Hlsohgskolan, Hgskolan i Jnkping

On Oral Health in Young Individuals with

Foreign and Swedish Backgrounds

Brittmarie Jacobsson

DISSERTATION SERIES NO. 22, 2011

JNKPING 2011

 Brittmarie Jacobsson, 2011

Publisher: School of Health Sciences
Print: Intellecta Infolog

ISSN 1654-3602
ISBN 978-91-85835-21-8

Abstract
In Sweden, children and adolescents with two foreign-born parents constitute
17% of all children in the Swedish population. AIMS: The aims of this thesis
were to collect knowledge of the prevalence of gingivitis, caries and cariesassociated variables, in the 3-, 5-, 10- and 15-year age groups with two foreignborn parents compared with their counterparts with Swedish-born parents in a
ten-year perspective (Study I). To investigate the prevalence of caries and
caries-associated variables in 15-year-olds in relation to foreign backgrounds
and to examine differences in the prevalence of caries in adolescents with
foreign backgrounds according to their length of residence in Sweden (Study
II). MATERIAL AND METHODS: In 1993 and 2003, cross-sectional
studies with random samples of individuals in the age groups of 3, 5, 10 and 15
years were performed in Jnkping, Sweden. The oral health status of all
individuals was examined clinically and radiographically. The children or their
parents also answered a questionnaire about their attitudes to, and knowledge
of, teeth and oral health care habits. The final study sample comprised 739
children and adolescents, 154 with two foreign-born parents (F cohort) and 585
with two Swedish-born parents (S cohort) (Study I). In Study II, all 15-year-olds
(n=143) at one school in the city of Jnkping were asked to participate in the
study. The final sample comprised 117 individuals, 51 with foreign-born
parents and 66 with Swedish-born parents. All the individuals were interviewed
using a structured questionnaire with visualisation e.g. food packages, sweets
and snacks. Information about DFS was collected from case records at the
Public Dental Service. RESULTS: In both 1993 and 2003, more 3- and 5-yearolds in the S cohort were caries free compared with the F cohort. In 1993, dfs
was higher among 3- and 5-year-olds in the F cohort (p<0.01) compared with

the S cohort. In 2003, dfs/DFS was statistically significantly higher in all age
groups among children and adolescents in the F cohort compared with the S
cohort. In 2003, the odds ratio of being exposed to dental caries among 10- and
15-year-olds in the F cohort, adjusted for gender and age, was more than six
times higher (OR=6.3, 95% CI:2.51-15.61; p<0.001) compared with the S
cohort (Study I). Fifteen-year-olds born in Sweden with foreign-born parents,
or who had arrived before one year of age, had a caries prevalence similar to
that of adolescents with Swedish-born parents, whereas children who had
immigrated to Sweden after seven years of age had a caries prevalence that was
two to three times higher (p <0.06) (Study II). Both in 1993 and 2003, the mean
of the percentage of tooth sites with plaque and gingivitis was numerically
higher in all age groups in individuals with foreign backgrounds compared with
Swedish

background,

except

between

the

15-year-olds

(Study

I).

CONCLUSIONS: The decrease in caries prevalence, in a ten-year perspective,

was less among children and adolescents with foreign-born parents compared
with children and adolescents with Swedish-born parents. In 2003, there was
statistically significantly more caries in all age groups among children and
adolescents with foreign-born parents compared with children and adolescents
with Swedish-born parents. Children who immigrated to Sweden at age seven
or later had a two to three times higher caries prevalence compared with their
Swedish counterparts. The odds ratio for being exposed to dental caries was
almost six times higher for 10- and 15-year olds with foreign-born parents
compared with their Swedish counterparts. The intake of carbohydrate-rich
food was higher among 15-year olds with foreign backgrounds compared to
those with Swedish background. There is an obvious need to improve the
promotion of oral health care programmes among children and adolescents
with foreign-born parents.
Keywords: dental caries, diet, epidemiology, foreign background, gingivitis, immigrant

Original papers
The Licentiate thesis is based on the following papers, which are referred to by
their Roman numerals in the text:

Paper I
Jacobsson B, Koch G, Magnusson T, Hugoson A. Oral health in young
individuals with foreign and Swedish backgrounds a ten-year perspective.
European Archives of Paediatric Dentistry 2011;12:151-158.

Paper II
Jacobsson B, Wendt LK, Johansson I. Dental caries and caries associated
factors in Swedish 15-year-olds in relation to immigrant background. Swed Dent
J 2005;29:71-79.
The papers have been reprinted with the kind permission of the respective
journals.

Contents
Abstract ......................................................................................................... 3
Original papers ............................................................................................. 5
Paper I ........................................................................................................ 5
Paper II ....................................................................................................... 5
Contents ........................................................................................................ 6
Introduction .................................................................................................. 8
Immigration History of Sweden ................................................................. 8
Social and Cultural Perspective.................................................................. 9
Local Demographic Data ......................................................................... 11
General Health.......................................................................................... 12
Oral Health ............................................................................................... 13
Oral Health Determinants......................................................................... 13
Gingivitis .................................................................................................. 14
Dental Caries ............................................................................................ 15
Oral Hygiene, Fluoride Use and Dietary Habits ...................................... 16
Oral hygiene ......................................................................................... 16
Fluoride use .......................................................................................... 17
Dietary habits ....................................................................................... 17
Oral Health Status and Foreign Backgrounds .......................................... 19
Oral Health Preventive Programmes in Jnkping .................................. 20
AIMS ........................................................................................................... 24
PARTICIPANTS ........................................................................................ 25
Study I ...................................................................................................... 25
Study II ..................................................................................................... 26
METHODS ................................................................................................. 28
Study I ...................................................................................................... 28
Study II ..................................................................................................... 28
Diagnostic Criteria ................................................................................... 29
Number of teeth (Studies I, II) ............................................................. 29

Dental caries (Studies I, II)................................................................... 30

Decayed and filled primary and permanent tooth surfaces (Studies I, II)
.............................................................................................................. 30
Plaque (Study I) .................................................................................... 30
Gingival status (Study I)....................................................................... 31
Background data (Studies I, II) ............................................................ 31
Dietary habits (Studies I, II) ................................................................. 31
Oral hygiene habits and fluoride exposure (Studies I, II)..................... 31
Ethical issues ............................................................................................... 31
Statistical methods...................................................................................... 32
RESULTS .................................................................................................... 34
Study I ...................................................................................................... 34
Number of teeth .................................................................................... 34
Caries-free individuals ......................................................................... 34
Dental caries (initial and manifest) and restorations ............................ 35
Plaque and gingivitis ............................................................................ 37
Associations between dental caries and foreign and Swedish
backgrounds ......................................................................................... 41
Study II ..................................................................................................... 44
Caries free individuals .......................................................................... 44
Dental caries (initial and manifest) and restorations ............................ 44
Caries in relation to age at immigration ............................................... 45
Oral hygiene ......................................................................................... 46
Fluoride use .......................................................................................... 47
Dietary habits ....................................................................................... 47
DISCUSSION ............................................................................................. 50
CONCLUSIONS......................................................................................... 60
Summary in Swedish .................................................................................. 61
Tandhlsan hos barn och ungdomar med utlndsk respektive svensk
bakgrund ................................................................................................... 61
Acknowledgements ..................................................................................... 64
References ................................................................................................... 66
Appendix I-V

Introduction
Immigration History of Sweden
The post-war period divides Sweden into two distinct immigration periods. The
first period was characterised primarily by work force immigration. It began in
1945 and ended in the first half of the 1970s. Immigrants were mainly recruited
from North-Western Europe, with the majority from Western Germany and
the Nordic countries. Like many other countries, Swedens refugee policy was
based on the UN Geneva Convention of 1951, which Sweden signed in 1954.
That decade became the immigrants decade in Sweden and approximately
30.000-60.000 people immigrated every year. Large groups came from
Mediterranean countries such as Yugoslavia, Greece and Turkey1. During the
second immigration period, the mid-1970s and onwards, other types of
immigration started to increase. They comprised categories of refugees with
more non-European immigrants and with reasons for immigrating other than
work. In the 1970s, the major immigrant population was made up primarily of
refugees from Chile, Poland and Turkey. In the 1980s, a new wave of
immigration came from Ethiopia, Iran and other Middle-Eastern countries.
According to the Swedish Aliens Act of 19892, subsequently amended in 20063,
Sweden can grant asylum to only one category of refugees, so-called convention
refugees. Outside this Act, Sweden co-operates with the UN High
Commissioner for Refugees, UNHCR, and admits its share of quota refugees.
In the 1990s, most immigrants came from Iraq, the former Yugoslavia and
Eastern European countries. During the first five years of the new millennium,
these countries still dominated. During the last 15 years, crises in different parts
of the world have meant that the majority of refugees have come from more
distant and unstable countries, e.g. South America, Africa, Middle-Eastern
countries and other parts of Asia. The immigrants to Sweden from these
8

countries consist of refugees or persons who are being reunited with family
members in Sweden1.
The proportion of individuals whose both parents are born abroad has
increased from 4.0% in 1960 to 10.6% in 19954. In 2008, 101.200 people
immigrated to Sweden, the largest figure ever. Sweden has become a
multicultural society in which 14% of the population are born abroad5, with the
largest immigrant groups coming from Asia, the Nordic countries, Africa and
Europe (outside the Nordic countries). Family reasons were the most common
reason for immigration5-6. In the same year, there were almost 330.000 children
with foreign backgrounds (born abroad or born in Sweden with two foreignborn parents) in Sweden, constituting 17% of all the children in the
population7.

Social and Cultural Perspective

Until the mid-1960s, immigrants were warmly welcomed. However, there was
no clear political objective when it came to how refugees and immigrants
should be integrated in society until the mid-1970s. At that time, a policy of
ethnic or cultural pluralism was implemented, based on three pillars equality,
freedom of choice and partnership. Immigrants were to have the same social
and economic rights and standards as native Swedes8. On average, individuals
with foreign backgrounds have a lower income and are unemployed to a greater
extent than those with a Swedish background. The difference in educational
level may be the main explanatory variable for differences in the employment
integration of immigrant groups on the Swedish labour market. Another
significant factor is how long a person has lived in Sweden. Immigrants who
have been in Sweden for less than five years have very low employment levels.
Those who have lived in Sweden for 20 years or more have a significantly
9

higher degree of employment, even if it is still below the level of Swedish-born

persons9. A lack of integration in the employment of immigrants has resulted in
a negative effect on relative incomes, as well as a lower level of welfare
inclusion10. Poor economy also determines the choice of accommodation. In
2002, only 31% of 0- to 17-year-old children with foreign-born parents (born
outside the Nordic and EU-countries) lived in detached houses, compared with
70% of their Swedish counterparts11. Many foreign-born parents bring their
lifestyle, such as food habits, tobacco smoking and policy relating to alcohol
use, to their new country. Refugees often have a background characterised by
stress, threat and fear and many families have been separated for long periods
of time. This also influences the entire family12.
According to one report by Save the Children in 200213, children with a foreign
origin run a four times higher risk of living in a poor family with regard to
economic conditions compared with children with a Swedish background.
Furthermore, the risk was twice as high if they lived in a family with two
foreign-born parents compared with a family with one foreign-born parent.
Children whose parents came to Sweden in the 1990s run the greatest risk of
living in a poor family. More than half the families who came to Sweden in the
early 1990s were still poor in 2000. Children and adolescents who do not have
Swedish as their mother language are involved in more accidents and run an
increased risk of certain diseases. This can partly be explained by the parents
low social position in society and the fact that this group of children and
adolescents recently came from countries with a higher prevalence of certain
diseases such as hepatitis B and C, tuberculosis and HIV, compared with
Sweden12. Children born in Sweden achieve better academic results than
foreign-born children at both compulsory school and upper secondary school.
There are several factors explaining this, such as the time a child has resided in
Sweden, the childs previous experience in school and the childs health5.
10

There is a strong negative relationship between socio-economic status and

dental health12,14-18. Despite the fact that, since 1974, Sweden has a general
dental care insurance19, which gives all children and adolescents access to free
dental care up to 19 years of age, this is not enough to achieve an oral health
status independent of social group. Socio-economic relationships are not,
however, the only reason that explains differences in caries prevalence. A
number of other factors also interact18.
All new immigrants should be offered an introductory programme in the
municipality where they live. Firstly, this programme should provide
information about Swedish society, education in the Swedish language and an
introduction to the labour market. This programme should also act as a
platform for public health issues. Refugees can, for example, obtain
information about successful Swedish prevention programmes for avoiding
dental caries, accidents and punishment12.

Local Demographic Data

Jnkping is one of the ten largest municipalities in Sweden, with
approximately 126.000 inhabitants of which approximately 19% have foreign
backgrounds. Almost 6.100 children have foreign backgrounds. This constitutes
20% of all the children in Jnkping20. In central town areas, the housing
mostly consists of blocks of flats with small apartments. In peripheral town
areas, there is a mix of detached houses and blocks of flats. There are also areas
with almost only detached houses, where the percentage of families with
children is larger than the average for the municipality. In these areas, the social
benefit dependence level is low. In Jnkping, there are economically
vulnerable and wealthy areas. Vulnerable areas like Rsltt and sterngen
often have a large percentage of foreign-born people and a large number of
11

unhealthy people. Rural areas and smaller villages are mostly populated by
elderly people and families with children. In these regions, the number of
unhealthy people is generally low, as is the percentage of both foreign-born and
single people21.

General Health
For a long time period, children and young people in Sweden experienced very
positive health trends. However, during the 1990s, differences in average
general health between social groups began to increase. This was most visible
between children in good social and economic circumstances, with parents with
a high educational level, compared with children in the opposite circumstances,
with parents with a low educational level12,22-23.
The health conditions for immigrants in Sweden are poorer at a group level
than those for native Swedes. Working conditions, level of education, family
situation and especially traumatic experiences of persecution and threats from
the native country, as well as a period of uncertain waiting during the asylum
process, are reasons for poorer health among immigrants12.
According to a report from the Swedish National Board of Health and
Welfare23, it was three to four times more common for individuals with foreign
backgrounds to report poor or very poor health compared with individuals with
a Swedish background. When the data were adjusted for social variables such as
work, low income and living in an apartment, the difference between the two
groups decreased.

