Abstract
ObjectivesTo test whether maternal education has a direct effect on gingival bleeding in adolescents aged 12 and to assess whether oral health behaviours over time mediate that association.MethodsTwo oral health studies nested in the 1993 Pelotas (Brazil) birth cohort study were carried out in participants aged 6 (n = 359) and 12 years (n = 339). The proportion of teeth with bleeding on probing (BOP) and the median number of teeth with gingivitis at age 12 were recorded. Maternal education at birth was the exposure. Toothbrushing frequency and dental visit at ages 6 and 12 years were investigated as mediators of the association between maternal education at birth and gingival bleeding. Time‐varying family income through childhood and adolescence was included as later confounder. Paternal education was taken as baseline confounder. The controlled direct effect (CDE) of maternal education at child's birth on gingival bleeding at age 12 was estimated using marginal structural models (MSM). Additionally, path analysis was employed to estimate standardized direct, indirect and total effects of maternal education at birth on gingival bleeding.ResultsAdjusted analyses using MSM showed that adolescents whose mothers had <8 years of education had 3.82 higher risk of having teeth with gingival bleeding above the median (rate ratio RR 3.82; 95% CI: 1.68‐8.19). Low maternal education doubled the proportion of gingival bleeding at age 12 not mediated by dental visit and toothbrushing frequency (RR 1.99; 95% CI: 1.52‐2.60). Path analysis revealed that maternal education had a direct effect on gingival bleeding independently of the mediators.ConclusionsThe pattern of oral health behaviours does not explain the association between mother's education and adolescent's gingival bleeding. Individual‐based approaches focused on oral health‐related behaviours tend to fail to prevent gingival bleeding.
Highlights
Gingival bleeding may be considered a marker of chronic gingival inflammation[1]; it is common among children and adolescents,[2] and it is associated with periodontitis.[3]
There is a direct effect of maternal education on adolescents’ gingival bleeding which is not mediated by oral health-related behaviours confirmed either using marginal structural models (MSM) or path analysis. These findings suggest that an alternative explanation for the effect of socioeconomic conditions, such as maternal education, on adolescents’ gingival health exists beyond oral health-related behaviour
The findings of our study suggest that early life exposure to detrimental socioeconomic conditions—in this case low maternal education— may have a harmful impact on adolescent’s gingival health
Summary
Gingival bleeding may be considered a marker of chronic gingival inflammation[1]; it is common among children and adolescents,[2] and it is associated with periodontitis.[3] Several epidemiological studies have reported an association between adolescents’ gingival bleeding and adverse socioeconomic conditions,[4,5] inadequate toothbrushing and flossing[6] and lack of dental attendance.[7]. Most theoretical models regarding the effect of socioeconomic position on periodontal health state that the main connection between the two is via oral health-related behaviours.[8,9] there are some important theoretical, methodological and statistical limitations in the most commonly adopted approaches. The ideal design to address the impact of different life course socioeconomic circumstances on health, including the role of potential mediators, is a birth cohort study
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