Abstract

The present study aimed to investigate the association between racial iniquities and oral health status. This is a systematic review with a protocol registered on the Prospero Platform (CRD42021228417), with searches carried out in electronic databases and in gray literature. Our study identified 3,028 publications. After applying the eligibility criteria and risk of bias analysis, 18 studies were selected. The results indicate that individuals of black/brown race/skin color have unfavorable oral health conditions, mainly represented by self-rated oral health, tooth loss, caries, and periodontitis. The results showed racial iniquities in oral health in different countries, for all analyzed indicators, with a greater vulnerability of the black population.

Key words:
Oral health; Health status disparities; Racial groups; Ethnic health

Introduction

The relationship between racial iniquities and oral health status can be explained by economic and social disadvantages, difficulties in accessing and providing adequate health care, and discriminatory attitudes towards the black population¹1 Guiotoku SK, Moysés ST, Moysés SJ, França BH, Bisinelli JC. Racial inequity in oral health in Brazil. Rev Panam Salud Publica 2012; 31(2):135-141.. By recognizing racism, ethnic-racial inequalities, and institutional racism as social determinants of health conditions, actions can be taken in low and middle-income countries to promote health equity for the black population²2 Silva NND, Favacho VBC, Boska GA, Andrade EDC, Merces NPD, Oliveira MAF. Access of the black population to health services: integrative review. Rev Bras Enferm 2020; 73(4): e20180834.^,33 Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Annu Rev Sociol 2015; 41:311-330.. Racism is an ideology in which one group exercises hierarchical power over another, based on the self-reported conception of superiority⁴4 Schuch HS, Haag DG, Smith JL, Paradies Y, Jamieson LM. Intersectionality, racial discrimination and oral health in Australia. Community Dent Oral Epidemiol 2021; 49(1):87-94.^,55 Organização das Nações Unidas para a Educação, a Ciência e a Cultura (Unesco). Declaração sobre a raça e os preconceitos raciais [Internet]. 1978 [acessado 2021 jul 29] Disponível em: http://www.direitoshumanos.usp.br/index.php/UNESCOOrganiza%C3%A7%C3%A3o-das-Na%C3%A7%C3%B5es-Unidas-para-a-Educa%C3%A7%C3%A3o-Ci%C3%AAncia-e-Cultura/declaracao-sobre-a-raca-e-os-preconceitos-raciais.html.
http://www.direitoshumanos.usp.br/index.... . Health inequalities are influenced by racism in three ways: first, cultural racism, which incorporates stereotypes and the naturalization of discriminatory practices; second, institutional racism, which limits this racial group’s access to the benefits they are entitled to by right, in addition to ignoring racial discrimination as a determinant of health iniquities, as there are no investments that promote strategies to identify discriminatory practices and promote health equity; and third, individual racism, which promotes physical and mental violence by institutions and individuals⁵5 Organização das Nações Unidas para a Educação, a Ciência e a Cultura (Unesco). Declaração sobre a raça e os preconceitos raciais [Internet]. 1978 [acessado 2021 jul 29] Disponível em: http://www.direitoshumanos.usp.br/index.php/UNESCOOrganiza%C3%A7%C3%A3o-das-Na%C3%A7%C3%B5es-Unidas-para-a-Educa%C3%A7%C3%A3o-Ci%C3%AAncia-e-Cultura/declaracao-sobre-a-raca-e-os-preconceitos-raciais.html.
http://www.direitoshumanos.usp.br/index....

6 Brasília. Secretaria de Políticas de Ações Afirmativas. Racismo como determinante social de saúde. [Internet]. 2011 [acessado 2021 ago 20]. Disponível em: https://www.gov.br/mdh/pt-br/centrais-de-conteudo/igualdade-racial/racismo-como-determinante-social-de-saude.
https://www.gov.br/mdh/pt-br/centrais-de...

7 Williams DR, Priest N. Racismo e Saúde: um corpus crescente de evidência internacional. Sociologias 2015; 17(40):124-174.^-88 Werneck J. Racismo institucional e saúde da população negra. Saude Soc 2016; 25(3):535-549.. In this context, it must be considered that exposure to structural and interpersonal racism contributes to the biological “incorporation” of exposures arising from this ecological and social context in which they live, favoring racial iniquities in health⁹9 Krieger N. Discrimination and health inequities. Int J Health Serv 2014; 44(4):63-125.^,1010 Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Public Health 2012; 102(5):936-44..

