10.59987/ads/2014.4.131-135
Aims. Teeth loss represents a major concern for the global oral health status of a population. The aim of this study was to describe the prevalence of teeth extraction among the Italian adult population, analyzing the association between teeth extraction in the last 12 months and sociodemographic characteristics.
Methods. This cross-sectional study is based on the national survey ‘Health Conditions and Healthcare Services Use’, carried out by the Italian National Centre of Statistics (ISTAT) in 2005. A univariate analysis was performed to investigate the association between the dependent and the independent variables (teeth extraction Vs socio-demographic characteristics). Multiple logistic regression analysis was conducted to assess the influence on the outcome (teeth extraction Yes/No).
Results. The present study highlights the relationship between teeth extraction and socio-demographic factors. Out of 128,040 individuals, the sampled population consisted of 124,677 subjects, representing 56,400,323 individuals in the Italian population. The prevalence of teeth extraction in the last 12 months was 8.2%. Subjects who underwent teeth extraction in the last 12 months were prevalent female (8.6%), smokers (10.4%), with a primary education (9.2%), married (9.2%), in poor health conditions (9.3%), age category of 55-64 years (11.1%), from Northeast of Italy (8.5%), with scarce household income (8.4%). The multivariate analysis confirmed most of the results of the univariate analysis.
Conclusions. Inequalities in health among groups of various socioeconomic status constitute one of the main challenges for public health; these inequalities might be reduced by improving educational opportunities, income distribution, healthrelated behaviour, or accessibility to health care.
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Annali di stomatologia
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Socio-demographic inequalities and teeth extraction in the last 12 months in Italy
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E. Barbato 
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Socio-demographic inequalities and teeth extraction in the last 12 months in Italy
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                                                                                                   Original article



    Socio-demographic inequalities and teeth extraction
    in the last 12 months in Italy




                                                                                                     i
                                                                                                   al
                                                                                                on
    Giuseppe La Torre, MD, MSC, DSC, MPH1                     The prevalence of teeth extraction in the last 12
    Umberto Romeo, MD, PHD2                                   months was 8.2%. Subjects who underwent teeth
    Gianluca Iarocci, MSC3                                    extraction in the last 12 months were prevalent fe-
    Orlando Brugnoletti, MD, DDS2                             male (8.6%), smokers (10.4%), with a primary edu-
    Leda Semyonov, MD1                                        cation (9.2%), married (9.2%), in poor health con-




                                                                                        zi
    Alexandros Galanakis, MD2                                 ditions (9.3%), age category of 55-64 years
    Ersilia Barbato, DDS, PHD2                                (11.1%), from Northeast of Italy (8.5%), with
                                                              scarce household income (8.4%). The multivariate




                                                                           na
                                                              analysis confirmed most of the results of the uni-
    1 Department of Public Health and Infectious Dis-         variate analysis.
      eases, “Sapienza” University of Rome, Italy             Conclusions. Inequalities in health among groups
    2 Department of Oral and Maxillo-Facial Sciences,         of various socioeconomic status constitute one




                                                                er
      “Sapienza” University of Rome, Italy                    of the main challenges for public health; these in-
    3 Istituto Superiore per la Protezione e la Ricerca Am-   equalities might be reduced by improving educa-
      bientale (ISPRA), Rome, Italy                           tional opportunities, income distribution, health-
                                                              related behaviour, or accessibility to health care.



                                                        t
    Corresponding author:
    Leda Semyonov, MD
                                                     In       Key words: socio-demographic factors, inequali-
                                                              ties, teeth extraction, health, Italy.
    Department of Public Health and Infectious Diseases
    “Sapienza” - University of Rome
    Piazzale Aldo Moro 5                                      Introduction
                                                  ni
    00185 Rome, Italy
    Phone: +390649694308                                      In recent years, much attention has been focused on
    Fax: +390649914562                                        oral health and teeth extraction worldwide (1).
                                    io

    E-mail: leda.semyonov@uniroma1.it                         In the past decades a limited number of epidemiologic
                                                              investigations have been conducted to determine the
                                                              reasons for the extraction of permanent teeth. In Italy
    Summary                                                   the progress of dental caries and their complications
                           iz



