Association between racial iniquities and oral health status: a systematic review

Reis, Laila Araújo de Oliveira dos; Miranda, Samilly Silva; Fonseca, Bruna Rebouças da; Pereira, Marcos; Natividade, Marcio dos Santos; Aragão, Erika; Lara, Tiago Prates; Nery, Joilda Silva

doi:10.1590/1413-81232024293.04882023EN

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THEMATIC ARTICLE • Ciênc. saúde coletiva 29 (3) • Mar 2024 • https://doi.org/10.1590/1413-81232024293.04882023EN copy

Association between racial iniquities and oral health status: a systematic review

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Abstract

The present study aimed to investigate the association between racial iniquities and oral health status. This is a systematic review with a protocol registered on the Prospero Platform (CRD42021228417), with searches carried out in electronic databases and in gray literature. Our study identified 3,028 publications. After applying the eligibility criteria and risk of bias analysis, 18 studies were selected. The results indicate that individuals of black/brown race/skin color have unfavorable oral health conditions, mainly represented by self-rated oral health, tooth loss, caries, and periodontitis. The results showed racial iniquities in oral health in different countries, for all analyzed indicators, with a greater vulnerability of the black population.

Key words:
Oral health; Health status disparities; Racial groups; Ethnic health

Authors/Year	Location	Design	Population	Exposure variable	Outcome variable	Assessment tool	Main findings
Fisher et al., 2004²⁷27 Fisher MA, Gilbert GH, Shelton BJ. A cohort study found racial differences in dental insurance, utilization, and the effect of care on quality of life. J Clin Epi Demiol 2004; 57(8):853-857.	USA	Cohort study	873 non-institutional individuals	Access to dental service/age/gender/race/income/number of teeth	Oral disadvantage: gum disease, sensitive tooth (hot and/or cold) or dental disease.	Interview and application of a structured questionnaire.	Whites were more likely to seek dental services than blacks. Among patients with severe periodontitis, white patients had more successful treatments.
Chavers et al., 2007³¹31 Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent 2007; 62(3):140-147.	USA	Cohort study	873 people	Dental care, demographic factors and socioeconomic factors	Oral disadvantage	Data were extracted from a prospective longitudinal study on oral health and dental care.	There are significant differences in the incidence of oral disadvantages based on the approach to dental care, race, gender, area of residence, level of formal education, and financial status.
Jimenez et al., 2009³²32 Jimenez M, Dietrich T, Shih MC, Li Y, Joshipura KJ. Racial/ethnic variations in associations between soci-oeconomic factors and tooth loss. Community Dent Oral Epidemiol 2009; 37(3):267-275.	USA	Cross-sectional study	16,821 people	Race/education/poverty income index/occupation, dental insurance/use of dental care/medical insurance/gender/region of residence/foreign origin.	Tooth loss	National Health and Nutrition Examination Survey III (NHANES III) - Clinical examination and interviews.	The association between the number of missing teeth and socioeconomic factors was attenuated among blacks and Mexican Americans, when compared to whites in this study population.
Guiotoku et al., 2012¹1 Guiotoku SK, Moysés ST, Moysés SJ, França BH, Bisinelli JC. Racial inequity in oral health in Brazil. Rev Panam Salud Publica 2012; 31(2):135-141.	Brazil	Step 1: Cross-sectional study Step 2: Ecological study	12,811 adults of both sexes aged 35 to 44. In a second moment, in an attempt to contextualize inequities, we started working with a group of 6,918 black and brown people.	Step 1: Average family income (in US dollars) and education (in years of study), access to the dentist and race/skin color. Step 2: average family income, human development index (HDI) and Gini index (IGini).	Stage 1: Caries (DMFT index), tooth loss, previous edentulism, dental pain, need for prosthesis and access to a dentist. Stage 2: average DMFT, average number of missing teeth and prevalence of previous edentulism, dental pain, and need for prosthesis, aggregated by state.	Secondary data from the SB Brazil 2002-2003 national survey. The oral examination was carried out at home by calibrated examiners.	Significant differences were observed between race/color groups for all outcomes studied. Racial inequities in oral health were evident in Brazil, with greater vulnerability of the black population (blacks and browns) in relation to whites.
Antunes et al., 2013²⁵25 Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos J L. Gender and racial inequalities in trends of oral cancer mor-tality in Sao Paulo, Brazil. Rev Saude Publica 2013; 47(3):470-478.	Brazil	Ecological study	8,505 people living in the city of São Paulo who died from oral cancer	Race, black skin color/male gender	Oral cancer	Mortality and Census Information System 2000.	The oral cancer death rate doubled for black men from 2003-2009
Bruno et al., 2013²¹21 Bruno IF, Rosa JAA, Melo CM, Oliveira CCC. Avaliação da doença periodontal em adultos na população quilombola. Interfaces Cien Saude Ambiente 2013; 1(2):33-39.	Brazil	Cross-sectional study	29 quilombola individuals	Race, black skin color	Oral Lesions/Periodontal Disease	Community Periodontal Index (CPI)	A high prevalence of periodontal disease was found (75.86%) in quilombolas.
Celeste et al., 2013²³23 Celeste RK, Gonçalves LG, Faerstein E, Bastos JL. The role of potential mediators in racial inequalities in tooth loss: the Pró-Saúde study. Community Dent Oral Epidemiol 2013; 41(6):509-516.	Brazil	Cross-sectional study	2,791 employees from a university campus in Rio de Janeiro	Behavioral markers/Self-reported discrimination/race	Self-reported tooth loss	Data were collected using a self-administered questionnaire	After adjustment, black people had an odds ratio of being in a higher category of missing teeth equal to 1.39 (95%CI 1.12-1.72), and brown people, 1.33 (95%CI 1.10-1.60), when compared to whites.