Iniquities, in turn, are characterized by the injustice that some groups suffer when they do not benefit from public actions or policies aimed at the entire population, and due to the fact that these differences are not avoided or repaired by public authorities⁵5 Organização das Nações Unidas para a Educação, a Ciência e a Cultura (Unesco). Declaração sobre a raça e os preconceitos raciais [Internet]. 1978 [acessado 2021 jul 29] Disponível em: http://www.direitoshumanos.usp.br/index.php/UNESCOOrganiza%C3%A7%C3%A3o-das-Na%C3%A7%C3%B5es-Unidas-para-a-Educa%C3%A7%C3%A3o-Ci%C3%AAncia-e-Cultura/declaracao-sobre-a-raca-e-os-preconceitos-raciais.html.
http://www.direitoshumanos.usp.br/index.... . Racial iniquities caused by institutional racism place black people in a situation of social vulnerability, as this portion of the population has less access to information and education; worse working, employability, and housing conditions; and less purchasing power, which directly influences access to health⁷7 Williams DR, Priest N. Racismo e Saúde: um corpus crescente de evidência internacional. Sociologias 2015; 17(40):124-174.^,99 Krieger N. Discrimination and health inequities. Int J Health Serv 2014; 44(4):63-125..

Assessing oral health status considering race/skin color can also express the existence of racial iniquities¹1 Guiotoku SK, Moysés ST, Moysés SJ, França BH, Bisinelli JC. Racial inequity in oral health in Brazil. Rev Panam Salud Publica 2012; 31(2):135-141.. Periodontitis, a disease that affects the supporting and protective tissues of the teeth, in addition to favoring tooth loss, triggers pro-inflammatory events, which appear in many ways in systemic diseases and disorders¹¹11 Linden GJ, Herzberg MC. Periodontitis and systemic diseases: a record of discussions of working group 4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013; 84(4 Supl.):S20-S23.. Tooth decay tends to cause pain and increases the likelihood of tooth loss¹²12 Amarasena N, Chrisopoulos S, Jamieson LM, Luzzi L. Oral Health of Australian Adults: Distribution and Time Trends of Dental Caries, Periodontal Disease and Tooth Loss. Int J Environ Res Public Health 2021; 2;8(21):e11539.. Self-rated oral health, in turn, can reflect the way individuals perceive their health and is therefore influenced by beliefs, sociodemographic profile, and various situations and oral health problems, such as pain, tooth loss, chewing difficulties, and esthetic needs, among others¹³13 Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MB, Bairros FS, Hilgert JB. Autopercepção de saúde bucal em comunidades quilombolas no Rio Grande do Sul: um estudo transversal exploratório. Rev Bras Epidemiol 2017; 20(1):91-101..

As the epidemiological situation of oral health in populations in low and middle-income countries is still quite serious³3 Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Annu Rev Sociol 2015; 41:311-330., the recognition of iniquities in oral health should be considered a priority research topic to reinforce the need to develop interventions aimed at improving the oral health of populations. By contrast, systematic review studies on racial iniquities in oral health are incipient. From this perspective, the present study aimed to analyze the association between racial iniquities and oral health status.

Method

Register and Protocol

This is a systematic review study conducted according to the Preferred Reporting Items for Systematic Reviews (PRISMA) standards¹⁴14 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Moher D. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. J Clin Epidemiol 2021; 134:103-112.. The study protocol was registered in PROSPERO under number CRD42021228417.

Eligibility Criteria

The eligibility criteria were based on population, exposure, outcome, and type of study, which were distributed as follows:

Studies published in any period, in Portuguese, Spanish or English, were included. Any study whose population was made up of children or adolescents, which did not have a racial profile, and which were experimental studies were excluded. Having a comparison group was not considered an inclusion criterion, so as not to exclude studies that only analyzed black/brown skin color groups.

Information sources

Study searches were carried out until October 14, 2022, in the following electronic databases: Medline/PubMed, Scopus, Web of Science, SciELO, Lilacs, ScienceDirect, and Embase. In addition, a search regarding the references for included articles, conference abstracts, and databases containing gray literature (ProQuest) was conducted in Google Scholar and in catalogs of theses and dissertations.

Search strategies

The descriptors were defined considering each database, for Medline, Scopus, Web of Science, and Science Direct, MeSH (Medical Subject Headings); for SciELO, Lilacs, ProQuest, Google Scholar, and catalogs of theses and dissertations, DECs (Health Sciences Descriptors); and for Embase, Emtree (Embase subject headings). When obtaining the descriptors representing the eligibility criteria, these were combined with the Boolean operators, OR and AND, so that the final search strategy was defined in each database mentioned above (Chart 1). The search strategies took into account the guidelines of the Peer Review Electronic Search Strategy (PRESS)¹⁵15 McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerste V. PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epi-Demiol 2016; 75:40-46..

Study selection

The search results were exported to the Rayyan Systems Inc. - Rayyan program (https://www.rayyan.ai)¹⁶16 Ouzzani M|, Hammady H, Fedorowicz Z, and Elmagarmid A. Rayyan - a web and mobile app for systematic reviews. Syst Ver 2016; 5:210.. Using this application, duplicate articles were checked and selected by title and summary by two researchers, independently. If the abstract was not available and, in this case, if the title was suggestive of inclusion, the article remained in the database and was passed on to the next stage of the assessment of eligibility by reading the full text. In this screening stage, if there was disagreement concerning the eligibility judgment between two reviewers, the decision to include or exclude articles was made by a third researcher.

