Dental caries is the most prevalent health condition worldwide (2). In recent years, Israel has worked to improve oral health among underprivileged populations by implementing legislation that provides free dental care for children and adolescents from birth to 18 years of age through a child dental care reform (CDCR) under the National Health Insurance Law (NHIL). A study on the utilization levels of the CDCR by Domb Herman et al. concluded that despite a significant increase in the percentage of children using the services from 8–33% with the inclusion of additional age groups, more efforts are needed to boost utilization (12). However, a recent study by Levy et al. showed that the provision of free dental care is not enough to reduce the overall dental treatment needs among Israeli youth (13), while it is enough to lower the untreated carious lesions in Israeli 6-year-olds, as Natapov et al. found (14). These findings highlight the need for decision-makers to implement strategies within dental health policies to further improve attendance rates.
The current analysis demonstrated a significant (p < 0.001) inverse correlation between ICS and the need for dental restorations, RCTs and extractions, even after adjusting for confounding factors, such as age, sex, BMI, and country of birth, in line with the findings reported in the literature (5, 15, 16).
ICS can influence dental treatment needs in multiple ways. For example, lower ICS may lead to less awareness of dental health, resulting in poorer dental hygiene habits, such as inadequate tooth brushing and infrequent use of dental floss (15, 17), leading to more dental plaque and periodontal disease (15, 18). Lower levels of parental education and patient ICS were also reportedly associated with greater consumption of cariogenic processed foods and sweetened beverages (4, 5, 19). Recently, Khatib et al. (20) found that a low educational level hinders Israeli Arab children from utilizing dental services covered under Israel's NHIL. According to the authors, this barrier arises because individuals with lower educational attainment require more explicit information about new services (20). Taken together, it can be suggested that low ICS and a low educational level not only contribute to the risk of caries but also impede effective treatment uptake.
Moreover, there was a direct association between lower ICS and SES in the current study cohort, raising the possibility that ICS may indirectly contribute to an increase in caries experience attributed to low SES (21). Low income and educational levels both contribute to poor health literacy, which negatively impacts self-assessed health, a common indicator of overall health (22). Children from lower SES backgrounds are reportedly more likely to attend dental clinics for urgent treatments and less likely to attend them for routine check-ups compared to children from higher SES groups (4, 23). This highlights the need to enhance dental care in underserved areas, addressing both resource limitations and factors such as educational levels and ICS. Implementing intervention plans, such as supervised tooth brushing programs (STBPs) in kindergartens, could help reduce dental health disparities, as evidenced by their effectiveness in low SES areas of Israel (24).
The recruits in the current study who were immigrants to Israel needed significantly more RCTs compared to native Israelis (p = 0.009). Immigration often involves a change to a more cariogenic diet, resulting in an increase in caries experience (25). Immigrant children in Israel might have had limited access to free dental care, depending on their age of arrival, and to school dental services (SDS), which could result in suboptimal dental care. In some communities, higher rates of dental caries have been observed not only among the first generation of immigrants but also in subsequent generations. (11).
Globally, oral health care is less accessible to less educated populations (6, 26), people from disadvantaged municipalities (27), people of certain ethnic backgrounds (3), children with no dental health insurance (28), and individuals in lower SES groups (2). Unfortunately, they comprise the groups with more prevalent dental caries (29). In fact, the cost of dental treatment in certain countries can be so significant that it can push families below the poverty line (30). Several studies have shown that dentists tend to offer less privileged patients more invasive treatments, such as tooth extractions, over more conservative approaches that tend to be more costly (3, 4). Patel et al. recently showed that dentists were more likely to offer RCT to a White patient and extraction to a Black patient (31).
There was also a significantly greater need for dental restorations among the current recruits who belonged to populations with lower SES and lower ICS (p < 0.001, Table 1), suggesting that further tooth loss can be anticipated without the implementation of significant intervention. In fact, the timing of dental checkups and preventive care appointments is crucial in treating caries, given its progressive nature. Even if a root canal treatment is needed, performing it on time can prevent the progression to tooth extraction.
Water fluoridation has been demonstrated as the most effective and widespread method for promoting community-level oral health and addressing dental health inequalities stemming from socioeconomic disparities (32). Regrettably, legislation enacted in 2014 banned water fluoridation in Israel, halting its beneficial effects and already demonstrating an increase in dental caries levels among Israeli children and in dental disparities (33). Therefore, the continuation of nationwide water fluoridation is vital for addressing the aforementioned dental health challenges arising from lower SES and ICS.
In the IDF, patients from low SES, and immigrants without parents in Israel receive a broader range of treatments compared to soldiers without financial issues, including dental crowns and implants. Based on our results, it may be advisable to update public policy accordingly, for example include populations with low ICS in future dental intervention plans, while ensuring the approach remains discreet and sensitive. Additionally, since individuals with lower educational levels and immigrants tend to use dental care services less frequently (12, 20), it is crucial to make information more accessible and clearer. For example, sending letters to parents from the school dental health service advising them that their child needs to see a dentist could help address this issue (23). Engaging healthcare providers beyond dentists, such as pediatricians and public health nurses, can also help in reaching these groups effectively (12).
Strength and limitations: the current study population is well suited for assessing the association between dental health, SES, and ICS because it is comprised solely of otherwise healthy young adults, thereby eliminating the potential confounding effects of chronic or systemic illnesses. Importantly, dental examinations are mandatory for IDF recruits, enabling the acquisition of data from the entire study population.
There are several limitations to this study. Firstly, the study had a low proportion of women (9%, N = 1,968), making it difficult to generalize any findings on sex differences to the wider population. Secondly, cariogenic behaviors, such as high sugar intake and oral hygiene practices, which could have influenced the results, were not taken into consideration. Thirdly, the methodology did not include the collection of data on former caries experience, such as filled or missing teeth, but rather focused solely upon treatment needs at the time of the examination.