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The Impact of Oral Health on the Academic Performance of Disadvantaged Children

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We measured the impact of dental diseases on the academic performance of disadvantaged children by sociodemographic characteristics and access to care determinants We performed clinical dental examinations on 1495 disadvantaged elementary and high school students from Los Angeles County public schools. We matched data with academic achievement and attendance data provided by the school district and linked these to the child's social determinants of oral health and the impact of oral health on the child's school and the parents' school or work absences. Students with toothaches were almost 4 times more likely to have a low grade point average. About 11% of students with inaccessible needed dental care missed school compared with 4% of those with access. Per 100 elementary and high school-aged children, 58 and 80 school hours, respectively, are missed annually. Parents averaged 2.5 absent days from work or school per year because of their children's dental problems. Oral health affects students' academic performance. Studies are needed that unbundle the clinical, socioeconomic, and cultural challenges associated with this epidemic of dental disease in children.
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The Impact of Oral Health on the Academic Performance
of Disadvantaged Children
Hazem Seirawan, DDS, MPH, MS, Sharon Faust, DDS, and Roseann Mulligan, DDS, MS
Poor oral health affects systemic health with
consequences that can seriously compromise
quality of life and life expectancy. Oral diseases
can lead to systemic diseases, emergency hos-
pital visits, hospital stays, medications, even
death. Moreover, oral disease can increase
personal, societal, and nancial burdens and
contribute to rising health care costs in
general.
1
Anecdotally, we know that there is an
epidemic of dental diseases among disadvan-
taged children in Los Angeles County, as is
consistently observed by health professionals and
community stakeholders. To quantify this obser-
vation, we established a campus---community
project with the goals of measuring this epi-
demic and its impact and designing appropri-
ate intervention programs to ultimately
reduce the burden of poor oral health among
these children. Previously, we documented
that the overall prevalence of dental caries in
this population of disadvantaged children
was 73% and that no important racial/ethnic
differences were found between Blacks, Asians,
White, and non-White or otherHispanics.
2
One aspect of this project, which we have
reported in this article, is to measure the
impact of dental diseases on the academic
performance of these disadvantaged children
by their sociodemographic characteristics and
access to care determinants.
It has been suggested that objective mea-
sures of oral health should be linked to mea-
sures of social outcome to place dental condi-
tions within a broader context that is relevant
to policymakers.
3
BasedontheNational
Health Interview Survey of 1989, it has been
estimated that 51 million school hours are
lost yearly because of dental disease based on
a 15-day recollection.
4
This result has been
widely cited. A Google search provided more
than 57 000 hits when queried for dental+
51 million school hours.According to the
Thomson Scientics Institute for Scientic
Information web of knowledge, this resource
has been cited in the scienticliterature55
times. More recently, the California Health
Interview Survey asked about the number of
school days missed in the past year because
of dental problems; the question was asked
only in the survey of 2007.
5
No other liter-
ature sources provide denitive estimates of
the number of school hours missed because
of dental problems besides that reported by
Gift et al.,
4
nor is there any estimation of the
impact of oral health on the studentsaca-
demic achievement. Furthermore, it should
be noted that the means and SDs reported by
Gift et al. were acknowledged as being in-
accurate, and no corrected estimates were
subsequently published.
6
We have provided
an updated estimate of the impact of dental
problems on disadvantaged children missing
school and parents missing school or work
based on their 1-year recall. Also, we ex-
plored the relationship of oral health with
academic achievement and attendance by
school level, gender, and race/ethnicity. We
will report other aspects of the project
elsewhere.
2
METHODS
We have published the detailed methods of
the study previously.
2
In summary, the study
recruited children in the age groups of 2 to 5,
6 to 8, and 14 to 16 years to represent the
3 stages of dentition in children: deciduous,
mixed, and permanent. The sampling frame for
each group included Women, Infants, and
Children centers and Head Start preschools (for
those aged 2---5 years), elementary schools
(for those aged 6---8 years), and high schools
(for those aged 14---16 years) in Los Angeles
County, California. We determined 2 site in-
clusion criteria: (1) the site must be either
a Women, Infants, and Children center or
a Head Start preschool, or (2) the elementary
and high schools needed at least 50% of their
students to be from a minority race or ethnic
group with at least 62% of them receiving the
reduced or free meals program. We chose
62% because it represents the average per-
centage of public schoolsstudents receiving
reduced or free meals programs in Los
Angeles County. We selected the inclusion
Objectives. We measured the impact of dental diseases on the academic
performance of disadvantaged children by sociodemographic characteristics
and access to care determinants
Methods. We performed clinical dental examinations on 1495 disadvantaged
elementary and high school students from Los Angeles County public schools.