Subsequently, all articles that were screened in the previous phase had their eligibility confirmed by reading the full text, also independently, by two reviewers. Any disagreement was resolved either by consensus or by a third reviewer, who was a professional with extensive experience in the field. At the end of the process, the total number of studies actually eligible to construct the systematic review was obtained.

Data Extraction

Data from the included articles were extracted by three independent researchers and subsequently compared. All information was organized in an Excel spreadsheet, focusing on the most relevant information:

Quality assessment of the included studies

All studies that met the eligibility criteria had their methodological quality assessed by two examiners, independently, and were subsequently compared. The Newcastle-Ottawa scale was used to assess the quality of cross-sectional and cohort observational studies¹⁷17 Wells GA, Shea B, O'connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. 2021 [cited 2021 ago 21]. Available from: https://www.ohri.ca//programs/clinical_epidemiology/oxford.Asp.
https://www.ohri.ca//programs/clinical_e... . This tool evaluates seven items (adapted for cross-sectional studies) and eight items (for cohort studies), divided into three groups: selection of study groups; comparability of groups; and verification of exposure or outcome of interest. Each item corresponded to a specific star score already determined by the scale. Studies evaluated using this scale could receive a maximum of 9 stars in total - the more stars, the lower the risk of bias¹⁷17 Wells GA, Shea B, O'connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. 2021 [cited 2021 ago 21]. Available from: https://www.ohri.ca//programs/clinical_epidemiology/oxford.Asp.
https://www.ohri.ca//programs/clinical_e... .

Data analysis

A description of the relevant aspects for the analysis of the studies selected for the systematic review was carried out, based on the creation of a summary table. The risk of bias assessment was organized in a table format. As all evaluators, independently, assessed all titles and abstracts, and all read them in full. It was deemed unnecessary to obtain the kappa agreement index to evaluate agreement between evaluators.

Results

Studies selected in the systematic review

The search process resulted in the identification of 3,028 publications. In the screening, duplicates were removed (n=631), resulting in 2,397 scientific articles, of which 75 were chosen to be read in full, and 2,322 records were excluded by reading the title, as they did not meet the eligibility criteria (Figure 1). After reading the article in full and comparing the reviewers, 18 scientific articles were included in this systematic review.

Characterization and study results

The included studies were conducted in Brazil, the United States and Australia. Of the seventeen articles selected, fifteen are cross-sectional studies, two are cohort studies, and one is ecological. The studies were published between 2004 and 2021 (Chart 2).

Of the eleven studies conducted in Brazil, six evaluated quilombola communities. The main outcomes analyzed were: oral health status¹⁸18 Sandes LFF, Freitas DA, Souza MFN. Oral health of elderly people living in a rural community of slave descendants in Brazil. Cad Saude Colet 2018; 26(4):425-431.^,1919 Figueiredo MC, Benvegnú BP, Silveira PPL, Silva A M, Silva KVCL. Saúde bucal e indicadores socioeconômicos de comunidades quilombolas rural e urbana do Estado do Rio Grande do Sul, Brasil. Rev Fac Odontol Lins 2016; 26(2):61-73., tooth loss²⁰20 Araújo RLMDS, Araújo EMD, Miranda SS, Chaves JN, Araújo JAD. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano. Epidemiol Serv Saude Ambiente 2020; 29(2):e2018428., negative self-rated oral health¹³13 Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MB, Bairros FS, Hilgert JB. Autopercepção de saúde bucal em comunidades quilombolas no Rio Grande do Sul: um estudo transversal exploratório. Rev Bras Epidemiol 2017; 20(1):91-101., periodontal disease²¹21 Bruno IF, Rosa JAA, Melo CM, Oliveira CCC. Avaliação da doença periodontal em adultos na população quilombola. Interfaces Cien Saude Ambiente 2013; 1(2):33-39., and access to dental services²²22 Miranda LP, Oliveira TL, Queiroz PDSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.. In general, quilombolas showed restricted access to dental care and a precarious oral health status.

