Self-Rated Oral Health Status And Social And Health Determinants Among 35-65 Year-Old Persons In One Region In Myanmar: A Cross-Sectional Study

Background

“Oral diseases are major public health problems worldwide and poor oral health has a profound effect on general health and quality of life.”¹ Generally, there has been an increase in focussing on health care that is patient-centered, and in this context, it is important to include both physical and social dimensions of health as well as oral health or self-rated oral health (SROH) status.¹ One’s SROH status may influence the utilization of dental care, and thus, knowing the determinants of SROH status can help in improving dental health care services.² Studies found that SROH status is significantly related to the oral health status examined clinically.³ There is scarce information on the prevalence and correlates of SROH among community-dwelling adults in Southeast Asian countries, including Myanmar.⁴ For example, in a survey among university students in five Southeast Asian countries, 27.7% of students (in Myanmar 28.8%) reported “to have sometimes, most of the time or always having toothache in the past 12 months”.⁴ The prevalence and correlates of poor or good SROH status depend on their sociocultural context, which may differ in Myanmar compared to countries in other world regions.^1,2

The two most common oral diseases in Myanmar include dental caries and periodontal diseases, and oral cancer has been increasing.⁵ “The high proportion of untreated caries showed lack of people’s awareness regarding oral problems, low utilisation of oral health care services, and unmet needs.⁵

Different national and regional studies on the prevalence of SROH status are described in Table 1, e.g., in Australia 17% “fair”or “poor”,⁶ in Brazil 44.7% “dissatisfied”or “very dissatisfied”,⁷ in Kenya 13.7% “poor” or “very poor”,⁸ in Nigeria 9% “poor’or “very poor”,⁹ in Qatar 5.9% “poor” or “very poor”,¹⁰ in South Africa 23.7% “neither good nor bad” or “poor” or “very poor”,¹¹ in Sweden 3.2% “poor”,¹² in Turkey 65% “poor”,¹³ and in USA 11.9% “poor”.¹⁴ (see Table 1).

Table 1 Studies On The Prevalence Of Self-Rated Oral Health Status

Sociodemographic factors associated with poor SROH status may include younger¹³ or older age,^6,15 male or female sex^6,11,15,16 and low socioeconomic position.^{6,7,11,12,16,17} Oral conditions, such as fewer teeth,¹⁸ bleeding gum, tooth sensitivity, bad breath,¹¹ dental caries,¹⁹ and toothache,^20,21 have been found to increase the odds for poor SROH include. Several general health status factors, such as chronic conditions,¹⁷ overweight,⁴ obesity,²² psychological distress,²³ depression^17,24 and sleep disturbance,²⁵ have also shown to be associated with poor SROH.

Oral health-risk knowledge and behaviour factors for poor SROH include low knowledge or literacy on oral health,^26,27 inadequate tooth cleaning,¹¹ poor oral hygiene behaviours,¹⁵ and no, low or frequent dental attendance.^{7,11,13,17,24,29} Several general health-risk behaviours, such as current smoking,^6,11,17,30 problem drinking,^6,17 poor diets,³⁰ and food avoidance (e.g., fruits and raw vegetables),³¹ have been found associated with poor SROH status.

The study aimed to estimate the prevalence and correlates of SROH status and associated factors in an adult community sample in Myanmar.

Methods

Sample And Procedure

Using a cross-sectional study design, 633 participants aged 35 to 65 years selected through multi-stage cluster random sampling from an “urban area of Magway Township” in 2015 were included in the investigation; more details have been described elsewhere.³²

The questionnaire used was translated from English to Myanmar using standard research procedures and piloted on a sample of 25 adults not forming part of the final sample to check validity and reliability.³² The study was approved the Committee for Research Ethics (Social Sciences), Mahidol University (MU-SSIRB No.: 2016/1421204), which is in full compliance with the ‘International Guidelines of Human Research Protection such as Declaration of Helsinki, The Belmont Report, and CIOMS Guidelines’, and the Committee of University of Community Health (Magway), Myanmar.³²ss

Informed written consent was obtained from all participants prior to the study.

