Income-related inequalities in dental service utilization by Europeans aged 50+

Inequalities in preventive and restorative dental services in England, Wales and Northern Ireland

Aims The objective of this study is to assess socioeconomic inequalities in the use of selected dental procedures.Methods Data is from the Adult Dental Health Survey 2009, a nationally representative cross-sectional survey of England, Northern Ireland and Wales. Overall, 6,279 participants were included in the analysis. Occupational classification and education were used to assess variations in the use of preventive, restorative services and tooth extraction using a series of logistic regression models, adjusting for age, sex, ethnicity, DMFT, self-reported oral health, dental visits and country.Results There were clear socioeconomic variations in the utilisation of preventive and restorative services. In the fully adjusted model those with no educational qualification were less likely to report ever having preventive services than those with a degree (OR 0.48, 95%CI: 0.36,0.65). Similarly, individuals in routine/manual occupation were significantly less likely to report ever having preventive services than those in managerial/professional occupation (OR 0.58, 95%CI: 0.46,0.74) in the fully adjusted model.Conclusion The findings imply that despite relatively equitable access and higher use of dental services in UK, the least educated and those at the bottom of social hierarchy are less likely to have preventive and restorative dental services.

Investigating social inequalities in older adults' dentition and the role of dental service use in 14 European countries

BACKGROUND

Oral disease, despite being largely preventable, remains the most common chronic disease worldwide and has a significant negative impact on quality of life, particularly among older adults.

OBJECTIVE

This study is the first to comprehensively and at a large scale (14 European countries) measure the social inequalities in the number of natural teeth (an informative oral health marker) in the over 50-year-old population and to investigate the extent to which such inequalities are attributable to dental service use.

METHODS

Using Wave 5 of the Survey of Health, Ageing and Retirement in Europe, which included internationally harmonized information on over 50,000 individuals across 14 European countries, we calculated Gini and Concentration indices (CI) as well as the decompositions of CIs by socioeconomic factors.

RESULTS

Sweden consistently performed the best with the lowest inequalities as measured by Gini (0.1078), CI by income (0.0392), CI by education (0.0407), and CI by wealth (0.0296). No country performed the worst in all inequality measures. However, unexpectedly, some wealthier countries (e.g., the Netherlands and Denmark) had higher degrees of inequalities than less-wealthy countries (e.g., Estonia and Slovenia). Decomposition analysis showed that income, education, and wealth contributed substantially to the inequalities, and dental service use was an important contributor even after controlling for income and wealth.

CONCLUSIONS

The study highlighted the importance of comprehensively investigating oral health inequalities. The results are informative to policymakers to derive country-specific health policy recommendations to reduce oral health inequalities in the older population and also have implications for oral health improvement of the future generations.

Inequality in Utilization of Dental Services: A Systematic Review and Meta-analysis

BACKGROUND

Dental diseases are among the most prevalent conditions worldwide, with universal access to dental care being one key to tackling them. Systematic quantification of inequalities in dental service utilization is needed to identify where these are most pronounced, assess factors underlying the inequalities, and evaluate changes in inequalities with time.

OBJECTIVES

To evaluate the presence and extent of inequalities in dental services utilization.

SEARCH METHODS

We performed a systematic review and meta-analysis by searching 3 electronic databases (MEDLINE, Embase, Cochrane Central Database), covering the period from January 2005 to April 2017.

SELECTION CRITERIA

We included observational studies investigating the association between regular dental service utilization and sex, ethnicity, place of living, educational or income or occupational position, or insurance coverage status. Two reviewers undertook independent screening of studies and made decisions by consensus.

DATA COLLECTION AND ANALYSIS

Our primary outcome was the presence and extent of inequalities in dental service utilization, measured as relative estimates (usually odds ratios [ORs]) comparing different (high and low utilization) groups. We performed random effects meta-analysis and subgroup analyses by region, and we used meta-regression to assess whether and how associations changed with time.

MAIN RESULTS

A total of 117 studies met the inclusion criteria. On the basis of 7 830 810 participants, dental services utilization was lower in male than female participants (OR = 0.85; 95% confidence interval [CI] = 0.74, 0.95; P < .001); ethnic minorities or immigrants than ethnic majorities or natives (OR = 0.71; 95% CI = 0.59, 0.82; P < .001); those living in rural than those living in urban places (OR = 0.87; 95% CI = 0.76, 0.97; P = .011); those with lower than higher educational position (OR = 0.61; 95% CI = 0.55, 0.68; P < .001) or income (OR = 0.66; 95% CI = 0.54, 0.79; P < .001); and among those without insurance coverage status than those with such status (OR = 0.58; 95% CI = 0.49, 0.68; P < .001). Occupational status (OR = 0.95; 95% CI = 0.81, 1.09; P = .356) had no significant impact on utilization. The observed inequalities did not significantly change over the assessed 12-year period and were universally present.

AUTHORS' CONCLUSIONS

Inequalities in dental service utilization are both considerable and globally consistent. Public Health Implications. The observed inequalities in dental services utilization can be assumed to significantly cause or aggravate existing dental health inequalities. Policymakers should address the physical, socioeconomic, or psychological causes underlying the inequalities in utilization.

Experience of dental care, knowledge and attitudes of older immigrants in Sweden-A qualitative study

OBJECTIVES

Knowledge about the oral health and dental care habits of older immigrants is limited. The aim of this study was to explore dental service utilization, oral care habits, and attitudes to and knowledge about oral diseases and their prevention among older immigrants in Sweden.

METHODS

A qualitative research method was used, and data were collected in individual interviews to gain a deeper understanding of the immigrants' views. Thirteen immigrants, seven women and six men, recruited from meeting places for older immigrants, participated, all aged between 59 and 88 (median 72 years). Interviews were tape-recorded and transcribed verbatim. Eight interviews were carried out with the help of an authorized interpreter.

RESULTS

In the analytical process, performed using the content analysis method, meaning units were identified and condensed into codes which were labelled and grouped into subcategories and categories. The interview analysis resulted in four categories: Experiences of dental care, Attitudes, Barriers and Prevention of oral diseases. The elderly immigrants described a mix of regular and acute dental care and were often not satisfied with the outcome of the treatments. They stated that oral health was important and that they were responsible for their own teeth. Barriers to dental care were costs, language problems and lack of confidence in dental services. Daily oral hygiene routines were performed using a traditional chewing stick and/or regular toothbrush.

