Oral Health

RESEARCH ARTICLE

Oral Health–Promoting School Environments and Dental Caries in Québec Children

Anu Edasseri, MSc,1 Tracie A. Barnett, PhD,2 Khady Kâ, PhD,3 Mélanie Henderson, PhD,4 Belinda Nicolau, PhD1

Introduction: Dental caries are highly prevalent among children and have negative health consequences. Their occurrence may depend in part on school-based environmental or policy- related factors, but few researchers have explored this subject. This study aimed to identify oral health promoting school environment types and estimate their relation with 2-year dental caries incidence among Québec children aged 8–10 years.

Methods: This study used data from two visits (completed in 2008 and 2011) of the QUALITY (Québec Adipose Lifestyle Investigation in Youth) cohort, which recruited white children at risk of obesity and their families from Greater Montreal schools. Measures included school and neighborhood characteristics, and Decayed, Missing, Filled-Surfaces index scores. Principal component and cluster analyses, and generalized estimating equations were conducted.

Results: Data were available for 330 children attending 200 schools. Based on a series of statistical analyses conducted in 2016, the authors identified three distinct school environment types. Type 1 and 2 schools had strong healthy eating programs, whereas Type 3 had weak programs. Type 1 schools had favorable neighborhood food environments, whereas Type 2 and 3 had unfavorable ones. Adjusting for potential confounders, children attending Type 1 and 2 schools had 21% (incidence rate ratio1⁄40.79, 95% CI1⁄40.68, 0.90) and 6% (incidence rate ratio1⁄40.94, 95% CI1⁄40.83, 1.07) lower 2-year incidence of dental caries, respectively, compared with Type 3 schools.

Conclusions: School-based oral health promotion programs combined with a favorable neighbor- hood can lower dental caries incidence in school children. Am J Prev Med 2017;53(5):697–704. & 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

              

INTRODUCTION

Despite improved detection and treatment

modalities, dental caries remain the most com-

mon chronic oral disease among children and a

major public health concern affecting 60%−90% of

school-aged children worldwide.1 Oral conditions

(untreated caries, severe periodontitis, and tooth loss)

affect nearly 3.9 billion people worldwide; untreated

decay in permanent teeth is the most prevalent condition,

affecting 35% of the population and ranking 80th among

the top 100 causes of disability-adjusted life years.2 North

American children have the second highest lifetime

caries experience measured by the Decayed, Missing,

and Filled-Teeth index (Decayed Missing Filled-

3

youth have experienced dental caries, with a higher prevalence and severity found among youth from a low socioeconomic background.4 Moreover, oral health is a determinant of general health and plays an important role in quality of life.5 Finally, oral disease is the fourth

From the 1Division of Oral Health and Society, Faculty of Dentistry, McGill University, Montreal, Québec, Canada; 2Epidemiology and Biostatistics Unit, Institut National de la Recherche Scientifique−Institut Armand Frappier, Laval, Québec, Canada; 3University of Montreal Hospital Research Centre, Montreal, Québec, Canada; and 4Department of Pedia- trics, Université de Montréal, Centre Hospitalier Universitaire Sainte- Justine, Montreal, Québec, Canada

Address correspondence to: Belinda Nicolau, PhD, Faculty of Dentistry, McGill University, 2001 McGill College Avenue, Suite 527, Montreal, QC Canada, H3A 1G1. E-mail: belinda.f.nicolau@mcgill.ca.

0749-3797/$36.00

https://doi.org/10.1016/j.amepre.2017.07.005

Teeth1⁄42.08) worldwide. More than half of Canadian

& 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights Am J Prev Med 2017;53(5):697–704 697 reserved.

