CHAPTER TWO:

Related Studies
Pattern of utilization of dental services at Federal
Medical Centre, Katsina, Northwest Nigeria
The goal of dental service utilization research is to
improve the health outcome of individuals and society
at large. In contrast to developed nations, studies
across sub-Saharan Africa have shown gross neglect of
oral diseases by individuals, policy makers, and health
planners. This is partly responsible for limited
availability of human and material resources for dental
services and consequential poor dental attendance. This
is compounded by limited availability of curative care
concentrated in urban areas.
The present study showed an overwhelming proportion of
dental services utilization was by the people belonging
to younger age bracket, with the 21-30 year age group
predominating. This is similar to the findings of
previous studies reported from West Africa and India.
Fotedar et al.

suggested that younger people have

fewer barriers to oral health. On the other hand,

Syrjala et al. [observed that the older age group
considered oral health of less significance in
comparison to their other chronic conditions. However,
Ajayi et al.

mentioned that the younger age population

of patients' health related morbidity is a reflection

of lower life expectancy among Nigerians.

We speculate

that all these factors might be responsible for the

younger age group observed in the current study.
Our data demonstrated that the proportion of males
seeking dental treatment was greater than females,

which is in agreement with the observations of

Olaleye et al. (Maiduguri)

and Oginni (Ile-Ife),

but

contradicts the report of Varenne et al. (Burkina

Faso). An association between dental anxiety and poor
dental utilization has been established in the
literature.

Recent studies

found that anxiety and

fear of dental treatment was more common in women,

especially from low socioeconomic background.
There is a growing challenge of oral diseases such as
dental caries, periodontitis, dental trauma, and oral
cancer in resource-challenged countries.

Dental caries

and its sequelae and, to a lesser extent, periodontal

disease were the most frequent reasons for receiving
dental treatment in the present study. This agrees with
many reports from Maiduguri and Ile-Ife from Nigeria,
as well as from other African states such as Burkina
Faso and Tanzania.

Episodic visit for relief of pain has been noted as the

major motivating factor for most patients presenting
for dental treatment.

However, self-medication,

whether western or traditional, has been reported by

several researchers.

According to the findings of this

study, some patients presented with life-threatening

complications like Ludwig's angina, which necessitated
emergency surgical care, expensive medications, and
long hospitalization, putting further strain on scarce
resource and manpower.
On the whole, there was slightly more demand for
conservative than surgical treatment in the present
study. This is not in concordance with previous studies

that demonstrated an overwhelming popularity of

surgical treatment.

If the outcome is satisfactory,

this approach to dental care may reduce the prevalence

of edentulism and the need for expensive oral
prosthesis in a resource-depleted setting.
It was found in the present study, in concordance with
earlier findings,

that tooth extractions accounted for

approximately 37% of dental treatment. Studies from

sub-Saharan Africa and other developing nations
observed that tooth extraction remains the most
frequent dental treatment.

This is probably because of

lower cost of dental extraction compared to

conservative dental care. Contrary to earlier
findings,

we observed a female bias toward tooth

extractions and a male preference for restorative

procedures in the present study. The low figure
recorded for scaling and polishing in the present study
might portend the necessity to promote preventive oral
care among our population.
Management of maxillofacial fractures in the present
cohort was by closed reduction technique of MMF in
accordance with numerous studies conducted across
Africa.

The controversy of the superiority of open

reduction and internal fixation (ORIF) over the former

remains inconclusive,

but globally, it is accepted as

the gold standard of craniomaxillofacial fracture

management.

Recent reports have implicated impediments

such as low funding of health sector, low socioeconomic

status of patients, limited theater space, high cost of
the titanium plates and screws, and lack of expertise
and training as being responsible for this preference.

