|Year : 2021 | Volume
| Issue : 2 | Page : 122-128
Prevalence and associated factors of self-rated oral health among a national population-based sample of adults in Ecuador: Results of the 2018 STEPS survey
Supa Pengpid1, Karl Peltzer2
1 ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand; Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa
2 Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa
|Date of Submission||08-Oct-2020|
|Date of Decision||30-Oct-2020|
|Date of Acceptance||15-Nov-2020|
|Date of Web Publication||17-Apr-2021|
Dr. Karl Peltzer
Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa.
Source of Support: None, Conflict of Interest: None
Objective: The aims of this study were to estimate the prevalence and correlates of self-rated oral health (=SROH) among adults in a national population-based survey in Ecuador. Materials and Methods: In the national cross-sectional 2018 Ecuador STEPS survey, 4,638 persons (median age = 39 years, range 18–69 years) responded to a questionnaire, physical measures, and biomedical tests. Results: The prevalence of poor SROH was 9.7%, 10.1% among females and 9.4% among males. In multivariable logistic regression analysis, aged 50–69 years [adjusted odds ratio (AOR): 3.06, 95% confidence interval (CI): 1.99, 4.72], Amerindian (AOR: 1.78, 95% CI: 1.23, 1.58), pain in the teeth/mouth (AOR: 2.03, 95% CI: 1.51, 2.73), impaired OHRQoL (OR: 3.94, 95% CI: 2.93, 5.29), dental visit more than past 12 months ago or never (AOR: 1.74, 95% CI: 1.32, 2.29), past smoking (AOR: 1.50, 95% CI: 1.08, 2.09) and history of heart attack or stroke (AOR: 1.57, 95% CI: 1.04, 2.37) were positively and having more than secondary education (AOR: 0.63, 95% CI: 0.43, 0.92) and teeth cleaning (≥twice/day) (AOR: 0.48, 95% CI: 0.37, 0.64) were negatively associated with poor SROH. Conclusions: One in ten participants reported poor SROH and several factors associated with poor SROH were found that can aid in designing programs to improve SROH in Ecuador.
Keywords: Adults, Ecuador, Health Variables, Oral Conditions, Self-rated Oral Health
|How to cite this article:|
Pengpid S, Peltzer K. Prevalence and associated factors of self-rated oral health among a national population-based sample of adults in Ecuador: Results of the 2018 STEPS survey. J Int Oral Health 2021;13:122-8
|How to cite this URL:|
Pengpid S, Peltzer K. Prevalence and associated factors of self-rated oral health among a national population-based sample of adults in Ecuador: Results of the 2018 STEPS survey. J Int Oral Health [serial online] 2021 [cited 2021 Oct 22];13:122-8. Available from: https://www.jioh.org/text.asp?2021/13/2/122/313849
| Introduction|| |
Poor oral health is a significant public health problem globally. Self-rated oral health (=SROH) has become more important considering both physical and psychosocial dimensions of health, and influences dental healthcare utilization. Studies have shown that SROH is significantly correlated with one’s clinical oral health. There are hardly any studies investigating the prevalence and correlates of SROH in population-based surveys among adults in South American countries, including Ecuador.,, Ecuador is an upper-middle-income country and the prevalence and correlates of SROH may be different to high-income countries, considering that factors influencing SROH may be determined by country-specific socio-cultural factors.,
In a national adult survey in 2003 in Mexico, the prevalence of poor SROH (any problems = yes) was 25.7%, in a population-based study among 318 years and older persons in Brazil, 32.6% reported that their oral health was not good or very good, in a community sample of older adults (60 years and older) in 2009 in Ecuador, 13% reported fair or poor SROH, and in a small study among Amerindians in Ecuador, 18.6% reported having poor teeth and 14.7% poor gums, and in a small study among indigenous groups (35–44 years old) in Central-West Brazil, the prevalence of poor SROH was 26.4%. In the 2015 national STEPS survey in Kenya, 13.7% of participants reported poor SROH, in South Africa, 23.7% had poor SROH, in Nigeria, 9% had poor SROH, in Australia, 17.0% had poor SROH, in the USA, 34.4% had poor SROH, and in Qatar 5.9% poor self-rated teeth and 4.6% poor self-rated gums.
As previously reviewed, factors associated with poor SROH include sociodemographic factors (older age, female, and low socioeconomic status), oral conditions (toothache, dental caries, sensitive teeth, bad breath, bleeding gums, and reduced number of teeth), general health status (overweight and obesity and diabetes), oral health risk behavior (inadequate tooth brushing, low oral hygiene behaviors, dental attendance), and general health risk behaviors (problem drinking, tobacco use, poor diets, food avoidance, and physical inactivity).
