Investigating the associations between dental behaviours and oral health outcomes, in the context of the social gradient in oral health

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Participants : 879 adults aged 45 to 54 from metropolitan Adelaide, South Australia. Research design : Data on SES (household income) and dental behaviours—including frequency of tooth brushing, mouth rinsing, interdental cleaning, dental visiting and self-care practices—were collected via questionnaire. Clinical examinations were completed for 709 participants to assess caries experience using the decayed, missing, and filled teeth (DMFT) index. Main outcome measures : Quality of life, extrapolated using the 14-item Oral Health Impact Profile (OHIP-14), and caries experience via DMFT scores. Results : An inverse SES gradient was observed for both quality of life and caries experience. Lower-income participants had reduced dental visiting scores [17.5 (95% CI: 17.1–18.0)] versus higher-income groups [20.0 (95% CI: 19.6–20.4)], and slightly higher dental self-care scores [17.7 (95% CI: 17.3–18.0)] than mid-income participants [17.6 (95% CI: 17.2–18.0)]. Higher-income individuals were more likely to have visited a dentist in the last 12 months (39.5%) and to brush daily (36.9%) than lower-income individuals (29.7% and 30.0%, respectively). Full behavioural adjustment significantly attenuated SES disparities in quality of life (unadjusted β=–2.7, 95% CI: –3.4 to –2.1; adjusted β=–2.0, 95% CI: –2.7 to –1.3), but not in caries experience (unadjusted β=–0.8, 95% CI: –1.3 to –0.3; adjusted β=–0.7, 95% CI: –1.2 to –0.1). Conclusions : Comprehensive dental behaviours can reduce socioeconomic inequalities in quality of life, but minimally impact caries experience. Dentistry Epidemiology Health Policy dental behaviours direct and indirect measures socioeconomic gradient dental health services oral health Figures Figure 1 Introduction The relationship between socioeconomic status (SES) and oral health is well-documented, with a robust evidence base demonstrating a persistent social gradient in oral health outcomes (Arrica et al., 2017; Holde et al., 2018; Jamieson and Thomson, 2006; Kim et al., 2018; Łysek et al., 2016; Molarius et al., 2014; Mejia et al., 2014). This gradient reflects a nuanced and cumulative effect, whereby oral health progressively deteriorates with decreasing SES, shaped by differential access to healthcare, education, nutrition, environmental conditions, and social support. The framework of the social determinants of health (SDoH) provides a compelling explanation for this phenomenon, positing that individuals in lower socioeconomic positions face a disproportionate burden of oral diseases due to structurally embedded disadvantages that influence both risk exposure and access to care (AE, 2007; de Abreu et al., 2021). Although upstream structural determinants remain critical in shaping oral health outcomes, individual-level dental behaviours—such as regular tooth brushing, interdental cleaning, mouth rinsing, and dental visitation—have the potential to mediate these effects and are more amenable to short-term intervention (Guarnizo-Herreño et al., 2019). However, evidence suggests that without careful contextual adaptation, behavioural interventions and policies intended to promote oral health (e.g., dental education programs or expanded welfare benefits) may paradoxically exacerbate disparities by being more accessible or beneficial to higher SES groups (Guarnizo-Herreño et al., 2019; Locker, 2000). Thus, while systemic reform is essential for long-term equity, a better understanding of how downstream behavioural factors operate across the social gradient is needed to inform interim and complementary public health strategies. Investigating the effectiveness of dental behaviours in attenuating the social gradient in oral health is especially pertinent in middle-aged adults, a demographic undergoing significant oral health transitions. Individuals aged 45–54 years are retaining more natural teeth and increasingly utilising dental services (Chalmers JM, 1999), with population trends indicating growing demand for restorative and periodontal care within this cohort (Joshi et al., 1996). Furthermore, demographic projections show that the proportion of middle-to-older adults will continue to rise, intensifying the burden on healthcare systems and reinforcing the need for early, preventive intervention (Ciobanu et al., 2024). Dental caries remains one of the most prevalent and enduring global health conditions, closely linked to SES, yet its underlying social and behavioural determinants are incompletely understood (Arrica et al., 2017; Patrick et al., 2006). In addition to clinical disease indicators, measures of oral health-related quality of life (OHRQoL) offer critical insight into the subjective and functional consequences of oral conditions, which are also unequally distributed across SES groups (Mejia et al., 2018; Knorst et al., 2021). Few studies have simultaneously examined the extent to which dental behaviours attenuate socioeconomic disparities across both clinical (e.g., caries experience) and non-clinical (e.g., quality of life) domains, particularly within a middle-aged adult population. The design of this study builds upon the work of Sanders et al. (Sanders et al., 2006), who investigated the explanatory role of dental self-care and attendance in mediating SES-related oral health disparities. While their study employed the Modified Dental Neglect Scale as an indirect measure of oral health behaviours, the current study expands this approach by incorporating both direct (i.e., DMFT scores) and indirect behavioural measures, including a refined adaptation of the Dental Neglect Scale (Sanders et al., 2006). This dual-method approach allows for a more comprehensive assessment of how behavioural factors influence oral health inequalities. The rationale for this study lies in addressing critical gaps in the literature: the underrepresentation of middle-aged adults in oral health inequality research; the limited understanding of behavioural self-management strategies among low SES populations; and the need for concurrent analysis of both clinical and patient-reported outcomes. Given the considerable financial, psychological, and physical burden of poor oral health – particularly for individuals of lower SES (Sanders et al., 2006; Locker, 2000; Chaffee et al., 2017; Silva Junior et al., 2020) – this research is timely and necessary. This study aimed to evaluate the role of dental behaviours in explaining socioeconomic inequalities in oral health. The specific objectives were to: (1) examine the associations between dental behaviours, quality of life, and caries experience; and (2) assess the extent to which these behaviours account for oral health disparities across SES groups. Methods Ethical considerations Ethics approval for this study was provided by the University of Adelaide Human Research Ethics Committee (H-74-2002). Reporting The reporting of this study was informed by the STROBE checklist for cross-sectional studies (von Elm et al., 2007), including discussion of the background and rationale for the study, objectives, study design, setting, participants, variables, data sources, discussion of bias and study size, statistical methods, key results, limitations and interpretation. Sample size determination The required sample size for the study, based on an alpha level of 0.05 and 80% power, was computed using PC-SIZE software. To calculate required sample sizes pertaining to use of services, an estimate of the percentage of dentate 45 to 54-year-olds in South Australia visiting a dentist within a 1-year period in 1992-1993 (1993) was used. A sample size of 138 per group would be adequate to discern differences in use of services of 15% or more, with an effect size required to obtain expected difference (Joshi et al., 1996). Based on the above calculation, a random sample of 2469 45 to 54-year-old persons were selected from metropolitan Adelaide, South Australia. Study design and sampling This study is a secondary analysis of data gathered for a 2007 study investigating caries experience among 45 to 54-year-olds in Adelaide, South Australia (Brennan et al., 2007). In the original study, 2248 persons aged 45 to 54 years were randomly sampled from metropolitan Adelaide, South Australia, using the electoral roll as a sampling frame during 2004-2005. Participants were sent a self-completed questionnaire to investigate the independent variables (dental visitation pattern, dental behaviour participation and socioeconomic status). Impact on quality of life was also gathered via the questionnaire (interpreted via assignment of an OHIP-14 score based on the participant responses). A reminder card and up to four follow-up mailings were sent to sampled non-respondents to encourage questionnaire completion. The questionnaire was completed by 879 persons. The respondents to the questionnaire were invited to participate in a clinical oral examination performed by calibrated dentists, in which caries experience data were gathered. Examinations were performed for 709 persons, producing a completion rate of 80.7%. A subset of 11 cases were re-examined to confirm reliability. The respondents who completed