                                                              are the leading reason for extraction of permanent
    Aims. Teeth loss represents a major concern for           teeth with an estimated overall prevalence accounting
    the global oral health status of a population.            for 34.4% of the teeth lost, with periodontal problems
          Ed




    The aim of this study was to describe the preva-          being the next most common reason. Moreover the
    lence of teeth extraction among the Italian adult         mean number of extracted teeth increases with the
    population, analyzing the association between             age (2). It is indubitable that teeth loss represent a
    teeth extraction in the last 12 months and socio-         major concern for the global oral health status of a
    demographic characteristics.                              population. The need and efficacy for health policies
    Methods. This cross-sectional study is based on           are verified through epidemiological studies (3, 4).
IC




    the national survey ‘Health Conditions and                So it is also for oral health policies. To achieve sus-
    Healthcare Services Use’, carried out by the Ital-        tainable oral health improvements and reduce oral
    ian National Centre of Statistics (ISTAT) in 2005.        health inequalities, both between and within coun-
    A univariate analysis was performed to investigate        tries, reliable analyses on the population oral health
C




    the association between the dependent and the in-         status are required.
    dependent variables (teeth extraction Vs socio-de-        Oral care in Italy is mostly provided by private practi-
    mographic characteristics). Multiple logistic re-         tioners (90% of the care performances); public oral
    gression analysis was conducted to assess the in-         care is mainly addressed to children and lower so-
©




    fluence on the outcome (teeth extraction Yes/No).         cioeconomic status population.
    Results. The present study highlights the relation-       Specific programs are also active to prevent oral neo-
    ship between teeth extraction and socio-demo-             plasm and to treat subjects with systemic pathologies
    graphic factors. Out of 128,040 individuals, the          that involve the oral cavity. Risk groups and programs
    sampled population consisted of 124,677 sub-              vary from region to region (5).
    jects, representing 56,400,323 individuals in the         In Italy a great number of data for epidemiological
    Italian population.                                       studies is available thanks to the periodic activity

    Annali di Stomatologia 2014; V (4): 131-135                                                                   131
    G. La Torre et al.


    (every 10 years) of National Institute of Statistics (IS-   Age groups were classified as follows: 15-24 years;
    TAT). Nevertheless, to date, no analysis of disparities     25-34 years; 35-44 years; 45-54 years; 55-64 years;
    in dental health and access to care in Italian popula-      65 years and older.
    tion has been published, even if scientific literature      Educational level was described as follows: university
    reports some studies on oral health conditions for          degree (reference group), upper secondary education,




                                                                                                          i
    smaller samples or specific age-groups (6-9).               lower secondary education and primary education.




                                                                                                        al
    The aim of this study was to describe the prevalence        Italian macro-regions of residence [north-west, north-
    of teeth extraction in a sample representative of the       east, centre, south (reference group), isles] were in-
    Italian adult population, with particular reference to      cluded because of the socio-economic differences




                                                                                                     on
    the association between this oral health indicator and      existing between different regions (5).
    socio-demographic factors, such as gender, age,             Concerning occupational status, the individuals were
    economical status.                                          classified as employed, unemployed or in search of
                                                                first occupation, housewives or students, other, fol-
                                                                lowing the ISTAT classification.




                                                                                           zi
    Materials and methods                                       Marital status was categorized as married, single/se-
                                                                parated/divorced (reference group), widow.
    Data source and study design                                Self assessed household income was classified as




                                                                             na
                                                                good and no good, as well as the self-assessed
    This study is based on the national survey ‘Health          health status (good and no good) (good as reference
    Conditions and Healthcare Services Use’, carried out        group).
    by the Italian National Centre of Statistics (ISTAT) in




                                                                  er
    2005 (10). The use of these data is justified, since
    this is the last available survey in Italy. A cross-sec-    Statistical analyses
    tional study was performed according to the STOBE
    checklist (11) as the exposure status (socio-economic       A univariate analysis was performed using the Chi-
    status, demographic characteristics, health status)