CONCLUSION

The participants stated that, despite the barriers to treatment described above, they valued good oral health and visited dental services when they needed to.

Dental hygienist attendance and its covariates in an ageing Swedish cohort

Delegation of tasks between professional groups is important to make health-care services accessible and effective for ageing people. Focussing on a Swedish 1942 birth cohort and guided by Andersen's Behavioral Model, this study assessed dental hygienist attendance from age 50 to age 70 and identified covariates at the population-averaged and person-specific levels. In 1992, a census of 50-yr-old subjects was invited to participate in a questionnaire survey. Of the 6,346 respondents, 3,585 completed follow-ups in 1997, 2002, 2007, and 2012. Multiple logistic regression analysis was conducted using a marginal model and a random intercept model. Cochran's Q test revealed that significantly more respondents confirmed dental hygienist attendance in 2012 than in 1992 (57.2% in 2012 vs. 26.0% in 1992). Population-averaged ORs for dental hygienist attendance across time were 3.5 at age 70 yr compared with age 50 yr (baseline); 2.0 if being a regular rather than an irregular dental attendee; and 0.7 if being of non-native origin compared with native origin. The corresponding person-specific ORs were 8.9, 3.2, and 0.5. Consistent with Andersen's Behavioral Model, predisposing, enabling, and need-related factors were associated with dental hygienist attendance at population-averaged and person-specific levels. This has implications for promoting dental hygienist attendance among ageing people.

Association between socio-economic status and dental caries in elderly people in Sichuan Province, China: a cross-sectional study

OBJECTIVES

As a vulnerable group, the elders' oral health gained less attention, particularly the relationship between socioeconomic status (SES) and dental caries. This study aimed to assess the associations and to explore the effects of confounders on the associations in elderly people.

DESIGN

Cross-sectional study.

SETTINGS

3 neighbourhood committees and 3 village committees in Sichuan Province, China.

PARTICIPANTS

744 people (362 men and 382 women) aged 65-74 years were included.

OUTCOME MEASURES

Oral health outcomes included the decayed, missing and filled teeth (DMFT) index and its components. SES was assigned by educational level, household income and type of household. The bivariate association between the participants' characteristics and DMFT was analysed using non-parametric tests. Four logistic regression models were used to analyse the associations between SES and dental caries by regulating confounders.

RESULTS

Poor oral health was observed in these participants. Bivariate analysis showed a significant association between SES and DMFT (p﹤0.05). Only adjusting gender, high educational level (adjusted (AOR)=0.34, 95% CI 0.17 to 0.66), high household income (AOR=0.47, 95% CI 0.41 to 0.77) were protective factors against dental caries, and living in agricultural families (AOR=1.86, 95% CI 1.32 to 2.63) was risk factor (p﹤0.05). After adjusting other confounders, SES was partly related to the dental caries. Moreover, an interaction existed among SES indicators.

CONCLUSIONS

SES is associated with dental caries, and older people with low SES have poor oral health. The associations were explained partly by diet, behaviour and awareness. Our results provide effective evidence in targeted policy-making and intervention measures and implicate that pertinence measures, economic assistance and medical insurance funds should be provided to older people of low SES. Furthermore, a follow-up design should attempt to confirm the causal relationship between SES and dental caries and evaluate the effect of intervention.

Enabling and Predisposing Factors for the Utilization of Preventive Dental Health Care in Migrants and Non-Migrants in Germany

Background

In many European countries including Germany, migrants utilize preventive services less frequently than the majority population. This is also true for the utilization of dental checkups. Little is known about which demographic, social, behavioral, and health-related factors influence the decision of migrants to seek preventive dental health care and how these factors differ from those in non-migrants. The aim of the present study was to examine the role of these factors among migrants and non-migrants residing in Germany.

Methods

Data from cross-sectional national health surveys are used, providing information on preventive dental health behavior from n = 41,220 individuals, of which 15.0% are migrants. Andersen’s Behavioral Model of Health Services Use is the conceptual framework of the investigation. Multiple logistic regression models were applied to examine the role of different predisposing and enabling factors. Interaction terms were included in order to examine whether determinants differ between migrants and non-migrants. Average marginal effects (AMEs) are reported in addition to odds ratios (ORs) as measures of effect size which are robust against bias arising from unobserved heterogeneity.

Results

Migrants are at an about 36% lower chance of utilizing regular dental checkups than non-migrants [OR = 0.64 (95% confidence interval, 95% CI: 0.61, 0.68); AME = −0.081 (95% CI = −0.093, −0.069)]. Differences are partly explained by the influence of demographic, social, behavioral, and health-related factors [adjusted OR = 0.69 (95% CI: 0.64, 0.73); AME = −0.065 (95% CI = −0.076, −0.053)]. Younger age, being male, lower socioeconomic status, a non-statutory health insurance, not living in a relationship, living in the Western part of Germany and in an urban setting, and poor limited social support were associated with a lower chance of utilizing regular dental checkups. Interaction effects could be observed for age and for the type of health insurance.

Discussion

The study identifies different enabling and predisposing factors that are relevant for the utilization of dental checkups among the population in Germany, some of which differ between migrants and non-migrants. Differences are particularly pronounced for younger ages. This differs from findings on other preventive services where older migrants tend to be more disadvantaged. Additional explanatory factors such as barriers that migrants experience in the dental health care system need to be considered in order to implement patient-oriented services and to reduce disparities in access to dental prevention.

Measuring socioeconomic inequalities in the use of dental care services among older adults in Brazil

OBJECTIVES

The primary objectives are to assess socioeconomic inequality in the use of dental care among older Brazilian adults and to analyse the extent to which certain determinants contribute to that inequality.

METHODS

A cross-sectional study using data from the National Oral Health Survey conducted in 2010. All individuals answered a structured questionnaire containing questions on their use of dental care and socioeconomic conditions and underwent a clinical oral examination by a dentist. Concentration indices were decomposed to determine the contribution of socioeconomic factors to inequalities.

