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Exploring salutogenic factors supporting oralhealth in the elderly

Elena Shmarina, Dan Ericson, Sigvard Åkerman & Björn Axtelius

To cite this article: Elena Shmarina, Dan Ericson, Sigvard Åkerman & Björn Axtelius (2021):Exploring salutogenic factors supporting oral health in the elderly, Acta Odontologica Scandinavica,DOI: 10.1080/00016357.2021.1990995

To link to this article: https://doi.org/10.1080/00016357.2021.1990995

© 2021 The Author(s). Published by InformaUK Limited, trading as Taylor & FrancisGroup on behalf of Acta OdontologicaScandinavica Society.

Published online: 23 Oct 2021.

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ORIGINAL ARTICLE

Exploring salutogenic factors supporting oral health in the elderly

Elena Shmarinaa,b , Dan Ericsonc, Sigvard Åkermand and Bj€orn Axteliusb

aPublic Dental Service, Region Kalmar County, Oskarshamn, Sweden; bDepartment of Oral Diagnostics, Faculty of Odontology, Malm€oUniversity, Malmo, Sweden; cDepartment of Cariology, Faculty of Odontology, Malm€o University, Malmo, Sweden; dDepartment of OrofacialPain and Jaw Function, Faculty of Odontology, Malm€o University, Malmo, Sweden

ABSTRACTAim: To explore associations between salutogenic factors and selected clinical outcome variables of oralhealth in the elderly, combining Antonovsky’s salutogenic theory and the Lalonde Health Field concept.Methods: The subjects comprised 146 individuals, aged 60 years and older, who had participated in apopulation-based epidemiological study in Sweden, 2011–2012, using questionnaire and oral examin-ation data. A cross-sectional analysis used the selected outcome variables, such as number of remain-ing teeth, DMFT-index and risk assessment, and salutogenic factors from the questionnaire, clusteredinto domains and health fields, as artifactual-material, cognitive-emotional and valuative-attitudinal.This selection was based on findings from our previous analysis using a framework cross-tabulatingtwo health models. The purpose was to facilitate analysis of associations not previously addressed inthe literature on oral health. Bivariate and Multiple Linear Regression analyses were used.Results: Numerous salutogenic factors were identified. Significant associations between outcome varia-bles and salutogenic factors previously unreported could be added. Regression analysis identifiedthree contributing independent factors for ‘low DMFT’.Conclusions: This study supports the usefulness of a salutogenic approach for analysing oral healthoutcomes, identifying university education, the importance of dental health organization recall systemand close social network, as important salutogenic factors. The large number of salutogenic factorsfound supporting oral health among the elderly indicates the complexity of salutogenesis and theneed for robust analysing tools. Combining two current health models was considered useful forexploring these covariations. These findings have implications for future investigations, identifyingimportant research questions to be explored in qualitative analyses.

ARTICLE HISTORYReceived 14 January 2021Revised 3 September 2021Accepted 4 October 2021

KEYWORDSOral health; salutogenesis;observational study; socialdeterminants ofhealth; elderly

Introduction

This article explored multiple factors influencing the oralhealth of older people from a salutogenic perspective, com-bining individual and structural societal levels. We usedbivariate and Multiple Linear Regression, of a novel epi-demiological data set for exploring salutogenic factors. Weexplored determinants of oral health in the elderly from asalutogenic perspective, using a framework previously devel-oped for analysis by combining two conceptual models,Antonovsky’s theory and the Lalonde Health Field concept[1]. This method using this framework allowed for concomi-tant disclosure of both theoretical perspectives and examin-ation of their congruence, and salutogenic factors for oralhealth and Oral Health Related Quality of Life (OHRQoL)were thus identified. However, it was concluded that for indi-viduals aged 60 years or older, there was a lack of studieswith specific reference to salutogenic factors, reviewed byShmarina et al. [1]. In the present study, this method of com-bination of two theoretical frameworks was applied to iden-tify salutogenic factors in a set of empirical data.

Conceptually, the group of older people may be of inter-est in this respect considering the lifelong impact of saluto-genic factors on oral health. Of special interest is howindividuals can successfully cope with detrimental factorsthat contribute to oral disease.

Antonovsky, in his theory, explains resilience to adver-sities, or why people stay healthy despite facing a wide var-iety of stressors, from microbiological to societal levels. Thetheory comprises two key elements, the Sense of Coherence(SOC) and Generalized Resistance Resources (GRRs) [2,3]. TheSOC concept includes the ability to identify and use one’sown health resources. It reflects a person’s view of life andcapacity to respond to stressful situations [2,3]. The GRR con-cept identifies resources available to enable movementtowards health, or to maintain good health, and includes arange of resources, e.g. knowledge, money, social supportand cultural capital [2–4]. For the purposes of this paper,GRRs are referred to as ‘salutogenic factors’, i.e. factors whichon the basis of epidemiological evidence, are known to pro-mote, strengthen and maintain oral health in older peo-ple [4,5].

CONTACT Elena Shmarina elena.shmarina@mau.se Department of Oral Diagnostics, Faculty of Odontology, Malm€o University, Malmo, Sweden� 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of Acta Odontologica Scandinavica Society.This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon inany way.