                                                          t     square test for qualitative variables, to investigate the
    and the outcome measure (teeth extraction) were
    measured simultaneously.
                                                       In       association between the dependent and the indepen-
                                                                dent variables (teeth extraction Vs socio-demograph-
    For the ISTAT survey, a questionnaire was adminis-          ic characteristics). To check the normality of the sam-
    tered every 3 months (March, June, September, De-           ple, Kolmogorov-Smirnov goodness-of-fit test was
    cember 2005) in order to avoid the seasonal effects         used; T-student test was used for normal distribu-
                                           ni
    as far as possible. The validity of the questionnaire is    tions, otherwise Mann-Whitney test was applied.
    witnessed by several surveys on this issue, carried         Multiple logistic regression analysis was conducted to
    out since the 1990’s. One-quarter of the sampled            assess the influence on the outcome (teeth extraction
                                 io

    population was interviewed each trimester: 50,474           Yes/No). Only the covariates, including potentially
    families and 128,040 individuals, resident in 1465          confounders, which were p<0.25 at the univariate
    municipalities.                                             analysis were selected. The goodness of fit of the re-
    A multi-stages municipalities families was chosen as        gression model was assessed using the Hosmer and
                         iz



    sample design and a stratification of municipalities        Lemeshow test.
    was undertaken. For each municipality, a cluster            The reference groups taken into account were: males
    sampling was conducted with the families of the clus-       (gender); non-smokers (smoking habit); 15-24 years
          Ed




    ters; the minimum number of families for each munici-       (age); university degree (educational level); resi-
    pality was 30.                                              dence in Southern Italy (macro-region of residence);
    The sample population of this study was extracted           unemployed (occupational status); single (marital sta-
    from the original ISTAT survey considering all individ-     tus), no good health status (self-assessed health sta-
    uals aged 15 years and older.                               tus); and no good household income (self-assessed
                                                                household income).
IC




                                                                Results are presented as odds ratios (OR) and 95%
    Measurement of dependent and independent vari-              confidence intervals (95% CI).
    ables                                                       The level of statistical significance was set at P≤0.05.
                                                                All statistical analyses were performed using Statisti-
C




    Information regarding socio-demographic characteris-        cal Package for the Social Sciences Version 19.0
    tics were collected (as it is shown in Tab. 1). The pre-    (SPSS Inc., Chicago, IL., USA).
    sent study analyzed the association between teeth
    extraction in the last 12 months (as the dependent
                                                                Results
©




    variable) and gender, smoking habit, age, educational
    level, Italian macro-region of residence, marital sta-
    tus, occupational status, self-assessed health status       Out of 128,040 individuals, the sampled population
    and self-assessed household income (as the inde-            consisted of 124,677 subjects, representing 56,400,323
    pendent variables).                                         individuals in the Italian population.
    Smoking habits were classified as smokers (refer-           The prevalence of teeth extraction in the last 12 months
    ence group) and non smokers.                                was 8.2%.

    132                                                                           Annali di Stomatologia 2014; V (4): 131-135
    Inequalities and teeth extraction in Italy


    The univariate analysis (Tab. 1) revealed significant                age category of 55–64 years appears to have twice
    differences. In this population, subjects who under-                 the risk (OR=2,05; 95% CI: 2,04 - 2,06). Concerning
    went teeth extraction in the last 12 months were                     marital status, married people shows the highest risk
    prevalent female (8.6%), smokers (10.4%), with a                     of teeth extraction (OR=1,23; 95% CI: 1,23 - 1,24).
    primary education (9.2%), married people (9.2%), in                  Furthermore, when analyzing smoking habits,




                                                                                                                i
    poor health conditions (9.3%). The age group with                    emerges that not smoking is a protective factor




                                                                                                              al
    the highest prevalence of teeth extraction was the                   (OR=0,68; 95% CI: 0,68 - 0,68), as well as not be un-
    age category of 55-64 years (11.1%) prevalently liv-                 employed (employed, housewife or student and other
    ing in Northeast of Italy (8.5%), with scarce house-                 working status conditions).




                                                                                                           on
    hold income (8.4%) and other working status condi-                   Finally, multivariate analysis, unlike the univariate
    tion (9.3%).                                                         one, also revealed that people who have no good
    Using multiple logistic regression model (Tab. 2), the               household income is less prone to undergo a teeth
    relationship between the same socio-demographic                      extraction in the last 12 months (OR=0,99; 95% CI:
    variables and the outcome (teeth extraction) has                     0,98 - 0,99).