Still in Brazil, other studies presented the following outcomes: the DMFT index (number of decayed, lost, and filled permanent teeth), tooth loss, anterior edentulism, pain of dental origin and need for prosthesis¹1 Guiotoku SK, Moysés ST, Moysés SJ, França BH, Bisinelli JC. Racial inequity in oral health in Brazil. Rev Panam Salud Publica 2012; 31(2):135-141.; tooth loss²³23 Celeste RK, Gonçalves LG, Faerstein E, Bastos JL. The role of potential mediators in racial inequalities in tooth loss: the Pró-Saúde study. Community Dent Oral Epidemiol 2013; 41(6):509-516.; periodontitis²⁴24 Celeste RK, Oliveira SC, Junges R. Threshold-effect of income on periodontitis and interactions with race/ethnicity and education. Rev Bras Epidemiol 2019; 14;22:e190001.; oral cancer²⁵25 Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos J L. Gender and racial inequalities in trends of oral cancer mor-tality in Sao Paulo, Brazil. Rev Saude Publica 2013; 47(3):470-478.; and self-rated oral health²⁶26 Karam SA, Schuch HS, Demarco FF, Barros FC, Horta, BL, Correa MB. Social and racial inequity in self-rated oral health in adults in Southern Brazil. Cad Saude Publica 2022; 38(3):e00136921.. Only one study did not associate a worse oral condition with race, but rather with income²⁴24 Celeste RK, Oliveira SC, Junges R. Threshold-effect of income on periodontitis and interactions with race/ethnicity and education. Rev Bras Epidemiol 2019; 14;22:e190001.. One Brazilian study showed that black people die more often from oral cancer than do white people²⁵25 Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos J L. Gender and racial inequalities in trends of oral cancer mor-tality in Sao Paulo, Brazil. Rev Saude Publica 2013; 47(3):470-478..

Six studies were conducted in the United States²⁷27 Fisher MA, Gilbert GH, Shelton BJ. A cohort study found racial differences in dental insurance, utilization, and the effect of care on quality of life. J Clin Epi Demiol 2004; 57(8):853-857.

28 Nazer FW, Sabbah W. Do Socioeconomic Conditions Explain Ethnic Inequalities in Tooth Loss among US Adults? Ethn Dis 2004; 28(3):201-206.

29 Muralikrishnan M, Sabbah W. Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults? J Racial Ethn Health Disparities 2020; 8(5):1293-1299.

30 Han C. Oral health disparities: Racial, language and nativity effects. SSM Popul Health 2019; 12:e100711.

31 Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent 2007; 62(3):140-147.^-3232 Jimenez M, Dietrich T, Shih MC, Li Y, Joshipura KJ. Racial/ethnic variations in associations between soci-oeconomic factors and tooth loss. Community Dent Oral Epidemiol 2009; 37(3):267-275.. The studied population was made up of adult individuals, with the most frequent outcome being tooth loss²⁸28 Nazer FW, Sabbah W. Do Socioeconomic Conditions Explain Ethnic Inequalities in Tooth Loss among US Adults? Ethn Dis 2004; 28(3):201-206.

29 Muralikrishnan M, Sabbah W. Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults? J Racial Ethn Health Disparities 2020; 8(5):1293-1299.^-3030 Han C. Oral health disparities: Racial, language and nativity effects. SSM Popul Health 2019; 12:e100711.^,3333 Pereira MG, Galvão TF. Heterogeneidade e viés de publicação em revisões sistemáticas. Epidemiol Serv Saude 2014; 23(4):775-778.. All research associated worse oral health status in exposed individuals than in the control group, in addition to associating a worse oral health status with racial discrimination²⁹29 Muralikrishnan M, Sabbah W. Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults? J Racial Ethn Health Disparities 2020; 8(5):1293-1299.. Finally, the Australian article, when evaluating racial discrimination, indicates a likely association with compromised oral health⁴4 Schuch HS, Haag DG, Smith JL, Paradies Y, Jamieson LM. Intersectionality, racial discrimination and oral health in Australia. Community Dent Oral Epidemiol 2021; 49(1):87-94..

The results recorded ethnic-racial iniquities in all of the analyzed indicators. The black population had less access to dental services²²22 Miranda LP, Oliveira TL, Queiroz PDSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.^,2727 Fisher MA, Gilbert GH, Shelton BJ. A cohort study found racial differences in dental insurance, utilization, and the effect of care on quality of life. J Clin Epi Demiol 2004; 57(8):853-857.. Precarious oral health status, a high rate of edentulism¹⁸18 Sandes LFF, Freitas DA, Souza MFN. Oral health of elderly people living in a rural community of slave descendants in Brazil. Cad Saude Colet 2018; 26(4):425-431., or tooth loss¹1 Guiotoku SK, Moysés ST, Moysés SJ, França BH, Bisinelli JC. Racial inequity in oral health in Brazil. Rev Panam Salud Publica 2012; 31(2):135-141.^,3232 Jimenez M, Dietrich T, Shih MC, Li Y, Joshipura KJ. Racial/ethnic variations in associations between soci-oeconomic factors and tooth loss. Community Dent Oral Epidemiol 2009; 37(3):267-275., a greater chance of tooth loss when compared to white people²³23 Celeste RK, Gonçalves LG, Faerstein E, Bastos JL. The role of potential mediators in racial inequalities in tooth loss: the Pró-Saúde study. Community Dent Oral Epidemiol 2013; 41(6):509-516.^,2828 Nazer FW, Sabbah W. Do Socioeconomic Conditions Explain Ethnic Inequalities in Tooth Loss among US Adults? Ethn Dis 2004; 28(3):201-206., and a higher mortality rate due to oral cancer²⁵25 Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos J L. Gender and racial inequalities in trends of oral cancer mor-tality in Sao Paulo, Brazil. Rev Saude Publica 2013; 47(3):470-478..

