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JDRXXX10.1177/0022034520901709Journal of Dental ResearchSocioeconomic Life Course Models and Oral Health

Research Reports: Clinical

Journal of Dental Research
2020, Vol. 99(3) 257­–263
Socioeconomic Life Course Models © International & American Associations
for Dental Research 2020

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DOI: 10.1177/0022034520901709
https://doi.org/10.1177/0022034520901709
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R.K. Celeste1 , H.S. Eyjólfsdóttir2, C. Lennartsson2, and J. Fritzell2

Abstract
We compared socioeconomic life course models to decompose the direct and mediated effects of socioeconomic status (SES) in different
periods of life on late-life oral health. We used data from 2 longitudinal Swedish studies: the Level of Living Survey and the Swedish Panel
Study of Living Conditions of the Oldest Old. Two birth cohorts (older, 1925 to 1934; younger, 1944 to 1953) were followed between
1968 and 2011 with 6 waves. SES was measured with 4 indicators of SES and modeled as a latent variable. Self-reported oral health
was based on a tooth conditions question. Variables in the younger and older cohorts were grouped into 4 periods: childhood, young/
mid-adulthood, mid /late adulthood, late adulthood/life. We used structural equation modeling to fit the following into lagged-effects life
course models: 1) chain of risk, 2) sensitive period with late-life effect, 3) sensitive period with early- and late-life effects, 4) accumulation
of risks with cross-sectional effects, and 5) accumulation of risks. Chain of risk was incorporated into all models and combined with
accumulation, with cross-sectional effects yielding the best fit (older cohort: comparative fit index = 0.98, Tucker-Lewis index = 0.98,
root mean square error of approximation = 0.04, weighted root mean square residual = 1.51). For the older cohort, the chain of SES
from childhood → mid-adulthood → late adulthood → late life showed the following respective standardized coefficients: 053, 0.92, and
0.97. The total effect of childhood SES on late-life tooth loss (standardized coefficient: –0.23 for older cohort, –0.17 for younger cohort)
was mediated by previous tooth loss and SES. Cross-sectional effects of SES on tooth loss were observed throughout the life course, but
the strongest coefficients were at young/mid-adulthood (standardized coefficient: –0.41 for older cohort, –0.45 for younger cohort). SES
affects oral health cumulatively over the life course and through a chain of risks. Actions to improve socioeconomic conditions in early
life might have long-lasting effects on health if they help prevent people from becoming trapped in a chain of risks.

Keywords: life cycle stages, structural equation modeling, tooth loss, socioeconomic status, birth cohort, gerontology