In conclusion, majority of the dental services

utilizers in the study population were males,
especially in the 21-30 years age group, with tooth
extraction being the most frequent dental treatment. We
recommend emphasizing on preventive oral care to reduce
the burden of oral diseases in our center.
http://www.smjonline.org/article.asp?issn=11188561;year=2014;volume=17;issue=3;spage=108;epage=111;au
last=Taiwo
Factors affecting utilization of dental health services
and satisfaction among adolescent females in Riyadh
City

Investigating patients views, desires, opinions, and

satisfaction with dental care may provide useful
information to those who are interested in
understanding or predicting patients behavior and
opinion about the dental services. This study included
five factors (access, availability/convenience, cost,
pain and quality) which represent the main sources of
satisfaction or dissatisfaction with dental services.
The participants were asked to evaluate the factors
which encourage/discourage their use of the dental
services in addition to the level of satisfaction with
the dental services.
In this study the quality of dental care was found to
be the most important factor in seeking and encouraging
continuous utilization of services in the chosen
clinic. The quality of dental care and competences of

the operators have been always used synonymously. They

were frequently cited as patients concern in many
countries including Saudi Arabia (Saeed and Mohamed,
2002, Butters and Willis, 2000, Albriecht and
Hoogstraten, 1998, Collet, 1969, Biro and Hewson,
1976,Lahti, 1996). Several studies found that the
quality of dental care is a determinant factor in
seeking or dropping out of care at dental clinics
(Saeed and Mohamed, 2002, Butters and Willis,
2000, Lahti, 1996, Gurdal et al., 2000, Esa et al.,
2006,Lafont et al., 1999, Ierardo et al., 2008, Stacey
et al., 1978). This is not surprising because the
outcome of the treatment depends largely on the quality
of dental care received and the operators competence.
Far location of the dental clinic from students homes
was found to be the main factor discouraging the
adolescents from continuing utilization of service in
their chosen dental clinic. This is not unexpected
knowing that the study was conducted in Riyadh, the
capital of Saudi Arabia, which is a very large city
with crowded streets and jammed traffic. Comparable
studies reported that the utilization of dental
services as well as satisfaction increased by
travelling shorter distances and within a relatively
small geographic area (Saeed and Mohamed, 2002, Mussard
et al., 2008). This, however, is in contradiction to
the finding of other study where there was no effect of
distance on satisfaction (Natabaye et al., 1998).
High cost of dental care was found to be an important
factor in discouraging students from continuing the
utilization of their chosen dental clinic among those
who received their treatment in the private sectors.

This is in accordance with the findings of previous

studies (Lafont et al., 1999, Ierardo et al.,
2008, Hashim, 2005, Chu et al., 2001, Goedhart et al.,
1996). This finding necessitates the importance of
reviewing the cost of dental services in private dental
clinics to make treatment fees more affordable to
public.
Post operative complications were found to have a
determinant effect on discouraging participants from
utilizing services in the government dental clinics. In
this study, the government clinics included dental
clinics in large hospitals, primary care centers and
the dental college. The government dental clinics
provide totally free of charge services to public. Most
of these clinics, however, are operated by general
dentists or dental students under the supervision of
faculty members in case of the dental school. Patients
were treated by specialists only in difficult cases.
This finding is in agreement with studies conducted
by Butters and Willis (2000)) and Matee et al.
(2006)) who reported that low quality of dental care
was among the top reasons of dropping out of care among
their study samples. This finding, however, is contrary
to the results of Awliya (2003)) who found that up-todate care was the primary reason for participants
coming to the dental college. Efforts should be made
for further improvement of delivery systems in these
centers to insure high quality of dental care and to
reduce any negative outcome of treatment.
This study showed that students who visited the dentist
for routine treatment were more concerned about the
quality of dental care compared to those who made their