RESULTS

Being in the fifth wealth, quintile was associated with higher odds of having recently visited a dentist (reference: 1st quintile, odds-ratio (OR) 2.26, 95% confidence interval (CI) 1.51-3.38). In addition, being in the top two quintiles of wealth was negatively associated with the use of public dental services. Having eight or more years of schooling was associated with higher odds of both having a recent dental visit and receiving preventive care (relative to having 0-3 years of education), and negatively associated with using public dental services. Results indicate pro-rich inequalities in recent dental visits and preventive dental care. Further, there was a pro-poor inequality in the use of public dental care services.

CONCLUSIONS

The recent use of dental care and the use of preventive care are disproportionately concentrated among wealthier older adults, whereas the use of public services is more common among poorer individuals. Wealth inequalities in dental care use were mainly explained by socioeconomic factors, such as wealth and education, rather than oral health factors, such as needing treatment or a dental prosthesis.

Dental care attendance and refrainment from dental care among adults

OBJECTIVE

The aim of this study was to analyse dental care utilization, refrainment from self-perceived needed dental care and the association with socioeconomic indicators among adult individuals.

MATERIALS AND METHODS

This cross-sectional survey included 3500 randomly selected adult individuals. Telephone interviews were conducted and the participants answered a battery of questions regarding dental visiting habits, health, socioeconomic position (SEP), behavioural factors and lifestyle indicators.

RESULTS

The outcome 'dental visits' was significantly correlated with SEP, especially with monetary dimensions, such as income and economic resources for unforeseen expenditures. However, educational level was not a significant predictor in the tested statistical models. Furthermore, other covariates that contributed significantly to the models were ethnicity, dental anxiety and lifestyle factors, albeit with a different pattern of impact on the two outcome dimensions. Important features of the SEP variables were the stepwise gradient relative to the outcomes, implicating that the lower the SEP status, the greater the risk of reporting irregular dental visiting habits and refraining from dental care due to financial problems.

CONCLUSIONS

Dental care utilization and refraining from dental care for financial reasons clearly reveal associations with socioeconomic positions among adult individuals.

Interventions for enhancing the distribution of dental professionals: a concise systematic review

BACKGROUND

A spatially unequal distribution of dentists or dental care professionals (D/DCPs), such as therapists or hygienists, could reduce the quality of health services and increase health inequities. This review describes the interventions available to enhance this spatial distribution and systematically assesses their effectiveness.

METHODS

Electronic databases (Cochrane CENTRAL, Medline, Embase, CINAHL) were searched and cross-referencing was performed using a standardised searching algorithm. Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series were included. Studies investigating a minimum of one of four interventions (educational, financial, regulatory and supportive) were included. The primary outcome was the spatial distribution of D/DCPs. Secondary outcomes were access, quality of services and equity or adverse effects. This review was registered (CRD42015026265).

RESULTS

Of 4,885 articles identified, the full text of 201 was assessed and three (all investigating national policy interventions originally not aiming to change the distribution of D/DCPs) were included. In one Japanese study spanning 1980 to 2000, the unequal spatial distribution of dentists decreased alongside a general increase in the number of dentists. It remained unclear if these findings were associated. In a second Japanese study, an increase in the number of dentists was found in combination with a postgraduate training programme implemented in 2006, and this occurred alongside an increasingly unequal distribution of dentists, again without proof of cause and consequence. A third study from Taiwan found the introduction of a national universal-coverage health insurance to equalise the distribution of dentists, with statistical association between this equalisation and the introduction of the insurance.

CONCLUSIONS

The effectiveness of interventions to enhance the spatial distribution of D/DCPs remains unclear.

Oral health behaviour in migrant and non-migrant adults in Germany: the utilization of regular dental check-ups

Background

Migrants in many European countries including Germany tend to utilize preventive measures less frequently than the majority population. Little is known about the dental health of migrants as well as about their oral health behaviour, particularly in the adult population. The aim of this study was to examine differences in the uptake of annual dental check-ups in adult migrants and non-migrants in Germany.

Methods

We used data from the cross-sectional survey ‘German Health Update 2010’ conducted by the Robert Koch Institute (n = 22,050). Data from 21,741 German-speaking respondents with information on the use of dental check-ups was available, of which 3404 (15.7%) were migrants. Multiple logistic regression models were applied to adjust for demographic and socioeconomic confounders, including the place of residence as well as type of health insurance.

Results

Migrants were generally younger, had a lower socioeconomic status and showed a lower utilization of dental check-ups. The unadjusted odds ratio (OR) for utilization was 0.67 (95%-CI = 0.61–0.73). After adjusting for demographic and socioeconomic confounders the chance only increased slightly (adjusted OR = 0.71; 95%-CI = 0.65–0.77).

Conclusions

The analysis shows that migration status is associated with a reduced chance of attending dental check-ups, independently of demographic and socioeconomic factors. The influence of other factors, such as type of health insurance and place of residence had also no influence on the association. Migrants are exposed to different barriers in the health care system, comprising the patient, provider and system level. Further studies need to examine the relevant barriers for the uptake of preventive dental services in order to devise appropriate migrant- sensitive measures of dental prevention.

Income-Related Inequalities in Access to Dental Care Services in Japan

Background: This study aimed to evaluate whether income-related inequalities in access to dental care services exist in Japan. Methods: The subjects included beneficiaries of the National Health Insurance (NHI) in Chiba City, Japan, who had been enrolled from 1 April 2014 to 31 March 2015. The presence or absence of dental visits and number of days spent on dental care services during the year were calculated using insurance claims submitted. Equivalent household income was calculated using individual income data from 1 January to 31 December 2013, declared for taxation. Results: Of the 216,211 enrolled subjects, 50.3% had dental care during the year. Among those with dental visits, the average number of days (standard deviation) spent on dental care services per year was 7.7 (7.1). Low income was associated with a decreased rate of dental care utilization regardless of age and sex. However, there was a significant inverse linear association between the number of days spent on dental care services and income levels for both sexes. Conclusions: There were income-related inequalities in access to dental care services, regardless of the age group or sex, within the Japanese universal health insurance system.

Higher education in Gerodontology in European Universities

Background

The rapid aging of the European population and the subsequent increase in the oral care needs in older adults necessitates adequate training of dental professionals in Gerodontology (Geriatric Dentistry). This study was designed to investigate the current status of Gerodontology teaching amongst European dental schools at the undergraduate, postgraduate and continuing education levels.