Introduction life course epidemiology has developed several models that

According to the Global Burden of Disease study, untreated
dental caries is the most prevalent condition in the world
(Kassebaum et al. 2015), and the total costs of oral health dis-
eases amounted to $544.41 billion in 2015, 67% of which was
due to tooth loss (Righolt et al. 2018). Treatment for oral con-
ditions accounts for 4.6% of global health expenditures, and
such expenditures are mostly made by high-income countries
(Righolt et al. 2018).
In the life course approach to aging, the effects of early-life
social and biological factors on health later in life have been
examined extensively because of the increasing evidence that
factors from early life are associated with a number of chronic
disease in later life (Pollitt et al. 2005). More recently, research
has acknowledged that early social factors are associated with
quality of life (Peres et al. 2009; Niedzwiedz et al. 2012).
Nonetheless, a “direct effect” has not been unequivocally
shown because early-life socioeconomic effects are consis-
tently reduced after controlling for socioeconomic status (SES)
in other periods of life (Pollitt et al. 2005). Most chronic dis-
eases have their onset in middle and later adulthood, and the
proposed mechanisms for such long latency effects reside in
structural or functional alterations and metabolic maladapta-
tion to the nutritional environment (Kuh et al. 2003). Therefore,
incorporate early- and later-life SES (Kuh et al. 2003). The
most common life course model is perhaps the accumulation
hypothesis, proposing that each exposure has a concurrent but
independent effect on health.
Regarding oral health, SES measured during childhood
(Poulton et al. 2002; Listl et al. 2014; Han and Khang 2017;
Fantin et al. 2018; Listl et al. 2018; Vendrame et al. 2018) and
during adulthood (Tsakos et al. 2011; Schwendicke et al. 2015;
Seerig et al. 2015) has been consistently associated to preva-
lent cases of tooth loss, chewing, or caries in adulthood.
Additionally, a systematic review suggests that earlier life con-
ditions, such as parental education or occupational status,
1
Department of Preventive and Social Dentistry, Federal University of
Rio Grande do Sul, Porto Alegre, Brazil
2
Aging Research Center, Karolinska Institutet / Stockholm University,
Stockholm, Sweden
A supplemental appendix to this article is available online.
Corresponding Author:
R.K. Celeste, Department of Preventive and Social Dentistry, Federal
University of Rio Grande do Sul, Rua Ramiro Barcelos 2492, Porto
Alegre, Rio Grande do Sul 90035-033, Brazil.
Email: roger.keller@ufrgs.br
258
Figure 1. Measurement model tested in confirmatory factor analysis.
might be associated with periodontal health (Schuch et al.
2017). Studies that assess social mobility and tooth loss, how-
ever, tend to show a more diverse picture. While some of these
studies showed that current adulthood SES (Pearce et al. 2004;
Bernabé et al. 2011; Bernabé et al. 2012; Astrom et al. 2015;
Delgado-Angulo and Bernabe 2015; Schwendicke et al. 2015)
is a more important predictor of oral health, others reported a
stronger effect of childhood SES (Poulton et al. 2002; Pearce
et al. 2009) or similar effects for downward and upward social
mobility (Peres et al. 2011; Han and Khang 2017). Studies that
used structural equation modeling (SEM) to decompose early
and adult SES effects on tooth loss showed no direct effect (Lu
et al. 2011; Broadbent et al. 2016) or a smaller direct effect of
early-life SES as compared with adult-life SES on oral health
(Bernabé et al. 2012; Vendrame et al. 2018).
There are theoretical and methodological challenges to esti-
mating direct and indirect effects of early-life SES without
some degree of collinearity with SES later in life. Most studies
use traditional regression methods to estimate independent
direct effects and therefore cannot appropriately estimate indi-
rect effects in the presence of intermediate confounding factors
(De Stavola et al. 2015). The use of SEM has been advocated
when there is an a priori theory that can be used to test relations
(Baker and Gibson 2014). In the presence of repeated measures
of the exposure and the outcome, SEM is a particularly appro-
priate method to decompose effects that go through a chain.
For example, SES in childhood is hypothesized to have an
effect on the outcome in 1) the cumulative model, 2) the sensi-
tive/critical model, 3) the so-called trajectories model (upward
mobility assumes poverty in early life), and 4) the chain-of-
risks model (assuming an indirect triggering effect via adult-
life poverty). Finally, another important problem resides in the
fact that almost all oral health life course studies used prevalent
outcomes in adulthood (Listl et al. 2018), while a longitudinal
study on oral health life course showed no associations of
early-life SES with changes in oral health from age 65 to 70 y
(Astrom et al. 2015; Gülcan et al. 2015). Because tooth loss is
a cumulative outcome, without repeated measures, it is impos-
sible to know if SES in childhood had an effect in childhood
Journal of Dental Research 99(3)
(more or less cross-sectionally) or if it had
an effect in adulthood in incident cases .
Therefore, the aim of this study was to
compare different socioeconomic life course
models with longitudinal data to decompose
the direct and mediated effects of SES in
different periods of life on oral health in late
life.
Methods
We used data from 2 longitudinal Swedish
panel studies that are linked at the individ-
ual level. The Level of Living Survey began
in 1968 and is based on a representative
sample of the Swedish population aged 15
to 75 y. Subsequent follow-up interview