12

Oral Health
Two broad definitions of health and oral health can be identified. First, there is
one involving biophysical wholeness24-25. In this case, the aim is to identify any
pathological sign that signifies the existence of a pathological lesion, such as
dental caries. An alternative definition of health has been presented by the
World Health Organisation26, which defines health as being different from the
absence of disease. Oral health means more than healthy teeth, it is a
determinant factor for quality of life. Oral health is integral to general health
and is essential for mental and social well-being27. An understanding of cultural
background is important in order to change health beliefs and attitudes. The
social context and ideas about oral health in other cultures have been described
by Kent & Croucher28.
It has been stated that there is a new oral disease pattern related to changes in
living conditions and lifestyles. The future challenges to dentistry and oral
public health care planning are limited to areas of expertise. This relates to nonclinical dimensions of dental practice, such as oral health promotion,
community-based preventive care and outreach activities29.

Oral Health Determinants

The motivation to maintain oral health is identified as being related to social
factors of importance rather than perspectives related to the treatment and
prevention of a disease process. An understanding of sociology (the study of
human groups), the impact of social class and the influence of culture in
determining health-related behaviour is necessary for the appropriate provision
of oral health care. Oral health epidemiology should also involve oral health
determinants. Figure 1 summarises several factors involved in understanding
13

the changing oral disease patterns worldwide30. Changes in lifestyle and

economic and social conditions are acknowledged as playing a more important
role when it comes to understanding the changing patterns in oral diseases29.
Another important factor is general health31.
POPULATION
Demographic factors
Migration

ORAL
HEALTH
and
ORAL
DISEASE

SOCIETY
Living conditions

ORAL HEALTH
SYSTEMS
Delivery models
Financing of care
Dental manpower
Population-directed/
high-risk strategies
ENVIRONMENT
Climate
Fluoride and water
Sanitation

Culture and lifestyles

Self-care

Figure 1. Principal factors involved in changing oral disease patterns worldwide. Adopted
from Petersen30.

Gingivitis
Plaque-associated gingivitis is the most prevalent form of gingival inflammation
and is caused by an accumulation of dental plaque on the tooth surface at the
gingival margin32. Plaque is a biofilm a community of micro-organisms
attached to a surface. These organisms are organised into a three-dimensional
structure enclosed in a matrix of extracellular material. Dental plaque is an
adherent deposit of bacteria and their products. The response to this biofilm is
an inflammation of the surrounding local gingival and periodontal tissue. The
inflammatory response subsides after the removal of the bacterial biofilm. The
presence of the dental biofilm is necessary for gingivitis to occur. The intensity
14

and duration of the inflammatory response varies between individuals and even
between different teeth in the oral cavity33.

Dental Caries
Dental caries is still a large public health problem. Extensive caries can lead to
large-scale suffering and a reduction in quality of life both functionally and
aesthetically34-35. It is still a major problem in most industrialised countries,
affecting 60-90% of schoolchildren and the vast majority of adults. It is also
one of the most prevalent oral diseases in several Asian and Latin-American
countries27.
Caries is a dynamic dietomicrobial site-specific disease36 and a result of the
interaction between the host (tooth and saliva), the microflora (the
microbiological ecology in the biofilm on the tooth) and carbohydrates in the
food (substrate for the microflora). These factors are involved in cycles of
demineralisation and remineralisation. The early stage of caries can be reversed
by modifying or eliminating etiological factors, such as the biofilm and the
sucrose in the diet, and increasing protective factors, such as regular toothbrushing with fluoride toothpaste and flossing. The amount and quality of
saliva are important defence factors against caries. Caries is therefore the result
of a disturbance in the balance between attack factors and defence factors37.
Lactobacillus and Streptococcus Mutans are tooth-colonising bacteria with a
great ability to produce acid. Simultaneously, they have the ability to tolerate an
acid environment. They are therefore regarded as central for the development
of caries. Mealtime frequency, the content of carbohydrates and food
consistency determine how intense the pH reduction becomes38-39.

15

The prevalence of dental caries varies in different countries40-41. During the last
two decades, the prevalence has decreased significantly among children and
young people in Europe and especially in Sweden34,42-45. Preventive
programmes based on information and instruction in oral hygiene, fluoride
administration and sugar restrictions have contributed to the improvement in
oral health45,46. Despite the fact that oral health has improved in recent years,
there are still individuals in the population with a large number of decayed
teeth. Today, approximately 20% of the population account for approximately
80% of the prevalence of dental caries14,41,47.
Several studies have shown that the improvement in oral health in 3- and 6year-olds now appears to have levelled out48-50. Some studies also indicate an
increase in the number of decayed and filled teeth in children and adolescents
in recent years44,49,51-52.

Oral Hygiene, Fluoride Use and Dietary Habits

Oral hygiene
Regular oral hygiene habits are associated with good oral health and poor oral
health is associated with gingivitis and caries53-54. Caries is said to be a toothcleaning neglect disease and regular oral hygiene habits are considered to be
more important than good dietary habits55-56. To a certain extent, good oral
hygiene habits are considered to compensate for poor dietary habits57-59.
Almost all the young people in the Nordic countries brush their teeth at least
once a day60-62. On the other hand, the use of proximal cleaning is not so
extensive63-64. Boys generally have poorer oral hygiene habits than girls in
16

corresponding ages65-66. In the work for caries prevention, education in good

oral hygiene habits is considered to be one of the most important strategies67-69.

Fluoride use
The acting mechanism of fluoride has been well known since the 1940s. The
local presence of fluoride in the mouth is important in order to protect the
teeth from caries. The saliva is the means of distributing the fluoride between
the teeth34 and fluoride has the best effect on clean tooth surfaces70.
Toothpaste with fluoride was introduced in Sweden during the latter part of the
1960s and today almost all toothpastes contain fluoride. The local effect of
fluoride in the mouth in order to prevent the start of caries is being increasingly
emphasised34,71-72. The Nordic countries have Europes highest figures when it
comes to the daily use of fluoride toothpaste63,73. The first fluoride toothpaste
of commercial importance contained about 1.000 ppm of fluoride. In Sweden,
the highest concentration currently allowed is 1.500 ppm of fluoride.
Toothpastes with a higher concentration of fluoride appear to provide better
protection from caries than toothpaste with a lower concentration34,74. Toothbrushing with fluoride toothpaste twice a day is currently regarded as a
sufficient basic preventive strategy against caries for children and adolescents15,
34,55,62.

Fluoride is the most used preventive measure for risk patients and

patients with high caries activity60. Regular tooth-brushing with fluoride

toothpaste is moreover thought to reduce caries in cases of frequent
consumption of cariogenic food34,55,75-76.

Dietary habits
Since the results of the Vipeholm Study were presented38, dental health
professionals have spread the information of the importance of reducing the
17

number of sugar-containing products between meals in order to reduce the risk

of caries, especially among children and adolescents12. In some respects,
children and adolescents have better dietary habits than adults, while these
habits are also poorer in some respects. Children generally eat low-fat
alternatives of milk and cooked fatty products, but they also eat too many
sugar-rich products, i.e. products with added sucrose and monosaccharides.
The major sugar sources are soft drinks and juices, followed by sweets,
flavoured dairy products and buns, cakes and biscuits. On average, children eat
sweet foods two to three times a day77.
During the last few decades, the pattern of sugar consumption has changed.
The intake of clean sucrose has decreased, while hidden sucrose, such as
sweetened cocoa powder, jam and marmalade, chocolate, sweets, soft drinks,
juices, ice-cream and pastries, has increased75,57. According to the National
Food Administration in Sweden77, there is a steady increase in the consumption
of sweets, soft ice-cream, snacks and pastries. Nearly a quarter of the calories
come from this kind of food. On average, children also drink about two
decilitres of juice and soft drinks every day and eat about 150 grams of sweets a
week. One in ten children in Sweden drink more than four decilitres of juice
and soda every day and eat more than 300 grams of sweets a week.
Several studies have shown that irregular dietary habits and a high consumption
of sweets between meals lead to an increased risk of caries in the primary
dentition78-81, as well as in the permanent dentition14,55,82. rnadttir et al.83
found a significant correlation between sugar consumption and caries. The
frequent intake of sugary products between meals was a definite risk factor for
the occurrence of caries, especially for subjects with previous caries experience.
Moreover, starch, especially when combined with soft drinks, is a contributory
factor in the development of caries79,84-87. This knowledge is important, since
18

the consumption of potato crisps and cheese doodles has increased

considerably among young people during the last decade77.
It is not the amount of food, but the frequency of food intake, that is important
when it comes to the risk of developing caries55. Dietary habit advice still plays
an important part in the prevention of dental caries88.

Oral Health Status and Foreign Backgrounds

In a report from the Swedish National Board of Health and Welfare49 about
differences in oral health and access to dental care, regions with a high
prevalence of caries coincide with regions with many people with foreign
backgrounds. Many studies have demonstrated apparent poorer oral health in
pre-school children with foreign backgrounds compared with native-born preschool children48,89-90. The results that have been presented when it comes to
the caries situation in permanent teeth in schoolchildren and adolescents
diverge, however. Flinck et al.14 and other studie91-92 have found a higher caries
prevalence in the permanent dentition in children and adolescents with foreign
backgrounds compared with their Swedish counterparts. Other studies of older
children and adolescents have not found any significant differences in caries
prevalence in groups with and without foreign backgrounds93-94.
When it comes to tooth-brushing habits and the use of flossing in adolescents
with foreign and Swedish backgrounds, the results in different studies also
conflict. In one study by Ekman91, no significant differences could be found,
while Dahllf et al.93 found that more adolescents with a Swedish background
brushed their teeth twice a day or more compared with adolescents with foreign
backgrounds. When it comes to the use of fluoride, no differences between

19

children and adolescents with and without foreign backgrounds have been
found91,93,95.
Cultural differences in standards and values in relation to the importance of
good oral health could contribute to the differences found in oral health67,96.
The immigration process, such as changing living conditions as a result of
settling in a new country and adopting new lifestyles, comprises sociobehavioural factors that have been shown to affect the risk of oral diseases,
particularly in children29.
Studies have also shown that children with foreign backgrounds have poorer
dietary habits and a more frequent intake of sugar-containing products between
meals90,91.
The level of these differences appears to depend on the degree of integration
into the new society, as well as on psychosocial and cultural factors. It is also
possible that immigrants have a poor knowledge of the structure and function
of the health care system in the new country. They may have different
expectations of care and they may lack the ability to communicate with health
professionals, including oral health services29.

Oral Health Preventive Programmes in Jnkping

The development of the Oral Health Preventive Programmes for Children and
Adolescents in the County of Jnkping began during the early 1970s as a
result of epidemiological information from different Public Dental Service
clinics within the county. When the oral health programmes started in
Jnkping, the county had a poorer oral health status than the average in
Sweden44. Through organised, systematic oral health care activities, oral health
20

gradually improved among children in Jnkping97 and became better than the
average in Sweden. This positive improvement continued until the early 1990s,
when this trend was broken. One of the reasons for the reversal of this trend
was that the resources for dental care in the county decreased at the start of the
1990s, in spite of the fact that the number of children and adolescents increased
in the county. The reduced requirements imposed on the Public Dental Service,
with reduced economic and staff resources, led to changes in the oral health
organisation and the preventive programmes at clinics. However, a conscious
choice was also made when primary oral health preventive programmes in
schools and kindergartens were reduced and replaced by more individual
treatment for patients at risk. Another reason for the overall impairment in oral
health during this period could be an increase in the number of children and
young people with foreign backgrounds with a poorer oral health situation98.
The oral health situation for children and adolescents in the County of
Jnkping during the last 10-year period has been described in several
publications44,50,63,68. In 1993, an increase in the number of decayed and filled
tooth surfaces was noted in 15- and 20-year-olds compared with the figures in
198399. Furthermore, an increase in plaque and gingivitis in adolescents was also
noted compared with 10 years earlier. Moreover, it was noted that the use of
professional fluoride varnish decreased between 1983 and 1993. The oral health
in different areas varied considerably, however, and the percentage of 19-yearolds without proximal manifest carious lesions in 2001 varied between 49% to
69% in different areas within the county98.
All the children and adolescents in the County of Jnkping take part in the
same preventive programmes from one year of age or from the year a child
arrives in Sweden. The first contact with dental staff takes place at a child care
centre or at a dental clinic. These preventive programmes provide regular
21

information and recommendations to brush the teeth at least twice a day using
fluoride toothpaste. Moreover, fissure sealants of all first permanent molars is
recommended in the guidelines for the Public Dental Service in the county100.
From three years of age, the child attends regular dental examinations, once a
year, up to 19 years of age. However, it is also important to consider the special
needs of the individual child. If a child has good dental health, there may be
more than one year between the examinations and, if the child has special
needs, he/she comes for more frequent check-ups. The 3- to 5-year-olds are
examined radiographically with two bite-wing radiographs when there is
proximal contact in the molar region. Unless there are special reasons, all
children from 6-19 years of age are examined radiographically (bite-wing
examination). In accordance with the instructions for epidemiological
registrations in the county, all carious lesions are registered in all teeth and for
all tooth surfaces (except third molars). Apart from registering the number of
filled surfaces and extracted teeth, each tooth surface with initial or manifest
carious lesions is registered. According to the instructions, caries is registered as
initial if the lesion has not passed the enamel-dentine border and as manifest
when the carious lesion reaches into the dentine101. In connection with the
examination, all children and adolescents are categorised into four different risk
categories, by dentists or dental hygienists. On the basis of risk category, each
child is then dealt with according to an individually based treatment regimen. In
addition to the basic prevention programme, an additional programme for
children and adolescents with a high caries risk is implemented. This
programme contains more oral hygiene information, motivation, instructions,
professional tooth cleaning, strengthened fluoride prevention, fissure sealants,
saliva tests and chlorhexidine rinsing100.

22

In accordance with the results from the Jnkping Cross Sectional Study in
199399, which was also an evaluation of Jnkping Oral Health Preventive
Programmes, 15-year-olds showed an increased number of decayed/filled tooth
surfaces in 1993 compared to 1983 and there was also a significant increase in
prevalence of plaque and gingivitis. This year was also the first year when
questions about foreign backgrounds were included in the questionnaire, which
gave the possibility to study similarities and differences in foreign and Swedish
backgrounds as regards to, among other things, dental health.

23

AIMS
The overall aim of this thesis was to collect knowledge about the prevalence of
caries, caries-associated variables and gingivitis in children and adolescents with
foreign and Swedish backgrounds, respectively, living in the County of
Jnkping in Sweden.

