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Erschienen in: BMC Oral Health 1/2017

Open Access 01.12.2017 | Research article

Common risk factors and edentulism in adults, aged 50 years and over, in China, Ghana, India and South Africa: results from the WHO Study on global AGEing and adult health (SAGE)

verfasst von: Alexander Kailembo, Raman Preet, Jennifer Stewart Williams

Erschienen in: BMC Oral Health | Ausgabe 1/2017

Abstract

Background

Edentulism (loss of all teeth) is a final marker of disease burden for oral health common among older adults and poorer populations. Yet most evidence is from high-income countries. Oral health has many of the same social and behavioural risk factors as other non-communicable diseases (NCDs) which are increasing rapidly in low- and middle-income countries with ageing populations. The “common risk factor approach” (CRFA) for oral health addresses risk factors shared with NCDs within the broader social and economic environment.

Methods

The aim is to improve understanding of edentulism prevalence, and association between common risk factors and edentulism in adults aged 50 years and above using nationally representative samples from China (N = 11,692), Ghana (N = 4093), India (N = 6409) and South Africa (N = 2985). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007–2010). Multivariable logistic regression describes association between edentulism and common risk factors reported in the literature.

Results

Prevalence of edentulism: in China 8.9 %, Ghana 2.9 %, India 15.3 %, and South Africa 8.7 %. Multivariable analysis: in China, rural residents were more likely to be edentulous (OR 1.36; 95 % CI 1.09–1.69) but less likely to be edentulous in Ghana (OR 0.53; 95 % CI 0.31–0.91) and South Africa (OR 0.52; 95 % CI 0.30–0.90). Respondents with university education (OR 0.31; 95 % CI 0.18–0.53) and in the highest wealth quintile (OR 0.68; 95 % CI 0.52–0.90) in China were less likely to be edentulous. In South Africa respondents with secondary education were more likely to be edentulous (OR 2.82; 95 % CI 1.52–5.21) as were those in the highest wealth quintile (OR 2.78; 95 % CI 1.16–6.70). Edentulism was associated with former smokers in China (OR 1.57; 95 % CI 1.10–2.25) non-drinkers in India (OR 1.65; 95 % CI 1.11–2.46), angina in Ghana (OR 2.86; 95 % CI 1.19–6.84) and hypertension in South Africa (OR 2.75; 95 % CI 1.72–4.38). Edentulism was less likely in respondents with adequate nutrition in China (OR 0.68; 95 % CI 0.53–0.87). Adjusting for all other factors, compared with China, respondents in India were 50 % more likely to be edentulous.

Conclusions

Strengthening the CRFA should include addressing common determinants of health to reduce health inequalities and improve both oral and overall health.

Background

Oral health is fundamental for general health, functioning and well-being. The Global Burden of Disease 2010 Study estimated that oral conditions (untreated caries, severe periodontitis and severe tooth loss) accounted for almost 2 % of all years lived with disability. Disability adjusted life-years (DALYs) due to oral conditions increased by 20.8 % between 1990 and 2010, largely due to population growth and ageing [13]. This epidemiological study describes patterns of edentulism (loss of all teeth) in four low- and middle-income countries (LMICs) in Asia and Africa. Although DALYs for edentulism have fallen world-wide, the profile of edentulism is not homogeneous between or within countries and evidence of oral health in LMICs is limited [4].
Scientific and technological developments in oral health treatments and improved hygiene have helped prevent and control diseases of the mouth, yet advances in oral health science have largely benefited more advantaged populations in high-income countries (HICs). Research aimed at improving oral health should take into account social as well as biological determinants. People are now living longer in all parts of the world and the impact of poor oral health on the quality of life of older adults is an important public health issue [5]. In particular, efforts need to be strengthened in LMICs [3, 68] where periodontal diseases and caries are often “solved” by tooth/teeth extraction instead of conservation [912].
Observational evidence points to tobacco smoking [13, 14], alcohol consumption [15, 16] and poor nutrition [9, 17] as behavioural risk factors for edentulism. Studies also show that socio-demographic characteristics such as increasing age, gender, rural geo-locality, less education, and lower socioeconomic status [1824] are also predictors of edentulism. In addition, both clinical and epidemiological associations have been observed between periodontal diseases and other chronic non-communicable diseases (NCDs) such as type 2 diabetes [25], angina pectoris [26], hypertension [27] and respiratory [28] and cardiovascular diseases [6, 29]. However all of these relationships vary according to the characteristics of the populations being studied [29].
In 2015, the proportion of people in the world aged 65 and above was 8.5 % of the total 7.3 billion people worldwide. This segment of the global population is expected to increase by more than 60 %, from 617.1 million to about one billion, between 2015 and 2030 - equivalent to about 12 % of the world’s population. The proportion of older people will continue to grow in the following 20 years. By 2050 people in the world aged 65 and above will comprise about 16.7 % of the estimated total population of 9.4 billion people. Therefore the average annual increase in the sheer numbers of people aged 65 and above between 2015 and 2050 will be 27.1 million [30].
Although the proportion of people aged 65 and above within the Asian region was 7.9 % in 2015 this translates to 341.1 million people or 5.3 % of the people in the world aged 65 and above. By 2050, about 975.3 million, or two thirds of the world’s population of people aged 65 and above will live in the Asian region. These figures are dominated by China and India, both of which have current populations exceeding one billion. In contrast, the African region has a relatively young age structure with about 3.5 % of the population aged 65 years and above in 2015. Yet the Region is facing major demographic shifts. It is estimated that by 2050 this proportion of older adults in the Region will double to 6.7 % being an almost fourfold increase from 40.6 million to 150.5 million adults aged 65 years and above between 2015 and 2050 [30, 31].
As the sheer numbers of older adults increases over the next decade, so will the burden of chronic periodontal and other NCDs, with a disproportionately higher share expected in LMICs [32]. Over the next 20 years the overall burden of NCDs is predicted to increase from 60 to 79 % in Asia and from 28 to 51 % in Africa [33].
Oral health has many of the same social and behavioural risk factors as other NCDs and oral health promotion is being given increasing attention in developed countries [34]. The “common risk factor approach” (CRFA) addresses risk factors shared with NCDs within the broader social and economic environment. Tobacco use, for example, is linked to periodontal disease, tooth loss, and 90 % of all lung cancers. Unhealthy diets are associated with coronary heart disease, type 2 diabetes, strokes, many cancers and dental caries. The CRFA offers an efficacious method of health promotion and illness prevention, which highlights the importance of the mouth-body connection for overall health and well-being [35].
The CRFA aims to address the broader social and economic determinants (of health) which, in turn, can help reduce unfair health inequalities and inequities in health [36, 37]. Some argue that failure to reduce inequalities in health in many HICs has been because strategies have focused too much on lifestyle change at the expense of not directing efforts and resources towards the broader social determinants of health [36, 38]. Inequalities in oral health reflect the same socioeconomic gradient that occurs in all populations whereby the poor and disadvantaged have the worst health [36, 37, 39, 40].
Edentulism is a “final marker of disease burden for oral health” [12, 41] and an important indicator of dental caries [4244]. If governments in developing countries are to adopt the CRFA to address oral health they need reliable standardised nationally representative epidemiological data and processes by which to convert evidence into information for policy and planning [7]. However evidence on oral health from developing countries is not consistent.
The oral health needs of older people in the African continent [45] are significant with edentulism prevalent in the poorest communities, among older adults and among the less educated [10]. Reports of edentulism prevalence in Asia are varied. In a study of community-dwelling adults aged 60 and above in India, almost one in six were completely edentulous and over 60 % of dentate subjects had decayed teeth or root caries [46]. Yet a study of community-dwelling 65 to 74 year olds in China found that the prevalence of edentulism was only 4.5 % and 3.5 % in urban and rural residents respectively [47]. There is a clear need to ensure comparability between sampling and methods of data collection in epidemiological studies in developing countries where oral health is an emerging public health issue [48, 49].
A recent epidemiological study by Peltzer et al. [50] investigated factors associated with edentulism in a pooled six-country data set comprising China, Ghana, India, Mexico, Russia and South Africa. The authors identified older age, lower education, NCDs, tobacco use, and inadequate fruit and vegetable consumption as risk factors for edentulism. However, the pooled analysis masks important differences within and between countries. In this study, we use a similar nationally comparable standardised study sample of adults to specifically investigate common risk factors for edentulism at the country level. The aim is to improve understanding of edentulism prevalence and association between common risk factors and edentulism (self-reported) in adults, aged 50 years and above, in China, Ghana, India and South Africa.

Methods

Data collection

The data source for this study is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007–2010) which aims to address the gap in reliable and scientific knowledge on ageing and adult health in LMICs. WHO-SAGE is a longitudinal study of nationally representative samples of adults aged 50 and above in China, Ghana, India, Mexico, Russia and South Africa. Smaller non-representative samples of adults aged 18 to 49 years were collected for comparative purposes. Data analysed here were collected from face-to-face interviews using structured household and individual questionnaires.
WHO-SAGE employed a stratified random sampling strategy in all countries, with households as the final sampling units. The strata ensure representation of a range of living conditions and urban and rural localities in each country. Household-level analysis weights and person-level analysis weights were calculated for each country with post-stratification weights to adjust for age and sex distributions and non-response [51]. When multiple countries are analysed as a single data set, age and sex standardisations based on WHO’s World Standard Population [52] adjust for between-country age and sex differences. WHO-SAGE data sets, including sampling weights, are in the public domain. Further details of WHO-SAGE are given elsewhere [53].

