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

Heavy consumption of dental services; a longitudinal cohort study among Finnish adults

Background

A reform to Dental Care legislation in 2002 abolished age limits restricting adults’ use of public dental services in Finland. In the Public Dental Service (PDS) unit of Espoo, the proportion of adult patients rose from 36% to 57%. The aim of this study was to investigate heavy use of dental services by adults and its determinants.

Methods

A longitudinal cohort study was undertaken based on a PDS patient register. Of all adults who attended the PDS in Espoo in 2004, those who had six or more visits (n=3,173) were assigned to the heavy user group and a comparison group of low users (n=22,820) had three or fewer dental visits. A sample of 320 patients was randomly selected from each group. Baseline information (year 2004) on age, sex, number and type of visit, oral health status and treatment provided was collected from treatment records. Each group was followed-up for five years and information on the number and types of visit was recorded for each year from 2005 to 2009.

Results

Most heavy users (61.6%) became low users and only 11.2% remained chronic heavy users. Most low users (91.0%) remained low users. For heavy users, the mean number of dental visits per year (3.0) during the follow-up period was significantly lower than initially in 2004 (8.3) (p<0.001) but 74.8% of heavy users had had emergency visits compared with 21.6% of the low users (p<0.001).

A third (33%) of the visitors in each group had no proper examination and treatment planning during the 5-year follow-up period and two or more examinations were provided to fewer than half of the heavy (46.1%) or low (46.5%) users.

The mean number of treating dentists was 5.7 for heavy users and 3.8 for low users (p<0.001).

Conclusions

Frequent emergency visits were characteristic of heavy users of dental services. Treatment planning was inadequate, probably partly due to the many dentists involved and too many patients requesting care. Better local management and continuous education are needed to ensure good quality adult dental care and to reduce heavy consumption.

Inequalities in the use of dental services among adults in inner South East London

Improving access to National Health Service (NHS) dentistry is a public health issue that has been a focus for successive governments and policy makers in the UK. To inform this process, commissioners of services need to understand trends in service use and demands of the local population. This study explored inequalities in dental services use among adults in a socially deprived, ethnically diverse metropolitan area of London; satisfaction with services; and public views for improvement of services. Data from 695 adults were analysed for this study (56% of the eligible sample). Inequalities in dental services use and satisfaction with care according to sociodemographic factors were assessed in unadjusted and fully adjusted models. The proportion of participants who reported attending the dentist in the last 24 months was 69%, with inequalities according to social grade, ethnicity, sex and age but not according to borough of residence. The most common areas identified by respondents for service improvement were availability of dentists, affordability of care, and accommodation of services. Among those who visited the dentist in the last 24 months, 90% were satisfied with the quality of care provided. However, there were inequalities in satisfaction with care according to borough and reason for the last dental visit.

Oral Health-Related Quality of Life in institutionalized elderly in Barcelona (Spain)

Objective: The objective of this study is to describe the oral health status and the factors associated with oral health-related quality of life (OHRQoL) in people aged 65 and older institutionalized in Barcelona in 2009. Study Design: Cross sectional study in 194 elderly. The dependent variable was poor OHRQoL, according to the Geriatric Oral Health Assessment Index (GOHAI). The independent variables were socio-demographic data, last dental visit, subjective and objective oral health status. Robust Poisson regression analysis was used to determine the factors associated with OHRQoL as well as the strengths of association (Prevalence Ratios with respective confidence intervals at 95%). Results: According to GOHAI, 94 women (68.1%) and 36 men (64.3%) had poor OHRQoL. The average DMFT index (number of decayed, missing and filled teeth) was 22.8, with mean 10.2 remaining teeth. According to the Community Periodontal Index only 1.9% were healthy. 33.8% of the sample (35.5% of women and 30.4% of men) presented edentulism, 54.2% needed upper dental prostheses (51.1% of women and 60.7% of men) and 64.7% needed lower ones (61.6% of women and 71.4% of men). Only 7.2% had visited a dentist in the past year (8.8% of women and 3.6% of men). After fitting several multivariate adjusted robust Poisson regression models, poor OHRQoL was found to be associated to self-reporting problems with teeth or gums, self-reporting poor opinion about teeth/gums/denture and also associated to functional edentulism, needing upper denture, but not to socio-demographic factors or time since last dental visit. Conclusions: The study population has poor objective oral health. A high percentage has poor OHRQoL associated to subjective and objective oral health conditions. Dental care is required and these services should be included in the Spanish National Health System.

