The impact of demographic, health-related and social factors on dental services utilization: Systematic review and meta-analysis

Restricting Periodontal Treatment Frequency: Impact on Tooth Loss in Danish Adults

OBJECTIVE

The study aimed to estimate the effect of a periodontal treatment policy that would restrict the receipt of periodontal therapy to no more than once every second year, on the 10-year risk of tooth extraction among Danish adults.

METHODS

Data from linked nationwide Danish registers consisted of a random sample of 20 000 50-year-olds who were followed from the beginning of 1990 to the end of 2021. The longitudinal modified treatment policies' causal inference framework was used. In each of two slightly different counterfactual scenarios, the receipt of supragingival or subgingival periodontal therapy was restricted to no more than once every second year. The cumulative incidence of tooth extraction from 2012 to 2021 was compared between the counterfactual scenarios and the observed periodontal visiting pattern, while informative censoring, and time-varying and time-invariant confounding were accounted for using the social, economic and dental service utilisation history.

RESULTS

During the 10-year follow-up period, 5021 (25.1%) individuals received at least one tooth extraction. In the two counterfactual scenarios, the number of years receiving supragingival or subgingival periodontal therapy was 30%-50% lower than in the observed data. The 10-year cumulative incidence of tooth loss was practically the same in the two counterfactual scenarios as under the observed periodontal visiting patterns.

CONCLUSION

The findings indicate that a considerable decrease in the number and frequency of periodontal care visits would not have significant impact on the incidence of tooth loss in Denmark.

Regular dental check-up status and related factors among Thai residents in Japan

The objectives of this online study were to determine the status of regular dental check-ups among Thai nationals living in Japan and to identify barriers to regular dental check-ups by comparing them with general health check-ups. We conducted the online survey twice, in 2021 and 2022, among Thai nationals aged 18 years and older living in Japan via social networking services by an organization that supports Thai nationals living in Japan. Respondents between the ages of 30 and 59 were included in this study. Independent factors included gender, age, length of stay in Japan, family economic status, confidence in Japanese and stay for work purposes. Dependent factors were regular dental check-ups and general health check-ups in the past year. Chi-square tests and multiple logistic regression analyses were used for analysis. 56.6% of respondents had regular dental check-ups. The adjusted odds ratio for the proportion of people with regular dental check-ups was significantly higher for those with high economic status, 2.15 (1.06-4.33), compared with those with low economic status. It was also significantly higher 1.88 (1.10-3.21) for those with confidence in the Japanese language compared with those without. The study suggested the need for Japanese language support in addition to financial support for dental health prevention programs for foreigners living in Japan.

Social determinants of health linked with oral health in a representative sample of U.S. adults

BACKGROUND

Oral diseases remain a significant public health problem worldwide, with growing gaps in oral health status among various socioeconomic groups. The objective of the current study is to analyze the impact of different social determinants of health (SDOH) on oral health outcomes (frequency of dental visits, self-reported oral health status, embarrassment because of oral health status, and tooth loss) among a representative sample of United States (U.S.) adults.

METHODS

Cross-sectional data for this observational study came from adults aged 18 and above (N = 5,320) participating in the nationally representative 2021 State of Oral Health Equity in America survey. Bivariate and multivariable analyses were conducted to examine the associations between oral health outcomes (dependent variables) and SDOH independent variables: structural (race/ethnicity, income, education); and intermediary (lack of transportation, food insecurity, racial discrimination, and housing instability), controlling for the confounding variables of age, gender, employment status, dental insurance, self-rated mental/emotional health, self-rated physical health, presence of one or more chronic conditions, and having had a routine physical examination in the past year.

RESULTS

When controlling for confounding variables, Black adults were less likely than White adults to have had a dental visit in the last year (odds ratio (OR) = 0.72 (95% confidence interval (CI) = 0.57-0.92, p < 0.05), more likely to report feeling self-conscious or embarrassed due to their oral health (OR = 1.67 (95% CI = 1.31-2.12, p < 0.05), and more likely to have at least one permanent tooth removed (OR = 1.67 (95% CI = 1.31-2.13, p < 0.05). Higher income and more education were significantly associated with greater odds of rating one's oral health positively and having had a dental visit in the past year and lesser odds of feeling self-conscious or having at least one tooth removed (p's < 0.05). All four intermediary determinants were associated with significant (p < 0.05) and negative odds of having a dental visit in the past year and reporting positive oral health, and with positive odds of having at least one permanent tooth removed. The odds of feeling self-conscious or embarrassed due to their oral health were significantly and positive associated with all intermediary determinants except for racial discrimination (OR = 1.21, 95% CI = 1.00-1.46).

CONCLUSIONS

Significant inequities still exist in the U.S. regarding SDOH and their relationship to oral health. Improving oral health will involve addressing SDOH. Successful policy and public health interventions must address not only structural factors but also intermediary SDOH.

Decomposition Analysis of the Prevalence of Denture Use Between Rural and Urban Older Individuals With Edentulism in China: Cross-Sectional Study

BACKGROUND

Edentulism impacts the physical health and quality of life of older individuals. The prevalence, influencing factors, and differences in terms of edentulism in urban and rural areas of China are unclear.

OBJECTIVE

This study investigated the denture-wearing conditions and causes affecting older patients with edentulism in urban and rural areas of China and analyzed the differences.

METHODS

This cross-sectional study included the data of 5139 older individuals (age>65 years) with edentulism obtained from 23 Chinese provinces in 2018. Participants were divided into urban and rural groups based on their household registration. Factors influencing denture use in both groups were explored using binary logistic regression, while factors influencing differences in denture wearing in both groups were explored using the Fairlie decomposition model.

RESULTS

Of the 5139 participants, 67.05% (808/1205) from urban areas and 51.12% (2011/3934) from rural areas wore dentures. In the urban group, participants with a higher level of education (1-6 years: odds ratio [OR] 2.093, 95% CI 1.488-2.945; ≥7 years: OR 2.187, 95% CI 1.565-3.055) or who exercised (OR 2.840, 95% CI 2.016-3.999) preferred wearing dentures, but individuals with BMI<18.5 kg/m2 (OR 0.558, 95% CI 0.408-0.762) or widowed (OR 0.618, 95% CI 0.414-0.921) did not. In the rural group, a higher level of education (1-6 years: OR 1.742, 95% CI 1.429-2.123; ≥7 years: OR 1.498, 95% CI 1.246-1.802), living alone (OR 1.372, 95% CI 1.313-1.663), exercise (OR 1.612, 95% CI 1.340-1.940), high economic status (OR 1.234, 95% CI 1.035-1.472), residence in the eastern area (OR 2.045, 95% CI 1.723-2.427), presence of chronic diseases (1 disease: OR 1.534, 95% CI 1.313-1.793; ≥2 diseases: OR 1.500, 95% CI 1.195-1.882) were positively associated and age≥80 years (OR 0.318, 95% CI 0.247-0.408), BMI<18.5 kg/m2 (OR 0.692, 95% CI 0.590-0.813), and widowed (OR 0.566, 95% CI 0.464-0.690) or other marital status (OR 0.600, 95% CI 0.392-0.918) were negatively associated with denture use. The Fairlie decomposition model revealed that the number of chronic diseases (16.34%), education level (11.94%), region of residence (11.00%), annual income (10.55%), exercise (6.81%), and age (-0.92%) were the main factors responsible for differences between urban and rural edentulism and could explain the difference in the denture-wearing rate (58.48%) between both groups.

CONCLUSIONS

Older individuals with edentulism with a higher education level and who exercise are more willing to wear dentures, while those with BMI<18.5 kg/m2 show a decreased willingness to wear dentures in both urban and rural areas in China. Controlling the number of chronic diseases, improving the education level and annual income, cultivating good exercise habits, and bridging the gap between the economic status of the east and west can narrow the differences in denture wearing among urban and rural older individuals with edentulism.

Health status, care dependency and oral care utilization among older adults: a register-based study

BACKGROUND AND OBJECTIVES

The aim of the study was to examine oral care utilisation among older Danes and to describe the extent to which oral care use is associated with the co-existence of challenges relating to general health and care dependency.

MATERIALS AND METHODS

The study used registry data covering the entire population of older adults (≥65 years) in seven municipalities in Denmark (N = 178 787 individuals). Oral care services utilisation was computed from administrative data on oral care contacts up to and including 2019, including both private oral care and a municipal oral care programme (MOCP). Various registry data sources were used to compute risk factors to describe oral care utilisation across indicators of general health and care dependency.

RESULTS

Indicators for poorer health were associated with larger proportions of individuals enrolled in the MOCPs and larger proportions of non-users of any type of oral care. Higher degrees of care dependency were associated with larger proportions of individuals enrolled in MOCPs and individuals with no use of any oral care services, with the exception of nursing home residents, who comprised a lower proportion of non-users than individuals receiving at-home care. Municipal oral care mainly enrolled older adults who were nursing home residents (60% of nursing home residents were enrolled).

CONCLUSION

Our findings support existing evidence on the link between oral care utilisation and general health and frailty. While the municipal care programmes assisted in covering oral care for those with the highest level of care dependency, future preventive strategies for ensuring care continuity for older adults that are increasing in frailty may want to focus on the earlier stages of frailty and of general health deterioration.