ACTA ODONTOLOGICA SCANDINAVICAhttps://doi.org/10.1080/00016357.2021.1990995

The Lalonde Health Field concept, as identified in theLalonde Report [6], was developed to provide a conceptualframework for issues related to health and disease. It identi-fies four principal components: human biology, lifestyle,environment, and health care organization. These four com-ponents are considered interdependent, and dynamic inter-actions between them over the course of a lifetimedetermine the level of disease, health and well-beingachieved by an individual. In this present paper, the focuswithin the environment health field has been on societal,structural factors.

Antonovsky emphasized focussing on structures support-ing health rather than on specific risk factors. He pointed outthe responsibility of society to create conditions which helpindividuals to make healthy choices and maintain theirhealth [2,7]. The Lalonde report likewise pointed out thatdeterminants of health extend beyond traditional medicalcare and that health is created by complex relationshipsbetween the individual and society [6]. In this sense, thehealth field concept offers a similar, yet wider structural per-spective on the importance of salutogenic factors.Appreciating the similarities between these two conceptsmight help in understanding factors influencing oral healthamong the elderly.

Researchers have mainly focussed on relating salutogene-sis to the SOC concept, thus leaving the concept of GRRunexplored [1]. Even though Antonovsky pointed out: ‘itseems imperative to focus on developing a fuller understandingof those generalized resistance resources which can be appliedto meet all demands’ [2, p. 5], the distribution of determi-nants of positive health has not been studied extensively [8].

Still, in salutogenic research in the field of oral health,publications are limited and concern mainly the SOC concept[9,10]. However, the focus of this study is on GRRs for oralhealth, since salutogenic factors are rather naturally clusteredwithin different GRRs, the operators for oral health. To ourknowledge, there is to date no study of the concept of oralhealth related to GRR in older people [1]. Therefore, there isa need for further investigation into the role of salutogenicfactors in oral health and how these factors contribute topositive development of oral health in the elderly. Thisunderstanding could provide a foundation for solutions tothe challenges of ensuring good oral health within anexpanding population of older people.

Aim

Our conceptual hypothesis was that salutogenic factors fororal health can more appropriately be studied in a group oforally healthy older people considering the lifelong impact ofsalutogenic factors on oral health. Thus, the aim was toexplore, in the elderly, the associations between salutogenicfactors and outcome variables of oral health, using three var-iables reflecting the profession’s traditional view on oralhealth (number of remaining teeth, DMFT-index, risk assess-ment), and two variables reflecting the patient’s view on oralhealth, using global variables related to OHRQoL. The varia-bles were selected by combining two theories of

salutogenesis [1], revealing several associations indicatingfactors for salutogenesis among elderly. Those factors weretested for validity in an empirical sample. We also focussedon identifying previously undescribed associations.

Material and methods

Study design

The population-based epidemiological study in the RegionKalmar countyThis cross-sectional study was based on data derived from apopulation-based epidemiological study carried out in theRegion Kalmar County, Sweden, 2011–2012. This region is acounty in the south-eastern part of Sweden. It is a ruralcounty where around 40 per cent of the population live inthe countryside. The business structure of the county ismainly represented by industries such as agriculture, forestryand manufacturing. The county is divided in twelve munici-palities with a total population around 245,000. One third ofpopulation in Sweden is aged 60 years or older (StatisticsSweden). The study was designed to collect informationabout characteristics relevant to the adult population’s oralhealth, and duplicated methods previously used for datasampling in the Region of Skåne. For detailed informationabout the clinical examination, see Lundegren et al. [11].

Briefly, a random sample of 900 individuals was obtainedfrom SPAR (The Swedish State Personal Address Register).SPAR holds information on every person registered as a citi-zen in Sweden. Individuals aged between 20 and 90 yearsold were invited to participate in a free oral examination,659 was reachable for contact and 402 accepted. The finalsample consisted of 380 participants (58%) who completedthe questionnaire and participated in the oral health examin-ation, and 146 were 60 years or older and comprised theevaluated sample (Figure 1).

The information was collected via a pre-existing question-naire consisting of 56 questions on general and oral health,need for dental care, experience of appointments for dentalcare, and on socio-economic factors [11]. The clinical exami-nations were undertaken by two dentists and were carriedout in four different public dental clinics. The dentists wereco-ordinated with respect to diagnostic criteria by means ofcomprehensive written instructions, practical exercises anddiscussion of clinical cases. All patients were examined usingstandard examination procedures in standard surgeries. Theclinical examinations included one panoramic and fourbitewing radiographs and five intra-oral clinical photo-graphs [11].

Clinical outcome variables included the number ofremaining teeth and risk assessment. The DMFT-index (28teeth) for each individual was calculated using the clinicalstatus form [12]. All missing teeth and restorations were con-sidered to be due to caries.

The risk assessment was developed and used by all dentalpractitioners in the public dental care in the Region KalmarCounty for several years at annual check-up appointment.The risk assessment was based on current scientific know-ledge and developed by relevant dental care developers. It

2 E. SHMARINA ET AL.

assessed the patient’s risk for developing dental diseases andwas used for applying an individual treatment plan. All den-tal practitioners were introduced and trained in using therisk assessment. Briefly, the risk assessment consisted of gen-eral risk, caries risk, periodontal risk and technical risk. Eachof those were divided into three categories depending onthe risk for developing disease (0–3). The score for each riskcategory added up to the risk sum.