We matched data with academic achievement and attendance data provided by
the school district and linked these to the child’s social determinants of oral
health and the impact of oral health on the child’s school and the parents’ school
or work absences.
Results. Students with toothaches were almost 4 times more likely to have
a low grade point average. About 11% of students with inaccessible needed
dental care missed school compared with 4% of those with access. Per 100
elementary and high school–aged children, 58 and 80 school hours, respectively,
are missed annually. Parents averaged 2.5 absent days from work or school per
year because of their children’s dental problems.
Conclusions. Oral health affects students’ academic performance. Studies
are needed that unbundle the clinical, socioeconomic, and cultural chal-
lenges associated with this epidemic of dental disease in children. (Am J
Public Health. 2012;102:1729–1734. doi:10.2105/AJPH.2011.300478)
RESEARCH AND PRACTICE
September 2012, Vol 102, No. 9 |American Journal of Public Health Seirawan et al. |Peer Reviewed |Research and Practice |1729
criteria to ensure that any selected school in
the sample would have a majority of racial or
ethnic minorities. We randomly selected the
sample sites in a proportional-to-size random
sample clustered by age group except for the
Head Start preschools, for which we used
simple random sampling. As the study pro-
gressed, we added several schools that met the
above criteria to increase the representation
of Asian and Black children. Our sample goal
was to recruit 50 students from 45 sites (15
sites for each age group) for a total of 2250
children.
We sent invitation letters to selected schools
and then telephoned principals to further ex-
plain the project. We sent consent forms and
a questionnaire to the parents to collect in-
formation about their childs sociodemographic
determinants, access to care, oral health be-
haviors, and the parentsattitudes toward oral
health. The investigated sociodemographic de-
terminants were race/ethnicity, gender, place
of birth, language spoken at home, parents
education, number of people living at home,
family household income, and whether the
child receives reduced or free meals at school.
Questions in the section Access to carein-
cluded recent toothache in the past 6 months
and unmet dental needs in the past 12 months.
The Association of State and Territorial Dental
Directors
7
proposed and worded these ques-
tions as During the past 6 months, did this
child have a toothache more than once, when
biting or chewing?and During the past 12
months, did this child need dental care but was
not able to get it?The questionnaires were
available to the parents in English, Spanish,
Vietnamese, and Chinese. The parents
reported race/ethnicity. These questions in-
cluded asking the number of days over the past
year the child missed school because of dental
problems or parents missed school or work
because of the childs dental problems. Two
general dentists conducted the clinical oral
health examinations for all the children at their
respective schools subsequent to having suc-
cessfully completed several calibration ses-
sions. This process resulted in an acceptable
jof 80%. We adapted the Association of State
and Territorial Dental Directors protocol for
basic screening surveys for the clinical ex-
aminations.
7
The outcome variables of the
examination included presence of dental
caries and type of treatment needed. We de-
ned cavitated dental caries as a minimum of
0.5 millimeters discontinuity of enamel and
white spot lesions (noncavitated dental le-
sions) as demineralization in which the color
and translucency of the tooth surface are
altered. We determined types of treatment
needed as (1) urgentfor immediate care
involving pain, infection, swelling, extensive
carious lesions, advanced periodontal condi-
tions, or suspicious soft tissue lesions; (2)
earlyfor care needed within 15 days to
treat dental caries, mild gingivitis, and mini-
mal calculus; or (3) routinefor dental care
within 6 months for prevention.
The Los Angeles Unied School District
(LAUSD) Ofce of Data and Accountability
compiled and provided the academic achieve-
ments and attendance information of the stu-
dents. The information included the students
number of absent days, California Standards
Tests scores, prociency levels for English
language arts and mathematics, and grade
point averages (GPAs; available for high school
students only). These data were for the past
2 years, when available. We coded prociency
levels from 1 to 5, where 1 indicates far below
basic(a serious lack of performance) and 5
indicates advanced(superior performance).
Levels 2, 3, and 4 indicate below basic,
basic,and procient,respectively.
We computed frequency tables, the v
2
test,
and logistic regression models. The depen-
dent variables were the total number of the
childs absent days (reported by the school),
numbers of the childs and parentsabsent
days because of the childs dental problems
(reported by the parent), scores and prociency
levels in English language arts and mathe-
matics, and GPA. We averaged the school
performance items per year from the available
information for the past 2 years, and when
used in logistic regression models, we coded
them into binary variables based on their
medians. The independent variables were
type of school (elementary vs high), gender,
race/ethnicity, plus 3 objective measures and
2 subjective measures of oral health. The
objective measures included all untreated
caries, untreated cavitated caries only, and
emergent dental needs. The subjective mea-
sures were the reported variables of tooth-
ache in the past 6 months and inaccessible but
needed dental care in the past year. We tested
2 additional independent variables for their
effects on the study outcomes: dental insur-
ance and English as the rst or main language
spoken at home. We adjusted the logistic
regression models for type of school, gender,
and race/ethnicity when needed.