Study variables

The binary dependent variable “edentulism” was derived from answers to the question in the individual questionnaire: “Have you lost all your natural teeth?” Those who responded “yes” were defined as edentulous, and those who responded “no” to this question were categorized as being “dentate”.
The choice of independent variables, or “common risk factors” was informed by the literature [35, 36]. Socio-demographic variables are sex, age, residence, education and wealth status. Sex is male or female. The age categories are 50–59 years vs. 60–69 years vs. 70–79 years vs. 80+ years. Residence (geo-locality) is urban or rural. Education refers to the highest reported achieved level of education and is grouped no schooling vs. primary vs. secondary vs. university or college. All of these independent variables were directly derived from the individual questionnaires.
Information on ownership of household assets was taken directly from household questionnaires and converted to a household wealth status variable. This was then linked to the individual questionnaires. The SAGE household questionnaire captures information on household characteristics (eg cooking oil, floor and roof types), ownership of durable goods (eg radio, car) and access to basic services (eg electricity, clean water and sanitation). In order to construct an asset-based index from this information it was necessary to develop weights to assign to household assets. Principal Components Analysis was used to generate weights from which raw continuous scores, indicative of household wealth, were derived. These scores were transformed into “wealth quintiles” with quintile one representing the lowest wealth and quintile five the highest [54, 55]. The above steps were undertaken by WHO.
Health behaviours are smoking (non-smoker vs. daily smoker vs. non-daily smoker vs. former smoker) alcohol use (drinkers vs. non-drinkers) and nutritional status derived from answers to the questions; “How many servings of fruit do you eat on a typical day?” and “How many servings of vegetables do you eat on a typical day?” Respondents with five or more servings are “adequate” and those with less than five servings are “inadequate”.
Chronic conditions are diabetes, angina and hypertension. Binary variables denote yes or no answers to questions that asked whether the respondents had “ever been diagnosed” with the condition. A country dummy variable (with China as the reference group) is included in the pooled multivariable analysis to adjust for country differences.

Study sample

The available data set of WHO SAGE Wave 1 individual respondents from China, Ghana, India, Mexico, Russia and South Africa comprised 47,443 respondents. The data for Mexico (n = 5548) and Russia (n = 4947) were not included because of high percentages of missing data on the dependent variable (52 % in Mexico and 13 % in Russia).
The analysis in this study compares two sets of countries in two distinct geographic regions – China and India in Asia and Ghana and South Africa in Sub-Saharan Africa. Individuals who did not complete the SAGE individual questionnaire were not included – China (n = 237), Ghana (n = 463), India (n = 968) and South Africa (n = 2). Respondents aged less than 50 years were also excluded from the study – China (n = 1636), Ghana (n = 805), India (n = 4670) and South Africa (n = 385). The potential study sample comprised SAGE Wave 1 respondents in China (n = 13,177), Ghana (n = 4305), India (n = 6560) and South Africa (n = 3840) who completed the surveys and were aged 50 years and over (N = 27,882). The final country study samples are reported in the Results section.

Statistical analysis

Only records with complete data on all study variables were analysed. Individual country samples are described by socio-demographic factors, health behaviours and chronic conditions. The prevalence of edentulism is estimated with 95 % confidence intervals (CIs) to allow statistical comparisons between countries. Chi-squared tests show differences in prevalence by socio-demographic characteristics, behaviours and chronic conditions.
Univariable logistic regressions describe associations between socio-demographic factors, health behaviours and chronic conditions and edentulism in each country, and in the pooled data set. The criterion for inclusion in the multivariable analyses was set at p < 0.05 in the pooled analysis. In some cases, eg sex in Ghana, India and South Africa, associations were not significant in the univariate analyses, but the variables were retained because of evidence of association with edentulism in the literature. Associations are presented as odds ratios (ORs) and 95 % CIs.
All analyses applied either country or pooled weights appropriate for making estimates representative of the populations. The analyses were carried out using STATA 13 software (StataCorp, 2013).

Results

The study sample of adults aged 50 years and over in the four countries pooled was 25,179. The largest sample was China (n = 11,692), followed by India (n = 6409), Ghana (n = 4093) and South Africa (n = 2985). Proportions of females to males were just above 50 % in China and South Africa and just under 50 % in Ghana and India. Overall almost half the study sample was aged 50–59 years, about 5 % were aged 80+ years, and 58 % were rural residents (Table 1).
Table 1
Weighted characteristics of the study population of adults aged 50+ years in China, Ghana, India and South Africa and pooled, SAGE Wave 1 (N = 25,179)
Characteristics
China
 
Ghana
 
India
 
South Africa
 
Pooled data
 
N = 11,692
N = 4093
N = 6409
N = 2985
N = 25,179
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
Sex
 Male
5492
49.7
2127
52.0
3230
50.6
1189
49.8
12,038
49.6
 Female
6200
50.3
1966
48.0
3179
49.4
1796
50.2
13,141
50.4
Age group (years)
 50–59
5067
44.9
1619
40.2
2862
47.9
1313
49.5
10,861
49.8
 60–69
3555
32.3
1136
27.2
2182
31.2
965
30.9
7838
29.4
 70–79
2464
18.6
931
22.9
1044
16.3
517
14.1
4956
15.9
 80+
606
4.2
407
9.7
321
4.6
190
5.5
1524
4.9
Residence
 Urban
6030
49.2
1659
40.6
1654
29.0
2006
65.3
11,349
41.6
 Rural
5662
50.8
2434
59.4
4755
71.0
979
34.7
13,830
58.4
Highest education
 No schooling
2727
21.7
2257
53.9
3286
51.7
771
24.1
9041
31.2
 Primary or less
4384
40.0
855
21.4
1642
25.0
1444
46.6
8325
25.2
 Secondary
4014
33.6
837
21.0
1162
18.3
617
23.3
6630
29.0
 University
567
4.7
144
3.7
319
5.0
153
6.0
1183
4.6
Wealth quintile
 1 (Lowest)
2259
15.7
812
18.2
1043
18.2
548
19.4
4662
16.5
 2
2284
17.8
802
19.0
1185
19.2
608
20.2
4879
18.3
 3
2337
20.3
828
20.9
1176
18.7
608
19.4
4949
19.6
 4
2429
23.6
843
20.9
1393
20.0
612
20.0
5277
22.4
 5 (Highest)
2383
22.6
808
21.0
1612
23.9
609
21.0
5412
23.2
Smoking
 Non-smoker
7794
64.1
3037
75.2
3048
45.7
1934
66.9
15,813
58.5
 Daily smoker
2849
26.7
402
8.1
2826
46.5
664
20.1
6741
32.8
 Non-daily smoker
302
2.5
112
2.6
195
3.0
115
3.2
724
2.7
 Former smoker
747
6.7
542
14.1
340
4.8
272
9.8
1901
6.0
Alcohol use
 Drinker
3612
33.9
2389
57.8
1015
15.9
827
25.4
7843
28.3
 Non-drinker
8080
66.1
1704
42.2
5394
84.1
2158
74.6
17,336
71.7
Nutritional status
 Inadequate
1413
9.6
2840
68.0
5711
90.4
2186
68.4
12,150
35.9
 Adequate
10,279
90.4
1253
32.0
698
9.6
799
31.6
13,029
64.1
Chronic conditions
 Diabetes
          
  Yes
785
6.7
161
3.9
471
6.5
297
9.6
1714
6.3
  No
10,907
93.3
3932
96.1
5938
93.5
2688
90.6
23,465
93.7
 Angina
          
  Yes
1059
8.0
138
3.7
320
5.5
176
4.9
1693
6.8
  No
10,633
92.0
3955
96.3
6084
94.5
2809
95.1
23,486
93.2
 Hypertension
          
  Yes
3254
26.8
548
14.0
1120
16.8
922
31.0
5844
22.8
  No
8438
73.2
3545
86.0
5289
83.2
2063
69.0
19,335
77.2
Table 2 gives the prevalence of edentulism by country and sample characteristics. Overall in the four countries, prevalence was 10.9 % (N = 2591). Prevalence was highest in India at (15.3 %; 95 % CI 13.4–17.5) and lowest in Ghana (2.9 %; 95 % CI 2.3–3.6). Prevalence was significantly different between countries except for China (8.9 %; 95 % CI 8.1–9.8) and South Africa (8.7 %; 95 % CI 7.0–10.8). In all four countries, the prevalence of edentulism was higher in females but the sex difference was significant (p < 0.001) only in China (44.4 % male vs. 55.6 % female). The prevalence of edentulism was significantly different (p < 0.001) by age in China, Ghana and India. Edentulism was more prevalent in rural areas in China (57.9 %) and in urban areas in Ghana (59.3 %) and South Africa (83.7 %). These differences were significant in China (p = 0.005), Ghana (p = 0.020) and South Africa (p < 0.001). Differences in education gradients were observed in China (p < 0.001) and South Africa (p = 0.004). The wealth gradient was also significant in China and South Africa (p < 0.001 for both). The country comparison for smoking status was significant for China (p < 0.001) and South Africa (p = 0.020) and for alcohol use the differences were significant for China (p = 0.001) and India (p = 0.001). There was a significant difference in nutritional status in China only (p < 0.001). The prevalence of diabetes was significantly different in Ghana (p = 0.012) and South Africa (p = 0.001), the prevalence of angina was significantly different in China (p = 0.001) and Ghana (p = 0.011), and the prevalence of hypertension was significantly different in China and South Africa (p < 0.001).
Table 2
Weighted prevalence of self-reported edentulism according to characteristics of study population of adults aged 50+ years in China, Ghana, India and South Africa and pooled, SAGE Wave 1
Characteristics
China
Ghana
India
South Africa
Pooled data
N
%
95 % CI
N
%
95 % CI
N
%
95 % CI
N
%
95 % CI
N
%
95 % CI
Prevalence
1250
8.9
8.1–9.8
112
2.9
2.3–3.6
916
15.3
13.4–17.5
313
8.7
7.0–10.8
2591
10.9
9.9–11.9
Sex
n
%
P-value
n
%
P-value
n
%
P-value
n
%
P-value
n
%
P-value
 Male
555
44.4
<0.001
47
45.0
0.220
436
47.0
0.274
105
38.2
0.713
1143
44.7
0.004
 Female
695
55.6
65
55.0
480
53.0
208
61.8
1448
55.3
Age group (years)
 50–59
161
13.9
<0.001
27
24.9
<0.001
225
30.8
<0.001
105
36.5
0.072
518
22.0
<0.001
 60–69
335
30.0
24
20.5
296
29.4
104
34.2
759
28.4
 70–79
526
39.2
25
24.5
278
31.1
79
20.0
908
34.2
 80+
228
16.9
36
30.1
117
8.7
25
9.3
406
15.4
Residence
 Urban
540
42.1
0.005
58
59.3
0.020
245
35.4
0.074
277
83.7
<0.001
1120
36.2
0.036
 Rural
710
57.9
54
45.7
671
64.6
36
16.3
1471
63.8
Highest education
 No schooling
531
42.0
<0.001
74
62.2
0.551
499
55.5
0.100
36
10.0
0.004
1140
49.4
<0.001
 Primary or less
464
39.5
17
17.9
259
25.8
176
51.5
916
33.1
 Secondary
224
16.8
17
15.7
127
14.9
93
34.4
461
15.2
 University
31
1.7
4
4.2
31
3.8
8
4.1
74
2.4
Wealth quintile
 1 (Lowest)
386
26.6
<0.001
24
17.8
0.861
136
18.8
0.854
28
8.5
<0.001
574
23.7
<0.001
 2
274
21.4
21
16.8
176
18.1
48
14.8
519
19.9
 3
264
22.9
24
24.7
178
17.5
74
16.5
540
20.0
 4
197
16.7
20
17.8
195
21.4
75
21.4
487
18.4
 5 (Highest)
129
12.4
23
23.0
231
24.2
88
38.8
471
18.0
Smoking
 Non-smoker
842
64.6
<0.001
85
72.6
0.300
429
48.1
0.150
187
57.6
0.020
1543
57.2
0.020
 Daily smoker
273
23.7
9
6.7
385
42.2
94
29.6
761
32.3
 Non-daily smoker
22
1.5
1
0.6
31
3.5
5
0.4
59
2.4
 Former smoker
113
10.2
17
20.1
71
6.2
27
12.4
228
8.1
Alcohol use
 Drinker
329
28.8
0.001
58
53.3
0.317
116
11.0
0.001
79
22.9
0.576
582
20.4
<0.001
 Non-drinker
921
71.2
54
46.7
800
89.0
234
77.1
2009
79.6
Nutritional status
 Inadequate
253
16.7
<0.001
75
66.9
0.816
798
89.4
0.500
235
74.2
0.207
1361
51.7
<0.001
 Adequate
997
83.3
37
33.1
118
10.6
78
25.8
1230
48.3
Chronic conditions
 Diabetes
               