Risk of bias

Regarding the risk of bias in the included studies, high methodological quality was observed in most articles. The average score on the scale was 7.4 in cross-sectional studies, in which the studies varied between 6 and 9 stars, while in the cohort studies this average was 7.5, with score variations ranging from 7 to 8. The aspects that scored negatively referred to limitations related to the sample, a lack of adjustments for confounding variables, and a description of the statistical analysis.

Discussion

The results of this review illustrated that the black population has a worse oral health status, mainly in relation to tooth loss, poor self-rated oral health, and cavities. The studies included in the systematic review, although presenting a low risk of bias, show a high heterogeneity, which placed limits on the meta-analysis, due to the possibility of raising questions about the validity of combining results³⁴34 Henshaw MM, Karpas S. Oral Health Disparities and Inequities in Older Adults. Dent Clin North Am 2021; 65(2):257-273.. As research involving race/skin color and oral health is still recent, many outcomes have been analyzed, which makes it difficult to cross-reference data.

The studies included reveal that quilombola residents are not happy with their self-reported oral health¹²12 Amarasena N, Chrisopoulos S, Jamieson LM, Luzzi L. Oral Health of Australian Adults: Distribution and Time Trends of Dental Caries, Periodontal Disease and Tooth Loss. Int J Environ Res Public Health 2021; 2;8(21):e11539.^,1919 Figueiredo MC, Benvegnú BP, Silveira PPL, Silva A M, Silva KVCL. Saúde bucal e indicadores socioeconômicos de comunidades quilombolas rural e urbana do Estado do Rio Grande do Sul, Brasil. Rev Fac Odontol Lins 2016; 26(2):61-73., and they have a high prevalence of cavities²⁰20 Araújo RLMDS, Araújo EMD, Miranda SS, Chaves JN, Araújo JAD. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano. Epidemiol Serv Saude Ambiente 2020; 29(2):e2018428., tooth loss²¹21 Bruno IF, Rosa JAA, Melo CM, Oliveira CCC. Avaliação da doença periodontal em adultos na população quilombola. Interfaces Cien Saude Ambiente 2013; 1(2):33-39., and periodontitis²²22 Miranda LP, Oliveira TL, Queiroz PDSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.. There was an association between black race/skin color and/or income and problems with the mouth, such as tooth loss, periodontitis, cavities and oral cancer¹³13 Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MB, Bairros FS, Hilgert JB. Autopercepção de saúde bucal em comunidades quilombolas no Rio Grande do Sul: um estudo transversal exploratório. Rev Bras Epidemiol 2017; 20(1):91-101.^,1919 Figueiredo MC, Benvegnú BP, Silveira PPL, Silva A M, Silva KVCL. Saúde bucal e indicadores socioeconômicos de comunidades quilombolas rural e urbana do Estado do Rio Grande do Sul, Brasil. Rev Fac Odontol Lins 2016; 26(2):61-73.

20 Araújo RLMDS, Araújo EMD, Miranda SS, Chaves JN, Araújo JAD. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano. Epidemiol Serv Saude Ambiente 2020; 29(2):e2018428.

21 Bruno IF, Rosa JAA, Melo CM, Oliveira CCC. Avaliação da doença periodontal em adultos na população quilombola. Interfaces Cien Saude Ambiente 2013; 1(2):33-39.^-2222 Miranda LP, Oliveira TL, Queiroz PDSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.^,2424 Celeste RK, Oliveira SC, Junges R. Threshold-effect of income on periodontitis and interactions with race/ethnicity and education. Rev Bras Epidemiol 2019; 14;22:e190001.