RESULTS
We recruited a total sample of 2313 chil-
dren from 59 sites (7 Women, Infants, and
Children centers, 10 Head Start preschools, 21
elementary schools, and 21 high schools) to
represent disadvantaged children in Los
Angeles County. Of them, 1495 students were
elementary and high school students, with their
parents indicating that 6.4% of the parents and
5.5% of the children missed school days or
workdays because of their childrens dental
problems. We excluded children aged 2 to 5
years from this analysis because they did not
have academic records. We retrieved and in-
cluded the academic records of 629 children
from LAUSD (considered the LAUSD subsam-
ple) in the analyses. These academic records
represented 87% of all the LAUSD elementary
and high school students enrolled in the study
who, with their parents, consented to the re-
lease of these records (720 gave permission,
but not all records were retrievable from the
school district). Approximately half of the
children in this LAUSD subsample were boys
(45%), 10% Asians, 24% Blacks, and 66%
Hispanics (Table 1). About 73% of the children
lived in homes with household family incomes
of less than $35 000. Both parents of about
one third of the children had less than a high
school education. About 36% of the children
lived in a home where English was not spoken
at all, and 15% were born outside the United
States (data not shown). In the total subsample,
the prevalence of cavitated caries was 40%,
and the prevalence of cavitated or white lesions
(noncavitated caries) was 69%. Nineteen per-
centof the children had a toothache in the past
6 months, 22% had dental needs but could
not access dental care in the past year, and
8.5% needed immediate dental care (data not
shown). These results from the LAUSD sub-
sample are similar to the results from the
complete sample (LAUSD or non-LAUSD).
2
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The students had an average prociency
level of 3.4 in English language arts and 3.0 in
mathematics, indicating that their level was
between basic and procient. High school
students performed poorer in mathematics
than did elementary school students (P< .001).
High school boys had a lower GPA than did
high school girls (P= .002). Asian students
performed consistently and statistically signi-
cantly better than did other races/ethnicities
(P< .001) and were the only race/ethnicity to
achieve an average GPA above 3 points and
a prociency level between procient and
advanced in English language arts. Elementary
school students averaged 6 absent days com-
pared with 2.6 among high school students.
Asian students had an overall average of 2.1
absent days per school year less than did all
others (P< .001). Children averaged 2.2 ab-
sent days per school year for dental problems,
and parents averaged 2.5 absent days from
work or school per year because of their
childrens dental problems (Table 1).
Table 2 details the impact of different sub-
jective (toothache and inaccessible needed
dental care) and objective (dental caries and
immediate dental needs) measures of oral health
on studentsschool absences because of dental
problems. Almost 16% of students with
toothaches in the past 6 months missed school
compared with 3% of those without tooth-
aches (P< .001). Also, almost 11% of stu-
dents with inaccessible needed dental care in the
past year missed school compared with 4% of
thosewhohadaccesstodentalcare(P<.001).
The impact of these subjective measures of
oral health (toothache and inaccessible
needed dental care) on attendance was consis-
tently and statistically signicantly higher among
those with poorer oral health when we com-
pared levels of schooling, genders, and between
Asians and other Hispanics. Of students with
caries, 6% missed school compared with 4%
of those without caries, which was not statisti-
cally signicant; however, 9% of students with
urgent dental needs missed school compared
with 5% of those without urgent dental
needs (P= .048; Table 2). Neither whether
the child had dental insurance nor whether
English was the rst or main language spo-
ken at home was statistically signicantly
correlated with the childs number of missing
school days for dental problems (data not
shown).