  Yes
101
7.8
0.210
8
9.0
0.012
77
8.4
0.135
68
18.0
0.001
254
7.7
0.067
  No
1149
92.2
104
91.0
839
91.6
245
82.0
2337
92.3
 Angina
               
  Yes
173
11.8
0.001
7
10.1
0.011
55
5.7
0.827
33
7.2
0.146
268
8.6
0.018
  No
1077
88.2
105
89.9
861
94.3
280
92.8
2323
91.4
 Hypertension
               
  Yes
465
34.5
<0.001
10
11.8
0.603
175
16.3
0.777
173
57.7
<0.001
823
25.5
0.026
  No
785
65.5
102
88.2
741
83.7
140
42.3
1768
74.5
Table 3 reports the results of univariable logistic regressions of common risk factors associated with edentulism. Women had about 30 % higher odds of being edentulous in China (p < 0.001). Age was significantly associated with edentulism in China and India whereby older aged respondents were more likely to be edentulous (p < 0.001). Rural residents in China were significantly (p = 0.005) more likely to be edentulous, and urban residents in Ghana (p = 0.020) and South Africa (p < 0.001) were more likely to be edentulous. An education gradient was evident in China wherby the more educated groups were significantly less likely to be edentulous (p < 0.001). The pattern was reversed in South Africa where respondents who had primary or secondary schooling were significantly more likely to be edentulous compared with those who had no schooling (p < 0.001). There were also country differences in the direction of association with smoking. Compared with non-smokers, the odds of former smokers being edentulous were about 60 % higher in China (p < 0.001) and the odds of daily smokers being edentulous were about 80 % higher in South Africa (p = 0.033). Compared with drinkers, the odds of non-drinkers being edentulous were 30 % higher in China and 60 % higher in India (p < 0.001 both). In China respondents with adequate nutritional status were half as likely to be edentulous (p < 0.001), respondents with angina had 60 % higher odds of being edentulous (p = 0.001) and the odds of respondents with hypertension being edentulous were about 50 % higher (p < 0.001). In Ghana respondents with angina were three times more likely to be edentulous (p = 0.016) and respondents with diabetes were over two and a half times more likely to be edentulous (p = 0.015). In South Africa the odds of respondents with diabetes being edentulous were 2.3 times higher (p = 0.002) and the odds of respondents with hypertension being edentulous were about 3.4 times higher (p < 0.001).
Table 3
Univariable logistic regression of common risk factors associated with edentulism, adults aged 50+ years in China, Ghana, India and South Africa and pooled, SAGE Wave 1 (weighted)
Characteristics
China
Ghana
India
South Africa
Pooled data
OR (95 % CI)
p-value
OR (95 % CI)
p-value
OR (95 % CI)
p-value
OR (95 % CI)
p-value
OR (95 % CI)
p-value
Sex
 Male
1
 
1
 
1
 
1
 
1
 
 Female
1.27(1.14–1.40)
<0.001
1.33(0.84–2.12)
0.221
1.19(0.87–1.63)
0.274
1.09(0.70–1.68)
0.713
1.25(1.07–1.45)
0.004
Age group (years)
 50–59
1
 
1
 
1
 
1
 
1
 
 60–69
3.19(2.52–4.04)
<0.001
1.22(0.64–2.32)
0.537
1.55(1.24–1.95)
<0.001
1.55(0.91–2.65)
0.105
2.32(1.98–2.71)
<0.001
 70–79
8.16(6.14–10.85)
<0.001
1.75(0.85–3.61)
0.128
3.80(2.81–5.13)
<0.001
2.05(1.23–3.41)
0.006
6.02(4.95–7.33)
<0.001
 80+
20.09 (14.31–28.20)
<0.001
5.45(3.05–9.75)
0.000
3.79(2.62–5.49)
<0.001
2.60(0.86–7.66)
0.093
10.19(7.86–13.23)
<0.001
Residence
 Urban
1
 
1
 
1
 
1
 
1
 
 Rural
1.36(1.10–1.69)
0.005
0.57(0.35–0.91)
0.020
0.71(0.48–1.04)
0.075
0.34(0.19–0.59)
<0.001
1.30(1.02–1.65)
0.036
Highest education
 No schooling
1
 
1
 
1
 
1
 
1
 
 Primary
0.46(0.39–0.55)
<0.001
0.72(0.31–1.64)
0.429
0.9(0.7–1.2)
0.669
2.81(1.64–4.81)
<0.001
0.55(0.47–0.63)
<0.001
 Secondary
0.22(0.17–0.29)
<0.001
0.64(0.35–1.17)
0.143
0.7(0.5–0.9)
0.041
3.90(2.04–7.48)
<0.001
0.29(0.24–0.35)
<0.001
 University
0.15(0.09–0.27)
<0.001
1.00(0.30–3.32)
0.996
0.7(0.4–1.1)
0.115
1.64(0.48–5.56)
0.426
0.29(0.20–0.44)
<0.001
Wealth quintile
 1 (lowest)
1
 
1
 
1
 
1
 
1
 
 2
0.67(0.53–0.85)
0.001
0.90(0.44–1.83)
0.762
0.95(0.74–1.23)
0.549
1.72(0.66–4.46)
0.263
0.73(0.60–0.88)
0.001
 3
0.62(0.53–0.73)
<0.001
1.21(0.55–2.65)
0.634
0.90(0.65–1.26)
0.504
2.02(0.86–4.77)
0.107
0.68(0.57–0.80)
<0.001
 4
0.38(0.30–0.48)
<0.001
0.86(0.43–1.75)
0.680
1.05(0.72–1.51)
0.810
2.61(1.15–5.92)
0.022
0.53(0.42–0.67)
<0.001
 5 (highest)
0.29(0.21–0.39)
<0.001
1.11(0.55–2.24)
0.761
0.98(0.69–1.37)
0.890
4.85(2.08–11.33)
<0.001
0.50(0.40–0.63)
<0.001
Smoking
 Non-smoker
1
 
1
 
1
 
1
 
1
 
 Daily smoker
0.87(0.71–1.07)
0.172
0.85(0.43–1.68)
0.635
0.84(0.66–1.08)
0.171
1.81(1.05–3.13)
0.033
1.01(0.86–1.18)
0.908
 Non-daily smoker
0.57(0.36–0.91)
0.019
0.23(0.03–1.70)
0.149
1.13(0.65–1.96)
0.660
0.14(0.03–0.70)
0.017
0.90(0.62–1.33)
0.604
 Former smoker
1.59(1.24–2.04)
<0.001
1.50(0.68–3.30)
0.314
1.30(0.86–1.94)
0.209
1.53(0.79–2.96)
0.207
1.45(1.20–1.78)
<0.001
Alcohol use
 Drinker
1
 
1
 
1
 
1
 
1
 
 Non-drinker
1.30(1.12–1.50)
<0.001
1.21(0.83–1.75)
0.318
1.64(1.22–2.20)
<0.001
1.16(0.68–2.00)
0.577
1.61(1.40–1.85)
<0.001
Nutritional status
 Inadequate
1
 
1
 
1
 
1
 
1
 
 Adequate
0.49(0.39–0.62)
<0.001
1.06(0.66–1.69)
0.816
1.15(0.77–1.70)
0.499
0.73(0.45–1.19)
0.208
0.48(0.40–0.58)
<0.001
Chronic Conditions
 Angina
1.60(1.22–2.12)
0.001
3.13(1.24–7.93)
0.016
1.06(0.65–1.72)
0.827
1.58(0.85–2.94)
0.149
1.3(31.05–1.70)
0.019
 Diabetes
1.20(0.90–1.60)
0.210
2.56(1.20–5.46)
0.015
1.38(0.90–2.13)
0.137
2.28(1.36–3.82)
0.002
1.27(0.98–1.65)
0.067
 Hypertension
1.49(1.27–1.76)
<0.001
0.82(0.38–1.75)
0.604
0.96(0.71–1.29)
0.777
3.43(2.18–5.41)
<0.001
1.19(1.02–1.38)
0.026
In multivariable logistic regression (Table 4) edentulousness was significantly associated with the oldest respondents (aged 80+) and females in Ghana (OR 1.56; 95 % CI 1.01–2.42), holding all other variables constant. In China association between female sex and edentulism attenuated to non-significance due to confounding, yet age remained significant in the presence of sex and all other covariates. Rural residents in China were significantly more likely to be edentulous (OR 1.36; 95 % CI 1.109–1.69) but rural residents were less likely to be edentulous in Ghana (OR 0.53; 95 % CI 0.31–0.91) and South Africa (OR 0.52; 95 % CI 0.30–0.90) when holding all other variables constant.
Table 4
Multivariable logistic regression of common risk factors associated with edentulism, adults aged 50+ years in China, Ghana, India and South Africa and pooled, SAGE Wave 1 (weighted)
China
Ghana
India
South Africa
Pooled data
Variable
OR (95 % CI)
p-value
OR (95 % CI)
p-value
OR (95 % CI)
p-value
OR (95 % CI)
p-value
OR (95 % CI)
p-value
Sex
 Male
1
 