25 Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos J L. Gender and racial inequalities in trends of oral cancer mor-tality in Sao Paulo, Brazil. Rev Saude Publica 2013; 47(3):470-478.^-2626 Karam SA, Schuch HS, Demarco FF, Barros FC, Horta, BL, Correa MB. Social and racial inequity in self-rated oral health in adults in Southern Brazil. Cad Saude Publica 2022; 38(3):e00136921.^,3232 Jimenez M, Dietrich T, Shih MC, Li Y, Joshipura KJ. Racial/ethnic variations in associations between soci-oeconomic factors and tooth loss. Community Dent Oral Epidemiol 2009; 37(3):267-275.; the oral health condition was worse in black individuals than in white individuals¹1 Guiotoku SK, Moysés ST, Moysés SJ, França BH, Bisinelli JC. Racial inequity in oral health in Brazil. Rev Panam Salud Publica 2012; 31(2):135-141.^,2323 Celeste RK, Gonçalves LG, Faerstein E, Bastos JL. The role of potential mediators in racial inequalities in tooth loss: the Pró-Saúde study. Community Dent Oral Epidemiol 2013; 41(6):509-516.^,2525 Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos J L. Gender and racial inequalities in trends of oral cancer mor-tality in Sao Paulo, Brazil. Rev Saude Publica 2013; 47(3):470-478.^,2828 Nazer FW, Sabbah W. Do Socioeconomic Conditions Explain Ethnic Inequalities in Tooth Loss among US Adults? Ethn Dis 2004; 28(3):201-206.^,2929 Muralikrishnan M, Sabbah W. Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults? J Racial Ethn Health Disparities 2020; 8(5):1293-1299.^,3131 Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent 2007; 62(3):140-147.^,3434 Henshaw MM, Karpas S. Oral Health Disparities and Inequities in Older Adults. Dent Clin North Am 2021; 65(2):257-273.; a worse oral health status was identified when exposed to racial discrimination⁴4 Schuch HS, Haag DG, Smith JL, Paradies Y, Jamieson LM. Intersectionality, racial discrimination and oral health in Australia. Community Dent Oral Epidemiol 2021; 49(1):87-94.^,3030 Han C. Oral health disparities: Racial, language and nativity effects. SSM Popul Health 2019; 12:e100711. and a probable relationship between tooth loss and low economic status³²32 Jimenez M, Dietrich T, Shih MC, Li Y, Joshipura KJ. Racial/ethnic variations in associations between soci-oeconomic factors and tooth loss. Community Dent Oral Epidemiol 2009; 37(3):267-275..

Among quilombola individuals, their compromised oral health can be explained by factors that characterize social inequalities. Quilombola communities are located in rural areas, far from dental care centers, which makes it difficult for this population to access oral health treatment and guidance. Another relevant factor is economic; these families mostly live on a subsistence economy, and because they live far from dental care points, travel costs can limit these people to only searching for a dentist in urgent situations. Quilombos were refuges for enslaved people, who were able to build safe homes for their families in these spaces¹³13 Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MB, Bairros FS, Hilgert JB. Autopercepção de saúde bucal em comunidades quilombolas no Rio Grande do Sul: um estudo transversal exploratório. Rev Bras Epidemiol 2017; 20(1):91-101.^,1919 Figueiredo MC, Benvegnú BP, Silveira PPL, Silva A M, Silva KVCL. Saúde bucal e indicadores socioeconômicos de comunidades quilombolas rural e urbana do Estado do Rio Grande do Sul, Brasil. Rev Fac Odontol Lins 2016; 26(2):61-73.^,2121 Bruno IF, Rosa JAA, Melo CM, Oliveira CCC. Avaliação da doença periodontal em adultos na população quilombola. Interfaces Cien Saude Ambiente 2013; 1(2):33-39.

22 Miranda LP, Oliveira TL, Queiroz PDSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.^-2323 Celeste RK, Gonçalves LG, Faerstein E, Bastos JL. The role of potential mediators in racial inequalities in tooth loss: the Pró-Saúde study. Community Dent Oral Epidemiol 2013; 41(6):509-516.. Historically, quilombos represent the resistance of a people who, to this day, suffer the consequences of colonialism when facing racial, socioeconomic, and health iniquities established by institutionalized racism³⁵35 Macedo JP, Dantas C, Dimenstein M, Leite J, Alves Filho A, Belarmino VH. Condições de vida, acesso às políticas e racismo institucional em comunidades quilombolas. Gerais Rev Interinst Psicol 2021; 14(1):e15488..

In general, socioeconomic status is relevant in maintaining good oral health, as it allows the individual access to treatments, prevention, and hygiene guidance²⁹29 Muralikrishnan M, Sabbah W. Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults? J Racial Ethn Health Disparities 2020; 8(5):1293-1299.^,3131 Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent 2007; 62(3):140-147.. The concentration of wealth and exploitation of the black population, previously with slavery and today with underemployment, as well as precarious housing and schools in outlying neighborhoods, keeps this population with less access to better living conditions, thereby promoting the health iniquities experienced by these individuals .