Table 3 shows the odds ratios (ORs) of
different subjective and objective measures of
oral health on studentsacademic achieve-
ments and attendance and on the parents
missing school days or workdays because of
their childrens dental problems. Students with
toothaches in the past 6 months were almost
4 times more likely to have a GPA lower than
the median of 2.8 compared with students
without a recent toothache (P< .001). Also,
students having toothache resulted in students
being nearly 6 times more likely to miss school
days and their parents 4 times more likely to
miss school or work because of the childrens
dental problems compared with students not
having toothache (P< .001). Students with in-
accessible needed dental care were 3 times
more likely to miss school days because of
dental problems than were those with access to
dental care (P< .001). Objective measures of
oral health were not as statistically signicantly
associated with the outcome variables. Stu-
dents having caries were more than 2 times as
likely to result in their parents missing school
or work days because of their childrens dental
problems (P= .01). Students categorized as
having urgent dental needs were also more
TABLE 1—Academic Achievements, School Attendance, and Impact on Parents: Impact of Oral Health
on Children and Parents, Los Angeles County, California, 2008–2009
Academic Achievements
a
Attendance Impact on Parents
Variables No. (%)
Test Score
(English Language
Arts), Mean (SD)
Proficiency
(English Language
Arts), Mean (SD)
Test Score
(Mathematics),
Mean (SD)
Proficiency
(Mathematics),
Mean (SD)
GPA, Mean
(SD)
No. of Child’s
Total Absent
Days,
a
Mean (SD)
No. of Child’s Absent
Days (for Dental
Problems),
b
Mean (SD)
No. of Parent’s Absent
Days (for Child’s Dental
Problems),
b
Mean (SD)
Level of school
Elementary 287 (45.6) 349.9 (53.8)** 3.5 (1.1) 369.7 (69.6)*** ... 6.0 (5.5)*** 2.1 (1.4) 2.6 (2.8)
High 342 (54.4) 338.2 (45.9) 3.3 (1.0) 307.5 (52.4) 2.5 (1.0) 2.6 (0.9) 2.6 (3.4) 2.3 (1.2) 2.4 (2.1)
Gender
Boy 283 (45.0)* 3.3 (1.1) 340.6 (69.0)* 3.1 (1.2) 2.4 (0.9)** 3.8 (4.3) 2.0 (1.2) 2.3 (1.9)
Girl 346 (55.0) 347.3 (48.3) 3.5 (1.0) 330.1 (66.8) 2.9 (1.2) 2.7 (0.8) 4.4 (5.1) 2.3 (1.4) 2.8 (3.0)
Race/ethnicity
Asian 60 (9.7) 380.9 (47.0)*** 4.2 (0.8)*** 389.1 (62.7)*** 3.8 (0.8)*** 3.3 (0.7)*** 2.1 (3.0)** 1.8 (1.0) 1.5 (0.7)
Black 147 (23.8) 345.9 (49.5) 3.4 (1.1) 338.9 (70.1) 3.1 (1.2) 2.6 (0.7) 4.8 (5.0) 2.5 (1.5) 2.9 (3.5)
White Hispanic 32 (5.2) 356.8 (58.3) 3.6 (1.4) 344.5 (71.5) 3.3 (1.3) 2.6 (0.9) 5.4 (6.9) 1.8 (0.5) 1.8 (0.5)
Other Hispanic 378 (61.3) 335.7 (46.4) 3.2 (1.0) 323.9 (62.3) 2.8 (1.2) 2.5 (0.9) 4.0 (4.6) 2.2 (1.4) 2.6 (2.0)
Total 629 343.3 (49.8) 3.4 (1.1) 334.7 (67.9) 3.0 (1.2) 2.6 (0.9) 4.1 (4.8) 2.2 (1.3) 2.5 (2.5)
Note. GPA = grade point average. LAUSD = Los Angeles Unified School District.
a
Data are from the LAUSD Academic Records database with n = 629.
b
Data are from the questionnaire completed by the parents with n = 1495.
*P< .05; **P< .01; ***P< .001.
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than 2 times as likely to miss more than 2.5
school days than were those without urgent
needs (P= .02; Table 3). None of these ORs
were confounded by level of school, gender,
or race/ethnicity.
DISCUSSION
Oral diseases affect individuals and societies,
contributing to studentslower academic
achievements and compromising adultsability
to maintain a job or receive promotions.
8
These effects are more prominent when ac-
companied by oral deformity.
9,10
Even at the
family level, the functioning of a family might be
affected when a member cannot play his or her
usual familial role because of oral health con-
ditions.
8
Not surprisingly, we found severe caries
to be associated with feelings of embarrassment,
withdrawal and anxiety, and absence from
and inability to concentrate in school, with the
associated pain possibly affecting social interac-
tions and daily behaviors and resulting in phys-
ical, social, and economic effects.
10,11
Because
of oral health disparities, the impact of oral
health on populations that suffer from poor oral
health conditions might be more pronounced.
8
The impact of oral health on social func-
tioning and quality of life has been documented
in the literature. Sanders et al. found that the
impact of oral disease disproportionately af-
fected disadvantaged groups.
12
Another study
found that dental caries in the primary denti-
tion had a signicant impact on childrens
well-being in terms of eating patterns and sleep
habits.
13
The World Health Organization ac-
knowledged the social impact of oral diseases
resulting in restricted school, work, and home
activities and loss of millions of school and
work hours annually.