Oral health of Dutch primary school children in relation to social and health aspects

OBJECTIVE

This research investigated the oral health status of Dutch primary school children aged 10-12 years in Utrecht and its association with demographic characteristics, lifestyle factors, general psychosocial health, and dental treatment, to guide targeted interventions to improve children's oral and overall well-being.

MATERIALS AND METHODS

A cross-sectional survey was conducted at 49 primary schools in Utrecht in 2017 and 42 schools in 2019. The questionnaire covered background characteristics (7 questions), psychosocial health (14 questions), nutrition and exercise (20 questions), school and leisure time (26 questions), home situation (23 questions), and oral health (4 questions). Associations were analyzed using multivariate logistic regression.

RESULTS

Data from 5,426 children were analyzed. Prior to the survey, 11% did not visit a dentist, 23% had a toothache, 22% had a cavity filled, and 8% had a tooth extracted. Independent predictors for increased odds of oral health problems were migration background, poor general health, drinking more than two glasses of soft drinks per day, having ever drunk alcohol, having fear of failure, experiencing problems at home and/or coming from average or low socioeconomic position group. Factors associated with increased odds of dental treatment, such as cavity filled and tooth extracted, were migration background, fear of failure and home problems.

CONCLUSIONS

These findings emphasize the need for targeted prevention to improve the oral health of children with a migration background, average or low socioeconomic position and/or with poorer general and psychosocial health, unhealthy diets and problems in the home situation, within a community-based and transdisciplinary approach.

A Comparative Analysis of Oral Health and Self-Rated Health: 'All of Us Research Program' vs. 'Health and Retirement Study'

Poor oral health can impact overall health. This study assessed the association between dental factors (dentate status and dental utilization) and self-rated health (S-RH) among older adults in two cross-sectional datasets: (1) NIH "All of Us (AoU) Research Program" (May 2018-July 2022 release) and (2) U.S. nationally representative "Health and Retirement Study" (HRS) 2018 wave. Participants aged ≥ 51 years were included in these analyses if (1) from AoU, they had clinical dental and medical data from electronic health records (EHRs) and surveys (n = 5480), and (2) from HRS, they had dental and socio-demographic survey data (n = 14,358). S-RH was dichotomized (fair/poor vs. better) and analyzed with logistic regression. Sample survey weights for HRS and stratification and averaging AoU results used the weighted HRS race-ethnicity and age distribution standardized respective analyses to the U.S. population. Fair/poor S-RH was reported by 32.6% in AoU and 28.6% in HRS. Dentate status information was available from 7.7% of AoU EHRs. In population-standardized analyses, lack of dental service use increased odds of fair/poor S-RH in AoU, OR (95% CI) = 1.28 (1.11-1.48), and in HRS = 1.45 (1.09-1.94), as did having diabetes, less education, and ever being a smoker. Having no natural teeth was not statistically associated with fair/poor S-RH. Lack of dental service was positively associated with fair/poor S-RH in both datasets. More and better oral health information in AoU and HRS are needed.

Dental service utilization in the general adult population in Bangladesh

OBJECTIVES

With the help of a national community-based survey, the analysis aimed to estimate the number of adults in Bangladesh who used dental services (DSU).

METHODS

The 8185 participants (18-69 years old) in the Bangladesh cross-sectional STEPS survey in 2018 provided national data for analysis. Predisposing, enabling, and need factors for DSU were included in the interview data, physical examinations, and biochemical analyses. To estimate the DSU (last 12 months) predictors, Poisson regression was employed.

RESULTS

Seven out of 10 participants (71.0%) had never DSU, 13.2% within the past 12 months, and 15.9% more than 12 months ago. In terms of predisposing factors, the final model showed a negative relationship between past 12-month DSU and living in the northern region (adjusted prevalence ratio-APR: 0.75, 95% CI: 0.59, 0.96). The enabling factors of living in an urban area (APR: 1.19, 95% CI: 1.01, 1.41) and seeing a doctor or other healthcare provider within the previous year (APR: 1.37, 95% CI: 1.08, 1.74) were positively correlated with DSU. In terms of need factors, dental pain (APR: 15.37, 95% CI: 9.68, 24.40), multimorbidity (APR: 1.26, 95% CI: 1.02, 1.55), oral health impact (OHI) speech problem (APR: 1.35, 95% CI: 1.13, 1.63), and OHI felt tense (APR: 1.34, 95% CI: 1.10, 1.64) were positively associated with DSU.

CONCLUSIONS

A low proportion of participants had DSU in the past 12 months and several associated factors were identified.

Differences in Cumulative Long-Term Care Costs by Dental Visit Pattern Among Japanese Older Adults: The JAGES Cohort Study

BACKGROUND

Long-term care (LTC) costs create burdens on aging societies. Maintaining oral health through dental visits may result in shorter LTC periods, thereby decreasing LTC costs; however, this remains unverified. We examined whether dental visits in the past 6 months were associated with cumulative LTC insurance (LTCI) costs.

METHODS

This cohort study of the Japan Gerontological Evaluation Study targeted independent adults aged≥65 years in 2010 over an 8-year follow-up. We used data from a self-reported questionnaire and LTCI records from the municipalities. The outcome was cumulative LTCI costs, and exposure was dental visits within 6 months for prevention, treatment, and prevention or treatment. A 2-part model was used to estimate the differences in the predicted cumulative LTCI costs and 95% confidence intervals (CIs) for each dental visit.

RESULTS

The mean age of the 8 429 participants was 73.7 years (standard deviation [SD] = 6.0), and 46.1% were men. During the follow-up period, 17.6% started using LTCI services. The mean cumulative LTCI cost was USD 4 877.0 (SD = 19 082.1). The predicted cumulative LTCI costs were lower among those had dental visits than among those who did not. The differences in predicted cumulative LTCI cost were -USD 1 089.9 (95% CI = -1 888.5 to -291.2) for dental preventive visits, -USD 806.7 (95% CI = -1 647.4 to 34.0) for treatment visits, and -USD 980.6 (95% CI = -1 835.7 to -125.5) for preventive or treatment visits.

CONCLUSIONS

Dental visits, particularly preventive visits, were associated with lower cumulative LTCI costs. Maintaining oral health through dental visits may effectively reduce LTCI costs.

Effectiveness of the 5As Model-Based Transitional Care Program among Chinese Patients with Type B Aortic Dissection Post-TEVAR: A Randomized Controlled Trial

Background

Thoracic aortic endovascular repair (TEVAR) is the primary treatment for Stanford type B aortic dissection (type B AD). However, patients often encounter significant difficulties post-TEVAR that endanger their safety when transitioning from hospital- to home-based care. Moreover, information on the ideal transitional care for patients with type B AD post-TEVAR is scarce in China. This single-masked randomized clinical trial aimed to assess the effectiveness of the Assess, Advise, Agree, Assist, and Arrange (5As) model-based transitional care in improving discharge preparation level and transitional care quality post-TEVAR among patients with type B AD in China.

Methods

This study was conducted at a hospital in China between January 2021 and October 2021. Patients with type B AD were randomly divided into intervention and control groups. Participants in the intervention group received the 5As model-based transitional nursing care. The 5As model is an evidence-based intervention strategy comprising: (1) Assess: assessing the preoperative cardiovascular risk behavior of patients with AD. (2) Advise: making suggestions according to the risk behaviors of the patients. (3) Agree: reaching a consensus on goals and action plans by making decisions with the patients and their families. (4) Assist: assisting patients in solving obstacles to implementing health plans. (5) Arrange: arranging follow-up visits according to the actual situation of the patients and guiding them in adhering to a schedule. The control group received the usual nursing care for the same duration and number of follow-up visits. A trained research nurse collected all the baseline data of the patients on admission, assessed discharge readiness level (using the Readiness for Hospital Discharge Scale) on the day of discharge, and collected transitional quality of care (by the Care Transition Measure-15) data on day 30 after discharge.

Results

Overall, 72 patients with type B AD were recruited. Discharge readiness level and transitional care quality in the intervention group were significantly superior to those in the control group.

Conclusions

This study showed that the 5As model-based transitional care program can effectively promote discharge readiness and transitional care quality of patients with type B AD post-TEVAR.

Clinical Trial Registration

The Chinese Clinical Trial Registry Center: ChiCTR2200060797 (https://www.chictr.org.cn/showproj.html?proj=167403).

Anterior Hyperfunction Syndrome: Literature Review and Conceptual Model

Combined Kelly syndrome, also known as anterior hyperfunction syndrome, is a complex pathological condition of the stomatognathic system, originally established by five characteristics but primarily triggered by edentulism, specifically, the absence of the upper and posterior mandibular teeth. This condition is characterized by a series of clinical features, such as bone loss, tuberosity growth, enamel wear, periodontal damage, muscle fatigue, pain, and temporomandibular joint issues. However, these features are not unique and rather reflect an oral hyperfunction state. There is a lack of consensus on the best way to assess and diagnose this condition, which is proposed to be understood as an "oral hyperfunction state" rather than a syndrome. This study aims to conduct a literature review to analyze the available information on anterior hyperfunction syndrome in dentistry, with the goal of proposing a conceptual model of the etiological risk factors that contribute to early diagnosis and the prevention of complications. This approach has important clinical implications, as it would allow for the early identification and management of risk factors, thus improving the quality of life of patients and preventing malpractice that could compromise their oral health.