Methods

An electronic questionnaire was developed by a panel of experts and emailed to the Deans or other contact persons of 216 dental schools across 39 European countries. The questionnaire recorded activity levels, contents and methodology of Gerodontology teaching as part of dental education programs. Repeated e-mail reminders and telephone calls were used to encourage non-responders to complete the questionnaire.

Results

A total of 123 responses from 29 countries were received (response rate: 56.9%). Gerodontology was taught in 86.2% of schools at the undergraduate level, in 30.9% at the postgraduate level and in 30.1% at the continuing education level. A total of 43.9% of the responding schools had a dedicated Gerodontology program director. Gerodontology was taught as an independent subject in 37.4% of the respondent schools. Medical problems in old age, salivary impairment and prosthodontic management were the most commonly covered topics in Gerodontology teaching. Clinical teaching took place in 64.2% of the respondent schools, with 26.8% offering clinical training in outreach facilities.

Conclusions

The vast majority of European dental schools currently teach Gerodontology at the undergraduate level. More training opportunities in oral care of frail elders should be offered, and more emphasis should be placed on interdisciplinary and interprofessional training, educational collaborations, and the use of modern technologies. Dedicated postgraduate Gerodontology courses need to be developed to create a significant number of specialized dentists and trained academics.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-017-0362-9) contains supplementary material, which is available to authorized users.

Older people's description of factors that facilitate and impede regular dental care - a qualitative interview study

OBJECTIVES

The aim of this study was to achieve an understanding of older people's view of the benefits of regular dental care and investigate factors that facilitate and impede regular dental care.

METHODS

A qualitative research method was used. To gain a deeper understanding of the elderly people's views, individual interviews were conducted. Fifteen respondents, eleven women and four men aged between 65 and 95, participated, all recruited from senior social centres. All interviews were tape-recorded and transcribed verbatim, and the content analysis method was then used. Meaning units were identified and condensed into codes which were labelled and grouped into categories and subcategories.

RESULTS

Findings were grouped into three categories: experiences of dental care, obstacles and facilitators to dental care and about oral health and responsibility. The elderly had experience of both regular and irregular dental care. Obstacles to visiting dental services included high costs and complicated dental insurance, other practical obstacles, lack of confidence in dentistry and seeing no benefits of dental care at their age. Views of the importance of oral health varied, and some people thought poor teeth were shameful. Some expressed that oral health was your own responsibility, while others thought that oral health was the responsibility of the dental services.

CONCLUSIONS

Several factors which hamper regular dental care have been identified, and taken together, these obstacles often became unsurmountable. However, individuals taking their own responsibility for their dental status and dental services making certain adaptations, both encourage people to seek regular dental care.

Oral health status in older immigrants in a medium-sized Swedish city

AIM

The aim of the study was to investigate oral health and oral care habits among older immigrants to Sweden from countries outside the Nordic region.

METHOD

Participants ≥60 years of age from senior social centers for immigrants were invited to attend oral examinations. Data was collected on the number of teeth, dentures, caries, periodontal status, saliva secretion, and plaque scores. Participants also described their general health and oral care habits.

RESULTS

Fourteen men and 28 women, median age 71.5 years, participated. Seventeen percent were edentulous, women often than men. Three out of four had caries and 63% had gingival bleeding. Two-thirds brushed their teeth twice per day and 60% had visited dental services in the last 2 years.

CONCLUSION

The group had a high prevalence of oral diseases and discomfort. They used dental services and brushed their teeth less frequently than Swedish populations of the same age.

Economic inequalities in dental care utilizations in Iran: Evidence from an urban region

BACKGROUND

Health utilization inequality is a major concern for health policymakers. Equality in utilization of services is very important for having a healthy society. The aim of this study was to describe inequality in dental care utilization in Iran, Therefore, concentration index, its curve, and the predictors of inequality in utilization of dental services and their spending were calculated.

METHODS

Data of a health utilization survey which previously had been gathered in Shiraz, Iran were used for this study. Tobit and Poisson estimators were used to estimate utilization and out of pocket models. Furthermore, concentration index and curve was calculated to show inequality in dental care utilization.

RESULTS

High inequalities was found in dental care utilization in Iran (concentration index=0.19). In the utilization model, the relationship between income and utilization was positive. People with higher income could utilize more services. Being covered by insurance increased the probability of dental care utilizations too.

CONCLUSION

Policy makers must find solutions like increase the coverage of dental insurances to decrease inequality in dental care utilization.

Differing types of medical prevention appeal to different individuals

We analyze participation in medical prevention with an expected utility model that is sufficiently rich to capture diverging features of different prevention procedures. The predictions of the model are not rejected with data from SHARE. A decrease in individual health decreases participation in breast cancer screening and dental prevention and increases participation in influenza vaccination, cholesterol screening, blood pressure screening, and blood sugar screening. Positive income effects are most pronounced for dental prevention. Increased mortality risk is an important predictor in the model for breast cancer screening, but not for the other procedures. Targeted screening and vaccination programs increase participation.

Wealth-related versus income-related inequalities in dental care use under universal public coverage: a panel data analysis of the Japanese Study of Aging and Retirement

BACKGROUND

There is a substantial body of evidence of income-related inequalities in dental care use, attributed to the fact that dental care is often not covered by public health insurance. Wealth-related inequalities have also been shown to be greater than income-related inequalities. Japan is one of the exceptions, as the the universal pubic health insurance system has covered dental care. The aim of this study was therefore to compare wealth- and income-related inequalities in dental care use among middle-aged and older adults in Japan to infer the mechanisms of wealth-related inequalities in dental care use.

METHODS

Data were derived from the Japanese Study of Aging and Retirement, a survey of community-dwelling middle-aged and older adults living in five municipalities in eastern Japan. Of the participants in the second wave conducted in 2009, we analyzed 2581 residents. Dental care use was measured according to whether the participant had been seen by a dentist or a dental hygienist in the past year. The main explanatory variables were income and wealth (financial assets, real assets and total wealth). The need for dental care was measured using age, the use of dentures and chewing ability. The concentration indices for the distribution of actual and need-standardized dental care use were calculated.

RESULTS

Among the respondents, 47.9% had received dental care in the past year. The concentration index of actual dental care use (CI) showed a pro-rich inequality for both income and wealth. The CIs for all three wealth measures were larger than that for income. A broadly comparable pattern was seen after need-standardization (income: 0.020, financial assets: 0.035, real assets: 0.047, total wealth: 0.050).