waves were in 1974, 1981, 1991, 2000, and 2010 (Fritzell et al.
2007). When individuals reached the upper age limit, they
were invited to continue in the Swedish Panel Study of Living
Conditions of the Oldest Old (Lennartsson et al. 2014), which
has completed 5 waves starting in 1992 and from which we
used data from 2002 and 2011. Both surveys have mainly been
conducted through face-to-face interviews, with no clinical
oral health data. The present study followed the STROBE
guidelines.
For this work, 2 birth cohorts (1925 to 1934, n = 923; 1944
to 1953, n = 1,195) were followed between 1968 (further
details are given elsewhere: Celeste and Fritzell 2018) and
2011 (Swedish Panel Study of Living Conditions of the Oldest
Old) or 2010 (Level of Living Survey). With these cohorts, we
were able to assess incidence of losing all or almost all teeth in
different age groups from 15 to 24 y to 77 to 86 y and evaluate
the cohort effects. Each cohort has 6 measurements over the
life course. For analytic purposes, those 6 measurements were
organized in the following 4 periods: T1) retrospective child-
hood and early-life conditions (data were collected in 1968),
T2) current young adulthood (merging interview waves 1968
and 1974), T3) current mid-adulthood (merging interview
waves 1981 and 1992), and T4) current late adulthood or late
life (merging interview waves 2000/2002 and 2010/2011).
Variables from different waves were combined in latent vari-
ables as shown in Figure 1 and explained as follows.
Self-reported oral health was obtained from the following
question: “Which of the following alternatives best describes
the condition of your teeth?” The 5 response alternatives were
as follows: 1, no teeth or mere remains; 2, dentures, whole or
part; 3, own teeth but in bad condition, many missing; 4, own
teeth but many fillings or bridgework; 5, own teeth in good
condition, no or few fillings.
Childhood SES was created as a compound/latent score for
SEM from 4 observed variables as described in a previous work
(Lennartsson et al. 2018). Information on SES in childhood was
collected retrospectively at the time of the first interview, in
1968. Mothers and fathers’ levels of education for both cohorts
were divided into 5 ordinal categories, with compulsory
Socioeconomic Life Course Models and Oral Health
Figure 2. Four structural models of life course socioeconomic status on tooth loss: t1, childhood; t2, 1968/1974; t3, 1981/1991; t4, 2000/2010.
education as the lowest education (0) and university education
as the highest (4). Childhood financial hardship was measured
dichotomously (yes = 0, no = 1), and the father’s social class
during the respondent’s childhood (first 16 y) was classified as
manual worker (0) or nonmanual worker (1).
Adulthood SES was also created as a compound/latent
score for SEM. Two variables in each survey year were com-
bined: the individual’s occupational social class and an
economic-based measure. The occupational social class, fol-
lowing the official Swedish socioeconomic classification, was
divided into the following 4 groups: 0 = unskilled manual
workers, 1 = skilled manual workers–lower nonmanuals I
(small farmers and self-employed people without employees),
2 = lower nonmanuals II (farmers with extensive land and/or
employees and self-employed people with 1 to 19 employees),
and 3 = higher nonmanuals (academic professionals and self-
employed people with ≥20 employees). The economic mea-
sure (cash margin) stemmed from the following question: “If a
situation suddenly arose where you had to come up with 2,000
SEK [Swedish crowns], could you manage it?” Response alter-
natives, in order of severity of economic hardship, were as fol-
lows: 0 = no; 1 = yes—by bank loan, help from friends, or
relatives; 2 = yes—by myself or with help from family. The
amount of SEK has been adjusted for inflation since the first
edition of the survey (1968), so it represents approximately the
same amount of money each year. In 2011, the requested
amount was 14,000 SEK (US ~$1,600).
Social Trajectories
Individual raw scores of adulthood and childhood SES were
obtained by summing the variables in each period of life and
259
then dichotomized with the median value. Childhood SES was
categorized in lower, middle, and higher SES.
Social trajectories were created by combining 2 periods:
childhood SES with 1 adulthood SES—the first from child-
hood to wave 1974, the second to wave 1991, and the third to
wave 2010/2011. Having childhood SES and 1 adulthood SES
score, we generate 4 categories: 0 = persistently lower, 1 =
downwardly mobile, 2 = upwardly mobile, and 3 = persistently
higher.
Measurement Model: Latent Variables
Our measurement model was composed of 3 latent oral health
variables and 4 latent SES variables (Fig. 1). The first oral
health latent variable combined the 5-point scale from 1968
and 1974, while the second combined years 1981 and 1991 and
the third 2000/2002 and 2010/2011. Although oral health does
not fit the definition of a latent variable, this procedure reduced
collinearity and random error from self-reported outcome. The
childhood and adulthood latent variables were composed as
described earlier.
Structural Model
We tested 4 distinct socioeconomic life course models follow-
ing the original life course theory (Kuh et al. 2003). However,
given previous studies (Lennartsson et al. 2018; Vendrame
et al. 2018), we incorporated in all models chains of lagged
effects for repeated measures of disease and risk factors (Fig.
2). We named those models as follows: M1) sensitive period
with late-life effect, M2) sensitive period with early- and late-
life effects, M3) accumulation of risks with lagged effects, and
260 Journal of Dental Research 99(3)