To investigate the caries, caries-associated variables and gingivitis

prevalence among children and adolescents in the age groups of 3, 5,
10 and 15 years with foreign backgrounds compared with their
Swedish counterparts in a ten-year perspective (Study I)

To investigate the prevalence of caries and caries-associated variables

in 15-year-olds with foreign backgrounds in relation to 15-year-olds
with a Swedish background (Study II)

To analyse whether the age at immigration was related to caries

prevalence (Study II)

24

PARTICIPANTS
Study I
In 1993 and 2003, a random sample of 130 individuals in each age group, 3, 5,
10 and 15 years, were selected from four parishes in Jnkping, Sweden. For
various reasons, 219 individuals (21%) of those invited declined to participate,
97 (19%) in 1993 and 122 (23%) in 2003. Eight hundred and twenty-one
children were thus examined. Fourteen individuals (2%), seven individuals in
each year, failed to answer the questions on ethnic background variables and
were excluded from the study. All the children and adolescents were divided
into groups based on their ethnic background according to Statistics Sweden102103.

Individuals with foreign backgrounds are defined as being born in a

foreign country or being born in Sweden with two foreign-born parents.

Individuals with a Swedish background are defined as being born in Sweden
or being born in a foreign country with two Swedish-born parents, while
individuals with mixed backgrounds are defined as being born in Sweden or
being born in a foreign country with one native-born parent and one foreignborn parent. Children and adolescents with mixed backgrounds (n=68) were
excluded from further analysis. The reason for excluding individuals with mixed
backgrounds was that an earlier study89, conducted in the same area, had shown
that, if one parent was born abroad and one in Sweden, there was no
statistically significant difference in caries prevalence between this group and
the group with a Swedish background. The final study sample thus comprised a
total of 739 children and adolescents of whom 154 (21%) had parents with
foreign backgrounds (F cohort) and 585 (79%) had parents with a Swedish
background (S cohort) (Table 1). Among foreign-born parents, 66% came from
Asia, 19% from other European countries, 7% from Africa, 2% from South
America, 1% from North America and 5% from Scandinavian countries. The
percentage of males and females was almost the same in the two cohorts. There
25

were 46% males and 54% females among the children and adolescents in the
F cohort and 51% males and 49% females in the S cohort. In the F cohort,
65% were born in Sweden and 35% were born in another country.

Study II
In 2001, all 15-year-olds (n=143) at Stadsgrdsskolan in Rsltt, Jnkping,
were personally invited to participate in the study and 131 (92%) accepted the
invitation. For various reasons, 12 individuals (8%) of those invited declined to
participate. The mean age was 15.4 years (range: 15.3-15.4) (95% CI) and the
number of boys and girls was almost the same (Table 1). The adolescents were
divided into three groups according to their parents background, according to
Statistics Sweden102, using the same criteria as in Study I. For the same reason
as in Study I, children and adolescents with mixed backgrounds (n=13) were
excluded from further analysis. Because of missing caries statistics, there was a
further drop-out of one subject. The final sample thus comprised 117
individuals of whom 51 (44%) had foreign backgrounds and 66 (56%) had a
Swedish background (Table 1). Among foreign-born parents, 65% came from
Asia, 22% from other European countries, 10% from Africa, 2% from South
America, 1% from North America and 1% from Scandinavian countries.

26

Table 1. Age distribution of the invited study population in Study I and Study II, divided
into those who arrived at the examination, foreign, Swedish and mixed backgrounds and
drop-outs, and the final study population and its distribution in genders.
Study I
(1993)
Age

invited

3
5
10
15

130
130
130
130

examined

100
107
114
102

foreign

Swedish

15
18
22
23

76
77
80
75

mixed

9
8
10
3

dropouts

0
4
2
1

included

male

female

91
95
102
98

42
52
60
50

49
43
42
48

(2003)
Age

invited

examined

foreign

Swedish

mixed

dropouts

included

male

female

3
5
10
15
Total

130
130
130
130
1040

96
96
110
96
821

18
23
24
11
154

63
63
77
74
585

14
8
7
9
68

1
2
2
2
14

81
86
101
85
739

32
45
48
40
369

49
41
53
45
370

Age

invited

examined

foreign

Swedish

mixed

dropouts

included

male

female

15

143

Study II
(2002)
131

51

66

27

13

117

50

67

METHODS
Study I
In 1993 and 2003, descriptive cross-sectional studies were performed in
Jnkping, Sweden. All the participants were personally invited to take part in a
clinical and radiographic examination performed by calibrated examiners from
the Institute for Postgraduate Dental Education in Jnkping, in respect of
their oral health status. In addition to the clinical examination, the 3- and 5year-olds were examined radiographically with two bite-wing radiographs when
there was proximal contact in the molar regions. In the 10- and 15-year-olds,
panoramic radiography and six bite-wing radiographs - two each on the left and
right sides and two in the frontal region - were taken. If recent radiographs
were available from the participants regular dentist, they were used. (For
detailed information on the methods used, see Hugoson et al50,63). In
connection with the clinical examination, the children or their parents (3- and
5-year-olds) answered a questionnaire about background data, attitudes to and
knowledge about teeth, oral health care habits and dietary pattern (Appendices
IIV). Data on foreign and Swedish background were extracted and organized
by the first author.

Study II
In 2001, a structured questionnaire interview study of 15-year-olds in Rsltt,
Jnkping, was performed. All the participants were interviewed individually,
by the first author, using a structured questionnaire with 40 questions divided
into four sections; background data, diet, oral hygiene habits and fluoride
exposure (Appendix V). Each interview took 15-20 minutes and was conducted
28

in a separate peaceful room at the school. To avoid language confusion,

different food packages, sweets and snacks were physically present to visualise
questions relating to food habits104. The items were placed on a table in the
same order as the questions in the questionnaire. The reported frequency of
food containing fermentable carbohydrates was converted to the number of
intakes per day. The answer Never/seldom was converted to zero. Once a
week was converted to 0.14. Two to three times a week was converted to
0.36. Once daily was converted to 1.0. Two to three times daily was
converted to 2.5 and Several times daily was converted to 4.0. Every single
reported frequency of snacks between principal meals was converted to daily
sugar intake by multiplying fermentable carbohydrates as standard portions105106.

Data on caries experience were extracted by the first author from the
individuals dental records that were drawn up at the participants yearly visit
when they were 15 years old. The clinical and the radiographic examinations
were made by four different examiners at the Rsltt Public Dental Service.
Four bite-wing radiographs two each on the left and right sides were taken
on all participants.

Diagnostic Criteria
Number of teeth (Studies I, II)
Primary teeth were recorded in the 3- and 5-year-olds. In the 10- and 15-yearolds, only permanent teeth, excluding third molars, were recorded.

29

Dental caries (Studies I, II)

Clinical caries: All tooth surfaces available for clinical evaluation were
examined for caries according to the criteria set by Koch101. Initial caries: loss
of mineral in the enamel causing a chalky appearance on the surface but not
clinically classified as a cavity. Manifest caries: A carious lesion on a previously
unrestored tooth surface that could be verified as a cavity by probing and in
which, on probing in fissures using light pressure, the probe became stuck.
Radiographic caries: Lesions seen on the proximal tooth surfaces as a clearly
defined reduction in mineral content. Initial caries: An approximal carious
lesion in the enamel that has not reached the enamel/dentine junction or a
lesion that reaches or penetrates the enamel/dentine junction, but does not
appear to extend into the dentine. Manifest caries: An approximal carious
lesion that clearly extends into the dentine.

Decayed and filled primary and permanent tooth surfaces

(Studies I, II)
The individual number of decayed (initial + manifest) and filled primary (dfs)
and permanent (DFS) tooth surfaces was calculated. Since almost all tooth
extractions were made for orthodontic reasons, missing teeth (m/M) were not
included in the calculations.

Plaque (Study I)
The presence of visible plaque was recorded for all tooth surfaces after drying
with air according to the criteria for plaque indices (PLI) grades 2 and 332.

30

Gingival status (Study I)

The occurrence of gingival inflammation corresponding to gingival indices (GI)
grades 2 and 3 was recorded for all tooth surfaces. Gingival inflammation was
thus registered if the gingiva bled on gentle probing107.

Background data (Studies I, II)

In addition to ordinary background data, questions about country of birth, for
both the participant and his/her parents, number of siblings and living
conditions were recorded. For those with a foreign background, the time at
which they came to Sweden was recorded (Study II).

Dietary habits (Studies I, II)

Questions regarding dietary habits, snacks between principal meals, sugarcontaining products between principal meals and frequency of intake were
recorded.

Oral hygiene habits and fluoride exposure (Studies I, II)

This part included questions about tooth-brushing and flossing, the use of
fluoride toothpaste, mouthwash, fluoride tablets and fluoride chewing gum.

Ethical issues
The ethical rules for research described in the Declaration of Helsinki108 were
followed in both studies. Both studies were also approved by the Ethics
Committee at the University of Linkping.
31

Statistical methods
Differences between means for the two cohorts were tested using Students ttest. Differences between groups were tested by an analysis of variance
(ANOVA), followed by a multiple mean test (Turkeys test) when the ANOVA
indicated a statistical difference between the groups (Study II). Based on the age
at immigration and on sugar consumption, the participants were stratified in
tertiles (Study II). Differences in proportions were tested with Pearsons ChiSquare Test and, when frequencies were fewer than ten, Fishers Exact
Probability Test was used (Study I). Associations between two variables were
evaluated with Pearsons correlation coefficient. Binary logistic regression was
used

to

evaluate

possible

associations

between

dental

caries

and

foreign/Swedish backgrounds. To test whether the regression parameters were

statistically significantly different from 0, the Wald test was used. Separate
logistic regression models were used for 3- and 5-year-olds and 10- and 15-yearolds, respectively (Study I). Dental caries, the outcome variable, was categorised
as: dfs=0 versus dfs 1 in 3- and 5-year-olds and DFS 3 versus DFS 4 in
10- and 15-year-olds. Foreign background was categorised as yes or no. All
analyses were adjusted for gender and age. In addition, the analyses for 3- and
5-year-olds were also adjusted for parents level of education (high=university,
intermediate=high school, low=upper secondary school), snacks between
principal meals (0-3 or 4 per day) and plaque index (PLI; low=0-4%,
intermediate=4.1-18%, high 18.1%), while the analyses for 10- and 15-yearolds were adjusted for principal meals ( 2 or 3-4 meals per day) and plaque
index (low=0-4%, intermediate=4.1-18%, high 18.1%) (Study I). Odds ratios
(OR) with 95% confidence intervals (CI) and predicted percentage correct were
calculated. All tests were two sided and a p-value of less than 0.05 was
32

considered statistically significant. All statistical analyses were performed using

the SPSS for Windows statistical software package (version 17.0; SPSS Inc.,
Chicago, IL, USA).

33

RESULTS
Study I
Number of teeth
There were no statistically significant differences in the mean numbers of teeth
between individuals in the F and S cohort in any age group in either 1993 or
2003. The mean number of teeth among 3- and 5-year-olds varied between 19.7
and 20.0, in 10-year-olds between 14.5 and 17.5 and in 15-year-olds between
27.0 and 27.3.

Caries-free individuals
The frequency of 3-, 5-, 10- and 15-year-olds without caries and restorations in
the F and S cohort in 1993 and 2003 is given in Table 2.
Table 2. Number of individuals (n) without caries and restorations (caries free) in 1993
and 2003 with foreign (F) and Swedish (S) backgrounds in the different age groups.
1993
Caries free
F
S
Age
group

3
5
10
15

5
2
3
0

%
33
11
14
0

n
60
43
3
2

%
79
56
4
3

2003
Caries free
S

F
p-value*

n %

0.001
0.001
0.113
0.584

8
6
6
0

47
38
47
16

*Fishers Exact Probability Test

34

44
26
25
0

%
75
60
61
22

p-value*
0.018
0.005
0.002
0.085

Both in 1993 and 2003, statistically significantly more 3- and 5-year-olds in the
S cohort were free from caries and/or restorations compared with those in the
F cohort. In 2003, this difference was also found in the 10-year-olds.

Dental caries (initial and manifest) and restorations

Both in 1993 and 2003, the mean number of decayed and filled tooth surfaces
(dfs) was statistically significantly higher in the two youngest age groups with
foreign backgrounds compared with individuals with a Swedish background.
For the 10- and 15-year-olds, there were no differences in DFS between the F
and S cohort in 1993, while there was a statistically significant difference in
DFS in both age groups between the cohorts in 2003 (Table 3).
In Table 4, the mean number (95% CI) of dfs/DFS on proximal tooth surfaces
is presented. Compared with those with a Swedish background, 5-year-olds
with foreign backgrounds had statistically significantly more dfs on proximal
tooth surfaces both in 1993 and 2003. Ten-year-olds with foreign backgrounds
had statistically significantly more DFS on proximal surfaces in 2003.

