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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

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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

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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

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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

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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/. 23

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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. 24

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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 25

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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. 26