Table 1. Incidence of Losing All or Almost All Teeth by Social Trajectories and Socioeconomic Status in Childhood in 2 Swedish Cohorts.

1968 to 1974 1981 to 1991 2000 to 2011

% n P Value % n P Value % n P Value

Trajectories from childhood to last survey year

Cohort: 1925 to 1934 (mean age) 38 to 44 y 51 to 61 y 70 to 81 y
Persistently lower 12.0 192 0.01 4.8 146 0.04 17.2 122 0.04
Downwardly mobile 12.7 55 7.8 64 12.5 56
Upwardly mobile 7.8 257 1.9 157 6.6 91
Persistently higher 3.7 241 1.2 162 6.3 95
Total 7.9 745 3.2 529 11.0 364
Cohort: 1944 to 1953 (mean age) 20 to 26 y 33 to 43 y 52 to 63 y
Persistently lower 3.1 322 0.01 0.4 244 >.99 2.8 215 0.36
Downwardly mobile 0.5 188 0.6 158 1.4 143
Upwardly mobile 0.8 260 0.4 236 1.5 134
Persistently higher 0.3 364 0.7 297 0.5 198
Total 1.2 1,134 0.5 935 1.6 690
Socioeconomic status in childhood
Cohort: 1925 to 1934 (mean age) 38 to 44 y 51 to 61 y 70 to 81 y
Lower 9.6 449 0.02 3.2 312 0.69 13.1 214 0.74
Middle 7.0 185 3.7 134 3.5 85
Higher 2.7 111 2.1 96 14.9 67
Total 7.9 745 3.1 542 11.2 366
Cohort: 1944 to 1953 (mean age) 20 to 26 y 33 to 43 y 52 to 63 y
Lower 2.1 583 0.02 0.4 487 0.86 2.3 349 0.06
Middle 0.4 272 0.9 234 1.8 166
Higher 0.4 280 0.4 234 0.0 175
Total 1.2 1,135 0.5 955 1.6 690

People with all teeth lost were removed from the baseline year. P values are for trend for socioeconomic status in childhood.