1
 
1
 
1
 
1
 
 Female
1.09 (0.86–1.37)
0.477
1.56 (1.01–2.42)
0.044
1.01 (0.67–1.52)
0.959
1.07 (0.66–1.74)
0.789
0.96 (0.77–1.20)
0.716
Age group
 50–59
1
 
1
 
1
 
1
 
1
 
 60–69
2.80 (2.25–3.50)
<0.001
1.16 (0.62–2.20)
0.635
1.51 (1.20–1.92)
0.001
1.45 (0.86–2.43)
0.162
2.03 (1.74–2.36)
<0.001
 70–79
6.74 (5.22–8.70)
<0.001
1.73 (0.83–3.59)
0.140
3.80 (2.84–5.09)
<0.001
1.70 (0.98–2.96)
0.059
4.94 (4.10–5.96)
<0.001
 80+
14.89 (10.88–20.37)
<0.001
5.25 (2.80–9.83)
<0.001
3.59 (2.50–5.16)
<0.001
2.89 (1.29–6.45)
0.010
7.67 (5.93–9.91)
<0.001
Residence
 Urban
1
 
1
 
1
 
1
 
1
 
 Rural
1.36 (1.09–1.69)
0.007
0.53 (0.31–0.91)
0.022
0.70 (0.45–1.08)
0.110
0.52 (0.30–0.90)
0.021
1.01 (0.77–1.32)
0.964
Education
 No schooling
1
 
1
 
1
 
1
 
1
 
 Primary
0.82 (0.67–1.00)
0.048
1.05 (0.44–2.53)
0.915
0.94 (0.72–1.22)
0.637
2.32 (1.31–4.12)
0.004
0.88 (0.75–1.03)
0.105
 Secondary
0.57 (0.44–0.75)
<0.001
0.98 (0.51–1.90)
0.960
0.76 (0.56–1.03)
0.081
2.82 (1.52–5.21)
0.001
0.58 (0.48–0.71)
<0.001
 University
0.31 (0.18–0.53)
<0.001
1.31 (0.38–4.54)
0.665
0.60 (0.33–1.12)
0.107
1.29 (0.36–4.58)
0.693
0.44 (0.28–0.68)
<0.001
Wealth quintile
 1 (lowest)
1
 
1
 
1
 
1
 
1
 
 2
0.89 (0.71–1.12)
0.317
0.87 (0.41–1.84)
0.714
0.91 (0.65–1.28)
0.586
1.68 (0.68–4.10)
0.258
0.85 (0.70–1.03)
0.100
 3
1.03 (0.84–1.27)
0.752
1.17 (0.56–2.45)
0.675
0.93 (0.66–1.29)
0.651
1.47 (0.61–3.57)
0.389
0.94 (0.78–1.13)
0.497
 4
0.76 (0.60–0.94)
0.015
0.80 (0.37–1.70)
0.553
1.08 (0.74–1.57)
0.703
1.61 (0.71–3.67)
0.256
0.83 (0.67–1.03)
0.094
 5 (highest)
0.68 (0.52–0.90)
0.007
0.94 (0.41–2.16)
0.890
0.99 (0.69–1.44)
0.974
2.78 (1.16–6.70)
0.022
0.82 (0.65–1.02)
0.076
Smoking
 Non-smoker
1
 
1
 
1
 
1
 
1
 
 Daily smoker
1.18 (0.89–1.57)
0.237
1.11 (0.53–2.35)
0.778
0.95 (0.75–1.21)
0.674
2.24 (1.22–4.13)
0.010
0.97 (0.80–1.16)
0.714
 Nondaily smoke
0.64 (0.38–1.07)
0.086
0.38 (0.05–2.81)
0.340
1.24 (0.74–2.08)
0.413
0.22 (0.04–1.15)
0.073
0.91 (0.62–1.34)
0.636
 Former smoker
1.57 (1.10–2.25)
0.015
1.86 (0.79–4.40)
0.157
1.29 (0.83–1.99)
0.260
1.81 (0.86–3.79)
0.118
1.36 (1.05–1.77)
0.020
Alcohol use
 Drinker
1
 
1
 
1
 
1
 
1
 
 Non-drinker
1.17 (0.98–1.40)
0.088
1.09 (0.70–1.69)
0.701
1.65 (1.11–2.46)
0.014
1.24 (0.57–2.70)
0.595
1.32 (1.08–1.60)
0.006
Nutrition
 Inadequate
1
 
1
 
1
 
1
 
1
 
 Adequate
0.68 (0.53–0.87)
0.003
1.05 (0.65–1.69)
0.846
1.31 (0.83–2.08)
0.243
0.68 (0.42–1.10)
0.114
0.82 (0.63–1.05)
0.113
Chronic conditions
 Angina
1.12 (0.80–1.57)
0.498
2.86 (1.19–6.84)
0.019
0.89 (0.50–1.59)
0.705
1.23 (0.67–2.26)
0.495
1.07 (0.81–1.42)
0.629
 Diabetes
0.93 (0.69–1.27)
0.659
2.57 (1.19–5.59)
0.017
1.46 (0.92–2.31)
0.111
1.24 (0.69–2.24)
0.472
1.24 (0.93–1.65)
0.143
 Hypertension
1.22 (0.98–1.52)
0.074
0.57 (0.24–1.31)
0.184
0.79 (0.57–1.09)
0.145
2.75 (1.72–4.38)
<0.001
1.10 (0.92–1.31)
0.305
Country
 China
        
1
 
 Ghana
        
0.21 (0.15–0.28)
<0.001
 India
        
1.51 (1.14–1.99)
0.004
 South Africa
        
0.86 (0.62–1.18)
0.349
Compared with those with no schooling, respondents with higher education in China were significantly less likely to be edentulous and respondents in South Africa with primary or secondary education were significantly more likely to be edentulous, when all other variables were held constant.
In the multivariable regressions, compared with non-smokers, former smokers in China were significantly more likely to be edentulous (OR 1.57; 95 % CI 1.10–2.25), and daily smokers in South Africa were significantly more likely to be edentulous (OR 2.24; 95 % CI 1.22–4.13). In the presence of all other variables, compared with drinkers, non-drinkers in India were significantly more likely to be edentulous (OR 1.65; 95 % CI 1.11–2.46) and respondents with adequate nutrition in China were significantly less likely to be edentulous (OR 0.68; 95 % CI 0.53–0.87). In the multivariable analysis in Ghana, respondents with angina were significantly more likely to be edentulous (OR 2.86; 95 % CI 1.19–6.84), respondents with diabetes in Ghana were significantly more likely to be edentulous (OR 2.57; 95 % CI 1.19–5.59), and respondents with hypertension in South Africa were significantly more likely to be edentulous (OR 2.75; 95 % CI 1.72–4.38).
In the multivariable regression of the data set for all countries pooled, the likelihood of edentulism was higher amongst those who were older and had less education. Holding all other variables constant, compared with 50–59 year olds, respondents aged 80+ years were seven times more likely to be edentulous (OR 7.67; 95 % CI 5.93–9.91), and those with university education were 60 % less likely to be edentulous compared with those with no education (OR 0.44; 95 % CI 0.28–0.68). Compared with drinkers, non-drinkers were 30 % more likely to be edentulous when all other variables were held constant (OR 1.32; 95 % CI 1.08–1.60). Compared with the reference country China and holding all other variables constant, respondents in India were 50 % more likely to be edentulous (OR 1.51; 95 % CI 1.14–1.99) and respondents in Ghana were 80 % less likely to be edentulous (OR 0.21; 95 % CI 0.15–0.28).