the questionnaire but did not follow up with an examination (107 persons) were analysed as a comparison group. The study design and sampling process is summarised in Figure 1 below. Variables The outcome measures were: (A) Quality of life, inversely measured using the 14-item Oral Health Impact Profile (OHIP-14). An overall OHIP-14 score was computed as the mean score, and all ordinal responses were multiplied by the number of items to produce a summary statistic that could range from 0 to 56. Higher OHIP-14 scores indicate greater impact, and poorer oral health status. (B) Caries experience, measured using DMFT (decayed, missing, filled teeth) scores. Teeth were categorised as decayed, missing or filled (DMFT). The independent measures were: frequency of tooth brushing, mouth rinse use and interdental cleaning, socioeconomic status (measured using household income), and dental visiting and self-care patterns. Dental visiting and self-care data were gathered from the questionnaire. For both variables, a score was calculated by examining responses to questionnaire items which were derived from a Modified Dental Neglect Scale (Supplemental Table A2). For further detail on how the variables were measured and categorised for analysis, please refer to Supplemental Table A1). Bias To ensure the study sample was representative of the population, use of the electoral roll provided was an acceptable sampling frame as it contains all Australian adults registered to vote. The approximation of the sample respondents to national data was determined by assessing them against several variables from the 2002 National Dental Telephone Interview Survey, which was weighted to reflect the estimated residential population (2003). Statistical analysis Univariable analyses using frequencies, and measures of central tendency were used to describe and explore distribution of the data. This was followed by bivariable analyses, which utilised T-tests and one-way ANOVA to explore any unadjusted associations between the independent and outcome variables. Linear regression models were produced to investigate the independent effect of the direct and indirect measures on quality of life and caries experience via a forward stepwise approach, based on causal inferences from the literature (Pearce and Lawlor, 2016). (A) An initial linear regression model was produced to investigate the independent effect of only SES on the oral health outcomes; without accounting for oral health behaviours. The aim of this model was to demonstrate the social gradient in oral health outcomes. (B) To account for the effect on oral health outcomes when demographic factors were controlled, a second model was created. (C) A third model was created in which oral health outcomes were controlled for dental behaviours. (D) Finally, to account for the effect on oral health outcomes when demographic factors and behaviours were simultaneously controlled, a fourth regression model was created. Beta coefficients and their 95% confidence intervals are reported. Linear regression models were chosen to model changes in quality of life and caries experience by income, as the focus was on estimating mean differences in outcomes across levels of SES. Results Table 1 describes the distribution of variables in the study, and demonstrates that there is high external validity of these results, as the sample parameters for this study were largely representative of the 2002 population estimates for Adelaide. There was no significant difference between the sample and true 2002 population in: number of teeth, the percentage receiving check-ups at the last visit or the percentage from higher income households (Fogg, 1997). Moreover, to assess whether the study population data trends from the 2007 paper are still valid, data were additionally included from the 2021 National Dental Telephone Interview Survey (Luzzi, 2023) and Australian Bureau of Statistics related to the 2021 Census (2021). Between the study population and 2021 Adelaide population for 45 to 54-year-olds, there was no significant difference in the mean number of teeth, last dental visit within 12 months, or time since last dental visit. Table 1 Distribution of variables and comparison of the study sample with the state population profile in 2002 and 2021 Study participants n (%) Missing data Population 2002 Population 2021 Socio-economic status Household income $ 80,000+ 209 (23.8%) 4.1% 24.5% 42.1% Household income tertiles: 4.1% Lower 311 (33.3) Mid 287 (30.7) Higher 299 (32.0) Oral health status Number of teeth - mean 25.4 (SD 5.0) 2.8% 26.9 25.1 Quality of life (OHIP) scores - mean 6.8 (SD 8.5) 0.5% - - Caries experience (DMFT) – mean 13.8 (SD 5.2) 26.6% - - Dental visit pattern Last dental visit < 12 months 541 (60.6%) 0.5% 65.4% 55.5% Check-up at last dental visit 361 (40.7%) 1.2% 41.7% 65.7% Last visit for relief of pain 135 (15.2%) 1.2% - 35.1% Number of dental visits in last 12 months – mean 1.5 (95% CI 1.4–1.7) 1.3% 1.8 - Dental behaviour Tooth brushing 1 + times per day 692 (81.4%) 5.0% - - Use of mouth rinse 1 + times per week 232 (26.2%) 1.4% - - Cleaned between teeth 1 + times per week 282 (31.6%) 0.4% - - In the study, the mean OHIP-14 score (representing quality of life) was 6.8 (SD 8.5), and the mean DMFT score (representing caries experience) was 13.8 (SD 5.28). An estimated 23.8% of participants had a household income greater than $ 80,000. Regarding dental visitation, a minority of participants had their last visit for relief of pain (15.2%) and most participants brushed their teeth once or more per day (81.4%). In Table 2 , as levels of dental visiting and self-care increased, OHIP-14 and DMFT scores were observed to decrease, with there being a 5.6% difference in mean OHIP-14 scores between high and low levels of self-care. There was no significant correlation between time since last visit on oral health outcomes (p = 0.4 for OHIP-14 and p = 0.4 for DMFT). Participants attending due to relief of pain had higher OHIP-14 scores than those attending for another reason (11.4 and 5.9, respectively). Those who did not floss had 4.0% higher OHIP-14 scores than those who flossed. Greater toothbrushing frequency was associated with lower OHIP-14 and DMFT scores; with there being a 5.7% difference in OHIP-14 scores between the groups. Finally, as household income increased, both OHIP-14 and DMFT scores significantly decreased; lower income tertile participants had 9.6% higher OHIP-14 scores than higher income tertile participants. Table 2. Oral health outcomes by oral health behaviours and income. OHIP-14 scores [1] DMFT scores [2] Mean (95% CI) Mean (95% CI) Household income tertiles Lower 10.0 (8.8-11.2) 14.6 (13.9-15.3) Mid 5.4 (4.6-6.2) 13.9 (13.2-14.6) Higher 4.7 (4.0-5.4) 12.9 (12.3-13.6) Dental visiting Low (8-16) 9.5 (8.4-10.6) 14.5 (13.7-15.3) Mid (17-21) 6.3 (5.4-7.2) 13.8 (13.2-14.4) High (22-25) 4.5 (3.7-5.2) 13.2 (12.6-13.9) Dental self-care Low (7-16) 8.7 (7.7-9.8) 14.8 (14.1-15.4) Mid (17-19) 6.0 (5.1-6.9) 13.6 (13.0-14.3) High (20-25) 5.6 (4.6-6.6) 13.1 (12.4-13.8) Time since last visit Within last 12 months 6.6 (5.9-7.3) 13.9 (13.5-14.4) More than 12 months ago 7.1 (6.1-8.0) 13.6 (12.9-14.3) Purpose of last visit Relief of pain 11.4 (9.5-13.2) 14.6 (13.6-15.6) Other 5.9 (5.3-6.4) 13.7 (13.3-14.1) Tooth brushing frequency 1+ times per day 5.9 (5.3-6.5) 13.5 (13.1-14.0) Less than once per day 9.1 (7.7-10.5) 14.9 (14.0-15.9) Mouth washing 1+ time(s) per week 7.6 (6.5-8.7) 13.9 (13.2-14.7) 0 times per week 6.4 (5.8-7.0) 13.7 (13.3-14.2) Flossing Performed 5.6 (4.9-6.3) 13.5 (13.0-14.0) Not performed 7.8 (7.0-8.7) 14.1 (13.5-14.7) [1] Higher OHIP-14 scores denote lower quality of life. [2] Higher DMFT scores denote greater caries experience. Regarding quality of life, Table 3 demonstrates significant attenuation of the beta coefficient (or social gradient) for household income when the entire set of behavioural measures were included, relative to the unadjusted model; the beta coefficient reduced from − 2.7 to -2.0. There was no significant attenuation of the beta coefficient when demographic factors only were controlled, indicating a significant impact of dental behaviours. Contrastingly for caries experience, the adjusted model 1, 2 and 3 beta coefficients, -0.7, lies within the 95% confidence interval of the unadjusted model beta coefficient (-1.3 to -0.3). As such, Table 4 shows insignificant attenuation of the beta coefficient for household income, even after accounting for all measures of dental behaviour and demographics relative to the unadjusted model. Table 3. Unadjusted and adjusted linear regression models for quality of life. Unadjusted model Adjusted model 1 [3] Adjusted model 2 [4] Adjusted model 3 [5] Parameter β (95% CI) β (95% CI) β (95% CI) β (95% CI) Household income (low to high) -2.7 (-3.4 to -2.1) -2.9 (-2.9 to -1.5) -1.9 (-2.6 to -1.3) -2.0 (-2.7 to -1.3) Purpose of last visit (relief of pain or other) 2.3 (0.7 to 3.8) 2.2 (0.7 to 3.8) Tooth-brushing frequency (1 or more times per day, or less than once daily) -1.0 (-2.3 to 0.3) -1.0 (-2.3 to 0.4) Interdental cleaning (1 or more times per week, or less than once per week) -0.6 (-1.7 to 0.6) -0.5 (-1.7 to 0.6) Mouthwash use (used 1+ times per week or less than once per week) 1.7 (0.5 to 2.9) 1.6 (0.4 to 