M4) accumulation of risks with cross-sectional effects. Age
and sex were included as independent exogenous variables
with direct effects on baseline measures.
Statistical Analyses
For descriptive purposes, crude prevalence and incidence of
losing all or almost all teeth are presented as percentages for
childhood SES and social trajectories (Table 1 and Appendix
Table 1). We collapsed self-reported tooth conditions catego-
ries 1 and 2 (score = 1) and categories 3, 4, and 5 (score = 0).
Then, new cases of people with all or almost all teeth lost could
be identified between every 2 waves.
In conducting SEM, the first step was to produce an identi-
fied measurement model to test in a confirmatory factor analy-
sis (see Appendix Table 2). This model evaluates how latent
constructs perform in terms of measurement validity. We then
tested the fit of the structural models described earlier.
Due to loss of follow-up, we adopted a pairwise approach in
SEM with the Mplus 7.11 software, and other descriptive anal-
yses were performed with Stata 13.1 (StataCorp).
Results
The response rate at baseline (1968) was 93.3% and 96.8% for
the older and younger cohorts with analytical samples of 923
and 1,195, respectively. At baseline, the older and younger
cohorts had 50% and 51% women and were on average 38.5
and 19.9 y of age. In the older cohort, 26.1% of the individuals
reported financial difficulties during childhood versus 9.1% in
the younger cohort. In the older and younger cohorts, 43.6%
and 34.9% had deceased before the last wave (2010/2011).
Among those still alive, there were missing data for 6.5% and
7.4% of respondents in the older and younger cohorts.
Low childhood SES was associated with a greater incidence
of losing all or almost all teeth between any 2 consecutive sur-
vey years. However, the incidence was statistically significant
only between the first and second waves (1968 to 1974) in both
cohorts (Table 1). Between the years 1968 and 1974, the group
of lower childhood SES for the older cohort (age, 38 to 44 y)
had a 9.6% incidence of losing all or almost all teeth; the mid-
dle childhood SES group, 7.0%; and the higher childhood SES
group, 2.7% (P = 0.04, chi-square test for trend). When this
cohort was followed between 1981 and 1991 (age, 51 to 61 y),
the respective incidences of losing all or almost all teeth were
3.2%, 3.7%, and 2.1% (P = 0.69, chi-square test for trend), and
when they were followed between 2000 and 2011 (age, 70 to
81 y), the incidences were 13.1%, 3.5%, and 14.9% (P = 0.74,
chi-square test for trend). The prevalence of losing all or almost
all teeth was associated with childhood SES in all waves
(Appendix Table 1).
There were no sex differences in childhood SES in the
younger (P = 0.86) or older (P = 0.38) cohort. However, there
was a significant association between the sexes in terms of life
course trajectories in both cohorts (P < 0.01). We found a
higher proportion of women among those persistently in lower
Socioeconomic Life Course Models and Oral Health 261

Table 2. Standardized Estimated Effects (Standardized Coefficients) of Life Course Structural Models in 2 Swedish Cohorts.

Cohort: 1925 to 1934 Cohort: 1944 to 1953

Outcome Variable: Independent Variable SPL SPEL AL AC SPL SPEL AL AC

Tooth loss in young/mid-adulthood

Female 0.04 0.04 0.01 −0.21 0.13 0.13 0.12 –0.02
Age in 1968 0.17 0.17 0.17 0.17 0.21 0.18 0.20 0.19
SES in childhood −0.48 −0.47 −0.48 −0.41
SES in young/mid-adulthood −0.41 −0.45
Tooth loss in mid-/late adulthood
Tooth loss in young/mid-adulthood 0.94 0.91 0.91 0.93 0.88 0.94 0.82 0.94
SES in childhood −0.09 0.12
SES in young/mid-adulthood −0.11 −0.03
SES in mid-/late adulthood −0.05 0.13
Tooth loss in late adulthood/life
Tooth loss in mid-/late adulthood 0.86 0.87 0.87 0.88 0.79 0.76 0.77 0.77
SES in childhood −0.50 −0.06 −0.35 −0.10
SES in mid-/late adulthood −0.06 −0.10
SES in late adulthood/life −0.06 −0.10
SES childhood
Age in 1968 −0.02 0.02 0.02 −0.03 −0.04 −0.05 −0.05 −0.06
SES in young/mid-adulthood
SES in childhood 0.59 0.71 0.66 0.53 0.59 0.67 0.65 0.57
Female −0.56 −0.56 −0.55 −0.56 −0.35 −0.36 −0.36 −0.36
SES in mid-/late adulthood
SES in young/mid-adulthood 0.99 0.96 0.96 0.96 0.91 0.88 0.89 0.87
SES in late adulthood/life
SES in mid-/late adulthood 0.97 0.97 0.97 0.97 0.90 0.89 0.88 0.89
Fit indices
CFI 0.94 0.98 0.98 0.98 0.92 0.95 0.95 0.96
TLI 0.93 0.97 0.97 0.98 0.91 0.94 0.94 0.95
RMSEA 0.08 0.05 0.05 0.04 0.07 0.06 0.05 0.05
WRMR 2.68 1.62 1.60 1.51 2.35 1.80 1.79 1.68

Bold indicates statistical significance at P < 0.05.