Key words:Oral health, homes for the aged, elderly, self-assessment, quality of life, geriatric oral health assessment index (GOHAI).

Measuring socio-economic inequalities in edentate Scottish adults--cross-sectional analyses using Scottish Health Surveys 1995-2008/09

OBJECTIVES

To investigate the appropriateness of different measures of socio-economic inequalities, in relation to adult oral health in Scotland, utilizing data from a series of large, representative population surveys.

METHODS

The Scottish Health Surveys (SHeS) (1995; 1998; 2003; 2008/09) are cross-sectional national population-based surveys used to monitor health status in those living in private households. The age groups included in this study are as follows: 45-54; 55-64 years: all survey years; 65-74: 1998 onwards; 75+: 2003 onwards. Primary outcome was no natural teeth (edentulism). Three measures of socio-economic position: Occupational social class, Education, Carstairs deprivation score (2001) were used. Simple (absolute/relative differences) and complex measures (Slope Index, Relative Index, Concentration Index and c-index) of inequality were produced for each age group across all four surveys.

RESULTS

Simple and complex (absolute) measures of inequality have both demonstrated narrowing disparities in edentulism over time in the 45- to 64-year-old group, a levelling off in those aged 65 and above, and a rise in those aged 75+. Complex relative measures (RII, Concentration Index and c-index), however, show an increasing trend in inequalities over time for all age groups, suggesting that rates of improvement in edentulism rates are not uniform across all social groups.

CONCLUSIONS

Simple absolute inequality provides a quick and easy indication of the extent of disparities between extreme groups, whereas complex measures (absolute and relative) consider the gradient in health across all social groups. We have demonstrated that both are useful measures of inequality and should be considered complementary to one another. The appropriate choice of complex measure of inequality will depend on the audience to whom the results are to be communicated. This methodological approach is not confined to oral health but is applicable to other health outcomes that are socially patterned.

Barriers to dental visits in Belgium: a secondary analysis of the 2004 National Health Interview Survey

OBJECTIVE

The study aims to identify barriers to annual dental visits in the Belgian population.

METHODS

We conducted a secondary analysis of data collected through the 2004 National Health Interview Survey in Belgium. Only respondents aged 15 years and older with complete information on dental consultations and the independent variables (n = 5940) were considered in this analysis. The associations between the lack of dental visits during the 12 months preceding the survey and covariates of interest were examined using a multivariable logistic regression analysis.

RESULTS

Almost one-half of the respondents (49.7 percent) did not visit a dentist in the 12 months prior to the survey. Region of residence was significantly the common variable for the three age categories. In the 15- to 34-year-old category, males and two-person households were significantly less likely to report a dental visit during the 12 months preceding the survey. For the 35- to 54-year-old category, a low level of education was the covariate associated with the lack of dental visit. In the 55 years or older category, the factors associated with the lack of a dental visit in the 12 months prior to the survey were: male gender, low level of education, low household income, low weekly alcohol consumption, current smoker, and body mass index of ≥ 25 mg/kg(2).

CONCLUSION

Barriers to dental visits in Belgium differ among age groups and are linked to personal and environmental factors. The findings confirm the existence of social health inequalities in dental visits among Belgian people.

Inequalities in dental attendance throughout the life-course

The purpose of this study was to identify socio-economic inequalities in regular dental attendance throughout the life-course. The analyses relied on data from SHARE (waves 1 to 3 of the Survey of Health, Ageing, and Retirement in Europe), which includes retrospective information on life-course dental attendance of 26,525 persons currently aged 50 years or greater from 13 European countries (Austria, Poland, Spain, Italy, the Netherlands, Belgium, Greece, the Czech Republic, France, Denmark, Switzerland, Germany, and Sweden). Inequalities in dental attendance were assessed by means of Concentration Indices. Socio-economic disparities in regular dental attendance were identified as early as childhood. Moreover, higher educational attainment resulted in increased probabilities of regular dental attendance throughout subsequent life-years in all nations. In most countries, inequality levels remained relatively inelastic throughout the life-course. These findings suggest that a considerable proportion of inequalities in dental care use is already established at childhood and persists throughout the life-course.