2.8) Dental visiting (subscale score) -0.2 (-0.4 to -0.1) -0.2 (-0.4 to -0.1) Dental self-care (subscale score) -0.2 (-0.4 to -0.0) -0.3 (-0.5 to -0.1) Age in years -0.1 (-0.3 to 0.0) -0.1 (-0.2 to 0.1) Gender (male or female) -0.0 (-1.1 to 1.1) -0.4 (-1.5 to 0.8) Place of birth (Australia or other) -1.4 (-2.6 to -0.2) -1.7 (-2.9 to -0.5) [3] Model 1: adjusted for demographic factors including age, gender and place of birth. [4] Model 2: adjusted for dental behaviours. [5] Model 3: adjusted for dental behaviours and demographic factors. Table 4. Unadjusted and adjusted and linear regression models for caries experience. Unadjusted model Adjusted model 1 [6] Adjusted model 2 [7] Adjusted model 3 [8] Parameter β (95% CI) β (95% CI) β (95% CI) β (95% CI) Household income (low to high) -0.8 (-1.3 to -0.3) -0.7 (-1.2 to -0.2) -0.7 (-1.2 to -0.2) -0.7 (-1.2 to -0.1) Purpose of last visit (relief of pain or other) -0.2 (-1.4 to 1.0) -0.2 (-1.4 to 0.9) Tooth-brushing frequency (1+ times per day or less than once daily) -1.1 (-2.1 to -0.1) -1.2 (-2.3 to -0.2) Interdental cleaning (1 or more times per week or less than once per week) 0.1 (-0.7 to 1.0) 0.1 (-0.7 to 1.0) Mouthwash use (used 1+ times per week or less than once per week) 0.6 (-0.3 to 1.5) 0.6 (-0.3 to 1.5) Dental visiting (subscale score) -0.0 (-0.2 to 0.1) -0.0 (-0.2 to 0.1) Dental self-care (subscale score) -0.2 (-0.3 to -0.0) -0.2 (-0.3 to -0.0) Age in years 0.2 (0.0 to 0.3) 0.2 (0.1 to 0.3) Gender (male or female) 0.0 (-0.8 to 0.8) -0.1 (-0.9 to 0.7) Place of birth (Australia or other) 0.7 (-0.2 to 1.6) 0.5 (-0.4 to 1.4) [6] Model 1: adjusted for demographic factors including age, gender and place of birth. [7] Model 2: adjusted for dental behaviours. [8] Model 3: adjusted for dental behaviours and demographic factors. Missing data was generally low across the independent and outcome measures (5.0% or less). For DMFT scores, 686 participant results were recorded (73.4%) and 249 responses were missing (26.6%). The missing data proportion accounts for participants that were intentionally selected in a non-examined, comparison group as part of the study design. Discussion This study explored the extent to which dental behaviours influence socioeconomic disparities in oral health outcomes. The findings indicate that while positive dental behaviours – such as frequent tooth brushing, flossing, and regular dental visitation – are associated with improved quality of life, they do not significantly attenuate the socioeconomic gradient observed in caries experience. Participants from lower-income households consistently reported poorer quality of life and a greater burden of caries experience, reaffirming well-established associations between lower socioeconomic status and adverse oral health outcomes (Kim et al., 2018; Molarius et al., 2014; Sabbah et al., 2009; Sanders et al., 2006). Building on the foundational work of Sanders et al. (2006) (Sanders et al., 2006), this study employed an expanded methodology that included behavioural measures and a targeted focus on middle-aged adults. The results corroborate earlier conclusions that individual dental behaviours, while beneficial, are insufficient in addressing the broader structural inequalities that shape oral health. Notably, a modest reduction in quality-of-life disparities was observed when a full suite of protective dental behaviours was considered, suggesting that behavioural improvements may yield some subjective benefit. However, this effect did not extend to objective measures such as caries experience, possibly due to its cumulative and multifactorial nature and nature as a long-term measure (in contract to quality of life, for which more short-term improvements can be observed). While previous literature has not examined the independent effects of indirect and direct behavioural measures, the notion that multiple protective factors are required in combination to adequately improve oral health outcomes has been demonstrated (Ganss et al., 2019; Ciancio, 2003; Matthews, 2012; Chung et al., 2017) This has important implications for public health policy and practice. Strategies aimed at reducing oral health inequities should prioritise upstream determinants, such as education, access to affordable care, and structural reforms that improve the social context in which health behaviours occur. Although downstream approaches such as oral hygiene instruction and dietary counselling remain relevant, their long-term effectiveness in disrupting the social gradient remains uncertain and likely limited in isolation. Several limitations were considered for this study. The interpretation of DMFT scores as a proxy for caries experience is complex, as higher scores may reflect both disease burden and access to treatment. Similarly, frequent dental visits may indicate either proactive care or greater treatment needs. The isolated analysis of behaviours – rather than their cumulative or interactive effects – may also obscure important relationships. For example, mouth washing alone was associated with poorer outcomes, likely reflecting inadequate oral hygiene when not accompanied by other behaviours. Furthermore, this study did not assess additional influential factors such as differential access to care, occupational exposures, dietary behaviours (e.g., sugar intake), or comorbid systemic conditions – all of which may confound the relationship between SES and oral health. While approximately one-third of the initial sample was included in the final analysis, demographic comparisons revealed a high degree of representativeness relative to the broader Adelaide population, with minimal evidence of non-response bias. In conclusion, while favourable dental behaviours are associated with improvements in quality of life, they do not significantly reduce socioeconomic disparities in caries experience. Addressing these inequities will require multifaceted strategies that go beyond behaviour change, targeting the broader social and economic determinants of oral health. Clinical Relevance This study found that an extensive combination of positive oral health behaviours can help reduce the inequality in oral health outcomes pertaining to quality of life across the social gradient. Hence, clinicians should take patients’ dental behaviours into consideration during an initial risk assessment and reinforce adequate adoption of such behaviours as much as possible, such as toothbrushing twice daily and more regularly visiting the dentist for check-ups. However, clinicians should be aware that focusing on improving dental behaviours may not improve patient outcomes related to caries experience, and, unless favourable dental behaviours are comprehensively implemented (i.e., several different modalities of affirming oral health behaviours are simultaneously practiced), individual dental behaviours alone have little effect on oral health outcomes. 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(2007) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 335(7624): 806-808. Additional Declarations The authors declare no competing interests. Supplementary Files SupplementalTables.docx Supplemental tables Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7285783","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495029429,"identity":"e2c59c5c-62ad-4bed-b969-bfaba81a9d62","order_by":0,"name":"Harsha Chugh","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0008-6638-5261","institution":"The University of Sydney","correspondingAuthor":true,"prefix":"","firstName":"Harsha","middleName":"","lastName":"Chugh","suffix":""},{"id":495029430,"identity":"0b000a59-ef98-456d-80ca-4cecf792728d","order_by":1,"name":"Bradley Christian","email":"","orcid":"","institution":"The University of Sydney","correspondingAuthor":false,"prefix":"","firstName":"Bradley","middleName":"","lastName":"Christian","suffix":""},{"id":495029431,"identity":"6ded640b-7b46-4d17-9bc2-abc15b4030d4","order_by":2,"name":"Liana Luzzi","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Liana","middleName":"","lastName":"Luzzi","suffix":""},{"id":495029432,"identity":"2311300f-c9d9-4488-ae3b-7c5d455cd74d","order_by":3,"name":"David Brennan","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Brennan","suffix":""}],"badges":[],"createdAt":"2025-08-04 00:44:39","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7285783/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7285783/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88413337,"identity":"97fb8c2f-941a-4443-9c4b-af0668a845d5","added_by":"auto","created_at":"2025-08-06 08:40:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55421,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design and sampling flowchart\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003eFigure adapted with permission from “Caries experience among 45-54 year olds in Adelaide, South Australia”, by DS Brennan, AJ Spencer and KF Roberts-Thomson, 2007, \u003cem\u003eAustralian Dental Journal\u003c/em\u003e, 52:(2):122-127 (Brennan et al., 2007).