The study was approved by the Regional Ethical Board atLund University, Dnr 2011/366. The participants receivedwritten and verbal information about the aim of the studyand were informed that they had the right to withdraw with-out having to specify the reason and that confidentiality wasguaranteed. All participants signed the informed con-sent form.

Participants

The study sample was selected from participants in thepopulation-based epidemiological study in the RegionKalmar County. We analysed the data from participants aged60 years and older. In total, 146 participants (male: 54.1 percent) were included (Figure 1) (mean age: 70.1 years; SD: ±7.3 years) as described in Table 1.

Variables

The selection of variables for analysis in the present studywas based on a framework combining two conceptual

models, Antonovsky’s theory and the Lalonde Health Fieldconcept, and intended to represent all components of thisframework. Detailed information on the framework can befound in Shmarina et al. [1]. The variables selected from thequestionnaire were determined with the aid of the frame-work so that salutogenic factors for oral health could beidentified in the empirical dataset. They encompass socio-economic factors, self-perceived oral health and treatmentneeds, as well as reported oral health self-care, and clusteredunder the appropriate GRR domains and health fields, suchas artifactual-material, cognitive-emotional and valuative-atti-tudinal (Table 2).

Outcome variablesThe status of the dentition was based on three clinical out-come variables as indicators of oral health: number ofremaining teeth, the DMFT-index and risk sum (Table 1). Forthe purpose of bivariate analyses, the population was sepa-rated into quartiles for each of three variables. Participantswith the best oral health are those with the quartiles withthe highest number of remaining teeth (quartile P75), thelowest DMFT-index (quartile P25) and the lowest risk sum(quartile P25). Participants with the poorest oral health areexpressed as those with quartiles with the lowest number ofremaining teeth (quartile P25), the highest DMFT-index (quar-tile P75) and the highest risk sum (quartile P75).

Two global outcome variables were also identified inresponses to the question ‘Are you confident of maintaininggood oral health for the rest of your life?’ with response cat-egories ‘yes’ and ‘no’, as well as the question ‘How do youassess your future dental care need?’ with response catego-ries ‘little or none’ and ‘large’ (Table 3). The rationale forintroducing these global variables was to reflect the saluto-genic perspective for OHRQoL. However, those variablescould also reflect important patient salutogenic characteris-tics. Previous studies have shown that self-perceived oralhealth can be used as relevant indicator of clinical find-ings [13–16].

Salutogenic factorsIn total 25 factors from the questionnaire were identified assalutogenic (Table 2), using a cross-tabulation described inTable 4. See factors identified for this study, indicated bybold text. Other factors were previously identified in the lit-erature [1].

Table 1. Descriptive statistics for age and dentition status assessed by threeoral health indicators (n¼ 146).

Variable Mean Sd Min Max

Percentiles

P25 P50 P75Age 70.1 7.3 60 90Number of remaining teeth 22.3 6.1 0 28 20 24 26DMFT-index 21.7 4.3 10 28 19 22 25Risk sum 8.6 2.2 4 14 7 9 10

Study in Kalmar 2011-2012

The current study

Excluded (n = 234) Participants younger than 60 years

Final sample (n = 146)

Men (n = 79)

Women (n = 67)

Dropout (n=22)

From SPAR register (n = 900)

Accepted (n = 402)

Participants (n = 380)

Invited (n = 659)

Refusals (n = 257)

Unreachable (n = 241)

Figure 1. Flow chart of the study enrolment process.

ACTA ODONTOLOGICA SCANDINAVICA 3

Table2.

Distributionof

salutogenicfactors,n(%

).

Health

field

Grrdo

main

Salutogenicfactor

Coding

N(%

)

High

numberof

remaining

teeth

Low

dmft

index

Low

risksum

Confident

inmaintaining

good

oral

health

Self-assessment

offuture

dental

care

need

Yes(1)/No(0)

Yes(1)/No(0)

Yes(1)/No(0)

Yes(1)/No(0)

Little

orno

ne(1)/

Large(0)

Hum

anbiolog

yPhysical

Gender

Female(1)

Male(0)

67(45.9)

79(54.1)

–0.180

–0.079

–0.300*

–0.055

0.046

Lifestyle

Artifactual-m

aterial

Refraintreatm

entneed

dueto

cost

No(1)

Yes(0)

126(86.3)

20(13.7)

0.426***

0.254*

0.287*

0.559***

0.180

Cognitive/Em

otional

Educationallevel

University

(1)

Lower

(0)

27(18.5)

119(81.5)

0.331**

0.142

–0.030

–0.081

–0.052

Self-perceivedtreatm

ent

need

atpresentfor

dental

check-up

No(1)

Yes(0)

74(50.7)

72(49.3)

–0.155

–0.081

–0.052

–0.257*

–0.025

caries

No(1)

Yes(0)

135(92.5)

11(7.5)

0.132

0.218

0.290*

0.366**

0.185

prosthetics

No(1)

Yes(0)

129(88.4)

17(11.6)

0.477***

0.407**

0.394**

0.518***

0.220*

toothwear

No(1)

Yes(0)

