School academic climate and oral health (tooth loss) in adolescents

Conclusion The school academic climate is associated with tooth loss, suggesting that educational aspi- rations are linked to adolescent oral health maintenance behaviors. Introduction Prevalence of tooth loss increases gradually with age [1] and in adolescents is associated with a number of deleterious outcomes including poor self-esteem [2], low quality of life [3], impact on daily performance [4], as well as impacts on social relations, and labor market outcomes (employability) [5]. It is worth noting that tooth loss before age 35 may be a risk factor for Alz- heimer’s disease at 65 years or over [6]. In adolescence, tooth loss often affects the first permanent molars since these are the earliest teeth to erupt [7] and the most affected by caries [8]. Preventing tooth loss depends on oral health maintenance behaviors, e.g., brushing with fluoridated toothpaste to prevent caries, avoid- ance of cigarette smoking and high consumption of sugars and refined carbohydrates, as well as regular and preventive dental check-ups. Socioeconomic disparities in oral health maintenance behaviors (and oral health status) have been extensively documented [9–12]. Adolescents from disadvantaged backgrounds (income poverty, low parental education) are less likely to engage in preventive behaviors. Socioeconomic inequalities in the practice of oral health maintenance behaviors can be explained by different behavioral theories which focus on disparities in health literacy, time & resource scarcity, differences in norms & attitudes, and self-efficacy [13]. Behav-

ioral theories such as the Theory of Planned Behavior and the Health Belief Model tend to emphasize factors operating at the level of individual decision-making, such as self-control beliefs, attitudes toward the behavior, as well as perceived social norms surrounding the behavior [14, 15]. While these theories provide a powerful set of tools to explain (and intervene on) health behaviors, they also miss the contextual influences that potentially drive behavior change [16]. That is, an exclusively individual focus on health behavior provides an incomplete picture of the social contextual factors which may motivate (or demotivate) the adoption of preventive prac- tices. To address this gap, the “scarcity hypothesis” from the field of behavioral economics sug- gests that socioeconomic disadvantage is characterized by uncertainty about the future, and that this can help to explain the lack of future orientation among youth raised in poverty [12]. In other words, the lack of motivation to invest for the future could be explained as a “rational” response to the individual’s pessimistic assessments of the future. If the prospects are slim for future employment, or reaching a ripe old age, how can youth be motivated to invest for the future, by avoiding health-damaging habits, or engaging in health maintenance behaviors? Emerging evidence corroborates the scarcity hypothesis. For example, in the United States after affirmative action in college admissions was struck down by a Supreme Court ruling,

rates of cigarette smoking increased among underrepresented minority adolescents [17, 18]. Education offers one of the surest ways for socioeconomically disadvantaged groups to experi- ence upward mobility. Lee et al. show that children with high educational aspirations are more likely to graduate from high school and also to have higher income at age 30 [19]. Adolescents who aspire to attend college are also more likely to do exercise regularly and to abstain from smoking [20]. In the realm of oral health, studies have reported an association between scho- lastic performance and the likelihood of visiting the dentist in the last year [21, 22]. School climate refers to the quality and character of school life, and encompasses distinct dimensions including: (i) safety, (ii) teaching and learning (academic climate), (iii) relation- ships between pupils, teachers and students, and (iv) the institutional environment (e.g., PLOS ONE School academic climate and tooth loss in adolescents PLOS ONE | https://doi.org/10.1371/journal.pone.0233505 May 21, 2020 2 / 11