Towards the integration of prevention and control of oral diseases within child primary healthcare: The case of Peru

OBJECTIVES

The Peruvian public health norm of primary healthcare (PHC) for growth and development medical check-ups (CRED, Spanish acronym) of children under 5 years of age was updated in 2017 with the inclusion of interdisciplinary prevention and control actions for oral diseases, such as dentist referral. The aim of this study was to explore the association between CRED and oral health services utilization (OHSU), throughout the heterogeneous Peruvian territory.

METHODS

A population-based cross sectional study was conducted using the 2021 Demographic and Family Health Survey of Peru and included data from 15 836 children aged 12-59 months. Poisson generalized linear models were used to evaluate the association between any CRED and OHSU, in the 6 months prior to the survey, including sociodemographic characteristics of the children and their mothers as confounding variables. A possible effect modification by natural region of residence (Metropolitan Lima/rest of the Coast/Highlands/Jungle) was evaluated. To examine the robustness of the regression model, a sensitivity analysis was performed using the cumulative number of CRED.

RESULTS

Children who had at least one CRED were almost twice as likely to report OHSU (aPR: 1.95; 95% CI: 1.73-2.21), which was greater in the regions of rest of the Coast (aPR: 2.56; 95% CI: 2.00-3.17) and Jungle (aPR: 2.03; 95% CI: 1.64-2.56). The sensitivity analysis showed consistent results for the association CRED-OHSU. Nevertheless, within the last 6 months, attendance at CRED and OHSU were only achieved by 43.7% and 13.7% of the children respectively.

CONCLUSIONS

Integrating oral health into Peruvian Child PHC seems to be a promising public health intervention to increase children's OHSU. For a greater scope, it is crucial to drive greater attendance at CRED and continuous monitoring and strengthening of CRED-based oral health promotion in all Peruvian natural regions with an equity-focused approach.

To appreciate the influence of contributed determinants on dental care utilization in the context of socio-economic inequalities

BACKGROUND

To appreciate dental care utilization in ‌the context of socio-economic inequalities, it is imperative to identify sources of inequalities and evaluate the extent to which dental care utilization is still related to socio-economic status. This study aimed to quantify the influence of contributed determinants on dental care utilization in the context of socio-economic inequalities amongst adults residing in Tehran metropolis.

METHODS

In this cross-sectional community-based study, a stratified random sample of 1,510 subjects aged over 18 years was investigated by the zero-inflated Poisson analysis to measure the effect of determinants on utilization of dental care, and concentration index as well as the decomposition approach to identify the contributions of deterministic variables to the socio-economic inequality. Data was obtained by employing a phone interview survey. Individuals who were not willing or able to answer the questions in the telephone interview due to hearing or neurological problems did not participate in the interview. Dental care utilization was measured using the number of dental appointments.

RESULTS

Gender (male), oral health-related behaviors (such as brushing and dental flossing), experience of toothache, and concern about dental appearance were associated with an increased likelihood of utilizing dental care. Individuals who belonged to advanced age groups and lived alone significantly underutilized dental care. The concentration index equaling 0.05 (SE = 0.05) corroborates a pro-rich inequality. Decomposition analysis demonstrated the impact of oral health-related behaviors (i.e. dental brushing and use of dental flossing), concern about dental appearance, toothache, gender (male), insurance coverage of dental care, and smoking habit on the poor-rich gap in the dental care utilization.

CONCLUSIONS

The influence of socio-economic inequalities on dental care utilization is discernable along the entire spectrum of socio-economic status. Individuals with lower socio-economic status experience more underutilization of dental care. Community subgroups, particularly the more deprived bracket, require consideration from key stakeholders, including policymakers and health professionals for the enhancement of dental care utilization as revealed by underlying determinants.

Oral health education strategies for patients living with cardiovascular disease within hospital settings: a scoping review

Objective

To identify and describe the impact of current oral health education programmes provided to patients in cardiology hospital wards and outpatient clinics.

Methods

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews statement. Searches were conducted using electronic databases: Cochrane, Medline, and Scopus, as well as grey literature searching.

Results

Three eligible studies were identified. All included studies reported generalised poor oral health in their participants at baseline, with significant improvement at follow-up. They all reported significant reductions in plaque deposits and gingival bleeding. One study reported significantly less bacteria on participant tongues, as well as fewer days with post-operative atrial fibrillation in the intervention group. Furthermore, in this study, one patient in the intervention group developed pneumonia, whilst four patients in the control group did.

Conclusion

Oral health education for patients with cardiovascular disease is limited and many have poor oral health. Educational programmes to improve oral health behaviours in patients with cardiovascular disease can improve both oral and general health outcomes.

Implications for public health

Oral disease is a modifiable risk factor for cardiovascular disease. Integrating oral health education into cardiology hospital settings is a simple strategy to improve access to oral health information and improve both oral and cardiovascular outcomes.

Impact of dental visiting patterns on oral health: A systematic review of longitudinal studies

AIM

To systematically review longitudinal studies investigating the impact of dental visiting patterns on oral health across the life course.

METHODS

Five databases (MEDLINE, Embase, Scopus, Web of Science, CINAHL) were searched up to March 2023. Results were screened based on eligibility criteria in a two-stage process: title and abstract, and full-text review. A backward search of reference lists and a forward search of citations of the included papers was also conducted. The quality of the included papers was assessed using the Newcastle-Ottawa Scale. Key study information was extracted and a narrative synthesis of the findings was performed.

RESULTS

Eleven papers from five longitudinal studies in five countries (Australia, Brazil, China, New Zealand, Sweden) met the inclusion criteria. Studies of moderate to high quality consistently reported that regular dental attendance was associated with having less dental caries experience, fewer missing teeth and better oral health-related quality of life. Inconsistent findings were observed for decayed teeth, and no association was found for periodontal condition.

CONCLUSIONS

This review highlights an association between regular dental visiting pattern and improved oral health, notably less dental caries experience and better oral health-related quality of life. Dental attendance emerges as an important predictor of oral health across the life course, underscoring the importance of routine dental care.

REGISTRATION INFORMATION

The PROSPERO registration number is CRD42023396380.

Exploring avoidance of dental care due to dental fear and economic burden -A cross-sectional study in a national sample of younger adults in Norway

AIM

To assess the prevalence of dental avoidance due to dental fear and economic burden and its distribution by utilization of dental care and socio-behavioural characteristics.

METHOD

A sample of 9052 Norwegian adults aged 25-35 years was invited to participate, and 2551 completed electronic questionnaires regarding lifetime prevalence of dental avoidance due to fear and last year prevalence of dental avoidance due to economic burden.

RESULTS

Cancelled- and avoided ordering appointments due to fear amounted to 14.7% and 30.5%, respectively. Avoidance of dental visits due to cost was 37.7%. Frequency of cancelled appointments due to fear was 30% and 16.6% among participants attending dental care several times annually and seldom, respectively. Multiple logistic regression revealed that avoiding dental visits due to cost was less likely among participants with higher household income (OR 0.4, 95% CI 0.3-0.5) and more likely among participants with dental care need (OR 1.8, 95% CI 1.2-2.7). Cancelled and avoided appointments due to fear was most likely among those with need for dental care and lower education. Early unpleasant experience with dental care remained a covariate of avoidance behaviour due to fear.

CONCLUSION

14.7%, 30.5%, and 37.7% confirmed cancelled appointments due to fear, avoided ordering appointments due to fear, and avoided visiting the dentist due to cost. Avoiding dental care due to fear and economic burden was more and less common among participants with respectively, frequent and seldom use of dental care. Dental avoidance behaviours were highest among socially disadvantaged groups, indicating a hole in the welfare state model that needs political consideration.

Dental Utilization Stratified by the Purpose of Visit: A Population-Based Study in Japan

BACKGROUND

This study aimed to provide a stratified description of dental visit utilisation by Japanese residents based on patient age, sex, prefecture, and the purpose of the visits.

METHODS

This cross-sectional study used the National Database of Health Insurance Claims of Japan to identify participants visiting dental clinics in Japan (April 2018-March 2019). Dental care utilisation by populations stratified by age, sex, and prefecture was assessed. We estimated the slope index of inequality (SII) and relative index of inequality (RII) to evaluate regional differences based on regional income and education.

RESULTS

Amongst the Japanese population, 18.6% utilised preventive dental care visits; 59,709,084 participants visited dental clinics, with children aged 5 to 9 years having the highest proportion. SII and RII were higher for preventive dental visits than those for treatments in all settings. The largest regional differences for preventive care were observed in SII of children aged 5 to 9 years and in RII of men in their 30s and women aged 80 years and older.