Measures

The questionnaire consisted of socio-demographic data (sex, age, household income and education), oral conditions, general health status, oral health knowledge and behaviour, general health behaviour and SROH status.

SROH was assessed with two questions, 1) “How would you describe the state of your teeth, and 2) gums?” Responses ranged from “1=excellent to 6=very poor”³³ (Cronbach alpha 0.80). “Poor SROH status was classified as having poor or very poor status of teeth and/or gums, and good oral health as having average to excellent status of teeth and/or gums”.³²

Oral Conditions

Loss of teeth was measured with the item, “How many natural teeth do you have? (Response options: 1=no natural teeth, 2=1-9 teeth, 10–19 teeth, and 20 teeth or more)”.³³ “Responses were classified into having 0–19 teeth and 20 or more teeth.”³²

Dentures. “Do you have any removable dentures?” (Yes, No).³³

Having cavities was defined as “1=having one or more cavities and 0=having no cavities,”³² based on the question “How many cavities have you had in your permanent teeth?”³³

Physical symptoms were asked with the question, “Within the previous month, did you experience any of the following common oral conditions? 1) bleeding gums when brushing, 2) teeth sensitive to heat or cold, 3) bad breath, or 4) none.”¹¹

General Self-Reported Health Status

Chronic medical conditions were measured with the variables,

Have you been diagnosed (by a doctor or other health worker) with … ? (Asthma, Arthritis, Diabetes or high blood sugar, High cholesterol/high blood lipids, Heart disease, Stroke, Kidney disease, and Cancer). Responses were classified into 1=having one or more chronic conditions and 0=having none.³²

Body mass index (BMI) based on self-reported weight and height was “classified according to Asian criteria: normal weight (18.5 to <23.0 kg/m²), overweight (23.0 to <25.0 kg/m²) and 25+ kg/m² as obese.”³⁴

The “Patient Health Questionnare-9 (PHQ-9)” was used to assess depression.³⁵

It has demonstrated high sensitivity (0.84) and specificity (0.77) in a validation study in Thailand (culturally similar to Myanmar), using a cut-off score of nine or more as indicative for major depression symptoms. (Cronbach alpha 0.84)^32,36

Sleep problems were defined as moderate, severe or extreme in response to the question,

Overall in the last 30 days, how much of a problem did you have with sleeping, such as falling asleep, waking up frequently during the night, or waking up too early in the morning? Response options ranged from 0=none, 1=mild, 2=moderate, 3=severe, and 4=extreme/cannot do.³⁷

Oral health knowledge was measured with eight items from an oral health knowledge or literacy questionnaire.³⁸ Items asked about prevention of tooth decay, permanent teeth, bleeding after brushing or flossing, management of pain and swelling in the mouth, link between oral health and general health. Response options were heterogeneous multiple-choice formats. Correct responses of the eight oral health knowledge items were summed, with scores from 0 to 3 indicating low and 4–8 high oral health knowledge.

Oral health behaviours were measured with four questions:³³

1) “How often do you clean your teeth?” (Responses: “1=never to 7 twice or more a day”); 2) “Do you use toothpaste containing fluoride?”(“Yes or No”); 3) “How long has it been since you last saw a dentist?” (Responses: “1=less than 6 months to 6=never received dental care”); 4) “Consumption of soft drinks?”(Responses: “1=more than once a day to 6=never”).

General Health Behaviour

Current smokers were defined as daily and/or not daily smokers, based on the question, “Do you currently smoke any tobacco products (such as cigarettes, bidis, cigars, pipes, betel)?”³³

Current smokeless tobacco use was defined as daily and/or not daily, based on the question, “Do you currently use any smokeless tobacco products (such as snuff or chewing tobacco)?”³³

Problem drinking was measured with the “Alcohol Use Disorder Identification Test (AUDIT)-C”.³⁹ (Cronbach alpha 0.86).

