382 Dental Journal (Majalah Kedokteran Gigi) 2025 December; 58(4): 382–387 Original article Social determinants and oral health among cement industry workers R. E. Haura Azzahra1, Rosa Amalia2, Derajad Sulistyo Widhyharto3, Dibyo Pramono2, Bambang Priyono2 1Master of Dentistry Study Program, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia 2Department of Preventive and Community Dentistry, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia 3Department of Sociology, Faculty of Social and Political Sciences, Universitas Gadjah Mada, Yogyakarta, Indonesia ABSTRACT Background: Cement industry workers are exposed to significant oral health risks due to hazardous conditions, but the role of social determinants in this context is not well understood. Purpose: This study investigates the association between social determinants and oral health among factory and office workers in the cement industry. Methods: A cross-sectional study was conducted at PT. Semen Padang, West Sumatra, Indonesia. A stratified random sample of 83 workers was selected. Social determinants were assessed using World Health Organization (WHO) 2013 and Perceived Stress Scale (PSS-10) questionnaires, while oral health was evaluated using decayed, missing, and filled teeth index (DMF-T), community periodontal index (CPI), and inspection. Ten calibrated dentists conducted dental examinations. Multiple linear regression was used for data analysis. Results: Factory workers exhibited higher rates of dental caries (95.83%), periodontal disease (87.50%), abrasion (91.67%), and attrition (87.50%), compared to office workers. Social determinants significantly associated with dental caries in factory workers included age, sugar intake, tooth-brushing frequency, and last dental check-up (r2 = 0.573), while only sugar intake was associated with caries in office workers (r2 = 0.290). For periodontal disease determinants associated with age, psychosocial factors, and smoking (r2 = 0.558) were significant in factory workers, whereas, in office workers, age, sugar intake, tooth-brushing frequency, last dental check-up, and smoking were significantly associated (r2 = 0.870). Age was the only significant determinant of abrasion and attrition in both groups. Conclusion: Social determinants influence oral health among cement industry workers, especially factory workers, due to physiological and psychological changes caused by working conditions. However, office workers also face oral health challenges due to poor oral health behaviors. Keywords: cement factory; factory workers; oral health; shift schedule; social determinant Article history: Received 8 July 2024; Revised 13 October 2024; Accepted 23 October 2024; Online 1 September 2025 Correspondence: R. E. Haura Azzahra, Master of Dentistry Study Program, Faculty of Dentistry, Universitas Gadjah Mada. Jl. Denta 1, Sekip Utara, Yogyakarta, 55281, Indonesia. Email: rehauraazzahra@mail.ugm.ac.id INTRODUCTION Occupation is recognized as a key social determinant of health,1 yet this aspect is often overlooked due to limitations in public health data systems.2 Previous research has predominantly focused on social determinants without considering working conditions.3–5 Consequently, research findings are frequently inconsistent, as the outcomes for higher social position do not always exhibit a linear relationship with good health.6–9 Demographic and socioeconomic factors frequently obscure the crucial role of occupational exposures. Historical evidence from the early days of occupational health, where company data showed that workers in hazardous environments experienced higher disease rates, highlights the consequences of occupational segregation.1,2 This has made it challenging for public health to define the social determinants that affect oral health, particularly among workers.2 The cement industry, known for its hazardous working conditions, poses significant risks to workers’ oral health. Exposure to harmful particles, including heavy metals and abrasive dust,10 has been associated with dental caries,11,12 periodontal disease,10,11,13,14 and tooth wear.12,15 Factory workers are particularly vulnerable to dental health problems due to their work environments and irregular work schedules, especially shift work.11 Shift work has been extensively linked to negative impacts on general health,16–19 yet its specific influence on oral health remains Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i4.p382–387 mailto:rehauraazzahra@mail.ugm.ac.id https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i4.p382-387 383Azzahra et al. Dent. J. (Majalah Kedokteran Gigi) 2025 December; 58(4): 382–387 understudied.7,11,20–23 Irregular schedules often disrupt physiological and psychological balance, leading to increased stress and poor oral health.11,23 The impacts of oral health problems among workers include the reduction of quality of life,24 loss of productivity,25 and economic burden for individuals and industry.26 This study aims