Index was, then, subdivided into three groups. Group G1, with Gini Index lower than 40.00, Group G2, with Gini Index between 40.01 and 50.00, and Group G3, with Gini Index higher than 50.01. The HDI was divided into four groups as well, Group H1, with HDI higher than .800, Group H2, with HDI between .700 and .799, Group H3, with HDI between .555 and .699 and finally, Group H4, with HDI lower than .554. ¹⁴

To correlate with the Gini Index the variable Extracted Teeth was then subdivided into other groups regarding which were removed, the Group D0 in which the patient removed only the wisdom teeth, D1 in which the patients removed other ones.

The subjects were divided into 4 groups representing their educational level, being (1) No Education (NE), (2) Elementary School (ES), (3) High School (HS), and (4) College and other Higher Education (CHE).

Data Analysis

The extracted data were analyzed in the Apple Number (Apple, Cupertino, CA, USA) and the Statistical Package for the Social Sciences (SPSS®ฏ), version 25.0 (IBM®ฏ, Armonk, NY, USA). Absolute and percentage distribution, mean, and standard deviation of the variables were obtained by descriptive analysis. The parametric test was conducted in the Friedman Test. Family income data along with the variables educational level, social inequality, and HDI, analysis of variance was used to determine bivariate correlation with Mann-Whitney Test. One-factor ANOVA tests were run to determine the existence of statistical differences between each one of the variables and the outcome of Extracted Tooth. Both used a p-value of p < .05 in a 95% confidence interval, to determine statistical significance.

Descriptive Analysis

Of the 3,984 patients, the female patients were predominant with 61.1%, followed by the male with 38.9%, in a 1.5:1 ratio. The average number of removed teeth was 2.27 per patient. The average age was 37 years old. Data from family income, social inequality, and the human development index is presented in Table 01.

Table 01

Family Income, Social Inequality, and Human Development Index (HDI) Descriptive Data and Correlation with Removed Tooth
Groups	Percentage	Other Teeth	Third Molars
Family Income
Group F1	23.96	.06 ^‡	.0866
Group F2	33.80	.01^‡	.0270
Group F3	42.24	.134	.01^‡
Social Inequality (Gini Index)**
Group G1	0.2	.877	.322
Group G2	9.6	.122	.128
Group G3	90.2	.356	.566
Human Development Index (HDI)***
Group H1	85.97	.266	.08
Group H2	8.63	.171	.12
Group H3	5.34	.599	.899
Group H4	0.06	-	-
* Group F1: Family Income inferior to US$ 500/ Month; Group F2: Family income between US$ 500 to US$ 1000/month; Group F3: Family income greater than US$1000.
** Group G1: Gini Index lower than 40,00; Group G2: Gini Index between 40,01 and 50,00; Group G3: Gini Index higher than 50,01.
*** Group H1: HDI higher than 0,800; Group H2: HDI between 0,700 and 0,799, Group H3: HDI between 0,555 and 0,699; Group H4: lower than 0,554.
^{‡ Present Statistical Significance}

Family Income

The family income was divided into three categories, and Group F3 was the most predominant with 42.24% of the patients, followed by Group F2, with 33.80%, and Group F1 with 23.96% of the patients. Third molar extraction was correlated with Group F3 (p = .01), on the other hand, the surgical removal of other teeth was related to both groups with minor financial conditions (F1, p = .06; F2, p = .01). The data is presented on Graphic 01.

Social Inequality

Groups were subdivided into three groups, based on the social inequality Gini Index. 90.3% of the patients were classified in the G3 group, with the higher representative inequality based on the patient's address. G2, 9.6%, and G1 with 0.2% were the following. None of the groups promoted a correlation between which teeth were removed.

Human Development Index (HDI)

The average HDI was 0.796 and was also divided into groups. Group H1 was the most predominant with 85.97%, followed by the Groups H2, H3, and H4 with 8.63%, 5.34%, and 0.06% respectively. Although, none of the groups presented a statistically significant correlation with which teeth were removed.

Educational Status

The patient's records were screened for the assessment of educational status. A relationship was established between patients without education and only elementary school with the removal of other teeth, molars, and anterior teeth, rather than third molars (p = .032). In addition to that, it was clear that patients with higher education status, such as college education and high school, removed only their third molar, without any other loss of permanent teeth (p = .006). Complete data from education status are presented in Table 02 and Graphic 02.