Discussion

This study of self-reported edentulism in adults aged 50 and above in four LMICs has two sets of important findings. The first is in relation to differences in the prevalence of self-reported edentulism in the two major emerging economies in Asia – China and India, and in contrast, two rapidly developing countries in the African continent – Ghana and South Africa. The second main finding relates to the distinct country-level differences in common risk factors for edentulism.
The high prevalence of edentulism in India (15.3 %) is consistent with other findings. The World Health Organization [44] estimated the prevalence of edentulism among 65–74 year olds in India at 19 % [44] and Peltzer et al. [50] reported edentulism prevalence in India at 16.3 % (95 % CI 14.3–18.4). Of the 1240 elderly Indian subjects examined in their study, Sha and Sundaram showed that 15.2 % were edentulous [46]. There has been a general trend in India to extract diseased teeth, especially among older adults and many take the view that teeth loss is a natural part of ageing [46].
Similar to the results of a previous study of oral health in SAGE countries [50] the prevalence in Ghana was only about 3 %, but three times higher in China and South Africa at 8–9 %. In younger African adults (aged 35–44 years) edentulism prevalence has been estimated at 1 % [7]. One reason for this is that many people in African countries live in rural communities where there is limited access to refined sugars, although this is changing with increasing urbanisation. However, urban to rural migration is occurring at different levels and rates in the African continent, which may also be a reason for the observed country differences in edentulism. In South Africa in 2010, only about 38 % of the population lived in rural areas compared with 42 % ten years earlier, while in Ghana about half the population lived in rural areas in 2010, compared with 58 % in 2000 [56].
The 9 % prevalence of edentulism in China in people aged 50 and over is consistent with the results of a national epidemiological survey conducted in China in 2005 in which edentulism prevalence was reported at 7 % in the 65–74 year age group and similar to a WHO estimate of 11 % [44]. China is also facing rapid rural to urban migration which, as noted above, is impacting on oral health [57]. For example about 60 % of the Chinese population lived in rural areas in 2000 compared with about 50 % in 2010 [56].
Between country differences are shown in the results of the pooled multivariable regression. After adjusting for sex, age, residence, education wealth, smoking, alcohol, nutrition, and the self-reported chronic conditions angina, diabetes and hypertension, compared with the reference country, China, respondents in India were significantly 50 % more likely to be edentulous and respondents in Ghana were significantly 80 % less likely to be edentulous. These findings are broadly consistent with WHO 2000 estimates of edentulism prevalence in 65 to 74 year olds of 11 % in China and 19 % in India [9, 44].
The association between tooth loss and older age has been widely reported in studies conducted in many countries throughout the world [6, 20, 49, 5861]. In the univariable analyses, differences in edentulism prevalence were significant across the four age categories (50–59, 50–69, 70–79 and 80+) in China, Ghana and India, but not South Africa. However, in China and India only, the likelihood of edentulism was significantly higher in all age groups, compared with the reference group (50–59 years) after adjusting for sex, residence, education wealth, smoking, alcohol, nutrition, and the self-reported chronic conditions angina, diabetes and hypertension. In the two African countries, the association between older age and edentulism was significant only when comparing the 50–59 and 80+ year groups. When a regressor is categorised the placing of cut points can influence results [62]. In order to investigate the sensitivity of the association between age and edentulism, we re-analysed the data using three, instead of four, age categories - 50–59 years vs. 60–69 years vs. 70+ years. The age groups 70–79 and 80+ years were collapsed because of relatively small cell sizes. As with the first analysis, there were positive age gradients in each of the countries, and in Ghana and South Africa the odds were significant only for the oldest 70+ age group.
In the univariable analysis, women in China were 30 % more likely to be edentulous but the association attenuated to non-significance after adjusting for age, residence, education wealth, smoking, alcohol, nutrition and the chronic conditions angina, diabetes and hypertension. In contrast, the association between sex and edentulism was not significant in Ghana in the univariable analysis, but in the multivariable analysis, women in Ghana were significantly 60 % more likely to be edentulous. Compared with the univariable regression, the multivariable regression for Ghana showed a lower likelihood of edentulism for the 80+ age group, rural residents, and those with self-reported angina and diabetes, suggesting that these factors confounded association between sex and edentulism in the univariable model.
However, evidence of associations between sex and edentulism in older adults is mixed. Observational evidence that females are more likely to be edentulous [21, 63, 64] has been attributed to both biological and social factors. Studies have shown association between osteoporosis and oestrogen deficiency and periodontal diseases and tooth loss [6567]. In some societies women, particularly those in higher socioeconomic groups, may be more concerned about their dental and facial appearance than men and therefore e more likely to opt for dentures when available [24, 64]. Other research shows that men tend to be more edentulous than women [68] or that the sex differences are not significant [10, 69] although this varies according to the populations studied [6]. It is important to note that differences in oral health are a function of both biological sex and gender with the later referring to behaviours resulting from the societal and cultural construction of male/female roles [23].
In China respondents in rural areas were significantly 40 % more likely to be edentulous while rural respondents in Ghana and South Africa were significantly 50 % less likely to be edentulous after adjusting for sex, age, education wealth, smoking, alcohol, nutrition, and the self-reported chronic conditions angina, diabetes and hypertension. Comparisons between urban and rural residents are complicated by the availability of and access to oral health treatment [6, 18]. In the African continent these issues are complicated by a limited oral health workforce and poor working conditions as well as logistic problems in reaching people in rural communities [7]. Dental treatments and extractions are less likely to be available in poorer rural communities. However, factors such as family and social support and informal networks can also play a role in promoting oral health care [70].
Respondents with higher levels of completed education were significantly less likely to be edentulous in China, after adjusting for sex, age, residence, wealth, smoking, alcohol, nutrition, and the self-reported chronic conditions angina, diabetes and hypertension. In the multivariable models, education to primary or secondary levels compared with no schooling, was significantly associated with edentulism in South Africa but the edentulism/education association was not significant for Ghana or India. A number of studies show that higher education is protective of edentulism in older adults [10, 20, 21]. This can be explained by the role played by education in promoting the utilization of oral health services where available.
After adjusting for sex, age, residence, education, smoking, alcohol, nutrition, and the self-reported chronic conditions angina, diabetes and hypertension, the likelihood of edentulism in the highest compared with the lowest wealth quintile was significant and 30 % less in China, and significantly almost three times higher in South Africa. Many studies in the literature report that oral health, like general health, is associated with lower socioeconomic status and wealth. However there apparent contradictory results may be due to a perception, which has been documented in African countries, that loss of teeth is an inevitable consequence of ageing. Elders are held in high regard in many traditional cultures in African countries, although this is gradually changing with increasing economic and social change [7, 45]. Another factor is that teeth extraction is seen in African cultures as being a socially acceptable solution for dental problems [10].
The patterns in the health behaviours smoking, alcohol use and nutrition are variable, possibly due to inconsistencies in self-reported responses. Adjusting for sex, age, residence, education, wealth, alcohol, nutrition, and the self-reported chronic conditions angina, diabetes and hypertension, former smokers in China were significantly 60 % more likely to be edentulous compared with non-smokers and in South Africa, daily smokers were significantly 20 % more likely to be edentulous than non-smokers. Smoking is widely cited as a risk factor for poor oral health including tooth loss [13, 71, 72]. The findings that non-drinkers in India were significantly 60 % more likely to be edentulous in the fully adjusted model is somewhat surprising given evidence of association between alcohol use and poor oral health [16, 72, 73]. However this is partly explained by the high proportion of non-drinkers (84 %) in the India study sample. In the fully adjusted models, respondents with an adequate intake of fruits and vegetables were significantly 30 % less likely to be edentulous in China, while in the other three countries the association between nutrition and edentulism was not significant. Diets rich in saturated fats and refined sugars and low in fibres and vitamins have been associated with NCDs including dental caries in a number of countries [17, 74, 75]. The result for China may reflect the traditional Chinese diet being high in fruits and vegetables, although this is now changing with increased economic development [44].
In the fully adjusted model, in Ghana, respondents with angina were significantly three times more likely to be edentulous and respondents with diabetes were significantly 50 % less likely to be edentulous. In South Africa respondents with hypertension were significantly almost three times more likely to be edentulous in the presence of sex, age, residence, education, wealth, smoking, alcohol, nutrition, angina and diabetes. There is evidence to support biological links between NCDs and oral health. Oral bacterial infections that normally precede tooth loss can influence systemic inflammatory and homeostatic factors such as C - reactive protein and leucocytes leading to vascular damage and atherosclerosis [76] and it has been suggested that having fewer teeth may affect healthier nutrient intake leading to increased risk of vascular diseases [77].

Limitations

It was not possible to establish causation because of the analyses were cross-sectional. Although the data collection was tightly controlled, it is possible that some respondents did not answer “honestly”, particularly in relation to questions about smoking and alcohol. We also acknowledge the possibility of selection bias with different life expectancies in these four countries.

Strengths

The WHO-SAGE data are collected in a highly consistent manner. To our knowledge, this is the first study of its kind to use standardised data and definitions to specifically investigate common risk factor patterns of edentulousness in these four LMICs. The analysis conducted separately for each country provides insights not possible with only a pooled multi-country analysis. The results provide a platform for further work to help build an evidence-base to inform the development of context-specific policies on oral health in LMICs.

Conclusions

The study calls for strengthening of the CRFA for oral and other NCDs [78]. The focus should be on the common determinants of health, community participation, partnerships with other sectors, healthy public policies and reducing health inequalities and inequities to achieve improvements in oral and overall health.

Abbreviations

CI, confidence interval; CRFA, common risk factor approach; DALYs, Disability adjusted life years; HICs, high-income countries; LMICs, low-and middle-income countries; NCDs, non-communicable diseases; OR, odds ratio; SAGE, Study on global AGEing and adult health; WHO, World Health Organization

Acknowledgements

We are grateful to the respondents of WHO- SAGE Wave 1 in China, India, Ghana and South Africa and to the WHO for making the WHO-SAGE dataset publically available. Support for WHO- SAGE-Wave 1 was provided by the United States National Institute on Aging (NIA) Division of Behavioral and Social Research (BSR) through Interagency Agreements (YA1323–08-CN-0020; Y1-AG-1005–01). We are also grateful to the feedback received from our reviewers.

Funding

AK is a Swedish Institute (SI) Scholarship Holder for the Master of Public Health program at Umeå University. RP received no funding for this work. JSW was supported by the FORTE grant for the Umeå Centre for Global Health Research (No. 2006–1512). The funders had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript.

Availability of data and materials

SAGE is committed to the public release of study instruments, protocols and meta- and micro-data: access is provided upon completion of the Users Agreement available through WHO’s SAGE website (www.​who.​int/​healthinfo/​systems/​sage) and WHO’s archive using the National Data Archive application (http://​apps.​who.​int/​healthinfo/​systems/​surveydata).

Authors’ contributions

AK made a substantial contribution to the conception of the study, analyzed data and wrote the first draft. RP participated in the conception of the manuscript and provided critical inputs to the Introduction and the Discussion. JSW directed the study, developed the first and last drafts, checked the analyses, drafted the response to peer review, provided critical inputs and advised at all stages of the manuscript. All authors approved the final draft.