14
The recent US Surgeon
Generals report on oral health acknowledged
that people with oral diseases might avoid
conversation, laughing, smiling, and other
nonverbal expressions to hide their mouth and
teeth; therefore, oral diseases are likely to
damage self-esteem and compromise the ability
to sustain and build social relationships, af-
fecting dating and mating behaviors, other
interpersonal contacts, and participation in
social or community activities.
15
The report
also emphasized that ignoring oral health
compromises well-being, has nancial and so-
cial costs, and diminishes quality of life.
15
There is, however, little published research
investigating the indirect costs of oral health
measured by absences as a productivity fac-
tor.
8
A study of 1992 employed adults in
Hartford, Connecticut found that almost 1 in 4
adults had an annual episode of work hours
lost because of dental problems with a mean of
1.3 hours lost per person per year. The study
found that the most important predictors of
these annual episodes (having lost time as a yes
or no question) were previous time lost, fre-
quent dental visits, being young, and belonging
to the higher social classes, whereas total time
lost from work (actual lost hours measured)
because of oral health was related to not only
previous time lost but also poverty, being
a member of a minority group, poor oral health,
and greater treatment need. The authors of this
study further explained that those who en-
gaged in receiving preventive care were less
likely to be absent from work overall, whereas
non-Whites and the less afuent were more
likely to miss more work hours because of ex-
tensive dental care needs, perhaps as a result of
delayed treatment. The study suggested that
because of the high prevalence of dental disease,
workdays lost may be a useful population
statistic in measuring the impact of oral health.
16
Gift et al. reported that females miss more
school hours than do males, White children
miss more school hours than do Blacks, and
the mean school hours missed increase with
age.
4
This study also reported that Hispanics,
those with income less than $35 000, and
TABLE 2—School Absences Resulting From Subjective and Objective Measures of Oral Health (n = 1495): Impact of Oral Health
on Children and Parents, Los Angeles County, California, 2008–2009
Variables
Subjective Measures of Oral Health, No. (%) Objective Measures of Oral Health, No. (%) Missing School
Days Because of
Dental Problems,
No. (%) Total No. (%)
Toothache,
Present
Toothache,
Not Present
Inaccessible
Needed Dental
Care, Present
Inaccessible
Needed Dental
Care, Not Present
Cavitated or
Noncavitated
Caries, Present
Cavitated or
Noncavitated Caries,
Not Present
Urgent Dental
Needs, Present
Urgent Dental Needs,
Not Present
Level of school
Elementary 20 (13.7) 18 (3.2)*** 15 (11.9)*** 35 (6.3) 5 (2.8) 6 (6.3) 34 (5.4) 40 (52.0) 781 (52.2)
High 19 (18.5) 16 (3.0)*** 11 (9.7) 20 (4.0)* 27 (5.7) 10 (5.1) 6 (17.7) 31 (4.9)** 37 (48.0) 714 (47.8)
Gender
Boy 13 (12.3) 14 (2.8)*** 11 (10.3) 16 (3.4)** 23 (4.9) 6 (3.4) 4 (6.7) 25 (4.3) 29 (37.7) 689 (46.1)
Girl 26 (18.2) 20 (3.5)*** 15 (11.3)** 39 (6.9) 9 (4.6) 8 (11.6) 40 (5.8) 48 (62.3) 806 (53.9)
Race/ethnicity
Asian 3 (7.3) 2 (1.0)** 3 (7.9) 3 (1.5)* 6 (3.0) 0 (0.0) 1 (3.1) 5 (2.2) 6 (8) 269 (18.7)
Black 9 (17.0) 10 (4.4)*** 4 (10.3) 13 (5.3) 14 (6.8) 6 (6.7) 3 (11.1) 17 (6.4) 20 (26.7) 307 (21.3)
White Hispanic 1 (11.1) 3 (5.9) 2 (20.0) 2 (4.4) 3 (6.3) 1 (7.7) 0 (0.0) 4 (6.9) 4 (5.3) 64 (4.4)
Other Hispanic 25 (17.5) 18 (3.1)*** 17 (11.6) 22 (4.1)*** 37 (6.7) 8 (3.9) 8 (12.9) 37 (5.3)* 45 (60) 800 (55.6)
Total 39 (15.7) 34 (3.1)*** 26 (10.8) 41 (3.9)*** 62 (6.0) 15 (4.0) 12 (9.3) 65 (5.1)* 77 (5.5) 1495(100)
a
Ninety parents did not answer the question about number of missing school days because of dental problems.
*P< .05; **P< .01; ***P< .001.