CONCLUSIONS

This nationwide population-based study revealed that the proportion of people utilising preventive dental care in Japan was low, with regional differences. Preventive care needs to be more easily accessible and available to improve the oral health of residents. The above findings may provide an important basis for improving policies related to dental care for residents.

Oral healthcare seeking behavior of Malaysian adults in urban and rural areas: findings from the National Health and Morbidity Survey 2019

BACKGROUND

The development and implementation of appropriate strategies to enhance oral health in the community can be aided by an understanding of oral healthcare seeking behavior among urban and rural populations. The purpose of this study was to identify the factors associated with oral healthcare seeking behavior of the Malaysians in urban and rural locations who self-reported dental problems.

METHODS

The National Health and Morbidity Survey 2019, a cross-sectional nationwide household survey that focused on non-institutionalised Malaysians, provided the data for this study on adults in Malaysia who were 18 years of age and older. A two-stage stratified random sampling technique was employed to ensure national representativeness. Data was collected using a multilingual (Malay and English), structured, and validated questionnaire via face-to-face interviews from July to October 2019. The dependent variable was oral healthcare seeking behavior (sought oral healthcare and self-medication). Independent variables were predisposing, enabling and health needs factor based on Andersen's Behavioral Model. Descriptive statistics were used to describe the characteristics and oral healthcare seeking behavior of the respondents. The relationship between the independent and dependent variables were investigated using multivariable logistic regression analysis.

RESULTS

The analysis comprised a total of 10,134 respondents, representing about 18.2 million Malaysian adults aged 18 and above. The overall prevalence of Malaysian adults who self-reported dental problems was low (5.5%) and was slightly higher in the rural than urban population. Almost half sought treatment from healthcare practitioners, and almost a quarter self-medicated. Ethnicity was associated with seeking healthcare and self-medication among urban dwellers. Among the rural population, income level was associated with seeking healthcare while education level was associated with self-medication.

CONCLUSION

Disparities in oral healthcare seeking behaviors exist between Malaysians living in urban and rural areas. Future policies should adopt focused strategies that concentrate on oral healthcare accessibility and health literacy of the vulnerable and rural populations to achieve the best oral healthcare for this population group.

Cost-effectiveness of school-based caries screening using transillumination

OBJECTIVES

School-based screening for caries lesions usually only employs visual-tactile detection means (standard of care). Near-infrared-light-transillumination (NILT) could be used to support school-based screening and to identify early proximal caries, facilitating referral and appropriate non- or micro-invasive management in dental practice.

METHOD

We assessed the cost-effectiveness of NILT for school-based caries screening. A German mixed-payers' perspective was adopted. A Markov model was used to simulate the consequences of true and false positive and negative detections and the subsequent decisions over the lifetime of initially 12 years old patients. Our health outcome was tooth retention in years. Costs were measured in Euro 2020. Monte-Carlo-microsimulations, univariate and probabilistic sensitivity analyses were conducted. The incremental cost-effectiveness ratio (ICER) and the cost-effectiveness-acceptability at different willingness-to-pay-thresholds were quantified.

RESULTS

NILT was minimally more effective (tooth retention for a mean (2.5-97.5%) 56 (53-59) years) and minimally less costly (515 (416-616) Euro) than standard of care (56 (50-59) years; 526 (427-628 Euro)). The ICER was -503 Euro/year, i.e. school-based caries screening using NILT saved money at higher effectiveness in the modelled population. The cost-effectiveness of NILT increased for payers with a willingness-to-pay for additional tooth retention time. The biggest driver of costs were (avoided) tooth replacements later in life.

CONCLUSIONS

NILT-based screening is likely to yield limited effectiveness gains and cost savings in the modelled populations. In countries where regular practice-based screening of children is less common than in Germany, the cost-effectiveness of NILT for school-based caries screening is likely higher.

CLINICAL SIGNIFICANCE

NILT-based caries screening in German schools is unlikely to be cost-effective. In countries with different utilization patterns or generally higher caries prevalence and risk, this may differ.

Is Dichotomization into Regular versus Irregular Dental Attenders Valid? A Qualitative Analysis

AIMS

To discover whether dental visiting behavior can be understood as a dichotomy of planned versus problem based, or whether there were a range of different types of understanding and patient behavior, recognizable as patterns of dental visiting behavior.

METHODS

Secondary analysis drawing on 2 qualitative studies of patients' accounts of dental attendance and oral health, with 1) opportunistic interviews with people attending urgent dental care services (n = 43; including 19 with follow-up) and 2) home-based, in-depth interviews with people attending a dental practice with a mixture of improved or deteriorated/poor periodontal health (n = 25).

RESULTS

Four distinguishable patterns of dental visiting were identified in patients' accounts: Accepting and Active Monitoring, as well as Ambivalent and Active Problem-based dental visiting behavior. Individuals' patterns were relatively stable over time but could shift at turning points. Accepting Monitors were characterized as accepting dentists' recommendations and dental practice policies relating to oral health and visits, whereas Active Monitors were more independent in judging how often to attend for preventive appointments, while still valuing anticipatory care. Ambivalent Problem-based visitors placed a relatively low value on anticipatory care for oral health maintenance and drifted into lapsed attendance, in part because of service-related factors. This contrasted with Active Problem-based visitors, for whom using services only in an emergency was a conscious decision, with low value placed on anticipatory care.

CONCLUSION

This article demonstrates the dynamic nature of patterns of dental visiting where the dental system itself is partly instrumental in shaping patterns of utilization in an ecological way. Thus, service-related factors tend to combine with patients' behavior in expanding inequalities. This illuminates the reasons why risk-based recalls are challenging to implement as a dental policy.

KNOWLEDGE TRANSFER STATEMENT

The results of this analysis can be used by clinicians and policymakers to inform policy around supporting uptake of preventive health care visits, contributing in particular to understanding how risk-based preventive visiting policies may be better adapted to patients' understanding of the purpose of visits, taking into account that this is in part shaped by service-related factors in an ecological way, arising from patients' and dental teams' expectations.

Using Andersen's behavioural model to examine individual and contextual factors associated with dental service utilization in Brazil

OBJECTIVES

The study aimed to examine individual and contextual factors associated with the frequency of dental service utilization among adolescents, adults and older adults Brazilians.

METHODS

This cross-sectional study used secondary data from the Brazilian 2019 National Health Survey (94 114 individuals). The outcome 'when was your last dental appointment?' was categorized into three groups: up to 1 year, more than 1 year and never had a dental appointment. Andersen's behavioural model was used to select contextual and individual variables. Multinomial logistic regression analysis was performed to calculate the odds ratio (OR) and 95% confidence intervals (95% CI).

RESULTS

The following variables showed increased probability to the outcome had the last dental appointment more than 1 year ago: older adult, illiterate or incomplete primary school, and without private dental insurance. The outcome never had a dental appointment was significantly associated with illiterate (OR 26.65; 95% CI 17.63-40.29), male (OR 2.38; 95% CI 2.17-2.61), without private dental insurance (OR 5.20; 95% CI 3.48-7.76), self-rated oral health as bad or very bad (OR 2.67; 95% CI 2.31-3.09), household not enrolled in primary care teams (OR 1.29; 95% CI 1.11-1.49), household in a rural area (OR 1.86; 95% CI 1.69-2.05), high household crowding (OR 1.08; 95% CI 1.04-1.14) and low household income per capita (OR 0.99; 95% CI 0.99-0.99).

CONCLUSIONS

This study showed that contextual and individual factors induce inequity in dental appointments. Moreover, Andersen's behavioural model demonstrated inequitable access for dental services in Brazil, in which social structure and enabling characteristics, rather than the need for the service, determine who receives health care. Living in a household enrolled in primary care teams favoured regular dental appointments. Thus, these findings may help policymakers improve health access by expanding coverage of dental services in primary health care.

Frailty as a determinant of dental attendance among community-dwelling older adults

OBJECTIVES

The aim of this study was to assess the association between different levels of frailty and dental attendance among home-dwelling older adults, in Belgium.

BACKGROUND

While many determinants of dental attendance among older adults have been identified, no study has focused on the role of frailty.

MATERIALS AND METHODS

This was a cross-sectional study on a random sample of home-dwelling adults aged 60 and over from two Belgian cities. Data were collected with a structured questionnaire through a participatory peer-research method. Time since the last dental attendance was the dependent variable. The independent variable was frailty, assessed with the Comprehensive Frailty Assessment Instrument, including physical, psychological, social, and environmental subdomains. Covariates were age, gender, having a partner, educational level, and household income, as well as self-perceived oral health. Data analysis included descriptive, bivariate (Chi-Square, ANOVA, and Kruskal-Wallis), and binomial logistic regression analyses.

RESULTS

The sample consisted of 1329 older adults with a mean age of 72.5 years (SD 8.9, range 60-103). In the low frailty group, 73% attended the dentist in the previous 12 months, while it was 62% and 54% in the medium and high frailty groups, respectively. In the fully adjusted model, the initial gradient in the relationship between overall frailty and dental attendance remained; those in the medium and the high frailty groups were respectively 1.46 (95% CI: 1.09, 1.95) and 1.67 (95% CI: 1.15, 2.43) times more likely to report no dental attendance in the previous year than the low frailty group. Similar associations could be seen in the physical and environmental frailty subdomains.