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7285783/v1/2e7e7bc5370a361d7f47f6cf.png"},{"id":88416062,"identity":"0bcf595a-6b28-4cc4-a6b1-15f78e5685b8","added_by":"auto","created_at":"2025-08-06 08:56:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1000963,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7285783/v1/d43343b2-e24d-43ad-859c-eb66aeb3e71b.pdf"},{"id":88413342,"identity":"966701df-f378-48d8-91af-ca77f7bcfeea","added_by":"auto","created_at":"2025-08-06 08:40:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18694,"visible":true,"origin":"","legend":"\u003cp\u003eSupplemental tables\u003c/p\u003e","description":"","filename":"SupplementalTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7285783/v1/538ca0a1b0968a52311de289.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eInvestigating the associations between dental behaviours and oral health outcomes, in the context of the social gradient in oral health\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe relationship between socioeconomic status (SES) and oral health is well-documented, with a robust evidence base demonstrating a persistent social gradient in oral health outcomes (Arrica et al., 2017; Holde et al., 2018; Jamieson and Thomson, 2006; Kim et al., 2018; Łysek et al., 2016; Molarius et al., 2014; Mejia et al., 2014). This gradient reflects a nuanced and cumulative effect, whereby oral health progressively deteriorates with decreasing SES, shaped by differential access to healthcare, education, nutrition, environmental conditions, and social support. The framework of the social determinants of health (SDoH) provides a compelling explanation for this phenomenon, positing that individuals in lower socioeconomic positions face a disproportionate burden of oral diseases due to structurally embedded disadvantages that influence both risk exposure and access to care (AE, 2007; de Abreu et al., 2021).\u003c/p\u003e\n\u003cp\u003eAlthough upstream structural determinants remain critical in shaping oral health outcomes, individual-level dental behaviours—such as regular tooth brushing, interdental cleaning, mouth rinsing, and dental visitation—have the potential to mediate these effects and are more amenable to short-term intervention (Guarnizo-Herreño et al., 2019). However, evidence suggests that without careful contextual adaptation, behavioural interventions and policies intended to promote oral health (e.g., dental education programs or expanded welfare benefits) may paradoxically exacerbate disparities by being more accessible or beneficial to higher SES groups (Guarnizo-Herreño et al., 2019; Locker, 2000). Thus, while systemic reform is essential for long-term equity, a better understanding of how downstream behavioural factors operate across the social gradient is needed to inform interim and complementary public health strategies.\u003c/p\u003e\n\u003cp\u003eInvestigating the effectiveness of dental behaviours in attenuating the social gradient in oral health is especially pertinent in middle-aged adults, a demographic undergoing significant oral health transitions. Individuals aged 45–54 years are retaining more natural teeth and increasingly utilising dental services (Chalmers JM, 1999), with population trends indicating growing demand for restorative and periodontal care within this cohort (Joshi et al., 1996). Furthermore, demographic projections show that the proportion of middle-to-older adults will continue to rise, intensifying the burden on healthcare systems and reinforcing the need for early, preventive intervention (Ciobanu et al., 2024).\u003c/p\u003e\n\u003cp\u003eDental caries remains one of the most prevalent and enduring global health conditions, closely linked to SES, yet its underlying social and behavioural determinants are incompletely understood (Arrica et al., 2017; Patrick et al., 2006). In addition to clinical disease indicators, measures of oral health-related quality of life (OHRQoL) offer critical insight into the subjective and functional consequences of oral conditions, which are also unequally distributed across SES groups (Mejia et al., 2018; Knorst et al., 2021). Few studies have simultaneously examined the extent to which dental behaviours attenuate socioeconomic disparities across both clinical (e.g., caries experience) and non-clinical (e.g., quality of life) domains, particularly within a middle-aged adult population.\u003c/p\u003e\n\u003cp\u003eThe design of this study builds upon the work of Sanders et al. (Sanders et al., 2006), who investigated the explanatory role of dental self-care and attendance in mediating SES-related oral health disparities. While their study employed the Modified Dental Neglect Scale as an indirect measure of oral health behaviours, the current study expands this approach by incorporating both direct (i.e., DMFT scores) and indirect behavioural measures, including a refined adaptation of the Dental Neglect Scale (Sanders et al., 2006). This dual-method approach allows for a more comprehensive assessment of how behavioural factors influence oral health inequalities.\u003c/p\u003e\n\u003cp\u003eThe rationale for this study lies in addressing critical gaps in the literature: the underrepresentation of middle-aged adults in oral health inequality research; the limited understanding of behavioural self-management strategies among low SES populations; and the need for concurrent analysis of both clinical and patient-reported outcomes. Given the considerable financial, psychological, and physical burden of poor oral health – particularly for individuals of lower SES (Sanders et al., 2006; Locker, 2000; Chaffee et al., 2017; Silva Junior et al., 2020) – this research is timely and necessary.\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the role of dental behaviours in explaining socioeconomic inequalities in oral health. The specific objectives were to: (1) examine the associations between dental behaviours, quality of life, and caries experience; and (2) assess the extent to which these behaviours account for oral health disparities across SES groups.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cu\u003eEthical considerations\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval for this study was provided by the University of Adelaide Human Research Ethics Committee (H-74-2002).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eReporting\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe reporting of this study was informed by the STROBE checklist for cross-sectional studies (von Elm et al., 2007), including discussion of the background and rationale for the study, objectives, study design, setting, participants, variables, data sources, discussion of bias and study size, statistical methods, key results, limitations and interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSample size determination\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe required sample size for the study, based on an alpha level of 0.05 and 80% power, was computed using PC-SIZE software. To calculate required sample sizes pertaining to use of services, an estimate of the percentage of dentate 45 to 54-year-olds in South Australia visiting a dentist within a 1-year period in 1992-1993 (1993) was used. A sample size of 138 per group would be adequate to discern differences in use of services of 15% or more, with an effect size required to obtain expected difference (Joshi et al., 1996). Based on the above calculation, a random sample of 2469 45 to 54-year-old persons were selected from metropolitan Adelaide, South Australia.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStudy design and sampling\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a secondary analysis of data gathered for a 2007 study investigating caries experience among 45 to 54-year-olds in Adelaide, South Australia (Brennan et al., 2007). In the original study, 2248 persons aged 45 to 54 years were randomly sampled from metropolitan Adelaide, South Australia, using the electoral roll as a sampling frame during 2004-2005. Participants were sent a self-completed questionnaire to investigate the independent variables (dental visitation pattern, dental behaviour participation and socioeconomic status). Impact on quality of life was also gathered via the questionnaire (interpreted via assignment of an OHIP-14 score based on the participant responses). A reminder card and up to four follow-up mailings were sent to sampled non-respondents to encourage questionnaire completion. The questionnaire was completed by 879 persons. The respondents to the questionnaire were invited to participate in a clinical oral examination performed by calibrated dentists, in which caries experience data were gathered. Examinations were performed for 709 persons, producing a completion rate of 80.7%. A subset of 11 cases were re-examined to confirm reliability. The respondents who completed the questionnaire but did not follow up with an examination (107 persons) were analysed as a comparison group. The study design and sampling process is summarised in Figure 1 below.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eVariables\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe outcome measures\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewere: (A) Quality of life, inversely measured using the 14-item Oral Health Impact Profile (OHIP-14). An overall OHIP-14 score was computed as the mean score, and all ordinal responses were multiplied by the number of items to produce a summary statistic that could range from 0 to 56. Higher OHIP-14 scores indicate greater impact, and poorer oral health status. (B) Caries experience, measured using DMFT (decayed, missing, filled teeth) scores. Teeth were categorised as decayed, missing or filled (DMFT).