698 Edasseri et al / Am J Prev Med 2017;53(5):697–704

most expensive condition to treat and is therefore a major economic burden to both society and individuals.1 Fortunately, dental caries are mostly preventable, and even reversible, if detected in early stages and if effective intervention is available. However, the effectiveness of oral health education and clinical preventive programs in improving oral health outcomes is questionable.6,7 Dental health education may increase knowledge, but whether it translates into better oral health behaviors is still a matter of debate.6–8 In fact, information giving alone may be ineffective and may even increase health inequity because people with the highest need are frequently less educated, with fewer economic resources to make healthier choices.9,10 Also, focusing on clinical prevention, such as sealants and topical fluorides, alone is palliative7 and not

cost effective.11 Health promotion strategies that go beyond the

individual level to integrate elements of policy develop- ment and social and physical environmental factors may be more effective for disease prevention than isolated behavior-specific interventions.7,12 The WHO’s concept of health promoting schools highlights the importance of the environment, and advocates for a comprehensive approach in transforming schools as healthy settings.13 Considering oral health promotion as an integral com- ponent of health promoting schools, WHO has proposed guidelines for oral health promoting schools.14 Schools worldwide have attempted to adapt and implement school-based oral health promotion programs according to these guidelines.

These initiatives generally had a favorable impact on reduction of dental caries in children,15–17 however, instances of failure were also reported.18,19 Although the Québec government responsible for schools in the current study published guidelines for school health promotion in 2005,20 the authors did not find any studies evaluating its effect on oral health outcomes.

Other school-related variables may play important roles in determining children’s health and health behav- iors, notably neighborhood disadvantage. For example, favorable school socioeconomic environment is inversely related to dental caries in Québec school children.21 In addition, school SES, based on average percentage of low- income families in the school neighborhood, appears to modify the association between oral health promotion and dental caries reduction, the effect being stronger among low SES schools,15 where the need is the greatest.

Disadvantaged neighborhoods may also have more nutritionally poor food sources; hence, children attend- ing schools located in disadvantaged neighborhoods may be more likely to adopt poor dietary habits. Some evidence suggests an adverse effect of an unhealthy food environment around schools on pediatric obesity.22

A previous study published by the QUALITY (Québec Adipose Lifestyle Investigation in Youth) cohort group found that a higher number of “unhealthful” compared with “healthful” food stores in the proximity of schools had undesirable effects on children’s dietary habits.23 However, studies on the surrounding food environment and children’s dietary habits provide inconsistent find- ings and are mostly cross-sectional22; there is a need for additional longitudinal studies.22

Despite major criticism of traditional preventive and behavioral approaches, many interventions targeting isolated behaviors persist. Few studies have looked at comprehensive programs in schools that incorporated policy elements and participatory approaches15,16,18; a literature search identified only one such study from Canada15 and none from Québec. In addition, fewer studies have considered school neighborhood disadvant- age,15,16 and the authors identified none that included the surrounding food environment in their assessment of the oral health promoting school environment. Therefore, the aims are to identify distinct school environments based on oral health promoting and neighborhood environmental factors, and to estimate the relation between school environment types and 2-year dental caries incidence among Québec children aged 8–10 years.

METHODS

Study Sample

Data were from an ongoing prospective study, the QUALITY cohort, which investigates the natural history of metabolic risk in youth. A full description of this study can be found elsewhere.24 Briefly, the QUALITY cohort recruited 630 white children aged 8–10 years at baseline from schools located within 75 km of three major urban centers in the province of Québec. Both biological parents had to be available and at least one of them had to be obese (BMI ≥30 or waist circumference 4102 cm in men and 488 cm in women) for inclusion in the study. An ancillary study included a formal evaluation of the schools attended by QUALITY partic- ipants and the neighborhood for children attending schools in the Montreal Census Metropolitan Area (home to 480% of QUAL- ITY participants). Among the 296 schools (attended by 506 children of the QUALITY study) in the Montreal Census Metropolitan Area, 247 schools (attended by 430 children) agreed to participate in the study. The current study uses data collected in Visit 1 (baseline, aged 8–10 years) and Visit 2 (children aged 10–12 years), which were completed in 2008 and 2011, respectively.