Competing interests

The authors declare that they have no competing interests.
Not applicable.
The SAGE study was approved by the Ethics Review Committee, World Health Organization, Geneva, Switzerland and the individual ethics committees in each of the SAGE countries. Written informed consent was freely obtained from each individual participant. Confidential records of participants’ consent are maintained by SAGE country teams.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
Literatur
1.
Zurück zum Zitat Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon J, Abdalla S, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2198–227. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon J, Abdalla S, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2198–227.
3.
Zurück zum Zitat Marcenes W, Kassebaum NJ, Bernabe E, Flaxman A, Naghavi M, Lopez A, Murray CJ. Global burden of oral conditions in 1990–2010: a systematic analysis. In: J Dent Res. 2013;92(7):592–97. doi:10.1177/0022034513490168 Marcenes W, Kassebaum NJ, Bernabe E, Flaxman A, Naghavi M, Lopez A, Murray CJ. Global burden of oral conditions in 1990–2010: a systematic analysis. In: J Dent Res. 2013;92(7):592–97. doi:10.​1177/​0022034513490168​
4.
5.
Zurück zum Zitat van der Putten G-J, de Baat C, De Visschere L, Schols J. Poor oral health, a potential new geriatric syndrome. Gerodontology. 2014;31 Suppl 1:17–24.CrossRefPubMed van der Putten G-J, de Baat C, De Visschere L, Schols J. Poor oral health, a potential new geriatric syndrome. Gerodontology. 2014;31 Suppl 1:17–24.CrossRefPubMed
6.
Zurück zum Zitat Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. In: Community Dent Oral Epidemiol. 2005;33:81–92. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. In: Community Dent Oral Epidemiol. 2005;33:81–92.
7.
Zurück zum Zitat Thorpe S. Oral Health Issues in the African Region: Current situation and future perspectives. J Dent Educ. 2006;70:8–15. Thorpe S. Oral Health Issues in the African Region: Current situation and future perspectives. J Dent Educ. 2006;70:8–15.
8.
Zurück zum Zitat Baelum V, van Palenstein Helderman W, Hugoson A, Yee R, Fejerskov O. A global perspective on changes in the burden of caries and periodontitis: implications for dentistry. In: J Oral Rehabil. England: 2007;34:872–906. discussion 940. doi:10.1111/j.1365-2842.2007.01799.x Baelum V, van Palenstein Helderman W, Hugoson A, Yee R, Fejerskov O. A global perspective on changes in the burden of caries and periodontitis: implications for dentistry. In: J Oral Rehabil. England: 2007;34:872–906. discussion 940. doi:10.​1111/​j.​1365-2842.​2007.​01799.​x
9.
Zurück zum Zitat Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003;31 Suppl 1:3–23.CrossRefPubMed Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003;31 Suppl 1:3–23.CrossRefPubMed
10.
Zurück zum Zitat Esan TA, Olusile AO, Akeredolu PA, Esan AO. Socio-demographic factors and edentulism: the Nigerian experience. In: BMC Oral Health, vol. 4. 2004. p. 3. Esan TA, Olusile AO, Akeredolu PA, Esan AO. Socio-demographic factors and edentulism: the Nigerian experience. In: BMC Oral Health, vol. 4. 2004. p. 3.
13.
Zurück zum Zitat Arora M, Schwarz E, Sivaneswaran S, Banks E. Cigarette smoking and tooth loss in a cohort of older Australians: the 45 and up study. In: J Am Dent Assoc. Volume 141. United States; 2010: 1242–1249. Arora M, Schwarz E, Sivaneswaran S, Banks E. Cigarette smoking and tooth loss in a cohort of older Australians: the 45 and up study. In: J Am Dent Assoc. Volume 141. United States; 2010: 1242–1249.
14.
Zurück zum Zitat Northridge ME, Ue FV, Borrell LN, De La Cruz LD, Chakraborty B, Bodnar S, Marshall S, Lamster IB. Tooth loss and dental caries in community-dwelling older adults in northern Manhattan. Gerodontology. 2012;29(2):e464–73.CrossRefPubMed Northridge ME, Ue FV, Borrell LN, De La Cruz LD, Chakraborty B, Bodnar S, Marshall S, Lamster IB. Tooth loss and dental caries in community-dwelling older adults in northern Manhattan. Gerodontology. 2012;29(2):e464–73.CrossRefPubMed
15.
Zurück zum Zitat Medina-Solis CE, Pontigo-Loyola AP, Perez-Campos E, Hernandez-Cruz P, Avila-Burgos L, Mendoza-Rodriguez M, Maupome G. Determinants of self-reported health © Med Sci Monit. 2014;20:843-52. doi:10.12659/MSM.890100. Medina-Solis CE, Pontigo-Loyola AP, Perez-Campos E, Hernandez-Cruz P, Avila-Burgos L, Mendoza-Rodriguez M, Maupome G. Determinants of self-reported health © Med Sci Monit. 2014;20:843-52. doi:10.​12659/​MSM.​890100.
16.
Zurück zum Zitat Kim HS, Son JH, Yi HY, Hong HK, Suh HJ, Bae KH. Association between harmful alcohol use and periodontal status according to gender and smoking. BMC Oral Health. 2014;14:73. doi:10.1186/1472-6831-14-73. Kim HS, Son JH, Yi HY, Hong HK, Suh HJ, Bae KH. Association between harmful alcohol use and periodontal status according to gender and smoking. BMC Oral Health. 2014;14:73. doi:10.​1186/​1472-6831-14-73.
17.
Zurück zum Zitat De Marchi RJ, Hugo FN, Padilha DM, Hilgert JB, Machado DB, Durgante PC, Antunes MT. Edentulism, use of dentures and consumption of fruit and vegetables in south Brazilian community-dwelling elderly. J Oral Rehabil. 2011;38(7):533–40.CrossRefPubMed De Marchi RJ, Hugo FN, Padilha DM, Hilgert JB, Machado DB, Durgante PC, Antunes MT. Edentulism, use of dentures and consumption of fruit and vegetables in south Brazilian community-dwelling elderly. J Oral Rehabil. 2011;38(7):533–40.CrossRefPubMed
18.
Zurück zum Zitat Vargas CM, Yellowitz JA, Hayes KL. Oral health status of older rural adults in the United States. J Am Dent Assoc. 2003;134(4):479–86.CrossRefPubMed Vargas CM, Yellowitz JA, Hayes KL. Oral health status of older rural adults in the United States. J Am Dent Assoc. 2003;134(4):479–86.CrossRefPubMed
19.
Zurück zum Zitat Pallegedara C, Ekanayake L. Tooth loss, the wearing of dentures and associated factors in Sri Lankan older individuals. Gerodontology. 2005;22:193–9.CrossRefPubMed Pallegedara C, Ekanayake L. Tooth loss, the wearing of dentures and associated factors in Sri Lankan older individuals. Gerodontology. 2005;22:193–9.CrossRefPubMed
20.
Zurück zum Zitat Dogan BG, Gokalp S. Tooth loss and edentulism in the Turkish elderly. In: Arch Gerontol Geriatr, vol. 54. Netherlands: A 2012 Elsevier Ireland Ltd; 2012. p. e162–6. Dogan BG, Gokalp S. Tooth loss and edentulism in the Turkish elderly. In: Arch Gerontol Geriatr, vol. 54. Netherlands: A 2012 Elsevier Ireland Ltd; 2012. p. e162–6.
21.
Zurück zum Zitat Gaio EJ, Haas AN, Carrard VC, Oppermann RV, Albandar J, Susin C. Oral health status in elders from South Brazil: a population-based study. Gerodontology. 2012;29(3):214–23.CrossRefPubMed Gaio EJ, Haas AN, Carrard VC, Oppermann RV, Albandar J, Susin C. Oral health status in elders from South Brazil: a population-based study. Gerodontology. 2012;29(3):214–23.CrossRefPubMed
22.
Zurück zum Zitat Mendes DC, Poswar Fde O, de Oliveira MV, Haikal DS, da Silveira MF, Martins AM, De Paula AM. Analysis of socio-demographic and systemic health factors and the normative conditions of oral health care in a population of the Brazilian elderly. Gerodontology. 2012;29(2):e206–14.CrossRefPubMed Mendes DC, Poswar Fde O, de Oliveira MV, Haikal DS, da Silveira MF, Martins AM, De Paula AM. Analysis of socio-demographic and systemic health factors and the normative conditions of oral health care in a population of the Brazilian elderly. Gerodontology. 2012;29(2):e206–14.CrossRefPubMed
23.
Zurück zum Zitat Russell SL, Gordon S, Lukacs JR, Kaste LM. Sex/Gender differences in tooth loss and edentulism: historical perspectives, biological factors, and sociologic reasons. Dent Clin North Am. 2013;57(2):317–37.CrossRefPubMed Russell SL, Gordon S, Lukacs JR, Kaste LM. Sex/Gender differences in tooth loss and edentulism: historical perspectives, biological factors, and sociologic reasons. Dent Clin North Am. 2013;57(2):317–37.CrossRefPubMed
24.
Zurück zum Zitat Wennstrom A, Ahlqwist M, Stenman U, Bjorkelund C, Hakeberg M. Trends in tooth loss in relation to socio-economic status among Swedish women, aged 38 and 50 years: repeated cross-sectional surveys 1968–2004. BMC Oral Health. 2013;13:63.CrossRefPubMedPubMedCentral Wennstrom A, Ahlqwist M, Stenman U, Bjorkelund C, Hakeberg M. Trends in tooth loss in relation to socio-economic status among Swedish women, aged 38 and 50 years: repeated cross-sectional surveys 1968–2004. BMC Oral Health. 2013;13:63.CrossRefPubMedPubMedCentral
25.
Zurück zum Zitat Kowall B, Holtfreter B, Volzke H, Schipf S, Mundt T, Rathmann W, Kocher T. Pre-diabetes and well-controlled diabetes are not associated with periodontal disease: the SHIP Trend Study. J Clin Periodontol. 2015;42:422–30. doi: 10.1111/jcpe.12391. Kowall B, Holtfreter B, Volzke H, Schipf S, Mundt T, Rathmann W, Kocher T. Pre-diabetes and well-controlled diabetes are not associated with periodontal disease: the SHIP Trend Study. J Clin Periodontol. 2015;42:422–30. doi: 10.​1111/​jcpe.​12391.
26.
Zurück zum Zitat Medina-Solis CE, Pontigo-Loyola AP, Perez-Campos E, Hernandez-Cruz P, Avila-Burgos L, Kowolik MJ, Maupome G. Association between edentulism and angina pectoris in Mexican adults aged 35 years and older: a multivariate analysis of a population-based survey. J Periodontol. 2014;85(3):406–16.CrossRefPubMed Medina-Solis CE, Pontigo-Loyola AP, Perez-Campos E, Hernandez-Cruz P, Avila-Burgos L, Kowolik MJ, Maupome G. Association between edentulism and angina pectoris in Mexican adults aged 35 years and older: a multivariate analysis of a population-based survey. J Periodontol. 2014;85(3):406–16.CrossRefPubMed
27.