visits due to pain. Regular attendants visit the

dentist more frequently; consequently, they are more
experienced and demand high quality of dental care.
While those who visit only in case of pain are pleased
by having the pain relieved, these findings are
consistent with previous studies (Lahti, 1996, Hashim,
2005, Goedhart et al., 1996).
Satisfaction of the students with their chosen dental
clinic was found to increase significantly with their
perception of receiving high quality of dental care and
going to modern equipped dental clinics, possibly,
linking between modern equipped clinics with high
quality of dental care. The same findings were reported
in other studies (Saeed and Mohamed, 2002, Butters and
Willis, 2000, Natabaye et al., 1998, Hashim,
2005, Mussard et al., 2008, Chu et al.,
2001,Mascarenhas, 2001). These studies concluded that
patient satisfaction with received care was found to be
a useful measure to evaluate dental care including the
quality and outcome of the treatment. Availability of
friendly staff and convenient appointments in addition
to these clinic recommended by friend or relative were
also found to increase students satisfaction. Several
studies reported that understandable communication,
humanness and friendly conduct of health team were
important factors for patients with direct effect on
utilization patterns (Saeed and Mohamed, 2002, Smith et
al., 1999). Too long to get appointments and difficulty
in getting appointments were found to be among the most
issues causing dissatisfaction in other studies (AlMobeireek and Al-Hussyeen, 2003, Awliya, 2003, Gurdal
et al., 2000).

Knowing adolescents concerns and views about the

availability of the dental services and insure their
satisfaction with dental care will ultimately increase
the utilization and level of compliance with dental
regimen, which in turn will promote the desired dental
health among this population.
Findings of this study indicated that adolescents
choice and utilization of dental service can be
improved if dental clinics were located closer to their
homes and if they provided high quality of dental care
with reasonable fees.
High quality of dental care, modern equipped dental
clinic which recommended by a relative or a friend and
have friendly staff, in addition to getting convenient
appointments were found to increase students
satisfaction significantly.
Utilization of oral health care services among adults
attending community outreach programs
The present study provides an excellent opportunity to
understand the pattern of utilization of oral health
care by people attending outreach programs.

Dentalvisits
The results from the study show that utilization of the
dental service among adults attending outreach program
was very low (28%). This is concordant with reports
from China (20%) and Spain (34.3%).

[3],[10]

In contrast,

dental service utilization is high in developed

countries, with figures of 75% in the US, 61% in the
Danish adult population, 47% in the UK, 56% in Finland,

and 43% in Singapore. Health insurance which covers

dental services in these countries can be speculated
for the high utilization, which is nonexistent in
India. Insurance schemes either at micro level or at
macro level for oral health services for our population
should be considered.

[10],[11],[12],[13],[14]

The present study showed no significant difference in

the pattern of dental visits between different agegroups. However, there was a tendency for increased
visits in the elderly age-group, which is similar to
the findings in the report from China. However, other
studies have shown the opposite trend in the dental
visit pattern.

[15]

The reasons for such trends are still

not clear but it can be speculated that the elderly

perceive their health status to be poor compared to
younger subjects.
Since Ujjivan members are females, the percentage of
female participants was high in this study. The number
of dental visits of these females was less than that of
males. This is because, in our population, females are
largely dependent on other family members, and
decisions regarding matters such as visits to the
dentists are made by others. On the other hand, women
in Western countries are twice as likely as men to use
oral healthcare services due to the higher illness
perception, higher health consciousness, and greater
social role of women in the West.

[8],[11]

Though previous studies have shown a positive

association of education with dental visits, the
present study did not show any impact of education on

dental visits. It appears that awareness regarding oral

health is low in our population, irrespective of the
level of education.[8]
Reasons of health care utilization
The majority of the dental visits by the participants
were for tooth extractions or treatment of acute
symptoms. This was similar to the study done in
Southern China, where the three most common treatments
received in the subjects' last dental visits were
fillings, extractions, and dental prosthesis.

[15]

The

data from Western studies suggests the main reasons for

oral care were dental examination (44.4%), tooth
restoration (35.0%), and dental cleaning
(32.1%).

[8]

Similarly, among Finnish adults, 43% of

subjects visited the dentist for a dental

examination.

[12],[13]

The reasons for the poor utilization of dental services

seen in this study could be: the existing preventive
dental health services, both through the public and the
private sector, has failed to reach this population;
and the choices for health care are largely determined
and conditioned by the social environment in which the
individual lives and works. There is no policy or
program in our country which focuses in improving the
social conditions that determine this behavior.