AC, accumulation: with cross-sectional effects; AL, accumulation: with lagged effects; CFI, comparative fit index; RMSEA, root mean square error of
approximation; SES, socioeconomic status; SPE, sensitive period: early- and late-life effects; SPL, sensitive period: late-life effects; TLI, Tucker-Lewis
Index; WRMR, weighted root mean square residual.

SES or downward mobility in the younger cohort (54.9% and
54.6%, respectively) and the older cohort (60.6% and 59.4%).
The group with persistently higher SES and the upward mobil-
ity category consisted of only 44% women in both cohorts.
In both cohorts, accumulation with cross-sectional effects
(M4) was the model with the best fit indices (Table 2). For the
older cohort, the values of root mean square error of approxi-
mation, comparative fit index, Tucker-Lewis index, and
weighted root mean square residual were 0.05, 0.98, 0.97, and
1.62, respectively. In the period 1968 to 1974, the coefficient
(β) linking SES to tooth loss was −0.41 (P < 0.01); the period
1981 to 1991, −0.05 (P = 0.08); and the period 2000 to 2010,
−0.06 (P = 0.11). The sensitive period with late-life effects
(M1) showed an unacceptable model fit, which improved with
the addition of early-life effects (M2). All effects of childhood
SES on early- and late-life tooth loss were mediated by adult-
hood SES. For models M3 and M4, no plausible modification
indices were suggested by the software to improve the model,
so no additional associations were added.
Direct, indirect, and total effects of each SES measure on
tooth loss in the last wave are presented in Table 3, showing
similar patterns in both cohorts. SES in early life and SES in
young to mid-adulthood had stronger effects than SES in late
adulthood and SES in late life.
Discussion
Our results showed that both versions of the accumulation
model (cross-sectional and lagged) presented good statistical
fit, but the lagged-effect model might be theoretically more
plausible. The sensitive period with early- and late-life effect
cannot be completely ruled out, and future studies may test
combinations of models. In fact, it seems likely that the models
play a role simultaneously. Although SES has a cumulative
effect on oral diseases over the life course, its strongest effect
was observed early in life, creating a socioeconomic gap that
seems to be pervasive throughout the life course (Celeste and
Fritzell 2018). This confirms other studies in which the sensi-
tive period and accumulation models were regarded as accept-
able models (Poulton et al. 2002; Pearce et al. 2009; Peres et al.
2011; Han and Khang 2017; Vendrame et al. 2018); however, it
refutes the hypothesis that early-life SES has a direct effect late
262 Journal of Dental Research 99(3)

Table 3. Standardized Coefficients for Total, Direct, and Indirect Effects of SES over 4 Periods of the Life Course on Tooth Loss in 2 Swedish
Cohorts.

Cohort: 1925 to 1934 Cohort: 1944 to 1953

Outcome: Tooth Loss in Late Adulthood/Life Total Effects Direct Effects Indirect Effects Total Effects Direct Effects Indirect Effects

M1: Sensitive period I—late-life effects

SES in childhood −0.50 −0.50 −0.35 −0.35
M2: Sensitive period II—early- and late-life effects
SES in childhood −0.51 −0.06 −0.45 −0.35 −0.10 −0.25
M3: Accumulation of risks—with lagged effects
SES in childhood −0.47 −0.47 −0.33 −0.33
SES in young/mid-adulthood −0.15 −0.15 −0.10 −0.10
SES in mid-/late adulthood −0.06 −0.06 −0.10 −0.10
M4: Accumulation of risks—with cross-sectional effects
SES in childhood −0.23 −0.23 −0.18 −0.18
SES in young/mid-adulthood −0.43 −0.43 −0.32 −0.32
SES in mid-/late adulthood −0.10 −0.10 0.01 0.01
SES in late adulthood/life −0.06 −0.06 −0.10 −0.10

Bold indicates statistical significance at P < 0.05.