The QUALITY cohort study obtained ethics approval from several IRBs, including the Centre Hospitalier Universitaire Sainte- Justine and McGill University. Parents and school principals signed consent forms and children provided assent.

Measures

Trained dentists performed the clinical oral health examination in a dental office during the hospital visit. This study used the Child Dental Health Survey of England, Wales, and Northern Ireland

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diagnostic criteria to record dental caries.25 Two-year dental caries incidence was measured as the difference in the Decayed, Missing, Filled-Surfaces (DMF-S) index between Visits 1 and 2. Surfaces that were not examined in either visit were excluded from the DMF-S index calculation. Five observations had negative DMF-S incremental values. In each of these cases, some of the initial caries lesions in Visit 1 were replaced by sealants in Visit 2 and thus were not counted in Visit 2, leading to negative differences. As this is equivalent to a difference of 0, the 2-year dental caries incidence in all these cases was also recorded as 0.

Data on age, sex, and parental SES were collected using structured questionnaires administered to parents at Visit 1. Parental SES was measured using two variables: parental education and parental income. Parental education, collected as a seven- category variable, was later combined for both parents and categorized into (1) one or two parents with high school or less; (2) one or two parents with collège d’enseignement général et professionnel/vocational or trade school; and (3) one or two parents with university degree. The annual household income before taxes was collected as 12 categories ranging from o$10,000 to ≥$140,000 Canadian dollars. This variable was later adjusted for the number of people living in the house26 and further grouped into quartiles.

Trained research assistants collected school environment data by interviewing school principals with the aid of structured questionnaires. Questions related to healthy eating promotion policies in schools were derived from recognized guidelines for Québec schools, including the Institute of Medicine Recommen- dations for Schools to Address Childhood Obesity,27 the School Health Index,28 the School Health Policy and Programs Survey,29 and the Coalition for School Nutrition.30

School neighborhood disadvantage information was obtained from the 2006 Canadian Census. The authors constructed a material deprivation index of the area within 1,000 m of street network around each school. The index comprises “the proportion of individuals without a high school diploma, the employment population ratio and the average personal income” for people aged ≥15 years in census dissemination areas, with a higher value representing lower deprivation.31 This variable was classified into tertiles ranging from high (0) to low (2) deprivation. The numbers of convenience and fast-food stores within 500 m around each school were calculated using the GIS from the Montreal Epide- miological and Geographic Analysis of Population Health Out- comes and Neighbourhood Effect database that contains information until May 2005.32 These variables were then dicho- tomized into at least one store within 500 m (unfavorable) versus none within 500 m (favorable).

Statistical Analysis

The analyses for this paper were conducted in 2016. Principal component analysis (PCA) with a polychoric correlation matrix was used to group variables measuring schools’ healthy eating promotion policies. Oblimin oblique rotation was applied to differentiate the components and those with eigen values 41 were retained.

Subsequently, the authors performed a hierarchical agglomer- ative average linkage cluster analysis using the components identified by PCA, along with variables that measured presence

of dental health/hygiene programs and formal healthy eating promotion initiatives, school’s surrounding food environment and SES, to identify distinct types of school environments. Cluster stop rules (Calinski−Harabasz pseudo-F index, and Duda−Hart and Je [2]/Je [1] indices) were used to select the optimal number of clusters.33

After preliminary descriptive and exploratory analyses, the authors used generalized estimating equations with a binomial link function, exchangeable correlation matrix, and school as the grouping variable, to model the association between school environment types and 2-year dental caries incidence in children, adjusting for potential confounders. All analyses were preformed using Stata/SE, version 12.

RESULTS

Out of the 430 children (attending 247 schools) for whom school data were available, 357 had data on dental caries for both visits. The authors further excluded 27 children because of missing data for other covariates. The mean age for the final sample of 330 children was 9.2 years (SD1⁄40.9 years) at baseline. The mean DMF-S for Visits 1 and 2 were 0.6 (SD1⁄41.4) and 2.0 (SD1⁄42.9), respectively (Table 3).