[16]

Assessment of barrier of health service utilization

This study revealed that the high cost of oral health
care, and fear of dentists or dental tools were the

major barriers for seeking oral health care. This was

true for all age group and educational status where as
time needed for child care was the major barrier for
female subjects. Similar results were observed in a
study from Southern China, with financial difficulty
and fear of the dentist being barriers for receiving
dental care.

[15]

In the present study, we did not

examine the association between income and other

dependent variables as all the study participants were
from economically disadvantaged backgrounds, with
monthly incomes of less than Rs. 5000.
It is important to remove the barrier of high cost of
health care by conducting free health camps, which have
proved to be effective in screening for diseases and
for providing preventive care. A free referral can also
be provided to the participants in these camps when
necessary.
Perception of oral health status
This study suggests that as age increased, positive
perception of oral health decreased. Also noted was
that as the education level increased, the perception
of good oral health increased.
Community outreach programs provide an opportunity for
investigating issues among groups of people who do not
utilize dental services, which should help in
understanding the barriers to accessing dental care in
these populations.
Limitations of the study

The measures of perceived dental care need were

subjective, as they were based on the individual's
conception of dental health and illness. Thus, dental
health perceptions may not only depend on one's
sensitivity to signs and symptoms of disease but may
also be influenced by one's knowledge of dental health.
Self-reports of utilization of services has a
considerable degree of inaccuracy, with a net tendency
to overestimate the actual number of visits. It seems
advisable to assess the validity of studies based on
this measure of utilization carefully.

Conclusion
Utilization of oral health care is an indicator of oral
health behavior, with underlying social determinants.
Since high cost is one of the main barriers to
utilization of oral health care, social and economic
upliftment through policies addressing the issues of
sickness and rehabilitation benefits, maternity and
child benefits, unemployment benefits, housing
policies, healthcare facilities, and women empowerment
is crucial for the successful delivery of oral health
services.

Time trends in socio-economic inequalities in the lack

of access to dental services among children in Spain
1987-2011

The results reported in this paper show evidence of a

reduction in childrens lack of access to dentists in
Spain over the period 19872011. However, this
reduction has not corrected the socioeconomic
inequalities in childrens access to dentists in Spain.
In line with other previous studies like Barriuso and
Sanz or Tapias-Ledesma et al., we have found a lower
access of children belonging to households with low
socioeconomic status. In addition, unlike most previous
studies (of a cross-section nature), we have done a
longitudinal study which has allowed us to show that,
far from being reduced, the inequality has remained or
even widened over the years.
Regarding our dependent variable having never visited
the dentist, it clearly indicates a lack of access
(either for treatment or just for prevention) to dental
care services. To some extent, this represents an
advantage with respect to other measures of access
(like the probability of visiting or the number of
visits to the dentist) that would require a dental care
need adjustment. Any child over 5 years old should have
visited the dentist for preventive reasons; in other
words, every single child is in need of these types of
services irrespective of her oral health state.
Therefore, not having visited the dentist before -by
the time of the survey- corresponds to a lack of
access. Not having to adjust for dental care need is a
methodological advantage. First, it skips the
controversial task of measuring dental care need.
Second, it avoids the potential problems of endogeneity
of a need variable, present in models of utilisation.
Unlike other health care services, a high proportion of
dental visits are preventive and if they are effective,