The aims of this study were to estimate the prevalence and correlates of SROH among adults in the 2018 Ecuador STEPS survey.
| Materials and Methods|| |
Participants and procedures
Cross-sectional data of 18- to 69-year-old persons from the 2018 Ecuador STEPS Survey were analyzed. A three-stage cluster sampling design was utilized to generate a nationally representative population-based ample of persons aged 18–69 years in Ecuador. The overall study response rate was 69.4%. The data were collected using electronic tablet devices. The Ethical Review Committee of the Ecuador Ministry of Health provided ethics approval of the study, and written informed consent was obtained from the study participants.
SROH was sourced from two items
- 1) How would you describe the state of your teeth?
- 2) How would you describe the state of your gums?
Poor SROH was defined as “having poor or very poor status of teeth and/or gums, and good oral health as having average, good, very good or excellent status of teeth and/or gums,” in line with previous research. Cronbach alpha’s for the two-item SROH scale was 0.72 in this sample.
Oral health-related behaviors were sourced from three items: (1) “How often do you clean your teeth?” (“1=never to 7=twice or more a day”); (2) “Do you use toothpaste?” (“Yes/No”); (3) “Do you use toothpaste with fluoride?” (4) “How long has it been since you last saw a dentist?” (“1=less than 6 months to 6=never received dental care”).
“Oral health-related quality of life” (OHRQoL) was measured with seven questions [see [Table 1]], e.g., “Difficulty in chewing foods in the past 12 months?” (“Yes/No”). Impaired OHRQoL was defined as a “yes” to any of the seven OHRQoL questions. Cronbach alpha for the OHRQoL scale was 0.76 in this study.
|Table 1: Oral health-related quality of life (OHRQoL) and self-rated oral health (SROH) (n = 4638)|
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Physical symptoms were sourced from the item, “During the past 12 months, did your teeth or mouth cause any pain or discomfort?” (“Yes/No”).
Oral conditions included, “Do you have any removable dentures?” (“Yes/No”).
Health risk behavior variables included past and current smoking, insufficient fruit and vegetable intake (<5 servings/day), high, moderate, or low physical activity measured with the “Global Physical Activity Questionnaire (GPAQ),” heavy episodic drinking (≥6 drinks/session) during any of the past 30 days., People who had visited a health care provider in the past 12 months were asked if they had received advice to reduce the consumption of sugary beverages.
Socio-demographic factor questions included age, sex, education, and ethnicity.
Using WHO STEPS standard methodology, raised fasting blood glucose or diabetes was classified as “fasting plasma glucose levels ≥7.0 mmol/L, and/or currently taking insulin or oral hypoglycemic drugs,” hypertension (BP) was defined as “systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg or currently on antihypertensive medication” (mean of the last two of three readings), raised total cholesterol (TC) (“fasting TC ≥5.0 mmol/L or currently on medication for raised cholesterol”). General body weight was measured and body mass index was classified as underweight (<18.5kg/m2), normal weight (18.5–24.9kg/m2), overweight (25–29.9kg/m2), and obesity (≥30kg/m2 obesity). History of cardiovascular disorders included self-reported “heart attack or stroke.”
Statistical procedures were conducted with “STATA software version 14.0 (Stata Corporation, College Station, TX, USA),” taking into account the multistage sampling design and weighting of the data. Frequencies, percentages, means/medians, and standard deviation/interquartile ranges were used to describe the sample and health characteristics. Simple and multivariable logistic regression was utilized to estimate predictors of poor SROH. Variables significant in the simple model were subsequently included in the multivariable logistic model. Missing values (<5%) were excluded from the analysis, and p < 0.05 indicated significance.
| Results|| |
Characteristics of the sample and oral health indicators
The sample comprised 4,638 persons aged 18–69 years (median = 39 years, IQR = 27–52), 58.1% were women, 51.7% had secondary or higher education, and 78.9% were Mestizo by ethnicity.
In relation to oral health behavior, 85.1% of respondents cleaned their teeth ≥2 times/day, 98.6% utilized toothpaste with fluoride, and 54.4% had seen a dentist in the past 12 months. More than one in three (34.6%) of the participants had impaired OHRQoL, 22.7% had removable dentures, and 36.8% had past 12-month pain in the mouth or teeth. Regarding general health status, 63.6% of the sample had overweight/obesity, 8.7% had a history of stroke or heart attack, 7.1% had diabetes, 34.8% raised total cholesterol, and 20.5% hypertension. In terms of general health behavior, almost one in four were past (24.4%) or current smokers (13.7%), 58.8% had 0–1 serving of fruit and vegetables per day, and 49.8% had high physical activity. One in ten participants (9.7%) reported poor SROH, 10.1% among females, and 9.4% among men [see [Table 2]].
|Table 2: Sample and oral health characteristics, Ecuador STEPS survey, 2018|
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OHRQoL and SROH
[Table 1] shows that the most common item of OHRQoL was “difficulty chewing” (22.6%) and that 35.6% had any impaired OHRQoL. For all seven OHRQoL items, the prevalence of poor SROH was significantly (p < 0.001) higher than in persons with good SROH [see [Table 1]].