CONCLUSIONS

The results showed that wealth-related inequalities in dental care use were greater than income-related inequalities in Japan, where most dental care is covered by the public health insurance system. This suggests that wealth-related inequalities in dental care use cannot be explained by economic budget constraints alone. Further studies should investigate the mechanisms of wealth-related inequalities in dental care use.

Disparity in dental attendance among older adult populations: a comparative analysis across selected European countries and the USA

BACKGROUND

The current study addresses the extent to which diversity in dental attendance across population subgroups exists within and between the USA and selected European countries.

METHOD

The analyses relied on 2006/2007 data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and 2004-2006 data from the Health and Retirement Study (HRS) in the USA for respondents≥51 years of age. Logistic regression models were estimated to identify impacts of dental-care coverage, and of oral and general health status, on dental-care use.

RESULTS

We were unable to discern significant differences in dental attendance across population subgroups in countries with and without social health insurance, between the USA and European countries, and between European countries classified according to social welfare regime. Patterns of diverse dental use were found, but they did not appear predominately in countries classified according to welfare state regime or according to the presence or absence of social health insurance.

CONCLUSIONS

The findings of this study suggest that income and education have a stronger, and more persistent, correlation with dental use than the correlation between dental insurance and dental use across European countries. We conclude that: (i) higher overall rates of coverage in most European countries, compared with relatively lower rates in the USA, contribute to this finding; and that (ii) policies targeted to improving the income of older persons and their awareness of the importance of oral health care in both Europe and the USA can contribute to improving the use of dental services.

Community factors predicting dental care utilization among older adults

BACKGROUND

Few investigators have studied the influence of community factors on dental care utilization among older adults. The authors' objective in this study was to investigate the effect of community factors on dental care utilization after adjustment for individual factors.

METHODS

Using data from a cross-sectional survey of Ohio residents, the authors assessed dental care utilization in a sample of 2,166 adults 65 years or older. They linked individual-level dental care utilization, predisposing factors (age, sex, race or ethnicity, marital status, education), enabling factors (poverty, dental insurance) and need-related factors (physical and mental health problems) with county-level data (socioeconomic environment and health resource environment) from the 2010 Area Health Resource Files (from the U.S. Department of Health and Human Services) and the American Community Survey (from the 2006-2010 U.S. census). By using multilevel logistic regression models, the authors evaluated the association between dental care utilization and community factors after adjustment for individual factors.

RESULTS

The results indicated that individual factors such as being female, married and nonpoor and having a higher educational level and private dental insurance were associated with higher odds of having utilized dental care. Furthermore, older adults living in a county with a higher dentist-to-population ratio were more likely to use dental services even after the authors adjusted the results for the individual-level factors (odds ratio = 1.10; P = .03).

CONCLUSIONS

County-level dentist-to-population ratio has independent effects on older adults' dental care utilization even after adjustment for individual-level characteristics. Practical Implications. A comprehensive policy plan is required to intervene at both the individual and community levels to improve dental care utilization among older adults. By understanding the factors influencing dental care utilization among older adults, U.S. dentists will be better positioned to meet the dental needs of this population.

Contextual and individual indicators associated with the presence of teeth in adults

OBJECTIVE The objective of this study was to analyze whether socioeconomic conditions and the period of availability of fluoridated water are associated with the number of teeth present. METHODS This cross-sectional study analyzed data from 1,720 adults between 20 and 59 years of age who resided in Florianópolis, SC, Southern Brazil, in 2009. The outcome investigated was the self-reported number of teeth present. The individual independent variables included gender, age range, skin color, number of years of schooling, and per capita household income. The duration of residence was used as a control variable. The contextual exposures included the period of availability of fluoridated water to the households and the socioeconomic variable for the census tracts, which was created from factor analysis of the tract's mean income, education level, and percentage of households with treated water. Multilevel logistic regression was performed and inter-level interactions were tested. RESULTS Residents in intermediate and poorer areas and those with fluoridated water available for less time exhibited the presence of fewer teeth compared with those in better socioeconomic conditions and who had fluoridated water available for a longer period (OR = 1.02; 95%CI 1.01;1.02). There was an association between the period of availability of fluoridated water, per capita household income and number of years of education. The proportion of individuals in the poorer and less-educated stratum, which had fewer teeth present, was higher in regions where fluoridated water had been available for less time. CONCLUSIONS Poor socioeconomic conditions and a shorter period of availability of fluoridated water were associated with the probability of having fewer teeth in adulthood. Public policies aimed at reducing socioeconomic inequalities and increasing access to health services such as fluoridation of the water supply may help to reduce tooth loss in the future.

Changes in socioeconomic inequalities in the use of dental care following major healthcare reform in Chile, 2004-2009

The study examines changes in the distribution and socioeconomic inequalities of dental care utilization among adults after the major healthcare reform in Chile, 2004-2009. We evaluated the proportion of people who visited the dentist at least once in the previous two years, and the mean number of visits. These outcome variables were stratified by sex, age (20-39, 40-59, 60-63; ≥64 years), educational level (primary, secondary, higher), type of health insurance (public, private, uninsured), and socioeconomic status (quintiles of an asset-index). We also used the concentration index (CIndex) to assess the extent of socioeconomic inequalities in the use of dental care, stratified by age and sex as a proxy for dental care needs. The use of dental care significantly increased between 2004 and 2009, especially in those with public health insurance, with lower educational level and lower socioeconomic status. The CIndex for the total population significantly decreased both for the proportion who used dental care, and also the mean number of visits. Findings suggest that the use of dental care increased and socioeconomic-related inequalities in the utilization of dental care declined after a Major Health Reform, which included universal coverage for some dental cares in Chile. However, efforts to ameliorate these inequalities require an approach that moves beyond a sole focus on rectifying health coverage.

Income-related inequality and inequity in the use of dental services in Finland after a major subsidization reform

OBJECTIVES

In Finland, a major oral healthcare reform (OHCR), implemented during 2001-2002, opened the public dental services (PDS) and extended subsidies for private dental services to entire adult population. Before the reform, adults born earlier than 1956 were not entitled to use PDS nor did they receive any reimbursements for their private dental costs. We aimed to examine changes in the income-related inequality and inequity in the use of dental services among the adult Finns after the reform.