                                                                                                   zi
    been examined. The multivariate analysis confirmed
    most of the results showed by the univariate analysis.
    Females (OR=1,20; 95% CI: 1,19 - 1,20), people with                  Discussion




                                                                                      na
    a lower secondary education (OR=1,19; 95% CI: 1,19
    - 1,20), living in Northern-east macro-region of Italy               The present study highlights the relationship between
    and Isles (both OR=1,09; 95% CI: 1,08 - 1,09), in                    teeth extraction in the last 12 months related to socio-
    poor health conditions (OR=1,04; 95% CI: 1,03 -                      demographic factors in Italy, using a large database




                                                                              er
    1,04) seem to have an increased risk of having a                     coming from the last available survey conducted at the
    teeth extraction in the last 12 months. In addition, the             national level. Our aim was concerning the assessment

    Table 1. Univariate analysis.



                                                                   t
                                                                In                    Teeth Extraction in the last 12 months
                                                                                     No (%)                             Yes (%)
    Gender                                        Male                               92.2                               7.8
                                                  Female                             91.4                               8.6
                                                  ni
    Smoking habit                                 Smokers                            89.6                               10.4
                                                  Non smokers                        92.4                               7.6
    Age                                           15-24 years                        95.2                               4.8
                                    io

                                                  25-34 years                        92.9                               7.1
                                                  35-44 years                        92.1                               7.9
                                                  45-54 years                        90.8                               9.2
                                                  55-64 years                        88.9                               11.1
                           iz



                                                  ≥ 65 years                         89.0                               11.0
    Educational level                             University degree                  92.8                               7.2
                                                  Upper secondary education          92.5                               7.5
            Ed




                                                  Lower secondary education          91.8                               8.2
                                                  Primary education                  90.8                               9.2
    Macroregion of residence                      North-west                         91.7                               8.3
                                                  North-east                         91.5                               8.5
                                                  Centre                             91.6                               8.4
                                                  South                              92.4                               7.6
IC




                                                  Isles                              91.7                               8.3
    Working status                                Employed                           91.8                               8.2
                                                  Unemployed                         92.4                               7.6
                                                  Housewife or student               92.5                               7.5
C




                                                  Other condition                    90.7                               9.3
    Marital status                                Married                            90.8                               9.2
                                                  Single/Separated/Divorced          93.5                               6.5
                                                  Widow                              91.5                               8.5
©




    Household income                              Good                               91.9                               8.1
                                                  No good                            91.6                               8.4
    Health conditions                             Good                               91.9                               8.1
                                                  No good                            90.7                               9.3
    Total                                                                            91.8                               8.2


    Annali di Stomatologia 2014; V (4): 131-135                                                                                133
    G. La Torre et al.


    Table 2. Socio-demographic predictors of Teeth Extraction - Multiple logistic regression model.

    VARIABLES                                                                           OR                95,0% C.I.
                                                                                                      Lower        Upper
    Gender                                  Male (reference)                            1




                                                                                                                i
                                            Female                                      1,20          1,19             1,20




                                                                                                              al
    Smoking habit                           Smokers (reference)                         1
                                            Non smokers                                 0,68          0,68             0,68




                                                                                                           on
    Age                                     15-24 years (reference)                     1
                                            25-34 years                                 1,33          1,32             1,33
                                            35-44 years                                 1,38          1,37             1,38
                                            45-54 years                                 1,61          1,60             1,62
                                            55-64 years                                 2,05          2,04             2,06




                                                                                                 zi
                                            ≥ 65 years                                  1,68          1,67             1,69
    Educational level                       University degree (reference)               1
                                            Upper secondary education                   1,11          1,11             1,12




                                                                                   na
                                            Lower secondary education                   1,19          1,19             1,20
                                            Primary education                           1,17          1,17             1,18
    Macroregion of residence                South (reference)                           1
                                            North-west                                  1,06          1,05             1,06