Among the most important oral diseases for public health are periodontitis and tooth decay. The first, in addition to contributing to tooth loss, can favor the occurrence and/or severity of diabetes, endocarditis, and metabolic syndrome, among others¹²12 Amarasena N, Chrisopoulos S, Jamieson LM, Luzzi L. Oral Health of Australian Adults: Distribution and Time Trends of Dental Caries, Periodontal Disease and Tooth Loss. Int J Environ Res Public Health 2021; 2;8(21):e11539.. Five studies included in this review cite a higher prevalence of periodontitis in black individuals, characterizing a greater exposure of this population to chronic diseases¹1 Guiotoku SK, Moysés ST, Moysés SJ, França BH, Bisinelli JC. Racial inequity in oral health in Brazil. Rev Panam Salud Publica 2012; 31(2):135-141.^,2121 Bruno IF, Rosa JAA, Melo CM, Oliveira CCC. Avaliação da doença periodontal em adultos na população quilombola. Interfaces Cien Saude Ambiente 2013; 1(2):33-39.^,2424 Celeste RK, Oliveira SC, Junges R. Threshold-effect of income on periodontitis and interactions with race/ethnicity and education. Rev Bras Epidemiol 2019; 14;22:e190001.^,2727 Fisher MA, Gilbert GH, Shelton BJ. A cohort study found racial differences in dental insurance, utilization, and the effect of care on quality of life. J Clin Epi Demiol 2004; 57(8):853-857.^,3434 Henshaw MM, Karpas S. Oral Health Disparities and Inequities in Older Adults. Dent Clin North Am 2021; 65(2):257-273.. The second is the result of the demineralization of dental hard tissues, promoted by dysbiosis of the oral microbiota. Its etiology is associated with multiple factors, such as a diet rich in fermentable carbohydrates, a lack of/poor oral hygiene, prevalence of cariogenic bacteria, genetic predisposition, and exposure time³⁶36 Sanz M, Beighton D, Curtis MA, Cury JA, Dige I, Dommisch H, Zaura E. Role of microbial biofilms in the maintenance of oral health and in the development of dental caries and periodontal diseases. Consensus re-port of group 1 of the Joint EFP/ORCA workshop on the boundaries between caries and periodontal disease. J Clin Periodontol 2017; 44(Supl. 18):S5-S11.. Without adequate treatment and biofilm control, cavities can lead to tooth loss²⁰20 Araújo RLMDS, Araújo EMD, Miranda SS, Chaves JN, Araújo JAD. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano. Epidemiol Serv Saude Ambiente 2020; 29(2):e2018428..

For both diseases, access to dental care and hygiene materials are the best prevention strategies. Fluoride associated with the disorganization of the biofilm promoted by brushing are the best resources to prevent cavities³⁶36 Sanz M, Beighton D, Curtis MA, Cury JA, Dige I, Dommisch H, Zaura E. Role of microbial biofilms in the maintenance of oral health and in the development of dental caries and periodontal diseases. Consensus re-port of group 1 of the Joint EFP/ORCA workshop on the boundaries between caries and periodontal disease. J Clin Periodontol 2017; 44(Supl. 18):S5-S11.. Another essential and low-cost measure for preventing cavities is water fluoridation³⁷37 Iheozor-Ejiofor Z, Worthington HV, Walsh T, O'Malley L, Clarkson JE, Macey R, Alam R, Tu-gwell P, Welch V, Glenny AM. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev 2015; 6:CD010856.. In Brazil, since 1974, water fluoridation has been governed by Law 6,050³⁸38 Brasil. Lei nº 6.050, de 24 de maio de 1974. Dispõe sobre a fluoretação da água em sistemas de abastecimento quando existir estação de tratamento. Diário Oficial da União 1974; 27 maio., and in 2011, Ordinance 2,914, issued by the Ministry of Health, established the maximum content of 1.5 mg of Fluoride per liter of water³⁹39 Brasil. Ministério da Saúde (MS). Portaria nº 2.914, de 12 de dezembro de 2011. Dispõe sobre os procedimentos de controle e de vigilância da qualidade da água para consumo humano e seu padrão de potabilidade. Diário Oficial da União; 2011.. A study carried out in the Quilombola Community of Cocalinho did not identify the presence of the ion in the water supplied by the city hall to the community; of the quilombolas, 72.41% had cavities, and 31.03% had already lost at least one tooth, confirming yet another health iniquity by depriving the quilombola population of the right to health⁴⁰40 Dias J, Pereira B, Ribeiro P, Monteiro L. Vulnerability in oral health: lack of fluoride in public supply water in a quilombola remaining Community. J Business Techn 2020; 13(1):57..

If prevention and treatment strategies for these oral diseases are not accessible, the likelihood of tooth loss increases, which explains the high prevalence of edentulism in this population²⁰20 Araújo RLMDS, Araújo EMD, Miranda SS, Chaves JN, Araújo JAD. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano. Epidemiol Serv Saude Ambiente 2020; 29(2):e2018428.. The lack of teeth directly impacts the quality of life of these individuals with impairments in chewing, speech, nutrition, esthetics, and psychological condition⁴¹41 Saintrain MVL, Souza EHA. Impacto da perda dentária na qualidade de vida. Gerodontologia 2011; 29(2):e632-e636.^,4242 Silva MÊS, Villaça ÊL, Magalhães CS, Ferreira E. Impact of tooth loss in quality of life. Cien Saude Colet 2010; 15(3):841-850.. One of the treatment possibilities is dental prosthesis. However, access to this service through the Unified Health System (SUS) is still precarious, as data from SB Brazil 2010⁴³43 Brasil. Ministério da Saúde (MS). Pesquisa Nacional de Saúde Bucal, SB Brasil 2010. Brasília: Editora MS; 2012 indicated that 68.8% of the Brazilian population needs a prosthesis, with this need being more prevalent among low-income individuals⁴⁴44 Medeiros JJ, Rodrigues LV, Azevedo AC, Andrade LIMAE, Machado LS, Valença AMG. Edentulismo, Uso e Necessidade de Prótese e Fatores Associados em Município do Nordeste brasileiro. Pesqui Bras Odontopediatr Clín Integr 2012; 12(4):573-578..