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those without insurance appear to have more
missed school hours. The California Health In-
terview Survey found that 4.3% of 6- to 8-year-
old children who were under 185% of the
federal poverty level (the level of the guidelines
that, in 2009, made a student eligible for the
reduced lunch program
17
) lost 1 or more school
days in 2007 because of dental problems (not
related to check-ups or cleaning visits). This
increased to 5.5% among 14- to16-year-old poor
(under 185% of the federal poverty level) chil-
dren.
5
In our study, we also found that about
5.5% of the children missed school days because
of dental problems in the past year, which was
not statistically different by level of school, gen-
der, or race/ethnicity; boys had 55 and girls 86
hours missed per 100 students of the same
gender compared with 82 and 155, respectively,
in the study by Gift et al.
4
Overall in our sample of children whose
parents completed the survey, there were almost
169 days lost by students (77 students ·2.19
days) because of dental problems and 218
days lost (86 parents ·2.53 days) by parents
because of their childrens dental problems.
Given the size of the LAUSD (136 873
students), these numbers translate to 16 431
school days annually. This is equivalent to
58 school hours missed each year per 100
elementary school-aged children and 80
school hours missed each year per 100 high
school---aged children (based on the number
of instructional minutes in LAUSD schools
18
).
Our estimate is lower than the estimate by Gift
et al. of 117 school hours missed each year
per 100 school-aged children.
4
To our knowledge, this is the rst compre-
hensive study of dental caries among disad-
vantaged children of Los Angeles County that
also investigates associated sociodemographic
and access to care determinants. We have
provided an estimate of the indirect cost of oral
health on school performance and attendance
of children and the school- or work-related
absence of parents. Our estimate of absence as
a result of oral conditions appears more con-
servative than does the previous estimation by
Gift et al.
4
This might be related to an im-
provement in the oral health conditions during
the elapsed 20-year period in the US popula-
tion of children during which the prevalence
of caries in the permanent dentition of 6- to
11-year-old children dropped from 9% to 7%
between 1988 and 2002.
19
Another limitation
of this direct comparison with the previous
study is that our results are based on a sample
of disadvantaged children from a specic geo-
graphic region and we attempted to recall
activities of the past year, whereas Gift et al.s
study was based on a representative sample of
US children with only a 15-day event recall.
4
Despite these methodological and temporal
differences, our results are remarkably consis-
tent with the results of Gift et al.
4
: both
conclude that there is a signicant impact of
oral health on overall child school attendance.
Although we did not collect information about
the reason for the dental visits associated
with absences, we have pointed out the high
rate of urgent dental needs expressed par-
ticularly in the high school population. It is
relevant to mention that Reisine and Miller found
that preventive visits accounted for most
episodes of time lost from work because of
dental problems (as a yes or no question) but
fewer hours of work loss, suggesting that
individuals with low socioeconomic charac-
teristics postpone treatment until symptoms
are more severe; thus they need more time off
from school or work because of greater
treatment needs.
16
TABLE 3—Subjective and Objective Measures of Oral Health: Impact of Oral Health Problems on Children and
Parents, Los Angeles County, California, 2008–2009
Subjective Measures of Oral Health, OR (95% CI) Objective Measures of Oral Health, OR (95% CI)
Outcome Variables Control Group Median Toothache
Inaccessible
Dental Needs
Cavitated or
Noncavitated Caries
Urgent
Dental Needs
Child’s attendance
No. of child’s total absent d (for any reason)
a
< 2.5 2.5 1.4 (0.9, 2.2) 0.9 (0.6, 1.4) 1.0 (0.7, 1.5) 2.3* (1.2, 4.7)
The child had 1 absent d (for dental problems)
b
No absence ... 5.7*** (3.5, 9.3) 3.0*** (1.8, 5.0) 1.5 (0.9, 2.7) 1.9 (1.0, 3.6)
No. of child’s absent d (for dental problems)
b
< 2 2 1.5 (0.5, 4.1) 1.2 (0.4, 3.7) 0.3 (0.1, 1.3) 0.4 (0.1, 1.6)
Parent’s absences because of child’s dental problem
The parent had 1 absent d (for child’s dental problems)
b
No absence ... 4.1*** (2.5, 6.5) 2.3** (1.4, 3.8) 2.2* (1.2, 4.0) 1.3 (0.7, 2.7)
No. of parent’s absent d (for child’s dental problems)
b
< 2 2 1.2 (0.4, 3.5) 0.8 (0.2, 2.3) 1.5 (0.4, 5.2) 1.1 (0.2, 4.8)
Academic achievement
Test score in English language arts 347 347 1.2 (0.8, 1.9) 1.5 (1.0, 2.4) 1.3 (0.9, 1.9) 1.1 (0.6, 2.1)
Test score in mathematics 329 329 1.2 (0.8, 1.9) 1.1 (0.7, 1.8) 1.3 (0.9, 1.8) 1.3 (0.7, 2.5)
Proficiency in English language arts 4 4 1.3 (0.8, 2.1) 1.5 (0.9, 2.3) 1.5* (1.1, 2.2) 1.0 (0.5, 1.9)
Proficiency in mathematics 3 3 1.0 (0.6, 1.5) 1.3 (0.8, 2.0) 1.2 (0.8, 1.8) 0.8 (0.4, 1.7)
GPA 2.8 2.8 3.7*** (1.8, 7.6) 0.7 (0.4, 1.3) 1.1 (0.7, 1.8) 2.6 (0.8, 8.6)
Note. CI = confidence interval; GPA = grade point average; OR = odds ratio.