PCA and cluster analyses were performed in 226 schools (21 schools were excluded because of missing values). PCA included ten variables, which loaded on three components (Table 1 and Appendix Table 1, available online). Three distinct types of school environ- ments were identified based on cluster analysis and the school types were defined by examining the mean or proportion of each variable within each cluster (Table 2). Type 1 included schools located in neighborhoods with high SES, favorable surrounding food environments, strong healthy eating promotion, and weak dental care programs (50.9% of all schools). Type 2 included schools located in neighborhoods with low SES, unfavorable surrounding food environments, strong healthy eating promotion and strong dental care programs (36.1%). Type 3 comprised schools located in neighborhoods with average SES, unfavorable surrounding food environ- ments, weak healthy eating promotion, and average dental care programs (13.0%).

Finally, the authors used generalized estimating equa- tion to model the association between the three variables representing school environment types and 2-year dental caries incidence. Using Type 3 school as a reference, children attending Type 1 and 2 schools had 21% (incidence rate ratio1⁄40.79, 95% CI1⁄40.68, 0.90) and 6% (incidence rate ratio1⁄40.94, 95% CI1⁄40.83, 1.07) lower 2- year incidence of dental caries, respectively, after adjust- ing for age, sex, parental SES, and baseline DMF-S index (Table 4).

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700 Edasseri et al / Am J Prev Med 2017;53(5):697–704 Table 1. Variable Loading Pattern in Principal Component Analysis

Component Variable 1 2 3 variance Unexplained

Willingness to participate in healthy eating promotion of:

School management 0.4876 — — 0.1524

Teachers 0.4423 — — 0.2016

Daycare managers 0.4740 — — 0.1964

Community 0.4478 — — 0.2851

Agreement with community to promote healthy eating within school 0.3448 — — 0.5884

School makes room for families to engage in volunteer activities — 0.5879 — 0.5096

Frequently informs parents about health promotion activities in schools — 0.5509 — 0.4839

Educates teachers on the importance of promoting healthy living — 0.5655 — 0.4078

Strict rule for approval of catering service menu by a nutritionist — — 0.6770 0.3284

School sells drinks and snacks in accordance with principles of healthy eating — — 0.6909 0.3417 during fundraising programs

DISCUSSION

This study aimed to identify school environment profiles based on oral health promoting and neighborhood environmental factors and estimate their impact on

2-year dental caries incidence. The study identified three distinct school environment types and the results suggest that a favorable school environment can lower the incidence of dental caries in children. These findings are in agreement with previous cross-sectional studies

Table 2. Description of the School Environment Types Based on the Variables Used in the Cluster Analysis

Cluster Variables used in cluster analysis 1 (n1⁄499)a 2 (n1⁄475)a 3 (n1⁄426)a

School Material Deprivation Index

M (SD) 1.22 (0.80) 0.67 (0.72) 0.92 (0.84)

Range 0 to 2 0 to 2 0 to 2

Presence of a convenience store or a fast-food store within 500 m around the school (yes1⁄41/no1⁄40)

Yes, n (%) 0 (0) 75 (100) 26 (100)

Formal school initiatives to promote healthy eating (yes1⁄41/no1⁄40)b

Yes, n (%) 83 (84) 75 (100) 0 (0)

Component 1: Willingness of school to promote healthy eating within school and involvement of community partnersb

M (SD) 5.34 (0.73) 5.38 (0.85) 5.05 (1.12)

Range 2.99 to 6.33 1.71 to 6.45 1.07 to 6.31

Component 2: Encouraging teachers and parents to promote healthy lifestyles in childrenb

M (SD) 3.36 (0.55) 3.26 (0.55) 2.97 (0.63)

Range 1.34 to 3.89 1.88 to 3.88 1.98 to 3.82

Component 3: Great attention to providing healthy food within schoolb

M (SD) 0.83 (0.54) 0.68 (0.56) 0.42 (0.49)