to investigate the association between social determinants (such as age, gender, education, psychosocial factors, oral health behaviors, and working conditions) and oral health outcomes (caries, periodontal disease, abrasion, and attrition), among factory and office workers in the cement industry. Considering these social determinants in the workplace may help design more targeted oral health programs and improve workers’ oral health and behaviors.27 MATERIALS AND METHODS This research is a cross-sectional study, employing an observational–analytical design, approved by the Research Ethics Commission of the Faculty of Dentistry–Prof. Soedomo Dental and Oral Hospital, Universitas Gadjah Mada (number 64/UN1/KEP/FKG-RSGM/EC/2024). This study was conducted in May 2024 at PT. Semen Padang, Padang City, West Sumatra, Indonesia. A stratified random sampling of 83 participants was determined by an analytical sample size calculation.28 Participants were required to be voluntary, factory workers with at least five years of experience or office workers with no prior factory experience, and free of orthodontic appliances, systemic diseases, and routine drug use. Data collection utilized a mouth mirror and a World Health Organization (WHO) periodontal probe. Social determinants were assessed using the WHO 2013 and Perceived Stress Scale (PSS-10) questionnaires, while oral health conditions were evaluated using the decayed, missing, and filled teeth index (DMF-T), community periodontal index (CPI), and number of abrasion and attrition affected teeth. Dental examinations were conducted by ten dentists who had undergone training and standardization to ensure consistent methodology and assessment of oral health. Dental examiners were trained and calibrated at the employee dental health care facility of PT. Semen Padang. Data analysis involved descriptive statistics, bivariate analysis using Pearson Correlation and Independent T-tests, and multivariate analysis using multiple linear regression to examine the relationships between social determinants and oral health outcomes. RESULTS A total of 83 workers from the cement industry participated in this study. The sample comprised 48 factory workers (57.83%) and 35 office workers (42.17%), with an average age of 40.50 years (SD = 7.00). See Table 1 for the subject characteristics. Based on Table 1 data, respondents aged 35–44 years were in the majority (48.19%), and more workers were male (75.90%). The most prevalent level of formal education was 12 years (42.17%). Sugar intake categorized as moderate was most dominant (44.58%). Most respondents brushed their teeth more than twice a day (83.13%). The stress level most reported was categorized as mild (50.60%). Most respondents had their last dental check-up less than one year ago (60.24%). More respondents were non-smokers (65.06%) compared to smokers. More participants were shift workers (57.83%) compared to non-shift workers. The prevalence of dental diseases was highest among factory Table 1. Subject characteristics Indicator n (%) Age 27–34 years 35–44 years 45–54 years 18 (21.69) 40 (48.19) 25 (30.12) Gender Male Female 63 (75.90) 20 (24.10) Education 12 years 15 years > 16 years 35 (42.17) 22 (26.51) 26 (31.32) Sugar intake Low Moderate High 14 (16.87) 37 (44.58) 32 (38.55) Tooth brushing frequency < 2 a day > 2 a day 14 (16.87) 69 (83.13) Psychosocial Mild Moderate Severe 42 (50.60) 36 (43.37) 5 (6.02) Last dental check-up <1 year >1 year 50 (60.24) 33 (39.76) Smoking Smoker Non-smoker 29 (34.94) 54 (65.06) Work Schedule Shift Non-shift 48 (57.83) 35 (42.17) DMF-T Factory workers Office workers 46 (95.83) 33 (94.29) Periodontal Disease Factory workers Office workers 42 (87.50) 24 (68.57) Abrasion Factory workers Office workers 44 (91.67) 29 (82.86) Attrition Factory workers Office workers 42 (87.50) 22 (62.86) Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i4.p382–387 https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i4.p382-387 384 Azzahra et al. Dent. J. (Majalah Kedokteran Gigi) 2025 December; 58(4): 382–387 workers in all categories: caries (95.83%), periodontal disease (87.50%), abrasion (91.67%), and attrition (87.50%). The social determinant most significantly linked to caries was sugar intake as presented in Table 2. Periodontal disease was significantly influenced by age, education level, stress level, and smoking habits. Attrition was significantly associated with age, and abrasion was significantly associated with age, education level, gender, and smoking. Table 3 shows that the social determinants significantly associated with caries for factory workers were age, sugar intake, tooth-brushing frequency, and last dental check- up. In contrast, for office workers, only sugar intake shows a significant association. The social determinants significantly associated with periodontal disease for factory workers were age, psychosocial factors, and smoking. Conversely, for office workers, age, sugar intake, tooth- brushing