35

F
95% CI
1.8-7.1
4.7-12.3
4.8-9.2
13.2-23.0

1993
Mean
0.6
2.7
5.5
18.2

S
95% CI
0.3-1.0
1.4-3.9
4.8-6.2
15.1-21.2

p-value*
0.008
0.006
0.196
0.985

Mean
5.8
7.7
3.4
11.8

F
95% CI
1.3-10.2
3.4-11.9
2.1-4.7
5.4-18.3

2003
Mean
0.9
1.6
1.1
5.5

S
95% CI
0.4-1.4
0.8-2.4
0.6-1.5
3.9-7.1

p-value*
0.035
0.008
0.002
0.009

Table 3. Mean number and 95% CI of decayed (initial and manifest) and filled tooth surfaces (dfs/DFS) in various age groups with foreign and
Swedish backgrounds in 1993 and 2003.
Age
group
Mean
3
4.5
5
8.5
10
7.0
15
18.1
*Students t-test

F
95% CI
0.0-1.6
1.4-4.6
0.3-2.0
4.0-10.1

1993
Mean
0.2
1.0
0.6
5.9

S
95% CI
0.0-0.3
0.5-1.4
0.4-0.8
4.2-7.6

p-value*
0.264
0.017
0.202
0.496

Mean
0.1
3.2
1.1
6.6

F
95% CI
0.0-0.2
1.4-5.0
0.5-1.7
1.6-11.7

2003
Mean
0.1
0.7
0.4
2.6

S
95% CI
0.0-0.2
0.2-1.3
0.2-0.7
1.7-3.5

p-value*
0.851
0.013
0.037
0.105

Table 4. Mean number and 95% CI of decayed (initial and manifest) and filled proximal tooth surfaces (dfs-proximal/DFS-proximal) in
various age groups with foreign and Swedish backgrounds in 1993 and 2003.
Age
group
Mean
3
0.7
5
3.0
10
1.1
15
7.0
*Students t-test

36

Figure 2 shows the percentages of 3-, 5-, 10- and 15-year-olds in the F and
S cohorts who were caries free or had initial and/or manifest carious lesions
and restorations on proximal tooth surfaces in 1993 and 2003. The percentages
of individuals among 3-year-olds in the F cohort whose proximal tooth surfaces
were caries free were 80% in 1993 and 94% in 2003. The corresponding figures
for those in the S cohort were 91% and 97%, respectively. No 3-year-olds had
proximal restorations in 1993 or 2003. The percentages of proximal caries free,
initial lesions, manifest lesions and restorations among 5-year-olds in the
F cohort were 33%, 11%, 45% and 11% in 1993. The corresponding figures in
the S cohort were 71%, 5%, 17% and 7% (dfs-proximal: p=0.017). Ten-yearolds with foreign backgrounds had a higher prevalence of carious lesions and
restorations compared with Swedish 10-year-olds both in 1993 and 2003 (dfsproximal: p=0.037). Among the 15-year-olds in the F cohort in 1993, there
were fewer caries-free individuals and more individuals with restorations
compared with the adolescents in the S cohort. In 2003, there were fewer
caries-free adolescents and also more individuals with initial and manifest
carious lesions and restorations on proximal surfaces among individuals in the
F cohort compared with the S cohort (Figure 2).

Plaque and gingivitis

The mean (95% CI) individual frequency of tooth surfaces exhibiting plaque
(PLI) as a percentage of existing tooth surfaces in 1993 and 2003 is presented in
Table 5. In both years of examination, the percentage of tooth surfaces with
plaque was numerically higher in all age groups in the F cohort compared with
the S cohort, except for the 15-year-olds, but the difference was only
statistically significant between the 10-year-olds in 1993 (p=0.012) and between
the 3- and 5-year-olds in 2003 (p=0.028 and p=0.002, respectively).

37

The mean (95% CI) individual frequency of tooth sites with gingivitis (GI) as a
percentage of existing tooth sites is presented in Table 6. The percentage of
tooth sites with gingivitis was numerically higher in all age groups in the
F cohort compared with the S cohort, except between the 15-year-olds in 2003.
However, the difference was statistically significant only between the 3- and 10year-olds in 1993 (p=0.005 for both groups) and between the 5-year-olds in
2003 (p=0.024).

38

39

Figure 2. Percentage of 3-, 5-, 10- and 15-year-olds with foreign and Swedish backgrounds, caries free, initial and manifest
carious lesions and restorations on proximal tooth surfaces in 1993 and 2003.

F
95% CI
3.4-23.5
4.6-22.5
35.4-70.8
18.1-45.5

1993
Mean
7.3
9.4
28.5
32.5

S
95% CI
4.2-10.3
6.7-12.0
22.3-34.7
25.8-39.2

p-value*
0.125
0.355
0.012
0.927

Mean
15.7
12.7
19.1
11.8

F
95% CI
8.2-23.2
9.5-15.9
10.5-27.6
5.9-17.6

2003
Mean
6.6
7.2
12.5
13.0

S
95% CI
3.4-8.8
5.5-8.9
9.7-15.2
10.0-16.0

p-value*
0.028
0.002
0.140
0.763

Table 5. Number of tooth surfaces with plaque as a percentage of existing tooth surfaces. Means and 95% CI in different age groups with foreign and
Swedish backgrounds in 1993 and 2003.

Mean
13.5
13.6
53.1
31.8

*Students t-test.

Age
group
3
5
10
15

F
95% CI
7.9-21.2
6.9-16.8
20.2-32.0
14.7-30.4

1993
Mean
4.4
8.7
17.2
20.8

S
95% CI
3.5-5.3
6.9-19.5
14.5-20.0
16.9-24.7

p-value*
0.005
0.152
0.005
0.675

Mean
9.7
8.0
14.9
8.6

F
95% CI
2.2-17.3
4.0-12.1
7.8-21.9
3.5-13.7

2003
Mean
5.2
3.2
8.9
10.9

S
95% CI
1.9-8.5
2.2-4.1
6.6-11.3
7.6-14.1

p-value*
0.218
0.024
0.110
0.600

Table 6. Number of tooth sites with bleeding on probing as a percentage of existing tooth sites. Means and 95% CI in different age groups with foreign
and Swedish backgrounds in 1993 and 2003.

Mean
14.6
11.9
26.1
22.5

*Students t-test.

Age
group
3
5
10
15

40

Associations between dental caries and foreign and Swedish

backgrounds
The OR for having dental caries for children with foreign backgrounds among
3- and 5-year-olds in 1993 was 8.47 (95% CI: 3.32-21.61; p<0.001) compared
with children with a Swedish background, adjusted for gender and age. In the
final logistic regression model, the OR for 3- and 5-year-olds (1993) with
foreign backgrounds was 7.94, adjusted for parents level of education, snacks
between principal meals and PLI (Table 7). In 2003, for 3- and 5-year-olds, the
OR for dental caries was 4.04 (95% CI: 1.89-8.64; p<0.001) for the F cohort
compared with the S cohort. In the final regression model, in 2003, the OR for
the F cohort was 2.48 compared with the S cohort.
In 1993, the OR for having dental caries among 10- and 15-year-olds with
foreign backgrounds was 3.24 (95% CI:1.17-8.92; p=0.023) compared with
adolescents with a Swedish background. In the final logistic regression model in
1993, the OR for this group was 1.23 (Table 8). In 2003, the OR for the
F cohort was 6.26 (95% CI: 2.51-15.61; p< 0.001). In 2003, the corresponding
figures in the final logistic regression model for adolescents with foreign
backgrounds having dental caries was 5.8, adjusted for principal meals and PLI.

41

No
Yes
Female
Male
3
5
High
Inter1.70
2.07

0.64-2.96

0.70-4.10
0.68-6.28

1.41-5.85

0.46-1.83

2.80-22.48

0.824
0.869

0.421

0.242
0.198

0.004

0.808

0.001

p-value*

1.37

0.44-1.87
0.38-3.17

1993
95% CI

0.90
1.09

n OR
146
28 7.94
87
87 0.92
87
87 2.88
38
103
33
127
47
81
70
23

Pred. perc.
correct

71.8

n
118
36
83
71
73
81
47
92
15
74
80
56
82
16

2.95
3.96

3.57

1.48
1.77

2.00

1.85

2.48

OR

1.23-7.09
0.98-16.07

1.61-7.93

0.62-3.54
0.45-6.94

0.94-4.27

0.84-4.06

0.95-6.50

2003
95% CI

0.015
0.054

0.002

0.377
0.410

0.073

0.127

0.064

p-value*

75.3

Pred. proc.
correct

Table 7. The association between foreign and Swedish backgrounds and dental caries among 3- and 5-year-olds in 1993 and 2003, adjusted
for gender, age, parents level of education, snacks between principal meals and plaque index, estimated by logistic regression. Odds Ratios
(OR) with 95% confidence intervals (95% CI).
Coherent
determinants
Foreign
backgrounds
Gender
Age
Parents level
of education
mediate

mediate

High

Low
Snacks between
0-3
principal meals
4
Plaque index
Low
Inter*Wald test.

42

*Wald test.

Principal
meals
Plaque index

Age

Coherent
determinants
Foreign
backgrounds
Gender

High

mediate

No
Yes
Female
Male
10
15
3-4
2
Low
Inter86
98

n
151
44
88
107
101
94
149
46
11
1.70-37.46

7.97

7.63
5.32

1.24-47.00
0.87-32.73

0.43-10.10

0.28-2.89

0.90

2.09

0.30-5.04

1993
95% CI

1.23

OR

0.028
0.071

0.361

0.009

0.861

0.770

p-value*
92.3

43

Pred. perc.
correct

95
28

n
120
24
80
64
73
71
127
17
21
7.22
6.72

3.19

4.78

1.15

5.80

OR

1.40-37.26
1.10-41.12

0.98-10.33

2.03-11.24

0.51-2.62

2.01-16.72

2003
95% CI

0.018
0.039

0.054

0.001

0.731

0.001

p-value*

73.6

Pred. perc.
correct

Table 8. The association between foreign and Swedish backgrounds and dental caries among 10- and 15-year-olds in 1993 and 2003,
adjusted for gender, age, principal meals and plaque index, estimated by logistic regression. Odds Ratios (OR) with 95% confidence intervals
(95% CI).

Study II
Caries free individuals
There were no statistically significant differences between those with foreign
and Swedish backgrounds in terms of the number of subjects free from caries,
having initial caries or manifest caries and/or restorations (Figure 3). Moreover,
the percentage of 15-year-olds with foreign and Swedish backgrounds with
initial and manifest caries was the same.

100

Dentine carious lesions

or restorations (DdFSproximal>0)

Cumulative per cent

80

47%

42%

"Caries free" (DedDSproximal=0)

60

40

Enamel carious lesions without

manifest carious lesions and/or
restorations (DeSproximal>0
and DdFSproximal=0)

29%

32%

24%

26%

20

immigrants non-immigrants
Foreign
Swedish
backgrounds
background

Figure 3. Percentage distribution of adolescents with foreign

and Swedish backgrounds in relation to caries status.

Dental caries (initial and manifest) and restorations

The 15-year-olds with foreign backgrounds had statistically significantly
(p=0.03) more caries and restorations compared with 15-year-olds with a
44

Swedish background. Proximal surfaces with initial caries accounted for the
main part of the decayed surfaces (p=0.02). There was no statistically significant
difference between the two groups regarding the mean value for surfaces with
manifest caries (Table 9).
Table 9. Mean number and 95% CI of decayed (initial and manifest) and filled tooth
surfaces (DFS) among individuals with foreign and Swedish backgrounds.
Foreign backgrounds
Cariesa DFStot

Swedish background

p-value

12.0 (8.6 -15.3)

7.8 (5.5 - 10.0)

0.03b

DStot

7.8 (5.1 -10.5)

4.3 (2.7 - 5.8)

0.02b

DFStot

4.2 (2.9 - 5.4)

3.5 (2.6 - 4.5)

NSb

DFSproximal

6.5 (4.7 - 8.2)

4.0 (2.9 - 5.2)

0.02b

DSproximal

5.5 (4.0 - 7.0)

3.3 (2.3 - 4.4)

0.02b

DFSproximal

1.0 (0.6 - 1.5)

0.7 (0.5 - 1.0)

NSb

a.
b.

Mean value (95% CI) caries (D) filled (F) surfaces (S); e= enamel (initial)
and d= dentine (manifest)
Students t-test; NS if p>0.05

Caries in relation to age at immigration

For the children with foreign backgrounds, the age of arrival in Sweden had an
obvious correlation with proximal caries (Figure 4). There was no statistically
significant difference between adolescents with foreign backgrounds, who were
born in Sweden or who had immigrated during their first year (n=23), in terms
of proximal caries prevalence compared with adolescents with a Swedish
background: 5.0 (3.2-9.0) and 4.0 (2.9-5.3) surfaces, respectively. In adolescents
who had immigrated after one year of age, but before seven years of age
(n=20), the mean number of proximal tooth surfaces with carious lesions was
6.4 (2.7-8.2). If the adolescents were more than seven years of age at
immigration (n=8), the mean number of proximal carious lesions (DFS) was
10.8 (4.0-13.1). The ANOVA test yielded a difference between the groups with
a p-value of < 0.06.
45

12

proximal caries

10

nonimmigrants

<1 year 1-7 years

>7 years

age at arrival to Sweden

Figure 4. Mean value (SE) for proximal caries (DFS) divided by

age at immigration to Sweden, ANOVA (p<0. 06).

Oral hygiene
Among the adolescents with foreign backgrounds, 88% (n=45) reported that
they brushed their teeth with fluoride toothpaste at least twice a day compared
with 98% (n=65) of the adolescents with a Swedish background. The remaining
seven respondents reported that they brushed once a day. Only 4% of all 15year-olds reported that they used dental floss or toothpicks regularly. Six 15year-olds with foreign backgrounds reported tooth-brushing only once a day.
These adolescents had almost twice as many proximal tooth surfaces with
carious lesions compared with adolescents with foreign backgrounds who
reported that they brushed twice a day [11.3 (3.2-19.5) and 5.8 (4.0-7.6),
respectively, p=0.04].

46

Fluoride use
All 15-year-olds who participated in the study used toothpaste with fluoride.
Mouth washing with sodium fluoride solution after school lunch and the daily
use of fluoride tablets or fluoride chewing gum were also equally common in
both groups (73% and 10%, respectively).

Dietary habits
Breakfast
Fewer adolescents with foreign backgrounds reported that they ate breakfast
regularly compared with adolescents with a Swedish background [45.1% and
80.3%, respectively, (p<0.001)]. Adolescents who did not eat breakfast regularly
(no/sometimes) had significantly more proximal carious lesions compared with
those who reported that they ate breakfast every day [6.5 and 4.3 tooth
surfaces, respectively (p=0.04)].
Sugar consumption
In adolescents with foreign backgrounds, a positive correlation between
proximal

caries

and

sugar

consumption

was

found

(total

sugar-

intake/day/tertiles) (r=0.36, p=0.009,) while no such correlation was found in

children with a Swedish background [r=0.24, p=0.096 (Figure 5)]. A positive
correlation between total sugar consumption per week and proximal caries was
also found (r=0.25, p=0.006).