Range −0.24 to 1.59 −0.31 to 1.56 −0.24 to 1.52

Visit by any dental health professional at school (yes1⁄41/no1⁄40)c

Yes, n (%) 88 (89) 71 (95) 24 (92)

Programs providing dental hygiene education (yes1⁄41/no1⁄40) c

Yes, n (%) 79 (80) 65 (87) 22 (85)

Programs other than the provision of dental hygiene education (yes1⁄41/no1⁄40)c

Yes, n (%) 46 (47) 28 (37) 14 (54)

aTotal 200 schools included in the complete case analysis. bThe types of schools were graded as strong/average/weak in healthy eating promotion, based the on the distribution of these variables in three

clusters. cThe types of schools were graded as strong/average/weak in dental care programs, based the on the distribution of these variables in three clusters.

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Edasseri et al / Am J Prev Med 2017;53(5):697–704 701 Table 3. Distribution of Sociodemographic Characteristics and Mean DMF-S in Children Within Each School Environment

Cluster

Type Total (n1⁄4330 1 (n1⁄4168 2 (n1⁄4119 3 (n1⁄443 Variable [100%]) [50.9%]) [36.1%]) [13.0%])

Age, years, M (SD) 9.2 (0.9) 9.2 (0.9) 9.3 (0.9) 9.0 (0.9)

Sex, n (%)

Boys 191 (57.9) 93 (55.4) 73 (61.3) 25 (58.1)

Girls 139 (42.1) 75 (44.6) 46 (38.7) 18 (41.9)

Household income, n (%)

o$29,070 78 (23.6) 38 (22.6) 33 (27.7) 7 (16.3)

$29,070–$42,579 79 (23.9) 40 (23.8) 30 (25.2) 9 (20.9)

$42,580–$56,271 85 (25.8) 33 (19.6) 38 (31.9) 14 (32.6)

4$56,271 88 (26.7) 57 (33.9) 18 (15.1) 13 (30.2)

Parental education, n (%)

One or both parents hold a high school degree or 25 (7.6) 15 (8.9) 10 (8.4) 0 less

One or both parents completed CEGEP/vocational 121 (36.7) 67 (39.9) 39 (32.8) 15 (34.9) or trade school

One or both parents hold a university degree 184 (55.8) 86 (51.2) 70 (58.8) 28 (65.1)

DMF-S Index, M (SD)

Baseline DMF-S 0.6 (1.4) 0.5 (1.2) 0.7 (1.6) 0.8 (1.5)

DMF-S Visit 2 2.0 (2.9) 1.6 (2.3) 2.3 (3.3) 3.0 (3.5)

CEGEP, collège d’enseignement général et professionnel; DMF-S, Decayed, Missing, Filled-Surfaces.

investigating the impact of comprehensive oral health promotion approaches.15,16 In contrast, a school-based study using a participatory approach to reduce sugar intake of children failed to bring about any change in diet

behaviors or reduction of dental caries. This failure may have been attributable to the narrow scope of the policy, which restricted children’s food intake to fruits and milk during school breaks rather than focusing on overall diet

Table 4. Association Between School Environment Types and 2-year Dental Caries Incidence (GEE, n1⁄4330)

Variables in the model Change in DMF-S over 2 years, M (SD) IRRa (95% CI)

School environment

Type 1 1.1 (1.7) 0.79 (0.68–0.90)

Type 2 1.7 (2.6) 0.94 (0.83–1.07)

Type 3 2.3 (2.7) 1

Age — 1.06 (1.00–1.12)

Sex

Male 1.4 (2.2) 1

Female 1.5 (2.2) 1.06 (0.96–1.18)

Household income

o$29,070 2.1 (2.7) 1

$29,070–$42,579 1.5 (1.8) 0.97 (0.85–1.10)

$42,580–$56,271 1.3 (2. 4) 0.98 (0.84–1.15)

4$56,271 1.0 (1.8) 0.95 (0.78–1.15)

Parental education

One or both parents hold a high school degree or less 3.0 (3.2) 1

One or both parents completed CEGEP/vocational or trade school 1.6 (2.1) 0.77 (0.67–0.87)

One or both parents hold a university degree 1.2 (2.1) 0.71 (0.62–0.82)

Baseline DMF-Sa — 1.08 (1.05–1.10)

aBaseline DMF-S was separately included in the model to better capture the variations in the baseline caries risk of children, which may not be captured by the difference in DMF-S indices over 2 years.