frequency, last dental check-up, and smoking were significantly associated. The social determinants significantly associated with abrasion for factory workers were age and education, while for office workers, only age was significantly related. Age and smoking were significantly associated with attrition in factory workers, while for office workers, only age was significantly associated. DISCUSSION The study involved factory workers on shift schedules and office workers with regular daytime schedules in the cement industry. Sugar intake was associated with incidence of caries among cement industry workers. This finding is in line with Vitosyte et al.5 who found that adults with high sugar intake scores had a high prevalence of caries. A meta-analysis concluded that sugar intake is a major cause of caries29 and several systematic reviews consistently showed that sugar intake is a primary cause of caries in children and adults.30–34 This could be attributed to easy access to sugary foods in the workplace, especially in office environments. Office workers have access to kitchens with a variety of foods available, including those high in sugar. The provision of various foods is a company’s contribution to supporting worker productivity. The study results also showed that age, education, tooth-brushing frequency, psychosocial factors, gender, last dental check-up, smoking, and working hours were not significantly associated with caries. Individuals in all categories experienced caries. These findings indicate a potential association between social determinants and caries, even though statistical significance was not achieved. Nonetheless, the present study revealed sugar intake as the primary determinant of caries. Table 2. Association between social determinants and oral health Variable DMF-T PPD Abrasion Attrition r p-value r p-value r p-value r p-value Age 0.115 0.301 0.329 0.002* 0.436 0.000* 0.535 0.000* Education -0.001 0.989 -0.340 0.002* -0.018 0.874 -0.217 0.049* Sugar intake 0.488 0.000* 0.125 0.261 -0.072 0.518 -0.080 0.470 Brushing frequency -0.151 0.174 -0.124 0.264 0.044 0.691 0.005 0.962 Psychosocial -0.038 0.733 0.271 0.013* 0.011 0.920 0.210 0.056 t p-value t p-value t p-value t p-value Gender -1.092 0.278 1.968 0.053 1.027 0.307 2.938 0.004* Last dental check-up -1.335 0.186 -0.830 0.409 0.146 0.884 0.773 0.442 Smoking 1.227 0.223 6.925 0.000* 0.751 0.455 2.764 0.007* Work schedule -1.254 0.214 3.453 0.001* 1.652 0.102 4.482 0.000* Statistical analysis using the Pearson correlation test and independent t-test; PPD=Periodontal Pocket Depth (> 4mm); r = correlation coefficient; t = t-value (tstudent = 1.664); p = significance value; *significance at the level of < 0.05. Table 3. Association between social determinants and oral health among factory and office workers in the cement industry Indicator Age Education Sugar intake Brushing frequency Psycho- social Last dental check-up Smoking r2 p-value p-value p-value p-value p-value p-value p-value DMF-T Factory 0.024* 0.898 0.000* 0.005* 0.834 0.035* 0.317 0.573 Office 0.518 0.294 0.029 0.481 0.446 0.185 0.274 0.290 PPD Factory 0.006* 0.580 0.160 0.611 0.007* 0.507 0.000* 0.558 Office 0.000* 0.083 0.024* 0.014* 0.369 0.012* 0.000* 0.870 Abrasion Factory 0.012* 0.026* 0.595 0.830 0.092 0.589 0.128 0.278 Office 0.005* 0.756 0.339 0.348 0.089 0.963 0.802 0.429 Attrition Factory 0.000* 0.217 0.669 0.996 0.179 0.644 0.011* 0.564 Office 0.045* 0.544 0.064 0.220 0.177 0.096 0.918 0.433 Statistical analysis using the multiple linear regression test; PPD = Periodontal Pocket Depth (> 4mm); p = significance value; r2 = coefficient of determination; *significance at the level of <0.05. Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i4.p382–387 https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i4.p382-387 385Azzahra et al. Dent. J. (Majalah Kedokteran Gigi) 2025 December; 58(4): 382–387 Age, education, and psychosocial factors were associated with increased periodontal disease among cement industry workers. These findings align with previous studies demonstrating that socioeconomic factors, such as lower education, socioeconomic status, and smoking, are linked to a higher prevalence of periodontal disease.35 Moreover, psychosocial factors and elevated salivary cortisol levels have been associated with periodontal disease.36 Older age, lower education, and higher stress levels may contribute to periodontal disease through weakened immune systems, reduced access to dental care, and unhealthy lifestyle choices, respectively. Additionally, shift work was associated with increased periodontal disease, consistent with previous research.7,11,20–23 The irregular sleep patterns and increased stress associated with shift work may compromise the immune system, making individuals more susceptible to periodontal disease. Furthermore, smoking was strongly linked to periodontal disease, with smokers exhibiting deeper periodontal pockets and greater attachment loss.37 The harmful effects of