METHODS

Representative data from Finnish adults born in 1970 or earlier were gathered from three identical postal surveys concerning the use of dental services and subjective perceptions of oral health. Those surveys were conducted before the OHCR in 2001 (n = 1907) and after the OHCR in 2004 (n = 1629) and 2007 (n = 1509). We used concentration index and its decomposition to analyse income-related inequality and inequity in the use of dental services and factors associated with them.

RESULTS

Results showed that pro-rich inequality and inequity in the overall use of dental services narrowed from 2001 to 2004. However, between 2004 and 2007, pro-rich inequality and inequity widened, so it returned to a rather similar level in 2007 as it had been in 2001. Most of the pro-rich inequality and inequity were related to regular dental visiting habit and income level. While there was pro-poor inequality and inequity in the use of PDS, there was pro-rich inequality and inequity in the use of private dental services throughout the study years.

CONCLUSION

It seems that income-related inequality and inequity in the use of dental services narrowed only temporarily after the reform.

Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries

A key policy objective in OECD countries is to achieve adequate access to health care for all people on the basis of need. Previous studies have shown that there are inequities in health care services utilisation (HCSU) in the OECD area. In recent years, measures have been taken to enhance health care access. This paper re-examines income-related inequities in doctor visits among 18 selected OECD countries, updating previous results for 12 countries with 2006-2009 data, and including six new countries. Inequalities in preventive care services are also considered for the first time. The indirect standardisation procedure is used to estimate the need-adjusted HCSU and concentration indexes are derived to gauge inequalities and inequities. Overall, inequities in HCSU remain present in OECD countries. In most countries, for the same health care needs, people with higher incomes are more likely to consult a doctor than those with lower incomes. Pro-rich inequalities in dental visits and cancer screening uptake are also found in nearly all countries, although the magnitude of these varies among countries. These findings suggest that further monitoring of inequalities is essential in order to assess whether country policy objectives are achieved on a regular basis.

Inequities in health care utilization by people aged 50+: evidence from 12 European countries

The aim of this study is to describe the magnitude of educational inequities in the use of health care services, by people aged 50+, in 12 European countries, controlling for country-level heterogeneity. We consider four services: having seen or talked to 1) a general practitioner (GP) or 2) specialist, 3) having been hospitalized, and 4) having visited a dentist (only for prevention). Data derived from the SHARE (Survey of Health, Ageing and Retirement in Europe) project, a cross-national panel that collects information from individuals aged 50 and over. A Fixed Effects approach is applied, which is a valuable alternative to the application of conventional multilevel models in country-comparative analysis. The main findings of this study confirm that there is substantial educational inequity in the use of health care, although relevant differences arise between services. A clear pro-educated gradient is found for specialists and dentist visits, whereas no evidence of educational disparities was found for GP use. On the other hand, less clear results emerge regarding hospitalizations. However, the analysis shows that micro-level dimensions, i.e. individual needs and predisposing and enabling population characteristics, and macro level factors, i.e. health care system and welfare regime, interact to determine people's use of health services. It can be concluded that people with more education level have more resources (cognitive, communicative, relational) that allow them to make more informed choices and take more effective actions for their health goals, however, the institutional context may modify this relationship.

Life-course social influences on tooth loss and oral attitudes among older people: evidence from a prospective cohort study

This study examined the relationship of trajectories in social condition with oral attitudes and major tooth loss, using the social mobility and accumulation life-course models in a cohort. Whether social-condition inequalities remained stable or changed from 65 yr of age to 70 yr of age was investigated. In 1992, 6,346 inhabitants born in 1942 and residing in two Swedish counties agreed to participate in a prospective survey. Of the participants in 1992, 3,585 (47.6% men) completed questionnaires in 1997, 2002, 2007, and 2012. In line with the social-mobility model, the prevalence of negative oral attitudes and major tooth loss in participants at 65 and 70 yr of age showed a consistent gradient according to social-condition trajectory, whereby it was lowest among those who were persistently high and highest among those who were persistently low, with the upwardly and downwardly mobile categories being intermediate. A linear graded association between the number of periods with disadvantaged social condition and oral health supported the accumulation model. Both the social mobility and accumulation life-course models were supported. Social-condition differentials in negative oral attitudes and tooth loss seem to remain stable or to narrow weakly after the usual age of retirement.

Dental health among older Israeli adults: is this a reflection of a medical care model inadequately addressing oral health?

OBJECTIVES

Israel's health-care system is considered as one of the most efficient worldwide. The purpose of the present study was to assess oral health outcomes, dental care use and respective social inequalities among the older segment of the Israeli population.

METHODS

Secondary analyses were conducted of recently available data from the Survey of Health, Ageing, and Retirement in Europe (SHARE Israel, wave 2), which specifically includes information on chewing ability, denture wearing and dental care use obtained from more than 2,400 Israeli people, 50+ years of age. Multivariate logistic regressions and concentration indices were used to analyse determinants of oral health and dental care use.

RESULTS

Seventy per cent of respondents reported being able to bite/chew on hard foods and 49% of respondents reported wearing dentures. Forty-three per cent of respondents had visited a dentist within the past 12 months, with about half of all dental visits being made for solely nonpreventive reasons. Significant income-related inequalities were identified, with higher income being associated with greater dental care use (particularly preventive dental visits), better chewing ability and less denture wearing.

CONCLUSIONS

For the older segment of the Israeli population and compared with other countries, the findings of the present study suggest a relatively low level of chewing ability, a high extent of nonpreventive dental visiting, as well as considerable inequalities in oral health and care. It seems that the Israeli health-care system may be improved even further by more comprehensive inclusion of dental care into universal health coverage.

Association between the longest job and oral health: Japan Gerontological Evaluation Study project cross-sectional study

Background

Inequality in oral health is a major challenge. Oral diseases and their risk factors accumulate throughout life. The objective of this cross-sectional study was to examine the association of longest job with oral health status and oral health behavior among older Japanese.

Methods

Subjects were a total of 23,191 (11,310 males and 11,881 females) community-dwelling individuals aged 65 or over, living independently and able to perform daily activities from 30 municipalities across Japan. The outcome variables were oral health status (number of teeth, use of denture or bridge and subjective oral health status) and oral health behavior (dental visit for treatment and use of interdental brush or dental floss). The longest job was used as an explanatory variable. Age, educational attainment, equivalent income, and densities of dentists and population in municipalities were used as covariates. Two-level (first level: individual, second level: municipality) multilevel Poisson regression analyses were performed for each sex.

