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Differences in Oral Health Status between Rural and Urban Populations of Korean Elders: A Population-Based Study from the Korean National Health and Nutrition Examination Survey VI (2013∼2015)
J Dent Hyg Sci 2019;19:181-9
Published online September 30, 2019;  https://doi.org/10.17135/jdhs.2019.19.3.181
© 2019 Korean Society of Dental Hygiene Science.

Yong-Keum Choi1 , Eun-Jeong Kim2,†

1Department of Dental Hygiene, College of Health Science and Genome-based BioIT Convergence Institute, Sun Moon University, Asan 31460, 2Dental Research Institution, School of Dentistry, Seoul National University, Seoul 03080, Korea
Correspondence to: Eun-Jeong Kim, https://orcid.org/0000-0002-6316-7807
Dental Research Institution, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
Tel: +82-2-740-8782, Fax: +82-2-766-8781, E-mail: kej1007@snu.ac.kr
Received July 25, 2019; Revised August 21, 2019; Accepted August 26, 2019.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background:

Edentulism is associated with socioeconomic status, rural residence, and chronic disease, but no studies have investigated edentulism and residence factors together. All information that drives a better understanding of the factors related to edentulism plays an important role in the planning and delivery of appropriate dental services for the elderly by national and oral health professionals. This study was designed to investigate the prevalence of edentulism in adults aged over 60 years in Korea and to examine whether there are differences in dentate status between people living in urban and rural areas after controlling for sociodemographic and other related factors.

Methods:

The data for this study were collected from 2013 to 2015 as part of the Korea National Health and Nutrition Examination Survey VI, those individuals aged over 60 years and who had complete datasets were included (5,071). The number of teeth and residence status were categorized into two groups: edentate and dentate (1 or more); urban and rural. Multiple multivariate logistic regression analyses were sequentially applied to assess the association between dentate status and residence status after adjusting for potential confounders.

Results:

Rural areas, lower household income, and lower education levels were associated with a higher edentate rate. The number of teeth was lower in rural areas than in urban areas. After adjusting for various factors, statistically significant associations were present for women, low household income, low education level, poor perceived health status, and alcohol consumption in participants.

Conclusion:

Elders living in rural areas had poorer oral health than elders living in urban areas. The government will need to provide effective systems for promoting oral health for elders living in rural areas.

Keywords : Aged, Oral health, Residence characteristics
Introduction

Edentulism is the loss of all of one’s natural teeth. It is considered a poor health result for oral health as well as for systemic health and can significantly reduce the quality of life1-3). Many researchers have pointed out that edentulism can have serious negative effects on mental and physical health. In addition, previous studies have reported that tooth loss among patients without teeth is associated with behavioral changes due to lake of self-esteem, disliked appearance, intimate relationships and close relationships and loss of behavior4). Another study found that the greater the number of missing teeth, regardless of age, gender, or education, the more daily life met the reduced behavior5).

The proportion of edentulism is decreasing as health concerns and policies are increasing worldwide. In 1976, 66% of people over 65 years old were dentulous, and in 1995, the prevalence had decreased to 42%6). In the US, edentulism among persons 45∼54 years of age decreased from 20% in 1960∼1962 to approximately 9% in 1988∼1994. In 1999∼2002, the Centers for Disease Control and Prevention (CDC) reported that 8% of US adults 20 years of age and older were completely edentulous7,8). However, a previous study on edentulism showed that the proportion of edentulous adults was reduced across the country, but in rural areas, the proportion of edentulous adults was higher and the rate of decline was slower than that of large cities9). The current oral disease patterns reflect the implementation of plans for improving life conditions, behavioral and environmental factors, oral health systems, and living conditions10). The biggest burden of oral disease is poor people worldwide. People living in rural areas can face many shortcomings associated with edentulousness. Nonmetropolitan populations are expected to be disadvantaged because of their low level of overall education, high poverty rates, high morbidity and mortality rates, and fewer dentists and other oral health professionals11-13). Not surprisingly, many of the rural dwellers have been found to be more condition than urban dwellers14).

Analyzing the causes of loss of teeth by individual case is a complex and multifactorial process involving subjective factors and less important factors, such as cultural factors, sociocultural status, diagnoses, and ethnicity, as well as many objective data, such as tooth decay, periodontal disease, and trauma15). Edentulism is associated with socioeconomic status, rural residence, and chronic disease, but no studies have investigated these factors with edentulism together. All information that leads to better understanding of the factors associated with edentulism plays an important role in the planning and delivery of appropriate dental services for the rural area dwellers by national and oral health professionals16).