47

b) non-immigrants
Swedish

a) immigrants
Foreign
backgrounds

proximal caries

10

10

low

high
sugar tertile

background

low

high
sugar tertile

Figure 5. Averages (SE) of the mean value of proximal carious lesions (DFS) by
increasing sugar intake divided into tertiles. ANOVA indicated a statistically significant
difference between the foreign background tertile groups (p=0.015) but not among the Swedish
background tertile groups.
Principal meals
Regular school lunch (64%), dinner (91%), and food before bedtime (45%)
were equally common, regardless of background. However, adolescents with
foreign backgrounds ate night meals more often [sometimes/regularly, 47.1%
and 28.8% respectively (p=0.047)] compared with adolescents with a Swedish
background.
Snacks between principal meals
Adolescents with foreign backgrounds had a higher intake of snack products
between principal meals compared with adolescents with a Swedish
background: on average, 64 and 39 intakes a week, respectively (p=0.003)
(Table 10). The high intake of snack products among adolescents with foreign
48

backgrounds consisted of several large intakes of carbohydrate-rich meals

between principal meals (Table 10). As a result of the high frequency of sugar
intake among adolescents with foreign backgrounds, their daily sugar
consumption was almost twice as high as that of adolescents with a Swedish
background [256 (189-324) g/day and 144 (118-170) g/day, respectively,
(p=0.003)].
Adolescents with a foreign backgrounds had a statistically significantly larger
intake of a number of sugar-containing products between meals compared with
those with a Swedish background (Table 10).
Table 10. Intake of sugar-containing products between principal meals and foreign and
Swedish backgrounds.
Number of Intakes/weeka
Foreign
Swedish
Sweet beverages
Coffee/tea with sugar
6.9 (4.3 - 9.5)
2.1 (0.9 - 3.3)
Soft drinks
7.5 (5.4 - 9.7)
4.0 (2.5 - 5.6)
Fruit juices
6.9 (4.6 - 9.2)
7.0 (5.2 - 8.8)
Fruit syrups
2.6 (1.1 - 4.1)
4.2 (2.7 - 5.7)
OBoy
2.8 (1.4 - 4.2)
4.8 (3.2 - 6.4)
Sport drinks
0.6 (0.3 - 1.0)
0.4 (0.2 - 0.6)
Sweets
Mixed sweets
6.2 (3.9-8.5)
2.7 (1.7 - 3.1)
Liquorice
3.0 (1.1-5.0)
0.6 (0.4 - 0.8)
Chewing gum with sugar
5.5 (3.2 - 7.9)
2.2 (0.8 - 3.6)
Chocolate with toffee filling
3.5 (1.8 - 5.2)
1.4 (1.0 - 1.7)
Plain chocolate
1.8 (0.5 - 3.1)
0.9 (0.7 - 1.1)
Starch-based snacks
Potato crisps/popcorn/
cheese doodles
2.5 (1.0 - 3.9)
0.6 (0.4 - 0.7)
Buns/biscuits
3.0 (1.7 - 4.4)
2.7 (1.9 - 3.6)
Fruit
Fresh fruit
9.8 (7.6 - 12.0)
5.2 (4.0 - 6.4)
Throat lozenges (pastilles)
Throat lozenges with sugar
1.0 (0.3 - 1.8)
0.6 (0.4 - 0.7)
Total number of snacks
64.0 (52.8 75.2)
39.3 (33.8 - 46.0)
a) Intakes per week presented as means (95% CI)
b) Students t-test; NS for p>0.05
A sucrose-sweetened, chocolate-flavoured milk beverage

49

p-valueb
0.001
0.008
NS
NS
NS
NS
0.006
0.015
0.017
0.019
NS
0.01
NS
0.001
NS
0.003

DISCUSSION
The main findings in this thesis were that in 1993, there was statistically
significantly more dental caries in 3- and 5-year-old children with foreign-born
parents compared with children with Swedish-born parents. Among 10- and
15-year-olds, there was no such difference. In 2003, the prevalence in dfs/DFS
was higher among children and adolescents with foreign-born parents
compared with children and adolescents with Swedish-born parents and the gap
between the F and S cohorts was considerably larger in 2003 compared with 10
years earlier. Adolescents who immigrated earlier in life did not differ from
Swedish adolescents, but children who immigrated to Sweden at age seven or
later had a two to three times higher caries prevalence compared with their
Swedish counterparts. Both in 1993 and 2003, the percentage of tooth surfaces
with plaque and gingivitis was numerically higher in all age groups in the
F cohort compared with the S cohort, except for the 15-year-olds.
This study also shows a greater intake of carbohydrate-rich snacks between
principal meals in 15-year-olds with foreign backgrounds compared with 15year-olds with a Swedish background. The odds ratio for being exposed to
dental caries, in a multivariate logistic regression analysis, was almost six times
higher for 10- and 15-year-olds with foreign-born parents compared with their
Swedish counterparts with Swedish-born parents.
The participants in this thesis were based on different samples. Study I was
based on two cross-sectional epidemiological studies with random samples of
individuals living in the city of Jnkping, Sweden. The ethnic composition of
these samples was consistent with the Swedish population as a whole.
50

However, participants with foreign backgrounds were relatively few in number.

Study II included all the 15-year-olds in an immigrant-dense area in the city of
Jnkping, where the two cohorts were equally in size. Since the immigrants
came from many different countries in Asia, Africa, North and South America
and Europe, it was not possible to further analyse the data in subgroups
because of too small sample sizes. Instead, all the participants were included in
one sample, the F cohort.
Study I was part of a series of epidemiological studies with calibrated examiners
involved in the clinical investigation. In Study II, the data on caries experience
were extracted from dental records from the participants yearly examination.
These examinations were performed by four different examiners. It is well
known that there is a wide variation in caries and caries risk assessment among
different examiners109, but there are also studies showing that dental records are
reliable and fully usable in scientific studies110. Since the four examiners
examined adolescents with both Swedish and foreign backgrounds, possible
differences in recordings are probably equally distributed in the two groups and
are unlikely to have influenced the results.
All official data on dental caries, both nationally in Sweden (National Board of
Health and Welfare) and internationally (World Health Organisation; WHO),
report dental caries solely as manifest caries, while initial caries is not reported.
Omitting initial carious lesions may lead to an underestimation of the total
caries situation. The studies included in this thesis have used both initial and
manifest carious lesions as criteria for dental caries. This definition of caries
needs to be taken into consideration when comparing results from other
studies44,68.

51

In Study I, the same questionnaire was used both in 1993 and in 2003 for all
age groups. Collecting data on food consumption and dietary habits, especially
regarding the consumption of lightweight sugar products, is difficult. According
to Sundin104, the visualised interview used in Study II helps subjects to give
correct information about their dietary habits. However, products such as a
piece of chewing gum might be difficult for the participant to recall during the
interview. Specifying how often a particular snack product is consumed might
also be difficult to recall. As a basis for performance processing, an estimated
average number of principal meals and the intake of certain snack products
between principal meals was therefore used. All structured interviews of dietary
habits were conducted by one examiner (the first author) in order to eliminate
inter-examiner bias.
The number of non-respondents in Study I differed between the age groups
and varied between 18% and 28%, while in Study II it was 8%. There were
many reasons for not taking part in the investigation, but it is unlikely that the
drop-outs had any significant influence on the results.
The percentage of caries-free children increased between 1993 and 2003. These
results are in line with other surveys from the Nordic countries48,67,111-112. There
was no statistically significant difference in caries-free 15-year-olds in the F and
the S cohort, which is consistent with the results from the Danish study by
Sundby & Petersen113. However, it is in disagreement with other studies
conducted in Denmark or Germany67,114. The results from these studies showed
a remarkably higher percentage of caries-free 13- and 15-year-olds among
adolescents with a non-immigrant background compared with individuals with
an immigrant background. It should, however, be noted that in those studies,
no radiographs were taken and only manifest carious lesions were registered.

52

In agreement with earlier results43,61,89, the oral health status of children and
adolescents with foreign and Swedish backgrounds improved between 1993
and 2003 and the mean number of decayed and filled tooth surfaces decreased
in both groups. The improvement in terms of dfs/DFS was more pronounced
for those with a Swedish background, which is also in agreement with findings
in other studies67,90. The finding that 3- and 5-year-olds with foreign
backgrounds had more tooth surfaces with carious lesions and fillings (dfs) in
both 1993 and 2003 corroborates previous reports by Sundby & Petersen113
and Skeie et al.48.
The gap between children and adolescents with foreign backgrounds and
children and adolescents with a Swedish background increased over the tenyear period 1993-2003. In Study I, there were no differences in DFS among 10and 15-year-olds in 1993, which is in agreement with the results in Study II.
However, ten years later, in 2003, both 10- and 15-year-olds with foreign
backgrounds had statistically significantly more initial, manifest and filled tooth
surfaces compared with their Swedish counterparts. This corroborates the
findings of Julihn et al.53 in their retrospective longitudinal study of dental
caries among 19-year-olds. They found that adolescents with foreign-born
parents ran a higher risk of proximal caries prevalence compared with
adolescents with Swedish-born parents, irrespective of whether or not the
children were born in Sweden. From the results in this thesis, and in agreement
with the results in other recent studies67,90,92, it is obvious that the determinant
two foreign-born parents is an important factor which is strongly associated
with caries prevalence in children and adolescents. Another interesting finding,
although not statistically significant, was that proximal restorations had
increased numerically among 15-year-old individuals with foreign backgrounds,
while they were fewer in adolescents with a Swedish background.

53

A likely explanation for the higher caries prevalence in children arriving in

Sweden at higher ages is that they take part in preventive programmes and
receive regular fluoride administration later in life than those who arrive in
Sweden at an earlier age. This result is consistent with the findings reported by
Locker et al.115 and Mendoza116 who found that all children in immigrant
families become socialised to their parents country of origin, but the extent of
this depends on their age at immigration. It should, however, be underlined that
only a few studies have investigated caries prevalence in relation to age at
immigration and more research is therefore needed to elucidate the possible
importance of this.
Lack of breakfast routines can affect both principal meals and snacks between
principal meals later in the day. It is known that many immigrant groups tend to
have a light breakfast and tend to eat their principal meal late in the evening115.
Principal meals and snacks between principal meals were strongly associated
with caries and foreign backgrounds. Almost twice as many 15-year-olds with a
Swedish background had breakfast before they went to school compared with
15-year-olds with foreign backgrounds. This difference might be due to cultural
differences with respect to the time of the day when the first meal takes place
and the foods that are consumed. Moreover, irregular breakfast habits were
strongly associated with proximal caries. This finding corroborates the results
from other studies investigating dietary habits in relation to caries88,117.
In a study of Icelandic adolescents (mean age 14 years), rnadttir et al.83 were
unable to find a significant association between the daily total sugar
consumption and proximal caries, but the frequency of sugar consumption
between principal meals was statistically significantly associated with proximal
caries. In Study II, a positive correlation between caries prevalence and daily
sugar consumption was found among adolescents with foreign backgrounds.
54

The corresponding relationship was not found in adolescents with a Swedish

background. The daily sugar consumption among Icelandic adolescents was
170 g, while the corresponding figure in the present study was 144 g for those
with a Swedish background. The adolescents with foreign backgrounds,
however, had a daily consumption of sugar that was almost twice as high, 256
g. Severat other studies have also found a relationship between sugar
consumption and caries62,88,118. Individuals with foreign backgrounds living in
families with a high sugar-intake frequency and a high intake of snacks run a
high risk of caries. These findings also agree with the findings from other
studies119-120. Irregular eating habits and a larger number of sugary snacks are
clear risk factors for dental caries. This has been known since the 1950s due to
the findings in the Vipeholm studies38. These connections have been confirmed
by many others14,82-83,121 and, as Johansson et al.88 have clearly shown, it is the
number of food intakes that increases the risk for caries in young children.
A report from the National Food Administration (NFA)77 in Sweden showed
that the consumption of snacks among children and adolescents has steadily
increased in recent decades. Above all, hidden sugar consumption has
increased, while the consumption of pure sucrose has decreased. Nutrient
intake among children and adolescents was very similar to that found among
adults77. It was also found that the children of parents with an education at
university level consumed more fruit and vegetables and had a better nutrient
density in their diet. The NFA also found that the children of parents with
foreign backgrounds ate more fruit and vegetables but drank less milk.
Johansson & Lif Holgerson122 showed that milk proteins inhibit the initial
attachment of cariogenic mutans streptococci to hydroxyapatite coated with
saliva. Some dietary products can also have a protective effect, and children and
adolescents with a Swedish background probably drink more milk during their
childhood. According to the NFA, the most desirable change in dietary habits
55

among children and adolescents is a reduction in the consumption of sweets,

soft drinks, snacks and pastries, as well as an increase in the consumption of
fruit and vegetables. This is also an important requirement when it comes to
improving oral health in children and adolescents from a caries point of view.
The snack products that primarily separated the two groups in the present
study were coffee and tea with sugar, sweets, soft drinks, potato crisps and
cheese doodles, where 15-year-olds with foreign-born parents had the highest
intake. In general, these types of snack product are a threat to both general and
dental health112,123.
It has been known for a long time that the lack of regular oral hygiene habits
plays a role in caries development. Those 15-year-olds with foreign
backgrounds who brushed their teeth only once a day had nearly twice as many
proximal carious lesions compared with 15-year-olds with foreign backgrounds
who brushed their teeth twice a day or more. The present results agree with
findings from the study by Hietasalo et al.62. Regular tooth-brushing with
fluoride toothpaste is a sufficient primary oral health care measure to minimise
the risk of caries. Only 4% of the 15-year-olds in Study II reported the regular
use of proximal cleaning devices in the form of dental floss. This shows that
proximal tooth cleaning is not given priority, despite the fact that most caries is
found on proximal tooth surfaces. According to recommendations from dental
and paediatric organisations124, and in line with current scientific evidence,
tooth-brushing with fluoride toothpaste twice daily is enough for effective
caries prevention. In addition, flossing is regarded as a part of tooth-cleaning
because it disrupts and removes proximal dental biofilm, but there is a lack of
evidence to support flossing to prevent proximal caries when people are
exposed to fluoride125. There are therefore no clear recommendations about the
age at which proximal dental flossing should start and the extent to which this
procedure should be used124.
56