\u003c/p\u003e\n\u003cp\u003eThe independent measures were: frequency of tooth brushing, mouth rinse use and interdental cleaning, socioeconomic status (measured using household income), and dental visiting and self-care patterns. Dental visiting and self-care data were gathered from the questionnaire. For both variables, a score was calculated by examining responses to questionnaire items which were derived from a Modified Dental Neglect Scale (Supplemental Table A2). For further detail on how the variables were measured and categorised for analysis, please refer to Supplemental Table A1).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eBias\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure the study sample was representative of the population, use of the electoral roll provided was an acceptable sampling frame as it contains all Australian adults registered to vote. The approximation of the sample respondents to national data was determined by assessing them against several variables from the 2002 National Dental Telephone Interview Survey, which was weighted to reflect the estimated residential population (2003).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eUnivariable analyses using frequencies, and measures of central tendency were used to describe and explore distribution of the data. This was followed by bivariable analyses, which utilised T-tests and one-way ANOVA to explore any unadjusted associations between the independent and outcome variables. Linear regression models were produced to investigate the independent effect of the direct and indirect measures on quality of life and caries experience via a forward stepwise approach, based on causal inferences from the literature (Pearce and Lawlor, 2016). (A) An initial linear regression model was produced to investigate the independent effect of only SES on the oral health outcomes; without accounting for oral health behaviours. The aim of this model was to demonstrate the social gradient in oral health outcomes. (B) To account for the effect on oral health outcomes when demographic factors were controlled, a second model was created. (C) A third model was created in which oral health outcomes were controlled for dental behaviours. (D) Finally, to account for the effect on oral health outcomes when demographic factors and behaviours were simultaneously controlled, a fourth regression model was created. Beta coefficients and their 95% confidence intervals are reported. Linear regression models were chosen to model changes in quality of life and caries experience by income, as the focus was on estimating mean differences in outcomes across levels of SES.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e describes the distribution of variables in the study, and demonstrates that there is high external validity of these results, as the sample parameters for this study were largely representative of the 2002 population estimates for Adelaide. There was no significant difference between the sample and true 2002 population in: number of teeth, the percentage receiving check-ups at the last visit or the percentage from higher income households (Fogg, 1997). Moreover, to assess whether the study population data trends from the 2007 paper are still valid, data were additionally included from the 2021 National Dental Telephone Interview Survey (Luzzi, 2023) and Australian Bureau of Statistics related to the 2021 Census (2021). Between the study population and 2021 Adelaide population for 45 to 54-year-olds, there was no significant difference in the mean number of teeth, last dental visit within 12 months, or time since last dental visit.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of variables and comparison of the study sample with the state population profile in 2002 and 2021\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy participants\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMissing data\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePopulation 2002\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePopulation 2021\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSocio-economic status\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold income \u003cspan\u003e$\u003c/span\u003e80,000+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e209 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold income tertiles:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e311 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e287 (30.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e299 (32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOral health status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of teeth - mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.4 (SD 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuality of life (OHIP) scores - mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8 (SD 8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaries experience (DMFT) \u0026ndash; mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8 (SD 5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental visit pattern\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLast dental visit\u0026thinsp;\u0026lt;\u0026thinsp;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e541 (60.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCheck-up at last dental visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e361 (40.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLast visit for relief of pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e135 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of dental visits in last 12 months \u0026ndash; mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5 (95% CI 1.4\u0026ndash;1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental behaviour\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTooth brushing 1\u0026thinsp;+\u0026thinsp;times per day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e692 (81.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUse of mouth rinse 1\u0026thinsp;+\u0026thinsp;times per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e232 (26.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCleaned between teeth 1\u0026thinsp;+\u0026thinsp;times per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e282 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the study, the mean OHIP-14 score (representing quality of life) was 6.8 (SD 8.5), and the mean DMFT score (representing caries experience) was 13.8 (SD 5.28). An estimated 23.8% of participants had a household income greater than \u003cspan\u003e$\u003c/span\u003e80,000. Regarding dental visitation, a minority of participants had their last visit for relief of pain (15.2%) and most participants brushed their teeth once or more per day (81.4%).\u003c/p\u003e\n\u003cp\u003eIn Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, as levels of dental visiting and self-care increased, OHIP-14 and DMFT scores were observed to decrease, with there being a 5.6% difference in mean OHIP-14 scores between high and low levels of self-care. There was no significant correlation between time since last visit on oral health outcomes (p\u0026thinsp;=\u0026thinsp;0.4 for OHIP-14 and p\u0026thinsp;=\u0026thinsp;0.4 for DMFT). Participants attending due to relief of pain had higher OHIP-14 scores than those attending for another reason (11.4 and 5.9, respectively). Those who did not floss had 4.0% higher OHIP-14 scores than those who flossed. Greater toothbrushing frequency was associated with lower OHIP-14 and DMFT scores; with there being a 5.7% difference in OHIP-14 scores between the groups. Finally, as household income increased, both OHIP-14 and DMFT scores significantly decreased; lower income tertile participants had 9.6% higher OHIP-14 scores than higher income tertile participants.\u003c/p\u003e\n\u003cp\u003eTable 2. Oral health outcomes by oral health behaviours and income.