title: Social determinants of dental treatment needs in Brazilian adults.
abstract: BACKGROUND
  The chronic cumulative nature of caries makes treatment needs a severe problem in adults. Despite the fact that oral diseases occur in social contexts, there are few studies using multilevel analyses focusing on treatment needs. Thus, considering the importance of context in explaining oral health related inequalities, this study aims to evaluate the social determinants of dental treatment needs in 35-44 year old Brazilian adults, assessing whether inequalities in needs are expressed at individual and contextual levels.
  
  
  METHODS
  The dependent variables were based on the prevalence of normative dental treatment needs in adults: (a) restorative treatment; (b) tooth extraction and (c) prosthetic treatment. The independent variables at first level were household income, formal education level, sex and race. At second level, income, sanitation, infrastructure and house conditions. The city-level variables were the Human Development Index (HDI) and indicators related to health services. Exploratory analysis was performed evaluating the effect of each level through calculating Prevalence Ratios (PR). In addition, a three-level multilevel modelling was constructed for all outcomes to verify the effect of individual characteristics and also the influence of context.
  
  
  RESULTS
  In relation to the need for restorative treatment, the main factors implicated were related to individual socioeconomic position, however the city-level contextual effect should also be considered. Regarding need for tooth extraction, the contextual effect does not seem to be important and, in relation to the needs for prosthetic treatment, the final model showed effect of individual-level and city-level. Variables related to health services did not show significant effects.
  
  
  CONCLUSIONS
  Dental treatment needs related to primary care (restoration and tooth extraction) and secondary care (prosthesis) were strongly associated with individual socioeconomic position, mainly income and education, in Brazilian adults. In addition to this individual effect, a city-level contextual effect, represented by HDI, was also observed for need for restorations and prosthesis, but not for tooth extractions. These findings have important implications for the health policy especially for financing and planning, since the distribution of oral health resources must consider the inequalities in availability and affordability of dental care for all.
authors.forename: Angelo Giuseppe
authors.initials: AG
authors.lastname: Roncalli
authors.affiliation: Department of Epidemiology and Public Health, University College London, London, UK. g.tsakos@ucl.ac.uk.
authors.forename: Georgios
authors.initials: G
authors.lastname: Tsakos
authors.forename: Aubrey
authors.initials: A
authors.lastname: Sheiham
authors.forename: Georgia Costa
authors.initials: GC
authors.lastname: de Souza
authors.forename: Richard G
authors.initials: RG
authors.lastname: Watt
mesh_terms: D000328:Adult; D001938:Brazil / Q000453:epidemiology; D003729:Dental Care / Q000706:statistics & numerical data*; D003731:Dental Caries / Q000453:epidemiology* / Q000517:prevention & control; D005260:Female; D006291:Health Policy; D006301:Health Services Needs and Demand; D054624:Health Status Disparities; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D015995:Prevalence; D012959:Socioeconomic Factors