                                                                        er
                                            North-east                                  1,09          1,08             1,09
                                            Centre                                      1,07          1,07             1,08
                                            Isles                                       1,09          1,08             1,09
    Working status                          Unemployed (reference)                      1
                                            Employed


                                                             t                          0,93          0,93             0,93
                                                          In
                                            Housewife or student
                                            Other condition
                                                                                        0,81
                                                                                        0,92
                                                                                                      0,81
                                                                                                      0,91
                                                                                                                       0,82
                                                                                                                       0,92
    Marital status                          Single (reference)                          1
                                            Married                                     1,23          1,23             1,24
                                            Separated/divorced                          1,12          1,11             1,12
                                            ni
                                            Widow                                       1,04          1,03             1,04
    Household income                        Good (reference)                            1
                                            No good                                     0,99          0,98             0,99
                                   io


    Health conditions                       Good (reference)                            1
                                            No good                                     1,04          1,03             1,04
                         iz



    Constant = 0,048


    of socioeconomic inequalities in oral health determined           64 and over 65. According to a review of 15 longitudi-
          Ed




    by gender, age, education, geographical region, self-             nal studies from seven countries regarding tooth ex-
    assessed health status, and household incomes.                    tractions during varying observation periods (2-28
    In the past decades it was generally accepted that, in            years), the annual incidence of persons losing one or
    many industrialized countries, the sequelae of dental             more teeth varied from 1 to 14% (13). Mean annual
    caries constituted the prime cause of tooth mortality             prevalence in this study over a representative sample
    in younger adults, and that over the age of about 40              of an Italian population was 8.2%, which is in the
IC




    years periodontal disease was the predominant                     range of tooth loss described in other studies in devel-
    cause of tooth loss (2). A great number of variables              oped countries, even if it is higher than the incidence
    are associated with tooth loss, and there is no con-              reported in a Norwegian population (6.5%), which is
    sensus whether dental-disease-related or socio-be-                considered an even more developed country.
C




    havioral factors are the most important risk factors              As confirmed by the literature reviews, the mean
    (12). Studies using regression analyses to assess                 number of lost teeth increase with age, and many
    predictors have generally shown that oral disease-re-             subjects aged 60 and over possibly need some kind
    lated factors were the most important, but demo-                  of prosthodontic treatment (12).
©




    graphic, behavioral and attitudinal factors and educa-            Several observations can be made when examining
    tion also made small contributions to variation in                the results from the multiple logistic regression mod-
    tooth loss in some studies (12).                                  el. An higher extraction risk for the unemployed sub-
    As demonstrated by other studies in other countries               jects is observable, this result probably meaning that
    several years ago, tooth loss increases with the age              this part of population has less access to conserva-
    (12), and so it can be noticed in this study, as inci-            tive treatments if compared with other parts of the
    dence of tooth loss was higher in the people aged 55-             population.

    134                                                                                 Annali di Stomatologia 2014; V (4): 131-135
    Inequalities and teeth extraction in Italy


    One of the strong points of this study is the very large                    G, Leinsalu M, et al. European Union Working Group on So-
    population taken into account, that is representative                       cioeconomic Inequalities in Health. Socioeconomic in-
    of the whole Italian population. Thus the obtained re-                      equalities in health in 22 European countries. N Engl J Med.
                                                                                2008;358(23):2468-81.
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                                                                           4.   Dye BA, Thornton-Evans G. Trends in oral health by pover-
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                                                                                                                         i
                                                                                ty status as measured by Healthy People 2010 objectives.
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                                                                                                                       al
                                                                                Public Health Rep. 2010;125(6):817-30.
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                                                                                                                    on
    is a self reported questionnaire. Generally other au-                  6.   Campus G, Solinas G, Cagetti MG, Senna A, Minelli L, Ma-
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                                                                                Sacco G. Differences in oral health among Italian adolescents
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                                                                                                          zi
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    23,8% when clinically recorded and 23% when self-                           Prev Dent. 2009;7(4):323-30.
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                                                                                          na
                                                                                liana G. Prevalence and socio-behavioral determinants of den-
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                                                                            er
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                                                                   t            2013 may 15]
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C
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    Annali di Stomatologia 2014; V (4): 131-135                                                                                          135