Thus, this study was designed to investigate the prevalence of edentulism in adults aged over 60 years in Korea and to examine whether there are differences in dentate status between people living in urban and rural areas after controlling for sociodemographic and other related factors.

Materials and Methods

1. Sampling procedures

The data for this study were collected from 2013 to 2015 as part of the Korea National Health and Nutrition Examination Survey (KNHANES), which is periodically carried out by the Korean Centers for Disease Control and Prevention (KCDC). The sampling protocol included a complex, stratified, multistage, probability-based design with proportional allocation, as well as a cluster survey of a representative sample of the noninstitutionalized civilian population in Korea. The Korean Ministry of Health and Welfare performed the survey. The target population of the survey included all noninstitutionalized civilian Korean individuals aged 1 year or older. The 2005 National Census Registry randomly selected the participants from various geographic areas, ages, and gender groups.

The survey consisted of questions about overall health (household survey, health interview survey, and health behavior survey), a nutrition survey (dietary behavior, dietary supplements, nutrition knowledge, food intake, and food stability), and oral and health examinations (physical measurement, blood and urine tests, blood pressure and pulse measurements, pulmonary function tests, visual acuity and refraction tests, color vision tests, and hearing tests). Face-to-face interviews were performed using a structured questionnaire by trained interviewers. The health interviews and health examinations were conducted by trained medical professionals and interviewers, and the oral examinations were performed by dentists and medical professionals. Before participating in the study, all participants signed an informed consent form.

2. Eligibility and exclusion criteria

Out of the 22,948 subjects who participated in the KNHANES, only those individuals aged over 60 years and who had complete datasets were included in this analysis. The final sample included 5,071 participants (2,194 men and 2,877 women). Detailed descriptions of the sampling methods and survey contents are described in previous studies (Fig. 1)17-19).

Fig. 1.

Overview of the study samples. KNHANES: the Korea National Health and Nutrition Examination Survey.



3. Assessment of the number of teeth and categorization of edentate and dentate

Trained dentists conducted the oral examinations of the participants and recorded their oral health status. Missing teeth, impacted teeth or implants, and third molars were excluded when counting the number of teeth20). The number of teeth was categorized into two groups: edentate (0) and dentate (1 or more).

4. Classification of residence

The residence status was categorized into two groups: urban and rural. An area was classified as ‘urban’ if the population was over 50,000 in the administrative district, and an area was classified as ‘rural’ if the population was less than 50,000 in the administrative district.

5. Assessment of potential confounders

Information on sociodemographic factors, oral health status and behaviors, and general health status and behaviors was collected from the participants’ responses to a standardized questionnaire through personal interviews. Participants were categorized into three age groups: 60∼69, 70∼79, and 80 years and over. Household income was the family income adjusted for the number of family members. It was categorized into quartiles: less than 25%, 25∼50%, 50∼75% and over 75%. The highest diploma earned was used to assess a participant’s education level.

The general health behaviors and status information included hypertension, diabetes mellitus, perceived health status, smoking status, and alcohol consumption. Hypertension was defined as an average systolic blood pressure over 140 mmHg or diastolic blood pressure over 90 mmHg. Diabetes mellitus was defined as a fasting glucose level over 126 mg/dl. Participants were categorized as normal (body mass index [BMI], 18.5 to <25 kg/m2), underweight (BMI <18.5 kg/m2), or obese (BMI ≥25.0 kg/m2)21). The self-reported perceived health status was divided into three categories: good, ordinary, and poor. Regarding smoking status and alcohol consumption, the subjects were divided into two groups: yes and no.

6. Statistical analysis

The integrated weights were calculated and applied when integrating data for each year from 2013 to 2015. All analytical procedures were performed in accordance with the Guidelines for the Use of KNHANES22).

In the analysis, the outcome variable was dentate status, and the main explanatory variable was residence status. Statistically significant differences in the characteristics of participants’ dentate status were examined using frequency chi-square tests. All data are presented as weighted percentages and standard errors.

Multiple multivariate logistic regression analyses were sequentially applied to assess the association between dentate status and residence status after adjusting for potential confounders. A multivariate logistic regression was used to compute unadjusted and adjusted odds ratios (AORs) and confidence intervals (CIs). The AORs, CIs, and trend p-values for multicategory variables were used. Subgroup analyses by age and gender were also performed to identify risk groups. All statistical analyses were performed using IBM SPSS Statistics for Windows/ Macintosh, ver. 21.0 (IBM Corp., Armonk, NY, USA). Statistical significance was set at a value of p<0.05.