Associations with poor SROH
In multivariable logistic regression analysis, aged 50–69 years (AOR: 3.06, 95% CI: 1.99, 4.72), Amerindian (AOR: 1.78, 95% CI: 1.23, 1.58), pain in the teeth/mouth (AOR: 2.03, 95% CI: 1.51, 2.73), impaired OHRQoL (OR: 3.94, 95% CI: 2.93, 5.29), dental visit more than past 12 months ago or never (AOR: 1.74, 95% CI: 1.32, 2.29), past smoking (AOR: 1.50, 95% CI: 1.08, 2.09), and history of heart attack or stroke (AOR: 1.57, 95% CI: 1.04, 2.37) were positively and having more than secondary education (AOR: 0.63, 95% CI: 0.43, 0.92) and teeth cleaning (≥twice/day) (AOR: 0.48, 95% CI: 0.37, 0.64) were negatively associated with poor SROH. In addition, in the unadjusted analysis, dentures and diabetes were positively associated with poor SROH [see [Table 3]].
|Table 3: Simple and multivariable logistic regression with poor self-rated oral health status|
Click here to view
| Discussion|| |
The prevalence of poor SROH (9.7% in 18–69 year olds; 17.0% in 50–69 year olds) in this first-ever national study in Ecuador seems to be higher than in a community sample of older adults (60 years and older) in 2009 in Ecuador (13% fair or poor SROH), in Nigeria (9%), and among adults in Qatar (5.9% poor self-rated teeth and 4.6% poor self-rated gums).
However, the prevalence of poor SROH in this study was lower than in various other studies among adult populations, such as in Mexico (25.7% poor SROH: any problems = yes), in Brazil (32.6% not good or very good SROH), in Kenya (13.7%), in Australia (17.0% “fair/poor” SROH), and in the USA (34.4% “fair/poor” SROH). In line with previous clinical assessments of oral health status among children in Ecuador, this SROH study showed that oral health problems may constitute a significant health burden in Ecuador.
This study showed that, among Amerindian (indigenous population) in Ecuador, the prevalence of poor SROH was higher (22.6%) than among other ethnic groups, such as the Mestizo (8.5%). The high prevalence of poor SROH in indigenous populations was also previously found among Amerindians in Ecuador (18.6% reported having poor teeth and 14.7% poor gums), and among indigenous groups in Central-West Brazil (26.4% poor SROH). Some of these ethnic differences may be attributed to the low prevalence of adequate tooth cleaning (60.3%), high prevalence of pain in the mouth or teeth (48.5%), the majority (72.8%) only sought dental consultation in response to pain and need for treatment and lower education (P < 0.001) among the Amerindians in this study. This could mean special efforts should be undertaken to improve oral health by, for example, oral hygiene education targeting Amerindians in Ecuador.
In agreement with several previous studies,,,,, this survey showed that poorer SROH increased with age, but we did not find significant sex differences in the prevalence of poor SROH. This could mean that men and women equally report oral symptoms and have equal access to oral health care. Previous studies found an association between low socioeconomic status, including lower education,,,,, and the prevalence of poor SROH. Similarly, in this study, the prevalence of poor SROH was much higher among persons with less than secondary education (14.7%) than those who had more than secondary education (4.8%). It is possible that lower general education translates into lower oral hygiene behavior leading to poorer SROH and a greater need for dental health care.
Consistent with previous studies,,,,, this study found that several oral problems, including impaired OHRQoL, pain in teeth/mouth, and dentures, were associated with poor SROH. As found in previous studies in Brazil and Sudan, this survey showed a high correlation between “difficulty in chewing” and poor SROH. Furthermore, in the adjusted and unadjusted analysis, stroke or heart attack and diabetes were found associated with poor SROH. These findings are consistent with previous studies.,,
Consistent with some previous studies,, this study showed significant associations between poor oral hygiene behavior (teeth cleaning <twice/day) and poor SROH. Regarding the association between dental attendance and poor SROH, previous research showed mixed results.,,, This study found a negative association between past 12-month dental attendance and poor SROH, which is consistent with some research studies., This finding may be attributed to the relatively high proportion (36.4%) of a dental routine check-up, consultation, or advice.