143(97.9)

3(2.1)

0.005

–0.123

–0.127

0.201

0.179

perio

dontal

disease

No(1)

Yes(0)

117(80.1)

29(19.9)

–0.023

–0.217

0.167

0.038

0.098

noself-perceived

treatm

entneed

atpresent

Yes(1)

No(0)

117(80.1)

29(19.9)

0.203

0.101

0.318*

0.172

0.220*

Confidentin

maintaining

good

oralhealth

Yes(1)

No(0)

20(13.7)

79(54.1)

0.521***

0.441**

0.552***

–0.473***

Valuative-attitudinal

Self-assessmentof

future

dental

care

need

Little

orno

ne(1)

Large(0)

57(39.0)

51(34.9)

0.409**

0.300*

0.321*

0.473***

–

Respon

sibilityforon

e’s

oralhealth

isthat

ofdental

person

nel

Little

(1)

Large(0)

23(16.0)

121(84.0)

0.050

0.193

–0.122

0.002

0.054

oneself

Little

(1)

Large(0)

10(6.8)

134(91.8)

–0.119

–0.185

–0.394**

–0.156

0.124

family

orsocial

network

Little

(1)

Large(0)

105(71.9)

34(23.3)

0.216

0.357**

0.032

0.084

0.141

Preventivehealth

orientation

Toothbrushing

�twiceaday(1)

�on

ceaday(0)

118(80.8)

28(19.2)

0.088

0.158

0.325*

0.231*

0.120

Interproximal

cleaning

�on

ceaday(1)

�on

ceaweek(0)

102(69.9)

44(30.1)

–0.066

–0.150

–0.097

0.031

0.015

Additio

nalfluoride

�on

ceaweek(1)

<on

ceaweek(0)

40(27.6)

105(72.4)

0.053

–0.077

–0.151

–0.008

–0.242*

Dentalcarevisits

�twiceayear

(1)

�on

ceayear

(0)

31(21.2)

115(78.8)

–0.088

–0.044

–0.209

–0.074

–0.285**

Self-initiated

latest

dental

care

visit

No(1)

Yes(0)

99(68.8)

45(31.3)

0.265*

0.090

0.053

0.259*

0.186*

Smoking

Never

(1)

Currently

orused

to(0)

69(47.3)

77(52.7)

0.302*

0.297*

0.484***

0.247*

0.226*

(continued)

4 E. SHMARINA ET AL.

Principle for analyses

Salutogenic factors selected for the analyses were sortedaccording to a previously developed framework combiningAntonovsky’s GRR domains and Lalonde’s health fields [1].For example, a salutogenic factor ‘refrain treatment needdue to cost’ was organized under the Lifestyle health fieldand further under the Artifactual-material GRR domain. Thecoding had a consistently salutogenic direction.

Statistical analyses

Data were analysed using the Statistical Package for theSocial Science (v.21, SPSS Inc., Chicago, Ill., USA). Frequencieswere used for descriptive statistics. To test associationsbetween oral health measures and variables of interest, weused Fisher’s exact test. A p-value �.05 was considered assignificant. A u coefficient was calculated for every variableto assess the degree of correlation. Significance levels of cor-relations of 0.05, 0.01 and 0.001 were considered as indicat-ing weak, moderate and strong, respectively.

A Multiple Linear Regression was used to analyze howDMFT-index was dependent on background variables.

Results

Sample characteristics

Table 1 presents the sample characteristics of population forthe three oral health indicators: number of remaining teeth,DMFT-index and risk sum.

Bivariate analysis

Table 2 presents the result of bivariate analyses for each sal-utogenic factor and outcome variable.

The answers to the global questions ‘Are you confident ofmaintaining good oral health for the rest of your life?’ and‘How do you assess your future dental care need?’ correlatedwell with one another as well as with the oralhealth indicators.

The overall impression was that a number of significantcorrelations were to be found, especially within the LifestyleHealth Field and Psychosocial GRR domains. Only singularcorrelations were found within the other three health fields.Ta

ble2.

Continued.

Health

field

Grrdo

main

Salutogenicfactor

Coding

N(%

)

High

numberof

remaining

teeth

Low

dmft

index

Low

risksum

Confident

inmaintaining

good

oral

health

Self-assessment

offuture

dental

care

need

Yes(1)/No(0)

Yes(1)/No(0)

Yes(1)/No(0)

Yes(1)/No(0)

Little

orno

ne(1)/

Large(0)

Environm

ent

Artifactual-m

aterial

Canafford

sugg

estedtreatm

ent

Yes(1)

No(0)

138(94.5)

8(5.5)

0.179

0.077

0.201

0.352**

0.052

Interpersonal-relational

Social

contacts

durin

gaweek

�6peop

le(1)

�5peop

le(0)

97(66.9)

48(33.1)

0.205

0.103

0.075

0.084

–0.023

Living

with

someone

No(1)

Yes(0)

33(22.8)

112(77.2)

0.051

–0.067

0.112

0.043

0.188*

Health care

organizatio

n

Valuative-attitudinal

Provider

oflatest

dental

care

visit

Public(1)

Private(0)

44(32.8)

90(67.2)

–0.061

–0.013

–0.007

–0.126

–0.109

Preventivehealth

orientation

Clinic’srecallsystem

Clinicinitiated

(1)