Childrens dental health can be influenced by parents oral health-related

attitudes and behaviour, as well as the parents own oral health status119,126-127.
Even though they were born in Sweden, children and adolescents with foreign
backgrounds, who have two foreign-born parents, grow up with their parents
values and knowledge of oral hygiene habits. As a result, these children will
miss the important regular oral health care habits and tooth-brushing with
fluoride toothpaste. It has previously been shown that foreign-born parents
have an impact on their childrens oral health92,120.
Both in 1993 and 2003 (Study I), the mean values for plaque and gingival
bleeding were higher in the F cohort compared with the S cohort in all age
groups, except among the 15-year-olds in 2003. Plaque was correlated to a
higher risk of caries and a prevalence of gingivitis among children with foreign
backgrounds. However, the differences between the groups in these respects
decreased with increasing age and, in the oldest age groups, the differences
regarding both plaque and gingivitis had levelled out. In the multivariate
analysis, plaque was still strongly associated with caries and foreign
backgrounds, which corroborates the findings by Wendt et al.54 and Wennhall
et al.80.
Although most children and adolescents in Sweden attend the preventionoriented Public Dental Service free of charge, it is obvious that inequalities in
oral health still exist and have even increased when it comes to children and
adolescents with foreign backgrounds. The preventive programmes that are
designed to reach all the children in the community resulted in a general
improvement in oral health among children and adolescents between 1993 and
2003. However, this improvement was not as pronounced in children with
foreign backgrounds. The gap in oral health between children and adolescents
57

with foreign and Swedish backgrounds had thus increased. The current
community preventive programme is addressed equally to all children and
adolescents in Sweden, but it has not been able to close the gap in oral health
between children with foreign and Swedish backgrounds. On the contrary, the
gap has increased. The educational level of the parents, eating snacks between
principal meals and the amount of plaque were strongly associated with both
caries and foreign backgrounds. Poor knowledge of the structure and function
of the health care system in the new country, different expectations of dental
health care and a lack of ability to communicate with health professionals might
be important barriers.
The results from this thesis show that in particular pre-school children who
immigrated at the age of one year or later make up a group that should be
prioritised in dental care. Maternal motivation is a key to relating and improving
health communication in an ethnic multicultural society67,128. Mothers want to
protect their children from harm, and this can be a driving force for social
action. There is therefore a need for deep commitment between mothers and
the oral health personnel in order to protect and promote the oral well-being of
children and adolescents with foreign backgrounds. It is therefore essential,
when a family with foreign-born parents arrives in Sweden, that the Public
Dental Service involves the children and adolescents in an organised oral health
care prevention programme as quickly as possible. It is also important to reach
and communicate with the mothers of the families and, if the mother is unable
to understand or speak Swedish, to use an interpreter129. Participation and
involvement in an oral health prevention programme has an empowering effect
in health communication from a multicultural perspective128.
There is a need to create tools and to improve the oral health preventive
strategies for children and adolescents with foreign backgrounds in order to
58

promote satisfactory oral health care habits and the early detection of initial
caries to obtain primary disease control. Wennhall et al.130 have shown that
adapted preventive programmes for children living in a multicultural, low socioeconomic area are cost effective and of great advantage to society, as well as
being of great benefit to the individual. In the future, the Swedish oral health
care system must have the capacity to meet the culture-specific needs for oral
health care among children and adolescents. Dental caries is still an urgent issue
among children131. A small group of children and adolescents still have high
caries activity and children and adolescents with two foreign-born parents run a
higher risk of belonging to this group. To strengthen the role of health
communication with families with foreign backgrounds, with regard to oral
health promotion and oral disease prevention, there is a need to improve the
promotion of oral health care programmes, to level out the differences that still
exist in oral health, and to fulfil the goals of Swedish dental care for children
and adolescents with a foreign background.

59

CONCLUSIONS

The prevalence in dfs/DFS, in a ten-year perspective, was higher

among children and adolescents with foreign-born parents compared
with children and adolescents with Swedish-born parents.

In 2003, there was statistically significantly more caries in all age groups
among children and adolescents with foreign-born parents compared
with children and adolescents with Swedish-born parents.

Children who immigrated to Sweden at age seven or later had a two to

three times higher caries prevalence compared with their Swedish
counterparts.

The odds ratio for being exposed to dental caries was almost six times
higher for 10- and 15-year olds with foreign-born parents compared
with their Swedish counterparts.

There was a greater intake of carbohydrate-rich food between principal

meals among 15-year-olds with foreign-born parents compared with
15-year-olds with Swedish-born parents.

In both 1993 and 2003, the mean percentage of tooth sites with plaque
and gingivitis was numerically higher in all age groups in individuals
with foreign backgrounds compared with Swedish background, except
in the 15-year-olds.

Due to these findings there is obviously a need to improve the

promotion of oral health care programmes among children and
adolescents with foreign-born parents.

60

Summary in Swedish
Tandhlsan hos barn och ungdomar med utlndsk
respektive svensk bakgrund
Barn och ungdomar i Sverige med tv utrikes fdda frldrar utgr 17% av alla
barn i befolkningen. SYFTE: Syftet med denna avhandling var att inhmta
kunskap om frekomst av karies och kariesassocierade variabler samt gingivit
hos barn och ungdomar 3, 5, 10 och 15 r med utlndsk bakgrund och jmfra
dessa resultat med svenska barn i motsvarande ldersgrupper i ett
tiorsperspektiv (Studie I). Syftet var vidare att med avseende p
kariesprevalens och kariesassocierade faktorer jmfra 15-ringar med utlndsk
bakgrund med ldersmatchade ungdomar med svensk bakgrund samt att
jmfra kariesfrekomst hos 15-ringar med utlndsk bakgrund i frhllande
till lder vid tidpunkten fr immigration. (Studie II). MATERIAL OCH
METOD: Under 1993 och 2003 utfrdes tv tvrsnittsstudier i Jnkping med
ett slumpmssigt urval av individer i ldersgrupperna 3, 5, 10 och 15 r.
Samtliga individers orala hlsa undersktes kliniskt och rntgenologiskt.
Barnen, eller deras frldrar, svarade ven p ett frgeformulr avseende
attityder till och kunskaper om tnder samt munhlsovanor. Totalt omfattade
studien 739 barn och ungdomar, 154 med tv utrikes fdda frldrar (F kohort)
och 585 med tv svenskfdda frldrar (S kohort) (Studie I). I en annan studie
inbjds 143 15-ringar p en kommunal skola i Jnkping att delta (Studie II).
Av dessa deltog 117 personer, 51 med tv utrikes fdda frldrar och 66 med
tv svenskfdda frldrar. Alla ungdomar intervjuades med hjlp av ett
strukturerat frgeformulr dr kostfrgor frtydligades med visualisering, dvs
exempel p frpackningar och varor. Information om DFS samlades in frn
journaler frn Folktandvrden, Landstinget i Jnkpings ln. RESULTAT:
61

Bde 1993 och 2003 var fler 3- och 5-ringar med svensk bakgrund (S kohort)
kariesfria jmfrt med motsvarande ldersgrupper med utlndsk bakgrund (F
kohort). r 1993 var dfs hgre bland 3- och 5-ringar i F kohorten (p<0,01)
jmfrt med S kohorten. r 2003 var dfs/DFS statistiskt signifikant hgre
bland barn och ungdomar i alla ldersgrupper i F kohorten jmfrt med S
kohorten. r 2003 var Odds Ratio fr karies hos 10- och 15-ringar i F
kohorten, justerat fr kn och lder, mer n sex gnger hgre (OR=6,3, 95%
CI :2.51-15 0,61; p<0,001) jmfrt med S kohorten (Studie I). Proportionerna
av kariesfria ungdomar var lika bland 15-ringar med utrikes fdda frldrar
jmfrt med 15-ringar med svenskfdda frldrar, dock hade ungdomar med
utlndsk bakgrund i genomsnitt mer karies och restaureringar (p=0.03) jmfrt
med ungdomar med svensk bakgrund. Det var ingen skillnad i kariesfrekomst
mellan 15-ringar fdda i Sverige av tv utrikes fdda frldrar och som hade
kommit till Sverige fre ett rs lder. De hade en likartad kariesprevalens som
ungdomar med tv svenskfdda frldrar. Dremot uppvisade barn som
immigrerat till Sverige efter sju rs lder en kariesprevalens som var tv till tre
gnger hgre (p<0,06) (Studie II). Bde 1993 och 2003 var det procentuella
medeltalet tandytor med plack och gingivit numerrt hgre i alla ldersgrupper
med utlndsk bakgrund i jmfrelse med individer med svensk bakgrund, utom
hos 15-ringar (Studie I). Intaget av sockerhaltiga mellanml var statistiskt
signifikant hgre hos 15-ringar med utlndsk bakgrund n hos 15-ringar med
svensk bakgrund. SLUTSATSER: Barn och ungdomar med tv utrikes fdda
frldrar uppvisade en hgre kariesfrekomst i ett tiorsperspektiv n barn och
ungdomar med tv svenskfdda frldrar. r 2003 hade samtliga ldersgrupper
med tv utrikes fdda frldrar statistiskt signifikant fler kariesangrepp n barn
och ungdomar med svenskfdda frldrar. r 2003 var oddskvoten fr att bli
utsatt fr karies nstan sex gnger hgre fr 10- och 15-ringar med tv utrikes
fdda frldrar i jmfrelse med 10- och 15-ringar med tv svenskfdda
frldrar. Regelbundna matvanor och goda munhlsovanor skapar ndvndiga
62

frutsttningar fr en tillfredsstllande oral hlsa i alla ldersgrupper oavsett

svensk eller utlndsk bakgrund.
Nyckelord: epidemiologi, gingivit, invandrare, karies, kost, utlndsk bakgrund

63

Acknowledgements
I wish to express my appreciation and sincere gratitude to:
Professor Anders Hugoson, my Assistant Supervisor and co-author, who
introduced me to the area of epidemiological research and guided and
encouraged me through the whole process. Without our productive discussions
I had not reached this goal. It is a privilege to benefit from your friendship.
Professor Tomas Magnusson, my Supervisor and co-author, who has supported
me and always has useful suggestions on my language and expressions.
Professor Lill-Kari Wendt, my co-author, and the one who introduced me to the
area of children with foreign backgrounds.
Professor Gran Koch, my co-author, and the outstanding specialist in the areas
of dental caries and pedodontics. Thanks you for all good advices.
Professor Ingegerd Johansson, my co-author, and the one who introduced me to
SPSS and learned me the working process with a new research material and
helped me to read SPSS outcome from my first article.
Assistant Professor Eleonor Fransson, my statistical supervisor. Thank you for all
your enthusiasm and support in my second article.
Doctoral student Alkisti Anastassaki-Khler, Assistant Professor Krister Bjerklin,
and Senior Lecturer Malin Stensson, for your valuable comments at my final
seminar.
Language Reviewer Jeanette Kliger, for excellent revision of the English language.
Librarian Stefan Carlstein, and Gunilla Brushammar, at Jnkping University
Library, for all your help with EndNote and scientific articles.
64

Research co-ordinator Susanne Johannesson and University Lecturer Thomas Ehn,

at School of Health Sciences, for deep friendship, help and always supporting
during my work.
Marketing Director Oskar Pollack at School of Health Sciences, for all
administrative help with my thesis.
My colleagues and friends at School of Health Sciences, Jnkping.
Heln Jansson, for help with my first figure.
Personnel and students at Stadsgrdsskolan in Rsltt.
Last, but certainly not least, my husband Inge Jacobsson, and our children Lina
and Adam, for your love and patience. You also let me know that there are
more important things in life than work and you are the one that gives me an
overwhelming feeling of happiness.
This thesis was supported from my employer, the School of Health Sciences,
Jnkping University.

Jnkping December 2011,

Brittmarie Jacobsson

65

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V9

Bor du i hyreshus eller villa? .

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inget
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Kommentar:
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inget aldrig
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Kommentar angende svenska sprket:..

B. Jacobsson1, G. Koch2, T. Magnusson1, A. Hugoson1

1
Centre for Oral Health, School of Health Sciences, Jnkping University, Jnkping, Sweden, 2Department of Paediatric
Dentistry, The Institute for Postgraduate Dental Education, Jnkping, Sweden.
Key words: Dental caries, epidemiology, gingivitis,
Key
words: xxxxxxxxxxxxxx
immigrants

Postal address: xxxxxxxxxxx

Dr B. Jacobsson, School of Health Sciences, Box 1026,
SE-551xxxxxxxxxxxxxxxxxxxxxxxxl
11, JNKPING, Sweden.
Email:
Email: brittmarie.jacobsson@hhj.hj.se

abstract
aIm: To investigate oral health status and coherent
determinants in children with foreign backgrounds compared with children with a Swedish background, over a
ten year period. DEsIGN aND mETHODs: In 1993 and
2003, cross-sectional studies with random samples of
individuals in the age groups 3, 5, 10 and 15 years were
performed in Jnkping, Sweden. All the individuals were
personally invited to a clinical and radiographic examination of their oral health status. They were also asked about
their attitudes to and knowledge of teeth and oral health
abstract
care habits. The final study sample comprised 739 children
adolescents, 154 with a foreign background (F
aIm: and
xxxxxxxxxx
cohort) and 585 with a Swedish background (S cohort).
REsulTs: In both 1993 and 2003, more 3- and 5 year
olds in the S cohort were caries-free compared with the
F cohort. In 1993, dfs was higher among 3- and 5 year
olds in the F cohort (p<0.01) compared with the S cohort.
In 2003, dfs/DFS was statistically significantly higher in
all age groups among children and adolescents in the F
cohort compared with the S cohort. When it came to proximal tooth surfaces, the percentages of individuals who
were caries-free, with initial carious lesions, with manifest
carious lesions and with restorations among 10-year-olds
in the F cohort were 55%, 23%, 4% and 18% in 1993. The
corresponding figures for the S cohort were 69%, 20%,
6% and 5% respectively. In 2003, the values for the F
Introduction
cohort were 54%, 29%, 4% and 13% compared with 82%,
12%, 1% and 5% in the S cohort. In 2003, the odds of
being exposed to dental caries among 10- and 15-yearolds in the F cohort, adjusted for gender and age, were
more than six times higher (OR=6.3, 95% CI:2.51-15.61;
p<0.001) compared with the S cohort. CONClusIONs:
There has been a decline in caries prevalence between
1993 and 2003 in all age groups apart from 3-year-olds.
However, the improvement in dfs/DFS was greater in the
S cohort compared with the F cohort in all age groups. The
difference between the F and S cohorts in terms of dfs/
DFS was larger in 2003 compared with 10 years earlier.
In 2003, the odds ratio for being exposed to dental caries
was almost six times higher for 10- and 15-year-olds with
two foreign-born parents compared with their Swedish
counterparts.