Inequality in oral health-care utilisation exists among older Thais despite a universal coverage policy

AIM

To assess socioeconomic-related inequality in oral health-care utilisation among older Thais.

METHOD

The data on 8951 and 11,402 older Thais (≥60 years) from national representative Thailand Health and Welfare Surveys (HWS) of 2003 and 2009, respectively, were analysed. Descriptive analyses were performed on oral health-care utilisation, and a concentration index (CI) quantified the extent of socioeconomic-related inequality in oral health-care utilisation.

RESULTS

Analyses indicated that socioeconomic-related inequalities in oral health-care utilisation among older Thais existed, and tended to favour those of higher socioeconomic status. However, the older poor were more likely to utilise oral health care at public facilities, particularly primary care facilities, than those of higher socioeconomic status.

CONCLUSION

Despite universal coverage policy, socioeconomic-related inequalities in oral health-care utilisations exist among the older Thais. To alleviate these, strengthening the primary health-care system deserves particular attention.

Embedding a population oral health perspective in the dental curriculum

Over the past 40 years, oral healthcare has changed dramatically as a consequence of changing disease profiles and population demography. However, dental disease continues to be highly prevalent and costly to treat. Furthermore, it has been recognized that there are inequalities, with tooth loss being influenced by social, cultural and economic factors. Undergraduate education has been task oriented, with a heavy emphasis on training in technical aspects of treating disease. However, oral healthcare education needs to include a population health perspective, and each professional programme should describe appropriate learning outcomes for population oral health. This includes the need to understand health systems and health trends, and to have knowledge of the evidence base for community prevention strategies and health promotion. A key challenge in embedding population oral health into the curriculum is to break down traditional boundaries in the curriculum and to make teaching of this subject context specific and interdisciplinary. Embedding population oral health offers the potential to create synergies between educators and health service providers with the ultimate benefit of producing a reflective and holistic oral health practitioner. There are challenges, but it is important to produce graduates whose attitudes and clinical practices will be shaped by a sound knowledge of population oral health.

Socioeconomic inequalities in dental services utilisation in a Norwegian county: The third Nord-Trøndelag Health Survey

Aim: To assess the level of socioeconomic inequity in dental care utilisation in Norway and enable comparison with recent international comparative studies. Methods: We studied dental care utilisation among 17,136 men and 21,414 women in the third Nord-Trøndelag Health Survey (2006–08). Respondents aged 20 years and above were included in the study, and analyses were also performed within subgroups of age and gender (20–39, 40–59, and ≥60 years). Income-related horizontal inequity was estimated by means of concentration indices. Education-related inequity was estimated as relative risks. Results: We found consistent pro-rich income inequity among men and women of all ages. The level of income inequity was highest among men and women ≥60 years, and in this group the income gradient was steepest between the poorest and the middle quintiles. Pro-educated inequity was found exclusively among men and women ≥60 years. General attendance was high (77%). Conclusion: The overall level of income-related inequity in dental services utilisation was low compared to other European countries as reported in two recent international studies of socioeconomic inequalities in dental care utilisation. Pro-rich and pro-educated inequity is a public health challenge mainly in the older part of the population.

Experience of socioeconomic-related inequality in dental care utilization among Thai elderly under universal coverage

AIM

To assess the socioeconomic-related inequality in dental care utilization among Thai elderly and to determine factors associated with the observed inequality after the country achieved universal coverage.

METHODS

The data were taken from the nationally representative Thailand Health & Welfare Survey 2007. Data of 10,096 Thai elderly (aged over 60 years) were selected. Descriptive analyses of the features of dental care utilization among Thai elderly were carried out, in addition to the concentration index (Cindex ) being used to quantify the extent of socioeconomic-related inequality in dental care utilization. Logistic regression was used to determine factors associated with inequality in dental care.

RESULTS

Socioeconomic-related inequality in dental care utilization among Thai elderly was shown. Also, utilization was more concentrated among wealthier older adults, as shown by the positive value of Cindex (equals 0.244). The poor elderly, however, were more likely to utilize dental care at public facilities, particularly primary care facilities. Multivariate analysis showed that certain demographic, socioeconomic and geographic characteristics were particularly associated with poor-rich differences in dental care utilization among Thai elderly.

