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OCR for page 13
CHAPTER 2
NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES
The first and perhaps most basic questions raised by the committee
centered on the need for and utilization of dental services. The major
sources of data used to analyze these questions are the national sur-
veys of the need for dental care and dental visits. This information
on variations in unmet need and differences in dental visit patterns
by certain sectors of the population was required for the committee's
consideration of priorities in benefits for certain subpopulations.
This chapter also includes a discussion of motives, learned behavior,
and beliefs related to the use of dental services. These behavioral
factors were considered by the committee in making recommendations
that would encourage and support behavior that results in more appro-
priate use of services.
There are differences in patterns of dental care utilization, demand,
and unmet need in various groups of the population. Although certain
characteristics of population, such as income, age, and race, are associ-
ated with differences in need and utilization, there appear also to
be factors of socioeconomic class, education, and value systems that
are more predictive of differences in utilization. Studies have found
these differences persisting even after financial and physical access
to treatment are equalized by prepaid dental plans.
Indicators of Need for Treatment
Needs of a population for dental treatment usually are inferred
from indicators of oral pathology. Dental caries is described by the
number of decayed, missing, or filled teeth (DMF); the inflammation and
the recession of gum and bone because of periodontal disease is scored
on a periodontal index (PI). These indices are accurate clinically
and useful epidemiologically, but their value in estimating national
needs for specific dental services is limited. Extent and severity
of dental disease in a population is only an indirect indicator of
the types and amount of treatment needed.
The primary dental health status data in this chapter are from the
1971-74 Health and Nutrition Examination Survey (HANES) conducted by the
National Center for Health Statistics (NCHS). The examiners in this
13
OCR for page 14
study ascertained the actual needs of the sample population. Because
these examinations did not use radiographs, a correction factor for
underestimation of disease has been incorporated in the method for
projecting expenditures.
"Need" in this chapter refers to unmet patient requirements for
specific quantities of dental services as determined in a national
population-based survey by dentist examiners performing a standardized
examination. The services include removal of debris and calculus;
treatment of gingivitis, other periodontal disease, severe malocclu-
sion, and decay in both permanent and primary teeth; and provision
of fixed bridges and partial and full dentures. The data are sum-
marized below 1/.
Demographic Factors
Age Table 1 displays the data by age groups. Sixty-four percent
of the entire population is in need of some kind of dental care. Pro-
phylactic and restorative services are most commonly needed from an
early age through adulthood. The need for treatment of malocclusion
is a phenomenon of childhood and adolescence; the requirements for
extraction and dentures tend to increase with age. Treatment of
gingivitis, debris and calculus, periodontal disease, decayed teeth,
and bridge and denture work constitute the dental problems of adults.
One-third of persons aged 65-74 are in need of repair of dentures
or bridges. This is further shown in Table 2.
Sex More males are in need of dental treatment than females. This
is true at all ages and in almost all categories of care, though the
differences are not great (Table 3~.
Race The HANES data show a consistently greater need for treatment
among blacks than among whites (Table 4). Differences are most marked
in the needs for the treatment of tooth decay and periodontal disease.
Income Table 5 shows that a greater need for dental services
exists among low income groups in every age category except persons
over age 65, who have fewer teeth.
Utilization of Services
Various social, economic, psychologic and demographic variables
are independently associated with differences in who uses dental ser-
vices, how frequently, and for what reason. (The impact of dental
insurance on utilization is discussed in greater detail in Chapter 5.)
The proportion of people who have never seen a dentist has declined
over the last fifteen years (Table 6), but about 30 percent of the
14
OCR for page 15
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population under age 17 in 1977 had never been to a dentist 2/. A
1964 survey of households found that less than two percent of the popu-
lation accounted for twenty-five percent of all dental visits 3/.
Demographic Factors
A number of studies have identified characteristics associated
with differences in utilization and have demonstrated the disparity
between need for and utilization of dental care 4-11/.
Age People under 5 and over 65 use dental care least, probably
because of the natural history of dental disease and the number of
teeth at risk. Also, a social bias against the treatment of primary
teeth may contribute to low utilization rates by younger children.
Among persons 65 and over, according to the Health Interview Survey
of 1971, more than 50 percent had no natural teeth 12/.
Awareness of need for treatment of permanent teeth is indicated
beginning in the 5 to 14 age group by a sharp rise in the percent
of the population who visit a dentist in any one year, and in the
number of dental visits made per year 25-27/.