CONCLUSION

Frailty is consistently associated with less favourable dental attendance, independent from age, gender, socioeconomic factors, family composition, and self-perceived oral health. Once frailty has been detected, good interprofessional communication and care are needed to avoid the drop-out of older adults from the oral healthcare system.

Perceived social status, socioeconomic status, and preventive dental utilization among a low-income Medicaid adult population

OBJECTIVES

Perceived Social Status (PSS) is a measure of cumulative socioeconomic circumstances that takes perceived self-control into account. It is hypothesized to better capture social class compared to socioeconomic status (SES) measures (i.e., education, occupation, and income). This study examined the association between PSS and dental utilization, comparing the strength of associations between dental utilization and PSS and SES measures among a low-income adult Medicaid population.

METHODS

A cross-sectional survey was administered to a random sample of low-income adults in Iowa, United States with Medicaid dental insurance (N = 18,000) in the spring of 2018. Respondents were asked about PSS, dental utilization, and demographics. A set of multivariable logistic regression models examined the relative effects of PSS and SES measures on dental utilization, controlling for age, sex, health literacy, whether the respondent was aware they had dental insurance, transportation, and perceived need of dental care.

RESULTS

The adjusted response rate was 25%, with a final sample size of 2252. Mean PSS (range 1-10) was 5.3 (SD 1.9). PSS was significantly associated with dental utilization (OR = 1.11; CI = 1.05, 1.18) when adjusting for control variables, whereas other SES measures-education, employment, and income-were not.

CONCLUSIONS

PSS demonstrated a small positive association with dental utilization. Results support the relative importance of PSS, in addition to SES measures, as PSS may capture aspects of social class that SES measures do not. Results suggest the need for future research to consider the effects of PSS on oral health outcomes and behaviors.

Explaining public dental service utilization: A theoretical model

OBJECTIVES

Constructing and validating a theoretical model of relationships between dental services use and socioeconomic characteristics, oral health status, primary care coverage, and public dental services.

METHODS

The first stage of the study consisted of developing a theoretical-conceptual model to demonstrate the expected relationships between variables based on the literature. In the second stage, we tested the proposed theoretical model using the Partial Least Squares Structural Equation Modeling (PLS-SEM) technique, using data from the Brazilian National Health Survey conducted in 2019 with a sample of 41,664 individuals aged 15 or older.

RESULTS

This study successfully defined a theoretical model that explains the systematic relationships involving public dental services utilization. Socioeconomic status was negatively associated with oral health status (β = -0.376), enrollment in primary care facilities (β = -0.254), and the use of public dental consultations (β = -0.251). Being black, indigenous, or living in a rural area was directly associated with lower socioeconomic status and greater use of public dental services.

CONCLUSIONS

The identified relationships, establishing a theoretical basis for further investigations, also provide evidence of a public access policy's effect on oral health services on equity, supporting the construction of more effective and equitable public policies.

Dental Therapy of Patients Prior to Endoprostheses: A Retrospective, Telephone-Based Cohort Study

The aim of this study was to assess, whether patients prior to endoprosthesis (EP) visit their dentist for need-oriented therapy and whether this would be associated with the occurrence of complications. Based on a cohort of patients, which was orally investigated prior to EP surgery between 04/2020 and 12/2021, a telephone interview was performed at least six months after EP implantation. Patients were classified into either low-risk (LR), moderate-risk (MR), or high-risk (HR) groups. Participants were interviewed based on a structured questionnaire regarding dental visits, dental therapy, and potential complications during the observational period. Out of the 311 patients from the baseline cohort, 96 patients after EP implantation could be included (participation rate of 31%). Nineteen patients were in LR (20%), 41 in MR (43%), and 36 in the HR group (37%). Overall, 79% (n = 76) of the patients followed the recommendation to visit their dentist; 94% of patients within the HR group visited the dentist (p = 0.02). Dental treatment procedures included tooth cleaning (57%), periodontal treatment (31%), restorative therapy/filling (28%), and tooth extraction (28%). In 64% of the HR patients (n = 23), the potential oral foci with a risk of EP infection were eliminated by their general dentist. Fourteen different complications occurred within the observation period, without any group effect (p > 0.05). In conclusion, most patients prior to EP visit their general dentist following referral, especially if they have a potential oral focus. The effect of dental clearance on infectious complications of EP remains unclear, whereby further clinical studies are needed.

Time elapsed since peruvian children's last dental care and head of household educational attainment: findings from a national database

BACKGROUND

It has been documented that the parents' highest level of education has an impact on their children's access to oral health services and the frequency of their use.This study aimed to determine the association between time elapsed since peruvian children's last dental care and head of household educational attainment.

METHODS

Cross-sectional study using a database of children aged 0 to 11 years, with a final sample of 8012 participants. The dependent variable in this study was the time elapsed since last dental care and the independent variable was the head of household educational attainment. Other covariates considered were natural region, area of residence, place of residence, altitude, wealth index, health insurance coverage, sex and age. Descriptive, bivariate and multivariate statistical analyses were applied.

RESULTS

Time elapsed since last dental care in the year 2021 was 5.68 years (SD = 5.25). A hierarchical multiple linear regression analysis was performed, analyzing the variables dimensions by separate and joint models. When head of household educational attainment was analyzed, there was no statistical significance (p = 0.262); however, other models did (p < 0.05). Model 4, which addresses all dimensions, was significant (p < 0.001) with an R2% of 0.011 and constant equal to 5.788; it showed significance with place of dental care, health insurance, altitude and age.

CONCLUSIONS

No association was found between head of household educational attainment and time elapsed since last dental care; however, the latter was associated with place of care, health insurance coverage, altitude and age in Peruvian children.

Does using the sociodental approach in oral health care influence use of dental services and oral health of adolescents living in deprived communities? a one-year follow up study

BACKGROUND

Oral health needs assessment is important for oral health care planning. This study compared dental treatment needs between normative and sociodental needs. We also longitudinally examined the relationships of baseline sociodental needs measures and socioeconomic status with one-year follow up measures of use of dental services, dental caries, filled teeth, and oral health-related quality of life (OHRQoL).

METHODS

A prospective study was conducted with 12-year-old adolescents from public schools in deprived communities in the city of Manaus, Brazil. Validated questionnaires were used to collect adolescents' sex and socioeconomic status, OHRQoL (CPQ_11 - 14) and behaviours (sugar intake, frequency of toothbrushing, regular use of fluoridated toothpaste and pattern of dental attendance). Normative need was assessed according to decayed teeth, clinical consequences of untreated dental caries, malocclusion, dental trauma, and dental calculus. The relationships between variables were tested thorough Structural equation modelling.

RESULTS

Overall 95.5% of adolescents had normative dental treatment needs. Of these, 9.4% were classified as high level of propensity. Higher normative/impact need and greater propensity-related need directly predicted use of dental services at one-year follow up. The latter mediated the association of normative/impact need and propensity-related need with incidence of dental caries and filled teeth. Normative/impact need and use of dental services were directly associated with filled teeth at one-year follow up. Poor OHRQoL at one-year follow-up was directly predicted by higher normative/impact need at baseline and less filled teeth at one-year follow up. Greater socioeconomic status was directly associated with better propensity-related need. Socioeconomic status indirectly predicted incidence of dental caries and filled teeth via propensity-related need and use of dental services.

CONCLUSIONS

Sociodental needs measures were related to use of dental services, dental caries, filled teeth and OHRQoL after one year among adolescents living in deprived communities. Adolescents with dental needs treatment priorities according to the sociodental approach had more filled teeth via use of dental services. Dental services utilisation did not attenuate the impact of normative and impact-related need on dental caries incidence and poor OHRQoL after one year. Our findings suggest the importance of developing oral health promotion and enhancing access to dental care to improve oral health of adolescents living in deprived communities.

Barriers and facilitators to dental care among culturally and linguistically diverse carers: A mixed-methods systematic review

OBJECTIVES

Culturally and linguistically diverse (CALD) communities experience widespread inequalities in dental care utilization. While, several studies have reported factors contributing to such inequalities, a synthesis of evidence is lacking for CALD carers. This review examined the barriers and facilitators to dental care utilization among CALD carers.

METHODS

Medline, CINAHL, ProQuest, Scopus and Web of Science were searched for dental utilization and related factors, without geographic limitations. An integrated mixed-method design was adopted, where both qualitative and quantitative findings were combined into a single synthesis. Critical appraisal was conducted using JBI tools, and a Universal Health Coverage (UHC) framework guided the synthesis approach. Reliability and researcher triangulation occurred throughout the conduct of this review.

RESULTS

A total of 20 papers were included: qualitative (n = 8), quantitative (n = 8) and mixed method (n = 4). Studies were from Australia, Canada, South Korea, Trinidad and Tobago, United Kingdom and the United States. Three studies insufficiently reported confounding variables and nine qualitative papers lacked philosophical perspectives. Affordability was the foremost barrier at the system level, followed by psychosocial negative provider experiences and language/communication issues at the provider level. Cultural, knowledge, attitudes and beliefs were individual-family level factors. Utilizing a UHC framework, the barriers and facilitators were aggregated at three levels; financial-system, provider and individual-family levels and illustrated in the rainbow model of CALD oral health.