A number of studies,,,,, showed an association between inadequate physical activity, insufficient fruit and vegetable intake, substance use (tobacco and alcohol), and poor SROH, but this study found such an association in the case of past smoking. This confirms previous research indicating strong associations between tobacco use and poor dental health.,
Study strength and limitations
The strength of this study was the large nationally representative sample in Ecuador, using the standard WHO STEPS survey methodology. The study was limited due to its cross-sectional study design. Moreover, self-report of the data, including oral health, which may have led to biased responses. Some relevant variables, such as tooth loss, dentition status, intake of sugar-containing foods, and soft drinks, were not available in the Ecuador 2018 STEPS survey. Furthermore, economic status or income was not included in the analysis, since too many cases were missing.
| Conclusion|| |
One in ten participants reported poor SROH and several associated factors were identified, including older age, lower education, Amerindian, teeth cleaning (<twice/day), pain in the mouth or teeth, impaired OHRQoL, dental visits more than 12 months ago or never, past smoking and history of heart attack or stroke. Targeting these factors in oral health programs may be beneficial.
The data source, the World Health Organization NCD Microdata Repository (https://extranet.who.int/ncdsmicrodata/index.php/catalog), is hereby acknowledged.
Financial support and sponsorship
This research received no external funding.
Conflict of interest
The authors declare no conflict of interest.
All authors fulfill the criteria for authorship. S.P. and K.P. conceived and designed the research, performed the statistical analysis, drafted the manuscript, and made critical revision of the manuscript for key intellectual content. All authors have read and agreed to the published version of the manuscript.
Ethical policy and institutional review board statement
Patient declaration of consent
Data availability statement
| References|| |
Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C The global burden of oral diseases and risks to oral health. Bull World Health Organ 2005;83:661-9.
Perera I, Ekanayake L Factors influencing perception of oral health among adolescents in Sri Lanka. Int Dent J 2008;58:349-55.
Blizniuk A, Ueno M, Zaitsu T, Kawaguchi Y Association between self-reported and clinical oral health status in Belarusian adults. J Investig Clin Dent2017;8. doi: 10.1111/jicd.12206.
Borda MG, Castellanos-Perilla N, Patiño JA, Castelblanco S, Cano CA, Chavarro-Carvajal D, et al
. Edentulism and its relationship with self-rated health: Secondary analysis of the SABE ecuador 2009 study. Acta Odontol Latinoam 2017;30:83-9.
Curtis DC, Ortega F, Monar J, Bay RC, Eckhart S, Thompson P Assessing self-reported oral health status of three Andean indigenous communities in Ecuador. J Int Oral Health 2017;9:207. doi: 10.4103/jioh.jioh_164_17
Michel-Crosato E, Raggio DP, Coloma-Valverde ANJ, Lopez EF, Alvarez-Velasco PL, Medina MV, et al
. Oral health of 12-year-old children in Quito, Ecuador: A population-based epidemiological survey. BMC Oral Health 2019;19:184.
Medina-Solís CE, Pontigo-Loyola AP, Pérez-Campos E, Hernández-Cruz P, Ávila-Burgos L, Mendoza-Rodríguez M, et al
. National survey of oral/dental conditions related to tobacco and alcohol use in Mexican adults. Int J Environ Res Public Health 2014;11:3169-84.
Nico LS, Andrade SS, Malta DC, Pucca Júnior GA, Peres MA Self-reported oral health in the Brazilian adult population: Results of the 2013 National Health Survey. Cien Saude Colet 2016;21:389-98. doi: 10.1590/1413-81232015212.25942015.
Arantes R, Frazão P Subjective oral symptoms associated with self-rated oral health among indigenous groups in central-west Brazil. Community Dent Oral Epidemiol 2018;46:352-9.
Pengpid S, Peltzer K Self-rated oral health status and social and health determinants among community dwelling adults in Kenya. Afr Health Sci 2019;19:3146-53.
Olutola BG, Ayo-Yusuf OA Socio-environmental factors associated with self-rated oral health in South Africa: A multilevel effects model. Int J Environ Res Public Health 2012;9:3465-83.
Olusile AO, Adeniyi AA, Orebanjo O Self-rated oral health status, oral health service utilization, and oral hygiene practices among adult Nigerians. BMC Oral Health 2014;14:140.
Mejia G, Armfield JM, Jamieson LM Self-rated oral health and oral health-related factors: The role of social inequality. Aust Dent J 2014;59:226-33.