Fruit and vegetable consumption were assessed with the questions,

How many servings of fruit do you eat on a typical day? [One standard serving = 80 grams, or 6–8 pieces of ripe papaya, water melon or pineapple, 1 banana, 1 tangerine, 4 rambutans, 1/2 cup of no-added-sugar processed fruit, 1/2 cup of canned fruit or 1/2 cup of 100% fruit juice]

and

How many servings of vegetables do you eat on a typical day. [One standard serving = 80 grams or 1/2 cup of cooked leafy vegetables, 1 cup of raw green leafy vegetables, 1/2 cup of tomato, carrot, pumpkin, cabbage, beans or white onion, or 1/2 cup of 100% vegetable juice]

Less than five servings a day was defined as insufficient.^33,40

Breakfast consumption was measured with the variable, “How often do you eat breakfast?” Response options were 1=Almost every day, 2=sometimes, 3=rarely or never. Less than “almost every day” was defined as skipping breakfast.

Statistical Analysis

All statistical analyses were conducted with “IBM SPSS (version 24.0) (Chicago, IL, USA)”. Logistic regression analysis was applied to estimate the association between socio-demographic variables, oral conditions, general health status, oral health knowledge and behaviour, general health behaviour and poor SROH. The selection of the determinants of SROH was based on literature review.^{4,6,7,11–13,15–25} To avoid Type 1 error p was set at <0.01 as significant in the multivariable model. “Variance inflation factor (VIF) and tolerance values” found that multicollinearity was not a cause of concern in the multivariable analysis.

Results

Sample Characteristics And Bivariate Analysis Between Individual Risk Factors And Poor SROH

The study sample consisted of 633 adults aged 35 to 65 years (mean age =45.0 years, SD=8.6), and 55.0% were male and 45.0% women. The study response rate was 98% of the 646 targeted household participants, 13 had declined the interview.

The proportion of participants who had 0–19 natural teeth was 11.1%, one or more cavity 48.2%, removable dentures 4.6%, experienced pain in the teeth or mouth 27.2%, bleeding gums when brushing 13.6%, and had teeth sensitive to heat or cold 17.5%. Almost one in five (17.9%) of the respondents had one or more chronic conditions, 27.2% overweight or obesity, 3.9% depressive symptoms, and 11.2% sleep problems.

In relation to oral health knowledge and behaviour, 52.3% scored 4–8 (high) on oral health knowledge, 58.0% cleaned their teeth ≥twice per day, 84.2% had used “toothpaste with fluoride”, 42.2% had soft drinks ≥once per day and 12.3% had consulted a dentist in the past 12 months. Overall, 13.6% of participants reported poor SROH, and 78.5% average or poor SROH.

In bivariate analysis, having oral conditions (tooth loss, cavities, dentures, pain in teeth or mouth, bleeding gums, and teeth that are sensitive to heat or cold), poorer general health status (having chronic conditions, short and/or long sleep), better oral health knowledge, poorer tooth cleaning habits, dental care attendance, general health-risk behaviour (smokeless tobacco use, and skipping breakfast) and lower education were associated with poor SROH (see Table 2).

Table 2 Sample Characteristics And Bivariate Analysis Between Individual Risk Factors And Self-Rated Poor Oral Health

Descriptives Of Oral Health Status By Gender And Age Group

Overall, 29.1% of participants rated the state of their teeth as good, very good or excellent, 58.0% as average, and 12.9% as poor or very poor, likewise, 34.9% of participants rated the state of their gums as good, very good or excellent, 56.9% as average, and 7.1% as poor or very poor. Women rated the state of their teeth and gums better than men did, and the older age group (50–65 years) rated the state of their teeth better than the younger age group (35–49 years) (see Table 3).