CONCLUSION

The review strengthens evidence for multilayered, system-related policies and culturally sensitive provision of services for reducing oral healthcare inequalities in CALD carers.

Oral Health Workforce in Africa: A Scarce Resource

The World Health Organization (WHO) African Region (AFR) has 47 countries. The aim of this research was to review the oral health workforce (OHWF) comprising dentists, dental assistants and therapists, and dental prosthetic technicians in the AFR. OHWF data from a survey of all 47 member states were triangulated with the National Health Workforce Accounts and population data. Descriptive analysis of workforce trends and densities per 10,000 population from 2000 to 2019 was performed, and perceived workforce challenges/possible solutions were suggested. Linear regression modelling used the Human Development Index (HDI), years of schooling, dental schools, and levels of urbanization as predictors of dentist density. Despite a growth of 63.6% since 2010, the current workforce density of dentists (per 10,000 population) in the AFR remains very low at 0.44, with marked intra-regional inequity (Seychelles, 4.297; South Sudan 0.003). The stock of dentists just exceeds that of dental assistants/therapists (1:0.91). Workforce density of dentists and the OHWF overall was strongly associated with the HDI and mean years of schooling. The dominant perceived challenge was identified as 'mal-distribution of the workforce (urban/rural)' and 'oral health' being 'considered low priority'. Action to 'strengthen oral health policy' and provide 'incentives to work in underserved areas' were considered important solutions in the region. Whilst utilising workforce skill mix contributes to overall capacity, there is a stark deficit of human resources for oral health in the AFR. There is an urgent need to strengthen policy, health, and education systems to expand the OHWF using innovative workforce models to meet the needs of this region and achieve Universal Health Coverage (UHC).

Oral Health and Pathologies in Migrants and Vulnerable Population and Their Social Impact: The Good Practices of the Intervention Model of a University Dental Clinic

Numerous studies have shown the high incidence of diseases affecting oral health in vulnerable populations. The Canary Islands is a region particularly affected by the low income of its inhabitants and a high migration rate. Poor oral health habits and limited access to health care have turned these groups into risk groups. The role of the Fernando Pessoa Canarias University (CDUFPC) dental clinic in the health care of these groups has been an example of good professional practice and a fundamental resource in their health care. The present study aims to identify the profile of pathologies as well as the impact on the oral health of vulnerable population groups served by the CDUFPC. This study was developed between September 2019 and July 2022 with a sample of 878 patients, of whom 267 (30.4%) belonged to vulnerable groups referred by institutions and social organizations. The results identified the prevalence of dental caries as the main pathology and the lack of good oral habits and commitment to oral health and care.

Effect of the 2008 economic crisis on oral health in Spain: analysis of serial cross-sectional, population-based health surveys

OBJECTIVES

To evaluate the impact of the economic crisis on the oral health of individuals in Spain based on variables including sex, unemployment, social class and educational level.

DESIGN

This was an analysis of serial cross-sectional, population-based health surveys conducted before the crisis (2003 and 2006) and during the crisis (2011, 2014 and 2017).

SETTING

National Health Surveys of Spain and the European Health Survey in Spain.ParticipantsA total of 189 543 participants were recruited.

OUTCOME MEASURES

The independent variables were sex, employment, social class and educational level. The dependent variables were related to oral health. Descriptive statistics, χ² tests and the Cochran-Mantel-Haenszel test were performed.

RESULTS

The results showed that there were differences (p<0.001) in all oral health indicators before and after the crisis. Compared with the precrisis period, men had a higher probability of tooth extractions (OR 1.41, 95% CI 1.37 to 1.45), dental fillings (OR 1.30, 95% CI 1.27 to 1.34), prostheses (OR 1.04, 95% CI 1.01 to 1.07) and missing teeth (OR 1.35, 95% CI 1.31 to 1.39). Unemployed individuals were more likely to have dental caries (OR 1.08, 95% CI 1.00 to 1.16) and missing teeth (OR 1.36, 95% CI 1.27 to 1.46). Working class individuals had a higher probability of tooth extractions (OR 1.63, 95% CI 1.59 to 1.67), bleeding gums (OR 1.04, 95% CI 1.01 to 1.07), prostheses (OR 1.05, 95% CI 1.02 to 1.07) and missing teeth (OR 1.36, 95% CI 1.33 to 1.39). Participants with a basic or intermediate level of education had a higher probability of dental mobility (OR 1.13, 95% CI 1.07 to 1.19), prostheses (OR 1.11, 95% CI 1.08 to 1.14) and missing teeth (OR 1.42, 95% CI 1.38 to 1.46).

CONCLUSIONS

The economic crisis affected the oral health of the Spanish population, with a more significant deterioration among men, working class individuals and unemployed individuals.

Inequality in access to dental services in a market-based dental care system: A population study from Norway 1975-2018

OBJECTIVE

To examine income-related inequalities in access to dental services from 1975 to 2018. In Norway, dental care services for adults are privately financed. This may lead to income-related inequalities in access. In the early 1970s, that is, at the beginning of the study period, there were marked inequalities in access to dental services according to personal income. However, from the beginning of the 1970s, there has been a large increase in gross national income per capita in Norway as a result of the growth of the oil and gas industry. This increase in income also meant that people with a low income in 1975 had a rise in their level of income. According to the law of diminishing utility, an increase in income leads to higher consumption of dental services for people with a low level of income compared to people with a high level of income. The study hypothesis is that the inequalities in access to dental services that existed in 1975 became less over time.

METHODS

Statistics Norway collected samples of cross-sectional health survey data for the following years: 1975, 1985, 1995, 2002, 2008, 2012 and 2018. For each sample, individuals 21 years and older were drawn randomly from the non-institutionalized adult population using a two-stage stratified cluster sample technique. Inequalities were measured using the concentration index. The dependent variable was the use of dental services during the last year, and the key independent variable was equivalized household income.

RESULTS

The concentration index for inequalities in use of dental services according to income decreased from 0.10 (95% CI = 0.09, 0.11) in 1975 to 0.04 (95% CI = 0.03, 0.05) in 2018. The decrease was particularly large from 2002 to 2012. This was a period with a large growth in gross national income.

CONCLUSION

People with a low income had a marked increase in their purchasing power from 1975 to 2018. This coincided with an increase in demand for dental care for this low-income group.

Behavioural intervention to promote the uptake of planned care in urgent dental care attenders: study protocol for the RETURN randomised controlled trial

BACKGROUND

People with disadvantaged backgrounds are less likely to visit the dentist for planned care, even though they have disproportionately poorer oral health. They are correspondingly more likely to experience dental problems and use urgent dental care, general practices and Accident and Emergency departments, which not only makes meeting their needs expensive, but, since these services often rely on prescriptions rather than addressing the clinical cause, can contribute to antimicrobial resistance.

METHODS

The RETURN intervention has been developed with substantial community co-production, to be delivered opportunistically in urgent dental care settings. This brief intervention is delivered by dental nurses and involves material relevant to the 'in-group' targeted. The material includes booklets relating to barriers to planned dental visiting with corresponding short video clips featuring local people and including a modelling element. Dental nurses are trained to have supportive and non-judgemental conversations, assisting patients to set personal goals and action plans, which are reinforced in a follow-up text within a few weeks. A randomised controlled trial will be undertaken in 3 types of sites: dental practices delivering urgent care (a) within working hours, (b) out of hours, and (c) in a Dental Hospital. The trial will recruit 1180 adult urgent dental care users over 12 months, who have not visited a dentist for a planned care appointment for 2 years or more and do not have a dentist who they visit for routine care. It aims to investigate the effectiveness and cost-effectiveness of the intervention and to explore whether the intervention has different effects across the socio-economic gradient. Participants will be followed up at 6, 12 and 18 months after randomisation. Co-primary outcomes are attendance at a dental practice for planned care within 12 months and self-reported oral health-related quality of life at 12 months.

DISCUSSION

This is a pragmatic trial, evaluating the effectiveness of the intervention under the usual condition in which it might be applied. Since dental practices work as independent contractors to the NHS, this brings implementation and fidelity challenges which will be explored and described in embedded qualitative work.

TRIAL REGISTRATION

ISRCTN registry identifier ISRCTN84666712. Registered 12/04/2021.

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach

BACKGROUND

Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach.

METHODS

We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists.

RESULTS

Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care.

CONCLUSIONS

According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.

Urban-Rural Disparities in Dental Services Utilization Among Adults in China's Megacities

Objective: China's dental care system is bifurcated between urban and rural areas. However, very few studies have examined the dental services utilization inequities in China's megacities, particularly in these urban and rural areas. This study aims to examine the urban-rural disparities in dental services utilization among adults living in China's megacities based on the Andersen dental services utilization model.