Other

(0)

99(68.8)

45(31.2)

0.265*

0.090

0.053

0.259*

0.186*

Thevariables

sorted

accordingto

theAn

tono

vsky

General

Resistance

Resources(GRRs)andtheLalond

eHealth

Fieldconcepts

(n¼146).B

ivariate

correlations

forsalutogenicfactorsandoralhealth

relatedou

tcom

eusing

Phicoefficient

(u)andFisher’sexacttest

(p).Thecoding

hasconsistently

asalutogenicdirection.

pdescrib

esdiffe

rencebetween20%

ofsubjects

with

high

estnu

mberof

naturalteethpresent(lowestDMFT,low

estrisk

sum)and20%

ofsubjects

with

lowest,usingFischer’s

exacttest.

Sign

ificant

diffe

rences

areindicatedin

bold

numbers:�

p<.05;

��p<.01;

��� p

<.001.

Table 3. Outcome variables and their coding. The coding has a consistentlysalutogenic direction.

Outcome variable Coding

High number of remaining teeth Yes (1)No (0)

Low DMFT-index Yes (1)No (0)

Low risk sum Yes (1)No (0)

Confident of maintaininggood oral health for the rest of your life

Yes (1)No (0)

Self-assessment of future dental care need Little or none (1)Large (0)

ACTA ODONTOLOGICA SCANDINAVICA 5

Table 4. Cross-tabulation of reported salutogenic factors significantly associated with better oral health among people �60 years, sorted according toAntonovsky’s salutogenic theory General Resistance Resources (GRRs), and the Lalonde Health Field concept.

Antonovsky’sSalutogenic theory

Lalonde health field concept

GRR domains Human biology Lifestyle Environment Health Care Organization

Genetic and constitutional GRRPhysical Younger old age (4) Light use of salt (2)

Male sex (3)Being nulliparous (1)No history of diabetes (2)Better physical function (1)BMI< 30 kg/m2 (1)Increased BMI for men (1)a

Systolic blood pressure<140mmHg (1)

Biochemical Higher saliva flow (2)Higher albumin level (1)Higher S-urea concentration in

serum (1)Lower concentration of fB-

Glucose (1)Lower concentration of S-urate (1)Longer duration of oestrogen

use (1)Fasting blood sugar< 110mg/dl (1)HDL-C< 40mg/dl (1)

Psychosocial GRRArtifactual-materialMaterial Higher family material possession

index (1)Lower income inequality (1)

Higher equivalent householdincome (1)

High level of basic living (1)

No self-perceived dentalcare need

Can affordsuggested treatment

Does not refrain treatment needdue to cost

CognitiveKnowledge-intelligence Higher intellect (1) Higher education (14) Longest job professional or

technical (1)Higher cognitive ability at age11 (1)

EmotionalEgo-identity Higher conscientiousness (1)

Having better self-rated health (1)Self-perceived need for dental

check-upNo self-perceived need for

caries treatmentNo self-perceived need for

prosthetic treatmentNo self-perceived treatment need

at presentConfidence in maintaining good

oral healthValuative-attitudinalCoping strategy: rational,

flexible and farsightedMore positive dental attitude (2)Likely to cooperate (1)Little or no self-assessed future

dental care needLarge responsibility for own

oral healthLittle reliance on family or social

network for own oral healthInterpersonal-relationalSocial support Being married (2) Higher social class (2)

Having four or more closefriends (1)

Higher neighbourhoodeducation level (1)

Social network diversity (1) Having easy access todentist (1)

Higher network contactfrequency (1)

Urban residence area (1)Living alone

Commitment Participating in sports and hobbyor friendship network atindividual level (1)

Participating in sports andhobby or friendshipnetwork at neighbourhoodlevel (2)

(continued)

6 E. SHMARINA ET AL.

General consistencyThere was a consistency of associations between a given sal-utogenic factor and the outcome variables. Thus, a given sal-utogenic factor correlated mostly in the same direction(negative or positive correlation) with the outcome variables.

Human biology health fieldWithin this field only one significant weak interaction wasfound (Table 2). Being male was weakly correlated with alow risk sum.

Lifestyle health fieldA large number of significant correlations were foundbetween salutogenic factors and outcome variables withinthis health field (Table 2). However, only three salutogenicfactors demonstrated associations with all oral health indica-tors, at various degrees of significance. These variables were‘refrain treatment need due to cost’, ‘self-perceived treatmentneed at present for prosthetics’ and ‘smoking’. Strong posi-tive correlations were disclosed between not ‘refraining treat-ment need due to cost’ and ‘high number of remainingteeth’, no ‘self-perceived treatment need at present for pros-thetics’ and ‘high number of remaining teeth’ as well as‘smoking’ and ‘low risk sum’.

Except for ‘smoking’, within the ‘preventive health orienta-tion’ domain, only two significant weak associations with oralhealth indicators and few with global indicators emerged. No‘self-initiated latest dental care visit’ was weakly correlatedwith ‘high number of remaining teeth’ as well as both global

indicators. ‘Tooth brushing’ at least twice a day was weaklycorrelated with ‘low risk sum’ and being ‘confident in main-taining good oral health’. ‘Dental care visits’ once a year orless and ‘additional fluoride’ used never or sometimes wereweakly correlated with ‘own assessment of future dental careneed’ as little or none.