CONCLUSIONS

Although socioeconomic-related inequality in dental care utilization among Thai elderly exists, the pro-poor utilization at public facilities, particularly primary care facilities, substantiates the concerted effort to reducing inequality in dental care utilization for Thai elderly.

High-acuity GIS mapping of private practice dental services in New Zealand: does service match need?

OBJECTIVES

New Zealand is a country with a relatively small population (4 million people) distributed unevenly over a relatively large land area. Adult oral health services in New Zealand are almost all delivered through a market-driven, private practice model and are funded directly by patient payments. Little attention has been given to the distribution of these services. This study reports the findings of a high-acuity examination of the distribution of private dental practices in New Zealand, using modern geographic information system (GIS) tools.

METHODS

A total of 1,045 private dental practices in New Zealand were geocoded. These dental practices overlaid 1,909 area units.

RESULTS

The highest practice: adult population ratios found in this study reflected the areas with the highest population densities of Maori and Pacific Islander people.

CONCLUSIONS

Oral health has a substantial impact on health-related quality of life and the utilisation of dental care services can contribute to its improvement. As such, it is expected that access to care should be focused on the population groups with the highest degree of need. However, in a market-driven, mostly private practice model, such as that in New Zealand, available care is concentrated largely in areas of high socioeconomic status and in populations with lower levels of oral disease.

Socio-economic inequality in oral healthcare coverage: results from the World Health Survey

The objective of this study was to assess socio-economic inequality in oral healthcare coverage among adults with expressed need living in 52 countries. Data on 60,332 adults aged 18 years or older were analyzed from 52 countries participating in the 2002-2004 World Health Survey. Oral healthcare coverage was defined as the proportion of individuals who received any medical care from a dentist or other oral health specialist during a period of 12 months prior to the survey, among those who expressed any mouth and/or teeth problems during that period. In addition to assessment of the coverage across wealth quintiles in each country, a wealth-based relative index of inequality was used to measure socio-economic inequality. The index was adjusted for sex, age, marital status, education, employment, overall health status, and urban/rural residence. Pro-rich inequality in oral healthcare coverage was observed within most of the countries, although lower income countries showed greater levels of relative inequality than higher income countries. Overall, lowest coverage and highest relative inequality were found in the low-income countries. The findings of this study may inform policies for oral health at global and national levels. To achieve universal coverage in oral healthcare, relevant interventions should reach the poorest population groups.

Income-related inequalities in denture-wearing by Europeans aged 50 and above

BACKGROUND

Despite its importance for the planning of future treatment needs and an optimised allocation of health care resources, only little is known about socio-economic inequalities in denture-wearing by late middle-aged and elderly generations.

OBJECTIVES

To describe income-related inequalities in denture-wearing by elderly populations residing in different European countries.

MATERIAL AND METHODS

Data from the Survey of Health, Ageing and Retirement in Europe (SHARE Wave 2) were used to assess income-related inequalities in denture-wearing by means of Concentration Indices (CI) for populations aged 50+ from 14 different European countries.

RESULTS

We could identify a significant disproportionate concentration of denture-wearing amongst the poor elderly populations in Denmark (CI = -0.3534, corresponding to the highest level of inequality), Sweden (CI = -0.3479), Switzerland (CI = -0.2013), Greece (CI = -0.1953), the Netherlands (CI = -0.1413), France (CI = -0.1339), Austria (CI = -0.0974), Czech Republic (CI = -0.0959), Belgium (CI = -0.0947), Germany (CI = -0.0762), Ireland (CI = -0.0575) and Spain (CI = -0.0482, corresponding to the lowest level of pro-poor inequality). Poland became evident as the only country in which individuals from the upper end of the income scale wear more dentures than their peers from the lower end of the income scale (CI = 0.0379). No significant income-related inequalities were observable in Italy.

CONCLUSIONS

There is considerable income-related inequality in denture-wearing by several elderly populations in Europe. Future resource planning for prosthetic care should, thus, specifically distinguish between the treatment needs of different socio-economic groups within elderly populations.