a
Data are from the LAUSD Academic Records database (n = 629).
b
Data are from the questionnaire completed by the parents (n = 1495).
*P< .05; **P< .01; ***P< .001.
RESEARCH AND PRACTICE
September 2012, Vol 102, No. 9 |American Journal of Public Health Seirawan et al. |Peer Reviewed |Research and Practice |1733
Limitations
This study has several limitations. The target
population of the study is disadvantaged chil-
dren in Los Angeles County; still we have
made inferences to all public schoolsstudents
in Los Angeles. In Los Angeles County, the
average and median percentages of public
schoolsstudents receiving reduced or free
meals programs are 62% and 71%, respec-
tively, and the average and median percentages
of public schoolsWhite students are 16%
and 6%, respectively, which could justify pro-
ling students in public schools in Los Angeles
County as disadvantaged. Despite assurances of
condentially, parents might have been biased
or might not have had accurate recall in their
responses to the questionnaire, which would
result in lower estimations of recent toothaches or
unmet dental needs. Some parents did not
consent to the release of the academic records of
their children. It is possible that the unreleased
records belong to students with low academic
standing, which might have resulted in an un-
derestimation of the correlations between poor
oral health and poor academic achievement.
We did not record the number of invitations
sent to the parents to participate in the study
at each site. Site coordinators resent the invita-
tions when no response (agreeing or declining
to participate in the study) had been received
from the parents, and then the coordinators ex-
panded the invitations to other classrooms until
the target goals of the sample from each school
site were reached. It is worth noting that only 68
parents declined to participate in the overall study.
Conclusions
We have illustrated that there is indeed an
impact of oral health on the studentsacademic
performance. Although at an individual level the
actual number of days absent from school to deal
with dental problems may be trivial, our subjective
and objective measures suggest that there are
likely to be many more days wherein the student is
suffering from the pain of untreated dental disease,
thus accounting for poorer academic performance.
In addition, the aggregated impact of these
indirect costs on the nation is enormous.
8
There
are very few high-quality outcome measures
in use in the evaluation of oral health policy and
environmental interventions; developing these
measures might advance oral health promotion
programs.
20
We suggest that measures such as
school and work absence because of dental
problems calculated at the population level will
serve these purposes. We agree with previous
recommendations that to eliminate disparities,
oral health education and programs must be more
integrated into other health, educational, and
social programs.
21
More studies are needed to
unbundle the clinical, socioeconomic, and cul-
tural challenges associated with this epidemic of
dental disease in children. j
About the Authors
At the time of this study, Hazem Seirawan, Sharon Faust,
and Roseann Mulligan were with the Ostrow School of
Dentistry, University of Southern California, Los Angeles.
Correspondence should be sent to Roseann Mulligan,
DDS, MS, Charles M. Goldstein Professor of Community
Dentistry at the Ostrow School of Dentistry, University of
Southern California, 3305B South Hoover St., Bldg A, Rm
120, Los Angeles, CA 90089-7001 (e-mail: mulligan@
usc.edu). Reprints can be ordered at http://www.ajph.org by
clicking the Reprintslink.
This article was accepted September 19, 2011.
Contributors
H. Seirawan and R. Mulligan contributed to the study
design and data analysis and interpretation. S. Faust was
a clinical examiner during the study. All authors partic-
ipated in the drafting and revision of the article.
Acknowledgments
The primary study from which this work was derived was
supported by First 5 LA, the Annenberg Foundation, the
California Endowment, and the California Wellness
Foundation.
The authors would like to thank Caswell Evans
(University of Illinois at Chicago), Julie Jenks and Harold
Slavkin (University of Southern California), and Kim Uyeda
andCynthiaLim(LosAngelesUnied School District)
for their valuable input. The authors would also like to
thank the following program ofcers: Conrado Barzaga,
MD, Reena John, MPH (First 5 LA), Beatriz Solis, PhD
(California Endowment), Mark Eiduson (Annenberg Foun-
dation), Sandra Martinez, MPH (California Wellness Foun-
dation), and Jan Kern (Southern California Grantmakers).