Results

Of the 5,071 participants, the prevalence of edentulism was estimated to be 14.9%. Tables 1 and 2 show the characteristics of the study participants according to the results of dentate status and residence status. As participants get older, the proportion of edentulism increases. Rural areas, lower household income, and lower education levels were associated with a higher edentate rate (rural residence: 34.5%, household income <25%: 56.0%, and primary school education level: 71.1%; data was now shown). The edentate rate was high when the perceived health status was poor (8.5%) and when participants smoked (8.5%; p<0.05). Table 2 shows the number of teeth according to the residence area. Overall, the number of teeth was lower in rural areas than in urban areas. The lower the income level, the lower the education level, and as age increased, the number of teeth was lower in rural areas than in urban areas. When the subjective health status was poor and when the participants smoked and consumed alcohol, the number of teeth was lower in rural areas than in urban areas.

Characteristics of the Participants according to Dentate Status (n=5,071)

 VariableTotalEdentate (n=340)Dentate (n=4,731)p-valueb


n% (95% CI)an% (95% CI)a
Age (y)<0.001
 60~692,642762.7 (2.1~3.5)2,56697.3 (96.5~97.9)
 70~791,9601678.9 (7.4~10.6)1,79391.1 (89.4~92.6)
 80 and over4699718.8 (15.3~22.9)37281.2 (77.1~84.7)
Gender0.132
 Men2,1941707.2 (6.1~8.5)2,02492.8 (91.5~93.9)
 Women2,8771706.0 (5.0~7.1)2,70794.0 (92.9~95.0)
Residence<0.001
 Urban3,7742065.6 (4.8~6.6)3,56894.4 (93.4~95.2)
 Rural1,2971349.3 (7.6~11.2)1,16390.7 (88.8~92.4)
Household income (%)c<0.001
 <252,0491999.2 (7.8~11.0)1,85090.8 (89.0~92.2)
 25~501,415765.5 (4.3~7.0)1,33994.5 (93.0~95.7)
 50~75919444.8 (3.4~6.7)87595.2 (93.3~96.6)
 >75688213.2 (2.0~4.9)66796.8 (95.1~98.0)
Education level<0.001
 Primary school2,8742428.2 (7.0~9.5)2,63291.8 (90.5~93.0)
 Middle school748314.8 (3.2~7.0)71795.2 (93.0~96.8)
 High school945514.9 (3.5~6.6)89495.1 (93.4~96.5)
 University or college504162.7 (1.6~4.6)48897.3 (95.4~98.4)
Perceived health status0.003
 Good1,153675.1 (3.9~6.6)1,08694.9 (93.4~96.1)
 Ordinary2,4221506.0 (4.9~7.2)2,27294.0 (92.8~95.1)
 Poor1,4961238.5 (7.0~10.4)1,37391.5 (89.6~93.0)
Smoking<0.001
 No3,0941605.2 (4.3~6.3)2,93494.8 (93.7~95.7)
 Yes1,9771808.5 (7.2~9.9)1,79791.5 (90.1~92.8)
Alcohol consumption0.001
 No1,2161058.9 (7.1~11.1)1,11191.1 (88.9~92.9)
 Yes3,8552355.8 (5.0~6.6)3,62094.2 (93.4~95.0)
Hypertension0.805
 No2,5191686.4 (5.4~7.6)2,35193.6 (92.4~94.6)
 Yes2,5521726.6 (5.6~7.8)2,38093.4 (92.2~94.4)
Diabetes mellitus0.299
 No4,0562626.3 (5.5~7.3)3,79493.7 (92.7~94.5)
 Yes1,015787.3 (5.7~9.4)93792.7 (90.6~94.3)

aWeighted percent, 95% confidence interval (CI).

bp-value obtained from chi-square test.

cMonthly average household income (√: the number of household members).


Number of Teeth Present in a Population Aged 60 Years and Older according to Residence, by Variable (n=5,071)