Patterns of utilization and utilization rates of adults seem to
be changing, perhaps as a result of increased private dental insurance.
Earlier studies showed peak rates between the ages of 6 and 24, follow-
ed by a gradual decline to age 65 28-31/. Table 7 contains more
recent data indicating that the number of dental visits remains constant
between ages 17 and 65.
Sex Many studies and surveys show that women use dental services
more than men up to age 65 33-36/. Beyond 65 the utilization rates are
about the same 37-38/.
Race Racial differences in utilization also have been demon-
strated 39-44/. Table 8 shows these differences at various income
levels.
Socioeconomic Factors
In general, the higher one's income, educational level, and
occupational status, the more likely one is to visit a dentist (Table
9~. Dental insurance seems to have a positive influence on the utili-
zation of services 46/, as is discussed more fully in Chapter 5.
Income In middle and high income groups, there is a strong
correlation between increments in income and increased utilization
(Table 8~. Lower income groups do not demonstrate such a strong re-
lationship 47-48/.
20
OCR for page 21
Table 8. PERCENT OF PERSONS WITH A DENTAL VISIT WITHIN A YEAR, BY RACE
AND INCOME 1977
,
Income Level White Other Races
Under $5,000 35.4 29.9
$5,000-9,999 38.9 34.3
$10,000 and over 58.6 41.9
Source: Health Interview Survey, National Center for Health
Statistics 45/
Education The education of the head of a household appears to
be the strongest predictor of rates of utilization of dental services
by family members. As education increases, utilization increases
49-52/. Table 9 shows the 1977 data from the Health Interview Survey.
Variation is greater when related to educational achievement than when
related to income. Although there is a study of several isolated
communities in which the black population does not completely fit the
model 53/, in the general population education is a very strong pre-
dictor of utilization.
Occupation To a great extent occupation is a product of educa-
tion and a determinant of income. The data in Table 10 from the
Health Interview Survey and other studies 54-56/, show that utili-
zation varies with occupation, and that people in white collar
occupations use dental services more than those in blue collar jobs.
This difference appears to persist long after financial barriers
are removed. In a case study of workers in a prepaid dental plan,
different occupational groups continued to show markedly different
utilization rates even after six years in the plan 57/.
Other Aspects of Utilization
Socioeconomic status (SES) is usually measured by income, educa-
tion, and occupation. But SES also implies differences in beliefs,
attitudes, and specific behavior patterns associated with social class
values. Although lower SES implies less disposable income and there-
fore reduced ability to pay for health care, cost is not the only
reason differences in utilization occur.
Individual behavior is particularly important in the consider-
ation of preventive health behavior. Many preventive practices, such
as toothbrushing, entail almost no cost, yet members of lower SES
groups are less likely to follow them than are people from higher
groups 60/.
Demographic and socioeconomic variables do not fully explain
differences in utilization of dental services. There are underlying
21
OCR for page 22
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Table 10. NUMBER OF DENTAL VISITS PER PERSON PER YEAR, BY SELECTED
OCCUPATIONAL CHARACTERISTICS: UNITED STATES, 1977
Characteristic
All Persons
Total white collar
Professional
Managers /Administrators
Clerical
Sales
Total Blue Collar
Crafts
Operators
Laborers (non-farm)
Total Service
Private household
Other service workers
Total Farm
Farm managers
Farm laborers and foremen
Visits per person per year
1.6
2.1
2.1
2.0
2.0
2.1
1.3
1.3
1.3
1.3
1.5
1.2
1.6
1.2
1.2
1.3
Source: Health Interview Survey, National Center for Health
Statistics 59/
sets of attitudes and behaviors. Three conceptual approaches to these
are 1) motives and barriers affecting utilization, 2) learned behavior
and 3) the health belief model.
Motives and barriers There is a relationship between social
class and the motivation to maintain healthy, natural dentition 61-62/.
Attitudes toward the cosmetic and social usefulness of healthy teeth
vary with socioeconomic level. Persons in higher levels attach more
importance to attractive teeth than do those in lower groups. However,
the strength of an individual's motivation must be considered with regard
to barriers to care--real or perceived--for a better understanding of the
differing patterns of utilization.
Cost is one barrier to seeking dental care. Several studies have
cited it as the most frequent reason needed care was not sought 63-64/.