Results

Multilevel Poisson regression analyses showed that all variables of oral health status and oral health behavior were significantly associated with longest job after adjusting for all covariates except denture/bridge use and dental visit for females. People whose longest jobs were sales/service, skilled/labor, agriculture/forestry/fishery or others, or who had no occupation were more likely to have poor oral health status and oral health behavior compared to those whose longest jobs were professional/technical.

Conclusions

The longest job may be one of the major determinants of oral health status and oral health behavior in Japanese older people.

Forgoing dental care for economic reasons in Switzerland: a six-year cross-sectional population-based study

Background

While oral health is part of general health and well-being, oral health disparities nevertheless persist. Potential mechanisms include socioeconomic factors that may influence access to dental care in the absence of universal dental care insurance coverage. We investigated the evolution, prevalence and determinants (including socioeconomic) of forgoing of dental care for economic reasons in a Swiss region, over the course of six years.

Methods

Repeated population-based surveys (2007–2012) of a representative sample of the adult population of the Canton of Geneva, Switzerland. Forgone dental care, socioeconomic and insurance status, marital status, and presence of dependent children were assessed using standardized methods.

Results

A total of 4313 subjects were included, 10.6% (457/4313) of whom reported having forgone dental care for economic reasons in the previous 12 months. The crude percentage varied from 2.4% in the wealthiest group (monthly income ≥13,000CHF, 1CHF ≈ 1$) to 23.5% among participants with the lowest income (<3,000CHF). Since 2007/8, forgoing dental care remained stable overall, but in subjects with a monthly income of <3,000CHF, the adjusted percentage increased from 16.3% in 2007/8 to 20.6% in 2012 (P trend = 0.002). Forgoing dental care for economic reasons was independently associated with lower income, younger age, female gender, current smoking, having dependent children, divorced status and not living with a partner, not having a supplementary health insurance, and receipt of a health insurance premium cost-subsidy.

Conclusions

In a Swiss region without universal dental care insurance coverage, prevalence of forgoing dental care for economic reasons was high and highly dependent on income. Efforts should be made to prevent high-risk populations from forgoing dental care.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6831-14-121) contains supplementary material, which is available to authorized users.

Income-related inequalities in preventive and curative dental care use among working-age Japanese adults in urban areas: a cross-sectional study

Background

Preventive dental care use remains relatively low in Japan, especially among working-age adults. Universal health insurance in Japan covers curative dental care with an out-of-pocket payment limit, though its coverage of preventive dental care is limited. The aim of this study was to test the hypothesis that income inequality in dental care use is found in preventive, but not curative dental care among working-age Japanese adults.

Methods

A cross-sectional survey was conducted using a computer-assisted, self-administered format for community residents aged 25–50 years. In all, 4357 residents agreed to participate and complete the questionnaire (valid response rate: 31.3%). Preventive dental care use was measured according to whether the participant had visited a dentist or a dental hygienist during the past year for dental scaling or fluoride or orthodontic treatments. Curative dental care use was assessed by dental visits for other reasons. The main explanatory variable was equivalent household income. Logistic regression analyses with linear trend tests were conducted to determine whether there were significant income-related gradients with curative or preventive dental care use.

Results

Among the respondents, 40.0% of men and 41.5% of women had used curative dental care in the past year; 24.1% of men and 34.1% of women had used preventive care. We found no significant income-related gradients of curative dental care among either men or women (p = 0.234 and p = 0.270, respectively). Significant income-related gradients of preventive care were observed among both men and women (p < 0.001 and p = 0.003, respectively). Among women, however, income-related differences were no longer significant (p = 0.126) after adjusting for education and other covariates. Compared with men with the lowest income, the highest-income group had a 1.79-fold significantly higher probability for using preventive dental care.

Conclusions

The prevalence of preventive dental care use was lower than that of curative care. The results showed income-related inequality in preventive dental care use among men, though there were no significant income-related gradients of curative dental care use among either men or women. Educational attainment had a positive association with preventive dental care use only among women.

Socio-demographic profile of child and adolescent users of oral health services in Victoria, Australia

The aim of this study was to investigate the socio-demographic characteristics of the eligible population of users of public oral health care services in the Australian state of Victoria, aged 17 years or younger. The study was conducted as a secondary analysis of data collected from July 2008 to June 2009 for 45,728 young clients of public oral health care. The sample mean age was 8.9 (SD: 3.5) years. The majority (82.7%) was between 6 and 17 years of age, and 50.3% were males. The majority (76.6%) was Australian-born and spoke English at home (89.1%). The overall mean DMFT was 1.0 (SD: 2.1) teeth, with a mean dmft of 3.16 (SD: 5.79) teeth. Data indicate that, among six year olds in the Significant Caries Index (SiC) category, the mean dmft was 6.82 teeth. Findings corroborate social inequalities in oral health outcome and provide suggestions for oral health services to develop strategies and priorities to reduce inequalities in health and well-being, and better coordinate and target services to local needs.

Oral health conditions and cognitive functioning in middle and later adulthood

Background

The purpose of the present study was to examine the impact of oral health conditions on cognitive functioning on basis of data samples from several European countries.

Methods

Secondary analyses were conducted of data from wave 2 of the Survey of Health, Ageing, and Retirement in Europe (SHARE) which includes 14 European countries and is intended to be representative of each country’s middle and later adulthood population. Information on word recall, verbal fluency, and numeracy as well as information on chewing ability and denture wearing status was available for a total of 28,693 persons aged 50+. Multivariate regression analysis was used to detect influences of oral health parameters on cognitive functioning (p < 0.05).

Results

Persons with good chewing ability or without dentures had significantly better word recall, verbal fluency, and numeracy skills than persons with chewing impairment or with dentures. The observed patterns of parameter estimates imply differential oral health impacts on numeracy compared to word recall and verbal fluency.

Conclusions

The present study provides novel large-scale epidemiological evidence supportive of an association between oral health and cognitive functioning. Future research should intend to verify the precise causal links between oral health conditions, various cognitive dimensions, and their neural correlates.

Socioeconomic inequalities in the use of dental care services in Europe: what is the role of public coverage?