Figueiredo et al., 2016¹⁹19 Figueiredo MC, Benvegnú BP, Silveira PPL, Silva A M, Silva KVCL. Saúde bucal e indicadores socioeconômicos de comunidades quilombolas rural e urbana do Estado do Rio Grande do Sul, Brasil. Rev Fac Odontol Lins 2016; 26(2):61-73.	Brazil	Cross-sectional study	120 quilombola individuals	Quilombola community and water fluoridation	Oral health condition	Structured questionnaire and periodontal examination, in addition to collecting drinking water	Wide prevalence of cavities, as well as tooth loss, with a higher rate associated with the rural quilombola community.
Bidinotto et al., 2017¹³13 Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MB, Bairros FS, Hilgert JB. Autopercepção de saúde bucal em comunidades quilombolas no Rio Grande do Sul: um estudo transversal exploratório. Rev Bras Epidemiol 2017; 20(1):91-101.	Brazil	Cross-sectional study	583 individuals belonging to the Quilombola community	Race, black skin color, low income	Negative self-rated oral health	Application of a structured questionnaire.	Negative self-rated oral health was reported by 313 (53.1%) individuals. Satisfaction with appearance and chewing is a factor associated with quilombolas' self-rated oral health.
Nazer and Sabbah, 2018²⁸28 Nazer FW, Sabbah W. Do Socioeconomic Conditions Explain Ethnic Inequalities in Tooth Loss among US Adults? Ethn Dis 2004; 28(3):201-206.	USA	Cross-sectional study	76,273 participants over 40 years old	Black/Hispanic/Other	Tooth loss	Use of secondary data. Application of a structured questionnaire over the telephone.	African Americans are more likely to have tooth loss than other ethnic groups. The significant association between ethnicity and tooth loss persisted even after adjusting for socioeconomic position.
Sandes et al., 2018¹⁸18 Sandes LFF, Freitas DA, Souza MFN. Oral health of elderly people living in a rural community of slave descendants in Brazil. Cad Saude Colet 2018; 26(4):425-431.	Brazil	Cross-sectional study	669 quilombolas, aged 65 to 74 years, living in 33 rural quilombola communities spread across 20 different municipalities	Socioeconomic conditions/use of dental services	Oral health condition	Interviews and examinations were carried out	The quilombolas analyzed choose to seek dental care only in cases of pain or extraction. Precarious oral health conditions, high rate of edentulism. Most elderly people reported being unhappy with their own oral health status.
Han, 2019³⁰30 Han C. Oral health disparities: Racial, language and nativity effects. SSM Popul Health 2019; 12:e100711.	USA	Cross-sectional study	12,307 adults	Education/household income/demographics	Visits to the dentist/	National Health and Nutrition Examination Surveys (NHANES)	Non-Hispanic blacks report worse self-rated oral health than non-Hispanic whites
Celeste et al., 2019²⁴24 Celeste RK, Oliveira SC, Junges R. Threshold-effect of income on periodontitis and interactions with race/ethnicity and education. Rev Bras Epidemiol 2019; 14;22:e190001.	Brazil	Cross-sectional study	9,779 individuals aged 35 to 44	Income/education/race	Periodontitis	Interview and oral examination	Higher income and education were associated with a decreased prevalence of moderate to severe periodontitis. There were no significant interactions between income and race or education, nor between race and education, nor between race and periodontitis.
Araújo et al., 2020²⁰20 Araújo RLMDS, Araújo EMD, Miranda SS, Chaves JN, Araújo JAD. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano. Epidemiol Serv Saude Ambiente 2020; 29(2):e2018428.	Brazil	Cross-sectional study	864 quilombola individuals	Socioeconomic and demographic variables and health conditions variables	Tooth loss	Application of a structured questionnaire.	The majority of quilombolas in the semi-arid region of Bahia reported losing at least one tooth due to extraction, and those who reported having tooth decay were more likely to have a tooth extracted.
Schuch et al., 2021⁴4 Schuch HS, Haag DG, Smith JL, Paradies Y, Jamieson LM. Intersectionality, racial discrimination and oral health in Australia. Community Dent Oral Epidemiol 2021; 49(1):87-94.	Australia	Cross-sectional study	2,798 individuals	Perceived racial discrimination/income/education	Compromised oral health	Based on data from the National Dental Telephone Interview Survey.	Perceived racial discrimination is associated with oral health problems, and this relationship is socially standardized.
Miranda et al.,2021²²22 Miranda LP, Oliveira TL, Queiroz PDSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.	Brazil	Cross-sectional study	406 quilombola elderly people	Sociodemographic characteristics of quilombola elderly people	Access to dental services	Structured interviews and clinical dental examinations.	Quilombola elderly people had precarious oral health conditions and had restricted access to dental services. Elderly people had greater difficulty accessing dental health services.
Muralikrishnan and Sabbah, 2021²⁹29 Muralikrishnan M, Sabbah W. Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults? J Racial Ethn Health Disparities 2020; 8(5):1293-1299.	USA	Cross-sectional study	4,858 individuals	Racial discrimination	Tooth loss	Behavioral Risk Factor Surveillance System (BRFSS) 2014	This study demonstrated a potential role for discrimination in tooth loss among American adults. Discrimination could also explain part of the ethnic inequalities in oral health.
Karam et al., 2022²⁶26 Karam SA, Schuch HS, Demarco FF, Barros FC, Horta, BL, Correa MB. Social and racial inequity in self-rated oral health in adults in Southern Brazil. Cad Saude Publica 2022; 38(3):e00136921.	Brazil	Cross-sectional study resulting from a cohort	537 individuals	Social and racial inequalities	Oral health self-assessment	Oral Health Study (OHS)	The results of this study demonstrate racial disparities in oral health regardless of income and education. Furthermore, negative self-rated oral health was identified as being more prevalent among participants belonging to racial/skin color minorities.