With respect to the Valuative-attitudinal GRR domain,‘dental personnel’ as a factor for greater ‘responsibility forone’s oral health’ did not correlate with any of the clinicaloutcome variables. However, taking a large ‘own responsibil-ity’ was moderately correlated to low risk sum and littleresponsibility of ‘family or social network’ showed a moder-ate correlation with low DMFT-index.

Two salutogenic factors were also assessed as global out-come variables, on the basis of their global character, namely‘confident in maintaining good oral health’ and ‘self-assess-ment of future dental care need’. Their global character washere demonstrated by strong positive associations with alloutcome variables. Being ‘confident in maintaining good oralhealth’ as well as ‘self-assessment of future dental care need’as little or none were correlated with a ‘high number ofremaining teeth’, ‘low DMFT-index’ and ‘low risk sum’.

Environment health fieldTwo positive significant associations were observed withinthis health field. ‘Can afford suggested treatment’ was mod-erately correlated with ‘confident in maintaining good oralhealth’. ‘Living alone’ was weakly correlated with little or no‘self-assessment of future dental care need’.

Table 4. Continued.

Antonovsky’sSalutogenic theory

Lalonde health field concept

GRR domains Human biology Lifestyle Environment Health Care Organization

MacrosocioculturalCultural stabilityMagicReligion, philosophy, art:

a stabile set of answersHappiness (1)

Undefined domainb

Preventive healthorientation

Regular dental care attendance (7)a Mother did not prefer sweetfood (1)

Higher oral health teamcoverage (1)

Moderate or no use of alcohol (5)a Public water fluoridation (1) Clinic’s recall systemNever, former or not current

smoker (17)a

Optimal oral hygiene behaviour (9)Regular life rhythm and sleeping

habits (2)Regular physical activity and eating

habits (2)Limited or no intake of sweet food

and drink (4)Vegetarian diet or greater intake of

dark green and yellowvegetables (2)

Daily intake of milk and milkproducts (2)

The brackets show number of articles published on each factor. Bold text indicates novel salutogenic factors found in this study. The Antonovsky GRR aredescribed and expanded on the left-hand side and the health fields of Lalonde are sorted as columns. The cross-tabulation highlights the correspondencebetween factors within the two theories. It is also apparent, as indicated by unfilled cells, that many areas are unexplored.aIndicates that there is at least one study reporting conflicting evidence for the factor.bThis GRR domain was described by Antonovsky with no detail of headline but clearly within psychological GRR.

ACTA ODONTOLOGICA SCANDINAVICA 7

Health care organization health fieldWithin this health field, three positive significant interactionswere found for one salutogenic factor. ‘Clinic’s recall system’was weakly correlated with ‘high number of remaining teeth’with being ‘confident in maintaining good oral health’ andto little or no ‘self-assessment of future dental care need’.

Multiple linear regression analysis. A Multiple LinearRegression model using DMFT-index (10–28) as the depend-ent variable, had a good model fit of R Square 0.499 (Table5). Three independent variables showed a significant (p< .05)

relation (B) to the DMFT-index: a university level education(p¼ .041, B �2.629); a high self-assessed importance of den-tal personals’ responsibility for one’s own oral health(p¼ .040, B �3.755); a high self-assessed importance of theresponsibility of the family or social network for one’s ownoral health (p¼ .006, B �4.381). In comparison to findings inTable 2, education level and high self-assessed importance ofdental personals’ responsibility for one’s own oral healthwere non-significant. A high self-assessed importance of theresponsibility of the family or social network for one’s ownoral health was significant (p¼ .01).

Table 5. Summary for linear regression analysis for salutogenic factors predicting DMFT-index (10–28, n¼ 74).

Health field Grr domain Salutogenic factor B SE (B)

95% CI

pLower Upper

Constant 25.892Human biology Physical Gender Female Ref

Male –0.001 1.250 –2.512 2.510 NSLifestyle Artifactual-material Refrain treatment need due to cost Yes Ref

No –0.470 2.514 –5.523 4.582 NSCognitive/ Emotional Educational level Lower Ref

University –2.629� 1.251 –5.142 –0.116 .041Self-perceived treatment need at present for

dental check-up Yes RefNo 1.776 1.860 –1.972 5.505 NS

caries Yes RefNo 3.045 2.397 –1.773 7.862 NS

prosthetics Yes RefNo –3.781 2.569 –8.998 1.436 NS

tooth wear Yes RefNo –3.644 4.894 –13.478 6.190 NS

periodontal disease Yes RefNo 3.244 1.924 –0.622 7.110 NS

no self-perceived treatment need at present Yes RefNo –1.186 1.949 –5.103 2.731 NS

Confident in maintaining good oral health No RefYes –2.483 2.011 –6.524 1.559 NS

Valuative-attitudinal Self-assessment of future dental care need Large RefLittle or none 1.019 1.426 –1.846 3.884 NS

Responsibility for one’s oral health is that ofdental personnel Large Ref

Little –3.755� 1.783 –7.338 –0.171 .040oneself Large Ref

Little 4.444 2.394 –0.368 9.256 NSfamily or social network Large Ref

Little –4.381�� 1.533 –7.462 –1.299 .006Preventive health orientation Tooth brushing � once a day Ref