However, lower utilization persists in populations with access to free
or prepaid dental care 65-67/. Lack of financial resources may be
more related to not seeking needed dental work than for going to the
dentist for preventive care 68/.
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Problems in access to dental care also can involve physical factors,
such as distance, availability of transportation, and other matters of
convenience. The convenience of making and keeping an appointment tends
to be related to socioeconomic level. The person paid hourly wages is
not likely to have great flexibility in setting work hours, and time off
work is costly. It may also be more complicated, because leave must be
requested in advance _ /.
If people have difficulty in finding dentists who have lower fees
or who will accept delayed payment, they may have to select dentists
who do not practice in or near their neighborhoods 70/.
Anxiety or fear of pain are significant barriers to seeking health
care 71-73/. Because persons from lower socioeconomic groups have
more extractions and less preventive treatment, they may be more fearful
of dental visits. But fear and anxiety have been shown to be associated
with differences in preventive care utilization at all income levels,
with no apparent differences between socioeconomic levels 74-75/.
A lack of knowledge or understanding of dental disease and the
need for treatment may result in a low priority for dental care 76-77/.
A study of persons of lower socioeconomic groups found that they tended
to choose false teeth when presented with a hypothetical case involving
a choice between having their teeth fixed or being given dentures 78/.
Learned behavior In this concept, behavior must be viewed apart
from attitude and beliefs, particularly the behavior related to pre-
ventive care. Positive attitudes do not necessarily evoke preventive
behavior. A belief in the usefulness of tooth brushing and visiting
the dentist may have little influence on the frequency of preventive
visits 79-80/.
Studies have demonstrated, however, that learned behavior is
closely related to dental services utilization 81-83/. Those
who visit a dentist first before they are 13 are more likely to make
visits when they are asymptomatic. Generally, those who take one
health-related action are more likely to repeat it than those who
have not. Kriesberg and Treiman state, "Apparently the use of dental
services is a specific pattern of behavior which is learned by precept
and example and may be learned without a comprehensive set of support-
ing beliefs, attitudes and values." 84/
The health belief model This postulates that readiness to seek
care without having disease symptoms depends on a combination of be-
liefs: (1) that one is susceptible to the disease in question, (2)
that the disease is potentially serious, and (3) that an action to
prevent or alleviate the disease is available.
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In a study of 430 factory workers whose care was covered by a
company-financed dental plan, almost 80 percent of those who held
all three beliefs made preventive dental visits 85/. In a three
year follow-up of the same population, the association between beliefs
and behavior persisted. More than 65 percent of those who believed
both in the susceptibility to dental disease and the benefits to be
derived from preventive care had made preventive visits to the dentist
between the studies, while only about 40 percent of those who did not
hold either belief had made preventive dental visits 86/. Associations
between beliefs in susceptibility and benefits and other kinds of preven-
tive health actions also have been found 87-90/.
None of the behavioral science models outlined above adequately
explains all differences in utilization. However, a relationship
between socioeconomic status and the utilization of dental services
has been confirmed repeatedly.
Summary and Conclusions
There is a substantial unmet need for dental services in the
United States; national surveys show that almost two thirds of the
population is in need of some kind of dental care. The needs vary
according to age, sex, race, income, and occupation. Among school-
age children, removal of debris and cavities and treatment of de-
cayed primary and permanent teeth are the greatest needs. Many of
these conditions could be prevented by community fluoridation and
preventive care. The committee therefore concluded that a basic
public program is required to assure the delivery of preventive
services to all children.
More men are in need of dental treatment than women, and blacks
have a greater need for dental treatment than whites. The unmet
need for dental services among low income groups is significantly
greater than those with incomes above the poverty level. The use
of dental services also is highly correlated with income: the
higher one's income, educational level, and occupational status,
the more likely one is to visit a dentist.
Financial barriers to obtaining needed dental services among
low income groups led the committee to conclude that the needs of
children in low-income families must be addressed, and that, at
a minimum, steps should be taken to assure that they have access
to the comprehensive dental services.
Variations in learned behavior, attitudes, and beliefs are
associated with differences in socioeconomic class and the use of
the dental services. National health policy with regard to dental
services, therefore, should not only address issues of equity in
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financial and physical access to care, but also encourage and
support behavior that results in more appropriate utilization
of these services. Thus, the committee emphasizes preventive
services, particularly for children, in its recommendations.
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Representative terms from entire chapter:
dental care