Morin NM, Dye BA, Hooper TI Influence of cigarette smoking on the overall perception of dental health among adults aged 20-79 years, United States, 1988-1994. Public Health Rep 2005;120: 124-32.
Cheema S, Maisonneuve P, Al-Thani MH, Al-Thani AAM, Abraham A, Al-Mannai GA, et al
. Oral health behavior and factors associated with poor oral status in Qatar: Results from a national health survey. J Public Health Dent 2017;77:308-16.
World Health Organization (WHO) (2018). STEPwise approach to surveillance (STEPS). https://www.who.int/ncds/surveillance/steps/en/ (accessed 22 August 2020).
Subsecretaría Nacional de Vigilancia de la Salud Pública, Subsecretaría Nacional de Promoción de la Salud e Igualdad, Dirección Nacional de Estrategias de Prevención y Control, Dirección Nacional de Promoción de la Salud (MSP, INEC, OPS/OMS). Encuesta STEPS Ecuador 2018. https://extranet.who.int/ncdsmicrodata/index.php/catalog/774 (accessed 22 August 2020)
World Health Organization. Global Physical Activity Questionnaire (GPAQ) Analysis Guide. Geneva, Switzerland: World Health Organization; 2012.
Australian government. Alcohol screen (AUDIT). Available from: http://nceta.flinders.edu.au/files/3314/2257/4957/Right_Mix_3.pdf (accessed 5 August 2020).
World Health Organization. The STEPS Instrument and Support Materials, 2016. Available at http://www.who.int/ncds/surveillance/steps/instrument/en/ (accessed 10 May 2020).
Vale EB, Mendes Ada C, Moreira Rda S Autopercepção da saúde bucal entre adultos na região Nordeste do Brasil [Self-perceived oral health among adults in Northeastern Brazil]. Rev Saude Publ 2013;47(Suppl 3):98-108. Portuguese. doi: 10.1590/s0034-8910.2013047004893.
Cárdenas-Bahena Á, Velázquez-Olmedo LB, Falcón-Flores JA, García-Zámano IE, Montes-Salmerón RE, Reza-Bravo GG, et al
. Self-perception of oral health in older adults from Mexico City. Rev Med Inst Mex Seguro Soc 2018;56(Suppl 1):S54-63.
Li KY, Okunseri CE, McGrath C, Wong MCM Trends in self-reported oral health of US adults: National Health and Nutrition Examination Survey 1999–2014. Community Dent Oral Epidemiol 2018;46:203-11. doi: 10.1111/cdoe.12355
Pattussi MP, Peres KG, Boing AF, Peres MA, da Costa JS Self-rated oral health and associated factors in Brazilian elders. Community Dent Oral Epidemiol 2010;38:348-59.
Masalu JR, Kikwilu EN, Kahabuka FK, Mtaya M, Senkoro AR Socio-demographic and behavioural correlates of oral health related quality of life among Tanzanian adults: A national pathfinder survey. Tanzan J Health Res 2012;14:212-9.
Jayasvasti I, Htun KCSS, Peltzer K Self-rated oral health status and social and health determinants among 35-65 year-old persons in one region in Myanmar: A cross-sectional study. Clin Cosmet Investig Dent 2019;11:339-48.
Khalifa N, Allen PF, Abu-bakr NH, Abdel-Rahman ME Chewing ability and associated factors in a Sudanese population. J Oral Sci 2013;55:349-57.
Mohamed HG, Idris SB, Ahmed MF, Bøe OE, Mustafa K, Ibrahim SO, et al
. Association between oral health status and type 2 diabetes mellitus among Sudanese adults: A matched case-control study. PLoS One 2013;8:e82158.
Afonso-Souza G, Nadanovsky P, Chor D, Faerstein E, Werneck GL, Lopes CS Association between routine visits for dental checkup and self-perceived oral health in an adult population in Rio de Janeiro: The pró-saúde study. Community Dent Oral Epidemiol 2007;35:393-400.
Liu Y The relationship between lifestyle and self-reported oral health among American adults. Int Dent J 2014;64:46-51. doi: 10.1111/idj.12061.
Ong G Periodontal disease and tooth loss. Int Dent J 1998;48(3 Suppl 1):233-8.
Krall EA, Dawson-Hughes B, Garvey AJ, Garcia RI Smoking, smoking cessation, and tooth loss. J Dent Res 1997;76:1653-9.
Liu H, Maida CA, Spolsky VW, Shen J, Li H, Zhou X, et al
. Calibration of self-reported oral health to clinically determined standards. Community Dent Oral Epidemiol 2010;38:527-39.
[Table 1], [Table 2], [Table 3]