Zurück zum Zitat Ayo-Yusuf OA, Ayo-Yusuf IJ. Association of tooth loss with hypertension. S Afr Med J. 2008;98(5):381–5.PubMed Ayo-Yusuf OA, Ayo-Yusuf IJ. Association of tooth loss with hypertension. S Afr Med J. 2008;98(5):381–5.PubMed
28.
Zurück zum Zitat Scannapieco FA. Role of oral bacteria in respiratory infection. J Periodontol. 1999;70(7):793–802.CrossRefPubMed Scannapieco FA. Role of oral bacteria in respiratory infection. J Periodontol. 1999;70(7):793–802.CrossRefPubMed
29.
Zurück zum Zitat Mattila KJ, Asikainen S, Wolf J, Jousimies-Somer H, Valtonen V, Nieminen M. Age, dental infections, and coronary heart disease. J Dent Res. 2000;79(2):756–60.CrossRefPubMed Mattila KJ, Asikainen S, Wolf J, Jousimies-Somer H, Valtonen V, Nieminen M. Age, dental infections, and coronary heart disease. J Dent Res. 2000;79(2):756–60.CrossRefPubMed
30.
Zurück zum Zitat He W, Goodkind D, Kowal P. U.S. Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015, U.S. Government Publishing Office, Washington, DC,2016. He W, Goodkind D, Kowal P. U.S. Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015, U.S. Government Publishing Office, Washington, DC,2016.
31.
Zurück zum Zitat World Health Organization. World Report on Ageing and Health. Geneva: WHO; 2015. p. 260. World Health Organization. World Report on Ageing and Health. Geneva: WHO; 2015. p. 260.
32.
Zurück zum Zitat World Health Organization. The Global Burden of Disease 2004 update. Geneva: WHO; 2008. p. 146. World Health Organization. The Global Burden of Disease 2004 update. Geneva: WHO; 2008. p. 146.
33.
Zurück zum Zitat Ng N, Kowal P, Kahn K, Naidoo N, Abdullah S, Bawah A, Binka F, Chuc N, Debpuur C, Egondi T, et al. Health inequalities among older men and women in Africa and Asia: evidence from eight Health and Demographic Surveillance System sites in the INDEPTH WHO-SAGE study. Global Health Action. 2010;Suppl 2:96–107. doi:10.3402/gha.v3i0.5420. Ng N, Kowal P, Kahn K, Naidoo N, Abdullah S, Bawah A, Binka F, Chuc N, Debpuur C, Egondi T, et al. Health inequalities among older men and women in Africa and Asia: evidence from eight Health and Demographic Surveillance System sites in the INDEPTH WHO-SAGE study. Global Health Action. 2010;Suppl 2:96–107. doi:10.​3402/​gha.​v3i0.​5420.
34.
Zurück zum Zitat McGrath C, Zhang W, Lo EC. A review of the effectiveness of oral health promotion activities among older people. Gerodontology. 2009;26:85–96.CrossRefPubMed McGrath C, Zhang W, Lo EC. A review of the effectiveness of oral health promotion activities among older people. Gerodontology. 2009;26:85–96.CrossRefPubMed
35.
Zurück zum Zitat Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol. 2000;28(6):399–406.CrossRefPubMed Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol. 2000;28(6):399–406.CrossRefPubMed
36.
Zurück zum Zitat Sheiham A, Alexander D, Cohen L, Marinho V, Moyses S, Petersen PE, Spencer J, Watt RG, Weyant R. Global oral health inequalities: task group--implementation and delivery of oral health strategies. In: Adv Dent Res. 2011;23(2):259-67. doi:10.1177/0022034511402084. Sheiham A, Alexander D, Cohen L, Marinho V, Moyses S, Petersen PE, Spencer J, Watt RG, Weyant R. Global oral health inequalities: task group--implementation and delivery of oral health strategies. In: Adv Dent Res. 2011;23(2):259-67. doi:10.​1177/​0022034511402084​.
37.
Zurück zum Zitat Watt RG. Social determinants of oral health inequalities: implications for action. Community Dent Oral Epidemiol. 2012;40 Suppl 2:44–8.CrossRefPubMed Watt RG. Social determinants of oral health inequalities: implications for action. Community Dent Oral Epidemiol. 2012;40 Suppl 2:44–8.CrossRefPubMed
38.
Zurück zum Zitat Petersen PE. Challenges to improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Int Dent J. 2004;54(6 Suppl 1):329–43.CrossRefPubMed Petersen PE. Challenges to improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Int Dent J. 2004;54(6 Suppl 1):329–43.CrossRefPubMed
40.
Zurück zum Zitat Hosseinpoor AR, Itani L, Peterson PE. Socio-economic Inequality in oral healthcare coverage : results from the World Health Survey. J Dent Res. 2012;91(3):275–81.CrossRefPubMed Hosseinpoor AR, Itani L, Peterson PE. Socio-economic Inequality in oral healthcare coverage : results from the World Health Survey. J Dent Res. 2012;91(3):275–81.CrossRefPubMed
41.
Zurück zum Zitat Cunha-Cruz J, Hujoel PP, Nadanovsky P. Secular trends in socio-economic disparities in edentulism: USA, 1972–2001. In: J Dent Res. 2007; 86(2):131-36. Cunha-Cruz J, Hujoel PP, Nadanovsky P. Secular trends in socio-economic disparities in edentulism: USA, 1972–2001. In: J Dent Res. 2007; 86(2):131-36.
42.
Zurück zum Zitat Fure S, Zickert I. Incidence of tooth loss and dental caries in 60-, 70- and 80-year-old Swedish individuals. Community Dent Oral Epidemiol. 1997;25(2):137–42.CrossRefPubMed Fure S, Zickert I. Incidence of tooth loss and dental caries in 60-, 70- and 80-year-old Swedish individuals. Community Dent Oral Epidemiol. 1997;25(2):137–42.CrossRefPubMed
43.
Zurück zum Zitat Fure S. Ten-year Incidence of toothlLoss and dental caries in elderly Swedish individuals. Caries Res. 2003;37:462–9.CrossRefPubMed Fure S. Ten-year Incidence of toothlLoss and dental caries in elderly Swedish individuals. Caries Res. 2003;37:462–9.CrossRefPubMed
44.
Zurück zum Zitat Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases (2002 : Geneva, Switzerland) Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation, Geneva, 28 January -- 1 February 2002. (WHO technical report series; 916) 160 pages. Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases (2002 : Geneva, Switzerland) Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation, Geneva, 28 January -- 1 February 2002. (WHO technical report series; 916) 160 pages.
45.
Zurück zum Zitat Ogunbodede EO. Population ageing and the implications for oral health in Africa. Gerodontology. 2013;30:1–2.CrossRefPubMed Ogunbodede EO. Population ageing and the implications for oral health in Africa. Gerodontology. 2013;30:1–2.CrossRefPubMed
46.
Zurück zum Zitat Shah N, Sundaram KR. Impact of socio-demographic variables, oral hygiene practices, oral habits and diet on dental caries experience of Indian elderly: a community-based study. Gerodontology. 2004;21:43–50.CrossRefPubMed Shah N, Sundaram KR. Impact of socio-demographic variables, oral hygiene practices, oral habits and diet on dental caries experience of Indian elderly: a community-based study. Gerodontology. 2004;21:43–50.CrossRefPubMed
47.
Zurück zum Zitat Lin HC, Corbet EF, Lo ECM. Tooth Loss, Occluding Pairs, and Prosthetic Status of Chinese Adults. J Dent Res. 2001;80(5):1491–5.CrossRefPubMed Lin HC, Corbet EF, Lo ECM. Tooth Loss, Occluding Pairs, and Prosthetic Status of Chinese Adults. J Dent Res. 2001;80(5):1491–5.CrossRefPubMed
48.
Zurück zum Zitat Hobdell MH, Myburgh NG, Lalloo R, Chikte UM, Owen CP. Oral disease in Africa: a challenge to change oral health priorities. Oral Dis. 1997;3(4):216–22.CrossRefPubMed Hobdell MH, Myburgh NG, Lalloo R, Chikte UM, Owen CP. Oral disease in Africa: a challenge to change oral health priorities. Oral Dis. 1997;3(4):216–22.CrossRefPubMed
49.
Zurück zum Zitat Thompson WM. Epidemiology of oral health conditions in older people. Gerodontology. 2014;31 Suppl 1:9–16.CrossRef Thompson WM. Epidemiology of oral health conditions in older people. Gerodontology. 2014;31 Suppl 1:9–16.CrossRef
50.
Zurück zum Zitat Peltzer K, Hewlett S, Yawson AE, Moynihan P, Preet R, Wu F, Guo G, Arokiasamy P, Snodgrass JJ, Chatterji S, et al. Prevalence of loss of all teeth (edentulism) and associated factors in older adults in China, Ghana, India, Mexico, Russia and South Africa. Int J Environ Res Public Health. 2014;11(11):11308–24.CrossRefPubMedPubMedCentral Peltzer K, Hewlett S, Yawson AE, Moynihan P, Preet R, Wu F, Guo G, Arokiasamy P, Snodgrass JJ, Chatterji S, et al. Prevalence of loss of all teeth (edentulism) and associated factors in older adults in China, Ghana, India, Mexico, Russia and South Africa. Int J Environ Res Public Health. 2014;11(11):11308–24.CrossRefPubMedPubMedCentral
51.
Zurück zum Zitat Naidoo N. Working Paper Number 5. In: WHO, editor. WHO’s Study on global AGEing and adult health (SAGE) Waves 0 and 1 sampling information for China, Ghana, India, Mexico, Russia and South Africa. Genève: WHO SAGE; 2012. p. 9. Naidoo N. Working Paper Number 5. In: WHO, editor. WHO’s Study on global AGEing and adult health (SAGE) Waves 0 and 1 sampling information for China, Ghana, India, Mexico, Russia and South Africa. Genève: WHO SAGE; 2012. p. 9.
52.
Zurück zum Zitat Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, Inoue M. Age standardization of rates: a new WHO standard. In: GPE Discussion Paper Series: No31. Geneva: World Health Organization; 2001. p. 14. Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, Inoue M. Age standardization of rates: a new WHO standard. In: GPE Discussion Paper Series: No31. Geneva: World Health Organization; 2001. p. 14.
53.
Zurück zum Zitat Kowal P, Chatterji S, Naidoo N, Biritwum R, Fan W, Lopez Ridaura R, Maximova T, Arokiasamy P, Phaswana-Mafuya N, Williams S, et al. Data resource profile: the World Health Organization Study on global AGEing and adult health (SAGE). In: Int J Epidemiol. 2012;41:1639–1649. doi: 10.1093/ije/dys210. Kowal P, Chatterji S, Naidoo N, Biritwum R, Fan W, Lopez Ridaura R, Maximova T, Arokiasamy P, Phaswana-Mafuya N, Williams S, et al. Data resource profile: the World Health Organization Study on global AGEing and adult health (SAGE). In: Int J Epidemiol. 2012;41:1639–1649. doi: 10.​1093/​ije/​dys210.
54.