OBJECTIVES

The aim of this study was to analyse inequalities in the use of dental care services according to socioeconomic position (SEP) in individuals aged ≥50 years in European countries in 2006, to examine the association between the degree of public coverage of dental services and the extent of inequalities, and specifically to determine whether countries with higher public health coverage show lower inequalities.

METHODS

We carried out a cross-sectional study of 12 364 men and 14 692 women aged ≥50 years from 11 European countries. Data were extracted from the second wave of the Survey of Health, Ageing and Retirement in Europe (SHARE 2006). The dependent variable was use of dental care services within the previous year, and the independent variables were education level as a measure of SEP, whether services were covered to some degree by the country's public health system, and chewing ability as a marker of individuals' need for dental services. Age-standardized prevalence of the use of dental care as a function of SEP was calculated, and age-adjusted indices of relative inequality (RII) were computed for each type of dental coverage, sex and chewing ability.

RESULTS

Socioeconomic inequalities in the use of dental care services were higher in countries where no public dental care cover was provided than in countries where there was some degree of public coverage. For example, men with chewing ability from countries with dental care coverage had a RII of 1.39 (95%CI: 1.29-1.51), while those from countries without coverage had a RII of 1.96 (95%CI: 1.72-2.23). Women without chewing ability from countries with dental care coverage had a RII of 2.15 (95%CI: 1.82-2.52), while those from countries without coverage had a RII of 3.02 (95%CI: 2.47-3.69).

CONCLUSIONS

Dental systems relying on public coverage seem to show lower inequalities in their use, thus confirming the potential benefits of such systems.

Socioeconomic inequalities in the non-use of dental care in Europe

INTRODUCTION

Oral health is an important component of people's general health status. Many studies have shown that socioeconomic status is an important determinant of access to health services. In the present study, we explored the inequality and socioeconomic factors associated with people's non-use of dental care across Europe.

METHODS

We obtained data from the European Union Statistics on Income and Living Conditions survey conducted by Eurostat in 2007. These cross-sectional data were collected from people aged 16 years and older in 24 European countries, except those living in long-term care facilities. The variable of interest was the prevalence of non-use of dental care while needed. We used the direct method of standardisation by age and sex to eliminate confounders in the data. Socioeconomic inequalities in the non-use of dental care were measured through differences in prevalence, the relative concentration index (RCI), and the relative index of inequality (RII). We compared the results among countries and conducted standard and multilevel logistic regression analyses to examine the socioeconomic factors associated with the non-use of dental care while needed.

RESULTS

The results revealed significant socio-economic inequalities in the non-use of dental care across Europe, the magnitudes of which depended on the measure of inequality used. For example, inequalities in the prevalence of non-use among education levels according to the RCI ranged from 0.005 (in the United Kingdom) to -0.271 (Denmark) for men and from -0.009 (Poland) to 0.176 (Spain) for women, whereas the RII results ranged from 1.21 (Poland) to 11.50 (Slovakia) for men and from 1.62 (Poland) to 4.70 (Belgium) for women. Furthermore, the level-2 variance (random effects) was significantly different from zero, indicating the presence of heterogeneity in the probability of the non-use of needed dental care at the country level.

CONCLUSION

Overall, our study revealed considerable socioeconomic inequalities in the non-use of dental care at both the individual (intra-country) and collective (inter-country) levels. Therefore, to be most effective, policies to reduce this social inequality across Europe should address both levels.

A multi-country comparison of reasons for dental non-attendance

The purpose of this study was to describe differences across countries with respect to the reasons for dental non-attendance by Europeans currently 50 yr of age and older. The analyses were based on retrospective life-history data from the Survey of Health, Ageing, and Retirement in Europe and included information on various reasons why respondents from 13 European countries had never had regular dental visits in their lifetime. A series of logistic regression models was estimated to identify reasons for dental non-attendance across different welfare-state regimes. The highest proportion of respondents without any regular dental attendance throughout their lifetime was found for the Southern welfare-state regime, followed by the Eastern, the Bismarckian, and the Scandinavian welfare-state regimes. Factors such as patients' perception that regular dental treatment is 'not necessary' or 'not usual' appear to be the predominant reason for non-attendance in all welfare-state regimes. The health system-level factor 'no place to receive this type of care close to home' and the perception of regular dental treatment as 'not necessary' were more often referred to within the Southern, Eastern, and Bismarckian welfare-state regimes than in Scandinavia. This could be relevant information for health-care decision makers in order to prioritize interventions towards increasing rates of regular dental attendance.

Measuring and decomposing oral health inequalities in an UK population

Objectives

With health inequalities high on the policy agenda, this study measures oral health inequalities in the UK.

Methods

We compare an objective clinical measure of oral health (number of natural teeth) with a self-reported measure of the impact of oral health (the Oral Health Impact Profile, OHIP) to establish whether the type of measure affects the scale of inequality measured. Gini coefficients and Concentration Indices (CIs) are calculated with subsequent decompositions using data from the 1998 UK Adult Dental Health Survey. Because the information on OHIP is only available on dentate individuals, analyses on the number of natural teeth are conducted for two samples – the entire sample and the sample with dentate individuals only, the latter to allow direct comparison with OHIP.

Results

We find considerable overall pure oral health inequalities (number of teeth: Gini = 0.68 (including edentate), Gini = 0.40 (excluding edentate); OHIP: Gini = 0.33) and income-related inequalities for both measures (number of teeth: CI = 0.35 (including edentate), CI = 0.15 (excluding edentate); OHIP: CI = 0.03), and the CI is generally higher for the number of teeth than for OHIP. There are differences across age groups, with CI increasing with age for the number of teeth (excluding edentate: 16–30 years: CI = 0.01, 65 + years: CI = 0.11; including edentate: 16–30 years: CI = 0.01, 65 + years: CI = 0.19). However, inequalities for OHIP were highest in the youngest age group (CI = 0.05). Number of teeth reflects the accumulation of damage over a lifetime, while OHIP records more immediate concerns.

Conclusions

There are considerable pure oral health inequalities and income-related oral health inequalities in the UK. Using sophisticated methods to measure oral health inequality, we have been able to compare inequality in oral health with inequality in general health. The results provide a benchmark for future comparisons but also indicate that the type of health measure may be of considerable significance in how we think about and measure oral health inequalities.