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PubMed (424 articles)	((“adult”[MeSH Terms] OR “adult”[All Fields] OR “adults”[All Fields] OR “adult s”[All Fields] OR (“young adult”[MeSH Terms] OR (“young”[All Fields] AND “adult”[All Fields]) OR “young adult”[All Fields])) AND (“humans”[MeSH Terms] AND “medline”[Filter]) AND ((“racism”[MeSH Terms] OR “racism”[All Fields] OR “racism s”[All Fields] OR “racisms”[All Fields] OR (“race relations”[MeSH Terms] OR (“race”[All Fields] AND “relations”[All Fields]) OR “race relations”[All Fields]) OR (“vulnerable populations”[MeSH Terms] OR (“vulnerable”[All Fields] AND “populations”[All Fields]) OR “vulnerable populations”[All Fields])) AND (“humans”[MeSH Terms] AND “medline”[Filter])) AND ((“tooth loss”[MeSH Terms] OR (“tooth”[All Fields] AND “loss”[All Fields]) OR “tooth loss”[All Fields] OR (“dental caries”[MeSH Terms] OR (“dental”[All Fields] AND “caries”[All Fields]) OR “dental caries”[All Fields]) OR (“periodontal”[All Fields] OR “periodontally”[All Fields] OR “periodontically”[All Fields] OR “periodontics”[MeSH Terms] OR “periodontics”[All Fields] OR “periodontic”[All Fields] OR “periodontitis”[MeSH Terms] OR “periodontitis”[All Fields] OR “periodontitides”[All Fields]) OR (“oral health”[MeSH Terms] OR (“oral”[All Fields] AND “health”[All Fields]) OR “oral health”[All Fields])) AND (“humans”[MeSH Terms] AND “medline”[Filter]))) AND ((humans[Filter]) AND (medline[Filter]))
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