 VariableUrban (n=3,774)Rural (n=1,297)p-value


Mean teeth present(95% CI)Mean teeth present(95% CI)
Age (y)
 60~6920.5420.00~21.0820.1119.25~20.970.08
 70~7917.07a16.39~17.7614.8513.83~15.87<0.001
 80 and over13.06a11.80~14.3110.288.49~12.060.301
Gender
 Men16.9716.18~17.7616.0514.99~17.090.025
 Women16.8116.04~17.5714.1212.91~15.32<0.001
Household income (%)b
 <2515.86a15.11~16.6214.6913.54~15.850.12
 25~5016.76a15.95~17.5714.5813.20~15.950.14
 50~7516.88a16.04~17.7315.6514.33~16.970.24
 >7518.0417.23~18.8615.3813.37~17.400.01
Education level
 Primary school15.8015.10~16.5013.4512.41~14.49<0.001
 Middle school16.2315.30~17.1615.1113.59~16.640.29
 High school16.9416.14~17.7415.4013.75~17.060.39
 University or college18.5817.70~19.4716.3414.64~18.040.45
Perceived health status
 Good17.3216.54~18.1015.1713.99~16.350.03
 Ordinary16.7816.09~17.4715.2514.11~16.40<0.001
 Poor16.5615.77~17.3614.8113.55~16.060.08
Smoking
 No18.1817.45~18.9216.8215.80~17.850.08
 Yes15.59a14.82~16.3713.3312.06~14.60<0.001
Alcohol consumption
 No17.2416.69~17.7815.6514.69~16.62<0.001
 Yes16.5415.69~17.3914.5013.29~15.710.06
Hypertension
 No16.5415.84~17.2514.5413.42~15.650.12
 Yes17.23a16.60~17.8715.6214.59~16.64<0.001
Diabetes mellitus
 No17.4316.83~18.0215.4614.56~16.340.47
 Yes16.35a15.54~17.1614.7013.30~16.10<0.001

Mean number of existing teeth, 95% confidence interval (CI), and p-value obtained from chi-square test.

The data were analyzed by the complex samples general linear model.

aStatistical significance test with, age: 60~69, gender: men, household income: >75%, education level: university, smoking, alcohol, hypertension, diabetes mellitus: no, perceived health status: good, at p<0.05.

bMonthly average household income (√: the number of household members).



Compared with urban areas, the odds ratios for becoming edentulous when living in rural areas are shown in Table 3. Based on the results in Table 3, after adjusting for sociodemographic factors and general health and behavior status factors, statistically significant associations were present for women (AOR=2.1, 95% CI=1.42∼3.09), low household income (AOR=1.5, 95% CI=1.02∼2.20 for <25%, AOR=1.71, 95% CI=1.01∼2.89 for 25∼50%), low education level (AOR=1.81, 95% CI=1.30∼2.52 for primary school), poor perceived health status (AOR=1.78, 95% CI=1.56∼2.73 for ordinary, AOR=1.58, 95% CI= 1.01∼2.46 for poor), and alcohol consumption (AOR= 1.72, 95% CI=0.27∼2.33) in participants.

Sociodemographic Characteristic Associated with Edentulism and Residence Status (Reference=Urban Area)

 VariableAdjusted odds ratio95% confidence intervalp-value

Rural
Age (y)
 60~691.170.69~1.970.562
 70~791.761.19~2.600.004
 80 and over1.350.80~2.280.256
Gender
 Men1.370.95~1.960.091
 Women2.101.42~3.09<0.001
Household income (%)
 <251.501.02~2.200.038
 25~501.711.01~2.890.047
 50~751.040.48~2.270.914
 >752.660.95~7.420.062
Education level
 Primary school1.811.30~2.520.001
 Middle school0.520.20~1.330.172
 High school1.220.57~2.610.822
 ≥University or college1.440.23~6.920.701
Perceived health status
 Good1.690.95~3.000.072
 Ordinary1.781.56~2.730.009
 Poor1.581.01~2.460.043
Smoking
 No2.121.24~3.18<0.001
 Yes1.400.97~2.010.071
Alcohol consumption
 No1.640.99~2.700.051
 Yes1.720.27~2.330.001
Hypertension
 No1.641.15~2.330.006
 Yes1.791.21~2.660.004
Diabetes mellitus
 No1.330.71~2.610.345
 Yes1.871.35~2.50<0.001

Models were adjusted for age, gender, household income, education, perceived health status, smoking, alcohol consumption, hypertension, and diabetes mellitus except the stratum.

Determined by multivariate logistic regression.


Discussion

Health inequalities mean differences, diversity and disparities in health outcomes between individuals and groups10). This health imbalance is an inevitable and unfair demographic health difference in terms of social justice, ethics and human rights23). While oral health has improved significantly over the past few decades, the social gradient of oral health stands out in the prevention and treatment of disease, and inequality still remains24). The greatest burden of oral disease worldwide appears in disadvantaged and poor populations25). There are significant differences in oral health service distribution, utilization and outcomes between developing and developed countries and urban and rural areas26,27). Thus, the results of this study show clear and distinct social gradient in clinical and subjective oral health indicators based on residence status after adjusting for age, gender, household income, education level, smoking status, alcohol consumption, hypertension, and diabetes mellitus. There are no reports on oral health behavior and the lack of social epidemiological data on oral disease in urban and rural areas. To the best of our knowledge, this study provides the first evidence to compare oral health status among urban and rural dwellers from a Korean population using a nationally representative data sample.