� twice a day –1.795 1.798 –5.409 1.818 NSInterproximal cleaning � Once a week Ref

� Once a day 1.993 1.070 –0.158 4.144 NSAdditional fluoride � Once a week Ref

� Once a week 1.667 1.198 –0.739 4.074 NSDental care visits � Once a year Ref

� Twice a year 1.155 1.701 –2.264 4.573 NSSmoking Currently or used to Ref

Never 1.949 1.278 –0.619 4.517 NSEnvironment Artifactual-material Can afford suggested treatment No Ref

Yes 1.446 2.572 –3.722 6.613 NSInterpersonal-relational Social contacts during a week � 5 People Ref

� 6 People 0.409 1.153 –1.908 2.726 NSLiving with someone No Ref

Yes –0.805 1.379 –3.576 1.966 NSHealth care organization Valuative-attitudinal Provider of latest dental care visit Private Ref

Public –0.347 1.295 –2.950 2.256 NSClinic’s recall system Other Ref

Clinic initiated 0.894 1.371 –1.861 3.649 NS

The variables sorted according to the Antonovsky General Resistance Resources (GRRs) and the Lalonde Health Field concepts. B denotes regression coefficient,SE (B) denotes standard error of the regression coefficient, 95% CI denotes confidence interval. R2 ¼ 0.499.� p< .05. �� p< .01.

8 E. SHMARINA ET AL.

Cross-tabulation

In this study, we did not identify any salutogenic factor fororal health in this population which could be added to previ-ously described empty cells in the cross-tabulation (Table 4)[1]. However, several salutogenic factors could be added tothree health fields: Lifestyle, Environment and Oral HealthOrganization, that already contained some salutogenic fac-tors as identified previously [1]. The majority of the saluto-genic factors identified were added to the Lifestyle healthfield and concerned ‘self-perceived treatment need’,‘responsibility for one’s oral health’ and ‘self-assessment offuture dental care need’.

Discussion

The aim was to explore relevant salutogenic factors for oralhealth in people aged 60 years and older. We could corrobor-ate the strength of our tool for exploring salutogenic interac-tions as used in our previous study reviewing salutogenicfactors for oral health [1]. Furthermore, we could add somepreviously unreported associations and also confirm resultsreported by other authors. Thus, our conceptual hypothesiswas corroborated, i.e. salutogenic factors for oral health canmore appropriately be studied in a group of orally healthyolder people considering the lifelong impact of salutogenicfactors on oral health.

We used epidemiological data, with special reference tounexplored associations identified in previous research [1].Even though we could not identify salutogenic factors fororal health in this population which could be added to previ-ously described empty cells in the cross-tabulation (Table 4),we could add several factors.

Previous research in the oral health field has focussed pri-marily on lifestyle factors, leaving other areas unexplored.Although lifestyle is important for maintaining good oralhealth, there might be a number of unknown salutogenicfactors in other health fields. Therefore, for this study, weselected data from a questionnaire, in order to extend thesearch for possible information beyond the lifestyle area. Ourresults indicate that there is a lack of information outside thelifestyle area with a need to expand the perspective byempirical studies focussing on unexplored areas. However, inthe complex relations between salutogenic factors and out-come variables, one must recognize that there are many con-founding indirect effects depending on hidden factors.

Sample

Internationally, the age-related number of natural teethvaries substantially. A study of 14 European countries andIsrael disclosed that in people aged 50–90 years, Sweden hasthe highest median (27.0) and mean (24.5) number of naturalteeth [17]. The same study also showed that Sweden is oneof the few countries where at least half of the populationaged 80 years or older has at least 20 teeth remaining [17].In our study, the population median and mean number ofremaining teeth did not differ considerably from the study

cited above. This similarity in the number of remaining teethcould be attributable to variations in age range and studymethods (self-reported number of teeth). Thus, the figure forremaining teeth in our sample may be considered represen-tative for this age group.

Bivariate analysis

Earlier research indicates that socioeconomic background,health-related behaviour patterns in early life, and previousdisease experience are important determinants of oral healthoutcomes up to middle age [18]. However, to date there islittle research into the influence of Health Care Organization,even though it is up to the individual to explore and benefitfrom the available health support. Compared with manyother countries, oral health care organization in Sweden ishighly developed. It might be assumed that the high level oftooth retention in Sweden is associated with a long historyof this general oral health care organization and the individ-ual’s ability to access it. This includes systematic preventiveefforts and subsidies for treatment, which might be reflectedin the current oral health status among elderly Swedes.

In this study, a number of significant correlations withinthe Lifestyle health field were identified. Within the otherfields, there were only a limited number of variables andsome single significant correlations. A reason might be thatthe original data used for this study comprised primarily life-style variables, leaving insufficient data for otherhealth fields.

The findings demonstrate associations indicating that it isof value to oral health if an individual takes his/her own ini-tiative and responsibility. Those who reported taking majorresponsibility had a significantly lower risk sum and thosewho placed little responsibility on family or social networkhad significantly lower DMFT-indices. These findings are con-sistent with theories [2] and previous empirical research, asexpressed by factors such as ‘higher conscientiousness’ [19]and ‘likely cooperate’ [20]. Dahlgren and Whitehead [21] intheir comprehensive model of the impact of social and com-munity network factors very clearly points out these factorsas contributing salutogenic factors [21].