The difficulty in accessing oral health services for the black population may explain part of this unfavorable oral condition found in the black and brown populations⁴⁵45 Akintobi TH, Hoffman LM, McAllister C, Goodin L, Hernandez ND, Rollins L, Miller A. Assessing the Oral Health Needs of African American Men in Low-Income, Urban Communities. Am J Mens Health 2018; 12(2):326-337.. Factors related to limited access to dental services are: few dental teams in the public health system; a lack of financial resources to pay for dental appointments/plans; difficulty in traveling to the place of care, whether due to insecurity, the cost of travel, difficulties, or lack of transportation⁴⁶46 Northridge ME, Schenkel AB, Birenz S, Estrada I, Metcalf SS, Wolff MS. "You Get Beautiful Teeth Down There": Racial/Ethnic Minority Older Adults' Perspectives on Care at Dental School Clinics. J Dent Educ 2017; 81(11):1273-1282.

47 Eisen CH, Bowie JV, Gaskin DJ, LaVeist TA, Thorpe Jr. RJ. The contribution of social and environmental factors to race differences in dental services use. J Urban Health 2015; 92(3):415-421.^-4848 Cavalcante IMS, Silva HP. Políticas Públicas e Acesso aos Serviços de Saúde em Quilombos na Amazônia Paraense. In: Tribunal Regional Federal da 2ª Região (TRF2). Quilombolas: aspectos políticos, jurídicos e políticas públicas inclusivas consequentes à edição do Decreto nº 4887-2003 e do julgamento da ADI nº 3239. Brasília: TRF2; 2019. p. 473-498.; and racial discrimination in the health services themselves⁴⁹49 Amaral Junior OLD, Menegazzo GR, Fagundes MLB, Sousa JL, Tôrres LHDN, Gior-dani JMDA. Perceived discrimination in health services and preventive dental attendance in Brazilian adults. Community Dent Oral Epidemiol 2020; 48(6):533-539.^,5050 Sabbah W, Gireesh A, Chari M, Delgado-Angulo EK, Bernabé E. Racial Discrimination and Uptake of Dental Services among American Adults. Int J Environ Res Public Health 2019; 16(9):e1558.. The health inequalities suffered by people of African descent confirm the cruelty exercised by institutional racism, which establishes a chain of social, economic, and health iniquities in such a way that it remains a structure of domination and exploitation of the black population⁵¹51 Kalckmann S. Racismo institucional: um desafio para a equidade no SUS? Saude Soc 2007; 16(2):146-155.^,5252 Jamieson L, Peres MA, Guarnizo-Herreno CC, Bastos JL. Racism and oral health inequities. An overview. EClinicalMedicine 2021; 34:e100827..

In general, the findings of this systematic review raise numerous aspects that need to be considered when planning public health interventions with a view to improving the oral health of the most vulnerable populations. By identifying and describing the existence of racial iniquities in oral health, the results provide a clear synthesis for the planning of public policies that recognize that individuals of black/brown race/skin color need to have a guarantee of equity in actions that involve improving one’s oral health status. If strong action is not taken to expose and eliminate structural racism in all countries, oral health iniquities will persist. Strategies range from the involvement of dental education institutions to strong policy regulation⁵²52 Jamieson L, Peres MA, Guarnizo-Herreno CC, Bastos JL. Racism and oral health inequities. An overview. EClinicalMedicine 2021; 34:e100827..

Although this review was broad in order to ensure the inclusion of as many published studies as possible, it is possible that the search strategy did not capture all studies on the topic. Furthermore, it is important to highlight that some studies did not include a control group, such as those that include only quilombolas in the sample, as well as the identification of different outcomes, which made it unfeasible to conduct a meta-analysis. The strengths of this review include the extensive search, the use of different analytical categories, and the assessment of the risk of bias. Furthermore, the study presented methodological rigor, carried out by independent reviewers, and qualitatively analyzed data from primary studies on oral health and racial iniquities.

Final considerations

Our results show that black and brown people had unfavorable oral health conditions. To change this scenario, it is necessary to establish public equity policies in order to provide black citizens with adequate oral health conditions. Necessary measures include informing the general population about racism and establishing programs to combat institutional racism; diagnosing the needs of the black race/color population, in order to offer differentiated and specific treatments, thus reducing the differences in vulnerability of this population; and expanding dental care networks in regions with a greater presence of the black population. The findings of this review, therefore, indicate the importance of strengthening the understanding that it is necessary to have a public point of view on the oral health of this group. Within the scope of professional practices, it is necessary to expand oral health promotion strategies in the black population, as well as encourage research with prospective methods, in an attempt to assess the impacts of racism on oral health.

References

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