Table 02

Correlation between Educational Status and Removed Tooth.
Groups	Other Teeth	Third Molars
No Education	.032^‡	.992
Elementary School	.031^‡	.221
High School	.520	.001^‡
College and Other Higher Education	.10	.006^‡
^{‡ Present Statistical Significance}

The impact of tooth loss should not be relegated, and it has been observed in society forever. John Speckled-Tooth’s Loss story, published in 1935 ¹¹ on JADA was one of the first scientific manuscripts that states the tooth removal topic in the modern days, presenting a childish lullaby story about dental care and tooth loss. There are many diseases that could play an important role in tooth loss ^2,12, however, these conditions are not only health-related but also with social inequality, poverty, and educational opportunities. The decision to extract a tooth is extremely multifactorial and the patient's desire for the treatment is core, however, at this moment, several factors may influence the treatment to be performed by the surgeon ^4,5.

Some of the remarkable non-healthy-related factors that could influence the decision to remove a tooth are the daily dietary intake ¹³, smoking ¹⁴, availability of public health services ¹⁵, and low income ^2,7. To our knowledge, no previous study aimed to correlate the social inequality, financial status, and educational level to the tooth extraction procedures.

The family income was an important factor and is clearly the pivotal point for a myriad of problems, which add up to the correlation between richer patients removing third molars (p = .01), usually symptoms-free, while poorer patients remove other functional teeth (p = .06). The correlation between personal gross, family income, and oral health is well-established in the literature in different countries ³.

In this study, both social inequality and HDI were concentrated on one group each, especially due to the sample distribution; these could have influenced the absence of correlation between the variables and the teeth extraction distribution. Other studies successfully described that relationship, even among the Brazilian population, as one of the most unequal on the Gini Index ranking. Neto et al. concluded that socioeconomic status below average, was strongly related to early teeth extraction ², those findings were observed in other Nordic countries, with top tier HDI and controlled social inequalities ^3,15.

The educational profile of the patients was traced in an attempt to establish a valid correlation between uneducated and early loss of functional teeth. Not surprisingly, the patients with college or other higher degrees sought dental treatment, with elective and scheduled removal of a non-functional third molar (p = .006), rather than patients without education or only elementary school diploma, that removed functional teeth (p = .032).

Other studies have described the situation of uneducated patients in unskilled jobs or with low income who had higher rates of early tooth extraction, especially due to caries and periodontal disease ³.

As said before, the factors that played a core role in the decision for dental extraction are multifactorial, and not only health-related. The economic, educational, and social features are directly related to the patient's desire, and usually the uneducated and poor opt for the early extraction, in an attempt to avoid further treatment and increased costs. On the other hand, the richer and educated are aware that oral health could play an important role in the healthy aging process, preferring elective wisdom tooth removal and, together with that, avoiding the premature tooth loss of other teeth ^1–5.

The results of our study suggest that oral health care and tooth removal are extremely multifactorial and not always a decision of the oral surgeon. Furthermore, economic, educational, and social aspects play a fundamental role in the patient’s desire to opt for the treatment. Wealthy and educated patients are aware of oral health promotion programs, and seeking elective treatment, especially third molars extractions, while the poor and uneducated, with less knowledge access and higher health and social vulnerability are demanding treatment for functional teeth removal, worsening chewing, and the patient's aesthetics. The oral health promotion public programs must include these patients with more effectiveness, breaking the wheel of oral health poverty.

Funding Statement

The authors did not receive any amount of money, investment, or material for the funding of this study.

Institutional Review Board Statement

This study was conducted under the recommendations of the Helsinki Declaration and was presented and approved without any consideration by the Research Ethics Committee of the Institution and the Brazilian Committee for Research Ethics, under Protocol n^o. 98621018.8.0000.5149.

AUTHOR CONTRIBUTION STATEMENT

All authors of this research paper have directly participated in the planning, execution, or analysis of this study; All authors have read and approved the final version here submitted.

Thank you for your consideration

Fernanda Brasil Daura Jorge Boos-Lima, DDS, OMFS, Ph.D.