Human Participant Protection
The approval of the University of Southern California and
the Los Angeles Unied School District institutional review
boards was obtained and satised throughout the project.
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RESEARCH AND PRACTICE
1734 |Research and Practice |Peer Reviewed |Seirawan et al. American Journal of Public Health |September 2012, Vol 102, No. 9
... Mexican American and non-Hispanic Black children have higher rates of dental caries compared to non-Hispanic White children in the United States (Centers for Disease Control and Prevention, 2019). Oral disease and associated pain contribute to poor performance in school (Seirawan et al., 2012), and emergency treatment for oral disease results in approximately 34 million hours missed from school (Centers for Disease Control and Prevention, 2019). Socioeconomic status (SES) not only influences access to oral health care but also contributes to inequities in child development and language acquisition. ...
... Language disorders may also result in children having difficulties expressing oral pain or discomfort. Oral disease and communication impairment that contributes to poor performance in school may negatively impact opportunities to progress in education and obtain employment (Conti-Ramsden et al., 2018;Seirawan et al., 2012). ...
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This paper analyzes the effects of dental conditions on social functioning by measuring the incidence of work loss days associated with dental problems and treatments in 1 year. A longitudinal study of 1992 employed adults in the Hartford, Conn. area was conducted. Participants were interviewed at baseline to collect data on sociodemographic, health care and health status factors and were followed for 1 year to assess the incidence of dental work loss days. The results showed that 26.4% of the sample reported an episode of dentally-related work, with a mean of 1.26 hours per person per year. The most important predictors of having work loss were high number of dental visits, previously having an episode of work loss, being young and being in the higher social classes. The most important variables explaining total hours of work loss were treatment severity, previous work loss, low income and being non-white. While work loss rates varied by some important treatment and sociodemographic factors, more sensitive outcome indicators are needed to detect individual differences in the effects of dental conditions on social functioning. Yet, the results do suggest that work loss days may be a useful population statistic in measuring oral health status because of the high prevalence of dental disease.
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This paper analyzes the potential of using measures of social function as health indicators in dental research. It discusses existing methodologies and presents findings from a cross-section of studies that adopt a social function perspective in the investigation of oral health status. While the literature in this area is small, much of the research concerns disability days associated with dental problems. The United States National Health Interview Survey reported in 1981 that 4.87 million dental conditions caused 17.7 million days of restricted activity, 6.73 million days of bed disability, and 7.05 million days of work loss. Other reports suggest that these data may be underestimates due to the National Health Survey's definition of disability days. Several other studies have found work loss to affect from 15 per cent to 33 per cent of samples studied resulting in many more work loss days than reported by the National Health Survey. Our study concludes that traditional measures of oral health status--such as decayed, missing, and filled teeth and the periodontal index--should be linked to measures of social outcome in order to place dental conditions within the broader context of health status in terms that are relevant to policy makers.
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It is well established that many systemic adverse health conditions have manifestations in the oral cavity. The purpose of this paper is to summarize the available scientific evidence that describes the opposite effect, how adverse oral health conditions affect three aspects of daily living: 1) systemic health, 2) quality of life, and 3) economic productivity. Examples of oral health affecting systemic health include rheumatic fever patients who develop infective endocarditis from oral bacteria and organ transplant patients who develop severe complications from oral infections. Both systemic health and quality of life are compromised when edentulousness, xerostomia, soft tissue lesions, or poorly fitting dentures affect eating and food choices. Conditions such as oral clefts, missing teeth, severe malocclusion, or severe caries are associated with feelings of embarrassment, withdrawal, and anxiety. Oral and facial pain from dentures, temporomandibular joint disorders, and oral infections affect social interaction and daily behaviors. The results of oral disorders can be felt not only physically and socially but also economically in our society. Dental disease accounts for many lost work and school days. Lower wage earners and minorities are disproportionately affected. Although there are many studies that evaluate these relationships, most are case reports, cross-sectional studies, or studies restricted to small or unique population groups. Lack of standardized measurements make comparisons across studies difficult. More population-based and longitudinal studies are needed to better understand the nature of these relationships.
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This pilot study assessed the possible effects of extensive dental caries on the quality of life in young children. Information was collected for 77 children (age 35-66 months, mean = 44 months) with severe caries in the primary dentition. Parents or guardians were asked questions concerning pain, eating habits, and social behavior of the children before and after oral rehabilitation. Dental disease was found to have an impact on children's well being. There was a significant change in complaint of pain, eating preferences, quantity of food eaten, and sleep habits before and after treatment of dental caries. This study demonstrated the effect of severe caries on quality of life in young children.