In the present population, only a few weak connectionscould be disclosed between oral health-related outcome vari-ables and salutogenic factors within preventive health. Theonly exception was ‘never smoking’, which was consistentlyassociated with all clinical and global oral health indicators.This is in accordance with earlier research [22–24].

Further, more frequent use of additional fluoride andmore frequent dental care visits were associated with self-assessment of future dental care need. Interpreting ‘frequentdental visits’ as healthy behaviour might need some modifi-cation, taking into account the reasons for the frequent vis-its. They might just as well be due to recurring problems asto preventive treatment recommended by the clinic.However, our other finding demonstrated an associationbetween frequent recall by the clinic and better oral healthoutcomes. Those who were recalled by the dental clinic hadmore teeth and also assessed their future dental care need

ACTA ODONTOLOGICA SCANDINAVICA 9

as little or none. This finding could support Antonovsky’stheory, placing the power ‘where it is legitimately supposed tobe’ [2, p.128], i.e. in the hands of dental professionals andthe dental organization system. The importance of an effect-ive dental recall system has also been reported previ-ously [25].

Moreover, some findings were consistent with previousresearch, e.g. financial security was associated with betteroral health [26,27]. Lack of self-perceived need for prosthetictreatment correlated positively with all outcome variables.This result is as expected, even with the high number ofteeth in this population. Tertiary education was positivelycorrelated with a higher number of natural teeth, which is inaccordance with earlier research [19,28,29].

The variables ‘confident in maintaining good oral health’and ‘self-assessment of future dental care need’ as little ornone, were significantly correlated with each other and withall other outcome variables. Thus, they can tentatively beregarded as global indicators of oral health. To our know-ledge, these variables have not been considered as such pre-viously [30,31].

Several research methodologies may be applied to assessthe nature of salutogenesis, what individually determinesbehaviour and the competence of the individual to actuallyfind and use societal structures supporting health [2].Certainly, a qualitative and more direct approach such asasking (interviewing) resilient individuals how they deal withtheir challenges, would help in understanding salutogenesis.

Multiple linear regression analysis

This model had a high model fit, i.e. it was well specifiedregarding its independent factors, which were selected froma theoretical standpoint emanating from those ofAntonovsky and Lalonde. Three independent factors weresignificantly associated with the dependent variable. A lowerDMFT index was more associated with a higher education(university education), thus confirming previous studies relat-ing a higher degree of education with better oral health [28].A lower DMFT index was also related to both a self-assessedlower importance of dental personals’ responsibility for one’sown oral health, as well as a lower self-assessed importanceof the responsibility of the family or social network for one’sown oral health. This implies that an individual in a well-functioning social network, either of professional or privatecharacter, will profit from this when the individual takes ownresponsibility in regard to oral health. A causal relationshipmust ultimately be based on theoretical reasoning. Themechanism for this case-effect relationship would presum-ably be through social networks offering social structuresempowering the individual towards healthy practices asstressed by both Antonovsky and Lalonde [2,3,6].

Limitations

One limitation was population size due to the data used inthe present study. The generalizability of the present findingsis also limited and cannot be regarded as representative of

the entire Swedish population, even though with respect tothe number of remaining teeth, the sample did not differfrom that of Stock et al. [17]. Moreover, the data in the pre-sent study was originally collected by using the same selec-tion procedures and methods as in a similar previous studyin Skåne [11]. Our findings demonstrate similar trends.

Although the lack of calibration among clinical examinerspresents a limitation, the experienced dentists were usingtheir regular clinical procedures and were co-ordinated withrespect to diagnostic criteria by means of comprehensivewritten instructions, practical exercises and discussion of clin-ical cases. For the purpose of this study these procedureswere considered appropriate.

Another limitation is that the original questionnaire wasconstructed from a pathogenic perspective, which limitedthe choice of variables for the present study. Empirical stud-ies designed from a salutogenic perspective are needed.Finally, because of the cross-sectional design, the presentstudy cannot claim causal relationships. There is a possibilityof bidirectional relationships between oral health indicatorsand the selected variables.

Conclusion

This study supports the usefulness of a salutogenic approachfor analysing oral health outcomes, identifying universityeducation, the importance of dental health organizationrecall system and close social network, as important saluto-genic factors. The large number of salutogenic factors foundsupporting oral health among the elderly indicates the com-plexity of salutogenesis and the need for robust analysingtools. Combining two current health models was considereduseful for exploring covariations between salutogenic factorsand several outcome variables within oral health. These find-ings have implications for future investigations, identifyingimportant research questions to be explored in qualita-tive analyses.

Acknowledgement

We acknowledge with gratitude statistical advice from Per-Erik Isberg,B.Sc., Department of Statistics, Lund University, Lund, Sweden.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Funding

This study was supported financially by the Public Dental Services of theRegion Kalmar County, Sweden.

ORCID

Elena Shmarina http://orcid.org/0000-0003-4331-255X

10 E. SHMARINA ET AL.

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