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOHIP-14 scores\u003cstrong\u003e[1]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDMFT scores\u003cstrong\u003e[2]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income tertiles\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Lower\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e10.0 (8.8-11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14.6 (13.9-15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Mid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5.4 (4.6-6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.9 (13.2-14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e4.7 (4.0-5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e12.9 (12.3-13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental visiting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Low (8-16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e9.5 (8.4-10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14.5 (13.7-15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Mid (17-21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6.3 (5.4-7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.8 (13.2-14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; High (22-25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e4.5 (3.7-5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.2 (12.6-13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental self-care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Low (7-16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e8.7 (7.7-9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14.8 (14.1-15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Mid (17-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6.0 (5.1-6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.6 (13.0-14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; High (20-25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5.6 (4.6-6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.1 (12.4-13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime since last visit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Within last 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6.6 (5.9-7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.9 (13.5-14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; More than 12 months ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7.1 (6.1-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.6 (12.9-14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePurpose of last visit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Relief of pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e11.4 (9.5-13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14.6 (13.6-15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5.9 (5.3-6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.7 (13.3-14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTooth brushing frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1+ times per day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5.9 (5.3-6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.5 (13.1-14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Less than once per day\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e9.1 (7.7-10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14.9 (14.0-15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMouth washing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1+ time(s) per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7.6 (6.5-8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.9 (13.2-14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 0 times per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6.4 (5.8-7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.7 (13.3-14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlossing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5.6 (4.9-6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13.5 (13.0-14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Not performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e7.8 (7.0-8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14.1 (13.5-14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e[1] Higher OHIP-14 scores denote lower quality of life.\u003c/p\u003e\n\u003cp\u003e[2] Higher DMFT scores denote greater caries experience.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003cp\u003eRegarding quality of life, Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e demonstrates significant attenuation of the beta coefficient (or social gradient) for household income when the entire set of behavioural measures were included, relative to the unadjusted model; the beta coefficient reduced from \u0026minus;\u0026thinsp;2.7 to -2.0. There was no significant attenuation of the beta coefficient when demographic factors only were controlled, indicating a significant impact of dental behaviours. Contrastingly for caries experience, the adjusted model 1, 2 and 3 beta coefficients, -0.7, lies within the 95% confidence interval of the unadjusted model beta coefficient (-1.3 to -0.3). As such, Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows insignificant attenuation of the beta coefficient for household income, even after accounting for all measures of dental behaviour and demographics relative to the unadjusted model.\u003c/p\u003e\n\u003cp\u003eTable 3. Unadjusted and adjusted linear regression models for quality of life.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted model\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted model 1\u003cstrong\u003e[3]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted model 2\u003cstrong\u003e[4]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted model 3\u003cstrong\u003e[5]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income\u0026nbsp;\u003c/strong\u003e(low to high)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e-2.7 (-3.4 to -2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-2.9\u003c/p\u003e\n \u003cp\u003e(-2.9 to -1.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-1.9\u003c/p\u003e\n \u003cp\u003e(-2.6 to -1.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-2.0 (-2.7 to -1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePurpose of last visit\u0026nbsp;\u003c/strong\u003e(relief of pain or other)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003cp\u003e(0.7 to 3.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2.2 (0.7 to 3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTooth-brushing frequency\u0026nbsp;\u003c/strong\u003e(1 or more times per day, or less than once daily)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-1.0\u003c/p\u003e\n \u003cp\u003e(-2.3 to 0.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-1.0 (-2.3 to 0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterdental cleaning\u0026nbsp;\u003c/strong\u003e(1 or more times per week, or less than once per week)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.6\u003c/p\u003e\n \u003cp\u003e(-1.7 to 0.6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.5 (-1.7 to 0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMouthwash use\u0026nbsp;\u003c/strong\u003e(used 1+ times per week or less than once per week)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003cp\u003e(0.5 to 2.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1.6 (0.4 to 2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental visiting\u0026nbsp;\u003c/strong\u003e(subscale score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003cp\u003e(-0.4 to -0.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.2 (-0.4 to -0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental self-care\u0026nbsp;\u003c/strong\u003e(subscale score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003cp\u003e(-0.4 to -0.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.3 (-0.5 to -0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.1\u003c/p\u003e\n \u003cp\u003e(-0.3 to 0.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.1 (-0.2 to 0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u0026nbsp;\u003c/strong\u003e(male or female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.0\u003c/p\u003e\n \u003cp\u003e(-1.1 to 1.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-0.4 (-1.5 to 0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of birth\u0026nbsp;\u003c/strong\u003e(Australia or other)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-1.4\u003c/p\u003e\n \u003cp\u003e(-2.6 to -0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e-1.7 (-2.9 to -0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e[3] Model 1: adjusted for demographic factors including age, gender and place of birth.\u003c/p\u003e\n\u003cp\u003e[4] Model 2: adjusted for dental behaviours.\u003c/p\u003e\n\u003cp\u003e[5] Model 3: adjusted for dental behaviours and demographic factors.\u003c/p\u003e\n\u003cp\u003eTable 4. Unadjusted and adjusted and linear regression models for caries experience.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted model\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted model 1\u003cstrong\u003e[6]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted model 2\u003cstrong\u003e[7]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted model 3\u003cstrong\u003e[8]\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income\u0026nbsp;\u003c/strong\u003e(low to high)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.8 (-1.3 to -0.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.7\u003c/p\u003e\n \u003cp\u003e(-1.2 to -0.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.7\u003c/p\u003e\n \u003cp\u003e(-1.2 to -0.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.7 (-1.2 to -0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePurpose of last visit\u0026nbsp;\u003c/strong\u003e(relief of pain or other)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003cp\u003e(-1.4 to 1.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.2 (-1.4 to 0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTooth-brushing frequency\u0026nbsp;\u003c/strong\u003e(1+ times per day or less than once daily)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-1.1\u003c/p\u003e\n \u003cp\u003e(-2.1 to -0.