The reported prevalence of edentulism currently varies from country to country, ranging from 6% to 78% of the population28). According to the results of this study, 14.9% of elders over 60 years of age were edentate, which is a lower figure than that of a Spanish population survey (20.7%)16) but higher than that of Chinese national data (8.64%)29). Many studies have identified a strong association between demographic and socioeconomic factors and edentulism30-32). The study also found age, residence area, education and economic level to be related to edentulism. The association between aging and increased tooth loss has been clearly demonstrated by previous studies. Our results agreed with this finding: as age increased, the proportion of edentate participants decreased significantly. As with other studies31,33), high economic status and education level are inversely related to the likelihood of tooth loss. In this study, the proportion of edentulous people was higher when the residence area was rural, the economic level was low, and the education level was low. This can be explained by the lack of oral health knowledge and behavior as well as lack of access of these groups to dentistry. There was an important association between residence status and oral status, which may be partly due to the relative difficulty of rural residents in accessing dental care. Many systemic diseases have been reported to be associated with tooth loss34-36); our study showed similar results as previous studies. Several previous studies have shown that smokers lose more teeth than nonsmokers due to the adverse effects of tobacco on oral health and dental caries32,33). Our study also showed results consistent with previous studies. There was a significant increase in edentulous elders in the group that smoked compared to the group that did not smoke.

After adjusting for well-known potential confounders in the fully adjusted model, it showed a dose effect trend. In rural areas, when the prevalence odds ratio of edentulism is analyzed by socioeconomic status by adjusting all variables compared with urban areas, the odds ratios are more than twice as high for women. When the household income and education levels are low and when participants smoke and consume alcohol, a high prevalence odds ratio of edentulism is seen. These our knowledge, no other study results have been reported results similar to our results, so it is difficult to compare to this study. However, this edentulism prevalence odds ratio seems to be high because the elders in rural areas are vulnerable to various socioeconomic conditions.

Tooth loss is thought to be an early marker of decline and weakness37). Edentulism is independently associated with the onset of physical disability38). Complete tooth loss is associated with slower walking speeds and physical and cognitive decline in a previous study37). As a result, functional decline can cause difficulties in performing oral hygiene practices and using dental services; thus, the elderly may be at risk of dental disease and tooth loss. In addition, a decline in masticatory function due to a large amount of tooth loss can lead to poor nutrition, which can lead to systemic diseases such as diabetes, cardiovascular diseases and dementia39). It is extremely important to encourage preventive oral health services for elderly living in rural areas where health services are not available. Implementing appropriate dental services and national programs for these older people will help reduce edentulism. This is especially important in rural and remote areas to which dental professionals have limited access.

Some limitations should be considered when interpreting our findings. First, due to the restriction of the cross-sectional design, the causality of the association between oral health status and dwelling status is unclear. Second, among the survey methods used in this study, the questionnaire method was used, and the risk of recall bias could have occurred because the participants could have experienced memory errors.

Nevertheless, this study has several strengths. A large-scale nationally representative sample of the Korean population was used in this study. Moreover, the quality evaluation of all steps (data collection, data processing, survey administration, and laboratory analysis) of this sample was performed by the KCDC22). In addition, a trained dentist assessed periodontal and oral health status, and a professional examiner conducted and documented all general health screenings. In addition, it was uncertain whether socioeconomic status would affect oral health status. To overcome this limitation, we analyzed various adjustments in the logistic regression model. The current study results provide evidence for an association between residential area and socioeconomic status and oral health status in Korean elders.

This study was conducted to provide information on the oral health of urban and rural populations, and the results will help plan and evaluate the national oral health program. Elders living in rural areas had poorer oral health than elders living in urban areas. As a result, the government will need to provide effective systems for promoting oral health for elders living in rural areas. It will also be important to include oral care items in the various existing health services of each country. Of course, new precautionary policies for elders in rural areas are also important, but it government include oral care in existing health services, it will get good results. In addition, rural areas, where dental visit are not easy to visit, will need to visit health centers to promote health center-linked programs and make efforts for more effective oral care by expanding on-site oral health care programs.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Ethical approval

The sixth KNHANES was a cross-sectional survey conducted by the Korea Center for Disease Control and Prevention (KCDCP) from 2012 to 2015. The KNHANES was approved by the KCDC Institutional Review Board (2013-07CON-03-4C, 2013-12EXP-03-5C, and 2015-01-02-6C).

Acknowledgements

We acknowledge the Korea Centers for Disease Control and Prevention (KCDCP) which provided data of the sixth Korea National Health and Nutrition Examination Survey (KNHANES IV) from 2012-2015 to be used in this study.

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