tobacco on periodontal tissues, including reduced blood flow, impaired wound healing, and immunosuppression, contribute to the development and progression of periodontal disease. While statistical analysis revealed no significant associations between sugar intake, brushing frequency, gender, and last dental check-up, periodontal pockets were observed in all groups regardless of these variables. This study suggests a relationship between social determinants and periodontal disease, with age, education, psychosocial factors, smoking, and work schedule emerging as the most influential factors. Abrasion in cement industry workers was associated with age and education. Sharma et al.12 found that tooth wear was related to age, education, and poor oral hygiene habits among cement industry workers. This is likely influenced by exposure to cement dust and brushing techniques among workers. The most common cause of tooth wear in cement industry workers, found in the cervical area, was attributed to incorrect brushing techniques, excessive brushing pressure, duration, frequency, brush bristle design, and abrasive toothpaste.38 Cement dust, containing abrasive particles such as silica, can adhere to teeth and when combined with saliva forms a hard paste that gradually erodes tooth enamel, especially when compounded by vigorous or improper brushing. Using a hard-bristled toothbrush, brushing vigorously, or brushing in a horizontal direction can exacerbate the abrasive effects of cement dust, accelerating enamel abrasion and potentially leading to increased tooth sensitivity and gingival recession. Despite the lack of statistically significant associations with other factors, abrasion was prevalent across all levels of education, sugar intake, brushing frequency, psychosocial factors, gender, last dental check-up, smoking, and work schedule. Attrition was significantly associated with age in cement industry workers, aligning with previous studies.39–41 Aging is associated with increased occlusal forces and bruxism, a condition characterized by involuntary grinding or clenching of the teeth, both of which contribute to attrition. Moreover, older individuals often experience higher stress levels, further exacerbating bruxism.42 Males exhibited higher levels of tooth wear compared to females, possibly due to dietary factors and stronger chewing forces.41 While no direct studies have compared the dental structure or saliva composition between genders, bruxism, which is more prevalent in males, is a likely contributing factor. Shift workers also demonstrated higher levels of tooth wear, potentially linked to increased stress and bruxism. Although direct evidence is lacking, the association between shift work, psychosocial stress, and bruxism is well-established.42 Similarly, smokers exhibited higher levels of tooth wear, likely due to increased stress and bruxism. While no direct studies have examined the relationship between smoking and tooth wear, the association between stress and bruxism is well-documented.42,43 Although other factors were not statistically significant, tooth wear was observed in all groups regardless of these variables. However, this study found that age, education, gender, smoking, and work schedule were the most influential factors contributing to tooth attrition. The incidence of dental caries in factory workers who work in shift schedules was significantly associated with age, sugar intake, brushing frequency, and last dental check- up. These findings align with previous studies,11 indicating a higher risk of caries among shift workers compared to those with regular schedules. A systematic review suggests that shift workers are more likely to experience disrupted eating patterns, consuming more unhealthy foods and sugary drinks.38 These dietary differences can lead to elevated blood sugar levels and reduced salivary flow, increasing susceptibility to caries.44 In contrast, dental caries incidence among office workers was primarily associated with sugar intake, consistent with findings from Janapareddy et al.24 The higher prevalence of caries among office workers is attributed to increased opportunities for sugar intake during working hours and easier access to sugary foods.24 Despite the lack of statistically significant associations with other factors, this study revealed that dental caries among factory workers were primarily influenced by age, sugar intake, brushing frequency, and last dental check-up, whereas office workers’ caries experience was primarily associated with sugar intake. Periodontal disease among factory workers who work shift schedules was related to age, psychosocial, and smoking. Shift workers exhibited higher levels of oral inflammation and periodontal health concerns. Periodontal disease increased with age.11,22 Stress and anxiety, which can lead to poor oral hygiene, increased smoking, and poor nutrition, can elevate cortisol levels and disrupt the balance between pro- and anti-inflammatory responses. In