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-1.2 (-2.3 to -0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterdental cleaning\u0026nbsp;\u003c/strong\u003e(1 or more times per week or less than once per week)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003cp\u003e(-0.7 to 1.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.1 (-0.7 to 1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMouthwash use\u0026nbsp;\u003c/strong\u003e(used 1+ times per week or less than once per week)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003cp\u003e(-0.3 to 1.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.6 (-0.3 to 1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental visiting\u0026nbsp;\u003c/strong\u003e(subscale score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.0\u003c/p\u003e\n \u003cp\u003e(-0.2 to 0.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.0 (-0.2 to 0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDental self-care\u0026nbsp;\u003c/strong\u003e(subscale score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003cp\u003e(-0.3 to -0.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.2 (-0.3 to -0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003cp\u003e(0.0 to 0.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.2 (0.1 to 0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u0026nbsp;\u003c/strong\u003e(male or female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e(-0.8 to 0.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e-0.1 (-0.9 to 0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of birth\u0026nbsp;\u003c/strong\u003e(Australia or other)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003cp\u003e(-0.2 to 1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.5 (-0.4 to 1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e[6] Model 1: adjusted for demographic factors including age, gender and place of birth.\u003c/p\u003e\n\u003cp\u003e[7] Model 2: adjusted for dental behaviours.\u003c/p\u003e\n\u003cp\u003e[8] Model 3: adjusted for dental behaviours and demographic factors.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003eMissing data was generally low across the independent and outcome measures (5.0% or less). For DMFT scores, 686 participant results were recorded (73.4%) and 249 responses were missing (26.6%). The missing data proportion accounts for participants that were intentionally selected in a non-examined, comparison group as part of the study design.\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the extent to which dental behaviours influence socioeconomic disparities in oral health outcomes. The findings indicate that while positive dental behaviours \u0026ndash; such as frequent tooth brushing, flossing, and regular dental visitation \u0026ndash; are associated with improved quality of life, they do not significantly attenuate the socioeconomic gradient observed in caries experience. Participants from lower-income households consistently reported poorer quality of life and a greater burden of caries experience, reaffirming well-established associations between lower socioeconomic status and adverse oral health outcomes (Kim et al., 2018; Molarius et al., 2014; Sabbah et al., 2009; Sanders et al., 2006).\u003c/p\u003e\u003cp\u003eBuilding on the foundational work of Sanders et al. (2006) (Sanders et al., 2006), this study employed an expanded methodology that included behavioural measures and a targeted focus on middle-aged adults. The results corroborate earlier conclusions that individual dental behaviours, while beneficial, are insufficient in addressing the broader structural inequalities that shape oral health. Notably, a modest reduction in quality-of-life disparities was observed when a full suite of protective dental behaviours was considered, suggesting that behavioural improvements may yield some subjective benefit. However, this effect did not extend to objective measures such as caries experience, possibly due to its cumulative and multifactorial nature and nature as a long-term measure (in contract to quality of life, for which more short-term improvements can be observed). While previous literature has not examined the independent effects of indirect and direct behavioural measures, the notion that multiple protective factors are required in combination to adequately improve oral health outcomes has been demonstrated (Ganss et al., 2019; Ciancio, 2003; Matthews, 2012; Chung et al., 2017)\u003c/p\u003e\u003cp\u003eThis has important implications for public health policy and practice. Strategies aimed at reducing oral health inequities should prioritise upstream determinants, such as education, access to affordable care, and structural reforms that improve the social context in which health behaviours occur. Although downstream approaches such as oral hygiene instruction and dietary counselling remain relevant, their long-term effectiveness in disrupting the social gradient remains uncertain and likely limited in isolation.\u003c/p\u003e\u003cp\u003eSeveral limitations were considered for this study. The interpretation of DMFT scores as a proxy for caries experience is complex, as higher scores may reflect both disease burden and access to treatment. Similarly, frequent dental visits may indicate either proactive care or greater treatment needs. The isolated analysis of behaviours \u0026ndash; rather than their cumulative or interactive effects \u0026ndash; may also obscure important relationships. For example, mouth washing alone was associated with poorer outcomes, likely reflecting inadequate oral hygiene when not accompanied by other behaviours.\u003c/p\u003e\u003cp\u003eFurthermore, this study did not assess additional influential factors such as differential access to care, occupational exposures, dietary behaviours (e.g., sugar intake), or comorbid systemic conditions \u0026ndash; all of which may confound the relationship between SES and oral health. While approximately one-third of the initial sample was included in the final analysis, demographic comparisons revealed a high degree of representativeness relative to the broader Adelaide population, with minimal evidence of non-response bias.\u003c/p\u003e\u003cp\u003eIn conclusion, while favourable dental behaviours are associated with improvements in quality of life, they do not significantly reduce socioeconomic disparities in caries experience. Addressing these inequities will require multifaceted strategies that go beyond behaviour change, targeting the broader social and economic determinants of oral health.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eClinical Relevance\u003c/span\u003e\u003c/p\u003e\u003cp\u003e This study found that an extensive combination of positive oral health behaviours can help reduce the inequality in oral health outcomes pertaining to quality of life across the social gradient. Hence, clinicians should take patients\u0026rsquo; dental behaviours into consideration during an initial risk assessment and reinforce adequate adoption of such behaviours as much as possible, such as toothbrushing twice daily and more regularly visiting the dentist for check-ups. However, clinicians should be aware that focusing on improving dental behaviours may not improve patient outcomes related to caries experience, and, unless favourable dental behaviours are comprehensively implemented (i.e., several different modalities of affirming oral health behaviours are simultaneously practiced), individual dental behaviours alone have little effect on oral health outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe well-documented inequality in oral health outcomes across socio-economic strata can be reduced for quality of life, but not for caries experience, by the normalisation of dental behaviours across the social gradient.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e(1993) Dental care for adults in Australia: proceedings of a workshop. Canberra: Australian Institute of Health and Welfare.\u003c/li\u003e\n \u003cli\u003e(2003) National Dental Telephone Interview Survey 2002. Canberra: Australian Institute of Health and Welfare.\u003c/li\u003e\n \u003cli\u003e(2021) \u003cem\u003e2021 Census All persons QuickStats\u003c/em\u003e. Available at: https://abs.gov.au/census/find-census-data/quickstats/2021/SAL40002.\u003c/li\u003e\n \u003cli\u003eAE S (2007) Social determinants of oral health: conditions linked to socioeconomic inequalities in oral health in the Australian population. Reportno. Report Number|, Date. Place Published|: Institution|.\u003c/li\u003e\n \u003cli\u003eArrica M, Carta G, Cocco F, et al. (2017) Does a social/behavioural gradient in dental health exist among adults? A cross-sectional study. \u003cem\u003eThe Journal of international medical research\u003c/em\u003e 45(2): 451-461.\u003c/li\u003e\n \u003cli\u003eBrennan DS, Spencer AJ and Roberts-Thomson KF (2007) Caries experience among 45-54 year olds in Adelaide, South Australia. \u003cem\u003eAust Dent J\u003c/em\u003e 52(2): 122-127.\u003c/li\u003e\n \u003cli\u003eChaffee BW, Rodrigues PH, Kramer PF, et al. (2017) Oral health-related quality-of-life scores differ by socioeconomic status and caries experience. \u003cem\u003eCommunity Dent Oral Epidemiol\u003c/em\u003e 45(3): 216-224.\u003c/li\u003e\n \u003cli\u003eChalmers JM ER, Thomson WM, Spencer AJ (1999) Aging and Dental Health. Reportno. Report Number|, Date. Place Published|: Institution|.