Zurück zum Zitat Ferguson B, Murray CL, Tandon A, Gakidou E. Estimating permanent income using asset and indicator variables. In: Murray CL, Evans DB, editors. Health systems performance assessment debates, methods and empiricism. Geneva: World Health Organization; 2003. Ferguson B, Murray CL, Tandon A, Gakidou E. Estimating permanent income using asset and indicator variables. In: Murray CL, Evans DB, editors. Health systems performance assessment debates, methods and empiricism. Geneva: World Health Organization; 2003.
55.
Zurück zum Zitat Howe LD, Galobardes B, Matijasevich A, Gordon D, Johnston D, Onwujekwe O, Patel R, Webb EA, Lawlor DA, Hargreaves JA. Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper. Int J Epidemiol. 2012. doi:10.1093/ije/dys037:16. Howe LD, Galobardes B, Matijasevich A, Gordon D, Johnston D, Onwujekwe O, Patel R, Webb EA, Lawlor DA, Hargreaves JA. Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper. Int J Epidemiol. 2012. doi:10.​1093/​ije/​dys037:​16.
58.
59.
Zurück zum Zitat Henriksen BM, Axell T, Laake K. Geographic differences in tooth loss and denture-wearing among the elderly in Norway. Community Dent Oral Epidemiol. 2003;31(6):403–11.CrossRefPubMed Henriksen BM, Axell T, Laake K. Geographic differences in tooth loss and denture-wearing among the elderly in Norway. Community Dent Oral Epidemiol. 2003;31(6):403–11.CrossRefPubMed
60.
Zurück zum Zitat Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report. 2003;52(50):1226-9. Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report. 2003;52(50):1226-9.
61.
Zurück zum Zitat Islas-Granillo H, Borges-Yanez SA, Lucas-Rincon SE, Medina-Solis CE, Casanova-Rosado AJ, Marquez-Corona ML, Maupome G. Edentulism risk indicators among Mexican elders 60-year-old and older. In: Arch Gerontol Geriatr, vol. 53. 53rd ed. Netherlands: 2010 Elsevier Ireland Ltd; 2011. p. 258–62. Islas-Granillo H, Borges-Yanez SA, Lucas-Rincon SE, Medina-Solis CE, Casanova-Rosado AJ, Marquez-Corona ML, Maupome G. Edentulism risk indicators among Mexican elders 60-year-old and older. In: Arch Gerontol Geriatr, vol. 53. 53rd ed. Netherlands: 2010 Elsevier Ireland Ltd; 2011. p. 258–62.
62.
Zurück zum Zitat Stewart Williams JA. Assessing the suitability of fractional polynomial methods in health services research. A perspective on the categorisation epidemic. J Health Serv Res Policy. 2011;16(3):147–52.CrossRef Stewart Williams JA. Assessing the suitability of fractional polynomial methods in health services research. A perspective on the categorisation epidemic. J Health Serv Res Policy. 2011;16(3):147–52.CrossRef
64.
Zurück zum Zitat Haikola B, Oikarinen K, Soderholm AL, Remes-Lyly T, Sipila K. Prevalence of edentulousness and related factors among elderly Finns. J Oral Rehabil. 2008;35(11):827–35.CrossRefPubMed Haikola B, Oikarinen K, Soderholm AL, Remes-Lyly T, Sipila K. Prevalence of edentulousness and related factors among elderly Finns. J Oral Rehabil. 2008;35(11):827–35.CrossRefPubMed
65.
Zurück zum Zitat Inagaki K, Kurosu Y, Kamiya T, Kondo F, Yoshinari N, Noguchi T, Krall EA, Garcia RI. Low metacarpal bone density, tooth loss, and periodontal disease in Japanese women. J Dent Res. 2001;80(9):1818–22.CrossRefPubMed Inagaki K, Kurosu Y, Kamiya T, Kondo F, Yoshinari N, Noguchi T, Krall EA, Garcia RI. Low metacarpal bone density, tooth loss, and periodontal disease in Japanese women. J Dent Res. 2001;80(9):1818–22.CrossRefPubMed
66.
Zurück zum Zitat Mohammad AR, Hooper DA, Vermilyea SG, Mariotti A, Preshaw PM. An investigation of the relationship between systemic bone density and clinical periodontal status in post-menopausal Asian-American women. Int Dent J. 2003;53(3):121–5.CrossRefPubMed Mohammad AR, Hooper DA, Vermilyea SG, Mariotti A, Preshaw PM. An investigation of the relationship between systemic bone density and clinical periodontal status in post-menopausal Asian-American women. Int Dent J. 2003;53(3):121–5.CrossRefPubMed
67.
Zurück zum Zitat Brennan RM, Genco RJ, Hovey KM, Trevisan M, Wactawski-Wende J. Clinical attachment loss, systemic bone density, and subgingival calculus in postmenopausal women. J Periodontol. 2007;78(11):2104–11.CrossRefPubMed Brennan RM, Genco RJ, Hovey KM, Trevisan M, Wactawski-Wende J. Clinical attachment loss, systemic bone density, and subgingival calculus in postmenopausal women. J Periodontol. 2007;78(11):2104–11.CrossRefPubMed
68.
Zurück zum Zitat Shimazaki Y, Soh I, Koga T, Miyazaki H, Takehara T. Risk factors for tooth loss in the institutionalised elderly; a six-year cohort study. Community Dent Health. 2003;20(2):123–7.PubMed Shimazaki Y, Soh I, Koga T, Miyazaki H, Takehara T. Risk factors for tooth loss in the institutionalised elderly; a six-year cohort study. Community Dent Health. 2003;20(2):123–7.PubMed
69.
Zurück zum Zitat Marcus PA, Joshi A, Jones JA, Morgano SM. Complete edentulism and denture use for elders in New England. J Prosthet Dent. 1996;76(3):260–6.CrossRefPubMed Marcus PA, Joshi A, Jones JA, Morgano SM. Complete edentulism and denture use for elders in New England. J Prosthet Dent. 1996;76(3):260–6.CrossRefPubMed
70.
Zurück zum Zitat Spolsky VW, Marcus M, Der-Martirosian C, Coulter ID, Maida CA. Oral health status and the epidemiologic paradox within Latino immigrant groups. BMC Oral Health. 2012;12:39.CrossRefPubMedPubMedCentral Spolsky VW, Marcus M, Der-Martirosian C, Coulter ID, Maida CA. Oral health status and the epidemiologic paradox within Latino immigrant groups. BMC Oral Health. 2012;12:39.CrossRefPubMedPubMedCentral
71.
Zurück zum Zitat Krall EA, Dawson-Hughes B, Garvey AJ, Garcia RI. Smoking, smoking cessation, and tooth loss. J Dent Res. 1997;76(10):1653–9.CrossRefPubMed Krall EA, Dawson-Hughes B, Garvey AJ, Garcia RI. Smoking, smoking cessation, and tooth loss. J Dent Res. 1997;76(10):1653–9.CrossRefPubMed
72.
Zurück zum Zitat Hanioka T, Ojima M, Tanaka K, Aoyama H: Association of total tooth loss with smoking, drinking alcohol and nutrition in elderly Japanese: analysis of national database. In: Gerodontology. 2007;24(2):87–92. doi:10.1111/j.1741-2358.2007.00166.x. Hanioka T, Ojima M, Tanaka K, Aoyama H: Association of total tooth loss with smoking, drinking alcohol and nutrition in elderly Japanese: analysis of national database. In: Gerodontology. 2007;24(2):87–92. doi:10.​1111/​j.​1741-2358.​2007.​00166.​x.
73.
Zurück zum Zitat Heegaard K, Avlund K, Holm-Pedersen P, Hvidtfeldt UA, Bardow A, Gronbaek M. Amount and type of alcohol consumption and missing teeth among community-dwelling older adults: findings from the Copenhagen Oral Health Senior study. J Public Health Dent. 2011;71(4):318–26.CrossRefPubMed Heegaard K, Avlund K, Holm-Pedersen P, Hvidtfeldt UA, Bardow A, Gronbaek M. Amount and type of alcohol consumption and missing teeth among community-dwelling older adults: findings from the Copenhagen Oral Health Senior study. J Public Health Dent. 2011;71(4):318–26.CrossRefPubMed
74.
Zurück zum Zitat Marcenes W, Steele JG, Sheiham A, Walls AW. The relationship between dental status, food selection, nutrient intake, nutritional status, and body mass index in older people. In: Cad Saude Publica. Brazil; 2003;19(3):809–816. Marcenes W, Steele JG, Sheiham A, Walls AW. The relationship between dental status, food selection, nutrient intake, nutritional status, and body mass index in older people. In: Cad Saude Publica. Brazil; 2003;19(3):809–816.
75.
Zurück zum Zitat Tsakos G, Herrick K, Sheiham A, Watt RG. Edentulism and fruit and vegetable intake in low-income adults. In: J Dent Res. United States; 2010;89(5):462–67. doi: 10.1177/0022034510363247. Tsakos G, Herrick K, Sheiham A, Watt RG. Edentulism and fruit and vegetable intake in low-income adults. In: J Dent Res. United States; 2010;89(5):462–67. doi: 10.​1177/​0022034510363247​.
76.
Zurück zum Zitat Desvarieux M, Demmer RT, Rundek T, Boden-Albala B, Jacobs DR, Jr., Papapanou PN, Sacco RL. Relationship between periodontal disease, tooth loss, and carotid artery plaque: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). In: Stroke. United States; 2003;34:2120–125. doi: 10.1161/01.STR.0000085086.50957.22. Desvarieux M, Demmer RT, Rundek T, Boden-Albala B, Jacobs DR, Jr., Papapanou PN, Sacco RL. Relationship between periodontal disease, tooth loss, and carotid artery plaque: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). In: Stroke. United States; 2003;34:2120–125. doi: 10.​1161/​01.​STR.​0000085086.​50957.​22.
77.
Zurück zum Zitat Lowe G, Woodward M, Rumley A, Morrison C, Tunstall-Pedoe H, Stephen K. Total tooth loss and prevalent cardiovascular disease in men and women: possible roles of citrus fruit consumption, vitamin C, and inflammatory and thrombotic variables. In: J Clin Epidemiol. England; 2003;56(7): 694–700. doi: http://dx.doi.org/10.1016/S0895-4356(03)00086. Lowe G, Woodward M, Rumley A, Morrison C, Tunstall-Pedoe H, Stephen K. Total tooth loss and prevalent cardiovascular disease in men and women: possible roles of citrus fruit consumption, vitamin C, and inflammatory and thrombotic variables. In: J Clin Epidemiol. England; 2003;56(7): 694–700. doi: http://​dx.​doi.​org/​10.​1016/​S0895-4356(03)00086.
Metadaten
Titel
Common risk factors and edentulism in adults, aged 50 years and over, in China, Ghana, India and South Africa: results from the WHO Study on global AGEing and adult health (SAGE)
verfasst von
Alexander Kailembo
Raman Preet
Jennifer Stewart Williams
Publikationsdatum
01.12.2017
Verlag
BioMed Central
Erschienen in
BMC Oral Health / Ausgabe 1/2017
Elektronische ISSN: 1472-6831
DOI
https://doi.org/10.1186/s12903-016-0256-2

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