SES, socioeconomic status.

in life. Unique to our study is that we managed to compare
models with repeated data for the exposure and outcome.
Because of this, the restrictive sensitive period model (M1) did
not have a good fit. M2 allowed for childhood SES to have
effects early and late in life, and it showed that childhood
effects on oral health later in life were mainly indirect.
In all models, a chain of risks had to be incorporated to
yield acceptable fits. This highlights the importance of a good
start in life because the effect of lower SES in childhood on
later-life oral health was mainly mediated through adulthood
SES. This confirms studies that showed a strong effect of chain
of risks in Sweden (Darin-Mattsson et al. 2018; Lennartsson
et al. 2018) and other countries (Vendrame et al. 2018). In soci-
ology, such a chain has been described as the Matthew effect
(Merton 1988), or the accumulation of disadvantage. Two
strong chains were described in this study: 1) SES early in life
leads to a similar SES later in life, and 2) oral health status
early in life leads to similar oral health later in life. While it is
difficult to revert the oral health indicator, which is based on
tooth loss, it is not impossible to break the SES chain. Our SES
score in adult life did not include education, because this var-
ied very little during adulthood, but parents’ education was
included in childhood SES. If parents’ education can be con-
sidered a good proxy for children’s early-life education, then
this shows the importance of investments in this issue. Indeed,
a randomized intervention mainly based on education in very
early life showed important effects in preventing several
important diseases (Campbell et al. 2014).
The strengths and limitations of this study should be taken
into account when interpreting the results. First, a limitation is
the self-reported measures of oral health. Although they have
been validated (Pitiphat et al. 2002), there is some measurement
error. To partially account for this, oral health outcomes were
considered as latent variables representing major periods of life.
Second, in spite of being plausible, reverse causation (poor oral
health leading to lower SES) was not incorporated into the life
course models; additionally, as with any observational study, it
cannot ensure causality, only temporality. There is some evi-
dence of reverse causation between psychological distress and
income (Darin-Mattsson et al. 2018), but such an issue seems
less likely in terms of oral health. Finally, the use of retrospec-
tive childhood data suffers from recall bias, despite the fact that
parental education is rather objective information, and eco-
nomic hardship was collected when participants were young
(34 to 43 y and 15 to 24 y). A strength is that our analyses were
based on a large and representative sample of the general popu-
lation with, as far as we are aware, the longest follow-up period
with oral health data and with high response rates. Therefore,
we were able to reduce sampling bias and test life course mod-
els appropriately. These models were originally proposed for
long-latency chronic diseases, while dental caries affects people
at younger ages and has shorter latency repeatedly over time.
Our findings show that SES affects oral health cumulatively
over the life course, and they highlight the importance of child-
hood SES as an indirect factor for oral health later in life. A
good start in life seems important to prevent people from
becoming trapped in a chain of risks; nonetheless, preventive
action in all periods of life might improve oral health and
decrease socioeconomic inequalities in oral health.
Author Contributions
R.K. Celeste, contributed to conception, design, data analysis, and
interpretation, drafted the manuscript; H.S. Eyjólfsdóttir, contrib-
uted to conception, data acquisition, and interpretation, critically
revised the manuscript; C. Lennartsson, contributed to conception,
data acquisition, and analysis, critically revised the manuscript;
J. Fritzell, contributed to conception, design, data acquisition,
analysis, and interpretation, critically revised the manuscript. All
authors gave final approval and agree to be accountable for all
aspects of the work.
Socioeconomic Life Course Models and Oral Health
Acknowledgments
This work was supported by grants from FORTE (2012:1950 and
2016-07206) and NordForsk (74637). R.K.C. holds a PQ-2
Fellowship from CNPq (310978/2016-5). The authors declare no
potential conflicts of interest with respect to the authorship and/or
publication of this article.
ORCID iD
R.K. Celeste https://orcid.org/0000-0002-2468-6655
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