CEGEP, collège d’enseignement général et professionnel; DMF-S, Decayed, Missing, Filled-Surfaces; IRR, incidence rate ratio. November 2017

702 Edasseri et al / Am J Prev Med 2017;53(5):697–704

behaviors. Moreover, the program did not include measures to raise the awareness of teachers, children, or parents regarding a healthy diet18 and did not consider the broader built and social environments around the schools, which could potentially influence children’s food habits.

In this study, Type 1 schools, which showed the strongest protective association with dental caries, had strong healthy eating environments inside the schools as well as favorable food environments around the schools. This finding suggests that an environment promoting healthy eating, that also incorporates the socioenviron- mental and policy aspects of health promotion, may be particularly effective in reducing dental caries. This observation aligns with the common risk factor approach to oral health promotion, which advocates for an integrated strategy, targeting risk factors (e.g., high sugar diet) that are common to multiple chronic diseases, and their underlying determinants.9

Moreover, this study’s results highlight the impor- tance of school neighborhood disadvantage factors on dental caries incidence in schoolchildren. Type 1 schools were located in the highest SES neighborhood and had favorable surrounding food environments, whereas Type 2 and 3 schools, located in neighbor- hoods with relatively low SES, had unfavorable surrounding food environments. The additional pro- tective influence of Type 1 schools may be attributable to the reduced access to nutritionally poor food sources in the school neighborhoods. A previous study in QUALITY cohort children reported that unhealth- ful stores around schools may have a negative influence on the dietary choices of children attending that school,23 which provides insight on the potential mediating pathway.

It is also notable that despite scoring the lowest in dental health-specific programs, Type 1 schools were associated with the greatest reduction in dental caries. However, this reduction was lower among schools with comparatively stronger dental health programs, possibly because these were isolated programs, which were not integrated with other initiatives (e.g., healthy eating initiatives) and did not have strong involvement of parents, teachers, and communities; additionally, these schools had unfavorable surrounding food environ- ments. The results are in line with previous studies concluding that dental care programs may play a role in lowering dental caries incidence; however, a more prominent role could be attributed to social and environ- mental factors.34,35 Moreover, a comprehensive and integrated effort toward oral health promotion, rather than a single focus on dental-specific preventive meas- ures and education, may be more effective.9

Limitations

There are some limitations to this study. The general- izability of the results may be limited due the study’s selection criteria, which included only white children with a family history of obesity. A comparison with the general population at baseline showed that the study population came from a relatively higher socioeconomic sector of society.24 Thus, study participants may already be at a lower risk for dental caries. Despite this, the study identified a significant decrease in dental caries incidence after adjusting for individual SES. It could be reasonably assumed that, if this study had included a more repre- sentative population of children from Montreal with a relatively lower SES, the protective association would have been higher than or at least as strong as the one observed. Moreover, the sample included substantial variation in terms of the range of the neighborhoods represented. However, potential selection bias due to voluntary entry into the study cannot be ruled out, as is the case with most studies. Another limitation is the relatively short follow-up period. However, future studies are planned on the same cohort of children with a longer follow-up period to confirm and expand the findings.

Another potential limitation is the possibility of bias due to a relatively high percentage of missing values, which may not be distributed completely at random (Appendix Table 2, available online). The authors performed a sensitivity analysis by imputing missing values through multiple imputation using chained equa- tions. There was no significant difference in point estimates for Type 1 school environments, where the greatest reduction in dental caries was observed. How- ever, the point estimate for Type 2 school environments, associated with moderate reduction in caries incidence, moved away from the null, possibly suggesting a selection bias; the effect measure remained non-significant (Appendix Table 3, available online).