Table 3 Descriptives Of Oral Health Status By Gender And Age Group

Associations With Poor Self-Rated Oral Health

In adjusted logistic regression analysis, oral conditions (tooth loss, cavities, bleeding gums, and teeth that are sensitive to heat or cold), better oral health knowledge, dental care attendance, and skipping breakfast were associated with poor SROH (see Table 4).

Table 4 Associations With Poor Self-Rated Oral Health Status Determined By Multivariable Logistic Regression

Discussion

High reports of poor (13.6%) and average or poor (78.5%) SROH were found in this study, which seem to be higher than in several previous studies in different countries.^6,8–12 The high prevalence of poor or average SROH in this study may be an indication of a high burden of oral health problems and unmet treatment need in this population in Myanmar.⁵ This survey discovered that some proportion of participants (6.5%) avoided visiting a dental care professional because of the costs in the past 12 months, despite having poorer SROH than those who did not avoid (P=0.037) (analysis not shown). Considering that most participants (59.5%) consulted a private dental practice rather than a government dental clinic (22.3%) in their last dental visit (analysis not shown), there should be consideration to make public dental health care services more accessible. Another possible reason for avoiding dental care is dental anxiety.^41,42

In contrast to previous studies,^6,13,15–17 this study did not find an association between sociodemographic risk factors and poor SROH. It is possible that such differences were not found because this urban study population was similar in terms of educational level and economic indicators. Consistent with previous studies,^11,18–22 this study found that having various oral conditions (tooth loss, cavities, bleeding gums, and teeth that are sensitive to heat or cold), increased the risk for poor SROH. In bivariate analysis, this investigation found an association between having chronic conditions and poor SROH. This result was also identified in some previous investigations.^20,28

While some previous investigations^26,27 found a negative relationship between oral health knowledge and poor SROH, this study found a positive relationship. “It is possible that in the epidemiological transition from infectious to non-communicable disease,”³² residents in urban areas are more likely to adopt lifestyle changes, including poor oral health practices, such as a diet high in free sugars, tobacco use and poor oral hygiene, which in turn can negatively affect the oral health status.³² In bivariate analysis, poor tooth cleaning practices were associated with poor SROH. Inadequate tooth brushing and poor oral hygiene practices have also been found related to poor SROH in previous studies.^11,15 Previous studies found a mixed results in relation to low or high dental attendance and poor SROH status,^{7,11,13,17,24,28,29} while this study, in agreement with some studies,^17,24,29 found a strong positive relationship between dental attendance and poor SROH status. The possible reason for the correlation between dental attendance and poor SROH status, may be related to the fact that the majority (91.9%) among those who had seen a dentist did consult because of “pain or trouble with teeth, gums and mouth and only 8.1% had gone for a preventative check-up (analysis not shown)”.³²

A number of studies^6,11,17,30 found an association between smoking and poor SROH, while in this study only in bivariate analysis an association between current smokeless tobacco use and poor SROH was found. Some studies^30,31 found an association between poor dietary behaviour and poor SROH, while this study found a strong association between skipping breakfast and poor SROH. A previous study found a clustering pattern of oral and general health-risk behaviours, e.g., current smoking, less frequent tooth brushing, skipping breakfast, current alcohol use, high intake of sugar and no dental visits.⁴³

Study Limitations

The study design was limited to the cross-sectional nature, the small geographic location (three wards in one district), and the use of only self-reported measures. For example, self-reported cavities may underestimate “the prevalence of dental caries by 9.3% in comparison to clinical evaluations but is valid for population-based health surveys with the aim of planning and monitoring oral health actions.”⁴⁴ In investigations in the future oral examinations should be conducted, in addition to self-reported measures.

Conclusion

A high proportion of poor or average SROH status was found and several risk factors (various oral conditions, oral health knowledge, dental care attendance, and skipping breakfast) were identified that can help in guiding oral health care programming in Myanmar.