Paper I

Oral health in young individuals with foreign and swedish

backgrounds a ten-year perspective
Introduction
In the second half of the 20th century, epidemiological studies revealed a substantial decline in dental caries prevalence
[Marthaler, 2004; Hugoson et al., 2007]. However, dental caries is still a global public health problem [Petersen, 2009] and
one of the most prevalent infectious diseases among children
and adolescents in most industrialised countries [Petersen,
2003; Ekman, 2006; Mattila et al., 2008]. Dental caries is a
complex disease with interplay between tooth surfaces, bacterial deposits, saliva and dietary habits, among other things.
However, other determinants or confounders, such as various behavioural and socio-economic factors, also influence
the likelihood of caries development at an individual level
[Wennhall et al., 2005]. There are therefore strong negative
connections between the average socio-economic situation
and dental health [Bissar et al., 2007; Flinck et al., 1999;
Gibson et al., 1999]. It is well known that inequalities exist
between social classes and ethnic groups in terms of both
general and oral health [National Board of Health and Welfare, 2009; Julihn et al., 2010]. Health disparities have been
shown to exist among different ethnic groups as regards
cardiovascular diseases, diabetes, psychiatric disorders, and
etc. [Taloyan et al., 2009]. Moreover, differences in oral health,
such as caries levels, have been demonstrated between individuals with different ethnic backgrounds [Ekman, 2006].
During the last few decades, Sweden has become a multicultural society in which 14% of the population were born abroad
and another 5% were born in Sweden with two foreign-born
parents. The largest immigrant groups are from Asia, Africa
and Europe [Swedish Migration Board, 2009; Statistics Sweden, 2009]. Family reasons are the most common cause
of immigration. The migration process involves changes
in living conditions, adaptation to new lifestyles and sociobehavioural factors.
As a result of widespread national oral health programs in
Sweden, the prevalence of dental caries has decreased dramatically in recent decades, but an oral health problem still
remains among children and young adults [Axelsson, 2006;
Hugoson et al., 2007]. Pre-school children with a foreign
background are reported to have a significantly higher prevalence of caries and cariogenic exposure than those with a
Swedish background [Wendt et al., 1999]. Socio-economic
factors, such as cultures, norms, attitudes and values relating
to oral health issues, may be reasons for these differences in
oral health status [Hedman et al., 2006].
In Sweden, few studies have focused on Swedish children
and adolescents with foreign backgrounds and the data from
these studies are conflicting. Flinck and co-workers [1999]
reported a higher prevalence of dental caries among 12-yearolds with foreign backgrounds, whereas others have found no
or only negligible differences [Dahllof et al., 1991; Jacobsson

European archives of Paediatric Dentistry 12 (Issue 3). 2011

151

Paper I

B. Jacobsson, et al.
and drop-outs, see Hugoson et al. [Hugoson et al., 2005a;
Hugoson et al., 2005b].

et al., 2005]. Sundby and Petersen [2003] reported that Danish 3- and 5-year-olds with foreign backgrounds had a higher
mean caries experience than native children, but, at the
age of 15, there were no differences in dental health status
between the two groups.

At the clinical examination, the children or their parents (3

and 5-year-olds) were interviewed about their attitudes to and
knowledge of teeth, oral health care habits and dietary pattern. The participants country of birth and the country of birth
of the mother and the father, as well as educational level,
were recorded. This information about heritage determinants
was used in the final evaluation. Fourteen individuals (2%),
seven individuals in each year, did not answer the questions
on ethnic background variables and were excluded from the
study.

In Swedish epidemiological studies, it has been possible to

follow changes in oral health over a 30-year period covering
ages from 3-80 years [Hugoson et al., 2005a; Hugoson et
al., 2005b]. In this material, it is possible to study differences
in terms of caries in children with foreign and Swedish backgrounds. The aim of this study was therefore to investigate
oral health status and coherent determinants in children
and adolescents aged 3-15 years with foreign backgrounds
(F-cohort) in relation to children and adolescents with a
Swedish background (S-cohort) in 1993 and 2003. The null
hypothesis was that the caries and gingivitis prevalence did
not differ significantly among children and adolescents in the
F cohort compared with the S cohort in 1993 and in 2003.

All the children, adolescents and parents were divided into

three groups based on their background according to nomenclature of Statistics Sweden [Statistics Sweden, 2003]:
individuals with a foreign background were defined as being
born in a foreign country or being born in Sweden with two
foreign-born parents, individuals with a Swedish background
were defined as being born in Sweden or being born in a foreign country with two Swedish-born parents and individuals
with a mixed background were defined as being born in Sweden or being born in a foreign country with one Swedish-born
parent and one foreign-born parent. Children and adolescents
with mixed backgrounds (n=68) were excluded from further
analyses. The reason for exclusion was that an earlier study
[Wendt et al., 1999], conducted in the same area, had shown
that, if one parent was born abroad and one in Sweden, there
was no significant difference in caries prevalence between
this group and the group with a Swedish background. Among
foreign-born parents, 66% came from Asia, 7% from Africa,
2% from South America, 1% from North America, 5% from
Scandinavia and 19% from other European countries.

material and methods

In 1993 and 2003, cross-sectional studies of oral health were
performed; random samples of 130 individuals in each age
group, 3, 5, 10 and 15 years, was selected from the same
four parishes belonging to the City of Jnkping, Sweden. All
the individuals were personally invited to participate in a clinical and radiographic examination of their oral health status.
For various reasons, 219 individuals (21%) of those invited
declined to participate, 97 (19%) in 1993 and 122 (23%) in
2003. Therefore 821 children were examined by calibrated
dentists from the institute for postgraduate dental education
in Jnkping. The 3 and 5-year-olds were radiographically
examined with two bite-wing radiographs when there was
proximal contact in the molar regions. In the 10 and 15-yearolds, a panoramic radiograph and six bite-wing radiographs
two each on the left and right sides and two in the frontal
region were taken. If recent radiographs were available
from the participants regular dentist, they were used. For
detailed information regarding study design, examinations

The final study sample comprised a total of 739 children and

adolescents of whom 154 (21%) had parents with foreign
backgrounds (F cohort) and 585 (79%) had parents with a
Swedish background (S cohort) (Table 1). There were 46%
males and 54% females among the children and adolescents

Table 1. Total number of children (ntot) in the foreign born (F) and Swedish born (S) cohorts, number of children (n1) in the F-cohort born in
Sweden. Number of caries-free children (n2) and frequency (%) in the different age groups in 1993 and 2003.
1993
Age

Group

ntot

n1

n2

ntot

n2

p-value*

ntot

n1

n2

ntot

n2

15

13

33

76

60

79

0.001

18

18

44

63

47

75

0.018

18

11

77

43

56

0.001

23

19

26

63

38

60

0.005

p-value*

10

22

14

80

0.113

24

20

25

77

47

61

0.002

15

23

75

0.584

11

74

16

22

0.085

78

41

10

308

108

76

59

20

277

148

*Fishers exact probability test

152

2003

European archives of Paediatric Dentistry 12 (Issue 3). 2011

in the F cohort and 51% males and 49% females in the S

cohort. In the F cohort, 65% were born in Sweden and 35%
were born in another country.

Diagnostic Criteria
Number of teeth. Primary teeth were recorded in the 3 and
5-year-olds. In the 10 and 15-year-olds, only permanent
teeth, excluding third molars, were recorded.
Dental caries. Clinical and radiographic caries was recorded
according to Koch [1967].
Clinical caries. All tooth surfaces available for clinical
evaluation were examined. Initial caries: loss of mineral in
the enamel causing a chalky appearance on the surface but
not clinically classified as a cavity. Manifest caries: a carious
lesion on a previously unrestored tooth surface that can be
verified as a cavity by probing and in which, on probing in
fissures using light pressure, the probe become stuck.
Radiographic caries. All proximal tooth surfaces seen on
the radiographs were evaluated. Initial caries: lesion in the
enamel but not involving the dentine. Manifest caries: lesion
extending into the dentine.
Decayed and filled primary and permanent tooth surfaces. The individual number of decayed (initial + manifest)
and filled primary (dfs) and permanent (DFS) tooth surfaces
was calculated. Since almost all tooth extractions were
made for orthodontic reasons, missing teeth (m/M) were not
included in the calculations.
Plaque. The presence of visible plaque was recorded for all
tooth surfaces after drying with air, according to the criteria
for Plaque Indices (PLI) grades 2 and 3 [Silness and Loe,
1964].
Gingival status. Gingival inflammation corresponding to
Gingival Indices (GI) grades 2 and 3 was recorded for all
tooth surfaces. Gingival inflammation was thus registered if
the gingiva bled on gentle probing [Loe and Silness, 1963].
Ethical considerations. The ethical rules for research
described in the Helsinki Declaration [Medical Assembly,
1989] were followed throughout the studies in 1993 and
2003. The Ethics Committee at the University of Linkping
approved the study in 2003.
Statistical methods. Differences between means for the
two cohorts were tested using Students t-test. Differences in
proportions were tested with Pearsons chi-square test and,
when frequencies were fewer than ten, Fishers exact probability test was used. Binary logistic regression was used to
evaluate the associations between dental caries and foreign/
Swedish backgrounds. To test whether the regression parameters were statistically significantly different from 0, the Wald
test was used. Separate logistic regression models were
used for 3 and 5-year-olds and 10 and 15-year-olds respectively. Dental caries, the outcome variable, was categorised

Paper I

Oral health in young foreign and Swedish individuals

as: dfs = 0 versus dfs 1 in 3 and 5-year-olds and DFS 3
versus DFS 4 in 10 and 15-year-olds. Foreign background
was categorised as yes or no. All analyses were adjusted for
gender and age. In addition, the analyses for 3- and 5-yearolds were also adjusted for parents level of education (high =
university, intermediate = high school, low = upper secondary
school), snacks between principal meals (0-3 or 4 per day)
and plaque index (low = 0-4%, intermediate = 4.1-18%, high
18.1%), while the analyses for 10- and 15-year-olds were
adjusted for principal meals ( 2 or 3-4 meals per day) and
plaque index (low = 0-4%, intermediate = 4.1-18%, high
18.1%). Odds ratios (OR) with 95% confidence intervals (CI)
and predicted percentage correct were calculated. All tests
were two sided and a p-value of less than 0.05 was considered statistically significant. All statistical analyses were
performed using the SPSS for Windows statistical software
package (version 17.0; SPSS Inc., Chicago, IL, USA).

Results
Number of teeth. There were no statistically significant differences in the mean numbers of teeth between children in
the F cohort compared with individuals in the S cohort in any
age group either in 1993 or in 2003. The mean number of
teeth among 3- and 5-year-olds varied between 19.7 and
20.0, in 10-year-olds between 14.5 and 17.5 and in 15-yearolds between 27.0 and 27.3.
Caries-free individuals. The frequency of 3, 5, 10 and
15-year-olds without caries and restorations in the two
cohorts in 1993 and 2003 is presented in Table 1. In both
1993 and 2003, statistically significantly more 3 and 5-yearolds in the S cohort were free from caries and/or restorations
compared with those in the F cohort. In 2003, this difference
was also found in the 10-year-olds.
Dental caries (initial and manifest) and restorations. In
both 1993 and 2003, the mean number of decayed and filled
tooth surfaces (dfs) was statistically significantly higher in
the two youngest age groups of children with foreign backgrounds compared with children with a Swedish background.
For the 10 and 15-year-olds, there were no differences in
DFS between the F and S cohort in 1993, while there was a
statistically significant difference in DFS in both age groups
between the F cohort and the S cohort in 2003 (Table 2).
In Table 3, the mean number (95% CI) of dfs/DFS on proximal tooth surfaces is presented. Compared with children
with a Swedish background, 5-year-olds with foreign backgrounds had statistically significantly more dfs on proximal
tooth surfaces in both 1993 and 2003. Ten-year-olds with
foreign backgrounds had statistically significantly more DFS
on proximal surfaces in 2003.
Figure 1 shows the percentages of 3, 5, 10 and 15-yearolds in the two cohorts who were caries-free, had initial or
manifest carious lesions or restorations on proximal tooth
surfaces in 1993 and 2003. The percentages of children

European archives of Paediatric Dentistry 12 (Issue 3). 2011

153

Paper I

B. Jacobsson, et al.
Table 2. Mean number and 95% CI of decayed (initial and manifest) and filled tooth surfaces (dfs/DFS) in various age groups with foreign (F)
and Swedish (S) backgrounds in 1993 and 2003.
1993
Age
Group

2003
S

Mean

95% CI

Mean

95% CI

p-value*

Mean

95% CI

Mean

95% CI

p-value*

4.5

1.8-7.1

0.6

0.3-1.0

0.008

5.8

1.3-10.2

0.9

0.4-1.4

0.035

8.5

4.7-12.3

2.7

1.4-3.9

0.006

7.7

3.4-11.9

1.6

0.8-2.4

0.008

10

7.0

4.8-9.2

5.5

4.8-6.2

0.196

3.4

2.1-4.7

1.1

0.6-1.5

0.002

15

18.1

13.2-23.0

18.2

15.1-21.2

0.985

11.8

5.4-18.3

5.5

3.9-7.1

0.009

*Students t-test

Table 3. Mean number and 95% CI of decayed (initial and manifest) and filled proximal tooth surfaces (dfs-proximal/ DFS-proximal) in various
age groups with foreign (F) and Swedish (S) backgrounds in 1993 and 2003.
1993
Age
Group
3

F
Mean

95% CI

0.7

2003
S

0.0-1.6

Mean

F
95% CI

0.2

0.0-0.3

p-value*
0.264

Mean

S
95% CI

0.1

0.0-0.2

Mean

95% CI

0.1

0.0-0.2

p-value*
0.851

3.0

1.4-4.6

1.0

0.5-1.4

0.017

3.2

1.4-5.0

0.7

0.2-1.3

0.013

10

1.1

0.3-2.0

0.6

0.4-0.8

0.202

1.1

0.5-1.7

0.4

0.2-0.7

0.037

15

7.0

4.0-10.1

5.9

4.2-7.6

0.496

6.6

1.6-11.7

2.6

1.7-3.5

0.105

*Students t-test

Table 4. Number of tooth surfaces with plaque as a percentage of existing tooth surfaces. Means and 95% CI in different age groups with
foreign (F) and Swedish (S) backgrounds in 1993 and 2003.
1993
Age
Group