office workers, periodontal disease was significantly associated with age, sugar intake, brushing frequency, last dental check-up, and smoking status, aligning with Kharbanda et al.45 However, this finding contradicts Zaitsu et al.7 and Copyright © 2025 Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index DOI: 10.20473/j.djmkg.v58.i4.p382–387 https://e-journal.unair.ac.id/MKG/index https://doi.org/10.20473/j.djmkg.v58.i4.p382-387 386 Azzahra et al. Dent. J. (Majalah Kedokteran Gigi) 2025 December; 58(4): 382–387 Ishizuka et al.20 who reported lower periodontal disease among daytime office workers. This discrepancy may be attributed to differences in oral health behaviors. Although other factors were not statistically significant, the results suggest that periodontal disease in factory workers is more influenced by systemic conditions such as age, psychosocial factors, and smoking, while in office workers it is more influenced by oral health behaviors. Abrasion in factory workers was associated with age and education, while in office workers, it was primarily related to age. These findings align with Ali et al.46 who reported that tooth wear is influenced by age, gender (especially in males), and brushing technique. Prevalence of tooth wear increases with age, and education level is often correlated with lifespan.46 Inappropriate brushing techniques among workers may be attributed to a lack of practical dental health knowledge. This could be particularly relevant to cement industry workers, who may have limited awareness of proper brushing techniques. Although other factors were not statistically significant, both factory and office workers experienced abrasion, and age was the most influential factor, possibly due to prolonged exposure to abrasive particles. Attrition in factory workers was associated with age and smoking status, while in office workers, it was primarily influenced by age. This aligns with Sharma et al.12 who reported an increase in attrition among cement industry workers with advancing age. The abnormal loss of tooth structure due to attrition is a consequence of occupational exposure. Prolonged exposure to cement dust exacerbates tooth wear.12 It is plausible that cement industry workers may experience stress-induced bruxism, which can contribute to attrition.47–49 Although other factors were not statistically significant, both factory and office workers exhibited tooth wear, with age being the most prominent factor. However, smoking status significantly influenced tooth wear only among factory workers, suggesting a potential synergistic effect of occupational exposure and lifestyle factors.15 This study demonstrates that social determinants significantly influence the oral health of cement industry workers, particularly factory workers, due to physiological and psychological changes caused by hazardous working conditions and work schedules. However, office workers also face oral health challenges, primarily due to poor oral health behaviors, especially high sugar consumption. The study found a strong correlation between sugar intake and dental caries among cement industry workers, and it highlighted the influence of age, education, psychosocial factors, and shift work on periodontal disease. The conditions of abrasion and attrition are significantly influenced by age, which is related to the duration that teeth are exposed to abrasive materials. Untreated abrasion and attrition can heighten the risk of caries and progression to pulpitis. Pulpitis observed in cement industry workers often manifests in the form of abrasion and attrition. These findings indicate that the causes of caries may also stem from tooth wear. However, this aspect is frequently overlooked by dental clinicians, and there is a lack of adequate research references related to this finding. This study has several limitations. For instance, this research did not investigate the relationship between length of employment and oral health condition. The duration of employment in the cement industry may influence the development and severity of oral diseases, especially among long-term exposed workers. The study did not explore oral hygiene practices such as frequency and technique, which could provide additional insights into oral health outcomes. The gender distribution in this study was imbalanced, with a majority of male participants, which could potentially influence the results due to gender differences in oral health. The use of alternative stress assessment tools might yield different results. Further clinical research is needed to investigate cement-dust-induced tooth wear and develop effective preventive measures. By understanding social determinants and working conditions, we can identify the causes of oral health problems more precisely, prioritize at-risk groups, and address oral health issues equitably in the workplace. ACKNOWLEDGEMENTS The author would like to thank PT. 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