Methods: This study used data from 4,049 residents aged 18–65 who participated in the “2019 New Era and Living Conditions in Megacities Survey.” Multivariate logistic regressions were employed to examine the associations between place of residence and dental services utilization for individuals from ten megacities in China. Predisposing variables (age, gender, marital status, living arrangement, and education), enabling variables (socioeconomic status, occupational status, income, insurance coverage, health attitude, and health behavior), and need variables (self-rated health, oral health status, gum bleeding) were controlled for.

Results: The mean age of the 4,049 adults was 45.2 (standard deviation = 13.0), and 30.4% (n = 1,232) had no dental visits at all. Adults who resided in urban areas were more likely to use dental services [odds ratio (OR) = 1.57, 95% confidence interval (CI) = 1.30 to 1.91] than those residing in rural areas after controlling for key covariates. Factors associated with higher odds of visiting dentists include having a higher income (OR = 1.44, P < 0.001), higher education level (OR = 1.53, P = 0.042), being covered by insurance for urban residents/employees (OR = 1.49, P = 0.031), having a positive attitude toward healthy diets (OR = 1.43, P < 0.001), attending regular physical examination (OR = 1.66, P < 0.001), having more tooth loss (OR = 1.05, P < 0.001), and having frequent gum bleeding (OR = 2.29, P < 0.001).

Conclusion: The findings confirm that place of residence is associated with dental services utilization while adjusting for key covariates. Despite rapid economic development in China, many adults had never visited dentists at all. More efforts should be taken to encourage widespread dental care, such as providing more dental coverage and better access to dental care services.

Perspectives on Social and Environmental Determinants of Oral Health

Most oral conditions have a multifactorial etiology; that is, they are modulated by biological, social, economic, cultural, and environmental factors. A consistent body of evidence has demonstrated the great burden of dental caries and periodontal disease in individuals from low socioeconomic strata. Oral health habits and access to care are influenced by the social determinants of health. Hence, the delivery of health promotion strategies at the population level has shown a great impact on reducing the prevalence of oral diseases. More recently, a growing discussion about the relationship between the environment, climate change, and oral health has been set in place. Certainly, outlining plans to address oral health inequities is not an easy task. It will demand political will, comprehensive funding of health services, and initiatives to reduce inequalities. This paper sought to give a perspective about the role of social and physical environmental factors on oral health conditions while discussing how the manuscripts published in this Special Issue could increase our knowledge of the topic.

Case Study Analysis: The Utilization of Health Services by Citizens at Area of Tangerang Selatan, Indonesia

BACKGROUND: Citizens are people who have a high risk of exposure to diseases due to unhealthy environmental conditions. This requires citizens to take advantage of health services in order to get optimal examinations. AIM: The purpose of this study was to determine the description and relationship between the characteristics of citizens, the characteristics of health services and the utilization of health services by citizens in the area of Tangerang Selatan, Indonesia in 2020. METHODS: The quantitative research method with cross-sectional design used random sampling techniques. The number of samples was 150 families in the area of Tangerang Selatan, Indonesia. The riset measured data using a questionnaire and collected data by interviewing the respondents. Data analysis used Chi-square analysis and multiple logistic regression analysis. RESULTS: The results showed that the variables related to the utilization of health services were knowledge variable (p = 0.001), number of families (p = 0.021), perception of pain (p = 0.001), and family support (p = 0.030). And the variables that were not related to the utilization of health services were ownership of health insurance (p = 0.750), transportation (p = 0.297), distance (0.340), health information (p = 0.538), and attitudes of health workers (p = 1000). As well as the dominant variable related to the utilization of health services, that is knowledge (p = 0.000) with odds ratio 12.876. CONCLUSION: It is hope that primary healthcare and health workers can involve more communities around the area in their work programs, such as providing health information.

Dental Attendances to General Medical Practitioners in Wales: A 44 Year-Analysis

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients’ reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

Promoting regular dental attendance in problem-orientated dental attenders: A systematic review of potential interventions

BACKGROUND

Problem-orientated dental attenders account for around one-third of the UK population, these being patients who do not seek regular dental care, instead only attending with dental pain. In order to develop intervention(s) to encourage regular dental attendance in these patients, any previous intervention development should be identified to aid idea generation or retrofitting of interventions.

OBJECTIVE

To identify previous interventions which have been developed targeted at problem-orientated dental attenders to facilitate the development and co-design of a new intervention.

METHODS

Eight electronic databases were searched for studies which included an intervention targeted at adult problem-orientated or irregular dental attenders to encourage regular dental attendance. Data on the intervention design mapped to the theoretical domains framework were extracted, alongside effectiveness and patient views where available.

RESULTS

Three studies fitted the inclusion criteria for the review. Interventions identified were attendance at a dental anxiety clinic, and a large advertising campaign promoting a free dental update where members of the public could visit local dental practices to look around and meet the dentists. One study looked at the effect of policy change by introducing free dental check-ups in Scotland. Interventions were poorly reported, with significant omissions in their description and a lack of clear identification of what composed the intervention.

CONCLUSION

There are very few interventions developed targeted at problem-orientated dental attendance, but important areas to consider in future intervention development include the following: dentist communication; dentist-patient relationship; increasing the awareness of need; the effect of free dental check-ups.

Inequalities in utilization and provision of dental services: a scoping review

BACKGROUND

There are many determinants that can affect inequality in oral and dental health. This study is aimed to explore the main determinants of inequality in both utilization and provision of dental services in Organization for Economic Co-operation and Development (OECD) countries.

METHODS

Four databases including PubMed, ISI WOS, Scopus, and ProQuest were searched up to 8 Aug 2020, applying the relevant keywords. Thematic analysis was used for synthesizing and extracting data. Trend analysis was applied to determine the trends of the inequality determinants.

RESULTS

Thematic analysis led to 6 main themes, 13 sub-themes, and 53 sub-sub-themes. The main themes represent the main inequality determinants for both utilization and provision of dental services. The streamgraph illustrated that fewer studies have been conducted on social and cultural determinants, and for almost all determinants the trend of published articles has been increasing since 2007, with the exception of health policies.

CONCLUSIONS

Inequality in the utilization and provision of dental services is addressed by various factors including individual, social, cultural and economic determinants, health policies, and availability of services. The first four determinants are related to utilization and the last two are related to the provision of services. All these aspects must be considered to reduce inequality in dental services.

Socio-economic inequalities in dental pain in children: A birth cohort study

OBJECTIVE

To describe socio-economic inequalities in dental pain and dental caries in 5 and 12-year-old children enrolled in a birth cohort.

METHODS

This prospective study was carried out with children enrolled in a birth cohort in Pelotas, Brazil. The main outcome was history of dental pain in the last six months, collected at 5 and 12 years of age. Dental caries was evaluated as a secondary outcome. Inequalities dimensions were investigated using maternal education and family income. The inequalities indicators used were the slope index of inequality (SII) and the concentration index (CIX).

RESULTS

Some 1,114 and 990 children were included in the analyses at the 5- and 12-year follow-ups, respectively. The prevalence of dental pain was 16.5% (95% CI 14.4-18.8) at 5 years and 31.6% (95% CI 28.7-34.6) at 12 years. Regarding SII, the difference in the prevalence of dental pain was 14 and 11 percentage points at 5 and 12 years, respectively, when comparing the less to the more maternal schooled strata. Relative inequalities (CIX) were found for dental pain only at age 12, considering family income (-5.8 CI95% -11.0; -0.6). Absolute socio-economic inequalities were also observed for dental caries in both ages.

CONCLUSION

Dental pain in the last six months and dental caries was unequally distributed. Economically disadvantaged groups had the highest prevalence of dental pain and dental caries in both dentitions. Actions to tackle socio-economic inequalities must be designed throughout life.

An Investigation of the Association between Health Screening and Dental Scaling in Korea

Dental disease is one of the most prevalent chronic diseases worldwide, and its expenditure is continuously increasing. Periodontal disease is increasing as a chronic non-communicable disease in adults and older people. Health screening has been shown to be cost-effective and improves the quality of life through the early detection of diseases. This study aimed to analyze the relationship between national health screening and dental scaling as a preventive service for periodontal disease. The study used sample cohort data from 2002 to 2015 provided by the National Health Insurance Sharing Service in South Korea. A logistic regression analysis of the utilization of dental scaling was performed to identify the independent effects of national health screening. People who underwent health screening showed a higher tendency to undergo dental scaling. Additionally, disparities in utilization according to socioeconomic status were reduced among those who underwent screening. The intervention to extend dental coverage could be more beneficial when combined with health screening, encouraging more people to participate and reducing inequalities in utilization.

Prevalence and Correlates of Dental Service Utilization among Adults in Solomon Islands

Aims and Objectives:

The aim of this study was to assess dental service utilization (DSU) among adults in a Pacific Island country.

Materials and Methods:

In a cross-sectional nationally representative survey in Solomon Islands, 2,533 individuals (18–69 years) responded to questions on DSU, sociodemographic and health information in 2015.