then a childs current oral health heavily depends on

past use of services. However, ad-hoc information of
need would be relevant to complete our analysis. If
information on childrens need for dental care had been
available for the period under study, we could have
analysed whether evidence elsewhere indicating that
need is relatively more concentrated among the lowest
socioeconomic groups, also happens in childrens oral
health. Llodra in a study with data from the 2010
Spanish Oral Health Survey shows evidence of a
socioeconomic difference in the prevalence of dental
caries (approached by the DMFT -Decay Missing Filled
Teeth- index) among children aged 12 and 15 (i.e.
prevalence increases in lower socioeconomic groups). If
this hypothesis is confirmed for childrens oral health
need -i.e. inequalities in lack of access that favour
higher socioeconomic groups evidenced in our research
are accompanied with inequalities in the distribution
of need (of the same nature)- then, there would be
evidence of the inverse care law that has been proven
elsewhere for childrens dental care. For instance,
Jones analysed the association between the British
National Health Service dental registration and
deprivation; the system worked as follows: children got
free dental treatment under a capitation scheme with an
NHS dentist but if children did not attend within
24 months, their registration lapsed and were deleted
from the capitation list; he found that registration
and lapse rates were significantly associated with
social deprivation.
It is also true that having visited the dentist at
least once does not guarantee an appropriate access to
these services. In order to further discriminate among

those who have visited the dentist, additional

information on use of dental care services in a given
period adjusted by dental care need (ideally
distinguishing between treatment and check-ups), would
give a more thorough view of access to dental care.
However this information was not available for the
period analysed.
The main policy change related to childrens dental
care in the period analysed has been the implementation
of the different regional PADI programmes. However, the
extent to which the results obtained in this research
are attributable to such programmes or to changes in
other demand and supply factors is something that
cannot be answered in this paper. In addition, given
the heterogeneity in the services provided in different
regions, it is likely that there may be different
effects among those regions with the infant oral care
programmes. For instance, Garcia-Gomez in a study of
the Pas Vasco concludes that such programmes have not
had a differential effect on the proportion of those
who have never visited the dentist, with respect to
regions that did not have it (in a comparative study
for the years 1987 and 2001); rather the reduction of
this proportion is attributable to a general trend in
Spain. Pinilla and Gonzlez conclude that in comparison
with regions without PADIs, the probability of using
dental services is greater and independent of household
income in those regions with PADI programme.
Additionally, Barriuso and Sanz conclude that the use
of oral health services is lower than recommended and
is positively correlated with the socioeconomic level
and with living in regions having a PADI of 10 or more
years running.

In our longitudinal study, it has been shown that

children living in regions with the PADI programme have
greater access to dental care services and this
condition has improved over time. An analysis that
takes into account not only the time but also the
geographical dimension in the application of the PADIs
would have been desirable to analyse to what extent the
reduction in the proportion of children who have never
visited the dentist is due to the effect of the infant
oral care programmes or to changes in other factors.
The ultimate aim of childrens dental care is to
improve oral health. Elsewhere, it has been shown that
the PADI has been effective in improving childrens
oral health; however, it would also be desirable to
know whether this improvement is also concentrated
among those households with higher socioeconomic level,
as expected, given the results obtained in our
research. In addition, it is interesting to note that
the differences in access by regions found in our
research are also in line with regional differences in
oral health found by Cortes-Martinicorena: according to
the childrens dental caries prevalence (approached by
the DMFT index), Pas Vasco and Navarra show lower
prevalence whilst Andaluca, Canarias and Extremadura
show higher prevalence, just the same distribution that
we have had for access in our paper.
If the final aim of a health care policy is to provide
health services that can be used by the whole society
including all population groups, then, the results
obtained in this research, particularly those that
evidence the persistence of socioeconomic inequalities
in the access to dental care services, should be taken

into account by health authorities when designing (or

improving current) childrens dental health programmes.
It might be of help to analyse first the reasons why
those children belonging to lower socioeconomic levels
experience a greater lack of access to dental care
services, that is, whether this inequality it is driven
by demand factors (i.e. those related to the
socioeconomic level or socio-demographic
characteristics) by supply factors (i.e. distance to
the point of consumption, difficulties in getting
appointments, waiting times, information in those more
deprived areas, etc.) or by a combination of both
Nevertheless, any reference to the policy implications
from the equity point of view must take into account
that the aim of our study was to analyse socioeconomic
inequalities in the lack of access to any type of
childrens dental care (both publicly and privately
financed) rather than a study of equity in access to
childrens dental care services.