2003
S

Mean

95% CI

Mean

95% CI

p-value*

Mean

95% CI

Mean

95% CI

p-value*

13.5

3.4-23.5

7.3

4.2-10.3

0.125

15.7

8.2-23.2

6.6

3.4-8.8

0.028

13.6

4.6-22.5

9.4

6.7-12.0

0.355

12.7

9.5-15.9

7.2

5.5-8.9

0.002

10

53.1

35.4-70.8

28.5

22.3-34.7

0.012

19.1

10.5-27.6

12.5

9.7-15.2

0.140

15

31.8

18.1-45.5

32.5

25.8-39.2

0.927

11.8

5.9-17.6

13.0

10.0-16.0

0.763

*Students t-test

among 3-year-olds in the F cohort whose proximal tooth

surfaces were caries-free were 80% in 1993 and 94% in
2003. The corresponding figures for the S cohort were 91%
and 97% respectively. No 3 year old children had proximal
restorations in 1993 or 2003. The percentages of proximal
caries-free, initial lesions, manifest lesions and restorations
among 5-year-olds in the F cohort were 33%, 11%, 45%
and 11% in 1993. The corresponding figures in the S cohort
were 71%, 5%, 17% and 7% (dfs-proximal: p= 0.017). Tenyear-olds with foreign backgrounds had a higher prevalence
of carious lesions and restorations compared with Swedish
10-year-olds in 1993 and 2003 (dfs-proximal: p= 0.037).
Among 15-year-olds in the F cohort in 1993, there were fewer
caries-free individuals and more individuals with restorations
compared with the adolescents in the S cohort. In 2003, there
were fewer caries-free adolescents and also more individuals
with initial and manifest carious lesions and restorations on

154

European archives of Paediatric Dentistry 12 (Issue 3). 2011

proximal surfaces, among individuals in the F cohort compared with individuals in the S cohort (Figure 1).
Plaque and gingivitis. The mean (95% CI) individual
frequency of tooth surfaces exhibiting plaque (PLI) as a
percentage of existing tooth surfaces in 1993 and 2003 is
presented in Table 4. In both years of examination, the percentage of tooth surfaces with plaque was numerically higher
in all age groups among individuals in the F cohort compared
with individuals in the S cohort, except for the 15-year-olds,
but the difference was only statistically significant between
the 10-year-olds in 1993 (p=0.012) and between the 3- and
5-year-olds in 2003 (p=0.028 and p= 0.002 respectively).
The mean (95% CI) individual frequency of tooth sites with
gingivitis (GI) as a percentage of existing tooth sites is presented in Table 5. The percentage of tooth sites with gingivitis
was numerically higher in all age groups among individuals in

Paper I

Oral health in young foreign and Swedish individuals

Table 5. Number of tooth sites with bleeding on probing as a percentage of existing tooth sites. Means and 95% CI in different age groups with
foreign (F) and Swedish (S) backgrounds in 1993 and 2003.
1993
Age
Group

2003
S

Mean

95% CI

Mean

95% CI

p-value*

Mean

95% CI

Mean

95% CI

p-value*

14.6

7.9-21.2

4.4

3.5-5.3

0.005

9.7

2.2-17.3

5.2

1.9-8.5

0.218

11.9

6.9-16.8

8.7

6.9-19.5

0.152

8.0

4.0-12.1

3.2

2.2-4.1

0.024

10

26.1

20.2-32.0

17.2

14.5-20.0

0.005

14.9

7.8-21.9

8.9

6.6-11.3

0.110

15

22.5

14.7-30.4

20.8

16.9-24.7

0.675

8.6

3.5-13.7

10.9

7.6-14.1

0.600

*Students t-test

the F cohort compared with individuals in the S cohort, except

between the 15-year-olds in 2003. However, the difference
was only statistically significant between 3- and 10-year-olds
in 1993 (p=0.005 for both groups) and between 5-year-olds
in 2003 (p=0.024). The hypothesis proposed in the aim could
not be verified.
Evaluation of dental caries and coherent determinants
in individuals with foreign or Swedish backgrounds. The
odds ratio (OR) for having dental caries for children with foreign backgrounds among 3 and 5-year-olds in 1993 was 8.47
(95% CI: 3.32-21.61; p<0.001) compared with children with a
Swedish background, adjusted for gender and age. In the final
logistic regression model, the OR for 3 and 5-year-olds (1993)
with foreign backgrounds was 7.94, adjusted for parents level

of education, snacks between principal meals and PLI (Table

6). In 2003, for 3 and 5-years-olds, the OR for dental caries
was 4.04 (95% CI: 1.89-8.64; p<0.001) for the F cohort compared with the S cohort. In the final regression model, in 2003,
the OR for the F cohort was 2.48 compared with the S cohort.
In 1993, the OR for having dental caries among 10- and
15-year-olds with foreign backgrounds was 3.24 (95%
CI:1.17-8.92; p=0.023) compared with adolescents with a
Swedish background. In the final logistic regression model in
1993, the OR for this group was 1.23 (Table 7). In 2003, the
OR for the F cohort was 6.26 (95% CI: 2.51-15.61; p< 0.001).
In 2003, the corresponding figures in the final logistic regression model for adolescents with foreign backgrounds having
dental caries was 5.8, adjusted for principal meals and PLI.

Table 6. The association between foreign and Swedish backgrounds and dental caries among 3- and 5-year-olds 1993 and 2003, adjusted for
gender, age, parents level of education, snacks between principal meals and plaque index, estimated by logistic regression. Odds ratios (OR)
with 95% confidence intervals (95% CI).
Coherent

1993

Determinants

OR

Predicted
%
95% CI

p-value*

2003

Correct

71.8

118

OR

95% CI

p-value*

2.48

0.95-6.50

0.064

1.85

0.84-4.06

0.127

2.00

0.94-4.27

0.073

92

1.48

0.62-3.54

0.377

15

1.77

0.45-6.94

0.410

3.57

1.61-7.93

0.002

2.95

1.23-7.09

0.015

3.96

0.98-16.07

0.054

Foreign
backgrounds

No

146

Yes

28

Gender

Female

87

Male

87

Age

87

87

Parents level
of education

High

38

Intermediate

103

1.70

0.70-4.10

0.242

Low

33

2.07

0.68-6.28

0.198

Snacks
between
principal meals

0-3

127

47

Plaque index

Low

81

Intermediate

70

0.90

0.44-1.87

0.824

82

High

23

1.09

0.38-3.17

0,869

16

7.94

2.8022.48

0.001

0.92

0.46-1.83

0.808

Predicted
%

36

Correct
75.3

83
71
73
2.88

1.41-5.85

0.004

81
47

74
1.37

0.64-2.96

0.421

80
56

*Wald test

European archives of Paediatric Dentistry 12 (Issue 3). 2011

155

Paper I

B. Jacobsson, et al.
Table 7. The association between foreign and Swedish backgrounds and dental caries among 10- and 15-year-olds in 1993 and 2003, adjusted
for gender, age, principal meals and plaque index, estimated by logistic regression. Odds ratios (OR) with 95% confidence intervals (95% CI).
Coherent

1993

Determinants
Foreign
backgrounds
Gender

n
No

151

Yes

44

OR

Predicted
%
95% CI

p-value*

2003

Correct

92.3

120

1.23

0.30-5.04

0.770

24

0.90

0.28-2.89

0.861

64

Predicted
%

OR

95% CI

p-value*

5.80

2.01-16.72

0.001

1.15

0.51-2.62

0.731

4.78

2.03-11.24

0.001

3.19

0.98-10.33

0.054

Correct
73.6

Female

88

Male

107

80

Age

10

101

15

94

Principal meals

3-4

149

46

Plaque index

Low

11

Intermediate

86

7.63

1.24-47.00

0.028

95

7.22

1.40-37.26

0.018

High

98

5.32

0.87-32.73

0,071

28

6.72

1.10-41.12

0.039

73
7.97

1.70-37.46

0.009

71
127

2.09

0.43-10.10

0.361

17
21

*Wald test

Discussion
The results of this study show that oral health among children and adolescents with foreign and Swedish backgrounds
improved between 1993 and 2003, i.e. the percentage of
caries-free children had increased and the mean number of
decayed and filled tooth surfaces had decreased. This change
in caries prevalence is in agreement with earlier results
[Wendt et al., 1999, Marthaler, 2004]. However, in 1993, dfs
was statistically significantly higher in 3- and 5-year-olds with
foreign backgrounds compared with those with a Swedish
background. There was no difference in caries prevalence
in the two older age groups, which is in agreement with the
results presented by Jacobsson et al. [2005]. Ten years later,
the improvement in terms of dfs/DFS was more pronounced
for all age groups in the S cohort compared with the F cohort.
This is in agreement with the findings in other studies [Stecksen-Blicks et al., 2008, Christensen et al., 2010]. As a result
of the greater improvement in individuals with a Swedish
background, the difference in oral health was now statistically
significant in all four age groups.
At the actual time of the investigations, the percentage of
young people with foreign backgrounds living in Jnkping
was about the same as in the Swedish population as a whole.
In addition, the proportion of foreign born parents from specific nationalities corresponded well with the population in
Sweden, but it should be noted that most of the children and
adolescents with foreign backgrounds were born in Sweden.
However, changes in Swedish society and the nature of and
reason for migration between 1993 and 2003, for example,
may also have influenced the results for oral health, but it
has not been possible to analyse this. This also applies to the
individuals year of migration to Sweden.

156

European archives of Paediatric Dentistry 12 (Issue 3). 2011

Contrary to most epidemiological studies, the definition of

carious lesions in this study included both initial and manifest
caries. Omitting initial carious lesions may lead to an underestimation of the total caries situation. As discussed in other
reports [Hugoson et al., 2007; Alm, 2008] this aspect needs
to be taken into consideration when comparing results from
similar studies registering only manifest carious lesions.
In 1993, the 5-year-olds in the F cohort had a statistically
significantly higher proximal dfs compared with the S cohort,
a finding that was also made in 2003 among 5 and 10-yearolds. One interesting finding was that proximal restorations
among 15-year-olds had increased in the F cohort while it had
decreased in the S cohort (Fig. 1). These results indicate an
increasing difference in caries status among the cohorts. The
main challenge in dentistry is to maintain healthy teeth and
detect enamel lesions at an early stage, followed by an intensive preventive programme. The results of this study indicate
that the dental delivery system for children has obviously
failed to take care of children with foreign backgrounds as
successfully as children with a Swedish background. In fact,
differences in caries prevalence that could already be seen
among 10-year-olds in the F cohort in 1993 had increased
ten years later, including more restorations, compared with
children in the Swedish cohort. The results are therefore not
in agreement with the Swedish Dental Act, the law which
specifies goals for dental care, where all individuals should
receive equal evidence-based dental care [Ministry of Health
and Social Affairs, 1985].
According to Declerck et al. [2008] the presence of dental
plaque is correlated to the severity of caries experience in
preschool children. At both the present examinations, the
mean values for plaque and gingival bleeding were higher

Paper I

Oral health in young foreign and Swedish individuals

Figure 1. Percentage of 3-, 5-, 10- and 15-year-olds with foreign and Swedish backgrounds, caries-free, initial and manifest caries lesions and
restorations on proximal tooth surfaces in 1993 and 2003.

in the F cohort compared with the S cohort in all age groups,

except among the 15-year-olds in 2003, implying a higher
risk of caries and an extended prevalence of gingivitis.
However, the difference between the groups in this respect
decreased with increasing age and, in the oldest age groups,
the differences regarding both plaque and gingival bleeding
had levelled out.
In Sweden, inequality in health issues is a matter of great
concern. Parents with foreign backgrounds bring with them
different cultures and different traditions. According to
Karlberg and Ringsberg [2006] it is difficult to change deeprooted standards related to oral health among adults with
foreign backgrounds. Small children, as well as teenagers,
are dependent on their parents and are influenced in terms
of food habits and oral hygiene habits by their parents social
contexts. This must be considered when organising preventive programmes and oral treatment.
The primary teeth in the 3 and 5-year-olds and the permanent
teeth in the 10 and 15-year-olds were examined for caries.
Because of this difference, and the fact that some groups
became somewhat limited in number, the cohorts were
dichotomised into 3 and 5-year-olds and 10 and 15-yearolds. Using bivariate analyses, the associations between
dental caries and different explanatory variables were tested
and predictable differences were examined through multivariate analysis.
The logistic regression analysis confirmed that foreign background, with two foreign-born parents, was a strong predictor
of the development of dental caries in all age groups, thereby
corroborating the results of previous studies [Declerck et al.,
2008; Julihn et al., 2010]. The educational level of the parents, eating snacks between principal meals and the amount

of plaque were strongly associated with both caries and foreign backgrounds.
In 1993, the 3 and 5-year-olds with foreign backgrounds ran
a higher risk of developing dental caries compared with their
Swedish counterparts, but this risk had almost levelled out
in 2003. This may indicate that dental health care for small
children had improved between 1993 and 2003.
Among the 10 and 15-year-olds, the opposite was found.
Principal meals and plaque were strongly associated with
caries and foreign backgrounds in both 1993 and 2003. The
risk of developing dental caries was almost six times higher
among adolescents with foreign backgrounds compared with
a Swedish background.
Although most children and adolescents in Sweden attend
the Public Dental Service, it is obvious that a social gradient exists for dental health. The preventive programmes
that are designed to reach all the children in the community
resulted in a general improvement in oral health in children
between 1993 and 2003. However, this improvement was
not so pronounced in children with foreign backgrounds. The
gap in oral health between children with foreign and Swedish backgrounds had therefore increased. There is a need to
create tools and change the oral health preventive strategy
for children and adolescents with foreign backgrounds, and
above all for their foreign-born parents, in order to promote
satisfactory oral health care habits and the early detection of
initial caries to promote primary disease control. Wennhall et
al. [2010] have shown that adapted preventive programmes
for children living in a multicultural, low socio-economic area
are cost-effective and of great benefit to both society and the
individual.

European archives of Paediatric Dentistry 12 (Issue 3). 2011

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B. Jacobsson, et al.
Conclusion
There was a decline in caries prevalence between 1993 and
2003 in children with both foreign and Swedish backgrounds
in all age groups except for 3-year-olds. The improvement
in dfs/DFS was greater among those with a Swedish background compared with those with foreign backgrounds. The
difference between the two groups was larger in 2003 compared with 10 years earlier. In 2003, the odds ratio for being
exposed to dental caries was almost six times higher for 10
and 15-year-olds with two foreign-born parents compared
with their Swedish counterparts.
acknowledgement
We would like to thank Eleonor Fransson, Assistant Professor of Statistics, for
statistical support.

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