Results:

More than half of the participants (55.3%) never had DSU, 36.4% had more than 12 months DSU, and 8.3% had past 12 months DSU. In adjusted multinomial logistic regression analysis, older age, ever screened for blood pressure, using toothpaste, and having had pain in teeth, gum, or mouth in the past year were associated with both >12 months and past 12 months DSU. Higher education, ever screened for cholesterol, being divorced, separated, or widowed, poor self-rated oral health (SROH), and experienced difficulty in chewing foods in the past 12 months were associated with >12 months or past 12 months DSU. High physical activity was negatively associated with >12 months DSU.

Conclusion:

Less than one in ten participants had past 12 months DSU and several factors were found, which can be targeted in interventions.

Time-to-Treatment in Oral Cancer: Causes and Implications for Survival

The purpose of this review was to identify and describe the causes that influence the time-intervals in the pathway of diagnosis and treatment of oral cancer and to assess its impact on prognosis and survival. The review was structured according to the recommendations of the Aarhus statement, considering original data from individual studies and systematic reviews that reported outcomes related to the patient, diagnostic and pre-treatment intervals. The patient interval is the major contributor to the total time-interval. Unawareness of signs and/or symptoms, denial and lack of knowledge about oral cancer are the major contributors to the process of seeking medical attention. The diagnostic interval is influenced by tumor factors, delays in referral due to higher number of consultations and previous treatment with different medicines or dental procedures and by professional factors such as experience and lack of knowledge related to the disease and diagnostic procedures. Patients with advanced stage disease, primary treatment with radiotherapy, treatment at an academic facility and transitions in care are associated with prolonged pre-treatment intervals. An emerging body of evidence supports the impact of prolonged pre-treatment and treatment intervals with poorer survival from oral cancer.

Avoidance of dental appointment due to cost and consequences for oral health-related quality of life: 25-yr follow-up of Swedish adults

We explored how socio-demographic and personal characteristics contribute to avoidance of dental appointment due to cost over time from age 55 (in 1997) to 75 (in 2017) and assessed the implications for oral health-related quality of life. In 1992, 6346 residents born in 1942 consented to participate in a prospective questionnaire survey, and 3060 (48.2%) of them completed postal follow-ups every fifth year until 2017. Oral health-related quality of life was assessed using the Oral Impact on Daily Performance inventory. The frequency of avoidance of dental appointment due to cost declined from 7.0% (in 1997) to 5.4% (in 2017), whereas the frequency of oral impacts declined from 26.0% in 2007 to 24.0% in 2017. Generalized Estimating Equation models revealed that avoidance of dental appointments due to cost was more likely reported in 1997 (OR: 1.5: 1.2-1.8) than in 2017, more likely in low educated people, and less likely in those using private dental care services. Avoidance of dental appointment due to cost was associated with impaired oral health-related quality of life. Social inequalities in avoidance of dental appointment due to cost and oral impacts did not vary across time but persisted into older ages despite the dental health care reforms that had been implemented.

Use of dental services among middle-aged adults: predisposing, enabling and need variables

OBJECTIVES

To examine if making a visit, number of visits and services varied by predisposing (gender, perceived health competence, education, previous relief of pain visit), enabling (dental anxiety, income, social support) and need (perceived need, number of teeth and oral pain) characteristics.

METHODS

Dental visiting and services data from a sample of middle-aged South Australian adults were collected from 61% of participants at 12-months (n = 603) and 59% after 24-months (n = 583). Visiting over 2-years, mean visits and mean services were analysed by log binomial and Poison regression using the Andersen and Newman model.

RESULTS

The percentage having a dental visit over 2-years was lower for males than females, prevalence ratio (PR, 95% CI) 0.91 (0.84, 0.99), and for higher than lower dental anxiety, PR = 0.78 (0.62, 0.98). Number of visits was associated with higher than lower income, rate ratio (RR, 95%CI) 1.20 (1.02, 1.41) but lower for those with higher social support, RR = 0.86 (0.74, 0.99). Services were lower for those with higher perceived health competence, RR = 0.72 (0.56, 0.92) but higher for those with perceived needs, RR = 1.22 (1.01, 1.46).

CONCLUSIONS

While need and cost factors predict dental service use, psychosocial variables such as health competence and social support also need to be considered.

Prevalence and correlates of dental service utilisation among a national general adult population sample in Sudan

BACKGROUND

Prompt dental service utilisation (DSU) is needed for the prevention and treatment of oral diseases, and it is therefore important to determine the facilitators and barriers of DSU. There is, however, scarce information available on DSU in Sudan. Therefore, this study aimed to investigate the prevalence and associated factors of DSU in a general population-based survey among 18-69 year-old persons in Sudan.

METHODS

Cross-sectional nationally representative data of 7,722 18-69 year-old persons (36 years median age) from the 2016 Sudan Stepwise approach to surveillance (STEPS) survey were analysed. Using questionnaire, anthropometric and biochemical measures, predisposing, enabling and health and lifestyle factors of DSU were assessed. Multinomial logistic regression was conducted to estimate the predictors of DSU (> 12 months and past 12 months, with never DSU as the reference category).

RESULTS

About two-thirds of the participants (64.6%) had never DSU, 22.0% had more than 12-month DSU, and 13.4% had past 12- month DSU. Among those who had ever DSU, the main reason for the last DSU was pain or trouble with teeth, gums, or mouth (66.9%), treatment or follow-up treatment 22.3%, and routine check-up treatment 5.0%. In adjusted multinomial logistic regression analysis, higher education (p < 0.001), urban residence (p < 0.001), screened for blood pressure (p < 0.001), raised total cholesterol (p < 0.05), poor SROH (p < 0.001), pain in teeth or mouth (p < 0.001), and not working because of teeth or mouth (p < 0.01) were positively and not knowing their household income (p < 0.01), high physical activity (p < 0.05), and having 20 or more teeth (p < 0.001), were negatively associated with both > 12 months and past 12 months DSU. Higher household income (p < 0.001), overweight/obesity (p < 0.05), using tooth paste (p < 0.001), and difficulty chewing (p < 0.001), were positively, and male sex (p < 0.01), and teeth cleaning twice or more times a day (p < 0.05), were negatively associated with > 12 months or past 12 months DSU.

CONCLUSION

More than one in ten participants had past 12 months DSU and several factors were detected which could be targeted in intervention activities. Study findings suggest to improve oral health awareness, in particular stressing the relevance of regular dental check-ups, by using different modalities of oral health promotion.

Epidemiological trends, predictive factors, and projection of tooth loss in Germany 1997-2030: part II. Edentulism in seniors

OBJECTIVE

This is the second part of a report on tooth loss in Germany 1997-2030. Here, we describe trends in the prevalence of edentulism in seniors 1997-2014, assess predictive factors for edentulism, and projected it into 2030.

MATERIAL AND METHODS

We used data from three waves of the cross-sectional, multi-center, nationwide representative German Oral Health Studies. Overall, 3449 seniors (65-74 years) were included (1997: 1367; 2005: 1040; 2016: 1042). Age, sex, educational level, smoking status, and the cohort were entered into age-cohort binary-logistic regression models to assess the association of predictors with edentulism and to project edentulism in 2030 via Monte Carlo simulations.

RESULTS

Between 1997 and 2014, the prevalence of edentulism decreased from 24.8 to 12.4%. With each year of age, the risk of being edentate increased (by 11%, p < 0.001); it was also significantly increased in female versus male (by 40%, p = 0.001), low versus medium and high educational level (up to 257%, p < 0.001), and in former and current smokers (up to 258%, p < 0.001). We predict the prevalence of edentulism to be reduced to 4.2% in 2030. The reduction will be higher in males, never and former smokers, and those with low socio-educational level. On an absolute level and despite a growing elderly population (aged 60-80 years), the number of edentate individuals will have decreased by 3.6 million in 2030 compared with 1997.

CONCLUSIONS

Edentulism in seniors has declined equitably in Germany. The decline is expected to continue until 2030. Further efforts are needed to tackle the underlying risk factors.

CLINICAL RELEVANCE

This study presents trends of edentulism in Germany for a period of three decades. It provides clinically relevant data for health care planning by 2030.

Equity in access to zero-fees and low-cost Primary Health Care in Aotearoa New Zealand: Results from repeated waves of the New Zealand Health Survey, 1996-2016

Primary Health Care in Aotearoa New Zealand is mainly funded through capitation-based funding to general practices, supplemented by a user co-payment. Funding is designed in part to keep the costs of care low for key groups in the population who have higher health needs. We investigated changes in the socio-demographic determinants of no-cost and low-cost access to Primary Health Care using data from sequential waves of the New Zealand Health Survey (1996/97-2016/17). Fees paid were self-reported and inflated using CPI-adjustment to the value of the 2018NZD. Over the 20-year study period, there was an increase in the population accessing low-cost care. Access to low-cost care was particularly high for Pacific people, but also higher for Māori and Asian people compared to Other/New Zealand European ethnicities. Area-level deprivation was a stronger predictor of access to low-cost care for non-Māori than for Māori. Although Māori were more likely than non-Māori to access low-cost care at all levels of deprivation, this was less evident in more deprived compared to more affluent areas. Given ongoing reported inequity for Māori being less able to afford primary health care, we suggest that future policies to improve access should be fully aligned with the articles of Te Tiriti o Waitangi and should focus on equity.