Additionally, some of the information on the school environment was reported by school principals, which may have resulted in over-reporting of positive attributes because of social desirability. Nonetheless, the chance that this would introduce bias is low, as over-reporting would occur in all the schools included in the study non- differentially. The study used multiple factors to classify school environments and these factors could not have been manually assigned to different clusters. Therefore, there is a possibility for mis-specification of clusters. However, given the complexity inherent to such a classification, this limitation may be inevitable.

One of the main strengths of this study is the use of a prospective design, providing a stronger basis for causal inference. The authors also carried out a comprehensive assessment of the school environment, which allows to

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disentangle, to an extent, the effects of environments within and outside the school and of SES on dental caries incidence.

CONCLUSIONS

Findings from this study indicate that school environ- ments with a comprehensive, integrated, and participa- tory approach to oral health promotion may be most effective in lowering dental caries incidence in children. Interestingly, favorable food environments seem to be a strategic component of oral health action, rather than dental care programs. The results do not suggest that dental care programs are unnecessary, but that such programs are less effective in isolation.

More favorable neighborhood characteristics around schools seem to have a strong influence in lowering dental caries incidence. Although socioeconomic aspects may not be directly modifiable, environmental-level policies can be implemented to modify built environ- ments around the schools, which in turn may buffer some of the socioeconomic inequalities. Although this study was not designed to directly recommend policy changes, the results add evidence in support of it.

Furthermore, the results provide policymakers with evidence-based data. The Québec government has been encouraging schools to promote healthy food, mostly to deal with the obesity crisis.36 An evaluation study from Québec concluded that, despite an improvement observed over the last years, the goal of providing only healthy food in schools was inadequately met.37 The authors call policymakers’ attention to the fact that promoting a healthy eating environment in Québec’s schools may have effects beyond obesity reduction, benefitting children’s oral health. Rather than focusing only on dental programs for caries reduction, they could re-allocate some resources to strategies including com- mon risk factor and participatory approaches, with a special emphasis on disadvantaged neighborhoods.

Future studies could target a more representative sample including a higher proportion of participants from lower socioeconomic sectors to confirm the findings.

ACKNOWLEDGMENTS

Dr. Marie Lambert (July 1952–February 2012), pediatric geneti- cist and researcher, initiated the QUALITY cohort. Her leader- ship and devotion to QUALITY will always be remembered and appreciated. We are also grateful to all the families that participate in the QUALITY cohort.

This study was supported by the Canadian Institutes of Health Research (Institute of Musculoskeletal Health and Arthritis and Institute of Genetics), the Heart & Stroke Founda- tion of Canada, the Fonds de Recherche du Québec−Santé, and

the Fonds de Recherche du Québec– Réseau de Recherche en santé buccodentaire et osseuse.

A. Edasseri was the recipient of a Graduate Excellence fellowship from the McGill University Faculty of Dentistry. K. Kâ was recipient of a PhD fellowship from the Canadian Institutes of Health Research−Strategic Training in Applied Oral Health Research. T.A. Barnett (Junior 2) and M. Henderson (Junior 1) are Fonds de recherche du Québec−Santé research scholars. B. Nicolau holds a Canada Research Chair (Tier 2) in Life Course Oral Epidemiology.

The QUALITY cohort study obtained ethics approval from several IRBs, including the Centre Hospitalier Universitaire Sainte-Justine (IRB Study Number: 2040) and McGill University (IRB Study Number: A02-M08-16A).

A. Edasseri conceived the hypothesis, conducted the data analysis, and led the writing. K. Kâ assisted with analysis; M. Henderson assisted with the study and edited the manu- script; and T.A. Barnett and B. Nicolau conceived and super- vised the study, including data analysis, and assisted with the writing.

No financial disclosures were reported by the authors of this paper.

SUPPLEMENTAL MATERIAL

Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j. amepre.2017.07.005.

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