\u003c/li\u003e\n \u003cli\u003eChung S-Y, Chung S-Y, Hwang H, et al. (2017) Socioeconomic inequalities in dental behaviors among Korean adults. \u003cem\u003eDental and Medical Problems\u003c/em\u003e 54: 235-240.\u003c/li\u003e\n \u003cli\u003eCiancio S (2003) Improving oral health: current considerations. \u003cem\u003eJ Clin Periodontol\u003c/em\u003e 30 Suppl 5: 4-6.\u003c/li\u003e\n \u003cli\u003eCiobanu LG, Baryshnikova NV, Jawahar MC, et al. (2024) Pre-COVID life expectancy, mortality, and burden of diseases for adults 70 years and older in Australia: a systematic analysis for the Global Burden of Disease 2019 Study. \u003cem\u003eThe Lancet Regional Health \u0026ndash; Western Pacific\u003c/em\u003e 47.\u003c/li\u003e\n \u003cli\u003ede Abreu M, Cruz AJS, Borges-Oliveira AC, et al. (2021) Perspectives on Social and Environmental Determinants of Oral Health. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e 18(24).\u003c/li\u003e\n \u003cli\u003eFogg SG, Diane; Goss, John; Hargreaves, Jenny; Kendig, Hal; Marlton, Peter; Mathers, Colin; Mathur, Sushma; Osborne, Deborah; Rosewarne, Richard; Wade, Jennifer (1997) Older Australia at a glance. In: Services DoHaF (ed). Canberra: Australian Government Publishing Service.\u003c/li\u003e\n \u003cli\u003eGanss C, Heins M and Schlueter N (2019) An oral care programme for adults- Evaluation after 15 years. \u003cem\u003ePLoS One\u003c/em\u003e 14(12): e0223960.\u003c/li\u003e\n \u003cli\u003eGuarnizo-Herre\u0026ntilde;o CC, Watt RG, Garz\u0026oacute;n-Orjuela N, et al. (2019) Explaining oral health inequalities in European welfare state regimes: The role of health behaviours. \u003cem\u003eCommunity Dent Oral Epidemiol\u003c/em\u003e 47(1): 40-48.\u003c/li\u003e\n \u003cli\u003eHolde GE, Baker SR and J\u0026ouml;nsson B (2018) Periodontitis and quality of life: What is the role of socioeconomic status, sense of coherence, dental service use and oral health practices? An exploratory theory-guided analysis on a Norwegian population. \u003cem\u003eJ Clin Periodontol\u003c/em\u003e 45(7): 768-779.\u003c/li\u003e\n \u003cli\u003eJamieson L and Thomson W (2006) Adult Oral Health Inequalities Described Using Area-based and Household-based Socioeconomic Status Measures. \u003cem\u003eJournal of public health dentistry\u003c/em\u003e 66: 104-109.\u003c/li\u003e\n \u003cli\u003eJoshi A, Douglass CW, Feldman H, et al. (1996) Consequences of success: do more teeth translate into more disease and utilization? \u003cem\u003eJ Public Health Dent\u003c/em\u003e 56(4): 190-197.\u003c/li\u003e\n \u003cli\u003eKim YH, Han K, Vu D, et al. (2018) Number of remaining teeth and its association with socioeconomic status in South Korean adults: Data from the Korean National Health and Nutrition Examination Survey 2012-2013. \u003cem\u003ePLoS One\u003c/em\u003e 13(5): e0196594.\u003c/li\u003e\n \u003cli\u003eKnorst JK, Sfreddo CS, de FMG, et al. (2021) Socioeconomic status and oral health-related quality of life: A systematic review and meta-analysis. \u003cem\u003eCommunity Dent Oral Epidemiol\u003c/em\u003e 49(2): 95-102.\u003c/li\u003e\n \u003cli\u003eLocker D (2000) Deprivation and oral health: a review. \u003cem\u003eCommunity Dent Oral Epidemiol\u003c/em\u003e 28(3): 161-169.\u003c/li\u003e\n \u003cli\u003eLuzzi L (2023) Adult Oral Health and Access to Dental Care in Australia.\u003c/li\u003e\n \u003cli\u003eŁysek R, Polak M, Szafraniec K, et al. (2016) Socioeconomic Status, Health Behaviours and Oral Health in Adult Urban Population of Krakow. \u003cem\u003eDental and Medical Problems\u003c/em\u003e 53: 66-77.\u003c/li\u003e\n \u003cli\u003eMatthews D (2012) Weak, unreliable evidence suggests flossing plus toothbrushing may be associated with a small reduction in plaque. \u003cem\u003eEvid Based Dent\u003c/em\u003e 13(1): 5-6.\u003c/li\u003e\n \u003cli\u003eMejia G, Armfield JM and Jamieson LM (2014) Self-rated oral health and oral health-related factors: the role of social inequality. \u003cem\u003eAust Dent J\u003c/em\u003e 59(2): 226-233.\u003c/li\u003e\n \u003cli\u003eMejia GC, Elani HW, Harper S, et al. (2018) Socioeconomic status, oral health and dental disease in Australia, Canada, New Zealand and the United States. \u003cem\u003eBMC Oral Health\u003c/em\u003e 18(1): 176.\u003c/li\u003e\n \u003cli\u003eMolarius A, Engstr\u0026ouml;m S, Flink H, et al. (2014) Socioeconomic differences in self-rated oral health and dental care utilisation after the dental care reform in 2008 in Sweden. \u003cem\u003eBMC Oral Health\u003c/em\u003e 14(1): 134.\u003c/li\u003e\n \u003cli\u003ePatrick DL, Lee RS, Nucci M, et al. (2006) Reducing oral health disparities: a focus on social and cultural determinants. \u003cem\u003eBMC Oral Health\u003c/em\u003e 6 Suppl 1(Suppl 1): S4.\u003c/li\u003e\n \u003cli\u003ePearce N and Lawlor DA (2016) Causal inference\u0026mdash;so much more than statistics. \u003cem\u003eInternational Journal of Epidemiology\u003c/em\u003e 45(6): 1895-1903.\u003c/li\u003e\n \u003cli\u003eSabbah W, Tsakos G, Sheiham A, et al. (2009) The role of health-related behaviors in the socioeconomic disparities in oral health. \u003cem\u003eSoc Sci Med\u003c/em\u003e 68(2): 298-303.\u003c/li\u003e\n \u003cli\u003eSanders AE, Spencer AJ and Slade GD (2006) \u003cem\u003eEvaluating the role of dental behaviour in oral health inequalities\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eSilva Junior MF, Sousa M and Batista MJ (2020) Reducing social inequalities in the oral health of an adult population. \u003cem\u003eBraz Oral Res\u003c/em\u003e 33: e102.\u003c/li\u003e\n \u003cli\u003evon Elm E, Altman DG, Egger M, et al. (2007) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. \u003cem\u003eBMJ\u003c/em\u003e 335(7624): 806-808.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"2889d5f2-b080-4d74-aa60-7bea17e676b9","identifier":"10.13039/501100000925","name":"National Health and Medical Research Council","awardNumber":"250316","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Sydney","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"dental behaviours, direct and indirect measures, socioeconomic gradient, dental health services, oral health","lastPublishedDoi":"10.21203/rs.3.rs-7285783/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7285783/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003eTo explore the associations between dental behaviours and quality of life/caries experience, model the influence of dental behaviours on these outcomes across socioeconomic status (SES).\u003cbr\u003e\n \u003cem\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e 879 adults aged 45 to 54 from metropolitan Adelaide, South Australia.\u003cbr\u003e\n \u003cem\u003e\u003cstrong\u003eResearch design\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e Data on SES (household income) and dental behaviours—including frequency of tooth brushing, mouth rinsing, interdental cleaning, dental visiting and self-care practices—were collected via questionnaire. Clinical examinations were completed for 709 participants to assess caries experience using the decayed, missing, and filled teeth (DMFT) index.\u003cbr\u003e\n \u003cem\u003e\u003cstrong\u003eMain outcome measures\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e Quality of life, extrapolated using the 14-item Oral Health Impact Profile (OHIP-14), and caries experience via DMFT scores.\u003cbr\u003e\n \u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e An inverse SES gradient was observed for both quality of life and caries experience. Lower-income participants had reduced dental visiting scores [17.5 (95% CI: 17.1–18.0)] versus higher-income groups [20.0 (95% CI: 19.6–20.4)], and slightly higher dental self-care scores [17.7 (95% CI: 17.3–18.0)] than mid-income participants [17.6 (95% CI: 17.2–18.0)]. Higher-income individuals were more likely to have visited a dentist in the last 12 months (39.5%) and to brush daily (36.9%) than lower-income individuals (29.7% and 30.0%, respectively). Full behavioural adjustment significantly attenuated SES disparities in quality of life (unadjusted β=–2.7, 95% CI: –3.4 to –2.1; adjusted β=–2.0, 95% CI: –2.7 to –1.3), but not in caries experience (unadjusted β=–0.8, 95% CI: –1.3 to –0.3; adjusted β=–0.7, 95% CI: –1.2 to –0.1).\u003cbr\u003e\n\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e Comprehensive dental behaviours can reduce socioeconomic inequalities in quality of life, but minimally impact caries experience.\u003c/p\u003e","manuscriptTitle":"Investigating the associations between dental behaviours and oral health outcomes, in the context of the social gradient in oral health","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:40:40","doi":"10.21203/rs.3.rs-7285783/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d937a5cd-c053-4642-88b5-4b7e87d8f05d","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52718316,"name":"Dentistry"},{"id":52718317,"name":"Epidemiology"},{"id":52718318,"name":"Health Policy"}],"tags":[],"updatedAt":"2025-08-06T08:40:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 08:40:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7285783","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7285783","identity":"rs-7285783","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}